Narjust Duma, MD, medical oncologist, Division of Hematology, Medical Oncology, and Palliative Care, University of Wisconsin ​School of Medicine and Public Health, discusses the importance of mitigating racial disparities in lung cancer research. 

In the lung cancer space, most data are collected from white, male populations, says Duma. This information is then extrapolated to underrepresented populations.

​The field should move toward overcoming this extrapolation to ensure treatment decisions are optimized for individual patients, Duma explains.

Notably, in 2019, the University of Washington and Fred Hutchinson Cancer Research Center evaluated the relationship between participation in clinical trials and overall survival (OS) in patients with metastatic non​–small cell lung cancer. Results showed that the patients ​who enrolled in clinical trial had a median OS that nearly doubled the OS of those who were not included. 

Ultimately, giving all eligible patient​s the opportunity to participate in clinical trials is necessary to provide optimal care ​and appropriately extrapolate data to underrepresented patients, Duma concludes. 

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Narjust Duma, MD, discusses the importance of mitigating racial disparities in lung cancer research. 








Dr. Duma on the Importance of Mitigating Racial Disparities in Lung Cancer Research   

Outbreaks of coronavirus disease 2019 (COVID-19) are on the rise in Latin America, with more than 4 million confirmed cases. In response to this health crisis, elective medical procedures, including cancer screening and care, as well as treatment for conditions beyond the virus, have been held.

Procedures that may not be considered elective are also being postponed, and patients are now being diagnosed with more advanced cancer, which in many cases are at incurable stages. For 2018, the International Agency for Research on Cancer (IARC) estimated 1.4 million new cancer cases in Latin America with more than 600,000 cancer deaths. It is projected that by 2040, cancer cases will increase by 91.4% in Central and South America.

 Unfortunately, during the COVID-19 pandemic, diagnostic procedures, research activities, and treatment plans have been disrupted; the clinical implications of these changes are still unknown.

Despite the measures implemented by some Latin American governments, the number of cases continues to climb. Some presumed reasons for this include lapses in social distancing implementation, in addition to crowded living conditions in urban areas. To date, 2.35 million confirmed cases of COVID-19 infections have been confirmed in Brazil, with over 85,000 deaths.

 Similarly, 378,000 positive cases have been reported in Mexico with over 42,000 deaths, and over 234,000 cases in Colombia with reports of 7,975 deaths. Notably, experts warn that the peak hasn’t been reached yet in that region.

As of May 2020, Central and South America were considered to be the new epicenter of the COVID-19 pandemic. Clinics and medical offices have been forced to close, raising concerns that healthcare systems could collapse, as has already happened in countries such as Ecuador. In March 2020, many European governments suspended breast, cervical, and colon cancer screening programs.

 In the United States, cancer screening programs were considered to be low priority.

 Although these practice changes are reasonable in light of this crisis, the negative impact could directly affect mortality in patients with cancer. Among Latinos, the cancer screening rate is already low, and COVID-19 may significantly worsen this situation.

In a national population-based modelling study done in the United Kingdom, investigators used linked National Health Service cancer registrations and hospital administrative datasets to estimate how the COVID-19 pandemic has delayed the diagnosis of cancer during lockdown measures. Compared with pre-pandemic figures, the authors estimate an 8% to 10% increase in the number of deaths due to breast cancer. It is estimated that for colorectal cancer, the number will increase from 1,445 to 1,563 additional deaths, and for lung cancer, additional deaths will jump from 1,235 to 1,372, a 4.8% to 5.3% percentage increase, respectively.

We have seen the severity of the impact of the pandemic on the United States. Despite clear data demonstrating the higher impact of COVID-19 in the Latino community, the effects of this virus in patients with cancer who live in Latin American countries is not well reported. Our study will focus on the effects of COVID-19 in oncology practices in Latin America. Data from the United Kingdom suggested that new cancer referrals decreased significantly due to concerns of contracting COVID-19; surgeries were delayed for more than 3 months across all stages of cancer and new chemotherapy practices were adopted by oncologists to avoid disruptions in cancer care.

 Our goal is to determine the extent of which the COVID-19 pandemic is affecting the care of patients with cancer in Latin America.

Understanding how the care of patients with cancer in Latin America has adapted during these unprecedented times, and the specific challenges experienced by providers caring for these patients, is essential to understand current limitations and disruptions in resource-limited healthcare systems. This survey will serve as an opportunity for hematologists/oncologists to share their perspectives on how COVID-19 has affected their communities.

 will take 10 minutes to answer and will be anonymous. These insights will hopefully guide future emergency preparedness plans on how to best deliver cancer care during a pandemic in low-income countries, and avoid cancer deaths due to lack of screening, surgeries, or availability of chemotherapy.

Horton J. Coronavirus: what are the numbers out of Latin America? BBC News. July 31, 2020. Accessed August 4, 2020. https://bbc.in/2DBbdo2.

Richards, M, Anderson, M, Carter, P, et al. The impact of the COVID-19 pandemic on cancer care. 

. 2020;1:565-567. doi:10.1038/s43018-020-0074-y 

Latin America and the Caribbean facts sheet. World Health Organization. March 2020. Accessed August 4, 2020. https://bit.ly/2ENQLB3. 

Andreoni M. Coronavirus in Brazil: what you need to know. New York Times. August 3, 2020. Accessed August 4, 2020. https://nyti.ms/3fu0s4m.

Resuming bowel cancer screening post-COVID-19. 

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Gorin SS, Heck JE. Cancer screening among Latino subgroups in the United States. 

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Maringe C, Spicer J, Morris M, et al. The impact of the COVID-19 pandemic on cancer deaths due to delays in diagnosis in England, UK: a national, population-based, modelling study. 

 Published online on July 20, 2020. doi:10.1016/S1470-2045(20)30388-0

Sud, A, Jones ME, Broggio J, et al. Collateral damage: the impact on outcomes from cancer surgery of the COVID-19 pandemic. 

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Articles

Outbreaks of coronavirus disease 2019 are on the rise in Latin America, with more than 4 million confirmed cases. In response to this health crisis, elective medical procedures, including cancer screening and care, as well as treatment for conditions beyond the virus, have been held.

Survey Aims to Identify COVID-19–Related Health Care Challenges in Latin America

Data suggest that up to 95% of patients with lung cancer score below the fiftieth percentile on sexual function during and after completion of cancer-directed therapy, with most issues related to sexual dysfunction persisting rather than improving over time.

 Data from previous studies have indicated that the impact of these therapies on sexual function is distressing to most patients with lung cancer, and sexual concerns are related to both higher symptom distress and worse functional status.

 Biological, psychological, and interpersonal factors all contribute to sexual dysfunction, and investigators have estimated that this dysfunction affects 40% to 100% of patients with lung cancer.

The subject of sexual dysfunction is not often addressed during routine oncology visits. A 2018 ASCO guideline on this topic states, “There remains an overall reluctance from both clinicians and patients to talk about cancer- and treatment-related sexual difficulties.”

 Several barriers are hindering the discussion of sexuality for patients with lung cancer, including a lack of adequate training for clinicians, the assumption that sexuality is only about intercourse, the speculation that older patients are not interested in having an active sex life, the misconception that treatments are not available, and an overall low comfort level discussing the subject.

Additionally, because of the lack of data surrounding sexual dysfunction in patients with lung cancer, it can be challenging to focus the discussion on the most common issues and learn about potential interventions to improve the problem. The scarcity of the data and the lack of awareness continue to make sexual dysfunction for women with lung cancer an 

 issue. Often, patients are timid or do not feel comfortable starting the conversation, so it is our duty as their oncology team to address this. Several tools exist for assessing sexuality, including questionnaires, and there are methods to inform how to broach the subject.

Most of the data on sexual dysfunction in patients with lung cancer precede the approval of the treatments that we are now using for the disease. As such, there is a need not only to understand how various cancer treatments affect aspects of sexuality in our patients with lung cancer, but also to move toward practical assessments that will help us develop targeted interventions to address sexual dysfunction in these patients.

To this end, in collaboration with the GO2 Foundation for Lung Cancer and the University of Wisconsin Carbone Cancer Center, we are launching the SHAWL Study (Sexual Health Assessment in Women with Lung Cancer), an international study designed to understand the effects of lung cancer treatments in women with lung cancer (

). The SHAWL study is the largest study to date to explore sexual dysfunction in this patient population. Results from the study are anticipated in early 2021. This research is expected to change the way we understand sexual health in female patients with lung cancer.

All women with lung cancer, independently of cancer stage, treatment type, and geographic location are eligible to participate in the SHAWL study. The survey takes between 5 to 15 minutes and is confidential. The survey is available at the GO2 Foundation Lung Cancer Registry. If you are already part of the registry, the survey can be found in your surveys tab. If you are new to the registry, you will need to create a profile, enter basic information about your lung cancer, and the survey will become available in your surveys tab. For more information on the SHAWL study, visit: https://bit.ly/2OikpQh.

Shell JA, Carolan M, Zhang Y, Meneses KD. The longitudinal effects of cancer treatment on sexuality in individuals with lung cancer. 

. 2008;35(1):73-79. doi:10.1188/08.ONF.73-79

Sarna L, Brown JK, Cooley ME, et al. Quality of life and meaning of illness of women with lung cancer. 

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Sarna L. Correlates of symptom distress in women with lung cancer. 

Furlow B. Sexual dysfunction in patients with lung disease. 

2014;2(6):439. doi:10.1016/s2213-2600(14)70081-5

Carter J, Lacchetti C, Andersen BL, et al. Interventions to address sexual problems in people with cancer: American Society of Clinical Oncology clinical practice guideline adaptation of Cancer Care Ontario guideline. 

2018;36(5):492-511. doi:10.1200/JCO.2017.75.8995

Bober SL, Varela VS. Sexuality in adult cancer survivors: challenges and intervention. 

2012;30(30):3712-3719. doi:10.1200/JCO.2012.41.7915

Annon JS. The PLISSIT model: A proposed conceptual scheme for the behavioral treatment of sexual problems. 

1976;2(1):1-15. doi:10.1080/01614576.1976.11074483

Mick J, Hughes M, Cohen MZ. Using the BETTER model to assess sexuality. 

2004;8(1):84-86. doi:10.1188/04.CJON.84-86

Data suggest that up to 95% of patients with lung cancer score below the fiftieth percentile on sexual function during and after completion of cancer-directed therapy.

SHAWL Study: A Sexual Health Assessment in Women With Lung Cancer

when I was waiting to be tested for COVID-19

. While waiting in my car, I could see our nurses crossing the lot wearing full suits and layers of personal protective equipment. I was, and am, so thankful to our nurses. They are risking their lives to test one health care worker after another. The test only took a few seconds to perform; the swab was done, and I was told, “You can drive away now.”

I knew it would take a few hours to receive the results. To pass the time, I did what I do best: get busy. I started with doing laundry, followed by cleaning the kitchen, bathroom, and bedrooms. I was still tired and experiencing symptoms, but I needed to keep my mind busy.

It was 4 PM on a Saturday when my phone rang. It was employee health and my test was negative for COVID-19. I shared the results with my husband and father and they were so relieved; 

 was relieved and the thought of going back to work excited me. However, I still had a cough and other symptoms. As such, I was not cleared by employee health right away; I needed to monitor those symptoms.

Sunday morning came around and the fatigue and cough grew worse—but why? My test was negative. I wrote and read all day, hoping to get better. When Monday arrived, and I was still not feeling better, employee health wanted to test me for influenza. That test also came back negative. Although I was still sick, I “saw” 10 patients over telemedicine, from my home, the following day. When I was interacting with my patients, all symptoms went away.

The idea of re-testing for COVID-19 came up during a conversation with our employees' Health Department. It was then, nearing the end of Tuesday, that I learned about the high false-negative rate in health care workers.

However, by Wednesday, 1 week after the symptoms started, I was finally feeling better. The cough has since resolved. I was officially cleared by employee health, and no additional tests were determined to be necessary. It turns out that it was a common cold, after all.

I was one of the lucky ones; I am one of the lucky ones. It was a common cold, one that in ordinary circumstances, I would have probably ignored. However, you cannot do something like that anymore. We may never be able to ignore a cold again. This pandemic is changing us, and it will continue to change our health care system. Nothing will be the same, but we are becoming stronger. We are learning from our mistakes, and we are valuing all the members of our teams because we are all in this together!

Narjust Duma, MD, is an assistant professor of medicine and a thoracic oncologist at the University of Wisconsin Carbone Cancer Center. 

Narjust Duma, MD, shares her experience with being tested for COVID-19 and discusses the lasting implications of the pandemic.

Close Call: Oncologist on Her COVID-19 Test and How Health Care Has Changed Forever

As oncologists, we often rely on guidelines to make treatment decisions, to pick the best approach for our patients, and to decide when and if surveillance scans are necessary. However, none of those guidelines include dealing with a pandemic such as COVID-19.

Many of our decisions are now based on when the virus-surge is happening and how we can keep our patients away from hospitals. We also lack guidelines on how to help our patients cope with their newfound isolation and this new way of life. We do not have a script, no flow charts, and no citations.

Data from our colleagues who have faced the virus before us are rapidly being published; these data come from their experiences, from their losses. Many of these articles are very informative and humanizing, but the majority do not apply to our unique healthcare systems in the United States. We lack universal health care, and not everyone has access to physicians, testing, and medications.

During medical training, emphasis is always placed on evidence-based medicine. I remember citing meta-analyses during rounds, seeing the look of approval from my attending physician, and receiving compliments because “I have reviewed the data.” In 2020, there are no meta-analyses to cite and high-level evidence-based guidelines to follow. We are more on our “own,” than ever before, and I will even go so far as to call this a new type of “precision medicine” that we are practicing. We are tailoring our treatment decisions not only to the histologic type or PD-L1 expression of a tumor, but also to the risk of developing complications if our patients become infected by the virus, our patients' ability to practice social distancing, as well as their financial stability while staying at home.

Large societies are creating guidelines to help physicians make these decisions, but as with many other guidelines, one size does not fit all. One senior physician said to me a few days ago, “We are becoming real doctors again,” But are we really? Is guessing treatment decisions becoming a real doctor? I do not have an answer to that, but I can say that this whole experience has been incredibly humbling. The words “I do not know” are often said during each patient encounter. Those words are the pure truth during this healthcare crisis: We do not know, but we may know many months from now.

I do have to say that the lack of high-level evidence is anxiety-provoking and often keeps me awake at night. How can I know if I am making the right decision? Can I extrapolate these or those data to my patients? We no longer have a map and need to rely on our instincts. Is that what becoming a real doctor means? The fathers of modern medicine like Hippocrates and Democritus used to rely on their instincts to practice medicine, but they also used to phlebotomize patients for headaches.

Listening to colleagues and patients have become the new guidelines. The sense of isolation is alleviated a bit when we share and discuss difficult cases with our colleagues; we are functioning as a large and continuous tumor board. We learn from each other’s experiences and we make decisions based on collective thoughts. We have also incorporated our patients’ comfort level into our recommendations. While this should always be part of our clinical decisions, questions like “Are you comfortable coming to the clinic?” or “How do feel about postponing scans for a few months?” have been introduced into daily conversations that we’re having with our patients. These have become our “new” treatment guidelines.

Many questions remain unanswered but working as a team provides us with some comfort as we determine our new approach for decision making in daily practice. I hope this practice does not evaporate as we overcome these dark times. We are better oncologists when we work together. We are better physicians when we listen to our patients' concerns, and we are better human beings when we accept that sometimes, we just do not know.

As oncologists, we often rely on guidelines to make treatment decisions; however, none of those guidelines include dealing with a pandemic such as COVID-19.
 

No Guides and No Lines: Cancer Care During COVID-19

It was Wednesday night, and I was feeling tired with new muscle pain. I have been working long hours and exercised more than usual. My mind started justifying every little symptom. “I could be feeling this way because of lack of sleep. This could be because of yoga. This new anorexia is probably due to stress.” That night, I fell asleep finding reasons for all the symptoms I was experiencing, while repeating a mantra to myself: “I am not getting sick. I am not getting sick.”

Thursday came around and the muscle pain was slightly worse. I noticed that the pain was present even when my body was at rest and it was affecting large muscles. At this point in time, I had also developed a dry cough; it was intermittent, not productive. That morning, I completed a re-assessment: What was new? Fatigue was new, but could that be due to lack of sleep? I have not been able to sleep for 1 week. I decided to work from home, setting up telemedicine encounters with my patients. Around noon, I noticed I was not hungry. I was busy, and that became a second thought. I had a conference call and a round table to record and time was limited.

That afternoon was busy; I continued to meet with patients over telemedicine while my husband was trying to cook and do laundry in the background. I had a deadline and a new article to write. Some of my symptoms were ignored. It was finally 6 PM, but I was still not hungry; however, this was not entirely new to me. When I am busy, I tend to not eat much. Again, I was justifying my symptoms. That evening, I started isolating myself from my husband. We discussed limits around the house. “You will use this bathroom, and I will use this one. I will sleep in this bedroom,” and so on. We could not kiss or hug anymore. I was getting sick.

I went to bed, but I could not sleep. Like I said, I have not been able to sleep for days; that was not new for me. I was not worried about my new symptoms, but I was worried about the consequences of getting sick. I made a list of all the people I have seen in the past 2 weeks. Luckily, I did not see many people, but some were essential workers. I was trying to recall if I was wearing my mask and shield when speaking with them. I was mortified by the fact that I may have unknowingly exposed them to something. However, at that time, I did not have symptoms and I was washing my hands so many times that they were turning red. I knew that I was wearing my mask during all patient contact, and that provided me with a slight sense of relief.

Friday morning arrived. Symptoms were present, but I had a full clinic, all via telemedicine. I stayed home and evaluated patients by video and phone. My nurse was serving as the ship captain in the cancer center, triaging requests, and “eyeballing” patients receiving chemotherapy. I wasn’t hungry, but I was busy. During the first encounters, I did not mention anything about my symptoms; I usually don’t when I have a common cold. Was this time the same? Probably not. For the first time, these symptoms were concerning. For the first time, these symptoms could mean more than a regular cold.

Around noon, the fatigue was worsening, and I started telling my patients that I have some “questionable symptoms.” I used that same phrase to write an email to my division chair and colleague. I did not have a fever, which I found to be reassuring. I had completed all visits at this point in time. The adrenaline of a busy clinic day disappeared, and the symptoms were becoming more noticeable. I was experiencing anorexia, fatigue, and muscle pain.

I finally made peace with reality and called our employee health department. I shared my symptoms and that I was attending the oncology inpatient service around 10 days ago. The nurse on the phone was clear: “You should be tested.” I knew it, and maybe that was the reason I did not want to call in the first place. After 10 minutes of instructions and getting a “password,” I was placed on “administrative leave” and scheduled for a drive-thru test.

Should I tell my family? My mother will probably freak out; my family members are far away, in different countries. They have already lost friends and medical school classmates to the virus. I decided to tell my father, as he is the most rational of the 2. He was expecting this call; he knew 1 of us would develop symptoms. I shared the symptoms I was experiencing with my 2 closest friends who are also physicians; they remained calm and they justified all my symptoms, as I had done before.

Saturday morning came around and my symptoms were worse. I do not know whether it is a regular cold, influenza, or COVID-19. I had to practice what I have been teaching my patients. Anxiety was present, as well as a new headache and a dry cough.

I am writing while waiting in my car to be tested. I have my password, my mask, and my car windows are up. It feels like a movie, seeing colleagues and friends in full-body suits walking around this parking lot. We were not expecting any of this, but we will overcome this new challenge. In several hours, I hope to get my results.

Narjust Duma, MD, is an assistant professor of medicine and a thoracic oncologist at the University of Wisconsin Carbone Cancer Center. At the time of publication, Dr. Duma was still waiting for her test results.

At 3 PM on Thursday, I was seeing patients by video, discussing their symptoms, and informing them of the adverse events associated with therapy. At one point, one of my patients asked me, “How are you?” In that second, I realized I was getting worse. My symptoms were more pronounced, I had not eaten all day, and I was in my fourth cup to coffee to cope with the fatigue. I answered, “I am okay.” But was I really? I decided not to mention my symptoms to my patients that afternoon. I did not want to add more anxiety to their day. I did not want them to worry about me.

Narjust Duma, MD, shares her personal experience with feeling ill during the COVID-19 pandemic.

You Should Be Tested: An Oncologist's Personal Experience With COVID-19 Symptoms

After completing medical school, surviving residency, and finally getting to study your disease of choice during fellowship, your program coordinator sends you an email titled, “Job opportunities.” Minutes after I received that email, anxiety started building up. Is it time to start looking for my first faculty job? How does this work? Where do I start?

Those questions followed me for days. Then I heard some of my co-fellows had already found their first jobs and were close to signing their contracts. And my anxiety turned into fear. A lack of knowledge, and an excess of coffee, just added fuel to the fire.

I am writing this article to share some of my experiences while looking for my first faculty position in medical oncology. This information is not unique to hematology-medical oncology and may be helpful to fellows from other specialties.

Starting with the medical school application, medical students live by a time line and an organized system. One perfect example of this is The Match: The application opens in July, you complete an application, the interviews go on for a few months, you create a ranking list, and at the end you receive an email with your new destination.

Finding your first job is quite different. A few job openings can be found on society websites, such as the American Society of Clinical Oncology or the American Society of Hematology, or career sites, but the most common style is word of mouth—and there is no official posting for many jobs. You can work with recruiters, and if you’re interested in working with the pharmaceutical industry, each company has a medical liaison that works with your institution developing and opening clinical trials. Ask your mentor or program director for the liasion's contact information and email them about your interest and curriculum vitae (CV).

2 Private Practice Versus Academia Versus Industry

Oncology practice has evolved over the years, and it no longer involves only the options described above; you can also pursue a career in government or with a consulting firm, among other options. All of them have their pros and cons, from salary to research time to the opportunity to wear jeans on Friday. It’s important that you define what type of environment best fits your professional and personal goals before you start looking for that first job.

It’s time to put all your accomplishments in writing again. You can follow your institution’s template, or whichever template you feel most comfortable using, but do not forget to write everything down: posters, local oral presentations, that time you taught a course in the medical school, and any award, however small or big, you received during your training. The people doing the hiring won’t know what you've done unless you tell them.

In my case, English is not my first or even second language, so I had a few people review my CV and cover letter for grammar and to make sure I didn’t accidently drop a Spanish word here or there.

The cover letter is more specific to the job and institution to which you are applying. Try to explain why you think this role and this place would be a good fit for you and how you can help the institution achieve its goals.

There are several ways of contacting potential employers: emailing the contact person listed in the job posting, cold emailing the division chair or disease-specific chair to see what positions might be available, asking your mentor to make inquiries for you, and contacting a recruiter who can help you establish those connections. In addition, you can connect with future employers at conferences and career fairs.

In my case, I emailed many people, many times, and had a decent success rate. The times when jobseekers were told “Do not contact program directors” are over; it’s your duty to seek an answer.

Before your visit is scheduled, your potential employer will contact you for a brief screening interview, a 10- to 15-minute conversation about your interests and what they are looking for. Research the person you'll be speaking with ahead of time and try to reduce interruptions. In the case of video interviews, wear business causal.

6 The In-Person Interview (first and second looks)

Congratulations! They want to bring you in for face-to-face meetings. This time around, your potential employer will cover the cost of your travel, such as airfare and hotel. Work closely with your fellowship program coordinator to plan time away and coverage if needed. Remember, we are still fellows.

The interview will vary depending on the type of practice you decide to pursue, but general concepts will apply. You will likely have a dinner with some people from the institution the night prior, and the following day you will meet with key people (eg, division chair, future colleagues, etc).

What to wear? For the interview day, full business attire is appropriate, so get that interview suit out of the closet! For the dinner prior, and perhaps after the interview, business causal is fine.

In academia, a second look is almost mandatory. The goal of this second visit is to see if the institution and city are a good fit for you. Second looks are a great opportunity to meet with future mentors and tour the city; in most cases, you can bring your partner/spouse for a real estate tour. On this visit, you’ll discuss salary and benefits, and you can meet with human resources to discuss vacation time, sick leave, and other benefits.

In many settings, you will be asked to give a “job talk,” or a summary of your research. Many people recommended against discussing a review topic, such as immunotherapy in lung cancer or CAR T-cell therapy in lymphoma, because you want to demonstrate that you are capable of starting and completing a project, and no one will know more about your research topic than you (hopefully).

The talk should last about 45 minutes. Avoid delivering excessive amounts of text in your PowerPoint, credit all your collaborators, and try to focus on only a few topics. Finally, tell a story that the attendees can follow.

You’ve been offered a job. Congratulations! This is a huge moment, so let yourself enjoy your success. That said, you still have work to do.

Remember, everything is negotiable. Consider their first offer to be a draft, and do not be afraid to ask for what you want—the worst they can say is no. You can negotiate clinical versus research time, salary, bonuses, conference attendance, participation on boards, access to support staff, in-patient time, and more.

Ask your mentors, friends, and co-fellows what they have negotiated. As someone once told me, “Nothing is off limits.”

This applies more for private practice where you negotiate partnerships. Many of my co-fellows had an attorney review their contract. A legal professional can help you navigate the noncompete agreement and other legal language that can be difficult to understand.

We all want to find the “perfect” faculty job with the plenty of clinical time, available start-up funds, and amazing coworkers. In reality, that perfect job may not exist. Understand the difference between your must-haves and your nice-to-haves, decide where you’re willing to compromise, and pick the job that best fits your personal and professional goals.

Additionally, your first job is just that, your first job. Important names in oncology have changed institutions and you can, too. Your goals and needs will likely change over time and more opportunities will come.

One final recommendation: Be honest and be you. You want to be hired for who you are and not for who you pretend to be.

Narjust Duma, MD, shares some of her experiences while looking for her first faculty position in medical oncology. This information is not unique to hematology-medical oncology and may be helpful to fellows from other specialties.

Finding Your First Oncology Job: 10 Things You Should Know

Study results demonstrate that men and women differ in their immunological responses to foreign and self-antigens. Women have stronger responses to vaccinations and infections than men.

 One potential cause of these immunologic differences is sex hormones: Among women, some differences in immune response are more apparent during puberty or child-bearing years. Furthermore, sex hormones might play a role in regulation of the PD-1/PD-L1 pathway, although this theory is based exclusively on data from animal studies.

Women also have exaggerated responses to auto antigens and are more likely to have autoimmune diseases.

 Some tumors might develop a more advanced self-editing process to defeat this “hyperactive” immune response and thrive. Women’s powerful immune activity might also affect how they respond to immune checkpoint inhibitors (ICIs).

On this basis, Mayo Clinic investigators hypothesized that women may be at increased risk of immune-related adverse events (irAEs) with anti—PD-1/PD-L1 therapy. Mayo Clinic investigators retrospectively reviewed all patients with diagnosed metastatic non–small cell lung cancer (NSCLC) at Mayo Clinic locations in Rochester, Minnesota, and Jacksonville, Florida, from 2015 to 2018. Patients with a history of autoimmune disorders, therapy with ICIs, and treatment with oral steroids (>10 mg prednisone daily) were excluded.

Of the 231 patients with NSCLC included in the study, 120 (52%) were women and 111 (48%) were men. Overall baseline characteristics, including prior ICI treatment, were similar between the sexes.

In our study population, women were more likely to experience irAEs compared with men (48% vs 31%; 

 <.008). We also observed differences in the irAEs. Women were more likely to develop pneumonitis (23% vs 12%; 

 <.04). However, dermatologic toxicities were more common in men (35% vs 9%; 

Aside from sex, no other clinical characteristics were associated with increased risk of irAEs. This includes histology, prior radiation, prior chemotherapy, and the presence of liver, brain, or bone metastases. In addition, there were no observed sex differences in irAEs greater than or equal to grade 3, although women were more likely to receive oral steroids as treatment for these reactions. This observation should be the starting point for further studies designed to answer the following: Are we treating women with irAEs differently? If the same rate of grade 3 irAEs exists across sexes, why are women receiving more oral steroids? This latter question is relevant because recent data show lower benefit from ICIs in patients receiving oral steroids.

Previously, we conducted a study of women with metastatic melanoma treated with anti—PD-1/PD-L1 agents and observed similar results. Compared with men and postmenopausal women, premenopausal women had the highest rate of irAEs and higher rates of endocrinopathies, such as hypothyroidism and adrenal insufficiency. In our NSCLC cohort, we counted only 6 premenopausal women, but an analysis of this subgroup was not possible due to the small sample size.

Perhaps sex as a biologic variable plays an important role in the development of irAEs and the differences between the sexes. We believe we need additional studies to better understand the significance of our observations, but these findings call attention to a very important issue: Women are biologically different and may require closer monitoring while receiving treatment with anti—PD-1/PD-L1 therapy for NSCLC. As more trials utilizing these agents open each day, we hope that the data regarding adverse events (AEs) will be reported by sex and that larger studies will result.

With the introduction of ICIs, the treatment landscape of multiple malignancies has changed. Clinical practices should adapt to these changes. For example, the AE focus is shifting from traditional treatment symptoms, such as nausea and vomiting, to rashes, joint pain, and coughs.

In February 2018, the American Society of Clinical Oncology and the National Comprehensive Cancer Network released guidelines for the treatment of irAEs.

 We advise all physicians to review them. Consistent adherence to these guidelines will enable our patients to receive the best care, whether they are treated at tertiary centers or in community practices.

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Study results demonstrate that men and women differ in their immunological responses to foreign and self-antigens.

Closer Study Required of Immunological Differences Between Sexes

I am writing this as a recently matched postgraduate year 3 internal medicine resident about to start a hematology-oncology fellowship in T minus 3 months. I hope my musings are relatable to rising fellows or reminiscent to those who felt similarly at the start of their hematologyoncology training.

As I look back, the hematology—oncology fellowship interview trail was both exhausting and exhilarating. Meeting future colleagues and hearing about the exciting advancements that medical oncology will see in the coming years gave me a sense of pride for my chosen field. I felt as if I was joining a movement that had already seen decades of momentum in research and development of novel therapeutics and care models. Needless to say, cancer therapy has changed dramatically over time. I imagined the innovations and milestones that I would see during my career and felt excited to complete internal medicine training and start my next adventure.

Soon after Match Day, my excitement was tempered by all the practical tasks ahead of me: a new state medical license, another new driver’s license, and to-do lists embedded in to-do lists. Moving across the country to a new place has punctuated every training step for me thus far. Although I enjoy exploring new cities and meeting people, it has been difficult to move away from close friends, colleagues, and the rhythm that my life had become. I also wondered about the transition to a new academic center. During residency training, you truly feel integrated in your institution, which affords familiarity with everything from where to find the stairwells to the reputations of specialists and other trainees to the culture of the place. Here I have learned how to get work done effectively and efficiently. I can only hope that I quickly establish the same familiarity at my new institution.

The Full Fellowship Experience Involves Doubts, Fears, and Understanding

Ahead of all the practicalities of moving and adjusting, I know that my new role as a hematology—oncology fellow will be the most formidable and satisfying challenge to overcome. My class of fellows and I will have to quickly rise to higher expectations for specialized knowledge and polished skills, a situation that feels reminiscent, yet more complicated, than in my early intern years. Today, I may ask for clinical advice from a fellow whose role I will be filling in a few short months. How strange and intimidating! But I remember how neat it was to transform into an autonomous, confident resident during intern year, and I can only imagine that this next transformation will be even more rewarding. This is the time when I will finally be doing what I wanted to do at the start of this journey. This time will likely shape my career trajectory more than any other segment of my training. As monstrous as it all seems, soon enough I will be reflecting on how quickly fellowship has passed as I look ahead to another transition.

I am writing this a second-year hematology— oncology fellow about to start the journey of finding that “dream” faculty position for which many of us have trained for the past 14 years. I am sharing some of my experiences during fellowship and hoping a hungry and tired fellow somewhere will know she or he is not alone.

During the interview trail, I always heard “the learning curve is steep,” but I didn’t realize it until the first day of my oncology continuity clinic. My first patient had a pleomorphic sarcoma. After I did some reading for 5 minutes, a sense of doom invaded my body. The fear of sounding “stupid” or losing my first oncology patient’s trust was overwhelming. After a long night trying to seize some basic knowledge about sarcoma, I met with 1 of our sarcoma faculty to discuss the case. He said, “There are more than 100 types of sarcoma,” and my heart skipped a beat. He took a piece of paper and kindly explained the basics about pleomorphic sarcomas. That was the moment when I realized that I was not alone, that our faculty was there to support us. Trainees’ relationships with faculty change as you advance in training. You are no longer one of the residents—you are now one of them.

Another unforgettable moment during my fellowship was the first time one of my patients passed away. We all have encountered death during our training (eg, intensive care unit rotations), but when you care for patients during their cancer journey, you develop a strong bond with them and their families. I remember receiving a message saying that “Mr M has passed away,” and immediately an incredible sense of sorrow pervaded my day. I asked myself, “Is this the right job for me?” and I questioned my decision to pursue a career in oncology. At the end of that day, I mustered the courage to call my patient’s family to offer my condolences. His wife picked up the phone and with a warm voice said, “Dr Duma, thank you for taking care of him. You two had a special connection.” A few tears rolled down my cheek, and all the fear disappeared—I had chosen the right field. After my 2 years of training in hematology-oncology, losing patients has not gotten easier, but I will always carry their memories and will continue fighting for them through my everyday clinical practice and research.

As you start your fellowship, you may feel lonely. You started with a class of 20-plus residents, and eventually you end up with a few fellows. That friend with whom you always had rotations together is no longer around. Going through a hematology-oncology fellowship is a life-changing experience that you share with only a few individuals. Over time, you will develop strong friendships with your co-fellows. They will become your confidantes, advisers, and even the future godparents of your children. James Cash Penney, founder of the retail store JCPenney, said, “Growth is never by mere chance; it is the result of forces working together.”

Lastly, ups and downs are common. One day your patient has a complete response and another day disease progression. Learning how to celebrate little victories has helped me to cope with the battles I have lost. Fellowship training has not only helped me grow as a physician but has also helped me become a better wife, daughter, friend, and teacher. I know the journey will not end after I secure a faculty position, but my experiences have taught me a lesson: We are lifelong learners, and we are not alone during this journey.

Candace Haddox, MD, and Narjust Duma, MD, address the uncertainty, the victories, and the defeats common in oncology fellowship programs.

Narjust Duma, MD