Sharon was a 40-year-old female patient, and she did not want chemotherapy. As a first-year hematology-oncology fellow, it was my job to convince her otherwise. Sharon was initially diagnosed with early stage, estrogenreceptor— positive breast cancer 2 years before my first visit with her. At that time, she was advised to have surgery, as well as hormonal therapy and, possibly, chemotherapy. Surprisingly, Sharon refused surgery and all adjuvant treatment. After multiple failed attempts to convince her otherwise, she agreed to be followed very closely by her medical team with breast exams and mammograms. As expected, her cancer progressed. She was ultimately diagnosed with stage 3A breast cancer several months prior to my initial evaluation.

	As I sat across from Sharon during our initial visit, I was first struck by her eyes. Penetrating and defiant, they seemed to reject my recommendations before I spoke. I then noticed that her mouth was fixed in a scowl, and it looked as though this was its normal position. Lastly, her sharp cheekbones were framed by straight, long, brown hair. Her face seemed to warn the world that she was formidable and anyone seeking to interact with her should be forewarned.

	As I began to interact with her, I was careful not to dwell on the past. I did not want to appear accusatory and knew that, despite saying otherwise, she understood that her life was in jeopardy because of a poor decision she had made years earlier. Immediately, I realized that my initial impression was correct—she had a particularly guarded and defensive demeanor. Later, I learned that she was frightened and angry about her diagnosis. She was also vain and having had a mastectomy the month prior, she was particularly focused on her appearance.

	Later in the encounter, I was able to delve deeper into why she had initially deferred therapy. Sharon had deeply held beliefs regarding her ability to “self-heal” and she was highly suspicious of the modern medical system.

	To her, the intensive treatments we use in oncology were the worst of all. She felt that chemotherapy was poison, hormones would cause additional cancer, and surgery and radiation were horribly disfiguring.

	Over the course of my interaction with Sharon, I found that she appreciated succinct, direct language. Knowing that her prognosis now depended on my ability to develop a meaningful rapport with her, I firmly, but sincerely, asked her if she wanted to live. At first she was surprised by my directness, but her scowl soon softened and she responded that, yes, she did want to live. I told her that I could not promise her a cure because of the extent of her disease, but that if she trusted me and the medical system, we would give her the best chance of cure. She replied that she was ready to listen.

	Because Sharon already had a mastectomy, she would now need intensive chemotherapy to kill any remaining cancer cells. Many of her questions focused on practical issues. She wanted to know if she would lose her hair. I replied that, yes, she would most likely lose her hair, but we would arrange for her to wear a wig until it grew back. Feeling disfigured, she wondered if she could go to the beach after having had a mastectomy. Yes, I replied. I reassured her that we would order a post-mastectomy swimsuit for her to wear. Lastly, she had a new job as a dental hygienist and wondered if we could schedule her treatments around her schedule. I responded that, yes, we could arrange for her to arrive and leave early in the day.

	After thinking about it overnight and asking several more questions, Sharon agreed to initiate dosedense doxorubicin and cyclophosphamide followed by weekly paclitaxel. Despite pretreatment anxiety and many work-related obligations, Sharon did well throughout her intensive chemotherapy regimen.

	Toward the end of her treatments, I broached the topic of radiation therapy. Sharon’s major concern was that she would not be able to have breast reconstruction surgery afterward. This common misconception was dispelled after a visit to both the radiation oncologist and the breast surgeon.

	When I returned to Sharon’s hospital after rotating at another hospital for 6 months, she had completed her radiation therapy. Her formerly long brown hair was in a short pixie-cut, further defining her angular cheekbones. Sharon told me she liked her hairstyle and would keep it short, at least for a while. After spending some time catching up, our discussion turned to the hormonal therapy that I knew she needed, but did not want. Anticipating resistance, I had printed out information from an online prognostic model. After reviewing the evidence in favor of hormonal therapy and taking it home to discuss with her family, Sharon ultimately agreed to take these important pills.

	Despite her initial misgivings, Sharon has successfully completed surgery, chemotherapy, and radiation therapy. Additionally, she is adherent with her ongoing hormonal therapy. Sharon may not be cured, but she now has a second chance at life.

Articles

Tailoring your approach to how you interact
with a patient can be beneficial.

A Second Chance

You probably shouldn’t pursue a surgical oncology fellowship. You have spent a grueling half-decade of residency acquiring and honing the physical and mental skills necessary for surgical competence. After a lifetime of education, you will finally be deemed a “real” surgeon, on par with your mentors. You now have the opportunity to make a good income and start paying down your debt. Isn’t it time to get on with your life?

You probably shouldn’t even consider a surgical oncology fellowship. Think how far you’ve already come. Remember how you used to doubt yourself and wonder if you had what it takes? Remember struggling through basic subcuticular stitches—hand shaking and brow sweating? Remember saying “yes” but thinking “no” when the attending physician asked if you understood the surgical anatomy? Remember how everything on the laparoscopic monitor looked like nondescript fat? All that has finally changed! Seize the moment&mdash;put your hard-earned skills to practice. You’re a “cutter” now, and you always will be.

Many surgical oncology fellowships include a research year. Do you really want to lay down the scalpel and pick up the books for a whole year? And why oncology, of all disciplines? You are already capable of performing multiple oncologic surgeries, which are a component of many non—fellowship- trained surgeons’ armamentariums. If a patient presents with an overly complex malignancy, you can always refer the patient to a subspecialist. Those cases tend to be exhausting anyway.

Then again, maybe you like the idea of being that subspecialist to whom complex patients are referred. Perhaps you find challenging cases to be the most intellectually stimulating. You have spent years developing procedural memory for routine cases, yet you relish the opportunity to exercise your intellect by solving unanticipated problems. You enjoy thinking on your feet (literally) and inventing approaches to novel challenges as they arise.

Maybe you see value in spending time in a center of excellence and observing similarities and differences with your own training institution. You might consider it an honor to be trained by some of the most esteemed surgeons in your field. As a future surgical oncologist, you hope to broaden your scope of knowledge by working closely with leaders from complementary disciplines, including radiation and medical oncology. You know that new experiences in a novel setting are inherently rewarding and any additional skills acquired will be icing on the cake.

These are the rewards I’m seeking as I enter the second year of my urologic oncology fellowship. During my research year, I learned more than I ever thought I’d know about biostatistics and research methodology—knowledge that will provide a solid foundation for future research endeavors. I have contributed to oncologic literature, and I’m optimistic these contributions will have a meaningful impact on patients. I feel better equipped to interpret and apply the oncologic literature to my own patients. Most importantly, I have formed relationships with inspirational clinicians and researchers with whom I hope to collaborate throughout a productive career.

Additional voluntary training is a major commitment with a significant opportunity cost. I wondered if my contemporaries had similar reasons for pursuing fellowship training.

“My decision to pursue additional training in surgical oncology was multi-factorial. I had a strong interest in oncology throughout residency and felt that additional training would afford me the opportunity to enhance and expand my technical skills while concurrently expanding my knowledge base to better understand disease processes— with the end goal of providing top quality care to my patients...” said Jasmir Nayak, MD, a urologic oncology fellow at University of Washington.

“A surgical oncology fellowship was an opportunity for me to not only continue developing skills in complex oncologic operations, but also to learn the comprehensive multidisciplinary approach to cancer care," said Alan Thong, MD, urologic oncology fellow at Memorial Sloan Kettering Cancer Center.

Although every physician’s reasons for pursuing a surgical oncology fellowship are unique, we clearly share similar values. So, if you don’t want to maximize your training such that you can confidently approach the most complex of cancer patients— in the clinic and in the operating room&mdash;then you probably shouldn’t consider a surgical oncology fellowship. But if you do share these values, then maybe you should!

Christopher B. Allard, MD, shares his views on pursuing a surgical oncology fellowship.

Should You Pursue a Surgical Oncology Fellowship?

You are so lucky! You have just matched in your topchoice hematology/oncology fellowship program at a great university. You have always wanted to become an academic investigator and contribute to help move the field forward, and, finally, you have the chance to do so. You may think it is too early to consider finding a mentor; that you may, instead, wait until you have completed your first clinical year of fellowship. Big mistake!

It is never too early to start thinking about your research mentor. Choosing a research mentor is one of the most important steps when beginning a successful academic research career. Therefore, selecting a mentor should be done in a very thoughtful and deliberate manner, and should not be taken lightly or done in hasty fashion. Whereas some fellows may have taken part in an accelerated MD/PhD track program, earned a PhD, completed several years of full-time research (whether clinical or laboratory research), decided to remain as fellows in the same institutions where they are finishing their internal medicine residency, formulated a clear idea about what type of research career they want, and connected with the mentor with whom they will be training (and may even have worked with already), the majority of fellows probably are not so prepared. A majority of fellows do not have an extensive amount of prior research experience when they match in a new program in a new city where they don’t know many people. Many enter this new role without a plan as to whether they want to work in academia, private practice, or industry; let alone have they thought about seeking a research mentor.

Just a few years ago, I was in the second category (the less prepared). I had just joined a prestigious fellowship program at a top-notch university with a worldwide reputation in cancer research, but I didn’t know anyone in the city or even in the university. Although I knew I wanted to have a career in hematologic oncology research, I was not sure whether I wanted to do laboratory or clinical research. Also, I had not yet identified a particular cancer area to study or a mentor with whom to work. With agonizing uncertainty, I remember spending long weeks and months trying to figure out where my future would take me career-wise and stressing about how to find a mentor who would fit my personality best and offer me the finest opportunity to become an independent researcher.

Looking back at those days, I thought I would share with you my experience in finding the right mentor and what time taught me in tackling this process. I should note here that before moving to the United States to pursue residency and fellowship for early phase clinical/translational research in hematologic malignancies, I had obtained my medical diploma in another country. Although my experience may vary from that of others who have finished medical school in the United States, have done basic laboratory research, or are interested in pure oncology research, I believe that the general thoughts and principles I highlight can apply across this entire spectrum.

Do not wait until you are about to begin the research portion of your fellowship to start looking for a mentor. This is likely to be a long and a time-consuming process in which you will talk to many different people and assess multiple prospective mentors. It is wise to start seeking a mentor as early as possible. You may even want to consider looking for a mentor as soon as you know which institution you have matched with (before you even start your fellowship).

You probably have heard that being an oncologist is a lifestyle, not just a career. Well, that is absolutely true and even more so for a clinical researcher in oncology. Not only will you conduct clinical research, but you will need to be an excellent and devoted physician to your patients. Your work is not likely to end when you go home. Rather, you will likely find yourself busily writing manuscripts, revising grants, preparing presentations, and calling referring community oncologists, among other tasks, after your regular work hours, on weekends, and even while you are away at conferences or on vacation.

As you read this, you may be wondering what this has to do with finding a mentor. Well, choosing a mentor before you know what you want to do is like putting the wagon in front of the horse. Whether you want to spend years using pipettes and injecting mice or feel that your niche may be in clinical research and direct patient care, you need to make a decision about your career goals early. No mentor will find your passion for you.

There is often a requirement or pressure to do laboratory research during a fellowship program. This opportunity might be beneficial to you, as it can help you to figure out if you like working in the lab or at least confirm that you don’t belong behind the bench. Keep in mind, though, that this lab-based knowledge will help your clinical research career, as well.

At the end of the day, remember that your future career is YOUR choice. You should not bow to pressure from others to do something you do not like. You will be doing this for many years, and you have to be conscious of what the lifestyle of a researcher entails and be comfortable with how it affects your personal life.

Consider the Experiences and Involvement of the Mentor Now that you have figured out the type of cancer that you want to study and treat and have decided whether you envision yourself as a lab-based scientist or a clinical/translational researcher, it is time to try to find the researcher (ie, your mentor) who will help you achieve the ultimate goal of research independence. It is very important to select a mentor based on your assessment of your experience in research and your current needs. Although many fellows have the natural tendency to seek a very well known, successful researcher in their area of interest, keep in mind that such a person is likely to be very busy with his or her own lab, grants, papers, personnel, committees, frequent trips for presentations and meetings, and administrative responsibilities. This individual may not have enough time to adequately and comprehensively supervise and mentor you. If you have a lot of experience and feel that you need only limited guidance and mentorship, this arrangement might work for you.

On the other hand, if you are relatively new to the research environment and think you may need a lot of hands-on training and supervision, finding a mid-level faculty member who is not as well known in the field and has more time to devote to you makes more sense. In many institutions, your fellowship program director will have excellent knowledge of the faculty and can discuss who may be a good fit for your research interests. Some institutions even have a research committee that can help with mentorship decisions. At the end of the day, remember that this is a 2-way process: the mentor will also need to feel that you will be a good fit in terms of your needs and his or her time availability.

Talking to prior mentees is a very important step when searching for a suitable mentor. Former mentees can provide you with their perspectives about what worked well and what didn’t, whether they felt they received adequate supervision, and if any unexpected problems arose. How the previous mentees are doing in terms of academic and research achievements, publication and grant records, and successful academic employment are all very important indicators. Your fellowship program should be able to link you with previous fellows who were mentored by your prospective mentor. Additionally, faculty usually keep a mentorship record because a successful mentorship typically is one of the criteria assessed for academic promotions. These faculty will most likely be more than happy to share that list with you.

Academic and research achievements of any prospective mentor are very important; however, it is vital for you to understand whether their personality is fit for a successful mentorship. Someone can be a successful researcher, very difficult to work with, a poor educator or communicator, or have a temper. Your program director and past mentees may alert you to such issues.

Figure Out Your Research Plan and the Available Timeline

	Set Your Expectations and Goals with Your Mentor Early On

You may have an uninterrupted 2-year period of dedicated research time or have blocks of several months that are interrupted by clinical rotations. This can make a huge difference in the type of research you do and the degree of success you can achieve. Your research plans should take into account your availability and clinical duties, and be doable within the available timeframe. Do not be unrealistic or overly ambitious. These factors, in turn, should influence your choice of a mentor, as the mentor should be willing to accommodate your clinical duties and the nature of your training schedule. Discuss this very early on with prospective mentors to avoid any false expectations or misunderstandings that could lead to major problems later on.

You should formulate a clear plan with your prospective mentor detailing your time commitment and expectations in terms of outcomes, benchmarks for presentations and publications, and applications for grants. Arrange to meet regularly and frequently with your mentor, and make sure you feel adequately supervised and supported. To avoid potential conflicts, it is important that you and your prospective mentor align in terms of goals and expectations for your research training. Having a research or mentorship committee of 3 or 4 faculty members that meets every 4 to 6 months and is not directly involved in your research, but provides oversight on your research progress, can be very helpful to make sure things remain on track.

Despite being very diligent at choosing your mentor, sometimes things just do not work out for one reason or another. You might realize after spending a few months in the laboratory that you hate bench work and prefer clinical research. You might find out that your mentor is very busy and unable or unwilling to provide you with the adequate mentorship or supervision that you need. If you feel things are not working as you hoped, address this issue as early as possible and work with your mentor on a plan to fix the issue. If the relationship becomes strained beyond repair, talk to your program director about ways to resolve the situation. At the end of the day, it is much better to switch mentors and research projects halfway through your research training than to remain in an unproductive and broken mentorship.

Choosing a research
mentor is one of the most important steps
when beginning a successful academic research
career.

December 2015 | Oncology Fellows

A Second Chance

Should You Pursue a Surgical Oncology Fellowship?

Choosing a Research Mentor During Fellowship