I have long dreamed of operating my own laboratory and serving as a leader in scientific research. Toward the end of my postdoctoral fellowship in the Tumor Immunotherapy Program at Princess Margaret Cancer Center in Toronto, Canada, I published my first high-impact research paper in 

. I began looking for opportunities in academia and saw ads for the new Caspar Wistar Fellows Program. What an intriguing opportunity to transition from postdoctoral fellow to independent scientist, I thought.

The Wistar Institute has an illustrious history, and I had always wanted to work at such an esteemed institution. I conducted further research and found the program was indeed a chance to enter a top research environment and take an accelerated path toward independence as a principal investigator (PI). I could refine my skill set and mature professionally while launching my own research program in a great academic setting and city.

When considering a fellowship, think about your goals: Where are you in your career? Where are you trying to go? What are the cultural values of the organization you’re considering? Who will be your mentor and guide your career? What is the environment beyond the organization? Can you reach out, collaborate, and meet other like-minded scientists at nearby institutions?

I joined Wistar as the first Caspar Wistar Fellow in June 2019 and moved to Philadelphia. It was a great honor and a very exciting time to join a boundary-pushing biomedical research institute with a rich history of discovery in cancer and immunology, vaccine creation, and infectious disease research. I’m getting to know the city’s robust and collaborative life sciences community and setting up my laboratory. I hired my first assistant in September.

A fast-tracked PI is quite different from a postdoctoral fellow. As a PI, I run my lab like my own business; for the first time, I have sole responsibility for managing funds and hiring people.

As a postdoctoral fellow, I was usually in charge of 1 main project and 1 side project, so it’s been an exciting leap at Wistar. On the fast track to a PI, I think and act with a much broader perspective. I get to choose and develop my own projects, and I’m currently working on 4. It’s important that I know the ins and outs of my field, so I’ve always got my head in a journal. I’m drafting foundation grants and preparing to submit federal grants by next summer. And of course, I will be working hard to publish my first paper as corresponding author.

I have joined the Immunology, Microenvironment, and Metastasis Program, and I’m part of a uniquely collegial, interdisciplinary scientific environment with very strong expertise in tumor immunology that will be a critical source of know-how and guidance as I explore my own scientific hypotheses.

My research centers on therapy options for patients with pancreatic cancer, which are consistently limited and largely ineffective. I am interested in characterizing molecular mechanisms that control macrophage immunosuppressive behavior and developing tools to target and open new therapeutic avenues for the disease.

Pancreatic cancer is surrounded by a highly immunosuppressive tumor microenvironment (TME) with a dense fibrotic stroma that limits drug penetration and effector T-cell responses. Macrophages are a major immune cell infiltrate, important for driving immunosuppression, T-cell dysfunction, and profibrotic events.

One facet of my research is exploring how alterations in the cell metabolism of macrophages affect their function. My findings so far highlight the importance of branched-chain amino acids (BCAAs) and their catabolism mediated by Kruppel-like factors (KLFs) in shaping the functional responses of macrophages in the tumor. My lab is interested in expanding our knowledge of KLF biology and BCAA catabolism in macrophages affecting cancer progression and therapy resistance.

Additionally, commensal microbiota are critical in shaping the TME and tumor progression.

Recent advances in the field indicate that host, dietary, and environmental factors contribute to changes in the microbiome. I am interested in identifying key factors that influence the healthy-symbiotic or disease modulating—dysbiotic microbiome and contribute to the refractory nature of the disease to eventually target these factors for therapies.

Beyond thinking about my research, I’m surrounded and learning from Wistar’s scientific leadership. I have regular meetings with Dmitry Gabrilovich, MD, PhD, the Christopher M. Davis Professor and leader of the Immunology, Microenvironment, and Metastasis Program, and David B. Weiner, PhD, executive vice president, director of the Vaccine & Immunotherapy Center, and the W.W. Smith Charitable Trust Professor in Cancer Research.

The vibrant atmosphere at Wistar is helping me begin collaborations with Wistar faculty as well as scientists at the University of Pennsylvania. I continue scientific exchanges with my mentors, Tracy McGaha, PhD, at the University of Toronto, and David Munn, MD, at Augusta University’s Georgia Cancer Center.

The Caspar Wistar Fellows Program is providing me with the best foundation to succeed. I’m gaining momentum and advancing my academic career with mentoring from top scientists in my field, in an environment that nurtures collaboration, creativity, and excellence. I look forward to obtaining federal grant funding and publishing quality research in top-tier journals. I want to achieve the skill sets needed to establish an innovative lab, solve key questions in the field of cancer, and one day, repay my good fortune by mentoring future generations of scientists.

This article was written by Rahul S. Shinde, DVM, PhD, Caspar Wistar Fellow, Immunology, Microenvironment and Metastasis Program, The Wistar Institute.

Articles

Rahul S. Shinde, DVM, PhD, reflects on his journey to realizing his dreams of operating his own laboratory and serving as a leader in scientific research.

Taking the Fast Track to Independence in Oncology

The other day I had the chance to reflect on my first year of oncology fellowship. Looking back, there is a craziness to it all that is hard to explain unless you experience it. I want to share reflections from what seemed like a typical day, with some advice for first-year fellows and trainees.

Alarm at 5 am. Get dressed. Grab breakfast on the go. Chug a triple-shot espresso.

I am one of the first cars in the hospital parking lot and one of the last out. I wonder if and when things will get easier. I make up in hours what I surely lack in experience. Chemotherapeutics, genomics, and controversies on Twitter over P values. Too much to learn each day. I’m thankful podcasts exist to consolidate my learning.

I take the stairs up to the fellow room. This is the peak of my exercise routine. I sign into the medical record to review patient charts. My colleague asks why I look so tired. I don’t answer. Doesn’t he know why? The fatigue, physical and emotional, adds up.

Training to be an oncologist has made me, at times, an absent friend and a preoccupied husband. I tell myself it is worth it. We all have friends who suffered from cancer. There is meaning in this profession.

There are 19 patients today who are admitted with a variety of solid tumors. All of their ailments make my complaints seem trivial. Their loved ones sleep on couches, and the patients who can sleep barely get any rest because we constantly interrupt them with blood pressure checks.

I start my rounds, and each visit begins with the typical, “How are you doing today?” The question often seems rhetorical. Most of our patients don’t like to complain, and we never have enough time to really engage anyway. We triage through who can go home, who has an impending emergency, and who needs more investigation.

Two cups of coffee later, the nurses remind me it’s time for discharge rounds with social work. We discuss the diagnosis, prognosis, and discharge plans for each patient. We evade talks of hospice, even though it is often on our minds. Maybe we will discuss it during the next admission.

I lose track of time, and now I’m 20 minutes late to noon lecture. Food brings my co-fellows together. It’s the 1 hour of protected education. I am to learn about new advances for metastatic kidney cancer. It is during this hour when our fellowship group text flashes with puns and complaints. I send a few memes. I survey the room for smirks. Eventually, it’ll all be immunotherapy. I think that was the conclusion of the lecture. I promise myself that I'll re-review the PowerPoint slides in a few weeks once I’m on my elective.

It’s time to run the list with the residents. We have many consults to call and outpatient oncologists to touch base with. I begin my first email:

Dear Doctor: Your patient is unfortunately admitted with new-onset ascites. Her scans suggest disease progression. We have shared the bad news. We hope to tie in a few things before discharge to prep for your next visit with her and her family. Let us know if there is anything else you’d like us to coordinate while she is admitted. social work and palliative care have been by to see her. Thank you.

I wonder how many of these emails it took before bad news became routine for me. At some distant time, the suffering of both patient and family was palpable. I can’t remember when that feeling went away.

I start revisiting the patients with whom we did not have a chance to truly engage. The next hour will be the only time in my day where I am not discussing medicine. Following the advice of a mentor, I primarily engage with patients about their grandchildren, favorite movies, places to travel, and the glory of ice cream. I wish the residents had the time to join; instead, they are plagued with progress notes.

I wonder how my wife is doing. She’s at home and a few weeks pregnant with our first child. We haven’t had a chance yet to visit family and share the good news.

I send her a text. She has been waiting to hear from me and sends a warm note back. She asks if I’ll make it home in time for dinner. I check with the charge nurse who confirms no beds for admissions today. I text back, “I think so.”

I walk back to the call room and prepare for the handful of patients I will be seeing in clinic tomorrow. I then realize I forgot about Ms Jones, the new patient admitted last night. She is 85, lives alone, and lacks resources. All her children live on the West Coast. Her performance status is poor. She was too sick to discuss her condition in depth on rounds this morning, so I promised to come back later.

I pull a chair into her room to start our second visit and try to follow the script I’ve been taught. “Good afternoon, Ms Jones. I wanted to check in and see how you’re feeling. I know we didn’t get a chance to talk this morning. I’m all yours for the next few minutes before I have to circle back and check in with the team.”

Selfishly, I am trying to keep this brief, hoping to finally be home for dinner.

“Doctor,” she starts with a smile, “I may be an old lonely lady, but I know how this works. All of the faces this morning suggested this was going to be my last visit to the hospital. I don’t need to be here. Let someone else have this bed. I’ve lived a good life.”

Years ago, at my medical school graduation, I received a reward for humanism. My classmates voted me as the person they’d like to care for their ailing loved ones. Is this who they expected me to be?

Today, I’ve fielded numerous consults. I learned the second- and third-line therapies for what was once a lethal cancer with few options. I supervised and taught our amazing residents. I shared research plans with my mentor. I prepared for journal club. I gave advice to my favorite social worker about where to eat in Italy. Yet I blew off the few minutes that truly mattered.

Later that day, after signing out, I returned to see Ms Jones. She was still smiling, and it seemed as if she knew I’d return. She was ready to speak and I to listen.

After nearly a year, the experiences with patients are what truly matter in oncology training. We all want to learn how to treat, but it is more important to teach yourself to care. First-line treatment may change over time, but what remains constant is this: Patients are our greatest teachers. They want to live normal lives. And they put their trust us—even when we are not deserving.

This article was written by Ramy Sedhom, MD, a Hemotology/Oncology Fellow at Johns Hopkins University School of Medicine.

Ramy Sedhom, MD, looks back on his first year of oncology fellowship and shares advice for first-year fellows and trainees.

Something Good Happened Today: An Oncology Fellow Reflects

A pair of fellows will be able to advance their innovative technology-based projects thanks to the 

 Innovation Challenge: Innovative Technology in Cancer Care.

Juliet Wolford, MD, a gynecologic oncology fellow at the University of California, Irvine (UC Irvine), won the top prize of $15,000 for her proposal to construct 3-D-printed speculums in Tanzania. Francesco Maura, MD, a fellow in the myeloma service at Memorial Sloan Kettering Cancer Center, took second place and $7500 for his plan to develop a machine learning approach to quantify a patient’s risk for melanoma and likely response to treatment.

“I was very impressed that our top 2 winners were fellows,” said Reshma Mahtani, DO, one of the judges for the challenge and an associate professor of medicine at the University of Miami’s Sylvester Comprehensive Cancer Center, in Florida. “It just speaks to where we’re headed [in cancer care] and how bright our future is.”

The Innovation Challenge charged contestants with combining technology and oncology to create a product to improve clinical practice and/or patient outcomes. Participants uploaded their proposals to the OncLive.com website, and visitors could vote for their favorite project. Six finalists were then invited to give a 5-minute presentation, which was followed by a 5-minute question-and-answer session, via online video. All contestants were rated on a 5-point scale for originality, creativity, rationale, and appropriateness.

Wolford proposed using 3-D printers to construct speculums to screen and treat cervical cancer in low-resource nations. Patients in wealthier countries typically go through a 3-step screening and treatment process. A woman first receives a pap smear. If the pap smear is abnormal, she returns for a colposcopy. If the colposcopy finds evidence of grade ≥2 cervical intraepithelial neoplasia (CIN), a precancerous condition on the uterus, the patient returns for treatment.

“That is way too cumbersome for a low-resource setting,” Wolford said.

Healthcare systems in countries that don’t have access to the human papillomavirus vaccine or pathologists to analyze pap smears or biopsy specimens often use visual inspection with acetic acid, a screening and treatment program endorsed by the World Health Organization. If the visual inspection shows any evidence of abnormality, the woman is treated during that visit.

“It’s 1 visit, 1 speculum. You’re screening and treating them,” she said.

The other problem is that speculums can be hard to come by in African nations. UC Irvine physicians tried to bring the devices to the university’s 2 healthcare clinics in Tanzania, but they were confiscated by government agents. “You have to go [through] this approval process to get them back, and [you have to] pay fees, so it ends up being a long process,” Wolford said.

Most of her prize money will go toward getting 3-D printers into those clinics. In the pilot study, investigators used filament that cost $25/kg. The speculums cost about $2.34 apiece to make, including the cost of the $350 printer.

Wolford said she would like to work with ReFab Dar, a global nonprofit that has developed a system to recycle waste plastic into 3-D printer filament, to keep costs down. ReFab Dar is established in Tanzania, where filament can cost as much as $80/kg, including shipping costs from China. Ultimately, she wants to see local providers create their own filament from recycled plastic as well as a self-sustaining system for printing any medical tool.

Mahtani called the project “spot-on” for improving access and outcomes for patients, and praised Wolford for the proposal’s originality.

“Instead of using things that we would have normally thought of as technology, like an app or some sort of computer-based algorithm, she used a 3-D printer,” Mahtani said. “That’s clearly technology and that’s something that I’m hearing about from my kids because it’s in their school.

“I was blown away. I said, ‘Wow. I would have never thought of that.’ It was really, really original,” she added. “This project was intended to use technology to improve outcomes for patients with cancer, and this fulfilled that criteria so clearly, and she presented it so eloquently and with such passion that it was an easy choice.”

Harnessing Artificial Intelligence to Improve Care

Maura said he recognized the value of next-generation sequencing (NGS), particularly whole genome sequencing, while working on the Wellcome Sanger Institute’s Cancer Genome Project. NGS, he said, can decipher the biology and pathogenesis of different hematological cancers and improve current clinical practice.

The combination of cancer genomic background and patient performance status are the key elements to define the best treatment option and predict clinical outcome. Maura noted that multiple myeloma survival has dramatically improved over the last several years thanks to the introduction of several novel agents, and physicians need to develop accurate models that can predict outcomes and support therapeutic decisions.

He developed a machine-learning algorithm to create an estimated quantitative risk assessment for each patient. The algorithm also can identify which patients are most likely to benefit from a certain treatment, thereby increasing efficacy and reducing toxicity.

“Physicians are struggling to learn how to prognosticate for patients,” Mahtani said. “This algorithm took different chromosomal abnormalities and mutations that were present in patients with multiple myeloma and was able to give the physician caring for those patients a retrospective look at how that patient may do.”

Judges were looking for ideas that could be implemented sooner rather than later, and both projects should be ready to go within a matter of months. “These monies, we really wanted to see [them] going to immediate use rather than going into a fund for use years later,” Mahtani said.

A pair of fellows will be able to advance their innovative technology-based projects thanks to the OncLive® Innovation Challenge: Innovative Technology in Cancer Care.

Fellows Take Top Prizes in OncLive Innovation Challenge

About 20% of fitness apps reviewed in a recent study were deemed appropriate for survivors of cancer, showing that they could be an effective tool in helping this population increase physical activity. Investigators from the University of Surrey in the United Kingdom and Spain’s Universidad de Oviedo said that, based on these data, physicians could recommend such apps to their patients.

Lead author Rubén Martín Payo, PhD; along with coauthors Jenny Harris, MSc, and Jo Armes, PhD; evaluated 67 free fitness apps available for iOS and Android for their suitability for use by patients recovering from cancer and their ability to improve physical activity for these survivors. They did not recommend specific apps but concluded that roughly one-fifth of the fitness apps examined included information suitable for people affected by cancer, suggesting that such programs could be an effective tool in helping patients and survivors improve physical activity.

“We think that it’s difficult to say what’s the best app or what’s the ideal app,” Armes, a reader in cancer care and lead for digital health at the University of Surrey, said in an e-mail. “As we concluded, apps should be selected based on the needs and preferences of the individual. Specifically, people affected by cancer have some needs that people without the illness don’t have.”

The apps most successful at inducing change in health-related behaviors focused on aerobic-based activities and tended to include goal setting, monitoring, and feedback.

“Clinicians are often hesitant to recommend fitness apps to help cancer survivors increase physical activity levels, as they are unsure of the quality and suitability of the information provided,” Harris, a research fellow at the School of Health Sciences at the University of Surrey, said in a news release. “Our ongoing research in this area has found that there are suitable fitness apps to help increase activity levels, and this will help equip clinicians with the knowledge and confidence in prescribing them, helping patients to benefit from the positive impact of physical activity.”

Guidelines issued by the American Cancer Society (ACS) in 2012 advise “healthy weight management, a healthful diet, and a physically active lifestyle” for long-term survivors to prevent recurrence, second primary cancers, and other chronic diseases.

 The US Department of Health and Human Services recommends that adults with chronic conditions or disabilities, including cancer, should do 150 to 300 minutes a week of moderate-intensity physical activity or 75 to 150 minutes a week of vigorous-intensity aerobic physical activity.

Unfortunately, survivors aren’t always diligent about sticking with an exercise regimen. Investigators in the Yale Fitness Trial assessed adherence to the ACS guidelines among female cancer survivors who participated in an exercise intervention trial for 1 year. In data published in May 2019, Park et al found that adherence was only moderate even among “highly motivated” survivors. Physical activity levels improved among participants, but there was no significant change in adherence to weight, dietary, or alcohol intake guidelines.

The investigators said that fewer than 25% of cancer survivors meet physical activity guidelines. Not only will physical activity help improve the quality of life of survivors, it lessens their risk of developing new conditions, such as osteoporosis or diabetes, they added.

Debra Patt, MD, MPH, MBA, a breast cancer specialist and executive vice president at Texas Oncology, discussed the effect that obesity has on patients with cancer with 

, in October 2019. Excess weight can reduce the effectiveness of some therapies, she said, and clinicians need to encourage patients to eat healthy food and exercise to both improve outcomes and prevent recurrence.

“For many patients who undergo surgery for the treatment of cancer, recovery is much faster if they [exercise] and their cardiovascular health [improves],” she said. “What we see here is that diet, exercise, and physical fitness can influence cancer outcomes in many ways.”

There are limited real-world data available suggesting how patients can adhere with the fitness guidelines, and Payo, Armes, and Harris hypothesized that smartphone fitness apps could serve as a virtual exercise trainer to keep patients motivated and adherent. By providing clinical data, the authors hoped that oncologists would feel comfortable recommending these apps to their patients. Apps that required payment, those that required the use of wearable technologies, and apps with inappropriate content, such as negative body images, and/or unfounded claims of efficacy, were excluded.

The investigative team rated the apps using the Mobile App Rating Scale (MARS), which evaluates factors like engagement, functionality, aesthetics, and information, as well considerations such as awareness and knowledge. The apps were also assessed for behavior change techniques, such as goal setting and monitoring. Each factor was rated on a 5-point scale, with 5 meaning “excellent” and 1 meaning “inadequate.”

More than half the apps were available on both iOS and Android. Forty-six percent focused on a combination of aerobic/strength training or stretching, while 39% provided only aerobic training.

Compared with Android apps, the investigators found that iOS apps were more likely to try to change users’ attitudes toward improving their health. iOS apps were also better at encouraging users to seek further help to address changing attitudes toward improving health and performed slightly better in terms of content and quality.

“Our findings contribute to helping physicians and other health professionals to understand that apps are potential options to assist patients to increase their physical activity but not all the apps can be recommended for them,” Armes said. “In any case, more research and evidence are needed as this was a preliminary study.”

She added that the research team is working develop tools that effectively help health professionals and patients to choose physical activity apps. “Additionally, it is necessary to highlight the constantly changing nature of the apps markets, which requires regular re-evaluation of research findings,” she added.

Payo RM, Harris J, Armes J. Prescribing fitness apps for people with cancer: a preliminary assessment of content and quality of commercially available apps. 

. 2019;13(3):397-405. doi: 10.1007/s11764-019-00760-2.

Rock CL, Doyle C, Denmark-Wahnefried W, et al. Nutrition and physical activity guidelines for cancer survivors [erratum in 

. 2012; 62(4):242-274. doi: 10.3322/caac.21142.

Department of Health and Human Services. Physical activity guidelines for Americans. HHS website. hhs.gov/fitness/be-active/physical-activity-guidelines-for-americans/index.html. Published February 1, 2019. Accessed October 29, 2019.

Park SH, Knobf MT, Kerstetter J, Jeon S. Adherence to American Cancer Society guidelines on nutrition and physical activity in female cancer survivors: results from a randomized controlled trial (Yale Fitness Intervention Trial). 

. 2019;42(3):242-250. doi: 10.1097/NCC.0000000000000602.

Patt D, Rosenberg J. How obesity affects cancer treatment—and how to talk with patients about prevention. 

About 20% of fitness apps reviewed in a recent study were deemed appropriate for survivors of cancer, showing that they could be an effective tool in helping this population increase physical activity. 

Fitness Apps Could Help Cancer Survivors Become More Active

As oncologists, we try to remain both optimistic and realistic in patient care, but clearly, our tendency to “hope for the best and prepare for the worst” may affect our judgment and objectivity. Karnofsky Performance Status (KPS) and ECOG performance status (PS) alone leaves a lot to be desired for the practicing oncologist and as a community, we can improve upon this measurement with the routine incorporation of patient-reported outcomes (PROs).

KPS and PS are physician-synthesized compilations of a patient’s symptoms, self-care ability, symptom burden, and mobility. PS is evaluated at each oncology clinic visit and used as a tool to quantify a patient’s physiologic reserve and level of function. Thus, PS is an important element in routine clinical practice, guiding cancer treatment recommendations and determining eligibility in clinical trials.

Oncologists employ PS rigorously to determine prognosis. Data suggest that an individual’s PS is likely a more accurate prognostic indicator than biologic age, medical comorbidities, or even cancer stage.

This was nicely demonstrated in a single institution study performed in Canada, where 10 physicians determined ECOG, KPS, and the Palliative Performance Scale scores at the end of an initial consultation for 1655 patients and then developed a simple prognostic model using PS. Survival analyses using the Kaplan-Meier method demonstrated a significant decline in median overall survival (OS) for each worsening performance level, with a median OS of 293, 104, and 25.5 days for ECOG 0, ECOG 2, and ECOG 4 patients, respectively.

Unfortunately, a static, subjective assessment of a patient in cancer clinic is not likely representative of longitudinal function. Previously published data demonstrated significant interobserver variability in the measurement of PS, with oncologists assigning higher PS scores than patients did at the same time points.

I have experienced this phenomenon in the thoracic oncology clinic during my fellowship. After obtaining what I thought was a thorough clinical history, the patient and I were given the same PS questionnaire. I assigned them an ECOG 1 and they self-assigned an ECOG 2. Incorporating PROs may be a way to address the disconnect in opinion between patient and physician.

In 2004, the National Institutes of Health developed the Patient-Reported Outcomes Measurement Information System (PROMIS) to validate PROs for use in both clinical oncology practice and clinical research. The PROMIS profile domains focus on physical health measures such as fatigue, physical function, pain intensity, pain interference, and sleep disturbance; mental health measures such as anxiety and depression; and social health measures such as the ability to participate in social roles and activities.

Patient self-reported outcomes may more accurately reflect an individual’s physical functioning and wellbeing because they are not subject to physician interpretation and bias, which can occur in a time-limited visit. Previous research demonstrated that incorporating PROs improves physician-patient communication, symptom awareness and management, and patient quality of life.

Additionally, a systematic review found that when PRO measures were routinely collected at the clinic, physicians were more likely to discuss patient outcomes during consultation visits. These discussions facilitated an increased number of supportive care referrals, improvements in patient satisfaction, and improved healthcare usage at end of life.

Implementation of PROs in the academic oncology practice can reduce emergency department visits and hospitalizations, and may even extend OS.

 A single institution study at a tertiary cancer hospital demonstrated the feasibility and success of PRO implementation in 766 patients with advanced cancer.

 Nurses were notified via email if a patient in the PRO intervention group reported a worsening or severe symptom, which resulted in clinical interventions such as new prescriptions, dose modifications, counseling, or referrals for symptom management.

The PRO group participants saw a 5-month improvement in median OS compared with the usual care group (31.2 vs 26 months; 

 = .03). These findings were both statistically significant in multivariate analysis (HR, 0.83; 

At Huntsman Cancer Institute, we performed a retrospective pilot study evaluating the 5 PRO domains— physical function, pain interference, fatigue, anxiety, and depression&mdash;at a single time point within 6 months of a diagnosis of metastatic melanoma or non—small cell lung, breast, or colorectal cancer.

On multivariate regression, we found that patientreported physical function was strongly correlated with both hospitalization-free survival and OS.

We can use this information to refer patients with metastatic cancer who report poor physical function to ancillary services such as physical and/or occupational therapy and palliative care services for early intervention. We hope that, given the high economic and emotional costs associated with hospitalization in patients with cancer nearing the end of life, prospective PRO data collection can identify declining patients at an earlier time point so that we may intervene to prevent hospitalization.

In recent years, there has been a growing interest in PROs within the oncology community. The National Cancer Care Network (NCCN) created a PRO/electronic health record (EHR) work group to develop PRO best practices and implementation strategies. Unfortunately, there have been challenges to incorporating the data into the EHR.

The results of a recently published national survey showed significant practice variation in the specific PRO measures collected, instruments used to gather PROs (66% of PROs were collected on something other than the practice EHR), and timing and frequency of PRO collection.

 At present, the field lacks a complete understanding and a standardized strategy on how to best obtain PRO data and then incorporate it into the clinical workflow for daily use.

Until the oncology community is willing to measure PROs and follow standardized guidelines on implementation, the onus will be on the individual practitioner to collect these data. When available, PROs should be incorporated into the oncologist’s treatment decision making and help guide both referrals to ancillary support services for symptom management and end of life care.

PROs can help support the oncology care provider’s assessment of patient PS to guide treatment decision making, supportive care interventions, and estimations of prognosis. In the future, PROs may supplant PS as the most important prognostic factor in cancer patients. Continued research efforts and buy-in from organizations like the NCCN will be important to develop best practices and confirm the benefit of PRO measurement in the oncology practice.

This article was written by Katie Kerrigan, DO, Hematology & Hematology Malignancies/Oncology Fellow, Huntsman Cancer Institute at the University of Utah. 

West HJ, Jin JO. Performance status in patients with cancer. 

. 2015;1(7):998. doi: 10.1001/jamaoncol.2015.3113.

Jang RW, Caraiscos VB, Swami N, et al. Simple prognostic model for patients with advanced cancer based on performance status. 

. 2014;10(5):e335-e341. doi: 10.1200/JOP.2014.001457.

Sørensen JB, Klee M, Palshof T, et al. Performance status assessment in cancer patients. An inter-observer variability study. 

. 1993;67(4):773-775. doi: 10.1038/bjc.1993.140.

Ando M, Ando Y, Hasegawa Y, et al. Prognostic value of performance status assessed by patients themselves, nurses, and oncologists in advanced nonsmall cell lung cancer. 

. 2001;85(11):1634-1639. doi: 10.1054/ bjoc.2001.2162.

Velikova G, Booth L, Smith AB, et al. Measuring quality of life in routine oncology practice improves communication and patient well-being: a randomized controlled trial. 

. 2004;22:714-724. doi: 10.1200/JCO.2004.06.078.

Kotronoulas G, Kearney N, Maguire R, et al. What is the value of the routine use of patient-reported outcome measures toward improvement of patient outcomes, processes of care, and health service outcomes in cancer care? a systematic review of controlled trials. 

. 2014;32(14):1480-1501. doi: 10.1200/ JCO.2013.53.5948.

Basch E, Barbera L, Kerrigan CL, Velikova G. Implementation of patient-reported outcomes in routine medical care. 

Basch E, Deal AM, Kris MG, et al. Symptom monitoring with patient-reported outcomes during routine cancer treatment: a randomized controlled trial. 

. 2016;34(6):557-565. doi: 10.1200/JCO.2015.63.0830.

Basch E, Deal AM, Dueck AC, et al. Overall survival results of a trial assessing patient-reported outcomes for symptom monitoring during routine cancer treatment. 

. 2017;318(2):197-198. doi: 10.1001/jama.2017.7156.

Zhang B, Lloyd W, Jahanzeb M, Hassett MJ. Use of patient-reported outcome measures in quality oncology practice initiative-registered practices: results of a national survey. 

. 2018;14(10):e602-e611. doi: 10.1200/ JOP.18.00088.

Stukenborg GJ, Blackhall LJ, Harrison JH, Dillon PM, Read PW. Longitudinal patterns of cancer patient reported outcomes in end of life care predict survival. 

. 2016;24(5):2217-2224. doi: 10.1007/s00520-015-3024-y.

Patel SB, Akerley WL, Ose D, et al. Prognostic value of patient-reported outcomes (PROs) in advanced cancer. 

. 2018;36(suppl 30; abstr 8). doi: 10.1200/JCO.2018.36.30_suppl.8.

Chastek B, Harley C, Kallich J, Newcomer L, Paoli CJ, Teitelbaum AH. Health care costs for patients with cancer at the end of life. 

. 2012;8(6):75s- 80s. doi: 10.1200/JOP.2011.000469.

Karnofsky Performance Status and ECOG performance status alone leaves a lot to be desired for the practicing oncologist.

Incorporating PROs Can Improve Patient Care and Outcomes in Oncology

I recently attended a CV writing workshop where the male speaker discussed how it helps to include personal information to provide your interviewer with a glimpse of who you are outside of work. He spoke about how he personally writes a blurb about being a father and how talking about his children has been a great ice-breaker in many interviews. A female colleague said she would be hesitant to do the same for fear of being judged as someone less devoted to work, pointing out that women’s discussions about their home lives provoke different reactions and are associated with various biases.

Over the years, many of my colleagues have made similar statements. I distinctly remember a conversation with a friend who was told that her pregnancy was “ill-timed” and would mark the “end of her career.” Many of my colleagues have voiced frustrations about vague, nonconstructive performance evaluations with scathing remarks that were not backed by any objective findings. As women, we, unfortunately, face obvious discriminatory behaviors and not-so-obvious microaggressions in our careers.

It is true that we have come a long way since 1847 when Elizabeth Blackwell, MD, was accepted into Geneva Medical College—an incident that began as a prank but that culminated in the long-delayed inclusion of women in medicine. Dr Blackwell, inspired by the death of a close friend who said her suffering would have been much alleviated if her care had been provided by a female physician, decided to apply to medical schools. As a joke, the all-male student body at Geneva voted “yes” to her application, assuming she would never join their ranks. In 1849, against all odds, Dr Blackwell was the first woman to receive a medical degree from a US medical school, paving the way for all of us who follow in her footsteps.

In 2017, for the first time in US history, more women (50.7%) than men entered medical schools. Women now make up an estimated one-third of US physcians.

 assessing outcomes for elderly hospitalized patients showed that female internists tended to use more patient-centered communication and provide more preventive care, and were more likely to adhere to clinical guidelines than their male counterparts.

The difference in clinical practice may translate into a difference in patient outcomes. The investigators concluded that patients treated by female internists had lower mortality and fewer readmissions.

Despite the strides made by women over the past 170 years, significant disparities remain, especially in academic medicine. Medical education literature has looked at bias during evaluation of female trainees, including polarizing and contradictory feedback and preconceived notions regarding how women are expected to conform to certain stereotypes.

Many institutions report the “leaky-pipeline” phenomenon, in which women faculty drop out at earlier professional levels, leading to their underrepresentation in advanced leadership positions. This talent drain has been attributed to conflicts between work and family responsibilities, disparities in recognition of efforts, inequalities in promotion opportunities, and lack of mentorship.

More recently, results from a survey of sexual harassment and gender disparities among gynecologic oncologists were presented at the 2019 American Society of Clinical Oncology (ASCO) Annual Meeting. Lead author Marina Stasenko, MD, a clinical fellow in gynecologic oncology at Memorial Sloan Kettering Cancer Center, and colleagues found that 71% of female respondents reported experiencing some form of sexual harassment during their training including sexist, offensive remarks; unwanted sexual advances; and being asked for sexual favors in exchange for academic advancement.

Although respondents said there was a workplace policy on how to report this behavior, most did not report the incidents due to fear of reprisal or concern of nonaction. Furthermore, women reported being denied opportunities for training and career advancement and receiving lower performance evaluations compared with their male peers, solely based on gender.

Nevertheless, it is an incredibly exciting and rewarding time to be a female oncologist, and awareness is growing about the unique challenges we face. Institutions are now openly acknowledging the gender gap and implementing various corrective initiatives, such as increased transparency regarding hiring decisions and professional advancement, ensuring a more equal representation of women in various committees, and education regarding unconscious biases that may be at play.

As a hematology/oncology trainee and early career physician, here are a few resources I personally find helpful:

Both the American Society of Hematology and ASCO have championed initiatives dedicated to improving diversity and inclusion in the hematology/oncology workforce. Each organization's annual meeting includes unique networking opportunities for women. Furthermore, special funding is available through Women Who Conquer Cancer, a program run by the ASCO Foundation nonprofit Conquer Cancer, that offers grants to young women researchers and clinical investigators to support their academic careers.

Social media has become a powerful tool for connection, with both Facebook and Twitter serving as forums to connect women, providing support and networking at all stages of your career.

Join your local women in medicine group. Most institutions have one. If you can’t find one, then consider starting one. Such groups provide space to discuss challenges and explore solutions with your colleagues, forge friendships, and create an invaluable support system.

Finally, remember to always pay it forward. No matter where you are in your career, there is always someone more junior who can use a mentor. An empowered woman can empower other women. Many professional societies, including ASCO, have a formal mentoring program, which is a great way to get involved.

As the saying goes, “Behind every successful woman is a tribe of other successful women who have her back.” Not only is that true, but it is imperative that our male colleagues also acknowledge our unique obstacles and take active steps to correct deeply ingrained biases and create a more collaborative and inclusive environment. It is essential that we, women and men, support each other in overcoming the gender disparity that still exists in our field and help pave the way for the incoming generation of women in oncology.

This article was written by Inas Abuali, MD, FACP, Hematology/Oncology—PGY5 University of Cincinnati Medical Center.

Markel H. How Elizabeth Blackwell became the first female doctor in the U.S. 

 website. to.pbs.org/1JZfCbg. Published January 23, 2014. Accessed October 15, 2019.

More women than men enrolled in U.S. medical schools in 2017 [news release]. Washington, DC: Association of American Medical Colleges; December 18, 2017. news.aamc.org/press-releases/article/applicant-enrollment-2017/. Accessed October 15, 2019.

Tsugawa Y, Jena AB, Figureroa JF, Oray EJ, Blumentha DM, Jha AK. Comparison of hospital mortality and readmission rates for Medicare patients treated by male vs female physicians. 

. 2017;177(2):206-213. doi: 10.1001/ jamainternmed.2016.7875.

Sklar, DP. Women in medicine: enormous progress, stubborn challenges. 

. 2016;91(8):1033-1035. doi: 10.1097/ACM.0000000000001259.

Stasenko M, Tarney CM, Veith M, et al. Survey of sexual harassment and gender disparities among gynecologic oncologists. 

. 2019;37 (suppl; abstr LBA10502). ascopubs.org/doi/abs/10.1200/JCO.2019.37.18_suppl.LBA10502?af=R.

Despite the strides made by women over the past 170 years, significant disparities remain, especially in academic medicine. 

December 2019 | Oncology Fellows

Taking the Fast Track to Independence in Oncology

Something Good Happened Today: An Oncology Fellow Reflects

Fellows Take Top Prizes in OncLive Innovation Challenge

Fitness Apps Could Help Cancer Survivors Become More Active

Incorporating PROs Can Improve Patient Care and Outcomes in Oncology

Conditions Are Better for Women in Oncology But More Work Needs to Be Done