Most patients with cancer fear the word “hospice.” It marks the “end of the road” and is to be avoided at all costs. Because of this misconception, which also affects physicians, many patients with cancer use excess hospital care and intensive care services at the end of life. Acute hospitalization accounts for nearly half of Medicare spending for patients with advanced cancer.

Introduced in the United States more than 40 years ago and added as a Medicare entitlement in 1982, hospice is the model for compassionate care for people in the last 6 months of life.

 Providing expert medical care, pain management, and emotional support, the goals for hospice care include promoting comfort and dignity, rather than prolonging life, and providing support for the patient’s family.

Although more than 1.4 million individuals in the United States received hospice care in 2016, patients with cancer made up only 27% of this group. Patients spend just a median of 19 days in hospice care.

Physicians will recommend hospice countless times while caring for patients with cancer. As much as patients are alarmed by this topic, we also dread these conversations. Although some of my patients receiving chemotherapy accept palliative care and have heard about hospice multiple times, it is still heartbreaking for both of us when I can no longer recommend therapeutic agents and instead recommend hospice care.

When I started my fellowship, my mentors told me I would become more comfortable with death and dying as I observed experienced providers and worked with my own patients. However, it was not until my second year of fellowship when I got the experience I needed all along: I visited my patient and her family in a hospice facility.

LS was a lovely middle-aged woman with stable pancreatic cancer and on her third line of chemotherapy when she was diagnosed with pneumonia in July 2017. She was treated with antibiotics and supportive measures at her local hospital. I assumed she would beat the infection, but her condition sounded worse every time I talked with her husband.

The antibiotics didn’t work, and she developed a blood stream infection. She became so confused that she could no longer communicate with us. Ultimately, her in-patient team and I recommended hospice. Her husband chose a facility close to their home.

As residents and fellows, we might have some experience with hospice. However, oncology trainees rarely, if ever, visit an off-site hospice facility, even though that is often what we recommend for our terminally ill patients. I had never been to a hospice facility, but I felt compelled to see LS. I was not at peace over her imminent and unexpected death.

On my Saturday off, I drove 30 minutes to visit LS. As I pulled up to the hospice facility, I was surprised by its homey appearance. Nonetheless, I still expected to walk into a bleak environment full of devastated patients. Inside, LS’s husband rushed toward me. He gave me a hug and whispered, “Dr Jenni, thank you so much for coming.”

He directed me to the communal space and introduced me to several close family members. Each person embraced me, told me that they had heard so much about me, and thanked me for caring for LS.

Sitting around a large table, they told me about their long travels to be there. They shared food and stories about LS. I discovered her quirks and her accomplishments, and I saw how deeply she was loved. As our conversations came to a close, her husband and I separated from them so that I could see LS.

As I walked into her room, I noticed the warm color of the walls. The wood panels were a pleasant contrast to the sometimes-bland hospital. She even had a sliding door leading to a small garden.

Immediately upon seeing LS lying in bed, I felt my eyes well up with tears. I was disappointed with myself and wondered how I could have prevented her current situation. The what-ifs built up quickly, but I never voiced them.

My heart felt heavy knowing that I would never again be greeted with her kind smile or hear her sweet laugh and gentle voice. Although she did not respond to words, her husband placed his head next to hers and said, “Dr Jenni’s here to see you.”

Sitting at her bedside and holding her hand, I told her how much I loved meeting her loved ones and seeing them gathered together. I recounted our year-long treatment journey and told her how blessed I was to know and care for her. I gave her one last hug.

Outside the room, her husband squeezed me a bear hug and thanked me again. As he started crying, the tears that I had held back rolled down my face. After some silence, I wanted to address our unspoken guilt and emptiness.

 chose hospice care for her and gave her the opportunity for family to come together in a beautiful and peaceful place to honor her life,” I said.

I shared this experience with my co-fellows, as it enriched my understanding of hospice and reshaped my conceptions of end-of-life care. For all my subsequent patients, my experience helped me better address their anxieties and uncertainties. Knowing what hospice is, is one thing; experiencing it is another.

I do not know many doctors have visited their own patients in hospice, but I’m grateful I was able to have this experience early in my career—the countless patients I’ll care for in the future will benefit. Oncologists develop an intimate trust with our patients that is forged through countless clinic visits over months or years. We owe it to them to be as informed as possible about each option we recommend. I am thankful to LS for teaching me to celebrate little victories, cope when our treatments fail, fill a life with loved ones, and die in peace.

Brooks GA, Li L, Uno H, Hassett MJ, Landon BE, Schrag D. Acute hospital care is the chief driver of regional spending variation in Medicare patients with advanced cancer. 

. 2014;33(10):1793-1800. doi: 10.1377/ hlthaff.2014.0280.

National Hospice and Palliative Care Association. History of hospice care. nhpco. org/history-hospice-care. Updated March 28, 2016. Accessed May 10, 2019.

Torpy JM, Burke A, Golub RM. Hospice care. 

. 2012;308(2):200. doi: 10.1001/ jama.2012.6210.

National Hospice and Palliative Care Organization. NHPCO’s facts and figures: hospice care in America [press release]. Alexandria, VA: National Hospice and Palliative Care Organization; April 2018. https://www.nhpco.org/hospice-statisticsresearch- press-room/facts-hospice-and-palliative-care. Accessed August 29, 2018.

Articles

Due to the misconception surrounding "hospice," many patients with cancer use excess hospital care and intensive care services at the end of life. 

Oncology Fellow Focuses on Compassionate End-of-Life Care

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

The path to becoming a physician is a long and often surprising one. There is, of course, the actual process of applications, tests, and learning the mechanics of taking care of patients. But I would argue that identifying a specialty that allows for personal and professional happiness should be a major point of discussion starting early in a physician’s career.

Entering medical school, we all have a general concept of what we want to do, whether it’s practicing in the community or conducting research in an academic setting. But life, as they say, happens when you’re making other plans. Despite the blueprint, things often change, and with every decision, the changes can be quite significant. We may go from dreaming of surgery to pediatrics or from picturing an illustrious career in academia to working in a rural private practice.

Why? Because each step on the long path of medical training impacts the next step. We change our priorities. We unexpectedly fall in love with a specialty. We recognize surgery isn’t for us. We have life-changing events. We don’t score as high as we would like on a test, and on and on.

Some of the “whys” are beyond our control. Other things we do not recognize as important until later. In my opinion, there are 2 major ways to combat the loss of opportunities or to respond to a unplanned twist in your career path: First, identify strong mentors. Mentors are exceptionally important as we home in on our ultimate goals, but they also provide guidance and sage advice. A mentor can help you think through big picture decisions or, at the completion of your fellowship, provide crucial insight for contract negotiations and help you identify the nuances that separate a job that is the right fit from one where you will struggle to have success.

The second way to respond to life’s surprises is through preparation. Identifying training opportunities that provide the exposure and training to fulfill your goals is exceptionally important. This is true not only if you have your heart set on a certain specialty or subspecialty, but also if you are unsure about the path of your life and career.

I didn’t always picture myself as a physician. Growing up, I thought I would be a sports broadcaster. As I got older, however, I realized that being a doctor would be an unbelievable honor. Working with patients and providers, building relationships, and pursuing scientific knowledge make being a doctor an amazing career.

Entering medical school, I could rattle off the handful of specialties I had interest in. I was exposed to anatomy, and surgical specialties took priority. I experienced training as an OB/GYN and found I could easily visualize a career rushing to a delivery at lunch time or being in the clinic one day and the operating room the next. I could see myself taking care of patients throughout their lives. I was fortunate to match into obstetrics/gynecology at The Ohio State University, which exposed me to subspecialties of that field, and provided amazing generalist training.

This is where I found my true calling: taking care of women with cancer, with performing complex surgeries, and providing comprehensive medical care. This was not the path I had expected, but the opportunity was there and the experience made me realize this was the career for me. I identified mentors who provided the guidance required to make these complicated decisions and to assist in positioning myself for a career.

After matching into my gynecologic oncology fellowship, I recognized along the way that I wanted to pursue an academic career. My future as a generalist community OB/GYN in Florida, where I grew up, was no longer the plan. I threw out that blueprint and drew a new one. Soon, I will be starting an academic gynecologic oncology position in Ohio, a situation I never would have imagined, even through medical school.

I am so fortunate that the pieces have fallen into place to allow me to have the career that I could never have envisioned. I wonder how any small step in a different direction could have changed everything; acceptance into a different OB/GYN clerkship or working with different residency faculty could have sent me in a different direction. These pieces came together, though, because each individual step not only shaped what my goals and desires were, but also provided the resources to fulfill them.

Identifying a specialty that allows for personal and professional happiness should be a major point of discussion starting early in a physician’s career. 

The Path We Pave and the Bricks We Use: An Oncologist's Career Journey

Obesity influences the development and management of gynecologic cancer through several mechanisms, including hormonal, inflammatory, and metabolic pathways. Prospective data demonstrate a significantly increased risk of mortality from cancers of the breast, uterus, cervix, and ovary in women who are considered obese.

 With nearly 40% of the adult population in the Unites States classified as obese (body mass index [BMI] ≥30kg/m

), gynecologic oncologists must be ready to address the specific needs and considerations for this population, including for patients who have entered survivorship.

Addressing modifiable risk factors for recurrence is the crux of survivorship goals following primary cancer treatment. Patients must be counseled regarding the known risks of obesity in the setting of a malignancy diagnosis. Nonobese women with endometrial cancer have better survival rates than obese women.

 Therefore, interventions aimed at addressing risk factors for cardiovascular disease will likely have greatest potential to improve survival in women with endometrial cancer, particularly low-grade and early-stage disease.

Patient education is key to successful survivorship. In a survey of 1500 healthy women, nearly 60% were not aware that obesity increased the risk of developing endometrial cancer.

 In another survey, only 53.5% of women with endometrial cancer were aware that obesity was a factor in the development of their disease.

Further, only 37% of patients report that their healthcare provider discussed the relationship between their obesity and development of gynecologic malignancy.

 In a survey of 450 gynecologic oncology providers, 40% reported feeling that they had adequate preparation to counsel patients on weight loss strategies, but only 11% of responders reported receiving formal training in obesity management, most often from conference lectures or self-directed reading.

 Women’s health providers must be poised to advise and support women on obesity’s relationship to cancer development and recurrence. Within this dialogue must be a discussion of tangible strategies to attain sustainable weight loss, including lifestyle changes, pharmacologic interventions, and bariatric surgery.

The Physician’s Role in Patient Counseling

Clinical evidence consistently shows that patients who receive directed counseling from physicians are more likely to lose weight and use appropriate methods to do so.

 Many national cancer organizations promote obesity education and weight loss as a priority for effective cancer care. The American Society of Clinical Oncology has recommended the Assess, Advise, and Refer framework as an approach for providers to address obesity with their patients. Providers should take the following steps:

 the patient’s BMI at each office visit. Any BMI that is not within normal limits must be qualified and discussed with the patient.

 a patient considered obese on the associated reproductive health risks, such as malignancy, infertility, surgical complications, and high-risk pregnancy and preterm birth. Acknowledging these events as potential downstream effects of obesity can be a productive first step in increasing patient motivation and engagement in strategies for weight loss.

 the patient to weight loss management centers, community programs, or bariatric surgery consultation, particularly for the population classified as morbidly obese.

Lifestyle Changes and Weight Loss Programs

Providing even a small amount of directed nutrition and lifestyle counseling leads to significant changes in patient diet and weight loss. Williams et al reported that 5 physician-directed counseling sessions over 1 year can successfully result in weight loss for women.

 Additionally, community-based programs offer the required consistency and affordability for patients who are uninsured, underinsured, or who lack financial support. YMCA organizations, for instance, provide nutrition consultations in addition to fitness education across the country. For cancer survivors, Livestrong provides 12-week, small-group programming to increase healthy nutrition and physical activity through the YMCA. More novel payment structures are required to support these community-based programs, but such structures may offer more financial availability to patients needing to meet out-of-pocket costs.

For patients who need pharmacologic intervention, there are 2 categories of anti-obesity drugs: central acting appetite suppressants, or satiety enhancers, and peripherally acting agents. The FDA has approved 5 pharmacologic agents for weight-loss management: orlistat, lorcaserin (Belviq), phentermine/topiramate, naltrexone/bupropion (Contrave), and liraglutide. These agents have been approved for use in patients with a BMI ≥30 or in patients with a BMI ≥27 with 1 obesity-related comorbidity. These medications are available as prescriptions, and orlistat can be purchased over the counter.

Common adverse effects of these drugs include nausea, vomiting, and constipation, and education regarding drug-specific effects is required for safe medication management. For providers, these agents may be used as safe adjuncts to lifestyle modifications and close counseling to achieve demonstrable weight loss.

Bariatric surgery, which commonly includes Roux-en-Y gastric bypass, adjustable gastric banding, and sleeve gastrectomy, has been shown effective in both short-term and long-term patient outcomes. This surgery lowers all-cause mortality and reduces the cardiovascular and diabetic effects of obesity.

 A US retrospective cohort demonstrated a 60% decrease in cancer-related deaths following bariatric surgery, providing evidence of the correlation between obesity and cancer.

 Depending on the procedure type, weight loss typically ranges from 15% to 32% within the first 2 years following surgery and stable loss of 15% to 25% at 10 years.

Patients may qualify for bariatric surgery if they have BMI ≥40 without comorbidity or BMI ≥35 with one or more severe obesity-related diseases.

 In spite of these well-documented benefits to health and quality of life, fewer than 1% of qualified patients undergo bariatric surgery. For patients with gynecologic cancer, systematic reviews show that patients favorably view a weight loss discussion with their cancer care provider, and patients are more likely to consider or receive bariatric surgery if a physician referred them for consultation.

A coordinated multidisciplinary and systematic effort is required to address the prevention and treatment of obesity, as the sequela of this disease is a clear risk factor for the development of gynecologic malignancy and other comorbidities. Support for weight loss interventions and transparent patient education are paramount. This worldwide health problem is ever growing, and women’s healthcare providers must be ready to address the specific needs and considerations for this population.

Calle EE, Rodriguez C, Walker-Thurmond K, Thun MJ. Overweight, obesity, and mortality from cancer in a prospectively studied cohort of US adults. 

. 2003;348(17):1625-1638. doi: 10.1056/NEJMoa021423.

Arem H, Irwin ML. Obesity and endometrial cancer survival: a systematic review. 

. 2013;37(5):634-639. doi: 10.1038/ijo.2012.94.

Ward K, Shah NR, Saenz CC, McHale MT, Alvarez EA, Plaxe SC. Cardiovascular disease is the leading cause of death among endometrial cancer patients. 

. 2012;126(2):176-179. doi: 10.1016/j.ygyno.2012.04.013.

Soliman PT, Bassett RL, Jr, Wilson EB, et al. Limited public knowledge of obesity and endometrial cancer risk: what women know. 

. 2008;112(4):835-842. doi: 10.1097/AOG.0b013e318187d022.

Beavis AL, Cheema S, Holschneider CH, Duffy EL, Amneus MW. Almost half of women with endometrial cancer or hyperplasia do not know that obesity affects their cancer risk. 

. 2015;13:71-75. doi: 10.1016/j. gore.2015.07.002.

Clark LH, Ko EM, Kernodle A, et al. Endometrial cancer survivors’ perceptions of provider obesity counseling and attempted behavior change: Are we seizing the moment? 

. 2016;26(2):318-324. doi: 10.1097/ IGC.0000000000000596.

Neff R, McCann GA, Carpenter KM, et al. Is bariatric surgery an option for women with gynecologic cancer? Examining weight loss counseling practices and training among gynecologic oncology providers. 

. 2014;134(3):540-545. doi: 10.1016/j.ygyno.2014.06.006.

Nawaz H, Adams M, Katz D. Weight loss counseling by health care providers. 

. 1999;89(5):764-767. doi: 10.2105/AJPH.89.5.764.

Liu L, Segura A, Hagemann A. Obesity education strategies for cancer prevention in women’s health. 

. 2015;4(4):249-258. doi: 10.1007/ s13669-015-0129-8.

Williams LT, Hollis JL, Collins CE, Morgan PJ. Can a relatively low-intensity intervention by health professionals prevent weight gain in mid-age women? 12-month outcomes of the 40-Something randomized controlled trial. 

. 2014;4:e116. doi: 10.1038/nutd.2014.12.

Vojta D, Koehler TB, Longjohn M, Lever JA, Caputo NF. A coordinated national model for diabetes prevention: linking health systems to an evidence-based community program. 

. 2013;44(suppl 4[4]):S301-S306. doi: 10.1016/j. amepre.2012.12.018.

Schauer PR, Bhatt DL, Kirwan JP, et al; STAMPEDE Investigators. Bariatric surgery versus intensive medical therapy for diabetes—3-year outcomes. 

. 2014;370(21):2002-2013. doi: 10.1056/NEJMoa1401329.

Adams TD, Gress RE, Smith SC, et al. Long-term mortality after gastric bypass surgery. 

. 2007;357(8):753-761. doi: 10.1056/NEJMoa066603.

Sjostrom L, , Narbro K, Sjöström CD, et al; Swedish Obese Subjects Study. Effects of bariatric surgery on mortality in Swedish obese subjects. 

Mechanick JI, Youdim A, Jones DB, et al; American Society for Metabolic & Bariatric Surgery. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient — 2013 update: cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic and Bariatric Surgery. 

. 2013;21(suppl 1):S1-S27. doi: 10.1002/oby.20461.

Jernigan AM, Mauer KA, Cooper K, et al. Referring survivors of endometrial cancer and complex atypical hyperplasia to bariatric specialists: a prospective cohort study. 

. 2015;213(3):350.e1-10. doi: 10.1016/j. ajog.2015.05.015.

Funk LM, Jolles S, Fischer LE, Voils CI. Patient and referring practitioner characteristics associated with likelihood of undergoing bariatric surgery: a systematic review. 

. 2015;150(10):999-1005. doi: 10.1001/jamasurg.2015.1250.

With nearly 40% of the adult population in the Unites States classified as obese, gynecologic oncologists must be ready to address the specific needs and considerations for this population, including for patients who have entered survivorship.

June 2019 | Oncology Fellows

Oncology Fellow Focuses on Compassionate End-of-Life Care

Finding Your First Oncology Job: 10 Things You Should Know

The Path We Pave and the Bricks We Use: An Oncologist's Career Journey

Managing Obesity in Survivors of Gynecologic Cancer