“I am a veteran and a fighter—I will do anything so that the cancer doesn’t come back,” my patient said to me as I sat with him and his daughter in clinic to discuss his treatment options.

The resected tumor was a locally advanced squamous cell carcinoma of the lung with high-risk features, indicating a high likelihood of disease recurrence. Most guidelines would recommend adjuvant chemotherapy; in fact, his daughter did her own research on the Internet and came to the same conclusion.

As I shifted my focus from the tumor back to my patient, the benefits of treating him with chemotherapy became less clear. Although he was recovering well from surgery, he was a frail male octogenarian with multiple medical problems who required assistance with some of his activities of daily living and all of his instrumental activities of daily living.

I asked myself, “Are the expected benefits from adjuvant chemotherapy going to outweigh the risks in a patient with limited life expectancy and decreased tolerance of stress? Is a good Eastern Cooperative Oncology Group (ECOG) performance status enough to pronounce him fit for chemotherapy?”

This type of scenario is becoming increasingly more common in the United States. A demographic shift known as the “silver tsunami” makes it likely that the number of older patients with cancer will increase.

 Age itself is a known risk factor for developing cancer: it has been reported that a majority of cancer diagnoses and deaths occur in patients older than 65 years.

 By 2030, it is predicted that 70% of cancer diagnoses will be made in adults in this age group.

When making treatment decisions for older cancer patients, the challenge is in selecting the appropriate therapy for the appropriate patient. Age alone should not be used to preclude a patient from receiving the best available treatment. For this reason, the field of geriatric oncology was born.

The specific needs of older cancer patients are different from those of younger adults. Older patients are more likely to have significant comorbidities, disabilities, and geriatric syndromes. Physiological changes also occur with age, such as decreased creatinine clearance, impaired gas exchange, and decreased cardiac output.

 Unfortunately, there is a lack of high-quality evidence to help guide clinicians in selecting treatment, as the majority of cancer treatment clinical trials have excluded older patients.

Most oncologists use scoring systems such as the ECOG and Karnofsky score to determine performance status.5 Compared with these scoring systems, the Comprehensive Geriatric Assessment (CGA) is more sensitive in detecting functional impairments in older adults and can help with clinical risk stratification and individualized treatment planning. The CGA evaluates key domains that are predictive of morbidity and mortality risk in older adults. These domains include functional status, comorbid medical conditions, cognition, psychological state, current medications, social support, and nutritional status.6

The American Society of Clinical Oncology (ASCO) is recognizing the increasing importance of geriatric oncology and is playing a large role in promoting this field. There have been many presentations and educational sessions surrounding the field of geriatrics during recent ASCO annual meetings. Additionally, more funding has been provided to promote research and career development. Geriatric oncology is now being recognized in major journals such as the 

A cooperative group, the Cancer and Aging Research Group, has made many important contributions to the field, including the development of a tool to help gauge the likelihood of chemotherapy toxicity in older adults.

 Outside of the United States, the International Society of Geriatric Oncology has established task forces to help in making treatment recommendations. The society now has a peer-reviewed journal called the 

 The National Comprehensive Cancer Network also has specific guidelines that pertain to older patients with cancer.

Most hematology and oncology fellowship program directors agree that geriatric oncology should be incorporated into fellowship curriculums. However, only one-third of hematology and oncology programs formally cover topics related to geriatric oncology as part of their curriculum.

Therefore, it is clear that although an understanding of the needs of geriatric patients is vital to successfully treating cancer in adults, many hematology and oncology trainees will complete fellowship without any formal exposure to geriatrics.

How can fellowship programs be structured to provide greater exposure to and knowledge of geriatric oncology? Didactics aside, programs can subscribe fellows to ASCO’s Education Essentials for Oncology Fellows, which includes general modules on geriatric oncology and disease-specific modules.

Some medical centers have a geriatric oncology clinic where fellows can do a rotation. Unfortunately, this is not yet commonplace. A required rotation in geriatrics could be beneficial, particularly for the purpose of allowing fellows to practice doing a CGA.

Interdisciplinary collaboration between geriatrics and oncology, in tumor board for example, can foster more discussion and participation between the specialties. Because geriatricians have recognized the shortage of practitioners in the field, they have collaborated with physicians in other specialties and developed strategies to educate trainees and inspire them to specialize in geriatrics. The Chief Resident Immersion Training (CRIT) in the Care of Older Adults program, developed at Boston University/Boston Medical Center, has been successful in promoting collaboration among disciplines in the management of medically complex older patients. In fact, an opportunity to participate in CRIT as an internal medicine resident helped develop my interest in geriatrics. This program, which focuses on case-based learning of geriatric principles and leadership, has been conducted in more than a dozen institutions nationwide.

In order to foster the creation of new leaders in the field, in 2006 the ASCO Hartford Foundation provided funding for the development of 10 geriatric oncology training programs.

Being a fellow at one of these programs provided me with a unique training experience. Aside from addressing the clinical requirements for board eligibility in medical oncology, approximately 1 year of the fellowship program is dedicated to core clinical geriatrics training; this includes rotations in the geriatrics inpatient service, nursing home care, rehabilitation medicine, the Alzheimer’s unit, palliative care, and an outpatient continuity clinic. In addition, fellows gain experience in performing outpatient comprehensive geriatric assessments of older adults who have been referred to the clinic for evaluation.

The integration of didactic, research, and clinical experiences in both geriatrics and oncology can lead to board eligibility in both specialties after 3 years. Some fellows have participated in an additional year of training in order to become board eligible for hematology. The most distinctive feature of my training at Boston University/Boston Medical Center is that I have the opportunity to practice in different models of care and to treat a remarkably diverse patient population. At Boston Medical Center, we care for a large, underserved, and international migrant population. Additionally, we care for veterans at the Boston Veterans Affairs Healthcare System. We also care for patients in a unique way at a Program of All-inclusive Care of the Elderly (PACE) site. (PACE is a capitated payment model focused on multidisciplinary team-based care.)

Whether it be to identify a seemingly frail older patient with metastatic colon cancer who would tolerate and benefit from standard treatment, or to prevent a frail older lung cancer patient from experiencing severe side effects due to adjuvant chemotherapy, oncologists are having to make difficult decisions with increasing frequency. Integrating geriatric oncology principles into fellowship training is one of the many efforts under way that can improve the field of geriatric oncology so as to improve patients’ quality of life, increase survival, and decrease treatment toxicity in our older cancer patients. As a saying in oncology goes, “If you are not a pediatric oncologist, you are a geriatric oncologist.”

		Guardian News and Media Limited. Martin Amis in new row over ‘euthanasia booths.’ The Guardian website. http://www. theguardian.com/books/2010/jan/24/martin-amis-euthanasiabooths- alzheimers. Accessed August 4, 2015.

		Pal SK, Hurria A. Impact of age, sex, and comorbidity on cancer therapy and disease progression. 

. 2010;28(26):4086- 4093. doi:10.1200/JCO.2009.27.0579.

		Smith BD, Smith GL, Hurria A, Hortobagyi GN, Buchholz TA. Future of cancer incidence in the United States: burdens upon an aging, changing nation. 

. 2009;27(17):2758-2765. doi:10.1200/JCO.2008.20.8983.

		Hutchins LF, Unger JM, Crowley JJ, Coltman CA Jr, Albain KS. Underrepresentation of patients 65 years of age or older in cancer- treatment trials. 

		Owusu C, Koroukian SM, Schluchter M, Bakaki P, Berger NA. Screening older cancer patients for a Comprehensive Geriatric Assessment: a comparison of three instruments.

		Comprehensive geriatric assessment. Tufts OpenCourseWare website. http://ocw.tufts.edu/data/42/499797.pdf. Accessed August 4, 2015.

		Geriatric assessment tools. Cancer & Aging Research Group website. http://www.mycarg.org/SelectQuestionnaire. Accessed August 4, 2015.

		SIOG - International Society of Geriatric Oncology website. http://www.siog.org. Accessed August 4, 2015.

		NCCN clinical practice guidelines in oncology (NCCN guidelines): older adult oncology: version 2.2015. National Comprehensive Cancer Network website. http://www.nccn.org/professionals/ physician_gls/f_guidelines.asp#senior. Accessed August 4, 2015.

		Naeim A, Hurria A, Rao A, et al. The need for an aging and cancer curriculum for hematology/oncology trainees. 

		American Society of Clinical Oncology (ASCO). Education Essentials for Oncology Fellows (EEOF). ASCO University website. http://university.asco.org/education-essentials-oncologyfellows- eeof. Accessed August 4, 2015.

		Chief Resident Immersion Training in the Care of Older Adults (CRIT). ADGAP - Association of Directors of Geriatric Academic Programs website. http://adgap.americangeriatrics.org/adgapprograms/ crit. Accessed August 4, 2015.

		Medicine grants: a commitment to geriatric oncology. The John A. Hartford Foundation website. http://www.jhartfound. org/grants-strategy/a-commitment-to-geriatric-oncology-ascofoundation. Accessed August 4, 2015.

Articles

Whether it be to identify a seemingly frail older patient
with metastatic colon cancer who would tolerate
and benefit from standard treatment, or to prevent a
frail older lung cancer patient from experiencing severe
side effects due to adjuvant chemotherapy, oncologists
are having to make difficult decisions with increasing
frequency.

Geriatric Oncology: Learning the Balancing Act of Treating the Older Cancer Patient

	Oncology Fellowship Is Not a Continuation of Residency

Congratulations! It took at least 4 years of college, 4 years of medical school, and 3 years of internal medicine residency to reach this point. But you’re finally here. There are no more agonizing personal statements to write, ERAS tokens to obtain, or “Why do you want to be an oncologist?” questions to answer. That’s the good news. As you begin your first year of oncology fellowship, I want to share with you a few things I’ve learned since standing in your shoes just 12 months ago.

During your first year of fellowship, you will confront challenges different from those encountered by your colleagues who have pursued specialty training in other fields such as cardiology, critical care, and gastroenterology. In most residency programs, the majority of inpatient rotations surround the traditional medical fields of general medicine, gastrointestinal medicine, intensive care, and cardiology. Inpatient oncology rotations are far less common, thus limiting your exposure to the acute medical complications faced by cancer patients. Moreover, even if you were to rotate on the inpatient oncology service, it would not be an accurate reflection of what you will experience as an oncology fellow, because the majority of oncology care takes place in the outpatient setting.

Your learning curve will be far steeper than those of your colleagues in other specialties, who gained substantial exposure to the core medical issues in their fields during their residency. Whereas words like heart failure, chronic obstructive pulmonary disease (COPD), diabetes, and hypertension roll seamlessly off the tongue of any resident, tongue twisters like blinatumomab and palbociclib do not. You’ll quickly learn that while residency may have prepared you for the acute management of a patient’s prerenal kidney injury, it did not necessarily provide you with the foundation for facing the day-to-day issues and challenges of cancer patients and their medical providers.

There’s another more subtle difference between the world of oncology and other medical fields. Think back (if you are brave enough) to your intensive care unit rotations, or time on the cardiology service. There was so much emphasis on preload, afterload, systemic vascular resistance, pressure, and flow. In other words, the emphasis was on physiology: “Why is the heart failing, why is there blood in the stool, and why are the urine casts granular?” In oncology, the focus is shifted to the pathology of disease: “What is the driver mutation of the cancer, what is the cellularity or dysplasia in the bone marrow, and what is the primary origin of the patient’s cancer?”

However, more important than the fundamental difference between pathology and physiology is the critical distinction between taking care of a patient’s medical condition and taking care of the patient. In residency, you were trained to resolve a patient’s COPD exacerbation, diurese fluid-filled lungs, and control rapid atrial fibrillation. In simple terms, your job was to identify the problem, fix it, and move on. During oncology fellowship, you will be expected to empathize with your patient’s struggle with cancer, understand how a mother’s chemotherapy schedule is interfering with her ability to care for her children, and recognize a patient’s right to choose between quantity and quality of life. The objective is not necessarily to distinguish which drug to use and when, but rather to also understand the emotional and psychological impact of the disease and its therapy.

	Research: A Few Dos and Don’ts for Your First Year

One challenge during your first year of fellowship will be to balance your excitement regarding the medical aspects of treating the disease with the equally important patient interactions, communication, and relationships. And although you are correctly thinking that this should be the case in all specialties, it is amplified in oncology, where the impact of disease is often more significant. Maintaining this balance is something that comes naturally to very few people. As you follow your attendings in clinic and in the hospital, take note of their words, phrases, and mannerisms as they discuss diagnosis, treatment, disease progression, and end-of-life issues with patients and their families. Almost anyone can follow an algorithm to determine therapy, but only the well trained can incorporate the psychosocial elements of cancer therapy into their oncologic treatment plan.

Most oncology fellowship programs have high research expectations for their fellows. That’s hopefully not news to you. Each program has a different research structure. However, as a general rule, the first year of fellowship revolves around clinical duties, while the next 2 years are more research focused. Nonetheless, there will be pressure on you to identify a mentor, begin to design a research project, and even start to think about participating in your institution’s clinical trials during your first year of fellowship. Dr Mireles-Cabodevila, director of the critical care fellowship program at the Cleveland Clinic, began his fellowship fascinated with the physiology of heart rate variability in the critically ill. For a variety of reasons, his fellowship research project failed, which prompted him to turn his experiences into the “Ten Commandments” of research during fellowship. I urge you to read these “Ten Commandments,” as they will certainly influence your approach to research during fellowship.

His advice is practical and includes common sense recommendations such as recognizing that everything takes longer than expected, that you will need more help than you think, and that you need to set deadlines. However, for those of you who won’t read the publication (even though it’s free!), I want to quote the take-home message from Commandment 8, entitled “You Can Always Say No:” 

While it may be hard to say “no,” it is generally better than saying “I could not deliver.” As a venerated mentor once said, “If you don’t use certain ‘two- letter words’ enough (ie, “no”), you’ll end up using certain ‘four-letter words’ a lot more.”

In other words, if you’ve gotten as far as an oncology fellowship, chances are you are at least moderately interested in research. As an anxious, excited, and eager- to-please first year fellow, you will meet many faculty members who would be thrilled to serve as your mentor. For example, after your leukemia rotation, you may be offered the opportunity to write a review article, or when rotating through lung cancer clinic, you may be asked to help with a retrospective data review based on your institution’s experience with a novel therapeutic. Learn to say “no.” Don’t agree to a project about which you are not excited. Remember that agreeing to a project and not seeing it to fruition is far worse than politely declining in the first place. Find the area of research that most excites you and the clinical questions that you want to answer. That is a guaranteed recipe for success.

You are entering your final stage of formal medical training. Whereas in residency you were merely one of 20, 30, or 40 residents training in internal medicine, you are now part of a select and small group of individuals. Most programs enlist only 4 to 8 hematology/ oncology fellows per year. This has critical ramifications for your current training and future career.

At this stage, your co-fellows and faculty are not merely fleeting figures in your academic and clinic training. Rather, they are potential future coworkers and employers, as well as individuals whom you may encounter time and again throughout the course of your career. Fellowship is unlike residency in that you are not constantly moving from one department to another; rather, you are developing sustained longterm relationships with faculty, advanced practitioners, and nursing staff.

In many ways, your fellowship is a 3- or 4-year interview. Your faculty are assessing whether you’re someone they would want as a future colleague and whether they would recommend you as a potential colleague to their contacts at other institutions. This is not meant to imply that you are expected to know all there is to know about oncology during your first few months of training. However, it does place a greater emphasis on the basics: be respectful to everyone, be kind, be willing to help out a colleague in need, be honest. Nurture the relationships you build during these critical years, as they will serve as the foundation for your future.

I saved the most important topic for last. As much as we yearn for more, there are still only 24 hours in a day. During the recent oncology fellowship graduation at Cleveland Clinic, Dr Matt Kalaycio, chairman of the hematology/oncology department, reminded the fellows of this fact. He explained that throughout a career in oncology, we will be asked and often required to give away our most precious asset—time&mdash;in response to demands from many sources, including patients and their families, research, and clinical duties. Especially during fellowship, as you aim to impress, it will quickly become easy for you to commit all of your time to others. He therefore asked the graduating fellows to consider the following: “I hope you will give yourselves the gift of time.”

Over the next 3 years, you will have many obligations, and it will not be difficult for you to allow your fellowship to take control of your life. Despite a plethora of data documenting the issue of burnout in oncology, there is surprisingly little mention of worklife balance during training. Whether your time away from work involves your family, exercise, religion, leisure reading, or some combination thereof, be sure you do yourself the service of ensuring an appropriate balance between your work and “life.” Physician, heal thyself—you and your patients will be grateful.

It’s been a long road and you’re nearing the end. Some of you have always dreamed of being an oncologist, and some of you have made that decision only within the last few years. Regardless of the timing of your decision, you have invested a tremendous amount of time, energy, and money in getting to where you are today. I urge you to take pride in your work. Be proud of your commitment to spend your days taking care of cancer patients. Feel fortunate to be a part of such an exciting and rapidly evolving medical field. Most importantly, remember, even in the darkest of days, to have fun. You owe yourself at least that much.

	1. Mireles-Cabodevila E, Stoller JK. Research during fellowship: ten commandments. 

As you begin your first year of oncology fellowship, I want to share with you a few things
Iâ€™ve learned since standing in your shoes just 12 months ago.

Preparing for the Unexpected: What You're Not Told During Orientation

From the onset of our medical training, and continuing into residency, we are exposed to academic medicine. Seldom do we have any interaction or experience with private practice. After residency, many of us choose to enter a fellowship program for additional specialized training. Others, including myself, decide to enter private practice. Many fellows are disgruntled, as they believe their colleagues who opted for private practice are making a substantially greater income and “getting on with their lives.”

My path is unique. I decided to pursue private practice upon graduation from residency. However, after a couple of years of practice, I realized that I missed research and teaching and returned to academic medicine by entering a fellowship program. I completed my training in urology in the Harvard Program in Urology at Brigham and Women’s Hospital in Boston, Massachusetts. Additionally, I accumulated over 60 publication credits, which included numerous presentations primarily dedicated to urologic oncology and supported my interest in pursuing fellowship after residency. Many of these presentations were delivered during national and sectional American Urological Association (AUA) annual meetings.

I also interviewed with fellowship programs in urologic oncology, with the intention of accommodating my wife’s desire to move closer to family. However, some programs not located in close proximity to family also interested me. While pondering this dilemma of whether to pursue my academic interests or satisfy family obligations, an opportunity emerged to enter community practice in Southern California. I interviewed with the practice and after considering the balance between work and family interests, I decided to pursue community practice. Community practice offered the clinical appeal of managing my own patients and encountering diverse types of clinical urology cases. During my time in practice, I treated a variety of urologic conditions, from stone management to female urology; however, I enjoyed urologic oncology cases the most. From the initial diagnosis, to treatment, to patient follow-ups, I found great joy in managing prostate, bladder, kidney, and testicular cancers. I also kept track of my patient outcomes and quickly realized there was a void in practice that I wanted to address.

I approached the administration at St. Joseph Hospital to ask if I could become involved with committees and organizations to help improve the quality of care provided to our patients. I found this opportunity satisfying, as it allowed me to embrace not just my own practice, but also practices in other disciplines in and around the community. After working on several fund-raising events, I was elected to the Foundation Board of Directors at St. Joseph, and received the hospital’s support in hosting a Los Angeles-based radio show, “The Men’s Health Hour.” A weekly, hour-long talk show, it featured discussions on relevant men’s health topics ranging from urinary disorders related to benign prostatic hypertrophy to prostate cancer.

Despite the amazing opportunities I was offered and the wonderful relationships I developed while in private practice, I greatly missed the investigative research and teaching components of academic medicine. While clinical practice was intriguing, it often left me wondering what more I could do to improve medicine. One evening, while I was reviewing my billing (which should be the highlight of the day and why we put forth all of our hard work), I remember saying to myself, “I would rather be writing a manuscript or contemplating my next research project.” In that instant, I realized that I did not want to continue my career in private medical practice. Rather, I decided, I wanted to get back into academic medicine. I was torn between continuing at my current practice or pursuing my academic interests. During my time in Boston and thereafter, I had stayed in contact with colleagues who respected my intention to pursue opportunities outside of academia.

These colleagues recognized my work ethic and were aware of my contributions to a variety of publications. Naturally, this made it easy for one of them to call my bluff when a fellowship opportunity at a leading urologic oncology program opened up. After some serious thought and discussion with my family and previous mentors (including the chairman from my residency), I decided to leave community practice and enter fellowship at The University of Texas MD Anderson Cancer Center in Houston.

Fellowship has been a wonderful experience thus far, especially in light of being in practice for some time, as my time in practice allowed me to identify areas that I want to improve clinically. I have engaged in several clinical and molecular epidemiology-related research projects that are satisfying my research appetite, and I’ve since had the opportunity to present at the Society of Urologic Oncology, Genitourinary Cancers-American Society of Clinical Oncology (ASCO), and AUA meetings. I’ve received several awards, including the ASCO Merit Award and the Comparative Effectiveness Research on Cancer in Texas research scholar award.

The second award led to a current research grant that supports my population-based comparative effectiveness research in prostate cancer. I have also extended my prior epidemiology research in prostate cancer into molecular epidemiology in bladder cancer, as MD Anderson has a wealth of resources dedicated to this field of research. Recently, I realized how my prior and current work has contributed to the field of urologic oncology and health policy decision making. I have been invited to speak at the Institute of Medicine in Washington, DC, to discuss my prior comparative effectiveness research in prostate cancer, which specifically evaluated the appropriate utilization of treatments. I see this as one of my greatest accomplishments, and I see it as a tremendous opportunity to support my current research and to help direct health policy decisions in order to optimize cancer care and decrease costs to our healthcare system. As I look back, I’m thankful that I decided to head back into academic medicine, and more importantly, I thank my amazing wife and family for allowing me to pursue my dreams.

There is no magic door to walk through at the end of our training (whether that be residency or fellowship) that leads to the perfect job. We are human. The decision to pursue a career in academic medicine or private practice is complex and is based on numerous factors of varying importance. My only advice to fellows and young physicians is to never have regrets and to always pursue your dreams.

Both you and your family have worked very hard to make your pursuit of a career in medicine possible. Pursuing your dreams is beneficial to both you and your patients.

There is no magic door to walk through at the
end of our training (whether that be residency or
fellowship) that leads to the perfect job.

September 2015 | Oncology Fellows

Geriatric Oncology: Learning the Balancing Act of Treating the Older Cancer Patient

Preparing for the Unexpected: What You're Not Told During Orientation

My Path to Fellowship: Slightly Different From Most