The United States has a very long and often complicated relationship with immigration. Although Ellis Island is lauded as a uniquely American symbol of freedom and hope, those moving to this country seeking better economic opportunities or to escape oppression and violence have not always received a warm welcome. Even today, several studies show that immigration status is often associated with health care disparities.

The American Society of Clinical Oncology, the American Society for Hematology, and the American Association for Cancer Research, among other industry groups, have all established initiatives aimed at improving cultural competency among practitioners and diversity in clinical trials. As physicians at the beginning of their careers, fellows are singularly positioned to make cancer care more inclusive for all patients.

According to findings from the Center for Immigration Studies published in December 2021, the immigrant population includes 46.2 million documented and undocumented people, the highest total in US history. Overall, 14.2% of people in the United States come from somewhere else.

Undocumented immigrants are foreign-born individuals who have migrated to the United States without authorization.

 Contrary to conventional wisdom and anti-immigration policies, approximately 50% to 70% of the undocumented immigrant population pays federal and state taxes. Despite their contributions to the American economy, the undocumented population continues to face discriminatory policies.

 Those who have been diagnosed with cancer and their loved ones, in particular, feel the sting of those disparities. These policies affect undocumented immigrants with cancer on emotional, financial, physical, and social levels.

Disparities Within the Health Care System

The Affordable Care Act is a federally funded initiative implemented in 2010 to allow more affordable health care options for millions of Americans. However, this initiative excludes many in the undocumented population.

Research shows that those who are undocumented are rarely able to attain full insurance coverage, whether it is private insurance from the marketplace or Medicaid. Multiple states have expanded Medicaid policies to cover service gaps for undocumented individuals (Emergency Medical Treatment and Active Labor Act), but this extended policy varies by state and solely covers emergency services. This affects individuals who are diagnosed with cancer for any type of treatment. Individuals who seek emergency services due to a diagnosis may receive emergency medical attention; however, it typically does not cover cancer treatment costs.

Thus, those who are undocumented and uninsured usually do not seek medical assistance or delay seeking care, for several reasons. Health insurance is closely linked to the number of times individuals seek medical assistance; this includes general checkups, annual physicals, and cancer screenings.

 Cancer screenings are typically delayed unless or until individuals experience extreme discomfort or a medical emergency. Undocumented individuals are likely to live with pain and discomfort to avoid receiving high medical bills. They may avoid seeking medical attention or put off annual physical exams to avoid fees and co-payments.

A delayed cancer diagnosis affects the prognosis and types of treatments that are available to patients. The quality of treatment is also compromised, as undocumented populations are more likely to be offered a less effective, more affordable treatment as opposed to the best available treatment, which is more expensive and linked to a higher survival rate.

Cancer: Financial and Emotional Consequences

Undocumented individuals facing a cancer diagnosis are at higher risk of struggling with the financial burden of cancer treatment. Because of the nature of diagnosis and treatment, most patients with cancer who are undocumented are unable to work, resulting in ineligibility to receive federally funded benefits such as extended family leave, paid time off, paid sick days, and short-term and long-term disability.

Furthermore, undocumented patients with cancer face unique traumatic experiences that increase stress and strain their mental health. Some of these traumatic experiences include discrimination because of immigration status, stigma related to status, language barriers, and racism. Such experiences can reduce the likelihood of patients seeking medical assistance for their cancer treatment or diagnosis.

Often undocumented individuals with a cancer diagnosis delay seeking medical assistance because of fear of deportation. It can be difficult for these patients to ask for help because, oftentimes, they are the ones supporting their families—financially and emotionally. Moreover, an extended illness can result in unemployment, a terrifying prospect for a person who may be the breadwinner for multiple generations of family members.

These experiences can be isolating for patients and are correlated with depression, anxiety, posttraumatic stress disorder, and other mental health conditions. Such conditions have a direct impact on a patients’ physical health as well as response to treatment and survivorship.

Despite multiple challenges and barriers preventing undocumented immigrants with cancer from receiving adequate treatment, support, and information, there are a plethora of ways to help this population navigate the challenges.

Cultural humility is defined as “a lifelong process of self-reflection and self-critique, whereby the individual not only learns about another’s culture, but one starts with an examination of their own beliefs and cultural identities.”

 Reflecting on one’s own core cultural identity and privileges one may hold allows the health care worker to empathize with structural and emotional challenges their patients may face. It also assists professionals with the emotional capacity of advocating for patients or assisting them with the tools to advocate for themselves.

Faith and spirituality are helpful factors at the micro-level that assist with coping skills and how individuals react to stressors and mental health challenges. Being connected with an outside force (whether it is religion or spirituality) assists patients to externalize traumatic experiences and can create a sense of hope and belonging.

Health and policy literacy is an important component in assisting this population. Most undocumented immigrants with cancer are unaware of policies that could assist them. Health care professionals who are informed about local and federal laws can help inform undocumented immigrants with cancer what they are eligible for. Because direct federal programs that assist financially are very limited, nonprofit organizations and Catholic charities are the main source of financial and emotional support for patients. These organizations do not include immigration status as a form of eligibility to receive financial and emotional support.

Although many factors affect health care in this population, creating a safe space and providing appropriate empathetic care are key to maintaining a patient’s sense of hope and faith in their treatment and their care team.

Olazagasti C, Duma N. Cancer care for all? tales of caring for undocu-mented patients with cancer. 

 2020;25(7):552-554. doi:10.1634/theoncologist.2020-0113

Camerota SA, Zeigler K. Immigrant population hits record 46.2 million in November 2021. Center for Immigration Studies. December 20, 2021. Accessed April 26, 2022. bit.ly/3vitcbq

Beck TL, Le TK, Henry-Okafor Q, Shah MK. Medical care for undocu-mented immigrants: national and international issues. 

2019;4(1):33-45. doi:10.1016/j.cpha.2018.08.002

Tervalon M, Murray-García J. Cultural humility versus cultural compe-tence: a critical distinction in defining physician training outcomes in mul-ticultural education. 

 1998;9(2):117-125. doi:10.1353/hpu.2010.0233

Articles

Undocumented immigrants continue to face discriminatory policies, which  affect those with cancer on emotional, financial, physical, and social levels.

Undocumented Immigrants With Cancer Face Unique Care Challenges

Brian I. Rini, MD, left Cleveland Clinic to join Vanderbilt-Ingram Cancer Center as its inaugural chief of clinical trials in 2020. The role tasks him with expanding oncology clinical research operations and training opportunities in clinical cancer research. As such, he works closely with the school’s oncology fellows.

Matthew Tucker, MD, was already a fellow at Vanderbilt when Rini came to the program. Tucker, who finishes his fellowship this June, was considering a career in genitourinary oncology, which is Rini’s specialty.

After a few meetings, both virtual and in person, the 2 men developed a relationship. Mentor and protégé sat down to discuss developing a career path and building a résumé, the value of writing review articles early in fellowship, the power of saying no, and the importance of saying yes.

The key to fellowship and junior faculty is finding a mentor [and] your niche. How did you get into GU [genitourinary]? How did you find projects? How did you ultimately end up choosing a mentorship team?

 It’s hard [to find a mentor and your niche] when you transition from residency to fellowship, especially if you change institutions. I had done research in GU in residency, so it’s certainly something I was interested in. But coming into fellowship at a new institution, it’s hard at first.

Vanderbilt [University Medical Cen-ter] has what they call research ombudsman assigned to you when you start out. Their job isn’t to be your mentor, but to help you navigate the waters, find potential mentors, [and] help with the early networking to find people you can work and mesh well with.

The whole key to first-year fellowship is figuring out who you’re going to be [and] which team you’re going to be part of, especially in a new institution. That’s difficult. What are the priorities as you enter that first part of fellowship?

Focusing on clinical duties comes first. You may be interested in a particular thing in residency, but fellowship is a whole new world. Keep an open mind. Take a hard look at what’s going on in your clinical duties with different exposures you’re seeing for the first time. You may find a totally different research interest or clinical question that piques your interest.

Meet with multiple people. Just because you’re meeting with them doesn’t mean you’re going to start doing research with them the next day. When you meet with different potential mentors, [it’s important to] talk about what the future may look like [and] what future projects may look like. Get a sense [of whether] that is something that meets your needs and interests moving forward.

Once you’ve decided, “I want to work with this group or this person,” [or in this case], “I want to be a GU oncologist,” how do you start finding projects? How do you start to build your résumé?

 Great question. One of the things that helped me early on—and I would strongly recommend it to any first-year fellow or early investigator—is writing a review article. Very early on, one of the first things you did was reach out to me and say, “Let’s work on this together. Let’s look at this particular [review project about] biomarkers in kidney cancer.” As a first-year fellow, you may not know anything about kidney cancer, [for instance, but] coming into it writing that review, you’re going to come out knowing a lot more than you did before.

Going through that process...I’d be looking for X, Y, or Z in the literature and not finding it. That may give you a springboard for what might be some interesting clinical questions, which may lead to future research projects. That helped me a lot early on, just trying to figure out what the framework [is] of what’s already out in the literature to try to get ideas and [think about] potential projects.

 I did a networking lunch at [the American Society of Clinical Oncology Genitourinary Cancers Symposium], and we talked a lot about...expanding [and maintaining] networks. How do you meet people?

 Twitter is a great resource. I’ve met Twitterers—we get a lot of ideas, see articles pretty quickly, then go to PubMed to delve [deeper]. But [Twitter is a great place] for getting that initial surface of what’s going on.

As far as being active [and posting] on Twitter, you [must] be careful in fellowship and have good mentors to learn from. I have a mentor who’s active on Twitter, and I can learn a lot from that—what can be said, what is too much to say, [and] how to get attention but also be appropriate and educational. There’s a good opportunity to learn a lot from Twitter.

I remember early on in fellowship and as junior faculty, one of the key skills is being able to say no to projects. Can you talk about that skill? You can get approached by a lot of people to do a lot of things, so how do you decide what to do and what not to do?

Early on, people [often] say, “It’s OK to say no,” and it is OK to say no, but it’s also OK to say yes early on. If you have just 1 project going on and it’s all you’re working on, you may hit roadblocks on the way—you may submit it for publication months down the road—so having something else to work on when certain projects may hit slow points is important, too.

[However], once you’re [working on] 2 or 3 projects, this is where it is important to be in close communication with your mentor and meeting regularly because they can tell you, “Hey, it looks like maybe you have too much going on right now.” Or maybe you have room for just 1 more, but [they can] keep you in line. If you start to hit that point where you’re doing too many things, then you just have to do exactly what you said and just say no. You’re going to be approached by [several] different people, different mentors, maybe even different institutions, but you want to make sure [you have time to do, and do well], what you’ve already committed to.

Brian I. Rini, MD, is the chief of Clinical Trials and the Ingram Professor of Cancer Research at Vanderbilt-Ingram Cancer Center. Matthew Tucker, MD, is a clinical fellow in the Department of Hematology/Oncology at Vanderbilt University Medical Center. 

Brian I. Rini, MD, and Matthew Tucker, MD, sit down to discuss developing a career path and building a résumé, the value of writing review articles early in fellowship, the power of saying no, and the importance of saying yes.

The Power of No, the Value of Yes

The clinical learning environment for medical trainees is the foundation of medical training programs. However, discrimination and bias during medical education is a nefarious and pervasive fact of life, particularly for women and under-represented minority groups. Not only are such experiences damaging to the trainee, but they can also adversely affect patient care and the learning environment as a whole. 

Several years ago, at our institution, we both noticed an uptick in discriminatory comments from patients that were directed toward our hematology/oncology Mayo Clinic School of Graduate Medical Education fellows. We both interact regularly with the fellows, so we had the privilege of hearing about these patient encounters firsthand. 

Instead of normalizing the fellows’ experiences, we chose to listen to what was happening in the learning environment, lean in, and be curious about what we were being told. From this choice—the choice to not shy away from difficult issues—the idea for our research study entitled “Assessment of Discrimination, Bias, and Inclusion in a United States Hematology and Oncology Fellowship Program” arose organically.

The qualitative study was an in-depth look at our trainees’ experiences surrounding discrimination, bias, and inclusion. We wanted to understand on a granular level what discrimination or bias they encountered during their clinical training, how those events were handled, whether they were reported, who was perpetrating the discrimina-tion, and how the trainees coped with such experiences. We chose to ask about inclusion, as well, along with what factors of the clinical learning environment were supportive and welcoming, with the idea that a learning environment is the collective result of both the negative and the positive. 

We originally intended to conduct our study as in-person, semistructured interviews, but soon learned that under Title VII and Title IX laws, we would be required to report any gender or personal characteristic discrimination, which could result in our participants being subjected to further investigation. Because we wanted our trainees to be able to speak freely and without fear of retribution, we changed our study design to an anonymous phone interview that was conducted by a qualitative research partner with no interaction or knowledge of the hematology/oncology fellows or the training program. During the interviews, no identifying information from either party was exchanged. This method was highly effective at creating a safe environment for trainees to share their experiences of discrimination, bias, and inclusion.

Several key themes emerged that pertained to discrimination and bias. Many of our fellows from diverse ethnic and racial backgrounds were made to feel unwelcome or “alien at home,” even if they were US citizens. Prior to the publication of our work, the description of feeling “alien at home” had not yet appeared in the body of medical literature surrounding discrimination in medical education. Another related theme was that of trainees who were born outside of the United States being treated as outsiders, even if they had been in the country for much of their lives.

Gender bias toward women was also extremely common. Worse, most trainees did not report these events because of the perception that it would be futile and not result in any substantive changes.

An intuitive but notable finding was that diversity itself begets inclusion. At Mayo Clinic, we have the great fortune of recruiting talented trainees from around the world, and we learned that the presence of people from diverse backgrounds made trainees feel welcome. The inherent diversity of the program combined with other factors created a culture of inclusion, even though 100% of the trainees interviewed either witnessed or experienced discrimination or bias. In a nutshell, the positive experiences outweighed the negative. 

We learned several valuable lessons from this study that can be directly translated into action. Most of the episodes of discrimination were micro-aggressions, which are subtle comments or actions as opposed to overt racism or discrimination. Most of the incidents were not of malicious intent but represent engrained societal percep-tions. In other words, the unconscious biases of patients, and sometimes staff, would manifest in words or actions toward trainees. 

Unconscious bias training has proven effective at highlighting the subcon-scious judgments we all make when we interact with the world. We would advocate that all individuals involved in medical education—ideally including patients—complete an unconscious bias training program. 

We also advocate for bystander or “upstander” training for all medical staff to provide practical tools and approaches for supporting medical trainees who experience discrimination or bias. We cannot prevent such events from occurring, but we can control our reactions and mitigate the impact on trainees’ well-being.

In response to our findings, Mayo Clinic has instituted ongoing efforts to combat discrimination. Dr Warsame conducted a department-wide retreat on diversity and inclusion. We developed an annual anonymous, online learning climate assessment survey within the fellowship program to keep track of the learning environment and the changes that occur over time. 

We have conducted bystander training and rolled out unconscious bias training. We continue to promote our institution’s patient and visitor misconduct policy that provides protection and validation to our trainees and employees who speak out against discriminatory behavior from patients and visitors.

Although we conducted this study at a single fellowship program in 2018, as an organization, Mayo Clinic is applying the lessons learned beyond the hematology/oncology department. We have developed and disseminated institution-wide faculty development education on topics such as uncon-scious bias, microaggressions in the learning envi-ronment, supporting trainees who encounter patient bias, and what to do when a patient refuses care because of factors such as gender, religion, or race.

Mayo Clinic now requires additional bystander intervention training for all employees, residents, and fellows. Furthermore, in 2020, more than 1800 residents and fellows participated in a survey regarding our learning climate. Administrators shared anonymous schoolwide and program-specific results to spur conversations and drive improvement initiatives in other programs and departments.

Perhaps the message we would like to share most is not new, but in our current polarized society, it has never been more important: Talking about sensitive topics is part of the solution, not part of the problem. Identifying and naming a problem does not create an issue or make it a reality but is, instead, the first step in helping to solve it. 

We learned so much about ourselves, our trainees, and our program during this process, and we strongly suggest that each institution and program take the steps to learn more about discrimination, bias, and inclusion, as well as how it affects their medical trainees. Together, we can take steps toward a more equitable and discrimination-free medical education.

Warsame RM, Asiedu GB, Kumbamu A, et al. Assessment of discrimina-tion, bias, and inclusion in a United States hematology and oncology fel-lowship program. 

. 2021;4(11):e2133199. doi: 10.1001/jamanetworkopen.2021.33199

The clinical learning environment for medical trainees is the foundation of medical training programs.

Mayo Clinic Physicians Seek to Address Bias in Medical Education

Many cancer organizations across the United States and internationally acknowledge a need for in-novative uses of social technology to improve cancer-related support and information provision. Patients and unpaid caregivers (ie, well-intentioned family members and friends) use social media and other on-line avenues for information and support during their journey with cancer.

 The ongoing challenge of can-cer misinformation online underscores the necessity for oncologists to have a presence in online cancer networks as a trusted information resource.

People primarily turn to social media following a cancer diagnosis to establish and maintain close relationships, gain social support, and find anecdotal health information, particularly on topics they are uncomfortable discussing with their providers.

 Patients and caregivers often consider topics such as finances, sexuality, nutrition, and integrative care to be inappropriate to discuss with their doctor. When patients with cancer and caregivers attempt to fulfill unmet information and support needs, they often turn to online spaces and places where they have established networks that they are comfortable lever-aging for these needs. 

Even before the COVID-19 pandemic, younger patients and caregivers in particular preferred online connections to traditional services, such as in-person formal support groups, and this preference has only accelerated in pace and breadth during the past 2.5 years.

 At the same time, cancer information on the internet is vastly unregulated by governing bodies and flourishes on user-generated sites such as social media and online forums. 

Scientists in communications, marketing, nursing, public health, and medicine continue to study the reasons why some cancer misinformation pervades online communities and why other medical misinfor-mation is less impactful. Some promising theoretical models show there are several charac-teristics of health misinformation that influence the breadth and depth of the penetration it has in online spaces.9,10Specifically, misinformation consid-ered to be novel and shocking, claims to reveal hidden truths, personal anecdotes from others with experiential knowledge accompanied by images or visuals, and information individual users deem as likely to be shared by their followers has the highest likelihood of penetrating networks by going viral.

Virality is not only incentivized for online popularity, but it is also typi-cally driven by underlying and often hidden financial incentives of the content curator.

 Many patients with cancer find themselves in a delicate health and finan-cial situation, which makes them espe-cially vulnerable to online cancer misin-formation and financial exploitation.

Cancer misinformation is uniquely concerning because it has the potential to directly affect patient and caregiver decision-making, treatment and medica-tion adherence, financial hardship, and cancer health outcomes. For example, 30% to 40% of social media articles contain misinformation that can harm patients.

 Patients with cancer have up to a 470% increased risk of death if they forgo evidence-based strategies in favor of unproven treatments, which are popular on user-generated social media sites.

 Appropriately addressing misinformation, and improving treat-ment decision-making as a result, has the potential to increase survival by more than 5-fold among patients with certain cancers.

Fortunately, there are tried-and-tested ways individual users in online spaces can neutralize the effects of cancer misinformation (FIGURE).

 A quick correction delivered by a trusted commu-nity member with an open-minded, accepting response that focuses on facts, as opposed to a response that rebuts or dismisses claims, can prevent bad infor-mation from spreading.

Other recommended approaches to dispelling general online health misin-formation include partnering with influencers to disseminate high-quality information, carefully disseminating scientific research so it is not miscon-strued in the media, and fostering expec-tations of fact-checking through online public health campaigns.

In clinical settings, oncologists can discuss with patients the importance of discovering the source of information, point out the strategies used by misinformation curators, and review financial incentives for misinformation campaigns online.

Increasing the value of online cancer networks requires concerted engagement from oncologists, who have historically been cautioned about engaging with online patient communities.

 Nonetheless, the changing dynamic of online health information seeking by patients and their caregivers demands recognition of a paradigm change in the way patients seek health information and the way physicians address it.

Given the high level of trust patients have in physi-cians, particularly in oncologists, this is a promising approach to addressing online cancer misinforma-tion.

 There are several high-profile exemplar oncologists with large social media followings. Mark Lewis, MD, a hematologist/oncologist with Intermountain Healthcare in Murray, Utah, dispenses valuable information on Twitter (@marklewismd). Sanjay Juneja, MD, of Baton Rouge General Hospital in Louisiana, does the same on Instagram and TikTok (@TheOncDoc).

Developing a successful and professional online presence is possible by employing the following best practices:

Be aware of boundaries, and do not offer medical advice on social media.

Review your employer’s rules and regulations about social media use, and follow their guidance for disclaimers. 

Be conscious of patient privacy and caution to avoid inadvertent patient disclosure.

Leverage referrals to other high-quality informa-tion. You do not have to know everything, but being aware of online resources, from federal, government, hospital, university, and community partners, will position you to disseminate high-quality cancer information in the face of misinformation.

Simply asking patients and their caregivers what they have learned online about diagnosis and treat-ment can open the door for opportunities to correct cancer misinformation in the clinic. However, oncolo-gists cannot feasibly answer all the questions patients and their caregivers have. Although many innovative patient and caregiver support and information services exist to address unmet information and support needs, patient and caregiver use of social media for cancer information has profoundly changed the way indi-viduals make decisions about their cancer care. There is an urgent need to recognize and ameliorate the threat cancer misinformation online poses to patients with cancer and their health outcomes.

Gage-Bouchard EA, LaValley S, Mollica M, Beaupin LK. Cancer commu-nication on social media: examining how cancer caregivers use Facebook for cancer-related communication. Cancer Nurs. 2017;40(4):332-338. doi:10.1097/NCC.0000000000000418

Warner EL, Kirchhoff AC, Ellington L, et al. Young adult cancer caregivers’ use of social media for social support. Psychooncology. 2020;29(7):1185-1192. doi:10.1002/pon.5402

Warner EL, Kirchhoff AC, Wilson A, et al. Social support enactments on social media during the first 6 months of young adult cancer caregiving. J Cancer Surviv. 2022;16(1):61-72. doi:10.1007/s11764-021-01004-y

Warner EL, Ellington L, Kirchhoff AC, Cloyes KG. Acquisition of social support and linguistic characteristics of social media posts about young adult cancer. J Adolesc Young Adult Oncol. 2018;7(2):196-203. doi:10.1089/jayao.2017.0076

Badr H, Carmack CL, Diefenbach MA. Psychosocial interventions for patients and caregivers in the age of new communication technolo-gies: opportunities and challenges in cancer care. J Health Commun. 2015;20(3):328-342. doi:10.1080/10810730.2014.965369

Gage-Bouchard EA, LaValley S, Devonish JA. Deciphering the signal from the noise: caregivers’ information appraisal and credibility assessment of cancer-related information exchanged on social networking sites. Cancer Control. 2019;26(1):1073274819841609. doi:10.1177/107327481984160

Dellmann-Jenkins M, Blankemeyer M, Pinkard O. Young adult children and grandchildren in primary caregiver roles to older relatives and their service needs. Family Relations. 2000;49(2):177-186. doi:10.1111/j.1741-3729.2000.00177.x

Warner EL, Kent EE, Trevino KM, Parsons HM, Zebrack BJ, Kirchhoff AC. Social well-being among adolescents and young adults with cancer: a systematic review. Cancer. 2016;122(7):1029-1037. doi:10.1002/cncr.29866

Hsu CC, Ajorlou A, Jadbabaie A. Persuasion, news sharing, and cas-cades on social networks. SSRN. Preprint posted online April 5, 2022. doi:10.2139/ssrn.3934010

Warner EL, Leroy G, Crane T, Basen-Engquist K, Badger T, Raber M. Use of academic citations in cancer nutrition misinformation on Pinterest. Presented at: Society of Behavioral Medicine 2021 Annual Meeting; April 12-16, 2021; virtual.

Johnson SB, Parsons M, Dorff T, et al. Cancer misinformation and harmful information on Facebook and other social media: a brief re-port. J Natl Cancer Inst. Published online July 22, 2021. 2021;djab141. doi:10.1093/jnci/djab

Johnson SB, Park HS, Gross CP, Yu JB. Complementary medicine, refusal of conventional cancer therapy, and survival among patients with curable cancers. JAMA Oncol. 2018;4(10):1375-1381. doi:10.1001/jamaoncol.2018.2487

Johnson SB, Park HS, Gross CP, Yu JB. Use of alternative medicine for cancer and its impact on survival. J Natl Cancer Inst. 2018;110(1): 10.1093/jnci/djx145. doi:10.1093/jnci/djx145

Gage-Bouchard EA, LaValley S, Warunek M, Beaupin LK, Mollica M. Is cancer information exchanged on social media scientifically accurate? J Cancer Educ. 2018;33(6):1328-1332. doi:10.1007/s13187-017-1254-z

Martel C, Mosleh M, Rand DG. You’re definitely wrong, maybe: correc-tion style has minimal effect on corrections of misinformation online. Media and Communication. 2021;9(1):2183-2439. doi:10.17645/mac.v9i1.3519

Trethewey SP. Strategies to combat medical misinformation on social media. Postgrad Med J. 2020;96(1131):4-6. doi:10.1136/postgrad-medj-2019-1372011

Vraga EK, Bode L. Correction as a solution for health misinforma-tion on social media. Am J Public Health. 2020;110(S3):S278-S280. doi:10.2105/AJPH.2020.305916

Guess AM, Lerner M, Lyons B, et al. A digital media literacy interven-tion increases discernment between mainstream and false news in the United States and India. Proc Natl Acad Sci USA. 2020;117(27):15536-15545. doi:10.1073/pnas.1920498117

Van Dessel P, Liefooghe B, De Houwer J. The instructed task-switch evaluation effect: is the instruction to switch tasks sufficient to dislike task switch cues? J Cogn. 2020;3(1):1. doi:10.5334/joc.90

Engelhardt EG, Smets EMA, Sorial I, et al.. Is there a relationship between shared decision making and breast cancer patients’ trust in their medical oncologists? Med Decis Making. 2020;40(1):52-61. doi:10.1177/0272989X19889905

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Many cancer organizations across the United States and internationally acknowledge a need for in-novative uses of social technology to improve cancer-related support and information provision.

Fellows Can Join the Fight Against Cancer Misinformation Online

Venous thromboembolism (VTE) is a common diagnosis indicating a blood clot located in a vein.

 Most hematology/oncology fellows will care for patients with this diagnosis throughout their training and long after their graduation from fellowship. Despite the prevalence of VTE, there are many nuances to its management. Here are some practical considerations when treating a patient with an acute VTE.

Step 1: Consider Characteristics of the Clot

Hematologists are often consulted to assess for underlying etiologies of VTE, for recommendations about duration of anticoagulation, or for assistance with selecting agents for therapeutic anticoagulation. Many factors contribute to this multifaceted evaluation, such as collecting a thorough medical history from the patient with consideration to pertinent, ongoing risk factors for the development of thrombosis. These basic pieces of information can help a hematologist determine whether additional laboratory testing is warranted.

One of the first steps is to evaluate the location of the thrombus, which can provide important clues about the underlying disease state. The most common VTEs are lower-extremity deep vein thrombosis (DVT) and pulmonary embolism (PE). However, uncommon thrombi such as those found in the cerebral venous, splanchnic venous, and portal vein may alert the hematologist to the possibility of an underlying cause. These thrombi warrant consideration for underlying precipitants such as myeloproliferative disorders, paroxysmal nocturnal hemoglobinuria, catastrophic thrombin-generating states, underlying liver disease, malignancy, and other conditions.

In addition, it is important to determine whether a clot was precipitated by known risk factors for thrombosis. These were historically called “provoked” clots, though recent nomenclature trends have been moving away from this term. This information can identify transient risk factors, such as estrogen exposure from oral contraceptive use, perioperative states, and illness-related immobility. In these situations, current guidelines typically recommend definitive courses of anticoagulation after transient risk factors have been removed.

Conversely, patients may have ongoing thrombotic risk factors, such as active inflammatory bowel disease, cancer, or others. In these cases, extended-duration anticoagulation may be warranted following a more in-depth assessment of the individual risks and benefits of continuing anticoagulation.

It may be easier to characterize potential thrombotic risk factors around the time of initial VTE diagnosis. Patients and family members may be more likely to recall potential thrombosis triggers in the acute setting; thus, inpatient hematology consultation may be beneficial in identifying risk factors. However, some patients may be too ill to provide this detailed history at the time of the initial event and may benefit from outpatient follow-up intervals to clarify risk factors and discuss thrombosis history in detail.

Bleeding is the most common adverse effect of any anticoagulant medication. Assessing bleeding risk will help determine whether anticoagulation should be started, optimize choice of anticoagulant, and potentially inform the duration of anticoagulation. For most patients with an acute VTE, the benefits of initiating anticoagulation outweigh the risks of bleeding. Exceptions may include acute central nervous system bleeding events concurrent with an acute VTE, when the addition of anticoagulation may result in life-threatening expansion or hemorrhage.

Some gastrointestinal (GI) bleeds may become life-threatening with the addition of anticoagulation. Areas of anatomic abnormality such as arterio-venous malformations, ulcers, and tumors tend to bleed more readily with the addition of anticoagulation. Definitively managing an underlying anatomic abnormality may help the patient tolerate anticoagulation and decrease the risk of bleeding. Examples may include a resection or radiation of an oozing site of malignancy or an endoscopic intervention on a GI bleed. It is important to remember that bleeding issues at the time of initial evaluation may prohibit anticoagulation for several weeks.

Frequent reassessment of tolerance for a particular anticoagulant provides an opportunity to individualize the approach for each patient. If a patient is taking an injectable anticoagulant such as enoxaparin, it may be useful to assess the patient within 2 to 4 weeks of starting injectable anticoagulants to ensure they are tolerating the injections.

Other factors that may increase bleeding risk include age 60 years or older, history of prior bleeding, active cancer, chronic hepatic or renal disease, thrombocytopenia, anemia, and other comorbidities including hypertension, poor functional capacity, and recent surgery. Use of the externally validated VTE-BLEED score may provide a frame-work for the identification of patients at risk for major bleeding during long-term anticoagulation.

Step 3: Consider Anticoagulation Options in Special Populations

There are certain patient populations or circumstances that may affect approaches to management of VTE.

Patients with acute DVT and absolute contraindications to anticoagulation caused by concurrent acute bleeding may be considered for retrievable inferior vena cava (IVC) filter placement. It is paramount to ensure prompt removal of IVC filters once anticoagulation can be restarted, as there is mounting evidence of harm from lack of retrieval.

 Of note, the 2019 American Society of Clinical Oncology Clinical Practice Update did not recommend IVC filters for patients with a chronic DVT diagnosed more than 4 weeks prior.

It is important to note that certain special populations with unique anticoagulation needs exist beyond the scope of this article, including patients who are pregnant, where low molecular weight heparins (LMWHs) or unfractionated heparins have long been the standard of care. Chronic kidney disease and hepatic disease are scenarios where the degree of organ dysfunction may dictate the choice of anticoagulation.

 Useful data for anticoagulation selection can be assessed by evaluation of the creatinine clearance, Child-Pugh score for cirrhosis, and review of the drug package insert for dosing guidance.

Direct oral anticoagulants may be relatively contraindicated in the setting of cirrhosis with a Child-Pugh score greater than B or C, depending on the agent. LMWHs are relatively contraindicated in renal insufficiency. Warfarin may be difficult to manage if the international normalized ratio is increased at baseline. Additional patient populations with specific anticoagulation considerations include patients with antiphospholipid antibody syndrome, active cancers, gastric bypass or other GI resection surgeries, and heparin-induced thrombocytopenia.

Centers for Disease Control and Prevention. What is venous thromboemolism? February 7, 2020. Accessed April 29, 2022. bit.ly3ywp9Ky

Kresoja KP, Ebner M, Rogge NIJ, et al. Prediction and prognostic importance of in-hospital major bleeding in a real-world cohoty of patients with pulmonary embolism. 

2019;1(290):144-149. doi: 10.1016/j/ijcard.2019.03.017

Klok FA, Barco S, Konstantinides SV. External validation of the VTE-BLEED score for predicting major bleeding in stable anticoagulated patients with venous thromboembolism. 

2017;117(6):1164-1170. doi:10.1160/TH16-10-0810

Choosing Wisely. IVC filters and acute VTE. October 30, 2018. https://www.choosingwisely.org/clinician-lists/american-society-hematology-inferior-vena-cava-filters-in-patients-with-acute-vte/. Accessed May 4, 2022

Becattini C, Agnelli G. Risk stratification and management of acute pulmonary embolism. Hematology Am Soc Hematol Educ Program. 2016 Dec 2;2016(1):404-412. doi:10.1182/asheducation-2016.1.404

Key NS, Khorana AA, Kuderer NM, et al. Venous thromboembolism prophylaxis and treatment in patients with cancer: ASCO Clinical Practice Guideline Update. 

2020;38(5):496-520. doi:10.1200/JCO.19.01461

Ortel TL, Neumann I, Ageno W, et al. American Society of Hematology 2020 guidelines for management of venous thromboembolism: treatment of deep vein thrombosis adn pulmonary embolism. 

2020;4(19):4693-4738. doi:10.1182/bloodadvances.2020001830

Becattini C, Agnelli G. Acute treatment of venous theomboembolism. 

2020;135(5):305-316. doi:10.1182/blood.2019001881

Lyman GH, Carrier M, Ay C, et al. American Society of Hematology 2021 guidelines for management of venous thromboembolism: prevention and treatment in patients with cancer. 

2021;5(4):927-974. doi:10.1182/bloodadvances.2020003442

Most hematology/oncology fellows will care for patients with venous thromboembolism throughout their training and long after their graduation from fellowship. Here are some practical considerations when treating a patient with an acute VTE.

Practical Considerations for Fellows Treating VTE

I remember asking my senior fellows this very question when I started my fellowship a few years ago. As a resident, I had enjoyed listening to a broad range of podcasts discussing current topics and fundamental reviews in internal medicine, and I was excited to see what was out there for the next phase of my training.

However, most of the fellows I spoke to weren’t familiar with the medical education podcast world. The recommendations I did receive were for highlevel podcasts that read more like the editorial pages of a medical journal or the Q&A at a professional conference than 

, an internal medicine podcast. I chalked this up to a small sample size—our program has just 21 fellows across all years—but as I looked around, I couldn’t find anything to match what I was looking for.

Then I forgot about it. For better or for worse, my first year kicked into high gear and my brief quest for podcasts was lost in the churn of call nights, conference presentations, and bone marrow biopsies.

Fast-forward 2 years to August 2021. I’ve become a senior fellow looking to pursue a career in nonmalignant hematology. I had just presented a case of relapsed Hodgkin lymphoma at our weekly case conference when I received a text from my friend Vivek G. Patel, MD, a fellow in the class behind me. He asked whether I would be interested in collaborating on a medical education project. Along with Ronak Mistry, DO, a first-year fellow, he had been looking into starting a podcast for hematology/oncology fellows, earlier-stage trainees, and any other individuals interested in the field.

All 3 of us found the podcast medium appealing. What other format could blend lighthearted banter, high-yield clinical pearls, and case discussions into an educational resource designed to be consumed in a broad range of settings? After all, you can’t work through a question bank on your commute to the hospital or pore over evidence-based guidelines on a jog through the park.

When we first met and began working on the project, we realized that we all had the same experience of looking for something that simply wasn’t there: a podcast reviewing the fundamentals of hematology and oncology. Don’t get me wrong; podcasts focused on the latest practice-changing research like 

, hosted by physicians at Vanderbilt, and Research to Practice are fantastic offerings. Free and open access to attending-level discussions on the field’s cutting edge is an incredible resource, but when we were medicine residents or first-year fellows looking to get up to speed, we weren’t there yet.

Vivek, Ronak, and I set out to create an asynchronous learning platform for individuals with an interest in the field while keeping a sense of fun and excitement at the heart of the experience. We wanted to introduce the basic science behind clinical phenomena, not as a burden to be memorized before in-service or board exams, but as a way to more deeply understand the disease states we see every day in the clinic and on the wards.

 in part to remind ourselves and our listeners of the stakes involved in our work. For a fellow, nights on call are your first major test as a clinician. You are expected to operate more independently and leverage your foundation of medical knowledge to make clinical decisions across a broad range of disease states: sickle cell, small cell, stem cell, and everything in between.

Although none of us had direct experience producing a podcast, Ronak had connections from his residency with podcast creators who were able to give him a rough road map to getting the project off the ground. Vivek had some experience with video and audio editing and set up the recording software and equipment we would need to generate a quality product.

Even with these advantages, getting started was a challenge. Finding the time to schedule a regular recording session each week wasn’t easy. In fact, the name of the show is partly in reference to Ronak’s intense first-year call schedule. We recorded our first episode 5 or 6 times—our collective suppression of the experience makes it tough to remember exactly how many times we talked about the work-up for thrombocytopenia—and we’ve had no shortage of technical hiccups along the way. We’re still learning the process as we go, but we’re still excited about the project and are hopeful that our listeners are too.

The goal of our show is to deliver the fundamentals, core concepts, and important management approaches in the field, as determined by the latest evidence and expert opinion. We have a long and growing list of topics we want to cover, and we’ve tried to organize clusters of topics into miniseries to provide additional structure to the episodes. We focused our first several series on emergency situations we face as fellows and critical knowledge areas we didn’t learn about in depth until we started fellowship, as reflected in our hematopathology series.

We have episodes planned about hemophilia, hyperviscosity syndrome, graft versus host disease, and a range of other subjects we didn’t see frequently in our internal medicine training. We’ve tried to maintain a balance of topics related to both hematology and oncology to keep our appeal as broad as possible. We’re also looking forward to collaborating with more guest hosts in the future, making sure we can expand the number of perspectives the podcast has to offer. Most of all, we are happy to know people are listening. The 3 of us could talk all day about the things we find interesting or a fascinating clinical pearl we’ve just learned. Having a way to share that sense of discovery is a dream come true.

We publish new episodes on Wednesdays, available to stream on Apple Podcasts, Spotify, and Google Podcasts. In each episode, Ronak, Vivek, and I provide bite-sized, simplified approaches to common questions that are perfect for anyone interested in hematology and oncology, from students and trainees to advanced practice providers and practicing physicians. Check out prior episodes and learn more about our show at www.TheFellowOnCall.com and follow us on Twitter @TheFellowOnCall and Instagram @thefellowoncall.

Daniel J. Hausrath, MD, is a clinical fellow in the Division of Hematology/Oncology at Vanderbilt University Medical Center.

Daniel J. Hausrath, MD, discusses a collaborative effort to produce a podcast for fellows that reviews the fundamentals, core concepts, and important management approaches in the field, as determined by the latest evidence and expert opinion. 

The Podcast by Fellows for Fellows

We use scientific truths in our profession every day. These truths allow us to meaningfully discuss the data supporting our decisions and prognoses with our patients. However, we are faced with a rise in false flags and half-truths that increasingly involve the medical field. If we do not question these halftruths and learn to trust what we see with our own eyes, we are at risk of becoming complicit in a message that ultimately undermines our ability to treat our patients safely and effectively.

However, we are pulled in so many directions that we often see the onslaught of these halftruths as far too great to overcome—certainly far too great for us to address. This includes falsehoods from other parties telling us what we should practice. As providers, we have too long ceded our place at the table when it comes to the art and practice of medicine.

We talk about that art with patients, but modern practice also involves managing the finances of patient care. We spend a great deal of time justifying things we know to be true in our practice: that step therapy is not OK for patients with cancer, that prior authorizations (PAs) delay care.

This is where you come in. As fellows, you are well versed in caring for patients, but you may need time to adjust to managing the challenges involved in the actual practice of medicine. In your professional career, you will be immersed in half-truths, and you will need to speak up.

You may call me a radical, but believe it or not, I see myself as a rule follower. That said, I also recognize that having a seat at the table means not just passively retweeting or liking a social media post or complaining about processes behind clinic doors.

Collectively, we have power, and it is past time that we use our clout to make tangible change. Some issues that started as public health benefits may actually be public health menaces, and it is incumbent on all of us to recognize that and take action.

Let’s look at PA, as defined by the American Medical Association (AMA):

“Prior authorization is a health plan costcontrol process enacted by insurance companies by which physicians and other health care providers must obtain advance approval from a health plan before a specific service is delivered to the patient to qualify for payment coverage. On the surface, the prior authorization process is an important tool to help cut health care costs and these measures are appropriate.”

However, the AMA also noted that physicians and their staff spend an average of 13 hours per week completing PA requirements for patient medicines, procedures, and medical services. In one AMA survey, 93% of responding physicians reported that the PA process delays patient access to necessary care. And some of these delays can be lengthy, with 26% of physicians stating that in the prior week, they waited an average of 3 or more business days to receive PA decisions. Furthermore, 82% reported that delays in the PA process led to patients abandoning treatment.

In fact, the American Society of Clinical Oncology (ASCO) has sent out a call to action based on recent findings from the US Office of Inspector General (OIG) report showing that 13% of PA denials in the Medicare Advantage (MA) program were for service requests that met Medicare fee-for-service coverage rules. Requests for imaging services, stays in postacute facilities, injection medications, and cancer care were often denied despite meeting Medicare coverage rules. We are constantly told that PAs cut down on spending. Instead, PAs can delay or prevent delivery of important, evidence-based patient care.

To publicly expose this issue, the New York Times published an article in April 2022 entitled, “Medicare Advantage Plans Often Deny Needed Care, Federal Report Finds.”

 I encourage all of you to read it. I’m glad a reporter at the Times wrote this piece, but the question is: Why didn’t we write it ourselves?

For too long in this field, we have buried our own observations and accepted others’ opinions about how we should best practice and provide for our patients. It was easier for us to accept these opinions than to protest. But we have to ask ourselves whether these opinions are still delivered with the noblest of intentions, or do we choose to believe that because it is easier?

I urge you to undertake the process of visible and courageous support of the truth. Tweet and tag key stakeholders, write letters to your elected officials, and align with ASCO or other professional organizations to make tangible change.

As health care providers, we are motivated to diagnose and provide treatment when we observe a threat to health and well-being. Consider the aforementioned half-truths as threats to health. As health care providers, we have more to offer than thoughts and prayers. We have our collective voice. This is our swim lane. Take the time to use it.

2016 AMA prior authorization physician survey. American Medical Association. January 2017. Accessed May 18, 2022. https://bit.ly/3zvuVN5

2021 AMA prior authorization physician survey. American Medical Association. February 21, 2022. Accessed June 2, 2022. https://bit.ly/3tcN4Lw

Abelson R. Medicare advantage plans often deny needed care, federal report finds. New York Times. April 28, 2022. Accessed May 18, 2022. https://nyti.ms/3llhMhp

Jill Gilbert, MD, is a professor of medicine and vice chair for Professional Development in the Department of Medicine at Vanderbilt University Medical Center.

Jill Gilbert, MD, urges healthcare providers to undertake the process of visible and courageous support of the truth in the medical field.

If We Want to Be Heard, We Must Speak Up

Mili Arora, MD, comes from a family of physicians, but she didn’t always plan to follow that path. In fact, that family history initially turned her away from a life in medicine. She majored in engineering as an undergraduate before realizing that she missed working with people. Hematology/oncology, she realized, gave her a chance to both treat patients and indulge her interest in research.

Mili Arora, MD, talks about changing the fellowship program at UC Davis, the effect the COVID-19 pandemic has had on her trainees, and the importance of working late nights with her fellows.

Vol. 14/No. 2 | Oncology Fellows