Persistence Is Key to Success

It's July 2021, and Vinay Edlukudige Keshava, MD, is making his rounds as a PGY-4 hematology-oncology fellow at Allegheny General Hospital and West Penn Hospital System, both part of Allegheny Health Network (AHN), in Pittsburgh, Pennsylvania. But something happened just 2 months prior that affected the clinical practice firsthand for some of his patients with lung cancer.

That something was the May 2021 FDA approval of the RAS GTPase family inhibitor sotorasib (Lumakras) for the treatment of patients with KRAS G12C–mutated locally advanced or metastatic non–small cell lung cancer, specifically for those who previously received at least 1 systemic therapy.¹ The KRAS G12C subtype must be determined by the QIAGEN therascreen KRAS RGQ PCR Kit and the Guardant360 CDx companion diagnostics, which were approved in conjunction with sotorasib.

“One of the targets that has been elusive to oncologists and researchers everywhere is KRAS G12C. When the research with [sotorasib] came out, we at AHN were quick to adapt to that,” Edlukudige Keshava said in an interview with Oncology Fellows. “[Approximately] 8 weeks after the major journal publication came out about the drug, we gave it to one of our patients. I was a fresh, first-year fellow when that happened. Now that patient is still doing well and is on the same medication. And I got to meet the patient. These are exciting times.”

Being on the front line for these changes was one of the valuable experiences Edlukudige Keshava said he held close during his fellowship. The journey has its challenges—moving to a new city and getting acclimated to a new environment, for starters—and a fellowship requires persistence and a sense of stubbornness to carry through.

But it’s worth it, according to Edlukudige Keshava. In the interview, he shared the story of his fellowship and provided advice on how to best transition to the next step in an oncologic career.

Oncology Fellows: What were your reasons for pursuing an oncology fellowship?

Edlukudige Keshava: I was going through residency training, and we used to see some patients who used to be referred to specialists in nephrology, hematology-oncology, etc. The fact that you could be a subject expert at something interested me. Once I started looking into hematology-oncology with all the new, exciting research that was going on and all the new types of treatments that we could offer our patients, all that excited me. So I gravitated toward hematology-oncology.

What specifically drew you to the fellowship program at AHN?

I had heard about the AHN fellowship program when I was in residency training through one of my friends. I looked it up, and then I talked to some of the fellows. All the camaraderie [among] the fellows was good.

There are programs they have in terms of cellular therapy, [chimeric antigen receptor] T-cell therapy, and tumor-infiltrating lymphocyte [TIL] therapy. All this was up and coming in West Penn Hospital as a part of our fellowship program.

Also, the 1 thing that also struck me was some of the fellows stayed back within the system as attending [physicians after they] graduated. In fact, most of our attending [physicians] at West Penn Hospital are trained in this very fellowship. That gave me comfort that the training is so good that they’re retaining the fellows as attending [physicians]. All these [were] factors.

A fellowship is a big undertaking. What concerns did you have about this new chapter?

I’m on a [J-1 classification] visa as an immigrant, so some of [them] would be visa [concerns]. For example, if we start a fellowship program, then we have to start our J-1 process all over again [for] the new institute. These are all streamlined processes, but when it goes through a new program, there will always be a fear of [that process not working out].

Other than that, with relocating to a new city, you’re packing your bags and then leaving. I got married in my third year of residency. My wife was in Texas, and I was in Philadelphia during residency. The thought of us finding a job in the same city, personal things—those were some of the fears. It did turn out OK.

Don't underestimate the move to a new city! What advice do you have for others trying to go through a similar moving transition?

One of the issues that I did not go through was changing state licenses, [because] I was coming from Philadelphia to Pittsburgh within Pennsylvania. Other than that, just finding a new apartment closer to the hospital we work in, the commute, and that sort of thing. We started looking at all this before we even finished the third year [of residency], so by the time I was done and had to start here, most of it was going to work out well.

Currently, what do you enjoy the most about your fellowship?

We have a continuity clinic in our fellowship program. That means fellows are designated as the primary hematologist-oncologist for our patients, and the attending [physicians] are there to guide us. It’s not [that] we are shadowing another physician; we are the oncologist [for] the patient. We get to answer their questions when they call back, and we see them in clinic every so often. I didn’t know this much before we got into fellowship, but you tend to become their go-to physician.

When someone has cancer, they tend to have all the questions with you. That brings a personalized relationship with the patient. A lot of my patients send me cards for [National] Doctors’ Day and so forth. That brings a lot of joy that cannot be quantified in any metrics. That is the best part of my fellowship.

Firsthand doctor-patient interaction is very important. What is it about AHN that perhaps sets their fellowship program apart from other institutions?

All the attending [physicians] are supportive. Some of them have freshly graduated fellowship, and some of them have worked with a lot of fellows in the past. That puts them at ease initially, because when you are starting a hematology-oncology fellowship—and I don’t know compared with other fields—it’s like you’re starting to learn a new language. In the first few days of whatever I learned in the past 10 or 12 years of medical training, I thought, “What did I even do? All this sounds new to me.”

You feel lost, and then sometimes you start questioning your own intellect. However, the attending [physician]’s job is to ease you through and say, “Everybody who chooses this goes through the same thing.” That really helped. You have all the other fellows who have gone through that and are in the same boat in their first, second, and third year, and we have 12 fellows in total. That helps rather than having 1 or 2 fellows. [We] all hang out, and it gives a sense of family. All the nursing and the ancillary staff have [also] been so wonderful.

What advice do you have for someone looking to apply for a fellowship?

For people trying to gear up for the fellowship application, some of the stuff I did was to talk to a lot of people [as a way to build] connections. Of course, once you start talking to people and expressing your interest, they might have insights as to how to proceed or places they know and places where they think you fit well. Going to some of these conferences, [such as those for] ASCO [American Society of Clinical Oncology] and ASH [American Society of Hematology], and trying to meet up with people would help.

The second thing is [that] as daunting as it looks, if you’re persistent in your journey, you make it in the end. Keep doing your research, keep working, find out about the place where you want to go, and talk to people about where they are.

The other thing that might help is doing an outside elective at a place where you like to go. I had applied to do an outside elective here at AHN, but [because of] COVID-19, I couldn’t do it. Now I see people are coming again and doing outside electives.

Your oncology specialty is lung cancer. How have some of your experiences in clinic been affected by the novel treatments and approaches brought to the lung cancer arsenal in recent years?

I don’t know where to begin. I was talking to one of our other thoracic oncologists, who has been doing this for 30 years or more. Twenty years ago, it sounded like stage 4 lung cancer treatments, with the chemotherapy treatments that we had, didn’t give a lot of benefit or hope to patients. In the past 10 years, with the advent of immunotherapy and all these targeted therapies that have come through now, overall survival and quality of life [have] gone up so much.

[In addition to sotorasib,] TIL research is also going on, and West Penn Hospital has a site opened for that as well. It is a lot to remember for a fellow, but it’s good for patients.

You can talk to patients, look them in the eye and say, “Hey, I have a lot of treatments that we can offer you, and then you would lead a good life. You could make it [to] your grandson’s graduation.” Those are some of the things that have come into our discussions with patients because all they care about is living longer and living better.

Vinay Edlukudige Keshava, PGY-5, is a hematology-oncology fellow at Allegheny General Hospital and West Penn Hospital System, Allegheny Health Network, in Pittsburgh, Pennsylvania.

Reference

FDA grants accelerated approval to sotorasib for KRAS G12C mutated NSCLC. FDA. May 28, 2021. Accessed May 10, 2023. https://www.fda. gov/drugs/resources-information-approved-drugs/fda-grants-accelerated-approval-sotorasib-kras-g12c-mutated-nsclc