What You’ll Learn

An oncology resident shares insights on NGS testing evolution, clinical trials integration with EMRs, and conversations with patients when no treatment options remain. His advice to medical students considering specializing in oncology: “if you want to always be on the cutting edge, and if you’re okay with never having a bread and butter day? Oncology.”

Interviewee: I’m an internal medicine resident, but I have a pretty extensive oncology background. I worked at an NCCN cancer center for a couple of years in oncology clinical research, specifically hematology, malignancies and BMT. Then I went to medical school, finishing up residency, and then I’m going to ideally do a fellowship in oncology.

My current research is geared towards that. I’m technically not board-certified yet, but as long as all my ducks are in order, that’s the plan.

The practice I’ve been with for two years, it’s actually two practices because of my training. I rotate through a private practice, and then I also get to rotate through a different NCCN cancer center. The private practice is only three doctors, but the cancer center within our division’s 20, I think. And then the greater health system, it’s 100 plus.

VIVO: And a percentage of that is lung cancer patients?

Interviewee: Yeah. In fact, within the cancer center there’s people who just do lung cancer.

VIVO: Do you deal with lung cancer a lot, personally?

Interviewee: Not as much as I thought I would. We’re in a heavy smoking area. But we do see it.

VIVO: What’s something that inspires you as somebody who’s especially new to all this?¬†

Interviewee: It’s funny because when I first started, it was the patient stories. There were patients from when I was a research coordinator who kept in touch with me through med school. And now I think it’s more the advancements. You just get inundated with patients.

I had the opportunity to sit in on a lecture on one of the new specific antibodies in multiple myeloma with an overall response rate of 80%, which in cancer is…

VIVO: Wow.

Interviewee: Exactly, it’s nuts. And seeing that, I was super inspired, we’re really getting somewhere.

VIVO: Yeah, things that are actually working and you’re not shooting in the dark, right?

Interviewee: Yeah. And some of the stuff I was doing phase one trials on four, five years ago are now standard of care.

VIVO: What’s an example of that?

Interviewee: I got to work on a couple of CAR T products actually. The Kite trials, the ZUMA trials. And now they’re standard of care and a bunch of different indications. I didn’t know until I finished med school and I started practicing, I was like, “Wait a minute, I know that drug.” And here we are.

VIVO: Anything that surprises you? Is there anything that now you’re in the middle of it, you’re going, “This isn’t what I thought at all.” Any big surprises?

Interviewee: I think once I started practicing, I realized that I had a very privileged position working at a cancer center on a specific disease site. In oncology, a lot of community oncologists still do a little bit of everything. Which to me sounds insane because there’s so many drugs, there’s so many trials. How do you keep it all straight? But some people still do it.

VIVO: With the doctors you work with right now, do you see a big difference in the way that they treat or the sources that they use to treat?

Interviewee: I think the way they treat has changed a lot, especially in the era of next-generation sequencing. So they can be way more targeted. It’s still so new and it’s still so unstandardized. The data is still out on whether or not that targeting is making a huge difference, but anecdotally it seems to be.

VIVO: Do you find that most doctors use NGS?

Interviewee: Honestly, at the cancer center, but even in the private practice they all use it too. Nobody’s had any trouble getting it covered or getting access to it, because a lot of the private practice doctors also used to work with this cancer center. So they all talk. They all share contacts. That’s why they share residents too.

VIVO: Do you see more tissue biopsies or do you see more liquid?

Interviewee: They shoot for tissue if they can. They still have it. They’ll prefer tissue over liquid. Really anything solid tumor, you’re going to want tissue.

VIVO: Is there a certain brand that they use predominantly? 

Interviewee: Yeah, I think the cancer center has an agreement with Foundation, and then I think the private practice uses Foundation and Guardant.

VIVO: Do you see differences in those? Or are they the same as far as what you need and the services that they provide, the information that they provide? 

Interviewee: I think the key difference between the two, they’re pretty similar, is that Foundation is integrated into our Epic, into our charting software. So it’s very easy to find. And sometimes integrated means they upload a PDF and you can find it. With Epic actually, put all the mutations in the lab section, and you can search for it, which is super easy. They’re edging out Guardant in that regard.¬†I’m sure Guardant’s going to catch up eventually.

VIVO: Do you find that there is testing being done repeatedly? Is it being done at a cadence or do you find that it’s tissue and then it’s done?¬†

Interviewee: I think in lung cancer, I think it’s tissue and it’s done. I’ve noticed a bit more of a cadence with breast cancer, because there’s certain five and 10-year benchmarks for the hormone modulators. And then, at those benchmarks or at certain points of progression. Specifically, if someone has brain mets, they’ll retest because they want to target the brain mets differently. They treat brain and body different.

Lung cancer, I haven’t seen that distinction just yet, between brain and body or at certain points of progression, but I think it might still be evolving.

VIVO: Is there anything that you see more prevalent? For instance, if it’s breast cancer, is there something that you see where they’re coming in more advanced or less advanced? If it’s lung cancer, do you see that they’re coming in more advanced or less advanced, etc.?

Interviewee: I think this is more of a paradigm of lung cancer. We do still see it. But it holds true that small cell comes in worse. It’s in and out faster in that they’re sicker diagnosis, they have a worse prognosis, and they have a rough course all around.

For some reason, we’ve seen an uptick in small cell near us. Whereas with non-small cell, it runs the gamut, especially with the lung cancer screening guidelines and all these opportunities to intervene sooner. Those courses tend to be better, because even if we’re catching more people, we’re catching them earlier. Whereas small cell is really a wrecking ball.

VIVO:  When somebody comes in and is in a pretty rough situation, do you have any general advice that you give patients? What kind of guidance, or hope, can you offer for your patients?

Interviewee: I think for me, I try to take it from an efficiency perspective. Because a lot of the work I do, I see them in the hospital at the time of diagnosis. I don’t see them in the outpatient when they get the treatment options. And in all honesty, I’m not as well versed in the small cell treatment options because sometimes it involves inpatient. And then in that case, we have to send them to a sister hospital. I don’t administer the inpatient chemo right now.

So it’s more, “Listen, this is a scary diagnosis.” But we’re at least in a very healthcare rich area where I can say, “Hey, I can get you an appointment tomorrow with a small cell expert, and we can get you on treatment within a week. And we can give you information to decide if you even want treatment and what the steps are.”

So I think some people appreciate the confidence in that approach of, “We’re going to go through this together and it’s going to be a quick and wild ride. But you’re in it and we’re in this with you.” That’s the best I can do.

VIVO: I’m sure it does help, right, if they don’t feel like they’re alone?

Interviewee: Yeah, definitely. I’ve worked at a couple different health systems. The other cancer center was a different health system. And this one, they really do move so quick to the point where they will schedule you the next day. And you’ll get a notification on your phone and they’ll give you instructions and your biopsy will be lined up for the day after that. And they move so fast that the patients feel taken care of.

Whereas in places where it takes a week for your initial consult, then we have to order tissue and that takes another week. And you’re sitting there freaking out. Whereas here, you’ll get biopsied the next day. Or if you’re the hospital, we’ll biopsy you in the hospital and we’ll get things done. So I think a lot of people really appreciate that they feel like they’re being taken seriously.

VIVO: When results come back and there is an alteration that is actionable, is that exciting news to deliver to your patients? Do you feel like that’s, “Hey, we got something, there’s a choice here, there’s a chance here.” Or do you think that it’s another treatment path?

Interviewee: I think it’s a little more exciting for me because I’m early on. And I still don’t have enough of my own personal data to determine if those treatment paths are really working.

I think for some of the more experienced oncologists, they’re like, “You know what? I’ve seen this before. We’ll see.” But for me, I’m like, “Oh, you’ve got something I can hit with Keytruda, let’s go.” That’s easy. So it definitely is exciting, but I know I still need more background.

VIVO: I would think that if an oncologist has been out of school for 20, 25 years, the landscape has changed so dramatically since then. Ever since you started, you’ve been involved in all this stuff. So this is completely different than an oncologist that never had any access to this. Do you sometimes see older oncologists still catching up?

Interviewee: Actually, oncology is one of the few places where you don’t, because you know going into oncology, you have to stay on top of stuff no matter what. There’s certain medicine-related things because all oncologists did medicine. We all were internal medicine doctors and then we become cardiologists, oncologists, et cetera.

So there’s certain medicine things I’ll teach them that have changed. But especially with how easy it’s to access NCCN guidelines and to read the citations and understand why they changed what they changed. It’s hard not to be on top of it, but you also signed up for that by being an oncologist. You have to enjoy learning about updates in the field.

And there’s so many opportunities. There’s ASH, there’s ASCO, there’s local society meetings, there’s webinars. Even now I get pages and pages of journals, mailed to me as a resident. So the oncologists are really good at keeping up. Some of the primary care, even some cardiologists, it’s tougher, because you’re so busy. But here, it’s our duty.

VIVO: If you work in an NCCN place, I would imagine that that is true. As opposed to maybe some other community oncology practices that might fall behind? Or do you think that in general oncology is something that pushes forward?

Interviewee: I think in general, oncology pushes forward because everyone uses the NCCN guidelines, even the private practice we rotate through. Same guidelines, same standards of care.

I think the privilege of working at an NCCN comes, again, from the access and the speed that we can get things done. And having the ability to pick up the phone and call someone at the bigger hospital and go, “Hey, I have this weird case, will you see them?” But in terms of the basics, I’ve seen them both private doctors and cancer center doctors pull up the same guidelines and use the same treatment.

VIVO: Is there anything that you see sometimes that you think, “I really wish we had this? I wish we could do this easier?

Interviewee: Those EMR integrations always going to be a thing because more of our life keeps getting EMR dictated. There is a very fancy version of Epic that integrates the NCCN guidelines into the Epic every six months, which even our institution doesn’t pay for. It’s insanely expensive, but that would be amazing.

I think also, as a former clinical trial person, integrating trials better and access. Because now that I think about it, that’s a privilege of the NCCN cancer centers. That they have the trials, they know what’s available and what’s not, and they know who to reach out to if they don’t have a spot.

Whereas, even in the community setting with our hospital that’s connected to the NCCN cancer center, one of our community hospitals. They have no idea what trials are available. They call their colleague in the main hospital and go, “Do you have anything?”

But we could probably access trials better if we had some better integration nationally of what’s open, what’s not. And then to be like, “All right, I have someone with a PTEN mutation plus A, B and C. Is there a trial that fits this criteria?” Plug it into a search engine, boom. “Where are the spots? Oh, hospital one and hospital two in our city have it.” That would be amazing.

VIVO: When there is a negative case, when there’s a situation that’s not great for a patient, what is the best advice that you can give your patient? What is a way that you can provide hope/console them and their family, or provide the right emotion for the moment?

Interviewee: It’s hard to generalize because every patient needs a slightly different approach. I think for me, I set the bar whenever I have a new patient at the start. Regardless of your prognosis, whether it’s a stage one breast cancer that, “We can put you on endocrine therapy, you’ll be fine.” Or a stage four lung cancer, “You should have these talks with your families. Set up an advanced directive, be prepared for the worst. So then God forbid we ever need to call on this conversation again, we can.”

And then if it’s a patient I’ve been following, I’ll be like, “I think it’s time we called on that conversation.” And they really do appreciate the honesty because even patients who come and see oncologists for benign heme, they still get scared of the oncologist.

They’ll see the name on their schedule and they’ll be like, “Oh, no, it’s the big C.” I’ve had very few patients that are scared of the honesty, and if anything are ready to embrace it. And be like, “All right. My doctor finally gave me the word. Now it’s time to start thinking about what I want.”

Interviewee: That’s the part that drew me to oncology too, is you form a really close bond with whoever you treat from beginning to end, whenever that may be. So there’s a lot of palliative aspects that get pulled into it.

VIVO: That was in your screener, that the amount of compassion in an oncologist is unmatched. I think you said, “A unique degree of compassion.”¬†

Oncology Resident: Yeah.

VIVO: Do you think part of that is, if it is toward the end, do you think part of that honesty is saying, “Let’s stop the treatment?”

Interviewee: Yeah, definitely. I think a lot of physicians struggle with good end-of-life care in any field, especially oncology. I keep getting bombarded with all these tools, but they don’t apply. I think, again, most people are receptive. There’s always a couple standout, it’s the family more than the patient, that are like, “Keep fighting, keep fighting, give them everything you’ve got.”

And there’s been a couple of situations where me and my colleagues are like, “This is inhumane at this point. I can’t in good conscience give you treatment. It’ll kill you faster than the disease.”

And then that’s probably the harder conversation of there’s different palliative options that could keep disease at bay while you regain some quality of life and some functioning. And people who are ready for the conversation can handle that too.

But people who aren’t ready for the conversation are really the biggest struggle, because at that point then, I can’t even offer you the palliative therapy because the goals don’t align with the point of therapy. You don’t understand curative versus palliative intent at this point. Or you’re trying to force my hand to give you chemo regimens that could kill a horse. And I can’t in good conscience do that.

VIVO: Generally speaking, when there’s so much fight left in the family and the person with it is kind of stop fighting. Is there something that gives them peace, generally speaking, or is that completely different no matter the situation?

Interviewee: Most of the time it’s a very peaceful conversation. Most of the time it’s very much like, “Listen, we don’t have a ton of options left. We should talk about getting comfortable.”

But when you hit that family that refuses to have that conversation, then you have to be a little more forceful with them. And they do get frustrated, they don’t take a lot of peace away from the conversation. But eventually, unfortunately, they either break through and they realize or the patient passes.

But I am blunt like that too, where I’ll say, “I can’t in good conscience continue to treat you. It would be doing more harm than good.”

And then sometimes they’ll seek second opinions and people in other institutions will say the same thing. Or maybe, some oncologists will treat with them out there, but even if they don’t understand the goals of care, because they’re going to keep coming back anyway.

But it’s tough. But I think sometimes you have to have a little tough love and you also have to empower the patient themselves because a lot of times it’s family driving the patient, because they’re not the ones feeling the disease.

When you’re in that position, you’re very vulnerable, because you’re weak, you rely on your support system. A lot of times with certain chemicals, you’ll get the neuropathies and you can’t really drive and you can’t really walk around. And so it’s tough, but a little bit of tough love, it’s necessary.

VIVO: On the other end of it, is there ever a time where it did look bleak and where it did look negative,  and suddenly something worked. What kind of story was that? Was it a certain stage of cancer or a certain type of cancer?

Interviewee: I’ve had a couple. When I first started at the old cancer center, pre-med school, I had a patient on a clinical trial with a daily pill. When you sign up for the trial, the company has to in writing say, “If you do all this treatment, we’ll make it for you indefinitely. Even if we don’t sell it because legally we have to. And also, it’s the least we can do if you derive benefit from our experiment.”

And this one guy, he had this really bad diffuse large B-cell lymphoma. And they’re running out of options, they tried him on the pill and it put him in a remission to this day. This was in 2017. And it’s a pill every day. No side effects. And the company never marketed the pill, so they make it for him.

He was one of my first patients. They gave him to me as a gift because they’re like, “He’s the easiest case you’re going to have. He’s going to take this pill forever and you have to get in his pills every year.”

VIVO: That’s a really great story about personalized care.

Interviewee: Absolutely, unintentionally personalized care. It happened to work for him. And so they’re going to use the drug in other indications, but he’s getting it for free for life.

VIVO: For someone who’s entering this and is like, “I don’t know. Maybe this isn’t right for me. There’s a lot of scary stuff happening.” What’s your best advice you can give somebody?

OncInterviewee: I think the best advice I’d give is actually general advice that a lot of medicine residents get: “Go through every specialty and look at the thing they do every day. Day in and day out, what’s their bread and butter? And if you can’t see yourself doing that every day, don’t do it.”

So a cardiologist manages heart failure day in, day out, pulmonologist manages COPD, and oncologist manages everything. A whole comprehensive care plan. Day in and day out, they’re having those tough discussions. They’re also having some success stories too. And so if you like that variability, and if you’re willing to keep up on the knowledge you have to at a very different level, go for it.

If you want something a little more consistent, which is completely reasonable, if you want to be an expert at heart failure, go for it. Which goal-directed medical therapy for heart failure probably won’t change. But if you want to always be on the cutting edge, and if you’re okay with never having a bread and butter day? Oncology.

Participant Profile

• Female internal medicine resident with oncology background
• Works in a “healthcare rich area” with a heavy smoking population
• 2 years in current position, plus previous experience as research coordinator at an NCCN cancer center
• Rotating between private practice (3 doctors) and NCCN cancer center (20+ doctors in division)
• Oncology with extensive background in hematology malignancies and BMT; planning to pursue oncology fellowship
• Sees varied oncology patients including lung cancer, with an uptick in small cell lung cancer cases
• Challenges/priorities: Efficient patient care delivery, integrating clinical trials better, and improving integration of resources like NCCN guidelines