First day in clinic!
5/10/19 pt. 2: clinic #1.
First day in clinic!
Friday, May, 10, 2019 (pt. 2)
TL;DR: We saw around seven
patients in total, ranging from those with newly diagnosed localized disease to
status checks (ongoing treatment) to metastatic disease – mostly for prostate
cancer. As I shadowed Dr. Marciscano and sat in on patient meetings, I was able
to learn about prostate cancer and the cutting-edge treatments offered at MSK.
The day started off bright and early as I
headed into the city on the 6:45 AM commuter bus with my dad, getting to New
York around 7:45. From Port Authority, I took the “shuttle”/subway to Grand
Central and another subway (the 6) from Grand Central to the 68th/Hunter
College station uptown. After a short walk, I made it to MSK’s main campus,
1275 York Avenue, ready to start the day around 8:15.
One of the first conversations Dr. Marciscano
and I had (in fact, in a call prior to clinic that day), was about his
schedule. Because he holds clinic in both Monmouth and New York, he splits his
days up between the two locations. In addition, rather than having a little bit
of clinic every day, he arranges his schedule to see all his patients on
Fridays (NY) – and occasionally Wednesdays (NY) – and Saturdays (Monmouth). He
uses the other days to catch up with administrative work, treatment planning (which
I’ll get into in the next post), and pursue research projects. As he explained
this schedule, I started to realize that doctors do not only see patients. They
may also pursue research on the side (typically through clinical trial work),
whether it be lab work or retrospective studies. Most importantly, he advised,
it’s all about finding where your passion lies (in the lab or in the clinic)
and developing a satisfactory balance between the two. (MD life advice #1!)
Once I got oriented as to where everything was
in the building (entrance, cafeteria, his clinic, his office), we looked over
the notes for the first patient together. During that time, I also started
looking through some of Dr. Marciscano’s recent presentations at MSK on
encouraging radiation therapy and immunotherapy combinations.
We met with around seven patients that day
(almost all newly diagnosed localized prostate cancer disease), including a
couple of add-ons. A relatively normal number of appointments, with some just
status checks and some new consultations, Dr. Marciscano described. While I
will not go into any specifics due to HIPAA regulations, I’ll go over a couple
of highlights/general findings that I learned as I shadowed Dr. Marciscano/sat
in with him during patient meetings:
- Newly diagnosed patients were given their diagnosis based on a
few tests… (*note: simplified)
- Prostate specific antigen (PSA) blood test – measures PSA levels
in the blood; because PSA is a protein made by the prostate/prostate cancers,
if there is a very rapid increase in the PSA levels then this could mean there
are cancer cells present in the prostate
- Digital rectal examination (DRE) w/ the PSA test
- Biopsy – remove tiny amounts of prostate tissue that are then
reviewed by the pathologist; the pathologist will assign…
- Gleason Score – pathologist reviews the tissue and gives a primary
and secondary pattern score randing from 3-5, with 3 being malignant tissue
closest to normal and 5 being high-risk/highly aggressive cancer; when these
two scores are combined, the prostate cancer is assigned a Gleason grade then helps
classify patients as low risk,
intermediate, or high-risk (and even further) – when used in conjunction with
other clinical factors like the DRE and PSA level.
- CT/MRI/bone scan – check if there is metastasis (if the cancer
has spread) by looking at the lymph nodes and the bone; whether or not the
cancer is pushing against anything/threatening to invade the nodes
- MSK IMPACT testing (specially offered by MSK) – blood test and
biopsy to see if there are any germ line mutations (passed down from family/if
there is family history of breast cancer/prostate cancer etc.) and potentially
use specific drugs to target these mutations
- After reviewing the results from these tests, Dr. Marciscano
works with his team to develop a treatment plan (if the patient so chooses to
pursue radiation and is a good candidate for this); there are a couple options
at MSK (not comprehensive):
- Radiation therapy (RT)
- Conventional (lower doses over longer period of time), moderately
hypofractionated, and stereotactic ultra-hypofractionated radiation therapy to
the prostate (higher doses over shorter period of time)
- May include combination with hormone treatment
- Surgery
- If there is still a rising/high level of PSA even after the
cancer is removed, it is possible there are some cancer cells left; in this
case, post-operative salvage RT + hormone treatment to cure the biochemical
recurrence
- Brachytherapy (can also be used alone or in conjunction as a
booster dose of radiation) – radioactive sources or “seeds” are implanted into
the prostate for either a short (high dose rate) period of time
intraoperatively or permanently (low dose rate)
- All of these therapies have various side effects, ranging from
fatigue to urination problems/incontinence to
- Ongoing treatment – more side effects associated with RT
- Newly diagnosed – IPSS helps track symptoms/sometimes have no
symptoms at all
- Palliative RT care can also be provided to patients whose cancer
is now metastatic
- Speaking another language is incredibly helpful – Dr. Marciscano
could personally connect with a patient speaking Spanish and I helped Dr.
Marciscano by speaking Chinese to a patient
Technicalities and specifics about prostate
cancer aside, I also witnessed the emotional, financial, and physical toll a
cancer diagnosis takes on patients and their families. It is incredibly
difficult to adequately inform patients on the extent of their disease while
also reassuring them of their treatment options and their path going forward.
Finding this balance is crucial – that’s why, at MSK, radiation oncologists,
like Dr. Marciscano, work together with surgeons/urologists to allow newly
diagnosed patients the opportunity to consider all options before making an
important decision on their treatment.
Dr. Marciscano’s team includes his nurse,
Mark, who prepares patients (vitals etc.), his assistant, Tabatha, who manages
his appointments, and many others at both campuses. Indeed, there is a lot of
administrative work (replying to emails, paperwork, patient compliance forms
for treatment, etc.). He also works with surgeons/urologists, pathologists,
physicists, dosimetrists (for MRI), medical oncologists, and more to ensure
that the patient is receiving the best possible care at every step.
At the end of the clinic day, I ultimately
realized that one of the most important aspects of going into the medical field
as a physician, and especially in oncology, is maintaining a warm
physician-patient relationship. Distilling medical jargon down to information
that can be shared with patients and their families is an important skill that
doctors must develop and hone; Dr. Marciscano is a wonderful example: he gently
eased patients into understanding their disease with layperson terms that were
clear and concise, knowing when to comfort and when to caution.
While my day finished around 4:30 to catch the
bus back to Jersey, Dr. Marciscano had a couple more patients left to see.
After each patient, he is very organized and updates all his notes, making sure
that every patient’s story is fully represented.
It was a pretty busy clinic day, but I’m happy to have learned
quite a bit about prostate cancer and its available treatments.
Friday, May, 10, 2019 (pt. 2)
TL;DR: We saw around seven patients in total, ranging from those with newly diagnosed localized disease to status checks (ongoing treatment) to metastatic disease – mostly for prostate cancer. As I shadowed Dr. Marciscano and sat in on patient meetings, I was able to learn about prostate cancer and the cutting-edge treatments offered at MSK.
The day started off bright and early as I headed into the city on the 6:45 AM commuter bus with my dad, getting to New York around 7:45. From Port Authority, I took the “shuttle”/subway to Grand Central and another subway (the 6) from Grand Central to the 68th/Hunter College station uptown. After a short walk, I made it to MSK’s main campus, 1275 York Avenue, ready to start the day around 8:15.
One of the first conversations Dr. Marciscano and I had (in fact, in a call prior to clinic that day), was about his schedule. Because he holds clinic in both Monmouth and New York, he splits his days up between the two locations. In addition, rather than having a little bit of clinic every day, he arranges his schedule to see all his patients on Fridays (NY) – and occasionally Wednesdays (NY) – and Saturdays (Monmouth). He uses the other days to catch up with administrative work, treatment planning (which I’ll get into in the next post), and pursue research projects. As he explained this schedule, I started to realize that doctors do not only see patients. They may also pursue research on the side (typically through clinical trial work), whether it be lab work or retrospective studies. Most importantly, he advised, it’s all about finding where your passion lies (in the lab or in the clinic) and developing a satisfactory balance between the two. (MD life advice #1!)
Once I got oriented as to where everything was in the building (entrance, cafeteria, his clinic, his office), we looked over the notes for the first patient together. During that time, I also started looking through some of Dr. Marciscano’s recent presentations at MSK on encouraging radiation therapy and immunotherapy combinations.
We met with around seven patients that day (almost all newly diagnosed localized prostate cancer disease), including a couple of add-ons. A relatively normal number of appointments, with some just status checks and some new consultations, Dr. Marciscano described. While I will not go into any specifics due to HIPAA regulations, I’ll go over a couple of highlights/general findings that I learned as I shadowed Dr. Marciscano/sat in with him during patient meetings:
- Newly diagnosed patients were given their diagnosis based on a few tests… (*note: simplified)
- Prostate specific antigen (PSA) blood test – measures PSA levels in the blood; because PSA is a protein made by the prostate/prostate cancers, if there is a very rapid increase in the PSA levels then this could mean there are cancer cells present in the prostate
- Digital rectal examination (DRE) w/ the PSA test
- Biopsy – remove tiny amounts of prostate tissue that are then reviewed by the pathologist; the pathologist will assign…
- Gleason Score – pathologist reviews the tissue and gives a combination of scores from 1-5, with 1 being tissue closest to normal and 5 being high-risk/highly aggressive cancer; when these two scores are combined, the prostate cancer can then be classified as low risk, intermediate, or high-risk (and even further)
- CT/MRI/bone scan – check if there is metastasis (if the cancer has spread) by looking at the lymph nodes and the bone; whether or not the cancer is pushing against anything/threatening to invade the nodes
- MSK IMPACT testing (specially offered by MSK) – blood test and biopsy to see if there are any germ line mutations (passed down from family/if there is family history of breast cancer/prostate cancer etc.) and potentially use specific drugs to target these mutations
- After reviewing the results from these tests, Dr. Marciscano works with his team to develop a treatment plan (if the patient so chooses to pursue radiation and is a good candidate for this); there are a couple options at MSK (not comprehensive):
- Radiation therapy (RT)
- Conventional (lower doses over longer period of time), Stereotactic hypofractionation accelerated radiation therapy to the prostate (SHARP) (higher doses over shorter period of time)
- May include combination with hormone treatment
- Surgery
- If there is still a rising/high level of PSA even after the cancer is removed, it is possible there are some cancer cells left; in this case, post-operative salvage RT + hormone treatment to cure the biochemical recurrence
- Brachytherapy (can also be used in conjunction as a booster dose of radiation) – radioactive “seeds” are planted into the prostate for either a short (high dose) or prolonged period of time (low dose)
- All of these therapies have various side effects, ranging from fatigue to urination problems/incontinence to
- Ongoing treatment – more side effects associated with RT
- Newly diagnosed – IPSS helps track symptoms/sometimes have no symptoms at all
- Palliative RT care can also be provided to patients whose cancer is now metastatic
- Speaking another language is incredibly helpful – Dr. Marciscano could personally connect with a patient speaking Spanish and I helped Dr. Marciscano 🙂 by speaking Chinese to a patient undergoing treatment
Technicalities and specifics about prostate cancer aside, I also witnessed the emotional, financial, and physical toll a cancer diagnosis takes on patients and their families. It is incredibly difficult to adequately inform patients on the extent of their disease while also reassuring them of their treatment options and their path going forward. Finding this balance is crucial – that’s why, at MSK, radiation oncologists, like Dr. Marciscano, work together with surgeons and urologists to allow newly diagnosed patients the opportunity to consider all options before making an important decision on their treatment.
Dr. Marciscano’s team includes his nurse, Mark, who prepares patients (vitals etc.), his assistant, Tabatha, who manages his appointments, and many others at both campuses. Indeed, there is a lot of administrative work (replying to emails, paperwork, patient compliance forms for treatment, etc.). He also works with surgeons, urologists, pathologists, physicists, dosimetrists (for MRI), medical oncologists, and more to ensure that the patient is receiving the best possible care at every step.
At the end of the clinic day, I ultimately realized that one of the most important aspects of going into the medical field as a physician, and especially in oncology, is maintaining a warm physician-patient relationship. Distilling medical jargon down to information that can be shared with patients and their families is an important skill that doctors must develop and hone; Dr. Marciscano is a wonderful example: he gently eased patients into understanding their disease with layperson terms that were clear and concise, knowing when to comfort and when to caution.
While my day finished around 4:30 to catch the bus back to Jersey, Dr. Marciscano had a couple more patients left to see. After each patient, he is very organized and updates all his notes, making sure that every patient’s story is fully represented.
It was a pretty busy clinic day, but I’m happy to have learned quite a bit about prostate cancer and its available treatments.
Just STEM thoughts 