Reflecting Back, Looking Ahead

Don S. Dizon, MD and Mary Anne Fenton, MD

Lately I’ve found myself looking back. Maybe it’s because I finally reached the pinnacle of academic medicine and made Professor; or maybe it’s because I have been an oncologist long enough to say, “Back when I was training…” But it boggles my mind to think I’ve been practicing for almost 20 years, and that I’ve witnessed such remarkable progress in how we treat cancer. I’ve also met phenomenal people, from my days in fellowship to today, and many of these relationships have not only lasted, but I find they sustain me. One of these people is Dr. Mary Anne Fenton, a colleague of mine at Lifespan Cancer Institute. I’ve known her for over a decade, having met her when I was working at Women & Infants’ Hospital (WIH).

Although she worked across the street, we collaborated on trials and on papers in breast oncology, and our paths crossed multiple times. I always had tremendous respect for her—her work ethic was incredible, and those times people I treated for breast cancer sought her out in second opinion, she’d call or e-mail me directly, and those same people came back with glowing reviews about her compassion and patience. We lost touch after I left WIH for different opportunities only to have come full circle, and returned to Providence—this time at Rhode Island Hospital, where she and I would be more than collaborators, we would be colleagues. These past few months, we would sit together and marvel about the new agents and strategies being approved to treat breast cancer, and each time, we would look back and remember what it was like to treat people with breast cancer before we had HER2-directed treatments, CDK4 inhibitors, and immunotherapy. Indeed, it was a different time. I asked Dr. Fenton to chat about why she chose oncology, her own experience in our field, and how she saw oncology evolve during her own career.

"I love the field of oncology, mostly because of those we meet each day. Everyone has a story, and people with breast cancer are more than patients. They are daughters, wives, mothers, teachers, nurses, college professors, hairdressers, first-generation immigrants, gardeners, marathon runners, grandmothers, to name a few, and I must include fathers, sons, husbands. For some, it’s a relationship I have with them that’s sustained over decades; for others it might only be one visit for a second opinion. The journey may start with the  diagnosis of breast cancer, adjuvant treatment, cure, relapse, remission, and along the way, milestones of marriage, children, grandchildren, birthdays, graduations, anniversaries to celebrate and for some, widowhood (or widowerhood), and divorce. I may be reminded of a person I’ve treated by their favorite song, special place, flower, a red dress, a picture of Snow White, the Grand Canyon, or the Dalai Lama. For me, every relationship stays with me in a subtle way.

Believe it or not, I was captivated by the promise of cancer immunotherapy as an undergraduate at the University of Connecticut in the 1980s, and it’s been remarkable to see that today we have targeted therapies such as monoclonal antibodies and checkpoint inhibitors to name a few. I am pleased to say the current state of clinical trials are focusing on patient-reported outcomes, personalized therapy and de-escalation of therapy rather than more cytotoxic therapy or different cytotoxic therapy. Though one thing I gotta say -- I did not see coming is the COVID-19 pandemic!

Still, I’ve been lucky; I’ve had professional opportunities throughout my career, and now more so. My Division provided financial support for a Visiting Professorship to Grand’Anse, Haiti in February 2020, and our group focused on cancers of the breast and female pelvis. We have initiated a bidirectional exchange with medical oncology colleagues in Tbilisi, Georgia, starting with a monthly metastatic breast cancer tumor board. In addition, I have taken up wonderful opportunities to lead our group’s participation in the ASCO Quality Oncology Practice Initiative. Indeed, we were among the first group to complete the ASCO Quality Training program, and all of this helped me discover a passion for quality improvement. I am lucky to work with colleagues and trainees on a number of projects, including in palliative care and breast cancer survivorship."

One of the more impressive aspects of our program has been the approach to multidisciplinary care, which is led by Dr. Fenton for medical oncology and Dr. Theresa Graves, the head of our surgical breast service. It’s a herculean task, but it works. I asked Dr. Fenton about what makes it special to her.

“Our Lifespan Cancer Institute (LCI) Breast Cancer Multidisciplinary Clinic includes the usual suspects including our Breast Cancer surgeon, Radiation Oncology, Radiology, and medical oncology. Survivorship begins at diagnosis and our social workers, physical therapist, and genetic counselors meet patients in LCI MDC at their first appointment. Most patients would agree the quiet hero of our practice is our breast cancer navigator Esther Llanos. Thanks to Esther many patients are able to navigate through the complex journey of cancer diagnosis, treatment, and survivorship. Esther’s goal is to eliminate barriers including financial, transportation, and cultural to name a few. Due to the COVID-19 pandemic and the need for social distancing, our LCI MDC transitioned within one week to Skype tumor board calls attended by all the players mentioned previously to discuss patient management and initiated telehealth visits whenever possible, including patient navigation, social work, and cancer genetics.”

As we looked back, I also wondered how she perceived the workplace, especially now in the midst of so much social change.

“In some ways the workplace is better for the working mother in medicine compared to 20 years ago, due to a larger proportion of working parents in the oncology workforce, and professional support from academic organizations including the Brown University Office of Women in Medicine and Science. Support is also found socially, like the MomDocFamily on Facebook, and the occasional (pre-COVID) hem/onc parent happy hour. My children, Kate, Kyle, and Ian, were born during my training, and maybe the working moms back then thought we just had to toughen up. Fortunately I had a supportive spouse and my children did not know any other life then our kooky, crazy family life. Back in the day (1980s), 90% of my partners were male with stay-at-home partners. In their defense, I don’t think they had any comprehension of the challenges for working parents. My partners’ wives took care of the twice-per-year dental appointments, school physicals, school orientation, etc.

I struggled being a good parent and being a good physician. Perri Klass wrote about the experience of being a mom and a primary care pediatrician, which provided me comfort (“So Where’s My Medal,” N Engl J Med 2005; 353:2107-2109). In it, she said “You do your best, you count your blessings, and you try to clean up the spills.” That’s it—I was not alone. When I first started… Now, we realize you should not have to choose between your family and your job. I personally have taken steps to ensure our faculty with young kids have their concerns taken into account in all aspects of academic oncology, from clinic structure, to offsite responsibilities, to promoting the importance of work-life balance. However, in other ways, the workplace is more challenging for working parents than it was previously. The electronic medical record has added a layer of duties not present when I started. We wrote or dictated our notes; nurses could enter verbal orders; documentation requirements were not as stringent as they are now.

Practice today requires so much more documentation, and many practitioners are completing charting and orders after they put their children to bed. In our group we have a few families where both parents are in the medical profession. This in and of itself makes for a complex balance of work and family time, not to mention the demands of call. I also think that while access to cell phones and secure messaging has enhanced patient care, we assume that doctors are always available, and this adds to stress and burnout. During the COVID-19 pandemic many of my colleagues lost access to childcare and traditional schooling. While they may have been able to spend more time home with telehealth, they also had the additional responsibility for home schooling, and there wasn’t a how-to book on that. One of my partners tells of teaching her 6-year-old son about vowels in between telehealth visits. I am amazed at their resiliency.”

What I found most impressive about Dr. Fenton is that I imagine her to be the optimist at our center. It’s not an “everything is rosy and will turn out fine” kind of approach; it’s more of a “things will get better and if it doesn’t, we’ll get through it.” I find those in training are drawn to her because of it, and it’s this inner strength that makes her the heart of our program. I asked her how she does it and this is what she said:

“I love the science of medicine. Twenty years ago we could only imagine checkpoint inhibitor therapy and personized medicine with tumor genomic sequencing, and here we are. The progress is motivating, but as important is the opportunity to work with trainees—it helps me recharge. But it’s more than that. It’s so important to unplug. I go outdoors—run, swim, bike. I take time off to go to Block Island, paddleboard at the Hopkinton Reservoir. I even try to golf. I spend time alone and quilt, and I make time for those I love, whether it be Sunday family dinner or Zoom happy hour with friends. Finally, it’s important to laugh at yourself and your foibles—and laugh at your colleague’s posts on TikTok. Always be ready for the next adventure.”