By Zuhir Bodalal, MD, MSc (Oncology), PhD candidate
As a medical graduate in Benghazi, Libya, I was faced with the age-old question: Where in medicine can I make the most meaningful impact?
My clinical training in Benghazi took place during the time of the Libyan conflict and, as such, the majority of patients in our hospitals were trauma victims. Patients requiring urgent surgical attention flooded the emergency rooms and our health care system needed to carry this unexpected burden. Naturally, this reality heavily influenced my initial decision to push my postgraduate training in the surgical direction, focusing on trauma surgery.
In the chaos of armed conflict, however, it is easy to forget non-trauma patients, particularly those with chronic noncommunicable diseases, such as cancer. Just as people were being rushed in for gunshot injuries or shrapnel wounds, we also received patients with acute oncologic emergencies like superior vena cava syndrome, febrile neutropenia, and cancer-related thrombotic events. Seeing these patients and following their journey in our hospital was a major contributing factor towards my decision to make the career change away from trauma surgery and towards oncology.
This was how I became introduced to the heroic staff of the Department of Oncology at Benghazi Medical Center. One memory that will be permanently imprinted in my mind is the first time I attended the daily round at the oncology department. As a result of delayed presentation, every single patient, without exception, was on palliative end-of-life care. Yet, in spite of acute shortages and limited treatment, the staff diligently provided the best available treatment to the patients. Witnessing this incredible work inspired me to pursue the path of a clinician-scientist in medical oncology.
My dream was (and still is) to become knowledgeable in both the clinical and research domains in order to offer my future patients, who may be at such terminal stages, treatment choices tailored to their specific tumour profile. I wanted to make a difference and offer a chance to a patient who would otherwise be out of options. For this, the path was clear: I needed to bridge different worlds.
As an early-career physician-scientist, I needed a lot of guidance and I’ve had the privilege to cross paths with many outstanding individuals, both in the clinic and in a research setting, who I am proud to call mentors. While this is only the beginning of the journey, I’ve had the privilege of learning a number of valuable lessons.
1. The human factor can never be excluded in oncology.
Starting out in oncology, I realized that educational resources and guidance were critical to success in the field. The online educational materials were the single greatest motivator for me to join ASCO. It was there that I was exposed to the latest guidelines for different types of cancer and it was there where I would be introduced to my first mentor in oncology.
When I joined, it just so happened that ASCO had opened a call for applicants for their Virtual Mentoring Program, where junior members would be partnered with experienced mentors. This idea resonated with me and I decided to apply, unsure of how willing they would be to take on a person who had only just begun. Two months later, I happily received two emails; one of my acceptance into the Masters of Oncology program at the Vrije Universiteit in Amsterdam and the second stating my acceptance into the ASCO Virtual Mentoring Program. Combining the formal education of an advanced degree with the semi-structured approach of the mentorship was ideal since it allowed me to really focus on specific topics (i.e., immuno-oncology) from multiple perspectives.
Given the distance between the United States and the Netherlands, my mentor, Dr. Ken Miller, and I used different video-conferencing programs to meet on a regular basis to discuss various topics. Early on, we decided to adopt the content of ASCO eLearning. We covered a wide array of tumours and learning points in the material and what struck me was the way that Dr. Miller viewed each topic. Balancing the master’s degree with the clinical mentorship added significant value since we would often link symptomology to biology, which helped cement core concepts.
Whenever we would start a new module (i.e., leukemia, breast cancer, etc.), he would add anecdotes and his experience with patients who suffered from the condition. In these patient cases, I found the human element that motivated me to transition to oncology. Dr. Miller taught me that we must never forget that the clinical/scientific material that we are learning reflects real patients with real stories.
2. Medical oncologists can excel not only in the clinic but also in translational research.
The field of oncology has witnessed significant growth in the past few decades both in the domains of research and clinical practice. As more insight is gained into tumour biology, more treatment options are being made available to patients with otherwise terminal disease. Following the Masters of Oncology program helped unlock this world for me, where concepts like the tumour microenvironment have shaped my views on therapeutic approach.
However, traditional medical graduates classically receive more thorough training during the clinical years with a heavy focus on symptoms, diagnostics, and disease management. In my experience, this led to a neglect of the more fundamental/translational sciences and a general disdain for research. A lot of my clinical colleagues firmly believed that doctors belong in the clinic, a sentiment echoed by “pure” biologists in the lab. Initially, it was highly discouraging to see “scientific segregation” in research.
Here, however, mentorship proved important once more.
During my internships, I had the good fortune of being embedded within the groups of two clinician-scientists. They helped show me that it was possible to excel not only in the clinic but also in translational science. Their research did not take away from their clinical capacity, nor vice versa, but rather they actively operated as scientific bridges. Sometimes the biologic experiments would be led by clinical observations, and other times, based on results seen in the lab, changes were made to clinical practice. Having them as positive role models and seeing them lead the way, making such an impact, inspired me to keep moving forward.
3. Clinicians can also lead and inspire in the technical domain.
Having successfully completed the master’s degree, I was looking for the next big step in my career, and it came in the form of a revolutionary concept that challenged one of my long-held beliefs on the clinical workflow. My mindset was that once a patient is admitted for care, a biopsy must be acquired for biologic stratification and molecular subtyping. Obviously, biopsies are far from ideal, suffering from sampling bias and posing morbidity for patient, but they were—in my opinion at the time—essential.
A new, surprisingly technical, concept was brought to my attention by my current mentor and PhD supervisor, Professor Regina Beets-Tan, in the Department of Radiology at The Netherlands Cancer Institute. At our cancer center, Prof. Beets-Tan leads the research being done in quantitative imaging and radiomics. In a nutshell, radiomic features are mineable quantitative parameters that can be extracted from routine radiologic images and can decode imaging phenotypes beyond what is discernible with the human eye. This revolutionary approach, coupled with artificial intelligence methods, enables us to build algorithms capable of making noninvasive predictions on outcomes ranging from prognosis to genetic status to therapeutic response. The promise of noninvasive radiomic markers astounded me and I became motivated to pursue this as my PhD project.
Here, I was inspired by a new sort of bridge—one between the clinical and technical worlds. In our department, work within multidisciplinary research and clinical teams helps drive collaborations between colleagues of different educational backgrounds. Prof. Beets-Tan showed me that when different disciplines work together, massive synergy is possible.
Today, I am proud to be working on a PhD project where I can bridge immunology, oncology, and radiomics. It has been a long journey filled with a lot of learning, but I feel blessed to have had the opportunity so far to work with and learn from so many amazing individuals. I hope to reach my goal and be able to offer more options to my patients.
Dr. Bodalal is a PhD candidate in the Department of Radiology at The Netherlands Cancer Institute.