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I AM A medical oncologist who cares exclusively for patients with advanced melanoma, most of whom have brain metastases or leptomeningeal disease (LMD). I always start conversations with patients during our first meeting by asking them what they understand about their illness. By doing so, I get a sense of what they know, and where I have to spend more time explaining. I have found that one of the best things about Internet search engines is that they empower my patients to learn about their cancer, but at the same time, these same Internet search engines can offer a lot of misinformation and false hopes. For example, one of my patients recently replied, “Oh my god, I searched LMD on Google, and it was so bad, I turned the computer off immediately without reading further.” However, this allowed me to pick up where the patient stopped reading, and to provide more understanding of their disease. Treatment for patients with metastatic melanoma and othermalignancies has changed dramatically over the last decade, as we now have effective options, including targeted therapies and immunotherapy. These new agents yield responses that we could only dream of a few years ago while being fairly well tolerated. Now, many patients with metastatic melanoma live many months or even years, and we oncologists have all seen patients who were incredibly sick but rose like a phoenix when treated with these new agents. However, I work in a large referral center, so most of my patients come to see me for a second opinion after having already received all those novel therapies. These patients are definitely more challenging since I often cannot offer further treatment, which can be heartbreaking. For my patients with LMD, life expectancy is typically weeks to months, and one of my jobs is to develop novel treatments for patients with this cancer complication. As a result, I constantly face heart-wrenching conversations with my patients about whether to offer treatment for LMD or whether to forego treatment and pursue a purely palliative approach.


When I finished my internal medicine residency and started my medical oncology fellowship a few years ago, I had not yet charted a specific academic focus within oncology, and I certainly had not thought much about melanoma. I was unlike many of my colleagues who knew before starting oncology training that they wanted to focus on a particular highly specialized academic area, such as molecular biology research, gastrointestinal cancers, or experimental therapeutics. However, when I was on the one-month melanoma rotation, I worked with Dr. Nicholas Papadopoulos, who we affectionately called “Dr. Papa” or simply “Papa.” Dr. Papa was a melanoma medical oncologist who practiced medicine before the discovery of effective therapeutics, when stage IV melanoma was essentially a death sentence for all patients, not just those with LMD. He offered chemotherapy to many patients nonetheless, like ...

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