Ideally, the practice of medicine is evidence based, and in cancer care, we are fortunate to have a multitude of high-quality phase 3 clinical trials that define appropriate management for patients with different stages of common cancer. These trials form the backbone of the evidence-based guidelines for the evaluation and management of cancer developed by organizations such as the National Comprehensive Cancer Network (NCCN) and numerous specialty societies. But, as all practicing clinicians know, there are always patients who do not fit neatly within a guideline; their presenting symptoms are atypical, imaging studies are confusing, and subsequent steps in evaluation are unclear. Although scholarly articles addressing complex presentations exist, just as a picture is worth a thousand words, discussion of an actual case is often the best way to bring clarity to management problems infrequently encountered by an individual practicing oncologist.
The Clinical Challenge is a brief (250-word case, 500-600 word discussion) scholarly article written by a limited number of authors (鈮�3) with a limited number of references (鈮�10) in which the critical facts of an interesting case are concisely presented along with a key image (radiographs, histology slides). A question regarding the diagnosis or next step in management is posed to the reader; the correct choice is then discussed, and relevant literature is succinctly summarized.
Clinical Challenges should focus on uncommon presentations of common diseases, unusual entities likely to be encountered by a busy oncologist, or diseases for which diagnostic evaluation or management strategies have recently changed. The Clinical Challenge is not a forum for presenting 鈥渮ebras鈥� or clinical situations a physician would encounter only once or twice in a lifetime. The material presented should allow the reader to make an informed judgment regarding the most likely diagnosis or appropriate next steps in management. The Clinical Challenge is not a showcase for photos of the largest or most deforming tumors encountered in a practice, as these cases are rare occurrences. Cases in which the correct diagnosis can only be ascertained by looking at a photomicrograph are also not particularly useful, since few oncology practitioners are called on to make histologic diagnoses. The value of a Clinical Challenge is enhanced if all the potential answers to the question posed are plausible, and if the discussion indicates why each of the incorrect answers was not the best choice.
Perhaps the best way to think of a Clinical Challenge is as a tumor board presentation with an audience response system. The key elements of the case should be included, the answers should be challenging enough to make it fun, and evidence supporting the key teaching points of the case must be provided.
Patients have rights to privacy in clinical publication. Thus, it is important to obtain permission for publication from any patients (or if deceased, a family member) who may be identifiable from the clinical description, even if only to themselves.
We invite you to submit a Clinical Challenge. Please see the JAMA Oncology Instructions for Authors at for additional guidance and challenge your colleagues.
Corresponding Author: Monica Morrow, MD, Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 300 E 66th St, New York, NY 10065 (morrowm@mskcc.org).
Published Online: October 3, 2019. doi:10.1001/jamaoncol.2019.4001
Conflict of Interest Disclosures: Dr Morrow received personal fees from Genomic Health and Roche outside the submitted work. Dr Disis reports grants from Precigen, Pfizer, EMD Serono, EpiThany, Seattle Genetics, Silverback Therapeutics, Celgene, and Janssen during the conduct of the study; in addition, Dr Disis had a patent to University of Washington pending, issued, licensed, and with royalties paid.