Anything but oncology
From a young age, Nicole Fleege, MD’s family told her she could be anything she wanted to be. She oscillated between dreams of being a doctor, a lawyer, or a veterinarian. However, when it came to deciding whether she wanted a career in medicine, she was hesitant.

“I took a detour from medicine because my dad got cancer when I was a junior in high school, and then passed away from lung cancer when I was a senior,” she explains. “So my first few years in college, I just wasn’t sure I wanted to do medicine.”

While an undergraduate at the University of Iowa, Fleege was a part of the College Student Leader Board, a group of approximately 20 members who act as liaisons between Volunteer Services, the college student volunteers, and the Staff Volunteer Supervisors in their assigned areas. Working in this group gave Fleege a detailed look into health services, exposing her to the many options of specialties she could pursue outside of oncology. That convinced her, she said, and enrolled in medical school at Iowa.

“I stayed for residency, and I realized that the things that made me nervous about pursuing oncology–getting close to patients, patient losses–are what make me better at it. I think that empathy and the experience of having had my dad go through that and being able to be there for patients going through similar things, is what gave me purpose, and where I felt strongest,” Fleege said.

Although the high-intensity situations with patients and families were part of what fulfilled her, it was the longer-term relationships she could build through ongoing patient care and regular touchpoints that became her compass.

“I went into fellowship knowing that I probably was going to focus on breast cancer, and I think that’s because in breast cancer we are often able to have long-term follow-up with our patients,” Fleege said. “We are lucky that treatment options for breast cancer keep expanding—allowing us to help our patients live longer and, in turn, getting to know them better.”

A fork in the road and a new path
Fellowship was the single detour in Fleege’s all-Iowa path to becoming an oncologist; she and her then-fiancé matched at the University of Michigan Health System, a research-focused institution. There, she embraced another side of academic medicine, earning a Career Pathway Grant in her second year of fellowship. This four-year grant allowed her to start a clinical trial studying the role that cannabidiol, or CBD, plays in treating side effects associated with aromatase inhibitors, a class of drugs used in the treatment of breast cancer in postmenopausal women and in men.

“One of the main limiting factors to people being able to tolerate aromatase inhibitors are intolerable joint and muscle aches and pains. We call this aromatase inhibitor-associated musculoskeletal symptoms, or AIMSS, but we don’t know why it happens,” Fleege explains.

There is now an FDA-approved formulation of CBD, meaning it can be prescribed if highly monitored. Fleege’s trial studies CBD’s impact on pain levels, and will also examine whether CBD can safely impact other symptoms related to treatment like insomnia and anxiety.

With the CBD trial set to complete this year, Fleege has been preparing her next research project: examining the impact of caring for a patient with metastatic breast cancer, who have comparatively more needs than patients who do not have a metastatic diagnosis.

“When I was at Michigan, one of the other projects I was involved in was looking at a care coordination program for patients with breast cancer that had spread to the brain and the spinal fluid. We found that more than half of caregivers enrolled in that program reported moderate to severe burden. From there, I started asking, well, what about other types of metastatic breast cancer?”

A lack of data in the literature is what compels Fleege to study this trend. “My goal is to talk with patients with metastatic breast cancer and their caregivers and explore what those needs are with a long-term goal of coming up with a way to support caregivers for whatever their area of greatest need is.”

“We work very closely with the breast surgeons, the breast radiation oncologists, our genetics team–and so I wanted to be somewhere where those relationships were fostered.”

– Fleege, on returning to the University of Iowa

Once a Hawkeye, always a Hawkeye
Fleege’s research portfolio threads a common theme: finding answers to questions that have not been asked before. This observant nature and inquisitiveness help position her as a rising star in the field, impacting research across many subspecialties in medical systems. That passion for multidisciplinary research is one reason Fleege returned to Iowa when seeking a faculty position.

“Through interviewing, I wanted to make sure I was somewhere that would give me the time and space to pursue the research I was interested in while also enjoying the people I work with,” she said. “Because it’s not just the medical oncologists–we work very closely with the breast surgeons, the breast radiation oncologists, our genetics team–and so I wanted to be somewhere where those relationships were fostered.”

Collegiality across disciplines at UI Health Care is at the root of faculty culture, as is mentorship. Throughout Fleege’s experience, she says each person she’s met has introduced her to someone else who helped propel her forward in her pursuits. Fleege lists Eli Perencevich, MD, MS; Richard Hoffman, MD, MPH; and her mentor Sneha Phadke, DO, MPH, as being especially influential in introducing her to the right people who could move the needle with her in her research.

“I had Dr. Fleege in my clinic as a resident and worked with her on breast cancer-related projects as her mentor,” Phadke said. “It’s been wonderful having her back now as a colleague and as a friend. She is a strong asset to our breast oncology group, and I’m so glad she decided to return to Iowa.”

Now, Fleege has been faculty in the Division of Hematology, Oncology, and Blood & Marrow Transplantation for more than a year. Although her journey through academia briefly took her out of Iowa, she describes coming back as feeling different than she did before. Things in her personal life changed–she married and welcomed her first baby while in Michigan–and her professional life accelerated, as well.

“I think becoming that mentor is such a weird flip,” Fleege said. “I think any first-year faculty will say that’s probably where you grow the fastest in the first year. And now just figuring that balance of, how I can focus on research? I’ve found such a great team, and my research is finally getting to the point where things are happening.”

In addition to her research, Fleege exemplifies support of the institution’s tripartite mission. Hematology-Oncology fellow Udhayvir Singh Grewal, MD, said, “Dr. Fleege is an exceptional clinician who truly believes in going that extra mile for her patients. She is a remarkable educator who quickly became the person that every fellow wanted to work with after she joined our division. Outside of being an exemplary oncologist and mentor, she is a friend and guide to so many of us. It’s just super easy to sit down with her and chat about life and fellowship. We are truly blessed to have her with us at UIHC.”

[Related: In 2021, while Fleege was a fellow at Michigan, we asked her to participate in our Where Are They Now? series. Her responses are here.]