Hi ,

Welcome back to the Oncology Insights Newsletter which fosters your continuous growth in oncology pharmacy practice

Last time you learned about watchful waiting, hyperviscosity syndrome, and a time warp to avoid

This week you'll learn about the oncology battery, bendamustine renal dose adjustments, and taking of blinders

Have a great week!

Kelley

🧠 IPS (Insight, Pearl, Sundry)

Insight

Oncology is like a battery

Batteries have 2 jobs

👉 Hold a charge

👉 Release a charge

When we learn something about a disease or drug, we are charging our oncology battery

When we apply our knowledge to answer a question or make a recommendation, we are releasing the charge from our oncology battery

It’s not sustainable to constantly be releasing without first charging the battery - you’ll wind up with a dead battery soon

We need a proactive learning/charging schedule to keep the battery topped off so it’s always there when we need it

Don’t forget to charge!

Pearl

Bendamustine is an interesting dual mechanism drug. Structurally, it has a mechlorethamine group responsible for its nitrogen mustard alkylating agent activity and a benzimidazole ring that mimics the structure of purine analogues. We think it causes interstrand DNA crosslinks leading to cell death, but like so many drugs, we’re not exactly sure.

While bendamustine is commonly dosed at 90 mg/m2 for indolent B-cell lymphomas, consideration for renal dose adjustment may be clinically considered for patients with mild-moderate renal dysfunction.

Even though it’s extensively metabolized hepatically, renal impairment has been shown to lead to increased toxicity including more profound thrombocytopenia, nausea, and fatigue

And interestingly, although the package insert recommending to avoid using it for CrCl <30 mL/min (depending on which one you look at), there are some data that supports its use in these patients with more severe impairment

In practice, we typically consider a dose reduction of ~20% for CrCl of ~50 mL/min or lower. For patients with more severe renal impairment (CrCl less than ~30 mL/min or somewhere in between 30-50 mL/min and/or with additional risk factors such as advanced age, comorbidities, etc), we might dose reduce by ~40%.

In these scenarios, it’s also common to use prophylactic growth factor and monitor closely for cytopenias as this can be more pronounced in renal dysfunction.

Sundry

Have you taken your blinders off?

We all have them, blinders. We get them from life and work experiences. Sometimes they are helpful to keep us focused, and sometimes they are to our detriment, by blocking us from seeing the broader picture.

At a recent conference, I was talking with 3 PGY2 oncology residents about academic blinders. Most PGY2 programs are at large academic centers. And most PGY2 graduates go on to work at similar centers which makes for really strong blinders.

I know this to be true because mine were very strong after following that path. It wasn’t until after moving into a community position where they started to disintegrate and I could see more of the oncology world around me.

Working in community practice showed me what the workflow looks like as the only oncology pharmacist, which is more common than you think. It was a shock to learn I would be the only pharmacist check on both the orders AND the product - definitely not best practice but something that is common in small cancer centers.

I learned to rely on my technician heavily. I learned the chaos that holidays bring and how you have to be very good at playing Tetris to fit every patient in when you lose a day of clinic.

I knew everyone in my clinic well, the 2 MDs, 1 PA, 1 social worker, and 4 nurses. I learned why patients liked coming to that center rather than drive another 20 min to go to the main campus. Parking was easier, they always knew their nurse, they could quickly navigate the phone triage system, the infusion center wasn’t complete chaos, and they didn’t get lost walking in the door.

I learned what it’s like to have a mixture of every disease state on any given day and how difficult it is to context switch when reviewing orders

All of this was invisible to me until I had the opportunity to take off the blinders and it changed my career. It made me appreciate and value my past experiences and want to seek out new ones that would continue to push me. It gave me empathy for those that work in small clinics and have to manage so much.

It is to our benefit to take our blinders off, not only for our own experiences and career but also for our patients. When we are well informed of the overall system, we can educate them on how best to navigate it.

Take some time today to take stock of what blinders you have on and what you can do to see the broader oncology picture

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