Hi ,

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

Last time you learned about getting drunk on ideas, substituting 5-FU in HNSCC, and my next project

This week you'll learn about hardship over ease, oncogenic addicted tumor cells, and how learning oncology is like driving at night

Have a great week!

Kelley

🧠 IPS (Insight, Pearl, Sundry)

Insight

Ease is a greater threat to progress than hardship

Take another second to read that again and really internalize it

This gem 💎 is from Denzell Washington and is a simple explanation of how progress is made

This is similar to the saying that happiness comes from the struggle - you are more happy if you have to work your tail off for something versus just being given it

So many pharmacists are in the weeds of that struggle. Many have failed the BCOP exam or feel like they are making zero progress in being more effective and confident at work.

They are doubting themselves - doubting how smart they are, doubting they can actually become a competent oncology pharmacist.

And when they do finally crack that nut (and they all will with time and effort), the elation is evident. It pours out of them, more so than someone who had an easier road to the same achievement.

Why is that? Because they were tested and found to be worthy, found to be tougher than steel.

Many people give up when they don’t succeed in a arbitrary amount of time. But the ones that don’t give up, the ones that dig in their heels even more, come out of it so much richer, and empathetic, for what they have endured.

Pearl

Oncogenic addiction is a weird term. It conjures up odd images of tumor cells smoking cigarettes and slamming tequila in a dive bar.

The term is used to describe tumor cells that are dependent on a mutated gene or cellular pathway to survive (interesting, NCCN must not like this word because it’s not in their guidelines)

This addiction is good for us because we can exploit that by using one of our many targeted agents to block that gene/pathway (we don’t have drugs for all of them but we have a lot)

One challenge this targeted approach brings is what to do with immune checkpoint inhibitor (ICI) therapy in this population

We know ICI is highly effective in lung cancer but the studies have largely excluded patients with oncogenic drivers so we’re not really sure how well they can play together in the sandbox.

On the unusual chance they find themselves in the same sandbox, we have seen some fights 🥊. Data show less benefit of ICI in patients with EGFR and ALK driven tumors and the guidelines address these specifically (but do not mention other driver mutations).

In addition to less efficacy, there may be an increase in toxicity, particularly lung toxicities. The FAERS database study found an odds ratio for developing pneumonitis of 5.09 in patients treated with an EGFR TKI + nivolumab versus 1.22 with just nivolumab 😳.

So maybe we shouldn’t given them concurrently, what about sequentially? 

There are some data that sequentially also isn’t great but we don’t know how much time in between is optimal.

This is coming up even more with ICIs used in early stage disease. Not all neoadjuvant/adjuvant ICI trials required molecular testing and not all patients are getting this testing at diagnosis.

What if we are giving adjuvant ICI and the patient progresses. They get molecular testing and it turns out they are ALK +, should we wait before giving the ALK inhibitor? And how long? If you want to read more about this, here is a great article.

Lot’s of murkiness which makes it an exciting time in oncology!

Sundry

Playwright E.L. Doctorow said: “Writing a novel is like driving a car at night. You can see only as far as your headlights, but you can make the whole trip that way.”

Learning oncology is just like this. You can’t see the entire trip, only what’s in front of you.

You can drive a little faster to try and get to the destination earlier but there is only so fast you can drive at night without veering off the road.

Trust your headlights and focus on what’s in front of you

And don’t forget to stock up on snacks and enjoy the road trip along the way!

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When you're ready, here are ways to get help

Learn with others in the ELO program

The ELO Collaborative is my signature oncology pharmacy membership community that was created for pharmacists working in oncology and trying to learn on the job. It combines a curated curriculum with access to expert oncology pharmacists to walk through case studies and answer questions.

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Prepare for BCOP with over 400 questions in the Oncology Pharmacy Question Bank (you can also add on example patient cases!)

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