Hi ,

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

Last time you learned about hardship over ease, oncogenic addicted tumor cells, and how learning oncology is like driving at night

This week you'll learn about the oncologist shortage, histology-specific pemetrexed use in lung cancer, and finding another way

Have a great week!

Kelley

🧠 IPS (Insight, Pearl, Sundry)

Insight

In case you’ve been living under a rock, there is a severe oncologist shortage

This shortage directly impacts us as pharmacists in a few ways

First, we might have to absorb clinics that close. A client of mine had a local center go under and they absorbed 200 patients almost over night.

Think about the logistics of that for a minute. Those patients are completely unknown to everyone in the clinic. They have to be seen by the oncologist, we need to understand what regimen they were on and whether it is appropriate to continue, we need to procure drug to accommodate this huge volume increase, which means a big cash flow expenditure for this community center. And of course the scheduling challenges are like playing a game of Tetris trying to fit everyone in within business hours.

Second, an oncologist shortage means pharmacists, and other advanced practice professionals need to step up and help fill the gaps in care that will be inevitable

This stepping up is the biggest challenge related to this shortage. And that’s because many of the shortages are in rural, non-urban areas where only ~10% of oncologists practice but almost 20% of Americans live.

Similarly, residency trained oncology pharmacists are most often found at the urban academic centers, which means our community centers have staff that need educational support, both pharmacists and nurse practitioners/physician assistants that support these centers as well.

Dr. Vyas is an oncologist in a community private practice in Georgia that described this issue in an interview, saying:

“My cancer center, I founded it, and I even have a small clinical trials division. I have a physician dispensing pharmacy. The problem in an area like where I practice is, it’s very... You don’t get an off-the-shelf nurse practitioner trained in hematology. You don’t have a clinical trials person you could just plug in. Everything requires training. So you have to be a little bit entrepreneurial and be willing to do that.”

This is true for pharmacists also. Most community centers don’t get off-the-shelf pharmacists trained in oncology and hematology. They are willing to train, as is Dr. Vyas, so put yourself out there! A willingness to learn and be coached will get you far.

Pearl

The terminology of lung cancer can be super confusing

The first piece to understand is the 2 big buckets of disease: small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC)

Small cell is less common (~15% of lung cancers), highly aggressive, and usually starts in the bronchi which makes sense when you know that almost all cases are due to smoking 🚬

If a lung cancer is not small cell, it is by default a non-small cell (the other 85% of cases)

Within NSCLC, there are several subtypes based on the site of origin (i.e. the histology - how they look under the microscope 🔬), with the most common being adeno, squamous cell, and large cell carcinomas

Adenocarcinomas originate in glandular tissue that secretes mucus, like the airways (bronchi and alveoli)

Squamous cells are flat cells that line the respiratory tract (and other parts of the body) so these tumors originate in the central part of the lung or the bronchi

Large cell carcinomas can occur anywhere in the lungs but are most often found around the outer edges

Why do these histologies matter to the pharmacist?

Because it impacts treatment of course!

The mainstay of chemotherapy in lung cancer is a platinum doublet 👇

Cisplatin or carboplatin in combination with another drug (many options: vinorelbine, etoposide, gemcitabine, paclitaxel, docetaxel, pemetrexed)

Which platinum we use depends on the stage, performance status, and comorbidities. Curable disease is more likely to get cisplatin (unless kidney issues) and stage IV more likely to get carboplatin.

How do you pick the other drug? One way is based on histology.

Pemetrexed plays favorites and squamous cell carcinomas are not in the cool crowd

Data shows that patients with squamous cell who received cisplatin + gemcitabine had a better overall survival than those that got cisplatin + pemetrexed

If you’re like me you’re probably wondering why that is 🤔

We don’t know exactly but we think it’s because pemetrexed inhibits thymidylate synthase (TS) as part of its mechanism of action and there is an increased expression of TS in squamous cell carcinomas

Sundry

Some things that work for others will not work for you so stop trying to bend yourself, your habits, your skills, into someone else’s mold

For the longest time I was trying to force myself to use project management tools to keep me organized but always ended up falling back to my sticky notes habits

It took me a while to realize that my brain thinks differently and I needed a system that matched that (I finally found it, although I do still enjoy some sticky notes 😉)

This goes for learning oncology too - how your colleagues learn best may not be how you learn best

Keep experimenting until you find what works for your brain

There is always another way, your job is to find it and invest time into it

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