Hi ,

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

Last time you learned about past Kelley's fears, PRRT therapy in NETs, and an interesting trend in oncology residency training

This week you'll learn about 15 mistakes oncology pharmacists make, interpreting the CheckMate 649 study in upper GI cancers, and how time unfolds us

Have a great week!

Kelley

🧠 IPS (Insight, Pearl, Sundry)

Insight

15 painful mistakes that oncology pharmacists make:

1. Focusing on the short term - oncology is a long game, it will take you years to feel confident
2. Ignoring the learning curve - assuming oncology is a straight line will only bring frustration
3. Putting off starting - time passes whether you make progress or not, start now
4. Focusing on drugs - understanding the biology of cancer is critical to understanding treatment
5. Being the lone wolf - no one can know everything, start forming connections of peers to lean on
6. Underinvestment - underinvesting in time or money stunts how fast you can make progress
7. Assuming NCCN has all the answers - it’s a great tool and resource, but it isn’t the end all be all
8. Neglecting networking - oncology is a small world and it’s hard to progress in your career without a network
9. Not asking for feedback - we all can improve, ask your colleagues for honest feedback
10. Being inconsistent - learning oncology comes down to habits, you either regularly learn or you don’t, and those that do make more progress
11. Lacking patience - you’re going to feel uncomfortable a lot and will want to speed up the process but there is only so much you can take in at a time
12. Setting unrealistic expectations - learning oncology is hard, setting an arbitrary timeline only brings disappointment
13. Lacking persistence - you’re going to feel like giving up, and some people do, don’t be one of them
14. Expecting to memorize - there is too much, focus on principles that you can apply to many scenarios
15. Not getting support - we don’t learn in bubbles, figure out what kind of support you need and find a way to get it

Pearl

Oncology is often really messy - sometimes it’s less about what “is best” and more about what “is not wrong”

For example, take the CheckMate 649 study which looked at the addition of nivolumab to chemotherapy (FOLFOX or XELOX) in advanced or metastatic, HER2-, upper GI adenocarcinomas (gastric, esophageal, or gastroesophageal junction)

They were looking for overall survival (OS) and progression-free survival (PFS) and initially enrolled all CPS scores but later amended it to include only CPS 5+

The dual primary endpoints were both significant for those with a CPS of 5+

And because they had patients with CPS <5, they also looked at them, and found significant differences in those with CPS 1+ and all comers (no matter the CPS)

This gets a little dicey - groups with CPS <5 are being enriched by those in the 5+ group

It’s like taking lemon concentrate, adding water, and making lemonade - would it taste like lemonade if you didn’t start with the concentrate? Or would it just taste like water…?

Now, if you’re the FDA, it’s a fairly black or white decision. There was a statistically significant benefit and reasonable safety profile for patients with CPS 5+, 1+, and even all comers. So the label can be broad and allow clinicians to use it pretty liberally because it worked in those populations and was reasonably tolerated.

If you’re NCCN or ASCO, you look at the data with a little more scrutiny. The intended population was CPS 5+ so that gets the highest grade recommendation (category 1, preferred). The panel recognized the dilution of the data in CPS <5 and graded it less strongly (2B).

If you’re the study sponsor, you’re feeling pretty good about yourself. We’ll never really know the benefit of those with CPS <5 because they won’t go back and specifically look at it in a randomized controlled trial.

If you’re the front line pharmacist, you end up having to practice a bit like an attorney, it’s all about the interpretation

So, is it wrong to add nivolumab to FOLFOX for a patient with a CPS of 3? No, it’s not wrong. Is it the best choice? We don’t know 🤷‍♀️

Knowing background like this can help you understand and educate others about flaws in our data and decision making and why it’s so important for pharmacists to continue to deepen their knowledge over time.

Sundry

“Time does not change us, it just unfolds us” (unknown)

This quote implies we don’t change over time, that we are always who we are and that we just don’t know how to access or use that depth when we’re young

This seems true on some level. I feel like a different person than I did when I was younger, although it’s hard to pinpoint exactly how.

💡 I take more risk

💡 I am more confident

💡 I understand what I’m capable of better

💡 I know how I work at my best and how I don’t

I suppose it’s about learning to lean into our true selves more and more with each passing year. That’s how confidence is built, knowing that you can do something because you have evidence that you’ve done if before. And even if you haven’t done that exact same thing before, you’ve probably done something similar.

This is very true for learning oncology too because when we all started school, we didn’t know much about medicine

Do you remember learning medical acronyms and abbreviations in first year and being blow away by how many new terms we had to memorize? 🙋‍♀️

And now those are second nature because we see them everywhere, from patient notes, to conversations with providers, to the studies we read

Those things were daunting at the start of our school journey and so is oncology at the beginning of that journey. But it will become second nature over time if we continue to lean into it.

How will you unfold over time?

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