Hi ,

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

Last time you learned about how learning oncology is like the Chinese bamboo tree, the newly approved zenocutuzumab, and a reminder that we can't control everything

This week you'll learn about freestanding headstands, how you know if treatment for ALL is working, and whether your career is as stable as you think it is

Kelley

PS - there won't be a newsletter next week as I take some time off for the holidays. I'll be back to ring in the new year with you so enjoy the last few weeks of 2024!

🧠 IPS (Insight, Pearl, Sundry)

Insight

There is a great analogy and story in Dorie Clark's book The Long Game (highly recommend)

She tells the story of someone that had made a decision to go all in on learning a new skill - the freestanding handstand 🤸

She took a workshop but when she wasn't getting there fast enough (which she estimated should be 2 weeks), she hired a coach (you can find someone to help you with anything!)

What she found out was that it takes months of daily practice for most people to develop this skill 😰

I’m all for optimism over here 👍 but if you jump into something with little research on what it will take to be successful, you’ll likely quit before you get to the outcome you want

Taking time to understand the process and learning from those with more experience will help you achieve your goal

As Dorie points out “if it takes everyone else three years to make something happen, don't assume you can knock it out in six months”

This is true in learning oncology. It’s a marathon, not a sprint. If you think you can learn everything about all cancers in a small window of time, you will be disappointed.

Pearl

How a patient responds to a cancer therapy is obviously a very important piece of information as it directs the next steps of treatment

But knowing what their response is can be a challenge, especially with the differences between solid and hematologic cancers

Today, we’ll go over the response definitions for ALL (acute lymphoblastic leukemia)

The treatment goal is to achieve a complete remission (CR) following induction therapy. In order to determine the response, we’ll get a bone marrow biopsy and lab work +/- scans. For a CR, we need to see:

• No circulating lymphoblasts (immature lymphocytes)
• No disease outside the bone marrow (i.e. extramedullary disease, such as in lymph nodes, spleen, skin, gums, testicles, CNS)
• Trilineage hematopoiesis (the bone marrow is producing all 3 lines of cells it should be - platelets, red blood cells, and white blood cells)
• <5% leukemia blasts (malignant cells)
• ANC >/=1000
• Platelets >/= 100,000

Sometimes the bone marrow takes longer to recover after treatment and the response may be a CR with partial hematologic recovery (CRh) or a CR with incomplete hematologic recover (CRi)

CRh means the response meets the definition of a CR except the platelets and ANC are slightly lower (>/= 50,000 and 500, respectively)

CRi means the response meets the definition of a CR but the platelets or ANC have not recovered. There are two scenarios you might see this:

• ANC >/= 1000 but platelets <100,000
• Platelets >100,000 but ANC <1000

If the disease is not in a CR, it will fall into one of these categories:

• Refractory disease: criteria for a CR (or CRh/CRi) was NOT met at the end of induction therapy
• Progressive disease: development of extramedullary disease, circulating leukemic blasts, or an increase in number of circulating or bone marrow blasts by 25%+ after therapy
  
• Morphologic leukemia-free state (MLFS): this one is a little wonky to follow but essentially means there isn’t leukemia but the bone marrow isn’t doing so hot
  • Leukemia blasts are <5%
  • No extramedullary disease
  • ANC <500 and platelets <50
  • Bone marrow shows >/=10% cellularity* and has 200+ cells from an aspirate that contains spicules
• Aplastic marrow: MLFS but the cellularity of the bone marrow is <10% and/or the aspirate has <200 cells
• Relapsed disease: when there was a CR and then blasts come back either in the blood, bone marrow, or in an extramedullary site

There are also separate criteria to assess response in those with disease outside the bone marrow at diagnosis 🤯

*bone marrow cellularity is the percentage of hematopoietic cells in the bone marrow in relation to fat and tells us how active the hematopoiesis process is (fun fact, it naturally decreases with age)

Sundry

There is no professional security

We might think what we’re doing is providing us career security but is it really?

What is security anyway? The feeling of predictability? That my job isn’t going anywhere?

We know there isn’t a crystal ball that can tell us what the future holds so why do you feel so secure?

Sure, healthcare is a stable industry (people will always get sick) but there are plenty of examples of organizations going under or merging and reducing staff.

Perhaps the lack of career security is better as it keeps us ready for the next adventure, keeps our eyes open to new possibilities around every corner

This is how I felt when consulting in the past. My original contract was for 12 months and I was essentially working to put myself out of a job, which felt very strange at the beginning. But over time, this mindset took hold and I leaned into the excitement on the other side of that. The world was full of possibilities, not of devoid of them.

Consider this gem from Helen Keller:

“Security is mostly a superstition. It does not exist in nature, nor do the children of men as a whole experience it. Avoiding danger is no safer in the long run than outright exposure. Life is either a daring adventure, or nothing.”

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