Hi ,

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

Last time you learned about patient overwhelm, sexual dysfunction after prostate cancer treatment, and why you should hone your sales skills

This week you'll learn about the 16 things that are obvious to me now but weren't always, the story of post-transplant cyclophosphamide, and a reminder that you get what you ask for

Have a great week!

Kelley

🧠 IPS (Insight, Pearl, Sundry)

Insight

Hindsight is 20/20 so don’t forget to look back at the lessons you’ve been learning along the way

Here are 16 things that are obvious to me now but weren’t always

💡 Great resources may not be great if it’s not the right time for you - you have to be ready to receive and implement them

💡 Consistency pays off but it’s so hard to see early on because you haven’t been doing it for long enough yet

💡 Everyone feels like they should be farther along - you’re not alone

💡 Learn to enjoy the journey because there isn’t a point when it all clicks into place and gets easy - there will always be things to learn

💡 Unlearn as much as you learn - take a close look at what you know and ask if it’s still true

💡 Group think can be dangerous - if you are surrounded by people that all agree, you’re not growing and seeing different perspectives that might hold the key you’re looking for

💡 The universe rises to meet you when you take a leap of faith, although that knowledge doesn’t make it any less scary

💡 It’s never too late to change course - when you have new information or perspectives, act on it

💡 Having an experimenter’s mindset makes life so much more interesting and enjoyable - be curious instead of stuck in your current thoughts and patterns

💡 Remember to look back and see how far you’ve come instead of always focusing on how far you still have to go

💡 Spending $$ to get on the fast train. Bootstrapping is fine in the beginning (I did that for 1.5 years) but you move so much faster when you invest in a faster car.

💡 Keep putting yourself out there, even if you can’t see a direct ROI of your actions because it does build up over time

💡 If you can’t afford to work with someone, or you aren’t sure if you’ll like working with them, look for a low commitment way to get in their world

💡 You don’t know what you don’t know, especially when it comes to the types of jobs oncology pharmacists can get - networking is the key to expanding your mind about what is possible

💡 Sunk cost is a real danger - that money is gone, don’t let it direct your future path

💡 Treat your career like a minimalist - when you buy a new shirt, you have to get rid of one and when you say yes to an opportunity, you have to turn another one down

Pearl

If you ask an experienced oncology pharmacist that specializes in BMT if they would undergo an allogeneic (allo) transplant, you might be surprised to hear many say no

The reason is because they have seen a lot of GVHD, graft versus host disease, a challenging post-transplant complication

GVHD occurs when T cells from the donor think the recipient's tissues are foreign cells that aren’t supposed to be there - and like a good army, they start fighting them ⚔️

And with all things in medicine, it’s nuanced - GVHD has a good 👼 and a bad 👹 side

The bad side is that it causes all kinds of problems in both the acute and chronic stages after transplant - it can impact almost anything in the body and is responsible for most of the high rates of morbidity and mortality associated with this treatment

So controlling GVHD is the key for an allo transplant to be successful, but control is the key word here because we don’t want to completely eliminate it

Weird, right?

We actually need a tiny bit of it because when those donor cells recognize the recipient cells as foreign, it can also recognize malignant cells

And when it sees those, it does the same thing - attacks them, which leads to better disease control and lower rates of relapse

Patients with no GVHD relapse at a higher rate than those who do have it - this is why we don’t want to use an identical twin donor to transplant for malignant diseases, they won’t have any GVHD and therefore are more likely to relapse

For many decades we used the same basic backbone to prevent GVHD, methotrexate and a calcineurin inhibitor - it was marginal at best with half of patients still getting GVHD

As we were researching new donor types (specifically haploidentical, or a 50% match donor), a new prophylaxis regimen was studied, called post-transplant cyclophosphamide (PTCy)

Now you might be wondering why we call it PTCy and not just cyclophosphamide but the ‘post-transplant’ part is pretty important

When you are learning about transplant, there are some cardinal rules, and one is that you don’t mess with the stem cells 😅

And one part of that is no chemo after stem cells are given. There is even a rest day built into the conditioning regimen the day before stem cells (called day -1) because we don’t want anything messing with their mojo

PTCy is given after the stem cells are infused

When this was being studied and talked about it was quite the eye opener - why are we giving chemo AFTER stems cells? Won’t it kill or damage them?

Turns out, no

Cyclophosphamide is an interesting drug. It’s an old school alkylator developed from mustard gas in the 1950s. In addition to anticancer activity, it has potent immune suppression effects, making it an effective agent in many non-oncology diseases, like autoimmune ones.

Its mechanism in preventing GVHD is still being understood but it has to do with blunting the effect of alloreactive T cells (which are the cells that identify non-self cells) while encouraging (and potentially increasing) the regulatory T cells which are suppressive of alloreactive T cells.

The overall effect is an immune suppressive environment

This is the reason we avoid steroids before PTCy - we don’t want to further mess with the immunosuppressive environment, so you’ll have to think outside the box for nausea/vomiting

Doses of PTCy are 50 mg/kg on days 3 and 4 after transplant - if you haven’t seen chemo doses used in transplant you might be shocked

Typically, we’d be worried about myelosuppression with such high doses but we aren’t because the stem cell infusion will fix that

The dose limiting toxicity of PTCy is actually cardiac ❤️ - it can cause acute congestive heart failure and myocardial necrosis and typically occurs in the first 10 days

Not a lot of exciting science reaches stem cell transplant, but PTCy is definitely one that has moved the needle. If you’re curious, read the results of the BMT CTN 1203 study.

Sundry

You get what you ask for

Why is asking for what you want so hard?! Regardless of why, you should practice doing this.

Taking a new job? Negotiate and ask for something they didn’t offer you.

Want to speak at a conference? Find someone involved and ask.

This is what I did recently - one ask has turned into 3 speaking opportunities

The answer is always no if you don’t ask, at least you get a shot by asking

💡 Have a topic you want to see discussed in the newsletter? Hit reply and share it! 💡

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

Learn with others in the Enjoy Learning Oncology (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 440 questions in the Oncology Pharmacy Question Bank (you can also add on example patient cases!)

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