The Changing Paradigm of Cancer Care
The Cancer Institute of New Jersey (CINJ) is 1 of 41 National Cancer Institute‒designated Comprehensive Cancer Centers in the United States. CINJ delivers advanced comprehensive care to adults and children, and CINJ investigators are heavily involved in research. Basic scientists and physicians work together to transform laboratory discoveries so that they can be applicable to clinical practice. CINJ provides education and outreach regarding cancer prevention, detection, and treatment. The CINJ network includes 15 hospitals in New Jersey, with Robert Wood Johnson University Hospital as its flagship hospital. The network provides care to more than one-third of people with cancer who live in that state.
The Oncology Pharmacist spoke with Michael P. Kane, RPh, BCOP, director of Oncology Pharmacy Services at CINJ, about care at CINJ and the evolving role of the oncology pharmacist.
What approach does your institution take to treating people with cancer?
Michael P. Kane (MPK): We have a well-rounded model of multidisciplinary care, with the patient at the center of the paradigm respected as equally important in decision making. This model gives the patient access to all disciplines involved in cancer treatment along the trajectory of care. Overlaying this paradigm, we recognize that participation in a clinical trial represents the best care option when available.
How does this model translate to better outcomes for your patients?
MPK: As pharmacists and the pharmacy department play a strong role in that paradigm, we resolve all clinical questions by including the patient in the discussion and learning firsthand about problems, comorbidity factors, and the patient’s goals. By the time we have these discussions, the patient’s and physician’s goals should be aligned. We consider whether the goals are heroic, palliative, or curative and whether patients are willing to tolerate side effects of therapy or the complexity of managing the regimen. Our model provides pharmacists with the opportunity to meet with the patient, educate him or her about treatments, and improve adherence, especially to oral drugs, as well as to drugs that address common comorbidities and supportive care. I can’t think of a better outcome than helping patients manage their side effects and comorbidities and therefore improve their adherence to treatment, whether in our infusion center or at home.
What are you excited about in the field of oncology right now?
MPK: This is tied to the previous question. I am particularly excited about the shift from injectable to oral targeted therapies for specific cancer types. This is an opportunity for oncology pharmacists to step away from the traditional role of preparing injectable medications to provide direction and education to patients about oral therapies so they understand optimal timing, frequency, and dosage, as well as expected and unexpected side effects and how they are to be managed.
Investigational therapies constitute a large portion of our treatment offerings at CINJ—40% of our clinical trials involve oral therapies. The new oral therapies are a superior option to injectable therapies due to different mechanisms of action and the ability to self-medicate; however, the new oral therapies won’t replace injectable therapy, but rather it appears that most will be used in conjunction with it. The addition of oral targeted therapy to current injectable regimens has improved survival in many cancers. Some oral targeted therapies are used as maintenance therapy; for example, gefitinib in lung cancer, while others (eg, lenalidomide, dasatinib) are used as adjuncts to chemotherapy to improve response and survival in certain heme malignancies. Additionally, new oral therapies are being approved to treat malignancies that historically have had very few options (eg, vemurafenib).
How has the role of the oncology pharmacist changed in the past 5 years?
MPK: The decision-making process has changed to include the oncology pharmacist in the discussions about selection and dosing of therapies. We discuss side effects of new oral therapies, and we participate in medication reconciliation to prevent drug-drug interactions from occurring, as well as drug-comorbidities contraindications. Additionally, patients often have comorbidities and preexisting end-organ dysfunctions that necessitate the input of a pharmacist to determine the best dosing options.
What inspired you to become an oncology pharmacist?
MPK: I’ve read a lot of editorials about this in pharmacy publications. Many people describe a key event that led them to their careers. For me, it was serendipity. I started with a job at a local hospital and applied for an opening as an oncology pharmacist. It didn’t take long for me to fall in love with this job, partly because of the opportunity to help patients with best supportive care and consulting at the bedside prior to discharge about their treatments and what to expect. Then I got another opportunity to move to CINJ 18 years ago, and with this position I could use all the knowledge and experience from the previous job, working at an institution with a strong research agenda. I could participate in taking an idea from the bench to the bedside to improve outcomes for cancer patients. I enjoy my job. Every day is a different day. The standard of care is a rapidly moving target, day to day, month to month, and from ASCO to ASCO. I’ve seen leaps and bounds in treating cancers happen within a small time frame. For example, patients with metastatic colorectal cancer used to have a survival measured in months, and now patients live from 2 to 5 years with good quality of life. This is happening across several solid tumors, and our involvement in hematologic cancers and transplantation at CINJ has also been optimistic. There is also great excitement in the area of cancer prevention. Whether it’s helping the public with smoking cessation or the effort put forth in developing vaccine therapies, prevention will be far more satisfying than treatment.
What advice would you give to pharmacists just entering the field?
MPK: Get your hands and your brain dirty. Keep current with the fast-moving target of standard of care. You need to be engrossed in the changing paradigm of cancer care. I am an advocate of board certification and board recertification for oncology pharmacists. This is not a requirement, but I recommend it to remain competitive for job opportunities. Follow and participate in clinical research!
What would you be if you weren’t an oncology pharmacist?
MPK: While evaluating colleges, I was originally attracted to the seminary but I decided on a different path. Now I would say that I would stay in clinical medicine in some capacity. I enjoy patient contact and hands-on care, but I would have liked to do benchtop research. I find patient contact extremely rewarding; it’s another form of religious work. Also, I think that the business education component of medical care is missing in much of our education. In my silver years, I will look to either pursue a business education or a teaching position.