Learning to Drink from a Fire Hose
John B. Bossaer, PharmD BCOP BCPS
Associate Professor of Pharmacy Practice
Bill Gatton College of Pharmacy
East Tennessee State University
Johnson City, TN
I can still hear my preceptor’s voice, with just a hint of derision, say, “That’s a good guess.” It was the first rotation of my postgraduate year 2 (PGY-2) oncology pharmacy residency. I thought I knew my stuff, so I was more than a little embarrassed when I hesitantly and uncertainly answered “thrombocytopenia” to the question about carboplatin dose-limiting toxicity.
Shortly thereafter, we had what Southerners call a come-to-Jesus meeting. My preceptor stressed the importance of knowing the fundamentals of chemotherapy, but staying current was equally important. If I didn’t know the basics about carboplatin, how could I learn the basics about the next new anticancer agent? And oncology was changing at a fast pace, he observed: “The New England Journal of Medicine has an oncology paper every week. The Journal of Clinical Oncology is now being published several times a month. The amount to be learned is overwhelming—it’s like drinking from a fire hose.”
This was before PD-1/PD-L1 inhibitors. Before VEGF-targeting TKIs that didn’t begin with the letter s. Before ibrutinib. This was when platinum doublet was the answer to every question about non-small-cell lung cancer. When chronic myeloid leukemia patients were still considered for hematopoietic stem cell transplantation. When daunorubicin 45 mg/m2 versus 60 mg/m2 was the big controversy in treating acute myeloid leukemia. The American Society of Clinical Oncology had a single journal then. Now it has five.
My preceptor-initiated awakening set off an almost epigenetic change in how I consumed new drug information. I subscribed to the e-mail table of contents for New England Journal of Medicine, Journal of Clinical Oncology, Blood, and other journals. I subscribed to e-mail listservs that pushed out daily updates. I attended HOPA’s annual conference yearly (except the year I had a 3-month-old at home). I learned how to stay current. But it took a while to figure out the best way to do that. It required prioritization. I began each workday with 10–15 minutes of skimming e-mails for updates that merited greater attention. I set aside this time just to see what was new and noteworthy. Anything that required in-depth reading I printed for consumption later in the day. Even if I didn’t have time to read the whole article, I would read the abstract. Then I was better prepared to critique the article when I did have time to read it in its entirety.
I also learned to focus on the disease states I encounter routinely in clinical practice. For some disease states (e.g., lung cancer), I read the whole paper and pay particular attention to details such as supportive care information that is available only in the appendix or the online-only protocol. For others (e.g., endometrial cancer), I read only the abstract. And I consider myself lucky if I get to read even the title of a paper on a pediatric malignancy.
Over time I became more efficient. I began to see trends. I could predict which primary endpoints would be used for a chronic lymphocytic leukemia study and how they would differ from those in a pancreatic cancer study. I started looking at the supplementary appendix to answer questions not dealt with in the paper. Of course, I often had to consult this publication or that package insert several times to truly master the necessary information. But I knew what literature was out there, where to find it, and how to evaluate it efficiently.
As a general oncology clinical pharmacist, I need to know a lot about the most common malignancies. However, I’m not able to devote the time to dive deep into every malignancy, especially rarer cancers. It’s not that I don’t have an interest in cutaneous T-cell lymphomas; it’s that I don’t see those patients often enough to justify the time to read about them in depth. What does one do in that case?
It was around this time that I starting listening to podcasts. I found them to be a great way to learn, laugh, or otherwise be entertained while running errands, exercising, or washing dishes. I failed to find any oncology pharmacy podcasts that fit my needs, so I started my own. OncoPharm, the podcast, launched in November 2017 and was listened to more than 8,500 times in 2018. The podcasts usually fall into one of three categories. The Foundations of Oncology Pharmacy series covers the “must-know” information for chemotherapy. These podcasts are ideal for learners, especially PGY-2 trainees in advance of that weekly topic discussion on anthracyclines. The Landmarks in Oncology Pharmacy series covers landmark publications (e.g., MOSAIC for colon cancer) that provide the basis for much of our current treatment practice. The last category covers current events and includes recent notable publications, new drug approvals, and changes to guidelines.
It is my hope that OncoPharm (available on most podcast apps) helps oncology pharmacists and other oncology clinicians consume a small, but pharmacy-focused, amount of information from the multitude of information released weekly. By keeping the podcasts to under 20 minutes, I hope listeners are able to retain the key points about a new drug approval or a notable publication. Then when the time comes, they’ll know where to go to review the information before making decisions affecting patient care. Admittedly, a breast cancer expert listening to OncoPharm probably won’t learn anything new about treating breast cancer. But that breast cancer expert may not be fully aware of the latest updates on treating chronic myeloid leukemia or prostate cancer.
To that end, I hope OncoPharm offers something for everyone, even if it does not do so every week. Some of the episodes I’m proudest of offer historical perspectives on how far we’ve come in treating EGFR-mutated non-small-cell lung cancer (“Tales of Brave Iressa”) or how we ended up with a “standard” rituximab dose of 375 mg/m2 (“Rituximab”). As OncoPharm grows, I’d like to host guests who could talk about their experience with newly approved drugs from investigational studies and offer clinical pearls based on their expertise. In the meantime, I will still focus on producing podcasts with basic information related to traditional and targeted antineoplastics. And I still have to record the carboplatin episode so I can convincingly answer the question regarding its dose-limiting toxicity.