Change, Challenge and Opportunity seemed like a very appropriate name for the Conference this year. Cancer treatments are becoming more complex and with the increased complexity of treatment protocols comes the increased risks of side-effects, drug-drug and drug-disease interactions. The number of oral treatments being used in cancer patients is also on the rise and oncology pharmacists need to plan and seize the opportunity to be involved closely in the care of these patients.
On the first day of the conference, Dr. Scott Edwards, clinical pharmacist at the Dr. H. Bliss Murphy Cancer Centre in St. John's, gave an excellent talk about the practical management of castration-resistant prostate cancer (CRPC) with Enzalutamide, where he presented recent data and also discussed patient cases integrating the role of the pharmacist. He pointed out that Abiraterone and Enzulatamide are both effective options for the management of CRPC. The sequencing of the drugs does not seem to affect patient response; however, sequencing does play an important role when it comes to meeting criteria for drug funding. Finally, from a pharmacist's perspective, he explained that caution needs to be used when combining Abiraterone with inducers and inhibitors of CYP3A4, and also when combining Enzulatamide with inducers of CYP3A4 (inhibitors do not increase Enzulatamide AUC significantly). Enzulatamide can be taken without regard to meals; however, Abiraterone can have almost 10-fold increase in AUC when given with food, so it is very important that it is taken on an empty stomach.
The management of blood clots in cancer patients can be challenging, particularly as they have a higher risk of both acute and recurrent thrombosis as well as bleeding. Patients with cancer also often have preexisting comorbidities or other risk factors that increase the probability of renal impairment before receiving potentially nephrotoxic therapies. One of the Friday morning symposiums discussed the management of VTE in cancer patients and reviewed the recently released CATCH (long-term tinzaparin vs warfarin in the treatment of acute VTE in cancer patients) study. The speakers concluded that LMWH is superior to warfarin and UFH for the long-term treatment of cancer-associated VTE. Larger LMWH molecules (tinzaparin and dalteparin) have less risk of bioaccumulation in renal impairment and they also have short half-lives, facilitating temporary interruption for procedures or thrombocytopenia.
Another very interesting symposium on Friday titled 'Clinical and Practical Implications of Subsequent Entry Biologics in Oncology' discussed the current regulatory environment and the landscape for biosimilars in the Canadian oncology world. The speakers provided their perspective on challenges that can arise with biosimilar production and quality control, and were also able to stimulate conversation among the audience about their perspectives regarding the assessment of Subsequent Entry Biologics.
The first session on Saturday started with cardiologist Diego Delgado discussing how risk factors and side-effect profiles of TKIs (Dasatinib, Nilotinib and newly marketed Ponatinib) can be used to guide therapeutic approaches in the management of Chronic Myeloid Leukemia (CML). He was followed by hematologist Brian Leber who reviewed the recent developments in the molecular pathogenesis of Myelofibrosis and Polycythemia Vera (PV) and discussed new evidence in the management of PV using janus kinase (JAK) inhibitor, Ruxolitinib.
Pam Rudkin, clinical pharmacist in the Hematology-Oncology Division at Eastern Health Care, St. John's, provided a good overview of the Chronic Lymphocytic Leukemia (CLL) trial which compared Rituximab plus the new oral phosphoinositide 3-kinase inhibitor, Idelalisib, versus Rituximab plus placebo. She went over the dosing and administration instructions of Idelalisib and discussed the importance of monitoring patients for diarrhea, colitis and transaminitis.
Michelle Lui, Pharmacy Oncology Fellow and clinical pharmacist in the lung clinic at the Odette Cancer Centre in Sunnybrook Health Sciences Centre provided an excellent overview of the management of metastatic non-small-cell lung cancer (NSCLC). She discussed how the emergence of targeted agents has immensely advanced the treatment of metastatic NSCLC and is an enormous step in improving survival and patient symptoms. Her presentation provided an algorithm that outlined the use of first-line treatment options based on histology and mutation status of the cancer. Patients with adenocarcinoma can now receive specific agents such as Erlotinib, Gefitinib, Afatinib and Crizotinib based on their mutaton status (EGFR-mutation vs ALK-mutation vs ROS-1 mutation vs wild-type). It was interesting to learn that patients with wild-type should not be treated with these agents as they can actually do harm.
One of the most powerful presentations at the conference was provided by Dr. Bill Evans from Hamilton Cancer Centre on the importance on smoking cessation in cancer patients. He discussed new evidence showing that it is almost never too late for cancer patients to stop smoking to derive benefit. He pointed out the negative impact of continued smoking on all cause and cancer-specific mortality, treatment-related toxicity, recurrence rates and second malignancies. He also briefly shared Cancer Care Ontario's initiative to screen new ambulatory cancer patients for their smoking status and to advise and refer for cessation interventions.
Table Top Cluster Discussions on Saturday afternoon had many interesting topics ranging from clinical discussions on Chemotherapy in Pregnancy, Immunotherapy in Melanoma, Cardio-Oncology and QT Drug Interactions to technical ones such as Practical Robotics and Integration of Mobile Devices, Apps and Social Media into Practice.
The Saturday night banquet with entertainment from the Spirit of Newfoundland Productions Ltd, a lively and talented group of vocalists and actors, was great. The evening was full of fun and laughter listening to their medleys of Newfoundland and Labrador music, humorous dialogue and stories.
I would like to sincerely thank CAPhO and the Awards Committee for awarding the travel grant to me. It was a wonderful opportunity attending this conference and networking with colleagues from all over the country!
