Sep 18, 2019
By Frederic Ivan L. Ting, MD
It was a chilly Chicago Tuesday morning and I was sitting in the lobby of my hotel when I saw a smiling gentleman cheerfully waving at me from his car. It was Dr. Lawrence Einhorn picking me up for our drive to Indiana. I was one of the recipients of the ASCO International Development and Education Award (IDEA). The IDEA provides support for early-career oncologists in low- and middle-income countries to be able to attend the ASCO Annual Meeting and provides them a mentor who will help them with their career and in establishing their goals for themselves and for their country of origin.
Coming as a medical oncology fellow-in-training at the University of the Philippines – Philippine General Hospital (UP-PGH), where financial toxicity is a limiting factor in cancer treatment, I was very eager to learn the latest in cancer care from the ASCO Annual Meeting and also to experience how cancer management is being done in high-income countries during my preceptorship. Having a mentor from the United States isn’t a new thing for me, since one of our division’s consultants is Dr. Edgardo Faylona, a U.S.-based hematologist/oncologist who visits us quarterly in the Philippines and maintains an online mentoring system with us trainees. (Interestingly, Dr. Faylona also did a fellowship at Indiana University with Dr. Einhorn!) However, experiencing firsthand how actual cancer care is done in the United States and having a constant personal mentor would broaden my perspectives—and, as I have come to realize today, would be life-changing.
During the Annual Meeting, I felt a bit intimidated and overwhelmed when I first set foot in McCormick Place, since the venue was composed of a lot of meeting spaces, filled up by more than 40,000 attendees from around the world. I still remember the unique feeling of being surrounded by the brainpower of people who are the world leaders in oncology care while listening to the lectures during the Plenary Session. Fortunately, a lot of people whom I met helped me maneuver my way through the meeting. The Cancer Takeaway lectures at the Trainee and Early-Career Oncologist Member Lounge were very helpful in summarizing the most important studies presented at this meeting.
After the Annual Meeting proper, I was set to spend a few days learning with my mentors, Dr. Einhorn and Dr. Nabil Adra, at the Indiana University (IU) Simon Cancer Center.
Given that he is one of the pillars of oncology—not to mention the fact that he led the team that discovered a cure for testicular cancer, a disease that was just short of a death sentence before the 1970s1—I was nervous and anxious about the 3-hour drive with Dr. Einhorn.
“You know what 45 years of clinical practice taught me, Fred? It’s the fact that you can never do it alone. You need to have a good team.” This was Dr. Einhorn’s first lesson to me, one I will never forget. My experience at IU pretty much revolved around the concept of team-based, collaborative care.
The Simple Complexity of Managing Germ Cell Tumors
On day 1 of my preceptorship, Dr. Einhorn and I saw a lot of patients with germ cell tumors. It was very interesting for me to note that while the simple and “textbook” cases were managed according to the standard of care, some patients with complicated presentations were treated uniquely, depending on the demands of the clinical situation.
“Germ cell tumors are relatively easy to treat, and our studies have found that most of the patients who have one are curable. At times, when the disease is seemingly complicated, you’d need to have a good surgeon and management should be decided by a multidisciplinary approach,” Dr. Einhorn told me as he called a surgeon and discussed a patient’s CT scan. They then came to a conclusion on the best course of treatment and other options, which were discussed with the patient.
This encounter exemplifies the fact that a multidisciplinary approach to cancer care is invaluable, since it has the potential not only to increase the patient’s survival but also improve their quality of life.2 Because of this experience, I will definitely be a champion in emphasizing the importance of a multidisciplinary approach in treating patients living with cancer in my country.
Research Improves Patients’ Lives
On the second day of my rotation, I had the privilege of being mentored by Dr. Nasser Hanna, a leading expert on thoracic oncology, specifically lung cancers, where I was very fortunate to see a lot of patients with lung cancer on immunotherapy.
Dr. Hanna explained to me that lung cancer management was really changed by the discovery of tyrosine kinase inhibitors for patients with actionable mutations and by the introduction of immunotherapy. Before these novel treatments, the 5-year overall survival (OS) rate of a patient with advanced non-small cell lung cancer was 5% to 6%. Today, the updated results of KEYNOTE-001 showed that patients with this type of cancer treated with pembrolizumab experienced an unprecedented 5-year OS as high as 25%3—and this is all thanks to the investigators and patients who dedicate their lives to research.
Being a distinguished researcher himself, Dr. Hanna taught me that clinical trials should be encouraged and are essential not only for the patients participating, but also for the future patients who will present with a similar disease. Dr. Hanna also discussed a lot of trials done in other institutions around the United States and abroad that have changed the landscape of lung cancer treatment and led to the current standards of care.
In my country, we do have ongoing clinical trials and this experience taught me to always give these options to patients who are eligible. Witnessing these patient encounters inspired me to think of possible clinical trials to initiate in the near future.
Quality Over Quantity of Life
On my last day at IU, we saw a 73-year-old woman with metastatic renal cell carcinoma who was previously on nivolumab plus ipilimumab with partial response, but treatment was stopped due to grade 3-4 adverse effects. A previous long discussion of treatment options between Dr. Adra, one of the genitourinary cancer experts at IU, and the patient had led to an informed decision not to continue treatment and just do surveillance. The patient is currently 6 months without treatment, and her scans show stable disease. The patient feels well and has good performance status (ECOG PS = 0).
“As oncologists, we are trained to treat patients by considering progression-free survival (PFS) and OS as our objectives. But let us never forget to always think about our patients’ quality of life—this is equally important as [survival],” Dr. Adra told me.
After examining the patient, Dr. Adra then explained the findings of the scans and assured the patient that he would relay and coordinate the findings to her other doctors, including her nephrologist and her palliative care physicians, again exemplifying the importance of multidisciplinary management. Furthermore, in these days where advancements in cancer treatment are successfully improving our patients’ PFS and OS, let us always remember that their quality of life is also of paramount importance.
My IDEA experience made me realize three main points. First, we can only provide our patients with the highest quality of cancer care if we all work together as a team through a multidisciplinary approach. Secondly, research has already led to many improvements in the treatment of our patients living with cancer, but we still have a long way to go and a lot of work still needs to be done to better understand the dynamics of cancer and how to cure it. Thus, let us always support research efforts by either initiating clinical trials ourselves or by simply being aware of the available ongoing clinical trials in our area and offering these as options to our patients. Finally, the importance of having a lifetime mentor who guides you not only in clinic but through life in general is indispensable.
As I go back to my own country, I bring with me so much inspiration from colleagues all over the world to improve cancer care. One of the major hurdles in treating patients with cancer in the Philippines is the associated financial burden. But with the recent government approval of the National Integrated Cancer Control Act, which aims to offer universal health care coverage specifically for patients with cancer, our main responsibility now is to make sure that these resources are channeled and used efficiently. With the help of my mentors and the networks established during the ASCO Annual Meeting and through the IDEA program, I hope to be able to take part in this process.
After fellowship training, I will be going back to Bacolod City in the province of Negros Occidental, where I am excited to establish regular multidisciplinary conferences and palliative services in our newly opened cancer center.
To say that the ASCO IDEA program is helpful would be an understatement. This experience has not only changed my perspective but has changed my life. I will forever be grateful to ASCO and the IDEA program for this privilege. The lessons learned will always be kept in my heart and continually shared with the people I encounter.