PPN: It’s easy to shrug off awards as something that other people care about—until you get one yourself. How did you feel when you found out you had won the HOPA award?
Dr. Ignoffo: It feels wonderful to be appreciated and recognized by your colleagues. You work so hard to reach a high level in your career, one that you are truly proud of. And although it’s important to have an inner sense of accomplishment, when someone else recognizes you for those efforts and achievements, it’s absolutely a great feeling.
PPN: Is there one achievement in your career that you are particularly proud of?
Dr. Ignoffo: The development of my clinical practice in the 1970s—at a time when the concept of clinical pharmacists playing a significant role in oncology care was really in its infancy—is a highlight for me. From the start, my strategy was to emphasize collaboration between pharmacists, oncology nurses, physicians and students. To be able to bring all of those players together and have it, rather early on, be such a successful merger—that is always something I will be proud of.
PPN: Speaking of your work with students, you’ve won a past award for your work as a pharmacy preceptor. How satisfying is it to mentor students in oncology pharmacy?
Dr. Ignoffo: It’s hard to adequately express the satisfaction I have gotten over the years teaching and guiding these students. Bringing them along to learn this complicated field, even though I’m only with them for about six weeks per rotation, to see them come into the program totally green, and by the end, having learned a great deal about oncology and how to manage patients, it’s just incredibly rewarding to see that progression. And it gives me the opportunity to convey to them that graduating pharmacy school isn’t the end goal; you need to be a continual seeker and learner. That’s true of any profession, but in oncology pharmacy, it’s particularly important, given its complexity and never-ending stream of new information.
I’m also proud of the fact that these early teaching and mentoring efforts at UCSF eventually led to the development of the university’s full-fledged oncology pharmacy residency program. It was one of the first to be launched in the United States, and continues to this day to be very popular, with two oncology pharmacy residents doing postgraduate year 2 experiential rotations. So, it has grown over the years and I am proud to say that I got it started.
PPN: The practice of oncology pharmacy has seen a lot of change since you first began in the specialty. Can you point to a few that are particularly striking?
Dr. Ignoffo: The advent of the 5-HT3 antagonist drugs in the early-1990s caused a huge shift towards outpatient oncology care, because drugs such as ondansetron gave us a powerful new treatment for controlling emesis and thus discharging patients earlier, where their continued care could be managed outside of the hospital. That shift toward the outpatient setting gained even more traction in the late 1990s and early 2000s, when targeted cancer therapies such as the tyrosine kinase inhibitors—many of them oral agents— became available. To this day, this continues to raise a huge issue: Once these patients leave the hospital or the cancer outpatient clinic, how do you ensure they’re complying with their medications or that their adverse reactions are being managed adequately? This is a huge continuity of care challenge that still has not been fully addressed.
PPN: Where do you think the focus needs to be in order to strengthen continuity of care?
Dr. Ignoffo: We need to do a better job of educating community pharmacists on how to help manage these patients’ side effects or compliance issues, or when they have a problem obtaining the drug. In the case of adverse reactions, with many of the new targeted therapies, we are dealing with toxicity profiles that are very different than older chemotherapy agents. For example, hypertension and dermatologic reactions require a different approach than we have had to deal with before.
So we need to bring more community pharmacy representation into the fold, and HOPA is aware of the issue, but it’s quite a challenge: There aren’t many pharmacists who are board-certified in oncology pharmacy who work in the community setting. So there’s training, education and credentialing issues to work through. And as far as membership goes, HOPA has traditionally been very focused on hospital-based oncology pharmacy practice. So, bringing in the community practitioner that focuses on oncology requires a lot more consideration. The good news is that with the advent of Accountable Care Organizations, opportunities may be available for collaboration between independent and chain drugstores in trying to educate community pharmacists about how best to follow their patients, and partnering with them in ways that ensures optimal outcomes.
Another potential solution is to incorporate more technology into the equation, using telepharmacy, for example, to keep tabs on the degree to which patients are adhering to their oral chemotherapy. Several health systems have had success with this, but we need more of these programs implemented nationwide to really address this issue.
PPN: Another practice challenge that has been affecting pharmacy in general is ongoing drug shortages. What do you think the prospects are for these shortages being fixed any time soon?
Dr. Ignoffo: People in the United States are not going to stand for continued non-access to important, potentially lifesaving cancer drugs. When you see outcomes that are worsened by shortages of important chemotherapy agents, as a recent NEJM study outlined [2012;367:2461-2463; Pharmacy Practice News, page 1, February issue], it’s an embarrassment for our country. So I am hoping, and actually am fairly confident, that some legislation eventually will solve this and keep the pipeline of these medications open. This is certainly part of HOPA’s legislative agenda.
PPN: If you were to take the metaphorical pulse of oncology pharmacy, what would it indicate about the overall health of the specialty?
Dr. Ignoffo: There’s no question that an oncology pharmacist offers a great deal to the care of the cancer patient, so in that sense, this is indeed a healthy and valuable specialty. Thus, I don’t think it’s a surprise that there continues to be a great demand for pharmacists with oncology expertise. The problem is whether we can continue to meet that demand. And I raise that question because as it stands right now, there simply are not enough pharmacy residencies available, not just in oncology but in all of pharmacy practice, to meet the growing demand for our valuable clinical services.
We need to be proactive in this regard, and so we’re working on a project right now at Truro, in collaboration with several organizations, including BPS [Board of Pharmacy Specialties], ASCO [American Society of Clinical Oncology], NCI [National Cancer Institute], AACP [American Association of Colleges of Pharmacy] and hopefully HOPA, where we are going to examine the state of the oncology pharmacy workforce. This is important work, because it will give us a sense of how we are positioned to respond to a related workforce issue: a looming shortage of medical oncologists. A survey by researchers at the American Association Of Medical Colleges [AAMC] estimates that by 2012, there will be a shortage of approximately 15,000 medical oncologists [J Oncol Pract 2007;3:79-86]. This should result in the increased use of physician extenders. The AAMC study cites nurse practitioners and oncology nurses as potential caregivers who could fulfill that role, but does not mention pharmacists. This is a problem we need to address, but the larger issue is the lack of residency programs in oncology pharmacy. If we don’t fix that problem, we are going to miss the boat when it comes to filling the looming physician gap.
So, we face many exciting challenges ahead—and opportunities as well. One key to success will be for pharmacists to obtain health care provider status. It will take a concerted effort on our part and HOPA’s to be at the table to effect legislation that will give us that status. On a personal level, I know that I certainly won’t slow down any time soon, and look forward to continue helping this specialty grow and prosper.