How have times changed for the Canadian hematologist?

In my role as President of the Canadian Hematology Society, I recently had a chance to reflect upon the changes that have occurred (and are still occurring) in the discipline of hematology. I recall my first experience on the hematology service as a rotating medical resident in 1985 and it was a vastly different medical subspecialty at that time. Many of the inpatients I cared for on that service would have been cared for in the outpatient setting (virtually non-existent at the time) in 2010. Furthermore, the diseases that were being treated in 1985 have been reclassified (and reclassified once again!), the diagnostic techniques have improved greatly and supportive care therapies are far superior. Interestingly, many of the basic treatments remain the same -- 7+3 for acute myelogenous leukemia, CHOP for non-Hodgkin lymphoma, ABVD for Hodgkin lymphoma, plasma exchange for thrombotic thrombocytopenic purpura, corticosteroids/splenectomy for immune thrombocytopenia and factor concentrates for hereditary and acquired coagulopathies -- although refinements have occurred. In fact, progress is being made in all areas of hematology. We now have a better understanding of the biology of many of the diseases we treat and it has led to diagnostic, prognostic and therapeutic breakthroughs that have revolutionized our specialty.

Targeted drug therapies exploded on the malignant hematology scene beginning with the arrival of tyrosine kinase inhibitors for chronic myeloid leukemia in the late 1990s and a cornucopia of agents have followed -- monoclonal antibody therapies, radioimmunoconjugates, immunomodulatory drugs, proteosome inhibitors, anti-angiogenic agents, hypomethylating agents, histone deacetylase inhibitors and JAK2 inhibitors. These often highly efficacious therapies have one thing in common -- they are all expensive, and this has drawn the clinical hematologist into the role of both resource manager and patient advocate. Government and institutional drug utilization committees have become increasingly aware of the cost of these new drugs and hematologists have had to become more active at participating in the approval (and funding) of targeted therapies.

Of course, the complexity of new treatments in hematology has led to subspecialization within the field and there are now, in addition to hematologic oncologists, thrombosis, bleeding disorder, transfusion medicine and apheresis specialists. In the largest centres in Canada, there are even disease-specific hematologists who are expected to act as a bridge between the clinic and basic science research, as well as shepherd industry-sponsored clinical trials of even newer therapies. It is no wonder that the general hematologist is a vanishing breed! It is also no surprise that internal medicine specialists and general oncologists are increasingly uncomfortable with managing common diseases such as chronic lymphocytic leukemia or multiple myeloma with the need to perform fluorescence in situ hybridization (FISH) analysis at diagnosis to assist in selecting from an expanding list of therapeutic options. Hematologists are receiving an increasing number of referrals from these physicians at a time when the success of the targeted therapies is already expanding their practice simply because patients are living longer. Despite the unique pressures that are being placed on Canadian hematologists, I am struck by how happy we appear to be -- in a 2009 survey of hematologists in Canada, 82% were either “satisfied” or “highly satisfied” in their practice. Perhaps this satisfaction relates to a better understanding of the diseases we treat or perhaps it is a reflection of the rapid expansion of therapies that are favourably influencing the quality of life and the duration of survival of our patients -- both good reasons to be a hematologist in 2010.

Thomas Nevill, MD
President
Canadian Hematology Society