When Cancer Care Becomes a Long Game

When Shawna Kraft, PharmD ’06, began her career as a clinical pharmacist specializing in cancer treatments, a diagnosis of metastatic melanoma meant very limited survival. Today, with advances in immunotherapy, she sees patients live with the disease for a decade or more. 

But that usually requires years of treatment, careful management of side effects and still more years of monitoring. Kraft and her fellow pharmacists in hematology and oncology are with patients every step of the way, educating, encouraging, monitoring and coordinating their complex care. 

Kraft staffs a clinic at Michigan Medicine for patients with advanced, hard-to-treat metastatic cases and rare and ultra-rare cases of melanoma affecting the eye or mucous membranes. The patient numbers are small, representing just 5 percent of all melanoma cases, but their care is so complex that the clinic specializes in seeing patients with these rare types of cancer.

Standard chemotherapy is generally not effective against melanoma, so the clinic relies on immunotherapy, which stimulates the patient’s T-cells to attack tumors. “We’re usually looking at IV therapy every three to four weeks for up to two years,” she says, although some forms of treatment are now given as a simpler subcutaneous injection in the infusion center. 

Caring for the Complications

Approved for use in 2011, immunotherapy and other targeted treatments have dramatically extended survival rates, but these gains come with their own complications. Patients may experience itching, suffer diarrhea or colitis, or incur liver damage. More severe side effects include liver or lung inflammation.

 These side effects are unpredictable. With breast cancer treatments, Kraft can reliably advise patients to expect certain side effects or reactions in a certain number of days or weeks after treatment. “It doesn’t work that way with immunotherapy and melanoma,” she explains. “The toxicities can happen, or not. They can show up in the first three months, or much later, or not at all.” She always educates patients about possible toxicities so they know what to look for. Still, when treatment is going smoothly, patients may have already forgotten about the possibility of side effects by the time they show up.

A rare but dangerous complication is myocarditis. “Our clinic has gotten very good at catching that before patients are symptomatic and treating it before there is permanent heart damage,” she says. She also keeps an eye on blood sugar levels that may be affected by steroid use and adjusts insulin if needed or adds medications to reduce infection risk during prolonged therapy, counseling patients at every stage.

Flexing to Fit the Patient

Treatment for the disease is long-term; the treatment for side effects can be as well.  

Immunotherapy sometimes damages the thyroid, which requires medication permanently. Some patients develop adrenal insufficiency that requires steroid therapy; those patients must carry an emergency dose of hydrocortisone at all times and be prepared to use it. Patients who need high-dose steroids may stay on them for months and taper off them slowly for six months to a year under careful medical supervision.

All this means that Kraft and her colleagues must continually and carefully monitor patients. In the clinic, she sees patients before treatment, assesses symptoms, reviews labs and, together with the patient, decides whether to go ahead with treatment that day. 

She starts consultations by asking her patients how they are feeling and if they feel ready for the next treatment. According to the scheduled regimen, “they are due for therapy, but you have an individual in front of you,” she says. “You need to consider how they are doing.” That patient-centric approach has become key to her practice over her 20-year career, and as a preceptor, she trains students to listen to meet patients’ unique needs.

For instance, a musician treated in the clinic recently was very concerned about how the therapy would affect his ability to perform because, after all, this was his livelihood. “We adjusted treatment in ways we normally would not have done in melanoma immunotherapy to support his well-being while not compromising his health or the effectiveness of the treatment. We listen and do everything we can to support their needs,” she says. 

Persistence and Persuasion for the Win

Kraft, who also staffs breast cancer and genitourinary cancer clinics, may see a patient every week or two to stay on top of their treatment, reactions and concerns. She recalls one patient in her late 60s who was scared to take her medication. Kraft invested extra time and partnered with the patient’s daughter to persuade her to take the first dose. “After that, I met with the patient weekly to help her through it. She was fabulous to work with,” Kraft recalls.

“This patient was against vaccines, but I was really worried about what COVID-19 might do to her in her condition. I’m proud that I built a really good relationship with this patient, to the point where, after much persuasion, I was able to convince her to get vaccinated.” Kraft recalls. “One day in clinic, she finally said, ‘I’ll do it.’” Immediately, Kraft called the patient’s daughter, who was waiting in the car due to COVID restrictions, and asked her if she could take her mother to get the shot at a clinic underway at Michigan Stadium. Kraft quickly booked an appointment, and the daughter took the patient straight to the Big House. “I won’t forget that day,” Kraft says.  

Learning from and Gaining Joy From Her Patients

Kraft learns from her patients and their idiosyncratic responses to treatment. She cared for one young high-school baseball player who was diagnosed with melanoma at 16 — highly unusual at that age — who developed very curly hair while in a clinical trial. “That’s how I learned that one of the side effects of that treatment was that it made your hair curly. That really hadn’t been reported.” The patient embraced the change, letting his hair grow into an Afro style and, after treatment, trying a Mohawk. “It was fun. He’d come in, and I’d say, ‘Let’s check out your hair today!’” she recalls. 

Early in his treatment, that young man was experiencing abdominal cramping that Kraft could not explain or control. “I was seeing him often, talking to his mom all the time, trying to figure out what was going on,” she recalls. “Finally, I learned that his mom liked to use herbal supplements with him, and they were interacting with the treatment.”

These supplements have become a constant challenge in her practice. Anecdotally, Kraft estimates that 75% of her breast cancer patients are taking herbal supplements, influenced by internet-driven advice. Her goal is to build enough trust with her patients so that they will tell her they are using supplements, which may not be allowed in clinical trials and may cause complications. 

“I tell patients that just because these herbal remedies are natural, that doesn’t mean they are safe,” she notes. “I recognize that it’s something that gives them a feeling of control and a way to participate in their care.” 

Knowing that her patients’ treatment can be grueling, Kraft tries to clear up any bureaucratic hurdles or payment issues that make the process that much harder. “I tell them, ‘I don’t want you to have to deal with this. If these issues come up, you need to come and tell us.’ I’m willing to do the coordination or figure out things that have little to do with what my job is to make them feel supported.”

Metastatic melanoma patients are never cured. With aggressive care, they achieve “no evidence of disease” status, but even with today’s extended survival rates, their prognosis is limited. Kraft reflects on how hard it is to lose a patient when she has worked with them so closely for years. It helps that she is surrounded by a close, supportive team that helps each other through the loss of a patient. And it is rewarding to know that she has helped patients in every way she could along the journey, she says. “I take pride in that.”