My route into medicine was not the typical one because I started my career as a pharmacist. I was always fascinated with how drugs can be used to change the biology of disease and I had a particular interest in the new therapies being developed to treat cancer.
After graduating in pharmacy from Trinity College in 1994 at the age of 21, I worked in Beaumont Hospital for two years as a pharmacist and I also worked as a community pharmacist. I then decided to switch to medicine and applied to the Royal College of Surgeons of Ireland. I continued to work part-time as a pharmacist during my medical degree and did my training in general medicine back in Beaumont.
My oncology training took me to St James’s Hospital, the Mater hospital and Beaumont. I then spent three years training with leading oncologists in the Memorial Sloan Kettering Cancer Centre in Manhattan, one of the largest cancer centres in the world. I moved back from New York with my wife almost five years ago to take up the position of consultant oncologist working between the Mercy Hospital in Cork and Cork University Hospital (CUH).
My work week starts at 7.45am on Monday with a multidisciplinary team meeting for bowel and colorectal cancer, where I discuss management plans for my patients. I do ward rounds from 9.30am to 11am, during which I see inpatients who are on treatment or experiencing complications.
I catch up on paperwork and emails for an hour before going over to Cork University Hospital at 12.30pm for an outpatient clinic that runs until 6pm. Most of the patients who attend this clinic have genitourinary (GU) cancer, gastrointestinal (GI) cancer and melanoma. I have a team of junior doctors and nurse specialists, and we make decisions about patient management plans and treatment.
On Tuesday mornings at the Mercy we have a two-hour multidisciplinary meeting about liver, bile duct, pancreatic and upper gastrointestinal cancers. After this, I do ward rounds until 10.15am and I then have an outpatient clinic at the Mercy that runs until at least 2pm most weeks.
I grab a quick sandwich on the go and do another round then to deal with problems on the wards and new patient consultations. In the afternoon, I frequently have family meetings which can take some time as many involve breaking bad news or discussing management of their loved ones who are inpatients. I finish my day with paperwork and generally get home by 7.45pm.
Rapid access clinics
On Wednesdays, I’m back over to CUH for a melanoma multidisciplinary team meeting from 7.30am to 9.30am. I then do a ward round in CUH of all my inpatients there. I attend a GU cancer multidisciplinary meeting at CUH where we discuss the management plans for patients who have been diagnosed with prostate, testicular, kidney and bladder cancer.
The rapid access clinics set up by the National Cancer Control Programme (NCCP) feed into this and many other team meetings. Thanks to this set-up, patients get a diagnosis made and a management plan is devised with minimal delay. In the afternoon, I run another outpatient clinic.
After that I might have to run back up to the ward to see a sick patient, or dictate letters, or catch up on post or paperwork.
On Thursday mornings, I have a genitourinary cancer multidisciplinary team meeting at the Mercy, followed by ward rounds. I then attend a clinical trials meeting in CUH to discuss all the clinical trials open in the region as well as trials open nationally.
I am a member of the Irish Co-operative Oncology Research Group (Icorg), a national body that brings international clinical trials to Ireland. Clinical trials are very exciting as they give patients access to new drugs they would not otherwise get. I’m in awe of the patients who put their faith in science, and their doctors, to go on these trials knowing that there is a chance they may not get the “new drug” being studied.
It is a lot of extra work for patients in terms of extra visits and scans, but it is a scientific fact that patients do better on clinical trials irrespective of whether or not they get the drugs, because they are seen so regularly and followed so closely by the clinical trial nurses.
At 1pm I attend Grand Rounds, a lecture series presented by various specialists in the hospital on a range of subjects. I usually spend Thursday afternoons catching up on paperwork, dealing with unexpected events on the ward and seeing sick patients. I also teach medical students then.
Every three weeks I have another outpatient clinic and on the Thursdays I don’t have it, I have time to interact with the laboratory-based scientists from the Cork Cancer Research Centre, which is based at University College Cork. We have exciting new trials opening up in conjunction with Breakthrough Cancer Research, which will open soon and offer new treatments to patients with metastatic melanoma.
On Friday mornings, we have a multidisciplinary meeting about colorectoral cancer at CUH. Then I teach non-consultant hospital doctors for an hour, discussing new developments in cancer as well as published journal articles.
After this, I see inpatients, decide on management plans and discuss patient care for the weekend. I do a ward round in the Mercy and then I meet the chemotherapy nurse specialists to discuss who is coming in for treatment the following week.
Every day, in both the Mercy and CUH, there are about 35 patients coming in for chemotherapy. I tutor medical students in the afternoon in conjunction with the UCC medical school. Sometimes I will grab a coffee at a meeting or eat a sandwich at my desk, but I don’t have lunch breaks as such. Occasionally I will attend NCCP meetings to advise on national strategies for cancer care or attend academic meetings around the country and overseas as part of my continuing professional development.
At the moment I am on call every second weekend, which means I frequently have to work 12 days in a row before I get a weekend day off. Weekend on-call usually consists of doing ward rounds in both hospitals and then taking calls from home. Occasionally I go into the hospital at night to see a patient who is seriously ill.
An era of immunotherapy
In terms of advances in cancer treatment, in my view we are now living in an era of immunotherapy. How the immune system can be harnessed to treat cancer is one of the seminal discoveries in cancer care. The new drugs being used to stimulate the immune system are much less toxic, better targeted and most likely will be more effective than traditional chemotherapy or older immunotherapies.
There are positive results emerging from clinical trials in the treatment of melanoma, kidney, bladder and lung cancer using immunotherapy. My own area of research is the stimulation of the immune system through a combination of new immunotherapy drugs with electrochemotherapy, which is a technology that gives a small charge of electrical current with chemotherapy to small parts of a tumour.
Scientists at the Cancer Research Centre in UCC are the national leads using electrochemotherapy and I am involved in a melanoma study there. I am on the board of the centre and one of their scientific advisers.
Another area I have a particular interest in is nutrition and cancer and why patients with certain cancers develop cachexia and sarcopenia (muscle loss) and have a worse outcome. We are looking at why this is happening and how to treat it in conjunction with the nutritional sciences department in UCC.
Cure for minority of cancers
For some cancers, there already is a cure. The majority of young men with testicular cancer and Hodgkin’s lymphoma are cured using traditional chemotherapies. Major progress has been made in other cancers.
The average life expectancy of a patient with advanced melanoma or advanced colon cancer has doubled, if not trebled, in the past 20 years, with cure possible in a subset of patients. While we can cure a small percentage of patients, I do not think a universal cure for cancer is realistic, as each cancer is very different. Knowledge of cancer genetics is helping us to understand this more. The decision to switch careers has been a good one for me.
Life as a medical oncologist is hard work, and hospital life can be very unpredictable and stressful. It is very hard to switch off from the job. I think about my patients all the time. Despite the stress, my job is very rewarding. It is a real pleasure to treat patients and try to make a difference in their lives. Patients make me realise how lucky I am in my own life.
Full article appearred in The Irish Times 25/7/15