CONQUEST | FALL 2010

Branching Out toConquer Cancer

One man’s vision+ a team’s dedication= a cultural shift

MD Anderson
takes its ‘normal’to Japan
By Sandi Stromberg8

[ Branching out ]In 2000, Naoto Ueno, M.D., Ph.D.,
traveled to Japan to talk about
Herceptin for breast cancer patients.
But he also listened. To patients,investigators, scientists, surgeons.
What struck him repeatedly was the Japanese“Could Japan benefit from this approach?” he asked himself. “Wouldit translate into another culture?”“I didn’t know how we could teach it,” says Ueno, professor in
MD Anderson’s departments of Breast Medical Oncology and Stem Cell
Transplantation and Cellular Therapy. “I just knew that MD Anderson
faculty did a good job of it. For us, it’s normal. I wasn’t even sure how
to define it.”
But he decided to try.

approach to cancer drug development, treat-A 10-year evolution

ment and patient care. While he had received
his medical degree in Japan, he’d never practiced medicine there, never experienced its
hierarchical nature or its traditions. Though
he had a deep respect for them, he also knew
how beneficial MD Anderson’s multidisciplinary care was for patients and health care
professionals.

Naoto Ueno, M.D., Ph.D., has shown how the power of one man’s
vision can galvanize a team of health care professionals andinspire a nation to re-evaluate its approach to cancer care. At theeducational workshop in Japan in November 2009, he presented
the ABC concept of multidisciplinary cancer care, which waspublished in the September 2010 edition of Nature Review
Clinical Practice.

The biggest challenge was to be culturally sensitive, honoring Japanesepride in their more paternalistic style of leadership while introducing adifferent way of thinking.
The other challenge was defining “multidisciplinary” and how totranslate it. “Multidisciplinary is hard to pronounce in Japanese,” Ueno
says. “But the word ‘team’ is easy, and ‘oncology’ has become a rather wellknown term. TeamOncology sounded good in Japanese so we decided tocall this the Japan TeamOncology Program, or JTOP.”
And that helped with the definition that began to take shape: cancer
care delivered by representatives of a variety of health care professions
and functions working in concert. At MD Anderson, not only do surgical,
radiation and medical oncologists work together to provide patient care,
but also mid-level providers like advanced practice nurses, pharmacists
and others are encouraged to expand their roles and take part in decisionmaking processes.
Over the last 10 years Ueno’s efforts, and those of the team heinspires, have evolved from a virtual presentation to 1,000 members of
the Japanese Society of Clinical Oncology in 2001, into three-day educational workshops each autumn since 2002, as well as training programs atMD Anderson each spring since 2003. More recently, a website — explaining the institution’s multidisciplinary concept in Japanese — receives
70,000 hits a month.
To date, JTOP has trained more than 420 Japanese health care
professionals, many of whom are in leadership positions promoting
multidisciplinary care in different oncology centers in Japan. And 49of those trained at MD Anderson provide similar workshops in their
medical communities.
“Our greatest, collective accomplishment, however,” Ueno says withgreat pride, “was our influence on the Japanese Diet’s passage of the Cancer
Act, similar to the one President Nixon signed in 1971. Initiated in spring
2007, it includes professional funding for promoting multidisciplinary
cancer care in Japan and for oncology professional development in 18
regional areas of the country.”

9CONQUEST | FALL 2010

MD Anderson’s team packs up to headback to Houston after the November
2009 workshop in Japan: (from left)
Hiroshi Fueki, Japan TeamOncology
Administration; Barry Feig, M.D., professor,
Surgical Oncology; Dina Patel and Hillary
Prescott, both Pharm.D., Pharmacy Clinical
Programs; Zhongxing Liao, M.D., professor,
Radiation Oncology; J.Jack Lee, professor,Biostatistics; Jeffrey Bryan, Pharm.D.,
Pharmacy Clinical Programs; Paul Scott,staff; Nicholas Szewczyk, advanced
practice nurse, Stem Cell Transplantation
and Cellular Therapy; Janis Apted, Faculty
Development; Richard Theriault, D.O.,
professor, Breast Medical Oncology; Joyce
Neumann, advanced practice nurse, Stem
Cell Transplantation and Cellular Therapy.

Branching Out toConquer Cancer

10A cohesive team of experts
Intent on ensuring the program is stable and ongoing, Ueno has
masterfully galvanized a team of experts to help it grow. The dedicatedMD Anderson team comprises surgical, radiation and medical oncologists, clinical statisticians, nurses and pharmacists.
In 2002, he recruited, among others, Richard Theriault, D.O., professor in the Department of Breast Medical Oncology, who is a memberof JTOP’s newly established Management Executive Committee.
“I went for the first workshop, and it was a phenomenal event,”
Theriault says. “Although it was no surprise, we were quick to see thatin Japan the system is dramatically different. Multidisciplinary care,
as we understand it, is a team of health care professionals working
together for the common good of the patient. Things aren’t quite that
open in Japan.
“But these workshops set out to explain what multidisciplinary
care is, how it’s practiced at MD Anderson, what training nurses andpharmacists receive and how they do their jobs.”
Each year, after general presentations, the 60 participants split into
groups of 15 with five surgeons, five nurses and five pharmacists ineach. Then, they are given the task of developing a clinical trial.
“It’s very intense,” Theriault says. “A physician helps lead each teamwhile a biostatistician roams from group to group, and the three professions work together to design a clinical trial and prepare to present it
to the other participants the next morning.”
Directly after those presentations, Ueno, Theriault and the other
MD Anderson experts discuss each attendee as they choose six people— two physicians, two nurses, two pharmacists — who will travel to
MD Anderson for a five-week training course the following spring.
They weigh criteria such as the person’s resume, participation in thepresentation and level of English.

[ Branching out ]Cultural sensitivity a must

Richard Theriault, D.O., professor, Department of Breast
Medical Oncology, takes part in the ice breaker activity
that helps improve communcation skills.

Nurses and pharmacists have played an equallyimportant role in the development of the program, taking
part in the fall workshops and the spring visits.
Having worked closely with Joyce Neumann on clinicalcases and knowing of her interest in professional nursing in Japan, Ueno
invited her to join them at the fall conference in 2002.
An advanced practice nurse and program director in the Departmentof Stem Cell Transplantation and Cellular Therapy, Neumann’s interestin Japan was kindled in 2001 when she lectured at a meeting on stem
cell transplantation. During that stay, she visited several hospitals andfelt she’d stepped back in time when she saw nurses still wearing white
uniforms and caps, and taking a much less assertive role in patient care.
“I’m an advanced practice nurse (APN) who functions much like anurse practitioner,” she says. “While they have the APN role as clinicalnurse specialists in Japan, they do not have the combined medical nursing
model that goes beyond the traditional nursing role. They were shocked
when I first spoke about expanded roles.”Neumann emphasizes that when the MD Anderson team (including
the nursing team) gives presentations in Japan, they continue to stressthat what they are discussing is one example of multidisciplinary care.
The expanded nursing role in Japan will mean a major shift in how theprofessional nurse is educated and viewed by other professionals, theirpatients and caregivers. This will mean further empowering the nurseand breaking some traditions that include gender, pay and hierarchy.
“Our model of multidisciplinary care might not be the right model forJapan, but the nurses are very interested in exploring a different professional model,” she says. “I talk about changes our culture has gone throughthat have helped shape this expanded role for nurses in the United States.”‘Leading from where you are’

Barry Feig, M.D., professor, Department of Surgical
Oncology, has been instrumental in developing theJapan TeamOncology Program, bringing his expertisein gastrointestinal and breast cancer surgeries. TheChinese character he holds — Wa — means “harmony”
and “team work,” qualities he brings to the program.

In 2006, Ueno realized the importance of leadership skills that makea multidisciplinary approach possible. So he brought in Janis Apted,associate vice president for Faculty Development.
“I found that a lot of the participants are young and not yet leaders,so I talked about ‘leading from wherever you are in the institution,’”Apted says. “Leadership, I tell them, is a set of behaviors, not a position.”
Ueno then asked her to take those ideas to the larger workshop groupin Japan that autumn. Since then, Apted’s presentation on leadership andcommunication is an integral part of the annual content and has led tothe establishment of an Academy of Cancer Experts, founded to focus
entirely on leadership.
“I focus on interpersonal skills, influencing others, communication,role playing, career development planning, their goals and how to getthere,” Apted says. “They’re hungry to learn, and they take away ideas on
how to keep growing and learning.”
The introduction of this model caused its own shift in the workshops.
“Three or four years ago, we adjusted the focus to help participants bemore successful in multidisciplinary care through three areas: leadership,communication and evidence-based medicine,” Ueno says.
11

CONQUEST | FALL 2010

“The majority of cancer patients in Japan are not seen
by oncologists, but rather by surgeons specialized
in a certain type of surgery, be it breast, thoracic,gastrointestinal. It’s the surgeon who takes care of
the patient through chemotherapy, radiation andany other type of therapy. Only recently are there
two programs that offer oncology training andcertification.”— Richard Theriault, D.O., professor, Department of Breast Medical Oncology

Emerging leaders join the effort
Hillary Prescott, Pharm.D., in MD Anderson’s Department ofPharmacy Clinical Programs, became part of JTOP in time for the 2007
November symposium in Japan. She is also a member of the newly
established Management Executive Committee.
“I am grateful that I was offered this unique opportunity to join theteam,” she says. “We’re encouraged to rely on our own expertise. And
while we work independently from our own perspectives, we take a teamapproach as we prepare.
“The other members,” she says of Ueno, Theriault and theMD Anderson team, “are incredible leaders. Everyone has a different
expertise and leadership style. It helps me better develop myself as a leader.”In Japan, she found that until recently physicians only dealt with otherphysicians. The JTOP model shows how much nurses and pharmacists
can take leadership roles. “In fact, the whole program shows that it takes
a skilled team with a strong vision to make change,” she says.
Ueno’s vision and his ability to infuse others with his enthusiasm havebrought JTOP to its 10th anniversary with strong financial backing fromunrestricted grants provided by Chugai Pharmaceutical Co., Roche and,since 2007, Novartis Pharma Oncology. Before 2005, Pfizer Oncology wasa partial supporter. Sister institutions in the development are St. Luke’s
Life Science Foundation and St. Luke International Hospital in Tokyo.
In addition, an advisory board and the Management Executive
Committee have taken form, passing leadership and decision making
to a larger, dedicated group. Beginning in 2010, the Tokyo Oncology
Consortium-MD Anderson Cancer Center Sister Institution agreement
supports this program through the Oncology Education Promotion
Foundation in Tokyo.
“Naoto Ueno has impacted cancer care in Japan and inspired a wholeteam at MD Anderson that participates with no fanfare and works very
hard,” Apted says. “We love this project and working with him. It’s nosmall achievement. He has what I call leadership magic — magic withpeople — and he’s brilliant in knowing how to get things done throughgroups of people.”

Five physicians, five nurses and five pharmacists, alongwith MD Anderson team members, work to design aclinical trial to present to workshop participants.

Jeffrey Bryan, a clinical pharmacy specialist, Department ofPharmacy Clinical Programs, helps participants discuss how
they can learn and expand their roles in the cancer setting.

Participants take the Myers-Briggs Personality Test to gain abetter understanding of each other and their differing work styles.

12[ Branching out ]What they bring, what they gain
Richard Theriault, D.O., professor in theDepartment of Breast Medical Oncology

Janis Apted, associate vice president in theDepartment of Faculty Development

What he brings: “I provide experience in oncology,
the ethics of clinical research, regulatory knowledge
and experience, the teaching of evidence-based
medicine and practice, clinical research expertise,a calm demeanor and a respectful attitude, and very
important, a sensitivity to cultural differences.”

What she brings: “I provide my experience inleadership development, communication skills
in a growing career, role playing, practicing. We
talk at some length about how they will develop
their careers when they won’t have access to these
programs. They take away ideas on how to keep
growing and learning.”

What he gains: “There are so many rewards, butI’ll name the big ones. I made many new colleagues
and had an apparent influence in developing new
education and research opportunities. I found experiencing a different culture uplifting, and I’ve seen
so many new things, from a 900-year-old Buddhist
temple to volcanic hot springs. But most of all it’s
the people. They’re extraordinarily kind and gifted.”

Joyce Neumann, advanced practice nurse inthe Department of Stem Cell Transplantation
and Cellular Therapy

What she brings: “I provide my many years ofexperience as an oncology advanced practice nursewith an expanded role, who has seen many changes
within our society and professional nursing. I’man active member of our ethics committee here at
MD Anderson and bring that experience by stressingthat nurses become strong patient advocates. I also
have experience in program development.”
What she gains: “It’s been an honor and privilege
to be involved in this program. It’s given me new
insight into nursing from a global perspective. It’s
evolved into a collaborative relationship, and I’ve
already witnessed changes in the Japanese nursing
profession. It’s gratifying to be a small part of theirchange and to be asked about some of the issues theystruggle with. I’m fortunate to have traveled there somany times that I think I have a sense and respectof their culture that many may not have.”

What she gains: “The exciting thing about doing thisis: It’s a gift. It’s an act of service, and it’s hard work.
We start at 6 a.m. and finish at 10-11 p.m., but it’sworth every minute. They’re so appreciative andenthusiastic. It also gives our MD Anderson
team the opportunity to sit down andtalk about some of the issues we havein Houston. The Japanese are also
excellent teachers.”

Branching Out toConquer Cancer
Hillary Prescott, Pharm.D.,
clinical pharmacy specialist inthe Department of Pharmacy
Clinical Programs

What she brings: “I bring my experience as a board-certified oncology clinicalpharmacist and my commitment to promoting
multidisciplinary cancer care. I go with a desire tohelp pharmacists realize their potential and advancethe pharmacy profession. I have an appreciation for
cultural differences and practices.”
What she gains: “This program has greatly enriched
my professional and personal life. I gain new friends
and colleagues and new ideas that enhance mywork. The program invigorates me and inspires me
to further my practice of pharmacy. We strive toenergize their practice. They, in turn, energize me.”13