Report
MD Anderson Cancer Center
Japanese Medical Exchange Program 2018

Shu Yazaki, M.D.
Clinical fellow
Division of Medical Oncology
St. Luke’s International Hospital1Personal Mission and Vision from JME Program 2018

●Mission:（Japanese）効果的な多職種チームで早期臨床試験やトランスレーショナル研究を行い、日本の新薬開発を促進する（English）My mission is to promote the biomarker-driven drug development through early phaseclinical trials and translational research with a multidisciplinary professional team.

●Vision: (Long-term)（Japanese）バイオマーカーや遺伝子変異に伴う個別化医療を確立させ、あらゆる進行がん患者に治療選択肢を提供する（English）My vision is to provide the novel treatment options for all patients with advanced cancer

through biomarker or genotype-based drug development.

●Vision: (Mid-term)（日本語）乳癌を中心とする新規抗がん薬早期開発のリーダーとなり、世界に遅れることなく革新的な治療選択肢を提供する（English）My vision is to become a leader of the early drug development focused on advanced breast

cancer and provide novel anti-cancer treatment without delay to the world.

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1. Purpose
Purposes of the Japanese Medical Exchange 2018 (JME2018):
Through the program in MD Anderson Cancer Center (MDACC),
1. To develop leadership and communication skills to foster better multidisciplinary cancercare.
2. To get experience with the MD Anderson multidisciplinary cancer care approach in theclinical setting.
3. To understand the philosophical and practical differences in the Japanese and American
medical systems.
4. To develop an individual career plan, which will lead to implementing their personal
mission and vision.
Training period: from August 30 to October 7, 201832. Methods
JME2018 Contents of Training
Training on Team Oncology
 Clinical observations with physicians, physician assistants (PA), nurse practitioners (NP),clinical nurses (CN), Clinical Pharmacists (CPh), and other professions.
-Breast Medical Oncology outpatient clinic-

Breast Surgical Oncology Clinic-

Stem Cell Transplant in-patient round-

Breast Surgical Oncology surgery observation-Radiation Oncology Clinic-Radiology Department-Pathology Department-

Breast Survivorship Clinic-Infusion Clinic-

WOCN (wound/ostomy/continence nursing) round-Ambulatory Treatment Center Observation in Multidisciplinary Clinic-

Inflammatory Breast Cancer Consensus Conference-Gynecology Conference Lectures on Nursing-Education, professions, research in nursing, Nursing Practice Congress, Primary TeamNursing-

Safety control/quality control system

 Observation of antimicrobial stewardship Special observation: Houston Hospice, MDACC Woodland (Breast Surgical Oncology)
 Participation in Nursing Ethics Round Participation in 22nd Annual Interdisciplinary Conference on Supportive Care, Hospice andPalliative Medicine
 Presentation of the JME2018 project
Training on Leadership/Career Development
 Lectures/workshop on leadership and communication-Difficult Conversations, Mentoring, Leadership, Team building Lectures on Ethics (Dr. Theriault)
 Meetings with Mentors
 Meetings with Dr. Ueno
-Individual Development Plan, CV, career development, leadership, mentoring, andother topics
43. Results
3.1

Training on MDA
I have studied at MDACC through training such as observation in the outpatient clinic,

in-patient ward round, operation room in Breast Medical Oncology, Breast Surgical Oncology, andStem Cell Transplant division, participation in multi-occupation/disciplinary conferences, otherspecial observations.
In comparison with our institution, MDA has more stuff (20,000 vs. 1,500) and outpatients(1440,000 vs. 640,000) through a year, but about the same number of inpatient (28,000 vs. 21,000).
This indicates that medical care in the U.S. is mainly outpatient setting.

3.1.1. Outpatient clinic
In the outpatient clinic, Physician, Registered Nurse, Mid-level practitioners (Nursepractitioner; NP, Physician assistant; PA, Clinical Pharmacist; CPh) make the team. This team shares
the working room which makes a team discussion easy.
Patient’s examination was carried as follows. The RN performs vital sign measurement andhistory taking. NP or PA do further history taking and physical examination. After the discussion ofthe team, the doctor does the physical examination again and makes a decision. Meanwhile, CPhchecks the blood test and orders the chemotherapy by double check with the doctor. I imagined thateach profession divides the labor, but I got a different impression. There were many overlapping parts.
The examination and explanation were repeated by each profession which ensures the quality andsafety of medical care.

3.1.2. Inpatient clinic
As with outpatient clinic, Physician, NP/PA, and CPh make the team and manage about ten
patients in the inpatient ward. It was surprising that they did inpatient round over the morning. I think
it depends on the work pattern of the doctor. I heard that faculty in MDA are in charge of inpatient
5ward for several weeks or months a year. During this period, it is the period of only managing
inpatients, and they can spend time for the inpatient ward round and education. NP can adjust thedose of immunosuppressive drugs and do the bone marrow aspiration. This is about the same work as
clinical fellow like me in Japan. Some NP said that doctors exist to decide difficult decision and toresearch on improving treatment for cancer patients. It was the moment I realized MDA is the bestcancer center in the U.S.

3.1.3. Surgery and pathological department
I had the opportunity to observe breast surgery. I was surprised that the Operating room andpathology room were on the same floor. Once after submitting a specimen, pathologist slices it andtakes X-ray imaging. Then, breast surgeons, pathologists, and radiologists discuss the assessment ofmargin status. This style is different from Japan because our pathologists slice the specimen afterformalin fixation.

3.1.4. Special observations
We visited MD Anderson Woodlands, Houston Hospice. In observation at Houston Hospice, Iwas able to learn the team-based approach in the hospice setting, which involved professions such as
nurses, social workers, chaplain, physicians, volunteers, and bereavement coordinator. However,physicians are not necessarily required for the team in the hospice. I didn’t know that only about 30%of patients in Hospice had cancer.
MD Anderson woodlands is a hospital where MDA and St. Luke’s Hospital is affiliated. The
practice style was similar with MDA, but I felt MD Anderson woodlands offer the common practiceas a community hospital (MDA offer more research-oriented practice).

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3.2

Leadership and communication skills
Ms. Janis gave us wonderful lectures on this topic. Dr. Ueno also supplemented the content. I

could learn about leadership development, team building, and difficult conversation. It was a precious
experience for me because there are few chances to receive this type of training in Japan. She
introduced us the book which she used for the lecture. What impressed me most was the word ofpsychosocial safety. Japanese do not speak much at conferences or meetings, especially at
multidisciplinary conferences. The team leader has to create a psychosocial safety which makes it
possible to talk about any trivial matter. I felt it is essential that each team members share their corevalues and vision as well as medical knowledge.

3.3

Career development and meeting with mentors
Based on the lecture of mission and vision which we received at J-TOP workshop on January,

we create our mission and vision before the JME program. We discuss the vision, mission andSMART goals with our mentors and Dr. Ueno.
My mentors are two medical oncologists, Dr. Bora Lim, and Dr. Richard Theriault. I enjoyedtalking with my mentors every week. Both of my mentors support my vision and mission. They gaveme professional and personal advice through discussions based on their own experience.
We also received much guidance on the preparation of our Individual Development Plan (IDP)and CV from Dr. Ueno. This kind of lecture was a valuable experience that we usually cannot receivein Japan. I was able to set goals, missions, and visions in the future by reviewing the activities that I
have done before. I want to continue updating this IDP and mentorship in the future and use it in myfuture career development.
In this training, I have created the following Mission and Vision. At the timing of my career, Dr.
Ueno advised me to set long-term and middle-term vision.

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Mission: My mission is to promote the biomarker-driven drug development through early phaseclinical trials and translational research with a multidisciplinary professional team.
Vision: (Long-term)：My vision is to provide the novel treatment options for all patients withadvanced cancer through biomarker or genotype-based drug development.
Vision: (Mid-term)： My vision is to become a leader of the early drug development focused on
advanced breast cancer and provide novel anti-cancer treatment without delay to the world.

Recently, the clinical trials are designed for molecular or genotype based approach rather than
only for cancer type. Immune checkpoint inhibitors are the best example to be successfully approvedfor clinical application based on the biomarker specific drug development, which can be used forMicrosatellite instability (MSI)-High advanced solid tumors. I think medical oncologists could play
an active role in the field of tumor-agnostic biomarker or genotype based drug development. In theMDA, almost all patients who considered participation in phase I trial had gene-panel testing.
Although there is the basis of high-level of basic research in Japan, there are few experts in early drug
development.
I would like to promote precision medicine using genome sequencing and provide the treatment
option for all cancer patients. First of all, I created a mid-term vision to be a leader in the early drug
development mainly in breast cancer in Japan and provide innovative treatment options without delay
to the world.

3.1.3 Presentation of the group projectIn the group project, our group decided on the theme of sexual dysfunction in male cancer
survivors. It was determined from the fact that we heard the lecture of the same topic at palliative care
conference participated during the period. Moreover, it was also contributing to that all members of
our group were male. The discussion of fertility has become active in Japan, but sexual problems likeerectile dysfunction and loss of libido have not been raised yet.

8As the preparation proceed, we realized the importance of tackling this problem because malecancer survivors who have sexual dysfunction are as much as 30-50% and the score of depression andanxiety scales is high. We were able to talk to Professor Dr. Wang who specializes in men’s health inurology with Joyce’s help. He gave us a lecture on how to manage the patients with sexual
dysfunction in MDA.
Using the experience of January’s workshop, we could overcome the small conflict andfinished the presentation successfully.
Finally, I introduced our group’s mission, vision, and oncology program.

Mission：
To offer the educational and interventional program for male cancer survivors in order to reduce thesexual dysfunction.

Vision:To create a society that relieves the suffering of sexual dysfunction from male cancer survivors

94. Future Prospects
I was able to understand multidisciplinary team care practiced in MDA as a real experience.
Through this program, I realized that the most important factors for team-based care are understandingof each other and communication skill. I felt the trust like the patients could receive the treatment on
the tightly stretched thread instead of walking a tightrope by demonstrating the individual leadership.
However, at the same time, I felt that the team-based care in our institution is also excellent.
Although the discussion with nurses and pharmacists is less frequent than in MDA, I usually discusswith pharmacists on supportive care for chemotherapy, and drug interactions and nurses also haveproposals to add tests based on the initial assessment. Social workers and clinical psychotherapists
actively participate in inpatient conference. I am blessed in this great environment as usual.
Making use of this experience, I would like to demonstrate individual leadership and bring ourpatient's care to a higher level. Also in the future, I may lead an oncology team somewhere. At thattime, it would be a big challenge to create a team like MDA or our institution. Firstly, I would like todevelop individual leadership in my daily activities.
In the area of career development, I have set goals for the aspect of clinical, research andeducation as shown below.
・ To learn about the principal (methodology, practice, regulation) of early phase clinical trial
and anti-cancer drug development
・ To write the protocol and conduct phase I/ II trial based on the proof of concept
・ To contribute the education for a junior oncologist in oncology practice and clinicalresearch.

While continuing the connection of J-TOP and relationship with mentors, I would like to pursue
toward realizing my vision and mission.

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Acknowledgment
I would like to express my thanks for this valuable training opportunity. I would like to thankeveryone who supported the JME Program 2018. In particular, I strongly appreciate Mr. Naoto Ueno
and Dr. Joyce Neummann. Without support from Mr. Fueki, Ms. Marcy and members of JME program
2017, our training never started. I would like to thank my wonderful supervisors and loving family
who forgave me for absence as well.

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