Pediatric oncologists are quite familiar with the question, “How do you do that?” There’s no doubt that caring for children with cancer is difficult. But Dr. Jennifer Domm, a pediatric hematologist-oncologist at The Children’s Hospital at TriStar Centennial, is one of those doctors who makes us think, “Thank goodness you do that.” In 2015, Dr. Domm and her colleague Dr. Haydar Frangoul established the pediatric oncology/hematology and stem cell transplant program at The Children’s Hospital at TriStar Centennial, and last fall, the hospital opened a pediatric myelosuppression unit. Dr. Domm admits the most challenging part of her job is the suffering, but she says supporting families through the good and the bad is an important part of her role. Our newest FACE of TriStar, Dr. Jennifer Domm sat down with us to delve into all this, as well as the ever-changing field of medicine.
How did you decide to go into hematology/oncology?
A lot of it has to do with who your mentors are and who you meet over the years and the people you connect with that take you under their wings. I always had really strong mentors like Dr. John Lukens — one of the original founders of the field of pediatric oncology. I had the opportunity to work with him when I was first in medical school, and I just had a connection. It felt almost like a calling. It wasn’t something that I honestly knew anything about before then. It wasn’t something I grew up thinking I wanted to do. At that point, I fortunately never had a personal experience with anybody who went through a cancer diagnosis. But, I just really enjoyed it. I loved seeing the relationships physicians had with their patients. I loved seeing that you really have to know your patients. They had obviously very serious illnesses, and we had very serious conversations with them, and I really liked the feeling of being essentially part of an extended family. That’s really the foundation for how I got into it. It was happenstance, but it really was just where I felt most comfortable. I tried to keep an open mind throughout my other clinical rotations, but I kept coming back to oncology.
Talk about the relationships you form with your patients and their families.
One of the things that is so unique is that you basically become the patient’s primary care provider, too, so you’re not only managing their leukemia or tumor, but you’re also then seeing them when they have an earache or a sore throat. You are really taking over their care and have an opportunity to see them on a very regular basis — sometimes three, four, five times a week! You truly do become an extended family. I just got a thank you card in the mail from a boy whom I took care of about 12 years ago. He just graduated high school, and the thank you note was really probably one of the nicest things that I’ve ever received. He said, “Thank you for giving me life, and thank you for allowing me to graduate high school. I love you, my parents love you. I wouldn’t be doing this without you.” I have seen him at events and fundraisers over the years, but he’s so far out from his diagnosis now that I don’t see him regularly. The fact that you have a teenage boy writing this kind of letter l think is really meaningful.
Letters and gestures must help keep you going, but how do you cope and help families cope when the outcome isn’t as positive?
I always try to approach it as we have a role to play with patients and families. Sometimes it can be very difficult. You are human and because of that strong relationship you have with patients, it is impossible not to have some emotional attachment and difficulty sharing bad news or being part of the death and dying process. I do feel like a pediatric oncologist’s role should be helping the family bridge through all that as well, so I am generally intimately involved. While outcomes are much better in pediatric oncology than they used to be, we are not able to save every child. I think what is really important is you help make their journey as comfortable, peaceful and happy as you can make it. I personally try to go to funerals. I think that’s a very personal decision, but I do generally go, unless there is an extenuating circumstance. That’s part of my own closure. It’s certainly not an expectation. I’ve heard from many families over the years that it can be really difficult because we have this longstanding and regular relationship, so when a family has a child pass, a whole section of their life is suddenly gone. They don’t come back to clinic, so I think it’s important for me to go and let them know that we’re still here if they ever want to talk. We usually invite a family two or three months later to come see us again as a team, whether it’s at the hospital or somewhere off campus. It helps with closure, and again, I think the relationship continues for a long period of time.
As you said, pediatric oncology outcomes are much better than they used to be. What improvements have you seen in the 12 years since you started?
I was just talking to my team and a patient about this exact issue because there are things that have significantly improved. What I was taught during my fellowship are really no longer even completely true anymore. There are two main things in my mind that are really continuing to progress. One is we are much better at detecting disease than we were in the old days. Technology has drastically improved to identify when a patient does have a disease. We can, for example, look at very small percentages of leukemia cells, like .1 percent or .01 percent. These are very small numbers, but they can significantly change the trajectory for treatment protocols. Back in the day, we would look at patient’s cells morphologically underneath a microscope with a hematopathologist, and we would call them negative, saying that they didn’t have leukemia. Now that technology can identify these very small percentages, we’re calling those patients not in remission and being much more aggressive with treating them up front to prevent them from eventually relapsing.
I was telling a patient’s family recently that 10 years ago, we would have called their daughter in remission, and now, we are saying you still have this very, very small percent of leukemia that could potentially put you at risk for relapse down the road. Therefore, we need to stop where we are and go a much more aggressive route to get that small percent to 0 before we call victory. They might not relapse, but they might, so then we would be in a whole different situation years later.
The other item that is significantly different is the number of drugs that are coming out. A lot of new options for drugs are in the immunotherapy category, rather than the traditional, standard chemotherapy category, and those are more targeted drugs. We are able to tell if a particular drug will work on a particular cancer cell. So that’s incredible that you can actually do testing on a tumor cell and say, “I know this drug is going to work.” It’s personalized medicine for their tumor cell.
One other item I want to bring up that has significantly changed in the field of stem cell transplants is the ability to use what we call haploidentical transplants, which is half match. Before, we would have mostly used a related donor that was a match. For example, a sibling was a full match for the patient, or potentially a donor from the registry who matched the patient. Now, we are able to perform successful transplants with haplo, with half identical donors. This significantly increases the number of patients that could be eligible for transplant, especially in the pediatric world because that would mean that a parent could donate to the child. This is huge if a child doesn’t have full siblings! It really gives patients who never had a chance to have a transplant before a whole new avenue to find a donor.
Talk about this importance of The Children’s Hospital at TriStar Centennial’s new pediatric hematology/oncology unit.
The really amazing aspect is it’s a myelosuppression unit. This means that we have separate air filtration that enables the kids to come out of their rooms. The whole unit is isolated, and they can go out to the play area, or to the nurse’s station. That has been honestly life changing, not just for us to have a beautiful space, but it enables the patients and their families to have a lot more interaction with each other. As you can imagine, the families become a part of each other’s support network, and the fact that families can socialize with each other and learn about each other is really part of their journey, too.
One thing that I remember clearly when we opened was a little girl who was about 9 years old and was a couple of months into chemotherapy. Along came a new patient who was about 5, and she was getting her first round of chemotherapy. We were talking about hair loss and what that was going to be like. Then, I saw the 9-year-old in the hall talking to the 5-year-old, saying, “Your head will itch, but it’ll be fine. You’ll look like me. We can put this hat on or this bandana on.” It was just really amazing to see, and those are the kinds of interactions you wouldn’t see if patients are isolated in a room.
What do you think is the biggest challenge going forward?
I think the biggest challenge is still the same challenge that there always has been: to continue to improve survival. Next steps are finding better treatment options with less side effects. Currently, the treatments that patients receive have complications like organ toxicity, especially for patients who have already had a lot of chemotherapy. We continue to strive to make things more efficacious but hopefully decreasing side effects.
What do you do when you’re not working?
I travel a lot, and I love travel for multiple reasons, but I think one of the big reasons is traveling opens your mind and allows you to learn about other cultures. I love learning about how other people in the world treat diseases and just in general how they live. The other thing — getting back to how I sort of cope with the difficult aspects of my job — I think travel is really good for that. I go on trips where I don’t have my phone hooked up all the time, and I’m not continuously checking emails or answering phone calls. For me, it’s truly a form of recharge, an opportunity to get away and do my own thing and come back to work refreshed.
Any closing advice for parents?
My advice is trust your instincts. I’ve seen a lot of families over the years who just felt like something wasn’t quite right with their child. They had that intuition, and they were just persistent. I think you have to speak up. I think it’s really important to communicate and trust yourself. So, if you are worried about something, reach out — that’s what we are here for!
Thank you, Dr. Domm. And thank you to Leila Grossman of Grannis Photography for the beautiful photos.
To learn more about The Children’s Hospital at TriStar Centennial or the myelosuppression unit, visit thechildrenshospitalnashville.com.