When Rick Silvia, Pharm.D., MA, FCCP, FAAPP, BCCP, wrote a chapter for the Pharmacotherapy Self-Assessment Program (PSAP) on the treatment of mental health in persons with cancer, he had no idea what it would lead to.

But in January, a few months after “Psychiatric Pharmacotherapy in the Oncology Patient” was published in PSAP 2024 Book 2, Hematology and Oncology, Silvia found himself on a multidisciplinary, forward-thinking panel formed by the National Cancer Institute (NCI).

Apparently someone shared that chapter with folks at the NCI, and they were in the process of building an “Innovations Lab” to look at the intersection of mental health, cancer, and the gut microbiome and how those 3 things might work off each other. After writing this chapter, they apparently thought I might be someone that could be useful in this Innovations Lab.

NCI sent Silvia an invitation to apply, and his application was accepted. He then became one of 34 participants in the Innovations Lab, which was charged with identifying new areas of research.

Participants were asked to imagine giving a presentation at a conference 20 years in the future exploring the relationship between cancer, mental health, and the gut microbiome. “You are the lead presenter at this conference,” Silvia and other attendees were told. “What is the headline? What are the 3 things you’re going to talk about at this conference?”

Outside moderators helped attendees organize and steer the process:

They put us in a virtual room for a week and basically said, “We want you to envision where you think things could or should be in 20 years related to the intersection of these 3 areas.” And they told us not to be limited by what’s available currently. They told us the sky is the limit. Don’t say, “This can’t be done,” because maybe, in the future, it can be done.

With that directive, participants broke into groups and developed their presentations. Silvia’s group developed an idea for an AI-based clinical decision support system.

You could take in all these patient characteristics—the microbiome, their cancer markers and biologic markers, their mental health history, their current meds, their other diagnoses, their labs, everything we know about them, even patient preferences and social determinants of health and other potentially subjective concerns. These would all go into this AI product. And it would essentially produce potential diagnoses and even a potential treatment plan for the end-user clinician to use in treating a patient.

Part of this concept was a wearable device that would feed data back into the AI system and continually update itself. The effect of such a system would be to streamline and personalize care.

Unfortunately, the final presentation to the NCI directors was delayed by the federal gag rule on external communications in late January. The presentations were recorded, however, and the directors viewed them in late February. Ultimately, they will be used to identify avenues for research, perhaps with support from NCI.

Regardless of the outcome, Silvia was grateful for the opportunity to work with a variety of health care providers—including physicians, dentists, and nutritionists—with expertise ranging from benchtop to clinical practice represented in the group. One of the outside moderators was a pharmacist, but Silvia was the only pharmacist on the panel itself.

It was interesting to hear folks from other disciplines. I work with MDs all the time, but they don’t have as much of that research background. Everyone thinks the gut microbiome is the bacteria that live in your gut, but it is so much more than that. It’s the bacteria, the viruses, the fungi, the proteins and nutrients that are there or not there. It’s not just what’s in your stomach, it’s throughout the GI transit.

Understanding the microbiome, then, became a goal of Silvia’s group.

How do you effectively measure the gut microbiome? Most people do fecal samples, but that’s only the last component of the GI tract. The gut microbiome is very different throughout the course. So how do you collect samples without doing biopsies or something? That is certainly nothing I had ever thought of before—how do we measure those different environments?

As the only pharmacist participating, Silvia also brought his unique perspective to the table.

I threw out a couple of ideas about how medications would be affected. For example, drugs need a certain pH to be absorbed. The example I used is H pylori, causing GERD (gastroesophageal reflux disease) and ulcers and such. Well, H pylori changes the pH of the gut. You change pH, you change drug absorption. If you eliminate H pylori, you change pH. So what does that do for gut absorption? And they said, “Oh yeah, that’s a good question.” We know gastric bypass surgeries—and there are many kinds—change absorption of their meds. And we don’t know how (the microbiome does this) because we’re in our infancy of understanding what the gut microbiome is, let alone what it does.

The overall experience was satisfying, if unexpected:

As a psychiatric pharmacist, I never imagined that I would ever be involved in an NCI program. When I tell people that I took part in an NCI program, they say, “Wait a minute, you’re a mental health psychiatric pharmacist. How did you get involved in a National Cancer Institute program?” And I say, “Right place, right time.” Had that PSAP chapter been published 6 months later, I probably wouldn’t have gotten that invitation. It was published at the right time, and the right person recommended me to the organizers of this program.