Pharmacist role in oncology care

The conscientious practice of an oncology pharmacist benefits every cancer patient, write Mahtab Hassan, Govind Shah, Vijay Roy and Dr Puneet Gupta

Pharmacist as a partner

Oncology pharmacists play a significant role in a cancer patient’s treatment by dispensing not just the prescription, but valuable information for the patient throughout the therapy, including side-effect counselling and management and proper handling techniques. Pharmacists are making significant contributions to the profession through specialised pharmaceutical care. The very nature of oncology drugs imparts a special responsibility for their appropriate and safe use.

The oncology pharmacist and the conscientious practice of his or her profession significantly benefits every cancer patient. Knowledge of appropriate doses, pharmacokinetics, incompatibilities, special administration procedures, acute and cumulative toxic manifestations, unique databases, counselling and avoidance of personal exposure are all attributes that are brought to the interdisciplinary team by an oncology pharmacist.

Effective antiemetic regimens have become part of standard care in oncology. The effort to control emesis has become an ideal setting for the collaboration of physicians, nurses and pharmacists. The goal of optimal control of emesis requires a knowledge of the more active drugs, experience with their use in combination, and consideration of the emetic risk of each patient. It is important that new studies are accurately interpreted and adapted to clinical practice. Precision in evaluation techniques is mandatory, if reproducible results are to be obtained.

Attention to the differing patient characteristics and to specific emetic patterns of individual chemotherapeutic agents must be considered in the design of trials and in the planning of an individual’s antiemetic treatment regimen. Ongoing studies investigating pharmacogenomics may reveal other factors that should be considered in antiemetic care.

Future research will need to concentrate on the reasons why some patients still do not have complete emetic control so that rational solutions for these patients can be found. The control of emesis is one of many important topics in the supportive care of patients with cancer.

In better delivery of cancer care

The training and development of a cadre of oncology pharmacist, coupled with significant pharmaceutical care advancement has resulted in the current era of high-quality multidisciplinary cancer care. In this period of uncertainty, when a patient fears to get treated for cancer, where the therapy cost burdens them, oncologists with the help of a pharmacist must develop a comprehensive approach that provides appropriate cost therapy, affordable brands and care for all patients in the community.

This requires strategies that result in predictable costs and predictable outcomes in a setting in which evaluation of outcome is feasible. It also requires a plan that allows for multidisciplinary care, broad access to practice based trials, and the incorporation of new, effective therapies as they become available.

Need for making standard pathways

The ability to deliver high-quality healthcare in an environment where cost is a primary consideration depends on broad agreement among specialists about the management of the common cancers. Guidelines are an overview of cancer treatments, appropriately sequenced for the management of specific clinical presentations.

These guidelines must include the common presentations of cancer patients and detail the multidisciplinary approach. Such a consensus approach allows some uniformity of pretreatment evaluation, treatment planning, and follow-up for patients across the country. It allows the providers to better estimate the costs of therapy.

This approach also has the advantage of protecting the providers against accusations of negligence or concerns that the pressures to reduce cost have unreasonably affected treatment planning. While the effectiveness of this approach remains under investigation, studies suggest that in oncology, guidelines are acceptable to most oncologists and can be effective in decreasing costs and improving outcomes.

The success of these guidelines is also apparent in their acceptance by payers and insurers as the standard of care. Clinical pathways provide a more detailed approach to patient management and allow the individual groups of providers to detail their specific resource use (eg, specific chemotherapy regimens, drug doses and schedules, schedules for imaging studies, follow-up parameters). While there is great uniformity in the guidelines developed to date, there is more diversity in the specifics of the clinical pathways being developed.

At the same time that these standardised approaches to care are being developed, providers must also develop case-management systems to ensure that the approaches agreed upon are being followed, and to deal with patients whose clinical situations do not fit a clear pathway. Pharmacists can be proactive in the care of the patient by following up with the physician or nurse to confirm that the chemotherapy regimen should continue as scheduled.

In practice based clinical research

The cost of patient care in clinical trials is an important issue for patients, physician, and payers. The recognition that a clinical trial in a cancer patient may be state-of-the-art therapy and not an experiment is clear to patient advocacy groups and professionals, but not yet completely accepted by payers and insurers. In oncology, where many major advances have been made by academic investigators a continuing monitoring is felt necessary.

The “off-label” use of anticancer drugs is an important issue because many of our most active drugs are used for indications that are not specifically approved. Oncologists are known for the speed with which they integrate new therapies into clinical practice. Thus, it is reasonable that patients receiving drugs used for off-label indications in diseases in which their efficacy has been demonstrated should be reimbursed under the same conditions outlined above.

A more difficult situation arises with drugs that are of unproven benefit. The possibilities for errors of dosage are sharply diminished when all personnel involved with patient care have access to a written protocol specifying the therapeutic regimen, particularly one that is immediately available on a computer. The oncologist is responsible for prescribing the proper drug and dose, but pharmacists and oncology nurses can serve as additional checks in the system. Personnel downstream from the oncologist could initiate an error for which the oncologist has to bear contingent responsibility.

There is much reason to anticipate that progress would be more rapid if clinical research were accepted as an integral part of the practice of medical oncology so that more oncologists and patients would participate than at present.

Patient counseling

Patient counseling refers to the process of providing information, advice and assistance to help patient for better adherence towards their treatment appropriately. It also includes information about the patient illness and life style modification. Oncology pharmacists can contribute to achieving the highest possible standards of patient care. Pharmacists are knowledgeable about side effects of chemotherapy regimens as well as drug interactions.

A pharmacist should be able to give recommendations to minimize side effects or determine which medications in the profile may be interfering with the effectiveness of chemotherapy. Pharmacists also need to counsel patients and their caregivers on proper handling of medication, especially reminding caregivers that oral chemotherapy drugs are not to be touched.

Chemotherapy admixture

Pharmacist can take the opportunity with challenges and utilise his sound knowledge of pharmacology and pharmaceutics. Pharmacist can help in monitoring of Intravenous (IV) admixture administration and preventing medication errors by reviewing the prescription and educating nursing professionals on safe handling and administration of cytotoxic drugs. In present practices either nurses or residents are evolved in admixture of chemotherapy, but where in real fact there curricula doesn’t have admixture preparations and not aware of IV admixture process.

Chemo drugs are very expensive and once the wrong selection of a solvent/diluents or improper shaking or maintaining inappropriate temperature during admixture, all this conditions may lead to crystal or precipitation or foam formation and ultimately will lead to reduction of the potency, stability and quality of the preparation. The storage duration varies once the drug is mixed with the solvent and may be different when the reconstituted solution has further been diluted for infusion. To exemplify Herceptin@ (HER-2 Monoclonal Antibody) a costly lyophilized powder when reconstituted with bacteriostatic solvent can be stored at room temperature or 2 – 8 degree centigrade for 28 days, whereas if further diluted in 5 per cent dextrose (shouldn’t be reconstitute with normal saline) has to be used within 24 hrs. when stored at 2 – 8 degree centigrade.

Therefore, when a single reconstituted vial has to be used as multiple weekly doses then make sure that no further dilution should be done for the whole vial. Despite proof that exposure to cytotoxic drugs can be harmful, a large percentage of health professionals continue to disregard personal protective measures. Direct exposure to cytotoxic agents can occur during admixture, administration or handling and involves inhalation, ingestion or absorption. Pharmacist is a professionally trained in drug admixture and helps in creating the infrastructure and expertise for making such preparation appropriately.

Economics in cancer care

Although there is a tremendous amount of claims data available for review-providers, insurers, and payers have historically focused on the cost of episodes of cancer care, rather than the cost of treatment during the continuum of an illness. Nevertheless, it is important for cancer physicians to understand the economics of cancer care. In a given study seventy-five percent of patients undergo a major surgical procedure, 40 per cent have one course of radiation therapy, and 20 per cent require a second course at a later date.

Approximately 60 per cent of cancer patients will be referred to a medical oncologist or hematologist, and two-thirds of these patients (about 40 per cent of the total) will receive chemotherapy. The oncology pharmacist with the help of physician’s can prepare a treatment protocol including approximate treatment cost for chemotherapy, radiation therapy, surgery, adjuvant therapy and per day bed charges etc. respectively. For details see Table1.

This will ultimately helps the patient to plan for their treatment accordingly. Pharmacist also helps in the selection of alternate brands in an affordable price. Almost all the chemo drugs (except a few) are expensive (from few thousands, upto 1.5 lakh). These drugs must be handled and kept safely to prevent losses, accidental over dosage and wrong medication.

Working as an oncology pharmacist is an image for pharmacist to be considered in a healthcare team to fight against the cancer.

The ability of the oncology pharmacist to recognise time as a critical factor in cancer therapy is important as well as when working through the financial concerns.

Conclusion

The pharmacist may have to act as the “coach” to promote winning as the patient fights the cancer battle. Pharmacists prove to be a significant asset to the “team” as the patient addresses how medications will affect the cancer, as well as daily life. The active role of a pharmacist as a partner in the treatment process is critical to the successful execution of an oncologist’s treatment strategy.

A physician can tell a patient what medicine to take, but if a patient doesn’t understand how or when to take the medicine, the treatment process is drastically impacted. Pharmacists can provide a variety of small but important services in making prescription medication easier for a cancer patient. Oncology pharmacy provides a unique opportunity to interact with patients who value and appreciate the knowledge of the pharmacist.

Mahtab Hassan and Govind Shah are oncology pharmacists, Vijay Roy is senior executive, pharmacy, while Dr Puneet Gupta is senior consultant, medical oncology, department of pharmacy, Apollo Cancer Institute. Indraprastha Apollo Hospitals, New Delhi