With the development and expansion of oral anticancer agents, the paradigm for cancer treatment has been shifting over the last decade.[1–3] Patients have expressed a preference for oral chemotherapy because it offers a noninvasive option perceived to be safer than intravenous agents. Convenience and ease of administration are viewed as an improvement to the patients’ quality of life. Nevertheless, the management of these patients constitutes a major concern, as oral administration is subject to additional risk factors: complex instructions for medication intake, narrow therapeutic index, supplementary drug interactions, and noncompliance risks because of the transfer of responsibility to the patient. The administration of intravenous chemotherapies used to be realized by nurses, now with the oral anticancer agents, the patients are responsible for their drug intake. Moreover, even if patients perceive oral anticancer agents as being safer, these treatments can potentially generate severe adverse effects.[5,6] These toxicities are unusual and different from conventional anticancer agents and required specific management strategies that become a new priority for the health care professional. For that reason, several programs have been developed to support patients using oral anticancer treatment at home. These programs are often home-based and propose monitoring of the patients during their treatment. Results from these programs have shown that they can improve patient's quality of life, reduce drug wastage, and optimize health care utilization.[7–12]
The role of clinical pharmacy plays a major part in the management of oral anticancer treatments and was particularly described by Leveque et al. With the understanding of drug interactions and adverse effects, clinical pharmacists with oncology training, could optimize the use of these therapies by providing timely information for health providers, as well as counseling to patients. Additionally, clinical pharmacists offer tremendous promise to help patients to improve their adherence to oral anticancer therapy. In their controlled study, Lam et al have shown that an oncology pharmacist-managed oral anticancer therapy program significantly improved oral anticancer drug adherence rates in patients with chronic myelogenous leukemia.
However, the timing of oral anticancer introduction is a particularly challenging moment in the patient's management. At treatment introduction, the lack of information may cause drug-related problems because of discrepancies between the prescription for the oral anticancer drug and the actual intake by the patient at home (administration at the wrong dose or wrong time), poor adherence or inadequate management of adverse effects. In our hospital, a multidisciplinary consultations program (MCP) has been initiated in order to support patients at this critical moment. The aim of this program is to better inform patients before they start their oral anticancer agent with a view to limit the risks associated with this kind of therapy. Hence, every patient is seen separately in consultation by an oncologist, an oncology pharmacist and a nurse. In some cases, a dietician, a psychologist or a beautician is also involved, depending on the patient's specific needs. Overall, 2 oncology pharmacists, who are hospital pharmacists with oncology specific training, have been involved in this MCP with the implementation of pharmacist consultations.
In our study, we would like to describe the implementation and the process of pharmacist consultations for oral anticancer treatments, realized by oncology pharmacists, in a hospital setting. The aim of this study is to highlight the importance of the medication assessment by the oncology pharmacist to identify drug or herbs interactions, the importance to explain to the patient their new therapeutic regimen but also the importance to better inform the community pharmacists who have to dispense the oral anticancer drug.
2.1 Setting and population
This descriptive study was conducted from August 1, 2015 to August 1, 2016 at the oncology unit of Brive Hospital. Oncologists proposed the MCP to all adult patients who started a new oral anticancer treatment. Pharmacist consultations were realized as part of the MCP. Patients gave informed consent and the study was approved by our local Ethics Committee No. 1-2016-1, Brive Hospital, France on August 31, 2016.
2.2 Multidisciplinary consultation program
Before the patient started their new oral anticancer treatment, a half-day appointment was proposed to the patient to participate in the MCP in the oncology unit. The MCP was divided into 3 sections: first the consultation with the oncologist, second with the oncology pharmacist, and then with the nurse. Benefits and challenges of oral anticancer treatment were explained to the patient during the consultation with the oncologist. Then, the oncology pharmacist provided education to the patient about the new drug during the pharmaceutical consultation. Afterward the nurse, for their part, summed up assimilated information given to the patient. In a number of cases, a dietician, a psychologist or a beautician were also involved, depending on the patient's specific needs.
At the end, each contributor completed the multidisciplinary report in the patient's medical record. This report was sent with a drug-specific factsheet (information about indication, dosage, regimen, adverse effects, safe handling, and drug or food interactions) to the patient's community pharmacist and the general practitioner.
2.3 Pharmacist consultation
The pharmacist consultation consisted of 3 steps. (1) The first one was the preparation of the medication assessment. To plan ahead the consultation with the patient, the oncology pharmacist read the patient's medical history and searched for specific allergies or contraindications with the new oral anticancer agent. A call was made to the patient's community pharmacist (phone number present in patient's medical record) to obtain the patient's medication history in order to identify potential drug interactions with the new anticancer agent. Vidal, DDI Predictor, Oncolien databases were used to check drug interactions and the website of the Memorial Sloan Kettering Cancer Center for herbs interactions. (2) The second step was the pharmacist consultation with the patient. The oncology pharmacist assessed the ability of the patient to self-manage their therapy at home with a brief questionnaire (Fig. 1). Then, the oncology pharmacist provided information about the new oral anticancer agent: name of the drug, indication, dosage form, and regimen. To obtain the best medication history, the community pharmacy's drugs list established was compared with what the patient really took (prescribed and nonprescribed drug or herbs). To prevent potential drug and food interactions, an individual medication plan was proposed to the patient by the oncology pharmacist (Fig. 2). The oncology pharmacist also recommended not using self-medication or herbal medicines without consulting the oncologist or the pharmacist first. As well, the oncology pharmacist gave appropriate advice to prevent and manage side effects at home. (3) Finally, after the consultation the multidisciplinary report was completed by the oncology pharmacist. The pharmaceutical section of this report contained a brief patient's medical history (cancer type and previous therapeutics), the information about the new treatment strategy and the conclusions of the pharmacist consultation: the assessment of patient's autonomy; information about specific time intervals between administration and food intake; drug and herbs interactions identified and the potential modification of the patient's regular medicines. This report was sent by secure e-mail or fax to the community pharmacist with the drug-specific factsheet.
The results of this study were expressed in number and/or percentage. Patient characteristics are expressed as medians. The impact of pharmacist consultations was measured by the number of patients unable to self-manage their therapy at home reported, the number of drug and herbs interactions identified, and the number of prescription modifications due to oncology pharmacist intervention. In order to assess the clinical relevance of these interactions, their potential impact was ranked by a clinician into 3 categories: serious, significant, and minor.
The hospital–city relationship established between oncology pharmacists and community pharmacists contacted for a patient starting oral anticancer agent, was assessed over a period of 7 months by a survey with a satisfaction digital scale (Fig. 3).
3.1 Patient characteristics
Over the period of analysis, 183 patients received a new prescription of oral anticancer agent. Only 90 patients (39 females and 51 males) were enrolled in the MCP with a pharmacist consultation. The other half of patients refused to participate to the MCP because they lived too far from the hospital. The mean age of the patients was 71 years (63–78). Patient's characteristics are described in Table 1. Oral anticancer treatment was first line of treatment for 19% of the patients, while 43% had already received intravenous chemotherapies, 39% hormone therapies, 20% other oral chemotherapies. Overall, 21 different anticancer agents were prescribed (Table 2). Of note, 66% of patients were polymedicated with a median of 5 drugs per day and per patient.
3.2 Pharmacist consultation
The pharmacist consultations were performed by 1 of the 2 oncology pharmacists based in the oncology unit. Oncology pharmacists have shown that 76% of the patients were able to take their medicine by themselves at home. Patients were able to mention the name and the indications of their medications and to take them at regular time each day. They were also independently able to take their medicine from their community pharmacy. Seventy percent needed family help (marriage partner) and 4% the assistance of a nurse. Where necessary, information about the new oral anticancer treatment was transmitted to patient's home caregiver by oncology pharmacists. Three patients unable to self-manage were reported by oncology pharmacists to the oncologists to implement home supports.
Potential drug and herbs interactions were identified on 32 patients by oncology pharmacists: 47% were interactions with anti-acid and gastrointestinal absorbents which could reduce oral anticancer absorption, 19% interactions with anti-vitamin K drug which required close monitoring and 25% were pharmacokinetic interactions. Interactions were reported to the oncologist to adapt or not the therapy. The impacts of these pharmacist interventions are summarized in Table 3. Eighty-four percent of the drug interactions reported were considered as “significant” by the clinician and 8% as “serious.” Overall, 4 patients discontinued 1 drug of their personal treatment and 2 patients stopped their herbal medicines. In addition, individual medication plans were implemented for 15 patients to limit drug and food interactions.
3.3 Hospital–city relationship
For each patient the community pharmacy was contacted by the oncology pharmacist which corresponds to 62 community pharmacies. Over a period of 7 months, 80% replied to the satisfaction survey. Community pharmacists gave a satisfaction average mark of 9/10 for hospital–city relationship, of 8.7/10 for the quality and the relevance of information provided and of 8.6/10 for support used to submit information. For 83% of community pharmacists, information delivered by oncology pharmacists helped them in adapting their interview with patients at the time of drug dispensing. Thanks to the information received, they were able to remind the patient how to take the medication during or between meals (not always specified on the prescription) and to give advice to manage adverse effects at home. This information also helped them to be more vigilant about drug and herbs interactions. Information provided was archived in 79% and shared with the community pharmacy's team in 76% of cases.
To date, no consensus has been established for patients’ management on oral chemotherapy, although their use is steadily increasing. The growing number of patients with oral anticancer therapies requires designing and adapting supportive care, relying on both hospital and community health care providers. Counseling patients about their new therapeutic is pivotal to ensure patients’ adherence to this treatment. Indeed, patients request additional information about oral anticancer agents, especially on drug interactions and tolerance.
In response a MCP with pharmacist consultations was implemented in our French hospital. This study wants to describe how to set up pharmacist consultations in a hospital setting for patients who start a new oral anticancer treatment. Results have shown that oncology pharmacists are a key component of this MCP because the implementation of pharmacist consultations allowed us to better inform patients about their new therapy: treatment regimen and dosage, potential drug, herbs and food interactions, and prevention and management of adverse drug events. Moreover, thanks to pharmacist consultations, our results have highlighted that some patients were not able to self-manage their treatment at home. Yet, the patient's inability to understand and/or to take their treatment properly contributes to poor adherence, associated with greater use of health care resources.[21,22] The evaluation by an oncology pharmacist of the patients’ ability to take their medicine by themselves is therefore critical. However, this evaluation has its limitations because the questionnaire used to assess the ability of the patient to self-manage their therapy was not validated. To our knowledge, there is little data in oncology about this kind of evaluation before the patients start their oral anticancer treatment. It would be interesting to develop and validate a specific questionnaire that also takes into consideration sociodemographic characteristics and patient's beliefs.
Oral anticancer drugs can interfere with food, herbs, and other treatment.[24–26] In this study, oncology pharmacists identified drug and herbs interactions in one-third of patients (36%). They were revealed by drawing up a complete and accurate patient medication list taking into account the community pharmacy's drugs list, the patient's medical records and the interview with the patient. The prevalence of potential drug interactions was even higher in the study of van Leeuwen et al with interactions detected in 46% of the patients of which 16% were major interactions. These interactions could decrease efficacy of drugs, increase drugs’ toxicities or require a close patient monitoring. Our findings are in accordance with Ribed et al study, they confirm that consultations by oncology pharmacists with a review of patient's concurrent chronic medications are crucial to prevent this drug-related problems.
However, a number of limitations have to be considered in this study. The number of patients is relatively small because this single-center study describes a local process specific of our hospital. Moreover, the lack of a control group or the noncomparison of the situation before the implementation of the MCP is also a weak point of this study. Our results only describe the time upon the patient start his oral anticancer agent, we did not continue to monitor the emergence of interactions due to new prescription by general practitioner or from self-medication. Neither to monitor if patients, that were deemed fit for self-management, were actually adherent. Literature data indicate that pharmacists help patient to improve adherence to oral chemotherapy.[14,15] Simons et al have shown that provision of intensified pharmaceutical care could enhance adherence to and prolong treatment for patients with capecitabine. Above all, they underlined the importance of multidisciplinary care to ensure the effectiveness of oral anticancer therapy. Unfortunately, in our study we could not measure the impact of the MCP on medication adherence because the oncology pharmacist did not see the patient again after he started his therapy to assess his compliance with a validate medication adherence questionnaire. In response, we could develop a follow-up consultation after 1 and 6 months based on the new relationship between oncology and community pharmacists. Thereafter, the satisfaction and quality of life of the patients should also be assessed.
Results of the satisfaction survey have shown that community pharmacists want to become further involved in patient management with oral anticancer treatment. For this purpose, the relationship between hospital and community pharmacists must be strengthened in order to anticipate the patient's requirements. As shown in the study of Renard et al, 96% of the patients with oral anticancer drug questioned their community pharmacists about their treatment while only 16% of community pharmacists felt able to answer them.[29,30] Community pharmacists have indeed requested more information and training about oral anticancer treatments. In our study, thanks to the hospital–city relationship established, information sharing allowed 83% of them to adapt their interview with patients: they were able to better advise the patients at the time of drug dispensing.
This relationship is absolutely essential because in France oral anticancer agents are almost entirely dispensed by community pharmacist, an important difference between other European countries. In contrast, in Spain oral anticancer agents must be dispensed through the hospital pharmacy, which allow oncology pharmacist to be better involved in the patient information and education (98.8% Spain vs 6% France). At the time of drug dispensing, because of their expertise, this involvement helps to reduce potential errors and to improve patient outcomes and compliance. On the other hand, as our hospital patients often live very far from the hospital of prescription they do not have a very easy time to come back to the hospital to recover their oral anticancer agents each month while they have a community pharmacy close to home. However, a compromise could be proposed with only the first dispensing of the oral anticancer agent by the oncology pharmacist at the hospital and then the following dispensing in the community pharmacy with the implementation of the relationship between oncology and community pharmacists. This compromise was also recommended in France by the Plan Cancer 2014–2019. The Plan Cancer also advocates the development of patient education programs about oral anticancer treatment. Nevertheless, in their study Occhipinti et al underline the time-consuming character of these programs compared to the implementation of MCP. Only 45.5% of cancer centers that have developed patient education programs would like to continue this activity whereas 90.9% plan to continue pharmacist consultations.
In our hospital, the implementation of the MCP, at oral anticancer therapy introduction, has appeared to be a needed option to improve patients’ management. The description of pharmacist consultations shows us how crucial the expertise of oncology pharmacists is in the MCP. They contribute to limit the drug-related problems especially by identifying drug and herbs interactions but also the patients unable to self-manage their therapy at home. They also play a key role in the coordination and collaboration between all health care professionals with a view to secure patient management.
Conflicts of interest statement
The authors have no conflicts of interest to disclose.
We would like to thank Alain Mengus and Florian Slimano for proof-reading the manuscript.
Financial support and sponsorship: none.
Presentation: Preliminary data were presented at the XI congress of the French Society of Oncology Pharmacy.
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Keywords:Copyright © 2018 The Authors. Published by Wolters Kluwer Health, Inc.
oral anticancer agent; pharmaceutical care; pharmacist consultation