Introduction: The future of healthcare and oncology pharmacy
A new medical era is upon us; recent breakthroughs are altering how we view and treat diseases in ways that seemed inconceivable just a few years ago, and technology giants such as Google, Microsoft, Apple and Amazon are investing heavily in healthcare. Between 2013 and 2017, Google's parent company, Alphabet, filed 186 healthcare-related patents, with an emphasis on chronic illnesses, such as diabetes, and the use of bioelectronics to create ‘smart’ operating rooms. During the same period, Microsoft and Apple filed more than 50 healthcare-related patents each, with substantial increases year on year.
With regards to oncology, several factors are driving significant changes in the market. Paramount among these is the increasing incidence of cancer, which is being driven by multiple factors, including changes in lifestyle resulting in conditions predisposing individuals to cancer, such as obesity; increased exposure to carcinogenic environmental pollutants and an ageing population. At the same time, a deeper understanding of the molecular processes underlying cancer has resulted in the development of revolutionary new treatments, including ever more sophisticated biological therapies, such as immuno-oncological checkpoint inhibitors, and cellular therapies such as chimeric antigen receptor T-cell therapy. Advances are likely to increase exponentially as cancer treatment enters the panoramics era, whereby a range of genetic and molecular biology techniques will be used to provide detailed analytical information on an individual patient level, with the ultimate aim of personalizing therapy. In fact, obtaining genetic information from individual tumours has already enabled us to identify the molecular changes in a specific patient's cancer, which will allow more efficiently targeted therapy, but in turn increases the complexity of the treatment landscape. Also, the number of indications per therapy is predicted to rise as pharmaceutical companies look to maximize return on investment and recoup research and development costs.
Personalized therapies also include drugs with narrow therapeutic range which can cause side-effects and unexpected results when used inappropriately. Healthcare professionals (HCPs) are in an ideal position to encourage adherence because of their existing relationships with the patient and their family/caregivers, involvement in the ongoing monitoring of the patient's health results and familiarity with the patient's specific treatment needs.
In light of the evolving medical landscape, the role of the pharmacist is also expanding as they transition toward a consultation-based, patient-centric and collaborative model of care, with increased responsibility and accountability for medicines management. Studies in Canada have shown that doctors, pharmacists, other HCPs and patients believe that the inclusion of pharmacists in primary care teams has improved the quality of patient care, is a valuable resource and helps patients to manage their medications. As a result, health reforms in Canada, the United Kingdom and the United States have resulted in the closer integration of pharmacists in general practice and affiliated care teams, expanding the reach of clinical services and broadening the scope of responsibility of pharmacists.
The increasing incidence of cancer and an ageing demographic are placing an increasing strain on medical oncology resources, resulting in an evolving role for oncology pharmacists. Their remit is expanding to include a wider range of services, such as administration of injections, and prescription of antiemetics and other support medications used in cancer chemotherapy; this frees up time for core medical oncology staff to provide other services. In the future, oncology pharmacists must become more visible and take on new roles in patient services to meet an increasing healthcare need and alleviate pressure on other areas of the healthcare system. Oncology pharmacists can play an important role in developing supportive care guidelines in communication with other HCPs. Novel technologies such as cancer blood screening, benchtop whole genome analysis, pharmacy management systems, polypharmacy, 3D-printed medications, 3D-printed human tissue and improved artificial intelligence all have the potential to significantly influence the role of oncology pharmacists in the near future.
Members of the European Society of Oncology Pharmacy (ESOP) met at the 4th European Conference of Oncology Pharmacy (ECOP) meeting in Nantes, France, in October 2018 for a symposium entitled The Future of Oncology Pharmacy 2025. This symposium highlighted the most important issues facing healthcare and oncology pharmacy and outlined a number of routes that ESOP is pursuing to adapt to these changes over the next decade, with the ultimate aim of improving outcomes for patients with cancer. The symposium provided an overview of ongoing ESOP activities, results from ESOP member surveys, which questioned various topics around the future of oncology pharmacy, and an introduction to the ECOP 2018 Resolution on the Future of Oncology Pharmacy.
European Society of Oncology Pharmacy: ongoing activities
ESOP is involved in several projects that aim to support oncology pharmacists and help improve outcomes for patients with cancer. Delegates at the ECOP symposium provided an update on the ongoing ESOP projects and activities and outlined future plans and objectives.
The ‘Empowering pharmacists to improve healthcare for oral chemotherapy patients’ (EPIC) project aims to establish a European best-practice model for oncology pharmacists, improve the quality of oncology patient counselling by pharmacists and improve patient understanding of pharmacotherapy and treatment adherence and compliance. Models such as this are valuable for several reasons: a large number of new anticancer drugs are approved each year; administration of complex treatment for oncology patients is shifting from the clinic/hospital to patients’ homes; potent oral anticancer drugs are generally dispensed in community pharmacies and patients need to be well informed about the medicines they take. EPIC received funding from the European Union Health Programme to conduct a pilot project between 2015 and 2018; a training programme and an oral anticancer drugs database (e-tool) were developed to support pharmacists in the counselling and pharmaceutical care of patients with cancer receiving oral anticancer medicines. The pilot study involved the rollout of the educational programme and e-tool in 3 EU countries – Slovenia, Estonia and Germany – and resulted in a greater awareness among pharmacists that their commitment and quality of advice for patients taking oral anticancer drugs contribute to a more effective and safer treatment, a greater confidence in pharmacists’ counselling of patients with cancer and the identification of barriers to counselling patients. Future objectives are to establish an international working group, harmonize the content of the database at the EU level and to produce a best-practice model for community pharmacists in all EU member states.
With a high number of medications available for the treatment of cancer, the oncology pharmacist has become an essential part of the cancer care team. Oncology pharmacists should be actively involved in all aspects of cancer care, from chemotherapy preparation, administration guidance, safety controls and patient education to their involvement in clinical trials and are now active members of multidisciplinary cancer care teams. Accordingly, ESOP is a member society of the European Cancer Organisation (ECCO), which provides a cohesive platform for numerous European cancer societies and organizations with an aim to work together to improve cancer patient outcomes. ECCO regularly develops Essential Requirements for Quality Cancer Care (ERQCC) articles, which are organizational specifications that complement existing cancer guidelines and give oncology teams, patients, policymakers and managers in Europe an overview of the elements needed to provide essential high-quality care throughout the patient journey. The specifications place a strong emphasis on advancing multidisciplinary collaboration, with the aim of shaping the policy environment at European and national levels, to improve the quality of cancer care across Europe and to decrease inequalities in cancer outcomes. The authoring process for these publications requires a collaborative process between participating experts, member/partnering societies and the ECCO Patient Advisory Committee, the formation of tumour-specific working groups, and a 6-month systematic review process culminating in a final consensus and publication in a peer-reviewed journal. Each cancer diagnosis or group of diagnoses is the subject of an individual article with the aim to cover both the most frequent and rare diagnoses. Regular updates will also be provided. Recent publications include ERQCC articles for melanoma, oesophageal and gastric cancer, colorectal cancer and soft tissue cancer. ECCO also regularly publishes position statements and policy articles on topics such as improved access to innovation in cancer care, integrated cancer care, the value of specialized cancer nursing, and multidisciplinary cancer care. With regards to oncology pharmacy, a future aim for this collaboration is to include more community pharmacists as core members of oncology multiprofessional teams (MPTs) to raise awareness of the impact of medication errors and treatment compliance on treatment outcomes.
Following many years of experience in education through the ESOP masterclasses, the ESOP Academy has developed a comprehensive educational programme for pharmacists named the European Specialization in Oncology Pharmacy (EUSOP), intended to be recognized by the European Commission. The programme was developed as a means of educating a large number of oncology pharmacists all over Europe, as well as in other interested countries. The 100-hour programme comprises international webinars, case studies with international workshops (eg Excellence Course for Oncology Pharmacy) and national training sessions, and includes modules on the basics of oncology pharmacy (18 h), oncology pharmacy on practice (11 h), clinical oncology pharmacy (46 h) and biologics in oncology pharmacy (25 h; Table 1). Overall, the programme is divided into 50 hours of e-learning, 12 hours of national training and 38 hours of international training. National training sessions are approved by ESOP's accreditation committee. After passing the entire EUSOP programme, the title ‘European Pharmacist in Oncology Pharmacy’ will be conferred.
Biosimilars are now a critical component for the cost-effective use of biological drugs by healthcare systems worldwide; hence, oncology pharmacists require a deep understanding of this rapidly expanding field within drug development. It is the pharmacists who should play the role of experts on biosimilars in their MPTs and who should be able to confer essential information both to their healthcare colleagues and their patients. ESOP has developed a biosimilar-focused training programme for oncology pharmacists, which includes information regarding basic concepts (analytical development, extrapolation between diagnoses, immunogenicity risks), current and emerging data, combination therapy, guidelines, regulatory approvals, pharmacoeconomics and recommended handling procedures. The programme is part of EUSOP curriculum Part 4 ‘Biologics in Oncology Pharmacy’ and is based on webinars by professionals in the field, regional lectures at scientific conferences and case discussions and can be delivered in the national language of most member countries.
In addition, the Quality Standards for the Oncology Pharmacy Service (QuapoS) provides a comprehensive set of standards for all aspects of oncology pharmacy, including quality assurance, personnel, anticancer drug protection and pharmaceutical care. QuapoS was developed by German hospital and community pharmacists who were members of the German Society for Oncology Pharmacy (Deutsche Gesellschaft für Onkologische Pharmazie). The first quality standard was published in 1997 and the current version (QuapoS 6) was published in 2018. The QuapoS standard is a short and clear statement, which is accompanied by commentaries which offer advice, examples and experience. QuapoS is available for free in 15 languages.
A further ESOP initiative is the Research about Environmental Contamination by Cytotoxics and Management of Safe Handling Procedures study, which evaluates levels of cytotoxic surface contamination in European hospitals, including pharmacies and hospital wards. The aim is to increase awareness among healthcare workers and their employers of the risks associated with working with cytotoxic drugs and to develop measures to improve working conditions by protecting hospital staff from occupational exposure to antineoplastic agents. A pilot study found cytotoxic surface contamination, to varying degrees, in the preparation and administration areas of all hospitals that were investigated. Future investigations, in collaboration with the European Society for Medical Oncology (ESMO), will evaluate potential body exposure of ward personnel to cytotoxic agents in the most contaminated hospital wards. Only independent analyses of this kind can provide unbiased output concerning the working environment and involved procedures. The unification of safety legislation on the European level, based on thorough research, would significantly improve the situation in this field of interest.
European Conference of Oncology Pharmacy 2018 surveys on the future of oncology pharmacy
ESOP is committed to meeting the needs of oncology pharmacists throughout Europe. To this end, an ESOP premeeting survey asked both board members and delegates attending the 2018 ECOP symposium to identify what they perceive to be the most important issues for the future of oncology pharmacy (Fig. 1). Drug shortages, voted for by 95% of responding countries (N = 20), were the most frequently cited issue for the future of oncology pharmacy. This is hardly surprising, given that medicine shortages have been reported across the whole of Europe; in a 2018 survey of 1666 hospital pharmacists from 38 countries, 91.8% considered medicine shortages to be a current problem, up from 86.2% in 2014, and 75% experienced shortages at least weekly.[16,17] The mean duration of a typical shortage was 2.2 months, and 39% of shortages were reported to be oncology medicines. Better systems are required for reporting drug shortages, and new technologies such as 3D-printed drugs may provide a long-term solution in specific cases. In our survey, the importance of establishing partnerships with national and international organizations was acknowledged by 90% of respondents, supporting the current push to increase the responsibility of oncology pharmacists beyond that of dispensing medicines toward the frontline of cancer care. Similarly, 85% of respondents considered the role of the pharmacist in oncology MPTs to be a key issue for the future. Patients with cancer attending a multidisciplinary oncology clinic benefit from the presence of a pharmacist, who can educate patients about their current and proposed medications, and discuss the importance of treatment adherence. Pharmacist screening for drug–drug, drug–food and drug–disease interactions also has the potential to prevent medication errors and to reduce adverse events. Congruent with the ESOP-sponsored initiatives mentioned above, other key issues provided by the survey respondents included guidelines for cleaning and disinfection of units (80%), EU legislation for compulsory monitoring of cytotoxics (75%), oncology pharmacist training and education (75%), biosimilars (70%) and expansion of EPIC across Europe (55%).
Subsequently, delegates attending the 2018 ECOP symposium were asked to vote on specific questions regarding the future of oncology pharmacy (N = up to 73 respondents; Fig. 2). In total, 88% of the delegates agreed that technological advances will lead to significant changes in pharmaceutical services in the future; however, 80% did not think this would decrease the need for pharmacists and 74% did not believe this would reduce their workload (Fig. 2A). A possible explanation for this is, again, the proposal to increase responsibilities for pharmacists; 74% of delegates believed they would or might be required to spend most of their working hours in the wards instead of in pharmacies, suggesting that advances in technology will enable pharmacists to provide a broader service. In support of this, 93% of delegates expected more communications between pharmacists and physicians to be needed in future. Also, 68% of the delegates did not believe that compounding of anticancer medicines will be completely automated, suggesting that a significant proportion of the pharmacists’ role will continue to be performed within the pharmacy.
Advances in diagnostic technologies will enable a shift away from the ‘one-size-fits-all’ concept toward personalized care, by increasing our ability to stratify patients and monitor therapeutic responses to optimize individual treatment regimens. Almost all of the delegates anticipated that the number of biologic medicines will continue to increase, but 84% did not expect these agents to completely replace conventional antineoplastics.
Finally, only 52% of the delegates considered themselves to be competent in patient education, interviewing clinicians and pharmaceutical communication techniques, suggesting that educational programmes need to be implemented to facilitate the evolving role of the oncology pharmacist.
Notably, the attendees believed that the ‘implementation of multidisciplinary working groups’ (40%) and ‘improved clinical management of cancer patients’ (32%) will be the main focus of oncology pharmacy in the future (Fig. 2B). ‘Technological advances’ (16%) and ‘new pharmaceuticals’ (13%) were considered of a lesser overall importance, despite the majority of the delegates agreeing in the premeeting survey that technological changes will have a significant impact on pharmacy and that the number of biologic medicines will continue to increase. One possible explanation for this might be that although prescribers and pharmacists rely heavily on technology to support their daily activities, the development of novel technologies such as pharmacy management systems will assist only in the dispensing, labelling, ordering and stock control of medicines, and the electronic storage of patient medical records, thereby enabling pharmacists to provide more value as a key stakeholder within the healthcare system as a whole.
European Conference of Oncology Pharmacy 2018 resolution on the future of oncology pharmacy
The symposium concluded with the ECOP 2018 Resolution on the Future of Oncology Pharmacy, presented by ESOP President Klaus Meier. This position statement details the ESOP view on how oncology pharmacy will evolve over the next decade and how it will adapt to these developments to support oncology pharmacists and achieve better outcomes for patients with cancer.
ESOP believes scientific, social and technological trends have driven the evolution and development of the pharmacy profession throughout history. External trends can be confidently predicted to continue to impact pharmacy over the next decade, with the ‘fourth industrial revolution’ likely to result in further technological breakthroughs that become mainstream across a number of fields, including artificial intelligence, robotics, nanotechnology, biotechnology, internet technologies and manufacturing processes, such as 3D printing.
In response to these developments, ESOP resolves to predict and respond early to technological and scientific drivers of change impacting oncology pharmacy to ensure that their potential to achieve better outcomes for patients with cancer is realized. The expertise and experience of oncology pharmacists must be leveraged to positively influence decision-makers in the commercial, research and governmental sectors who are leading technological and scientific change.
The ESOP board plans to produce a report on the future of oncology pharmacy in consultation with the ESOP membership and wider stakeholder community. The report will focus on the primary technological and scientific drivers of change over the next decade and the opportunities and potential threats they pose to improving outcomes for patients with cancer. It will also offer guidance to pharmacists, companies, research institutions and policymakers on how to capitalize on advances in science and technology to drive improvements in oncology pharmacy and improve patient outcomes. An interim publication will be released at the ESOP members’ meeting on September 2019 and final publication is planned for the 5th ECOP meeting in 2020.
The focus of cancer treatment is shifting from a general medicine-based approach toward personalized, precision medicine on the basis of the molecular profile and individual circumstances of the patient. The role of the pharmacist is adapting to meet the demands of the changing medical landscape, with a transition toward a patient-focused, consultation-based model of care. Pharmacists will become more integrated throughout the healthcare system and provide a wider range of services.[21,22] In oncology pharmacy, this could involve the prescription of antiemetics and other support medications used in cancer chemotherapy, patient education and counselling, development of supportive care guidelines, drug development research and more frequent participation as investigators in clinical trials.
The overarching aim of ESOP is to improve outcomes for patients with cancer through the development and promotion of oncology pharmacy practice. As part of this aim, members of ESOP met at the ECOP 2018 symposium to discuss the most important issues facing healthcare and oncology pharmacy over the next decade, and to provide an update on ongoing ESOP projects to support pharmacists involved in the care of patients with cancer. The EPIC project aims to establish a European best-practice model for oncology pharmacists, and EUSOP is an ESOP Academy educational programme for oncology pharmacists that is recognized by the European Commission. Collaborations with organizations such as ECCO will raise awareness of the important role oncology pharmacists can play within MPTs and the wider healthcare community.
In response to anticipated changes in the near future, ESOP has developed the ECOP 2018 Resolution on the Future of Oncology Pharmacy, detailing how it will adapt to the changing medical landscape and continue to support oncology pharmacists in providing optimal care for patients with cancer. ESOP will leverage the expertise and experience of oncology pharmacists to positively influence decision-makers and respond early to new technological breakthroughs to realize their potential in improving patient outcomes.
All authors made a substantial contribution to conception and design, and/or acquisition of data and/or analysis and interpretation of data for the work; drafted the work or revised it critically for important intellectual content; gave final approval of the version to be published and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Conflicts of interest statement
All authors have active roles within the European Society of Oncology Pharmacy (ESOP). The authors have not been involved in any sponsored activities related to the topics covered in this article.
Medical writing assistance was provided by Chris Williams and Paul Scutt of Spirit (Manchester, UK).
Financial support and sponsorship: The project was funded by Sandoz.
2. Sen N, Thomas H, Stirling C, van den Heuvel R. The future of oncology: a focused approach to winning in 2030, 2017. Available at: https://assets.kpmg/content/dam/kpmg/cn/pdf/en/2018/04/the-future-of-oncology.pdf
(Accessed July 2019).
3. Bode AM, Dong Z. Precision oncology: the future of personalized cancer medicine? NPJ Precis Oncol
4. Birand N, Boşnak AS, Diker Ö, et al. The role of the pharmacist in improving medication beliefs and adherence in cancer patients. J Oncol Pharm Pract
2019; 1–11. doi: 10.1177/1078155219831377 [Epub ahead of print].
5. Pharmaceutical Society of Australia 2019. Pharmacists in 2023: a discussion paper. Pharmaceutical Society of Australia, 2019. Available at: https://www.psa.org.au/wp-content/uploads/2019/02/Pharmacists-In-2023-digital.pdf
(Accessed July 2019).
6. Dobish R, Chambers C, Iwaasa K, et al. Expanding the role of clinical pharmacists in community oncology practice. Oncol Exchange
2014; 13:24–28. Available at: http://oncologyex.com/pdf/vol13_no4/feature_dobish-pharmacists-expanded-role.pdf
(Accessed July 2019)
7. EPIC. Empowering pharmacists to improve health care for oral chemotherapy patients: establishment of a European best-practice model: EPIC Project 2019. Available at: https://www.esop.li/epic.php
(Accessed July 2019).
8. ESOP. European Cancer Organisation (ECCO), 2019. Available at: http://www.esop.li/ecco.php
(Accessed July 2019).
9. ECCO. European requirements for quality cancer care, 2018. Available at: https://www.ecco-org.eu/ERQCC/About
(Accessed July 2019).
10. Aapro M, Astier A, Audisio R, et al. Identifying critical steps towards improved access to innovation in cancer care: a European CanCer Organisation position paper. Eur J Cancer
12. Boşnak AS, Birand N, Diker Ö, et al. The role of the pharmacist in the multidisciplinary approach to the prevention and resolution of drug-related problems in cancer chemotherapy. J Oncol Pharm Pract
2018; 1–9. doi: 10.1177/1078155218786048 [Epub ahead of print].
13. ESOP. European Specialization in Oncology Pharmacy (EUSOP), 2019. Available at: http://www.esop.li/eusop.php
(Accessed July 2019).
14. ESOP. QuapoS 6: Quality Standards for the Oncology Pharmacy Service, 2018. Available at: https://www.esop.li/downloads/QuapoS%206.pdf
(Accessed July 2019).
15. ESOP. MASHA project, 2019. Available at: http://www.esop.li/masha.php
(Accessed July 2019).
16. European Association of Hospital Pharmacists. EAHP's 2018 Survey on medicines shortages to improve patient outcomes, 2018. Available at: http://www.eahp.eu/practice-and-policy/medicines-shortages/2018-medicines-shortage-survey
(Accessed July 2019).
19. Goundry-Smith S. Examining the role of new technology in pharmacy: now and in the future. Pharm J [Internet], 2014. Available from: https://www.pharmaceutical-journal.com/examining-the-role-of-new-technology-in-pharmacy-now-and-in-the-future/11134174.article
(Accessed July 2019).
20. Evangelou SJ. Artificial intelligence and the future of medicine, 2018. Available at: https://medicalxpress.com/news/2018-12-artificial-intelligence-future-medicine.html
(Accessed July 2019).
21. Smith J, Picton C, Dayan M. Now or never: shaping pharmacy for the future. Royal Pharmaceutical Society, 2013. Available at: https://www.rpharms.com/Portals/0/RPS%20document%20library/Open%20access/Publications/Now%20or%20Never%20-%20Report.pdf
(Accessed July 2019).
22. National Pharmacy Association. Core belief: there is a clear choice of future, 2017. Available at: https://www.npa.co.uk/2017/08/23/core-belief-clear-choice-future/
(Accessed July 2019).