A pharmacist-led medication assessment of geriatric cancer patients found a high prevalence of polypharmacy, excessive polypharmacy, and potentially inappropriate medication, according to the report online ahead of print in the Journal of Clinical Oncology (doi: 10.1200/JCO.2014.58.7550).
The researchers, from Thomas Jefferson University's Jefferson School of Pharmacy, reported that among 234 geriatric cancer patients:
- 41 percent were taking five to nine medications (including prescription, non-prescription, and complementary medications and supplements, but not cancer treatments);
- 43 percent were taking 10 or more medications, and
- 51 percent were taking potentially inappropriate medication.
The mean number of medications used by each patient in this study was 9.2; the mean age of patients was 80, and approximately two-thirds were female.
A comprehensive medication review is considered to be an integral part of the geriatric oncology assessment, but current guidelines do not state which health care professional should be performing the medication assessment, the researchers wrote.
“Physicians should be aware that a high percentage of patients are taking five or more concurrent medications, which increases the risk for adverse drug effects, drug-drug interactions, and non-adherence as a result of increased pill burden and regimen complexity,” the first author, Ginah Nightingale, PharmD, Assistant Professor in the Department of Pharmacy Practice at Jefferson, said in an e-mail exchange.
A comprehensive medication assessment should be done prior to anti-cancer therapy initiation and then periodically, she said. Because some senior adult oncology patients may have a poor prognosis or a diagnosis of terminal cancer, a comprehensive medication assessment is important to adjust or reduce the use of unnecessary medications.
“The focus of the assessment should be on prioritizing the patients' goals of care, such as relieving symptoms and maintaining functionality.”
The most prevalent potentially inappropriate medications were benzodiazepines, gastrointestinal medications, NSAIDs, antiplatelet medications, and first-generation antihistamines.
Specific comorbidities associated with those potentially inappropriate medications were cardiovascular, neurologic, and psychiatric conditions.
Nightingale said that including prescription, non-prescription, and complementary medications and supplements in the study did not overstate the problem of polypharmacy. Rather, “it provides a more transparent sneak peek of what's in the ‘medicine cabinet’ of the cohort of senior adult oncology patients seen at our center, a sense of the landscape of their medication use.”
She noted that a patient can meet the criteria for excessive polypharmacy and not be on a potentially inappropriate medication, although the study did show that the more medications a patient takes the greater the potential for inappropriate medication use.
Potentially inappropriate medications were identified using the 2012 Beers Criteria, the Screening Tool of Older Person's Prescriptions (STOPP), and the Healthcare Effectiveness Data and Information Set (HEDIS). The researchers recommended the development of a medication assessment tool that integrates the 2012 Beers and STOPP criteria and said that clinicians should also consider cancer diagnosis, prognosis, and cancer-related therapy.
She noted that the 2012 Beers criteria are currently being updated by the American Geriatric Society, with the 2015 version scheduled to be released this summer.
She said her research team is awaiting this update, and is also evaluating the draft of the National Comprehensive Cancer Network update for the guidelines for treatment of older adults with cancer, which also address some of the limitations associated with the 2012 Beers criteria.
Nightingale and her coauthors acknowledged in the article that this single-institution study had a small sample size compared with previous studies and did not include any anticancer treatments or cancer-related therapies.
Also because medication use in this population changes continuously, especially for patients who will begin anticancer and/or supportive care-related therapies, follow-up data on the acceptance of pharmacist interventions would further strengthen the study findings, the paper stated.
“The literature shows that pharmacists are underused in the ambulatory oncology setting and have an opportunity to play a critical, long-term role in providing safe, effective, and affordable medication-related care,” Nightingale said.
‘We All Need to Be Geriatric Oncologists’
“All adult oncologists are now geriatric oncologists,” noted the author of an accompanying editorial (JCO: doi: 10.1200/JCO.2014.60.3548), Stuart M. Lichtman, MD, Attending Physician at Memorial Sloan Kettering Cancer Center and Professor of Medicine at Weill Cornell Medical College.
Geriatric oncology is no longer a niche field with only a few dedicated researchers. “Clinicians should not fear the words ‘geriatric assessment.”
He elaborated in an e-mail exchange: “The fear of geriatric assessment is multiple: not enough time, not enough knowledge; and being uncertain how to use the information and not sure of its importance.”
Geriatric assessment should no longer be the purview of the geriatrician, but will need to be incorporated into daily practice in all oncology fields, he said.
“We all need to become well-educated geriatric oncologists,” he said, but he added that it's going to take time for physician education to catch up.
Standard medical practice now incorporates drug use as part of routine evaluation, but it is well established that the traditional oncology evaluation is not adequate, and will fail to uncover many specific problems. “But with minor modifications this can be made to focus on older patients,” he said.
Discontinuing unnecessary medication is the most important thing, Lichtman said, particularly drugs like statins to lower cholesterol. “Does an older patient with advanced cancer really need statins?”
Lichtman said the study by Nightingale and colleagues highlights an important aspect of geriatric assessment in patients with cancer: “Evaluating polypharmacy by using the accepted guidelines is one way clinicians can begin to feel comfortable with geriatric evaluation and make a tangible impact on patient care.”