The purpose of this article is to outline the benefits that pharmacists can play in cancer care. Each discipline within the interdisciplinary cancer team has people trained in a specific area of expertise. With the amount of information, the number of drugs, and the many changes taking place in oncology these days, the pharmacist is the expert best trained in the medications themselves. Physicians are aware of what constitutes the best regimens for the specific pathology, but when it comes to counseling patients on medications, including intravenous and to oral medications, and helping with any side effects management, pharmacists can provide a lot of benefit in practice. This also includes helping the nononcology clinical disciplines understand any issues of additional medications that the patient with cancer may be taking for comorbidities.
At our cancer institute at St. Luke’s, when our physicians have questions about medications—such as dose adjustment for renal or liver functions or dosing based on other medications or drug interactions—the pharmacist is the one who can answer those questions. Physicians at cancer practices should be encouraged to call the pharmacist, who may not be present at the clinic but may be at the infusion center or down the hall in the pharmacy; a simple phone call and a quick conversation with the pharmacist may promptly resolve any dosing-related questions or concerns.
Infusion Therapy/Antiemetic Medication Protocol
The role of the pharmacist in infusion therapy likely varies by institution. At St. Luke’s, the pharmacist is responsible for the process once the physician orders infusion treatment for the patient. When we get the orders for the chemotherapy, it is the pharmacist’s role to evaluate that it is the right drug for the right indication, and that any other medications that the patient is taking will not interact with or interfere with the chemotherapy. The pharmacist double-checks the laboratory results to make sure that that particular chemotherapy is appropriate for that patient’s blood count, and that the dose is appropriate if the patient has renal or hepatic dysfunction.
Our role is to check that we are preparing the medication correctly, that the dose is correct, that it is what the patient gets, and it matches what the physician ordered. According to our antiemetic protocol, the pharmacists are the ones who help to determine what antinausea medications are given to the patient before chemotherapy, and any other premedications for a particular type of chemotherapy, as well as ensuring that the patient gets those medications.
Individual protocols vary from center to center. At St. Luke’s, our protocol is based on a combination of guidelines. One of our pharmacists evaluated the National Compre-hensive Cancer Network (NCCN), the American Society of Clinical Oncology, and Multinational Association of Supportive Care in Cancer guidelines to determine what protocol we would use. The goal was to evaluate the emetogenic potential of chemotherapy, and to see how that translates into what medications we should be giving the patient. Although this may differ from state to state, the pharmacists ultimately need to follow the protocol, while taking into account any patient-specific abnormalities or changes and apply them to the center’s protocol.
Our protocol is standardized: if the emetogenic potential is this, then these are the medications we have to give. But there are situations within the protocol that say, “Under these circumstances, you can add this medication. Under those circumstances, you can take away this medication.” If it is necessary to seriously deviate from the protocol, we discuss this with the physician and make sure that we are on the same page before we move forward with that different approach.
This further highlights the value of the interdisciplinary team, these steps are in place to help foster the interaction between the various disciplines. Our infusion center is just down the hall from where the physicians are seeing their patients. It is therefore very easy for us, the pharmacists, to walk over and chat with the physicians, or vice versa; physicians and mid-level personnel often come to the pharmacy to ask questions related to patients, symptoms, or medication side effects, such as “The patient is having this symptom. What do you think about adding in this medication?”
Our physicians see approximately 20 patients daily, so they are very busy. Sometimes, when the laboratory results are not yet available, they rely on us to double-check the results when they arrive and talk to them if there is something abnormal. If the blood count comes back abnormal, we check with them to and see what they want to do. It may involve dose reduction or postponing the chemotherapy.
Oral Chemotherapy Program
In our oral chemotherapy program (see December 2011 issue), we have been able to vastly improve patient access to medications, as well as the understanding of medications. St. Luke’s has a unique oral chemotherapy program that includes a full-time pharmacist who is dealing only with oral chemotherapy; this is unique in the way the program is set up, in the way the pharmacist interacts with the physicians, the nurses, the social workers, our financial advocates, and the whole system.
It has taken us a couple of years to work out this program, but the result is very beneficial for our patients, as well as for the healthcare system as a whole. We may not be the only center that is involving pharmacists in the oral chemotherapy program in this way, but our actual process and this particular setup may be different.
The oral chemotherapy program is managed by a pharmacist. When the physician and the patient decide to start on an oral chemotherapy agent, the prescription is sent to our central pharmacy in Boise, ID. In Boise, we have oncology-trained pharmacists who are running the office, where all the oral chemotherapy agents are received. Once the patient has received the prescription and has actually received the medication, the pharmacist makes sure to follow up with the patient on a weekly basis during their first chemotherapy cycle. We have a scheduled weekly call to the patient to ensure that everything is going well, to see how the patient is doing, and whether the patient had any problems taking the medication, or if the patient is having any side effects or other things of that nature.
Managing Drug Costs
One of the things that we all face with cancer medications is high cost. On average, these medications range from a couple of hundreds of dollars monthly for cheaper generics, such as oral cyclophosphamide, and up to $10,000 monthly or more for some of the newer oral agents. That can be a major issue, especially for patients who may be taking such agents until their disease progresses. Spending $10,000 a month for up to 2, 3, or 4 years, or longer in the case of some of patients with chronic myeloid leukemia, is very costly.
That is a serious burden for the center, as well as for the patient and the healthcare system. For patients, depending on their insurance, some of these medications can be covered by Medicare Part B or their major medical plan. However, in many cases, they are still responsible for up to 20% of the drug, and 20% of $10,000 is still $2000.
The other issue is patients who go through their prescription drug benefits, such as Medicare Part D, do not necessarily have a supplement to help them get through the donut hole. In many of these cases, their first fill is going to skyrocket them through that donut hole, and they are going to be responsible for up to $5000 of that first fill. After that they will only be responsible for approximately 5% based on their Part D plan. But if we cannot get them through the first fill, they are not going to make it to their second or third one.
We try to find ways to help with cost by assisting with prior authorizations and through our financial advocates at Mountain States Tumor Institute. They are familiar with the programs for free drugs, copay assistance, and other programs that can help patients afford these medications. We recently conducted an evaluation that showed that only approximately 1% of our patients do not receive their medications because of insurance or cost issues. Therefore, we have been able to help greatly reduce nonfulfillment rates, compared with the 10% to 20% reported in the literature.
Supportive/Palliative Care Clinics
Another unique feature at our center is the involvement of the pharmacists in the multidisciplinary supportive care clinic or palliative care clinic. We have been able to do this thanks to a grant we received through our National Cancer Institute (NCI) Community Cancer Centers Program (NCCCP). This program helps to provide a unique benefit to patients, by allowing us to bridge the gap between patients who may not get to see a pharmacist and those who now are getting a full work-up and a full medication reconciliation, with the pharmacist through this program.
The supportive/palliative care clinics at St. Luke’s are a part of the NCCCP. Within this NCI program, we have been able to hire a part-time pharmacist to help with these clinics. Having a pharmacist who can sit down with these more complex patients and do full medication reconciliation greatly improves cancer care for our patients. This program has enabled us to find many places for improvement, such as therapy duplications (eg, patients using multiple breakthrough narcotics or multiple sleep medications causing them to be too drowsy in the morning) or in drug interactions and adverse reactions.
This is particularly beneficial for our patients, because 95% of them (if not more) have multiple providers. Their oncologist is not their primary care physician (PCP) so they are seeing their PCP as well, and possibly even a cardiologist or a diabetes specialist. As a result, the patient may be seeing many physicians from different disciplines who are all prescribing medications and often are not talking to each other. That is why it is beneficial for the pharmacist to be involved in the supportive care clinic and help with the medication reconciliations. We can help every provider know for sure what is going on with the patient, and we give that patient the updated medication list.
It would be beneficial to have a pharmacist sit down with every patient and review the medications, because we have found that even patients with cancer are not always reporting all the medications they are taking. Within this supportive care clinic, we ask the patients to bring all their medication bottles, not a list but actual bottles, so that we can physically look at them and know for sure what they are taking.
The best suggestion I have for pharmacists is to talk to every patient. You can get a lot out of reading the progress notes and talking to the physician, but until you actually talk to the patient, you do not know exactly what is going on with that patient. We have found that especially in cancer care, patients do not always reveal everything to their physicians, in part because they do not want to disappoint their oncologist. They will sometimes reveal things to a pharmacist or a nurse rather than their physician. They may also worry that if they tell the treating physician they are having a side effect, the physician will reduce the dose of the chemotherapy. They associate that dose reduction with less likelihood of success of the chemotherapy. Another reason is that some patients say they do not want to bother their doctors, because they are so busy. Therefore, a pharmacist can sometimes get information regarding side effects that he/she can share back with the physician, to help improve the care and symptom management of that patient.
Symptom management can involve the amount of pain the patient has, or medication side effects that they do not always want to talk about. Some of those side effects, especially with chemotherapy, can be easily managed at home, if they just let us know. For example, we can help to get their nausea under better control, or control mouth sores or mouth pain by providing rinses or special counseling points, such as avoiding alcohol-based mouthwash. Opening that conversation with the patient can help give the patient peace of mind about what they should and should not be doing, and also give them a little more control over their disease itself, and their symptoms.
The goal of including a pharmacist in the care of patients with cancer is to avoid creating a silo where the only focus is oncology. In reality, to treat patients with cancer, we must be able to treat the whole patient; this includes knowing, understanding, and reviewing the other comorbidities these patients may have. A pharmacist is uniquely trained to understand all the medications a patient may be using and how those interact with the cancer treatment medications. It is our hope that pharmacists will continue to have a key role in the treatment and management of cancer patients as part of the very important interdisciplinary team.