Q&A with Kelly Gaertner, PharmD, BCOP, BCPS
Hematology/Oncology Clinical Pharmacy Specialist
Allegheny Health Network Cancer Institute
Pharmacy Purchasing & Products: What are the benefits of oral vs IV chemotherapy?
Kelly Gaertner, PharmD, BCOP, BCPS: Oral anticancer medications are becoming an increasingly integral part of hematology/oncology treatment. Recent years have witnessed an increase in the approval of new oral anticancer drugs and expanded indications for existing medications. Oral anticancer therapy offers several benefits compared with IV therapy, as oral therapy is less invasive, more flexible, and more convenient. For patients, this may result in fewer trips to the infusion center and improved quality of life.1 Furthermore, patients receiving palliative chemotherapy often prefer oral chemotherapy, as long as efficacy is not sacrificed2; a more recent review also suggests that patients prefer oral to IV anticancer therapy.3
PP&P: What unique concerns accompany oral chemotherapy use?
Gaertner: Although oral anticancer medications offer a more convenient route of administration for the patient compared with IV chemotherapy, use of oral chemotherapy agents is accompanied by additional considerations.
PP&P: What are the benefits of developing a formal plan to monitor and manage these drugs?
Gaertner: Ensuring patient safety is the primary objective when developing a formal plan to monitor and manage oral anticancer therapy. Because oral anticancer therapy is associated with a wide range of potential adverse effects, close monitoring is key to symptom identification and management.
Toxicity management may also improve adherence, which in turn can improve patient outcomes, and thus should be continually assessed. Incorporating a routine toxicity and adherence evaluation into the formal monitoring program can help to achieve maximal drug benefit. Follow-up within 7 and 14 days after the start of treatment, and prior to each refill, is suggested.9
PP&P: What is the role of the pharmacist in managing oral chemotherapy?
Gaertner: As the medication experts, pharmacists should be closely involved with patient counseling, assessing adherence, managing side effects and drug-drug interactions, and facilitating a patient-provider relationship of communication.
Without pharmacist consultation and recommendation, unconventional methods of administration should not be routinely advised. Rather, in general, patients should be counseled to swallow tablets or capsules whole, not crush, chew, or dissolve them. However, if patients are having difficulty swallowing the medication in its commercial dosage form, pharmacists can assist with identifying any literature or recommendations that may allow the tablet or capsule to be crushed, opened, or dissolved into an alternative form to ensure patient adherence and maximize the drug benefit.
PP&P: What strategies can be employed to ensure patient adherence to oral anticancer medication?
Gaertner: Patient adherence is yet another challenge with oral anticancer therapy, as compliance to therapy is more difficult to assess than with IV medications. Poor patient adherence may result in reduced efficacy and subsequently impact outcomes. Patients should be followed closely while on oral anticancer medication; however, the health care team may have less direct contact with the patient taking oral compared with IV anticancer medication. Ultimately, the use of oral anticancer therapy puts more responsibility on the patient, making patient adherence critical to achieving optimal outcomes and minimizing toxicity.8,11
Multiple strategies can be employed to ensure patient adherence, including the following:
The selected adherence tool should reflect the patient’s preference and be routinely used.11 Given that oral anticancer medications are typically hazardous drugs, they must be kept in a separate pillbox, if one is used. However, it is important to review the storage and handling information for each drug, as some are recommended to be kept in their original packaging. Finally, patients should be counseled on what to do in the event of a missed dose.
PP&P: How can the pharmacy ensure patients receive appropriate financial assistance to support access to oral anticancer medications?
Gaertner: Obtaining oral anticancer medications is significantly more complex than the processes for most other medications. Oral anticancer medications usually must come from specialty mail order pharmacies and may have distribution restrictions. If the use of a particular specialty pharmacy is mandated, this information is usually noted on the product website. The patient’s insurance also may dictate the source of the prescription.
Oftentimes, the specialty pharmacy can assist with identifying financial assistance programs. It is important that the specialty pharmacy maintain open and ongoing communication with the clinic, so that the prescribing team is kept abreast of any insurance or copay issues and can discuss available options and next steps with the patient. It would also be helpful to have someone on the multidisciplinary care team who is able to facilitate use of patient assistance programs and assist with obtaining the medications.
PP&P: What specialized oral anticancer medication training should be provided to pharmacists?
Gaertner: Pharmacists should receive training on oral anticancer medication safe handling and administration, as well as monitoring. With regard to adverse event monitoring, pharmacists must be aware of class effects of medications, as well as important clinical pearls with individual medications. Pharmacists should also be knowledgeable about which supportive medications are necessary for each oral anticancer medication, as use of recommended supplemental medications may reduce adverse events. Finally, pharmacists must have access to drug information and interaction databases.
Kelly Gaertner, PharmD, BCOP, BCPS, is a hematology/oncology clinical pharmacy specialist practicing with Allegheny Health Network Cancer Institute in Pittsburgh, Pennsylvania. She received her Doctor of Pharmacy degree from Duquesne University in Pittsburgh and completed her oncology pharmacy training at the University of Virginia Health System in Charlottesville, Virginia. Kelly’s professional interests include breast cancer and gastrointestinal malignancies, supportive care, and oral chemotherapy
Mackler E, Segal EM, Muluneh B, et al. 2018 Hematology/Oncology
Pharmacist Association best practices for the management of oral oncolytic therapy: pharmacy practice standard. J Oncol Pract. 2019;15(4):e346-e355.
For More Info on Oral Chemotherapy
Ensuring Adherence to Oral Chemotherapy
By Megan May, PharmD, BCOP
Improve Adherence to Oral Chemotherapy Agents
By Chukwuemeka Nnamdi Nzelibe and Adenike Uchenna Omoyosi
Managing Oral Chemotherapy
By Niesha Griffith, MS, RPh, FASHP; Julie Kennerly, PharmD, MS, BCPS;
and Sarah Hudson-DiSalle, RPh, PharmD
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