Oral Chemotherapeutic Agents: How Have They Transformed Pharmacy and Oncology?

ORAL CHEMOTHERAPEUTIC AGENTS AND HOW THAT KNOWLEDGE HELPS US OPTIMIZE ONCOLOGY OR ONCOLOGIC PHARMACOTHERAPY

Oral chemotherapeutic agents, how will they transform the practice of pharmacy and oncology?

You're listening to ReachMD. Welcome to Focus on Pharmacy. I am Dr. Charles Turck, PharmD, your host, and with me today is Dr. Susan Goodin, PharmD, the Director of the Division of Pharmaceutical Services at the Cancer Institute of New Jersey, a board-certified oncology pharmacy specialist and fellow of the American College of Clinical Pharmacy. Dr. Goodin is also an Associate Professor of Medicine at the University of Medicine and Dentistry of New Jersey.

DR. CHARLES TURCK:

Dr. Goodin, welcome to the program.

DR. SUSAN GOODIN:

Well, thank you Dr. Turck.

DR. CHARLES TURCK:

Now as I mentioned before, you're the director of pharmaceutical services of the Cancer Institute of New Jersey. I was wondering if you could give the listeners a sense of what that job entails.

DR. SUSAN GOODIN:

Certainly, the Cancer Institute is a relatively new Cancer Center. We are an MCI designated comprehensive Cancer Center based in central New Jersey and we have only been in existence for just about 15 years, and I was happy to say that early on our director recognized the value of clinical pharmacy services and I was the third person recruited to the Cancer Institute some 15 years ago, so it was really here at the ground level to get pharmacy services started, which was an enormous opportunity for me as well as I think for the patients that we take care of here at the Cancer Institute and as such was able to deal with that pharmaceutical services and actually pharmaceutical sciences department into what we do today, which is typically the idea that folks have about what pharmacists do, certainly we provide dispensing of medications, but in our center, we have the opportunity to do quite a bit more than that. We interact with all of our patients that come in to our ambulatory clinic every day. Every patient that comes in to see or to receive chemotherapy or to receive treatment, actually does see a clinical pharmacist, who reviews their medication profile, who goes through their treatments, counsels the patients on their medications, side effects. We also do a great deal of side effect management from nausea and vomiting to pain management to anti-coag, as well as a thorough review of what's become, I think, a very challenging area is drug interactions because not only of the complicated nature of the therapies that we are giving, but also because of all of the supplemental or complementary medicines that we know our cancer patients are taking. I think probably the final area where we play a role in the patients at our center is in the area of clinical trials. We certainly fulfill that standard role of investigational drug dispensing, but again we go sort of that extra step and again all of those patients have thorough med histories, medication reviews with the pharmacist. They also go through the informed consent with the patient to make sure they understand the agents that are under investigation and are there again and available for consultation throughout that whole drug development process. So we probably are providing somewhat of a different role, but somewhat similar to many institutions around the country.

DR. CHARLES TURCK:

You mentioned that pharmacist spend what sounds like a good portion of time with patients, I just want to get a sense of how long the pharmacists session typically lasts with patients?

DR. SUSAN GOODIN:

We probably follow that similar format that many practices do and physician practices in that, you know, the initial patient visit when they come in prior to starting their treatment, a pharmacist will spend anywhere from 15 to 20 minutes really focusing on drug therapy, getting a full med history, getting a history of any over-the-counter alternative, complementary medications that the patients are taking, reviewing for drug interactions, and then counseling the patient on the trial or the treatment that the patient is going to receive. So that initial visit probably is somewhere 15 to 20 minutes. Followup visits can certainly take half that time because these patients are in sometimes on a weekly basis, sometimes on an every 3 week basis and it certainly depends upon the schedule of treatment, but on those followup visits we probably spend anywhere 5-10 minutes or more as needed and then our patients do have access to the pharmacist even once they have gone home to call or to ask questions and many of our patients do call back and either, you know, certainly seek clarification because it's an overwhelming process or have some sort of symptom or side effect that they need some input on as to what would be appropriate therapy.

DR. CHARLES TURCK:

Changing tracks just for a moment, you've had years of experience in oncology-pharmacy practice. One of your interests in particular is oral chemotherapeutic agents. I was interested in getting sense of what it is that attracts you to that side of patient care?

DR. SUSAN GOODIN:

The paradigms of managing cancer patients is continuously changing and when I came into practice a few years ago, the concept of putting patients in the hospital to treat their cancer was really the way we managed them and we were really just transitioning into that ambulatory treatment making sure that the patients could continue working, quality of life, all those things associated with the ambulatory care patients, and you know what I noticed, and probably more because of our interest here as a center in the drug development process, because we certainly here in New Jersey sit right in the heart of the drug cabinet if you want it to look at it that way, what we saw and what I realized very early on is that changing paradigm that we are getting away from these even IV therapies and moving into oral therapies, and I was fortunate enough to be interviewed some 10 years ago where at that time someone asked me what do I feel the future of chemotherapy was and I sort of tongue-in-cheek said that, well, you know, I thought that we would be moving towards a day where we were managing patients with all oral therapy and today here we are and it creates a different challenge in oncology than we've ever seen in the past, the transition from the inpatient to the outpatient was really a change in settings, and we had to get better delivering care in a timely fashion and getting patients out the door and more importantly managing their side effects, but this transition from getting out of our, you know, our infusion suites to where they take them at home has created a great deal of concern for me because in oncology we've never worried about adherence. We always knew when our patients showed up, but that paradigm has changed because with oral therapy we are not sure about adherence and it's probably a bigger challenge for us because we are so new to thinking about the concept. It also brings in a different issue of who is managing these patients because with the advent of specialty pharmacy is that are really changing the way we manage patients, that management is being transitioned over for better or worse to specialty pharmacists, who know very little about our patients and then sort of that final pieces of side effect management because while they are oral, they are not without their side effects, and I think without appropriate counseling by pharmacists or by a nurse or whoever it happens to be, patients have often times, and I've seen this, they want to tough it out. They want to do well for their healthcare provider, they want to do well for their family, so they can start with something as benign as just some diarrhea, which very rapidly could progress and have them hospitalized because they don’t speak to anyone about that side effect or may be they go to their refill pharmacy and ask for suggestion of how to manage that and our retail pharmacist are really going to be coming into that frontline in the management of these patients because that's where we know most of our consumers, most of our patients are going to the retail pharmacy to try to manage those side effects.

DR. CHARLES TURCK:

For those of you, who are just tuning in, I am Dr. Charles Turck and I am speaking with Dr. Susan Goodin from the Cancer Institute in New Jersey. We've been discussing several aspects associated with oral chemotherapeutic agents, old and new, how they work and how that knowledge helps us optimize oncology or oncologic pharmacotherapy.

Now, Dr. Goodin, you had mentioned several challenges, one of which was monitoring adherence to therapy, what do you think is the best way, if there is such a best way?

DR. SUSAN GOODIN:

I wish we knew the best way. I think what we are all trying to do is learn from the cardiovascular folks and psychiatric groups as well as those that manage HIV patients and how to educate patients and how to maintain that contact with them so that patients continue to be compliant with their therapy and you know in oncology as well as in these other disease states, it brings into that issue of is it adherence issue or is it a persistence issue, do we need them to take a note. Do we say, well if you take 80% of your doses, we think you are doing well, and we are not really sure what that right answer is and as such we are not sure the best way to help patients. When I look at sort of the literature and when I looked what's out there, this is a prime area for research that needs to be conducted as well as an opportunity for us to do a better job to manage our patients so while certainly the traditional pill counts that we've done in the past, diaries, those sorts of things are certainly somewhat helpful, we are still struggling with what the best model is in order to assure that our patients are taking the medications as directed first of all and then secondly are taking and continuing to take them or even modifying their dose when side effects occur. So there is no great model. We are still trying to find, I think define the best model, and I am not sure I could define that for you today, but what I can say is that it's a fantastic opportunity for research for a pharmacist or nurses and for physicians to better understand what makes their patients decide to take or to not take their therapies.

DR. CHARLES TURCK:

What are some of the characteristics you look for, are there any tell tale signs of adherence or nonadherence or predictors?

DR. SUSAN GOODIN:

You know the biggest thing that we know of at this point are side effect management, again an opportunity for pharmacists, for nurses to really help our patients. We know and there has been in oncology the biggest area where we looked at this is in long term treatment or the 5-year followup of women with breast cancer. We know that the use of a drug like tamoxifen or one of the newer agents, Anastrozole or Letrozole both can result in a decrease in recurrence of the disease if these patients take these medications for the 5-year period and what the recent data is telling us is the reasons why patients don’t take them or not compliant with their therapy really have to do with side effects, and so I think that's where we as healthcare professionals have to sit with our patients and spend that time helping them to understand what we expect to occur, meaning the side effects and having a discussion with them and then also talking with them about managing or coping with those side effects because it really becomes a risk versus benefit profile that I think our patients have to understand. I think too often in oncology with intravenous agents, we often talk amongst ourselves as healthcare professionals about the risk-benefit profile and then we try to articulate that to our patients, but I don’t think we do as good a job with oral therapy because it's so easy to write a prescription and send the patient out the door and we have to spend that time at the time of writing the script or at somewhere in that process having a discussion about that risk benefit profile, about the side effects that are going to occur and then provide them with mechanisms or therapies that might help them manage or cope with those side effects, but I think in regards to sort of globally the side effect management is the biggest piece. Other areas the people have talked about is certainly the cost. These newer agents are extremely expensive. Now, are they more expensive than the IV agents that we give in our clinics?, not clear. There are some small pharmacoeconomics studies that have been performed and it appears that they actually while they are expensive to the patient, they actually are cheaper than bringing the patient into an infusion clinic and giving them an IV medication, so it's really a shift in who is paying is really where the cost is being, I think more shocking to the patients, but cost has certainly been listed as another barrier to dealing with compliance in this patient population.

DR. CHARLES TURCK:

Dr. Susan Goodin has been our guest in our discussion of oral chemotherapeutic medications. Susan, thank you so much for joining us.

DR. SUSAN GOODIN:

Thank you Dr. Turck.

DR. CHARLES TURCK:

I am Dr. Charles Turck, and you've been listening to Focus on Pharmacy on ReachMD, The Channel for Medical Professionals.

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