Role of pharmacists in optimizing the use of anticancer drugs in the clinical setting

Figures & data

Table 1 Oncology pharmacist practice for supportive care

• Hematology support

○ Anemia EPO, non-EPO

○ Colony-stimulating factor

○ Anticoagulation clinic

• Chemotherapy administration follow-up

• Chemoprotective agents - protocol development, dosing

• Gastrointestinal side effect support - N/V/D/C/mucositis

• Cutaneous/dermatological support - extravasation, hand-foot syndrome, hand-foot rash syndrome, maculopapular rash management

• Pain management - opiates, side effect management, nonnarcotic medications

• Infectious disease and antibiotic support

○ Immunization

• Parenteral nutrition support

• Palliative care

• Chronic disease medication management - hypertension, hyperlipidemia, cholesterol management, asthma control, diabetes control

Notes: Data taken from.^{10,11,120,121}

Abbreviations: EPO, erythropoietin; N/V/D/C, nausea/vomitting/diarrhea/constipation.

Table 2 Oncology pharmacist drug-specific interventions

• Adverse drug-reaction prevention and monitoring

• Medication administration support, premedication, hydration

• Addition of necessary medications

• Discontinuation of drugs

• Dose adjustments for organ dysfunction, weight, age

• Therapeutic drug monitoring

• Pharmacokinetic monitoring

• Laboratory monitoring

• Switch intravenous to by-mouth formulations

• Writing prescriptions and refills

• Medication reconciliation and allergies

• Patient education

• Assuring medication adherence

Note: Data taken from.^{10,11,120,121}

Figure 1 Range of pharmacist skills.

Notes: Adapted with permission from Council on Credentialing in Pharmacy, Albanese NP, Rouse MJ. Scope of contemporary pharmacy practice: roles, responsibilities, and functions of pharmacists and pharmacy technicians. J Am Pharm Assoc. © 2010.¹⁰
Abbreviations: BCOP, board-certified oncology pharmacist; BCPS, board-certified pharmacotherapy specialist.

Figure 2 Medication management: seven critical processes from the Joint Commission.

Notes: Data from http://www.jointcommission.org/standards_information/standards.aspx.⁹

Table 3 Targeted therapies for cancer

Drug	Trade name	Antigen target	Indication
Monoclonal antibody
Alemtuzumab	Campath	CD52	B-cell CLL
Bevacizumab	Avastin	VEGF	MM
Bortezomib	Velcade	NF-ΚB	MCR
Cetuximab	Erbitux	EGFR	MCR
Denosumab	Xgeva	RANKL	GCT
Dabrafenib	Tafinlar	braf	MM
Gemtuzumab	Mylotarg	CD33	AML
ozogamicin
Ipilimumab	Yervoy	CTLA4	MCR
Ibritumomab tiuxetan	Zevalin	CD20	MM
Panitumumab	Vectibix	CD20	NHL
Pertuzumab	Perjeta	HER2	BCA
Ponatinib	Iclusig	BCR-ABL	CLL
Rituximab	Rituxan	EGFR	NHL, CLL
Tositumomab	Bexxar	CD20	NHL
Trametinib	Mekinist	MEK1 and 2	MM
Trastuzumab	Herceptin	HER2	MBC
Ofatumumab	Arzerra	CD20	CLL
Tyrosine-kinase inhibitors
Afatinib	Gilotrif	EGFR, HER2, HER4	NSCLC
Bosutinib	Bosulif	Bcr-Abl	CML
Erlotinib	Tarceva	EGFR	NSCLC
Gefitinib	Iressa	EGFR	NSCLC
Imatinib	Gleevec	Bcr-Abl	CML
Multikinase inhibitors
Cabozantinib	Cometriq	VEGF, RET	MTC
Sorafenib	Nexavar	VEGFR, PDGFR	HCC, RCC
Sunitinib	Sutent	VEGFR, KIT	RCC, GIST, pNET
Pazopanib	Votrient	TKI	Kidney, STC
Regorafenib	Stivarga	VEGFR	CRC

Abbreviations: AML, acute myelogenous leukemia; BCA, breast cancer; CLL, chronic lymphocytic leukemia; GCT, giant-cell tumor; NHL, non-Hodgkin’s lymphoma; NSCLC, non-small-cell lung cancer; CRC, colorectal cancer; MCR, metastatic colorectal; CML, chronic myeloid leukemia; MBC, metastatic breast cancer; MM, metastatic melanoma; HCC, hepatocellular cancer; RCC, renal cell carcinoma; GIST, gastrointestinal stromal tumor; pNET, pancreatic neuroendocrine tumor; CD52, CAMPATH-1 antigen or cluster of differentiation 52; VEGF, vascular endothelial growth factor; NK-KB, nuclear factor kappa-light-chain-enhancer of activated B-cells; EGFR, epidermal growth factor receptor; RANKL, receptor activator of nuclear factor kappa-B ligand; BRAF, proto-oncogene B-Raf; CD33, siglet 3; CTLA4, cytotoxic T-lymphocyte antigen 4; CD20, activated-glycosylated phosphoprotein; HER2, human epidermal growth factor receptor 2; BCR-ABL, the Ph chromosome defective mutated gene; EGFR, epidermal growth factor receptor; MEK1 and 2, mitogen-activated protein kinase kinase; HER4, human epidermal growth factor receptor 4; RET, rearranged during transfection; PDGFR, platelet derived growth factor receptor; KIT, receptor tyrosine kinase and a type of tumor marker; TKI, tyrosine kinase inhibitor; STC, soft-tissue sarcoma; MTC, medullary thyroid cancer.

Notes: Data taken from.⁶⁸

Table 4 Oncology pharmacist role in oral-targeted therapy

• Preauthorization of prescription

• Third-party reimbursement expertise

• Patient education on safety for handling and disposal

• Medication administration

○ Taken with or without food

○ Crushability

○ Address issues for dissolution of capsule contents

○ Allergic reaction - hives and itching, hypotension - prophylaxis with histamine antagonist (diphenhydramine)

○ Flu-like symptoms - chills, fatigue, fever, muscle aches, and pain (acetaminophen, corticosteroid)

○ Nausea - antiemetics

• Adverse side effect management

○ Diarrhea

○ Skin rashes

○ More serious side effects

■ Infusion reactions - shortness of breath, hypotension

■ Hematological - white blood cells and platelets

■ Cardiac - congestive heart failure

■ Dermatological - sores and rashes, mucositis

■ Bleeding

• Monitor adherence

○ Pill counts

○ Verification with refill

Notes: Data taken from.^69–72

Council on Credentialing in Pharmacy, Albanese NP, Rouse MJ. Scope of contemporary pharmacy practice: roles, responsibilities, and functions of pharmacists and pharmacy technicians. J Am Pharm Assoc (2003). 2010;50:e35–e69.

 Web of Science ®Google Scholar

Wong WM, Ignoffo RF. If there are expert systems and dose checks, why do we still need the clinical pharmacist? Pharm Pract Manage Q. 1996;16:50–58.

 PubMedGoogle Scholar

Hutten BA, Prins MH, Gent M, Ginsberg J. Incidence of recurrent thromboembolic and bleeding complications among patients with venous thromboembolism in relation to both malignancy and achieved international normalized ratio: a retrospective analysis. J Clin Oncol. 2000;18:3078–3083.

 PubMed Web of Science ®Google Scholar

Hutchison LC, Castleberry A. The pharmacist’s new role as part of an interdisciplinary care team. J Am Soc Aging. 2012;35:62–68.

 Google Scholar

Joint Commission. About our standards. Available from: http://www.jointcommission.org/standards_information/standards.aspx. Accessed October 22, 2013.

 Google Scholar

US Food and Drug Administration. Drugs: hematology/oncology (cancer) approvals and safety notifications. Available from: http://www.fda.gov/drugs/informationondrugs/approveddrugs/ucm279174.htm#updates. Accessed October 30, 2013.

 Google Scholar

Weingart SN, Spencer J, Buia S, et al. Medication safety of five oral chemotherapies: a proactive risk assessment. J Oncol Pract. 2011;7:2–6.

 PubMedGoogle Scholar

Partridge AH, Avorn J, Wang PS, Winer EP. Adherence to therapy with oral antineoplastic agents. J Natl Cancer Inst. 2002;94:652–662.

 PubMed Web of Science ®Google Scholar