The Oncology Care Pharmacist in Health-System Pharmacy

Oncology pharmacists play an important role in the delivery of care to patients living with cancer.¹ Historically, pharmacists have focused on operational roles in the pharmacy, with an emphasis on dispensing accurate and safe medications. However, as cancer treatments become more complex, as the population ages, and as the oncology drug market increases, the need for knowledgeable health care practitioners has grown and the role of a clinical pharmacist has expanded to encompass all phases of patient care as part of the cancer care team.

Training and Practice Settings

According to the National Cancer Institute, almost 40% of men and women will be given a diagnosis of some form of cancer in their lifetime.² A study looking at physicians, nurse practitioners, and physician assistants estimated a shortage of qualified oncology and hematology practitioners by 2020.³ Because of their specialty knowledge and extensive training, oncology pharmacists are perfectly positioned to deliver high-quality care to cancer patients and offset some of the shortage of practitioners.⁴

The American College of Clinical Pharmacy describes clinical pharmacists as practitioners who provide comprehensive medication management and related care for patients in all health care settings.⁵ Clinical pharmacists work with physicians, other health professionals, and patients to ensure that prescribed medications contribute to the best possible health outcomes. They are also involved in the assessment of care, including medication history and reconciliation, counseling patients, supporting the health care team, and monitoring and evaluating therapies for their appropriateness and effectiveness.

The Hematology/Oncology Pharmacy Association (HOPA) developed a scope-of-practice document that details the competencies and training of an oncology pharmacist.¹ All licensed pharmacists have a degree in pharmacy and have passed national drug and law exams. An oncology pharmacist either has completed a postgraduate residency (1 or 2 years), with the first year focusing on general pharmacy practice and the second year specializing in oncology, or has a combination of postgraduate and on-the-job training specific to oncology pharmacy. Many oncology pharmacists also have an advanced specialty certification through the Board of Pharmacy Specialties.

The knowledge and training of an oncology pharmacist support a wide variety of functions across all aspects of patient care, and they represent a broad range of expertise in levels of practice, skills, and responsibilities. These pharmacists work in many different inpatient and outpatient settings, including inpatient rounding on patients with the health care team; dispensing chemotherapy in pharmacies and infusion centers; providing input on guidelines, research, and technology; and managing supportive care in ambulatory care settings.

Clinical Roles and Responsibilities

Oncology pharmacists ensure safety in compounding, preparing, and dispensing chemotherapy. They are responsible for minimizing drug waste, managing drug shortages, and decreasing exposure to hazardous drugs. Pharmacists are also viewed as medication experts who focus their time on providing direct patient care, offering patient education, and participating in clinical decision making.¹

Because of their expert knowledge of medications, pharmacists play an important role in educating patients, caregivers, and other health care professionals. With education and pre- and post-treatment planning, many adverse effects (AEs) of chemotherapy can be managed, thereby increasing regimen tolerance, decreasing extra visit costs, and improving quality of life for patients.⁶ One study’s results showed that getting the pharmacist involved in patient education improved the use and outcomes of antiemetics in patients undergoing cancer chemotherapy, both decreasing the incidence and severity of AEs.⁷

As cancer therapies become more targeted and personalized, these skilled pharmacists are key resources in educating and managing the AEs and toxicities of treatment, while emphasizing the importance of medication adherence and providing supportive care. Not only can oncology pharmacists be great educational resources for patients and their caregivers, they can also be involved in the education of other pharmacists and health care providers by providing educational materials, assisting in chemotherapy order writing, lecturing, and teaching residents and students.⁵

One setting where oncology pharmacists have a key role is in ambulatory clinics and infusion centers. Pharmacists work with the oncology team to deliver a wide variety of services to patients, including education, aiding with chemotherapy order writing, monitoring AEs, evaluating drug—drug and drug–disease interactions, and providing supportive care. Supportive care services may include those for nausea and vomiting, pain management, constipation and diarrhea, anemia, anticoagulation, and treatment with anti-infectives.⁴

Some states recognize pharmacists as providers and, depending on institutional policies, they may be able to prescribe or administer drugs under a scope-of-practice or collaborative practice agreement.⁴ CMS currently does not recognize pharmacists as providers even though some states do. Because of this, pharmacists are not able to routinely bill for outpatient visits; however, initiatives are in development to cover the services of pharmacists in the future.

Many biologic and cancer therapies are expensive and available only through restricted channels or specialty pharmacies. Oncology pharmacists are well equipped to navigate the retail and reimbursement process. Along with members of the patient care team, they may be able to locate resources for co-pay assistance, drug replacement, or manufacturer discounts.

Because of their therapeutic and regulatory knowledge, oncology pharmacists are also positioned to be influential in the development of institutional evidence-based guidelines, policies, and standards. An oncology pharmacist should be part of the decision-making process on committees as they discuss formulary management, treatment protocols, compliance with regulations, and improvement of patient outcomes.¹

Oncology pharmacists are also a valuable resource on investigational drug services and research teams where they provide education, manage AEs, collect and evaluate data, and participate on institutional review boards.⁹ The HOPA editor, Barry Goldspiel, PharmD, BCOP, BCPS, described an oncology pharmacist’s credentials as “uniquely qualified to provide this level of expertise, which includes understanding the basic characteristics of drugs, knowledge of supplier issues, mixing, methodology of administrations, informed consent, and helping with supportive care related to the study.”¹⁰ Pharmacists also have a role in pharmacogenomics, as they study how individual variations in the human genome affect the clinical response to oncology medications.

Advances in technology have had huge impacts on the safety, quality, and efficiency in health care. An oncology pharmacist can be an important part of the informatics team by providing input on safe medication prescribing and dispensing practices. Pharmacists are influential in building oncology order sets, assisting in implementing computerized order entry, building technology interfaces, developing protocols within information systems, and working to optimize existing technology to monitor side effects and drug interactions.

Along with better technology is the opportunity to track medication costs, decrease medication errors, identify safety issues, capture pharmacist interventions, and identify areas for process improvement. The allocation of pharmacy resources and the value of services has often been tied to metrics, such as products dispensed, or by retrospectively quantifying pharmacy interventions. Now that pharmacists are such an integral part of the health care team, many of their interventions are done proactively, which is why documentation tools are so important. By capturing the interventions, value can be tied to metrics based on quality of care, cost management, and patient outcomes, like decreasing the drug cost per hospital admission, reducing readmissions, addressing duplicate ther- apies, managing high-cost drugs, and monitoring therapeutic levels of drugs.

Future Direction

There are still areas for growth in oncology pharmacy. Opportunities include having a greater presence in ambulatory clinics, infusion centers, and other settings; developing medication therapy management services; developing prescribing protocols; and being involved in cancer prevention and survivorship.¹ The profession continues to expand as these pharmacists become invaluable members of the cancer care team.

References:

• Hematology/Oncology Pharmacy Association. The role of hematology/oncology pharmacists. HOPA website. hoparx.org/images/hopa/advocacy/Issue-Briefs/HOPA-_About_Hem_Onc_Pharmacist_Issue_Brief.pdf. Published August 22, 2014. Accessed October 26, 2016.
• National Cancer Institute. Cancer statistics. NIH website. cancer.gov/about-cancer/understanding/statistics. Accessed November 1, 2016.
• Erikson, E Salsberg, G Forte, Bruinooge S, Goldstein M. Future supply and demand for oncologists: Challenges to assuring access to oncology services. J Oncol Pract. 2007;3(2):79-86. doi: 10.1200/JOP.0723601.
• Sessions JK, Valgus J, Barbour SY, Iacovelli L. Role of oncology clinical pharmacists in light of the oncology workforce study. J Oncol Pract. 2010;6(5):270-272. doi: 10.1200/JOP.000037.
• American College of Clinical Pharmacy. Standards of practice for clinical pharmacists. Pharmacotherapy. 2014;34(8):794-797. doi: 10.1002/phar.1438.
• Avery M, Williams F. The importance of pharmacist providing education in oncology. J Pharm Pract. 2015;28(1):26-28. doi: 10.1177/0897190014562382.
• Hoelle LM, Boehnke ML. Oncology pharmacists in health care delivery: vital members of the cancer care team. J Oncol Pract. 2014;10(3):e142-145. doi: 10.1200/JOP.2013.001257.
• Dobish R, Chambers C, Iwaasa K, Hubley B, Brigden M. Expanding the role of clinical pharmacists in community oncology practice. Oncology Exchange website. oncologyex.com/pdf/vol13_no4/feature_dobish-pharmacists-expanded-role.pdf. Published November 2014. Accessed October 28, 2016.
• Bauer A. Spotlight on: oncology pharmacists — part 1, a Q&A. ASCO expert corner: the role of an oncology pharmacist. Cancer.net website. cancer.net/blog/2014-06/spotlight-oncology-pharmacists-–-part-i-qa. Published June 10, 2014. Accessed December 8, 2016.
• HOPA introduces first investigational drug service best practice standards for institutions and infusion clinics [news release]. Chicago, IL: newswise; September 29, 2014. newswise.com/articles/hopa-introduces-first-investigational-drug-service-best-practice-standards-for-institutions-and-infusion-clinics. Accessed November 7, 2016.