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Pharmacy Practice in Focus: Oncology
The high acceptance rates of these interventions demonstrate the key role in optimizing patient care that clinical oncology pharmacists with access to medical records play.
The high acceptance rates of these interventions demonstrate the key role in optimizing patient care that clinical oncology pharmacists with access to medical records play.
Image credit: Monet | stock.adobe.com
Oral oncolytic medications are typically dispensed at specialty pharmacies. Patients prescribed these therapies require close monitoring, including assessment of laboratory parameters, toxicities, and adherence. Medically integrated oncology specialty pharmacies can access patients’ charts, assess therapy, and efficiently communicate with prescribers to optimize patient care through the implementation of pertinent clinical recommendations made by clinical oncology pharmacists.
To highlight the impact of pharmacist-led clinical interventions within a medically integrated oncology specialty pharmacy on therapy management in patients receiving oral oncolytics.
A single-center, retrospective, descriptive analysis of pharmacist-led clinical interventions on oral oncolytics during a 17-month period.
We included pharmacist-led clinical interventions for patients 18 years or older who were receiving oral oncolytic therapy between April 1, 2022, and August 31, 2023, from a medically integrated pharmacy servicing a multilocation community-based cancer care provider. We excluded patients receiving medications subject to a risk evaluation and mitigation strategy program, supportive care medications, or nonformulary medications. Pharmacist-led clerical interventions and nursing-led clerical and clinical interventions also were excluded. The primary outcome was the number of pharmacist-led interventions. Secondary outcomes included intervention acceptance rates, frequency of each intervention type (ie, strength and dosing, clarification of prescription directions, drug-drug interactions, treatment discontinuation or hold, treatment cycle, laboratory abnormalities, or multiple intervention type), and most commonly intervened-on medications.
We identified a total of 3528 pharmacist-led clinical interventions within the 17-month period. Pharmacist-led interventions pertaining to treatment discontinuation or hold, strength and dosing, clarification of prescription directions, and treatment cycle were the most common, with respective acceptance rates of 81%, 82%, 89%, and 91%. The average acceptance rate across all types of interventions was 81%. The most commonly intervened-on oral oncolytics were oral chemotherapy drugs that are administered in cycles or have a significant impact on blood counts.
The results of this analysis highlight the essential role of pharmacists in maintaining the continuity of high-quality coordinated oncology care. Having access to a patient’s medical record enables medically integrated pharmacists to maximize therapy outcomes and disease management through collaboration with providers to ensure that each patient is receiving the most appropriate and most current evidence-based treatment.
The American Cancer Society estimated that more than 2 million new cases of cancer would be diagnosed in the United States in 2024.1 The majority of patients with cancer in the US are treated at community oncology centers,2 which provide access to care for patients living in rural areas, large cities, and everything in between. Community oncology centers prioritize patient-centered care (enabling the care team to get to know each patient and their unique needs), are easily accessible, provide patients with access to clinical trials in their community, and often deliver high-quality care at a significantly lower cost—contributing to better patient care and outcomes.2 Additionally, community oncology centers may also have medically integrated dispensing pharmacies that promote a patient-centered, multidisciplinary team approach focusing on the continuity of coordinated quality care.3
Medically integrated oncology specialty pharmacies have access to electronic medical records, enabling their pharmacists to review patient charts, assess therapy, and efficiently communicate with prescribers. This allows optimization of patient care by implementing pertinent clinical recommendations made by clinical oncology pharmacists. Published literature has shown that oncology pharmacists on a multidisciplinary team play a unique role in contributing to overall positive outcomes for patients, and that implementing a pharmacist-managed oral anticancer medication program improves identification of potential drug interactions, patient understanding of their treatment, adherence, and management of adverse effects, all of which are essential for optimal treatment and outcomes.4-6
In a large health care network such as Florida Cancer Specialists & Research Institute, the intricate and complex nature of oncology care necessitates significant collaboration between numerous health care providers. Pharmacists within the medically integrated oncology specialty pharmacies are crucial to this coordination, ensuring all patients receive the highest level of care. We conducted this study to quantify and qualify the positive impact of pharmacists within an extensive health care network’s medically integrated pharmacy.
This single-center, retrospective, descriptive analysis assessed pharmacist-led clinical interventions for patients 18 years or older who were receiving oral oncolytic therapy between April 1, 2022, and August 31, 2023, from Rx To Go, the medically integrated oncology pharmacy of Florida Cancer Specialists & Research Institute, which services nearly 100 locations across the state. We identified patients through utilization of a Microsoft Power BI report. Clinical intervention data were categorized by the following intervention types: strength and dosing, clarification of prescription directions for use (ie, Sig), drug-drug interactions, treatment discontinuation or hold, treatment cycle, laboratory abnormalities, or multiple (ie, included more than 1 intervention type). Patients were excluded if they received medications subject to a Risk Evaluation and Mitigation Strategy (REMS) program, supportive care medications, or nonformulary medications. Of note, we excluded REMS oral oncolytics (ie, lenalidomide [Revlimid; Bristol Myers Squibb], pomalidomide [Pomalyst; Bristol Myers Squibb], and thalidomide [Thalomid; Celgene Corporation]) from this analysis primarily due to nursing-driven initiatives around those agents. Pharmacist-led clerical interventions (eg, assessing correct quantity, provider, clinic, or a dispense-as-written change/drug substitution) and nursing-led clerical and clinical interventions were also excluded.
The primary outcome was the total number of pharmacist-led clinical interventions within the 17-month period. Secondary outcomes were intervention acceptance rates, frequency of each intervention type, and most commonly intervened-on medications. Statistical analysis was conducted using descriptive statistics.
This study was exempt from institutional review board approval.
Sig, prescription directions for use.
A total of 3528 pharmacist-led clinical interventions were identified in the 17-month review period. The most common pharmacist-led interventions pertained to strength and dosing (48% of total interventions), followed by treatment discontinuation or hold (21%), prescription direction clarification (12%), and treatment cycle (9%) (Figure 1). The average clinical intervention acceptance rate was 82% (n = 2910); a total of 618 interventions (18%) were declined. See Figure 2 for acceptance rates by intervention type. The medications with the most frequent interventions were oral chemotherapies that are administered in cycles (eg, capecitabine [Xeloda; Genentech], venetoclax [Venclexta; AbbVie], temozolomide [Temodar; Merck]) or that significantly affect blood counts (eg, capecitabine) (Table). Capecitabine was the most frequently intervened-on drug for most of the clinical intervention categories (strength and dosing, treatment discontinuation or hold, prescription direction clarification, treatment cycle, and laboratory abnormalities), accounting for 16% to 37% of those interventions. Venetoclax accounted for 45% of drug-drug interaction interventions, followed by acalabrutinib (Calquence; AstraZeneca) at 11% and apalutamide (Erleada; Janssen Products, LP) and enzalutamide (Xtandi; Astellas Pharma Inc), at 7% each.
We performed this retrospective study to evaluate the impact of pharmacist-led clinical interventions within a medically integrated oncology specialty pharmacy. The results demonstrate the vital role that oncology clinical pharmacists play in ensuring patients receive the most appropriate therapy based on their individual needs to maximize treatment outcomes. A total of 2910 interventions were accepted, corresponding to an 82% overall acceptance rate for pharmacist-led clinical interventions. This high acceptance rate highlights the importance of a pharmacist within the medically integrated oncology specialty pharmacy who can assess oral oncolytic therapy and collaborate with providers. The nonacceptance of clinical interventions (n = 618) was most often due to a discussion with the provider who wished to proceed with therapy, very closely monitor the patient, and schedule timelier follow-up. Given the nature of oncology and how quickly treatment plans change, it is crucial that pharmacists review patient charts and provider notes to proactively identify potential issues (eg, strength and dosing adjustments, treatment discontinuations or holds, changes in directions or cycles) before sending the patient medication. Additionally, oncology has several gray areas (eg, off-label indications, palliative measures, literature-supported evidence), requiring clinical oncology pharmacists to possess expertise and clinical reasoning for determining the most appropriate course of action when clinically relevant. This results in great benefit to the patient by ensuring they promptly receive the most effective and tailored care based on the latest evidence and sound clinical judgment.
Sig, prescription directions for use.
aA total of 3528 pharmacist-led clinical interventions were identified within the 17-month study period, with an average acceptance rate of 82% (n = 2910).
Most medications with interventions were those that often have significant drug-drug interactions, are administered on a cycle, or have the potential to be significantly myelosuppressive. For example, venetoclax was the leading medication requiring intervention for drug-drug interactions (Table), which resulted in subsequent dose reductions. Venetoclax is widely used for patients with acute myeloid leukemia (AML) and chronic lymphocytic leukemia (CLL), with its dosing dependent on indication and concomitant medications. Because of its risk of tumor lysis syndrome, venetoclax is initially administered on a ramp-up dosing schedule to gradually reduce tumor burden and decrease risk of tumor lysis syndrome. For example, in CLL, venetoclax is gradually increased over 5 weeks from 20 mg to the recommended daily dose of 400 mg.7 When prescribed for AML, venetoclax is ramped up over 3 days from 100 mg to the target dose of 400 mg daily.8 Additionally, venetoclax is a major substrate of CYP3A and a minor substrate of P-glycoprotein, which leads to a number of drug-drug interactions, including with cardiac medications such as carvedilol (Coreg; Waylis Therapeutics LLC), amiodarone, diltiazem, and verapamil.9 Patients with AML are often also prescribed supportive care medications such as azole antifungals that simultaneously impact CYP3A, affecting drug metabolism and venetoclax dosing.10 Pharmacists at a medically integrated pharmacy are able to access the patient’s chart to determine the proper indication and obtain an accurate medication reconciliation to proactively screen for drug interactions that may impact venetoclax dosing.
Sig, prescription directions for use.
aThe percentages represent the frequency of interventions for that drug of all medications intervened on in the category (eg, capecitabine was intervened on 272 times of 1682 total [16%] strength/dosing interventions, which included 100 different drugs).
bDrugs in bold type represent the top 3 intervened-on medications overall.
Additionally, oral oncolytics such as temozolomide and capecitabine are prescribed for a variety of disease states, with dosing and cycle recommendations that are dependent on various factors such as concomitant radiation dates and laboratory abnormalities. For example, chemoradiation with capecitabine or temozolomide requires efficient coordination with the health care team to properly align the medication dose, duration, and timing of delivery to ensure the patient has their medication in a timely manner that aligns with scheduled radiation days. Because the dose for these medications is based on body surface area, it is crucial to verify the patient’s weight and height to ensure they receive the correct dosage. The fact that a patient’s weight can change significantly during therapy is another reason why a pharmacist with access to the medical record should review treatment dosing before each dispense and confirm with the provider whether it is appropriate to modify dosing.
Pharmacists also conduct continuous medication monitoring for patients on medications with considerable toxicities known to impact the patient and their treatment plan. For example, because one of the major laboratory abnormalities associated with alpelisib (Piqray; Novartis Pharmaceuticals Corporation) is hyperglycemia, pharmacists assess the patient’s baseline glucose levels at treatment initiation and frequently throughout treatment.11 Upon recognizing a patient on alpelisib with increased blood glucose from baseline and after reviewing the package insert recommendations for hyperglycemia management, pharmacists communicate the laboratory change to the provider and suggest possible dose modifications and the initiation of glucose-lowering agents. Pharmacists in a medically integrated pharmacy have access to patient laboratory reports, enabling them to proactively assist with monitoring these patients and managing this drug-induced hyperglycemia with each prescription fill.
Natalie Kaufman, PharmD, is a clinical staff pharmacist at Florida Cancer Specialists & Research Institute in Fort Myers.
Nicole Bentivegna, PharmD, BCOP, is a clinical pharmacy services manager at Florida Cancer Specialists & Research Institute in Fort Myers.
Roger Orr, PharmD, BCOP, is director of clinical specialty pharmacy operations at Florida Cancer Specialists & Research Institute in Fort Myers.
A potential limitation of this analysis is the exclusion of REMS oral oncolytics (ie, lenalidomide, pomalidomide, and thalidomide), for which a large quantity of both clinical and clerical interventions are made on a daily basis. However, for this review, our sole focus was on pharmacist-led clinical interventions, and our institution’s REMS monitoring programs include nursing-led initiatives. If we had included these interventions, the total acceptance rate most likely would have been higher. Future directions for this type of analysis could include the total of both pharmacist-led and nurse-led clinical and clerical interventions to highlight all interventions that can be made by a multidisciplinary team to improve patient care.
Our findings highlight the essential role of clinical pharmacists in the continuity of high-quality coordinated oncology care. Because medically integrated pharmacists have access to the patient’s medical record, they can proactively identify potential issues, recognize opportunities to optimize treatment plans and disease management, and work collaboratively with providers to deliver the best care for each patient based on the most appropriate, most current evidence-based practices.
No funding was received in relation to the study/article. There are no relevant disclosures.
![TABLE. Most Commonly Intervened-On Medications and Frequency (%) by Intervention Typea,b -- Sig, prescription directions for use. aThe percentages represent the frequency of interventions for that drug of all medications intervened on in the category (eg, capecitabine was intervened on 272 times of 1682 total [16%] strength/dosing interventions, which included 100 different drugs). bDrugs in bold type represent the top 3 intervened-on medications overall.](/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpharmacytimes%2F8588f84b5d498c27c14c7d7006435b1f4996955c-1528x470.png%3Ffit%3Dcrop%26auto%3Dformat&w=3840&q=75 "TABLE. Most Commonly Intervened-On Medications and Frequency (%) by Intervention Typea,b -- Sig, prescription directions for use. aThe percentages represent the frequency of interventions for that drug of all medications intervened on in the category (eg, capecitabine was intervened on 272 times of 1682 total [16%] strength/dosing interventions, which included 100 different drugs). bDrugs in bold type represent the top 3 intervened-on medications overall.")
