The Impact of COVID-19 on Oncology Pharmacy and Patient Care, Part 2

Editor's Note: This is the second of 2 parts in this article series. The first part was published in the February 2021 issue of Directions in Oncology Pharmacy®.

The role of oncology pharmacists is vital to all aspects of care for patients with cancer, whether working in an outpatient or inpatient setting. Despite the global coronavirus disease 2019 (COVID-19) pandemic, the continuation of cancer treatments is needed to maintain disease control and improve patient outcomes.

In Part 1, we discussed the need to overcome COVID-19 barriers to cancer treatment. Telehealth, patient care teams, and the need for innovative strategies were identified as key for continuing treatments and achieving medication adherence.

In the infusion center setting, there is significant opportunity to streamline interventions and to apply lessons learned by oncology pharmacists during the pandemic.

Strategies for Overcoming COVID-19 Barriers in Oncology Pharmacy Practice

Moving Treatment Regimens from Inpatient to Outpatient

One strategy to consider is moving inpatient treatment regimens to the outpatient setting.¹ The literature has demonstrated the feasibility, safety, and effectiveness of etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, highdose methotrexate, and cytarabine, among others, in this setting. These interventions can aid in the conservation of hospital resources and available beds for acute care. Another option includes the use of oral anticancer therapies when clinically appropriate. Several considerations should be addressed, including treatment goals, patient comorbidities, degree of frailty, and the presence of caregivers.

Extending Intervals of Chemotherapy Agents

To minimize chair time, extending therapeutic intervals when administering chemotherapy agents can also be considered.¹ Patients often present to infusion centers 1 to 2 hours before chemotherapy to allow for premedications to be administered. Some patients may be provided with an outpatient prescription and encouraged to premedicate prior to arrival, to limit the time in the infusion center. Additionally, certain biologic therapies require titration, resulting in prolonged infusion times of several hours.

Data support rapid or accelerated infusions of select agents that are well tolerated and can reduce chair time. When clinically appropriate, clinicians may consider switching patients to more convenient delivery methods. Certain products are available in a “ready-to-use” formulation, eliminating the need for pharmacy personnel to compound the infusion, and allowing for further preservation of personal protective equipment.

Incorporation of Home Infusion Services

For certain patients, home infusion services may be an appropriate option.¹ Nursing services are warranted to train and educate the patient and caregivers on proper administration, considerations for handling, adverse effects, and goals of therapy. These services can also provide laboratory testing or blood collection if needed before the patient receives chemotherapy.

Home infusion services coupled with telehealth visits may allow the number of routine office visits to be reduced, thus limiting exposure risk. Several factors should be considered to determine whether a patient is able to receive home infusion services, including disease severity, anticipated adverse effects, and insurance coverage.

Approach to Supportive Care Measures

Supportive care measures are essential to mitigate the risk of treatment-related complications when managing patients with cancer.¹ Before the pandemic, routine office visits were often needed to allow administration of supportive care therapies, such as erythropoietin-stimulating agents, bone-modifying agents, and infection prophylaxis.

The European Society for Medical Oncology (ESMO), in its clinical guidance, addresses the use of granulocyte colony-stimulating factor (G-CSF) in patients with cancer during the pandemic.² Specifically, to lower the risk of febrile neutropenia, ESMO recommends considering expanding the indication for G-CSF to patients with intermediate (10%-20%) and high (>20%) risk of febrile neutropenia, particularly for elderly patients with comorbidities.

In patients with COVID-19, there is an increased risk of thromboembolic events and associated complications, thus prophylaxis using low-molecular–weight heparin or new oral anticoagulants is recommended.² Self-administration of supportive care medications for certain patients can be a safe and effective option and can improve both patient and nursing satisfaction.¹ When selecting an agent for self-administration, a formulation with ease of administration (with preference given to oral or subcutaneous routes) and a convenient dosing frequency should be prioritized.

The guiding principle of care delivery during the pandemic is to provide service in a safe environment for patients and health care providers, prioritizing the treatment of patients with curative intent and caring for those in need of symptomatic palliation.³

Prioritization of patient care involves consideration of the patient’s clinical condition, facility status, number of infected patients, available resources, and health of the workforce. Appointments and resource utilization should be prioritized on the basis of patient condition and disease status. All patients should be risk stratified. The hospital should have a policy on the use of critical resources, such as intensive care unit beds and ventilators. Goals of care and advance directions should be discussed with all patients and recorded in the chart.⁴

According to the ESMO, cancer care prioritization and intensity should be adapted to the pandemic scenario, health facilities, and resources.² Proper screening and testing protocols should be in place. Active and progressing cancer status, advanced age, poor performance status, smoking status, comorbidities, cancer type, and administration of cytotoxic chemotherapy have been identified as significant risk factors for COVID-19 severity and mortality. The decision to transfer a patient to the intensive care unit depends on the strain on the unit and should be adapted according to the pandemic scenario. Maximizing the number of patients who survive COVID-19 with a reasonable life expectancy should be given the highest priority.

Clinical research activities face a multitude of challenges stemming from the pandemic, which can ultimately stall progress for cancer research.³ Many patients participate in trials to have access to new and otherwise unavailable therapies, whereas other patients need access to alternative options or experimental agents due to adverse effects. Investigators may need to compete for prioritized resources, including diagnostic tools, imaging, and laboratory services.

The safety of patients should remain the priority and a risk:benefit assessment regarding trial continuation for current patients and recruitment of new participants should be conducted. Protocol amendments may need to be instituted to include COVID-19 risk assessments, symptom management, and periodic testing. If a patient tests positive, it is crucial to ensure that the diagnosis of COVID-19 is compatible with protocol treatments.

Lessons Learned and Continued Challenges

The COVID-19 pandemic has universally affected health care delivery for patients with cancer. It has forced health care providers to develop innovative strategies to deliver the highest quality of care while mitigating the need for frequent health visits to prevent infection. By assisting with telehealth visits, adjusting treatment regimens to minimize clinic visits, prioritizing preventive measures, and incorporating home infusion centers, the oncology community has risen as a unified front against COVID-19 to secure the provision of cancer care.

As the pandemic and economic crisis continues, pharmacists will need to continue to assist in optimizing cancer care and develop strategies to assist institutions in financial recovery.

Organizations have been at the forefront of providing recommendations to assist health care providers effectively manage current and future outbreaks. Notably, the American Society of Clinical Oncology (ASCO) developed a summary of recommendations addressing risk minimization; care prioritization of patients; health care team management; virtual care; management of patients with cancer undergoing surgical, radiation, and systemic therapy; clinical research; and recovery plans to assist providers in managing ongoing challenges.³

These recommendations place a key emphasis on protecting patients and health care teams from COVID-19 exposure while maintaining timely cancer care and ensuring health care providers are prepared to handle a surge of new COVID-19 cases. These recommendations serve as a valuable resource for pharmacists in various clinical practice settings to remain adaptable to changes in the delivery of cancer care, while maintaining engagement in research, management, and leadership initiatives in their area of practice.

COVID-19 has changed the outlook and trajectory of cancer clinical trials in several ways. On a positive note, the pandemic has enabled immense collaboration, as investigators have come together and created robust research programs such as the COVID-19 and Cancer Consortium to better understand the disease course, treatment options, and potential complications of COVID-19 in cancer patients.

Pharmacists can be at the forefront of such research initiatives and can advocate for involvement within their institutions to promote advancements in the knowledge of COVID-19 in this population. With regard to approval of standard cancer treatments, clinical trials for cancer care have been disrupted because of the need to reallocate resources toward the discovery of therapies to treat COVID-19, and because of necessary restrictions in the direct patient interactions needed for recruitment and follow-up in these trials. Pharmacists should be aware of such restrictions and be at the forefront of collaboration, protocol optimization, and development of strategies that promote flexibility to remove potential barriers that exist in cancer care research, given its vital utility in patient care. COVID-19 has caused further collateral damage in that cancer screening rates have dropped dramatically with the inability to maintain routine health care visits for several outpatient facilities. ASCO reported that 64% of Americans have delayed cancer screening or cancelled previous appointments secondary to COVID-19.⁵

Oncology and ambulatory care pharmacists can advise patients on home screening or ensure that routine visits for cancer screenings are maintained according to national guideline recommendations. The utmost priority in all cases is maintaining patient safety and mitigating this vulnerable population’s risk of infection. This will require clinicians to devise innovative solutions in developing home testing or screening kits to avoid missed opportunities for cancer treatment in early stages.

Pharmacists must work to keep patients informed and safe, so they can continue to deliver life-saving care. Most importantly, pharmacists must remain adaptable to the changing landscape of clinical care and to innovations in technology and communication to sustain their vital relationships with patients and care teams.

KIROLLOS HANNA, PHARMD, BCPS, BCOP, is an oncology pharmacy manager at M Health Fairview pharmacy services at the University of Minnesota Medical Clinic in Maple Grove, and assistant professor of pharmacy at Mayo Clinic College of Medicine and Science in Rochester, Minnesota.

ASHLEY BARLOW, PHARMD, is a PGY2 oncology resident at MD Anderson Cancer Center in Houston.

BROOKE BARLOW, PHARMD, is a PGY2 critical care resident at the University of Kentucky HealthCare in Lexington.

REFERENCES

1. Hanna KS, Segal EM, Barlow A, Barlow B. Clinical strategies for optimizing infusion center care through a pandemic. J Oncol Pharm Pract. 2021;27(1):165-179.doi:10.1177/1078155220960211
2. Curigliano G, Banerjee S, Cervantes A, et al. Managing cancer patients during the COVID-19 pandemic: an ESMO multidisciplinary expert consensus. Ann Oncol. 2020;31(10):1320-1335. doi:10.1016/j.annonc.2020.07.010
3. Jazieh AR, Chan SL, Curigliano G, et al. Delivering cancer care during the COVID-19 pandemic: recommendations and lessons learned from ASCO Global Webinars. JCO Glob Oncol. 2020;6:1461-1471.doi:10.1200/GO.20.00423
4. A timeline of COVID-19 developments in 2020. News release. AJMC. Accessed December 10, 2020. https://www.ajmc.com/view/a-timeline-of-covid19-developments-in-2020
5. National survey reveals racial differences in perceptions of inequities in health care and concerning delays in cancer screenings amid COVID-19. News release. ASCO. October 1, 2020. Accessed November 9, 2020. https://www.asco.org/practice-policy/policy-issues-statements/asco-in-action/2020-national-cancer-opinion-survey-new-findings