The Role of the Oncology Pharmacist in the Cancer Care Continuum

Pharmacy Times® interviewed Dwight Kloth, PharmD, FCCP, BCOP, director of pharmacy at Fox Chase Cancer Center, on the role of the oncology pharmacist on the cancer care continuum, and how this role has been impacted by the COVID-19 pandemic.

Alana Hippensteele: Hi, I'm Alana Hippensteele from Pharmacy Times. Today, I’m speaking with Dwight Kloth, the Director of Pharmacy at Fox Chase Cancer Center at Temple University, on the role of the oncology pharmacist on the cancer care continuum, and how this role has been impacted by the COVID-19 pandemic.

So, Dwight, in your role as an oncology pharmacist, how do you collaborate with oncologists and the others as a part of the cancer care team?

Dwight Kloth: Well, the role of the oncology pharmacist takes many forms. It can be different on the inpatient setting, as compared to the ambulatory infusion center setting, as compared to the specialty retail outpatient setting. There's roles that the pharmacist plays to contribute to patient care in all 3 of those.

They manifest differently. Inpatient, of course we're all familiar with the rounding on the inpatient team, that can be quick clinical hot spot rounds or lengthy teaching rounds spanning several hours. There's that modality.

In the fast-paced, ‘have to keep the chairs turning over’ ambulatory infusion setting, it's a different type of collaboration, that’s more focused on the planned regimen that is an elective procedure for that day, whether it's fulfox with bevacizumab or doxorubicin/cyclophosphamide for adjuvant therapy for breast cancer patients. The role that the oncology pharmacists play in symptom monitoring, in lab assessment, in dose checking, many of those roles are well-established.

In the ambulatory, as in outpatient retail setting, increasingly pharmacists play a role in verifying the correct dose for an oral agent, supporting adherence and compliance, and supporting patient education. One of the things that we discovered a number of years ago is when we bring a patient in to our ambulatory infusion center, or when we have them as an inpatient in the inpatient hospital, we control all the variables. We know exactly what will be administered because we control that. When a patient is taking an oral medication—a [tyrosine kinase inhibitor] or any other oral med that is chronically administered at 28 days, a month, 30 days, every day, whatever the regimen may be, with or without a week off periodically, according to the regimen of the medication—we are not at the patient's elbow to make sure that adherence to time of day, fasting or with food conditions, etc. We're not there to assure all of those considerations. But we can play a role in educating the patient at the time that they receive their prescription and in follow-ups, which we do all the time.

Our outpatient specialty pharmacists are calling patients at home, checking in with them, seeing how they're doing with their compliance, if they're having any unexpected symptoms that the oncologist needs to hear about, and so forth and so on.

So, there's a huge spectrum of roles that the pharmacist plays. It's very different than when I was a rookie without any gray hair and without even knowing what drugs cost—because I didn't at that time. Back then, every patient was admitted because we didn't have ambulatory infusion programs. So the role of the clinical pharmacist then, the role that I played at the beginning of my oncology career, was purely inpatient.

So, these other 2 major areas have developed over the succeeding years, and the roles are different, but they're valuable in their own way. They all reflect collaboration with our partners, our oncology nurses, our oncologists, and our hematologists—it's all a team effort. Whether it's inpatient infusion room or in the chronically self-administered oral cytotoxic setting at home.

Alana Hippensteele: Are you able to discuss treatment recommendations with oncologists as a part of a patient's care team, and do you find your recommendations are generally accepted and applied?

Dwight Kloth: Well, I'm going to answer that with regard to compliance with [National Comprehensive Cancer Network (NCCN)] guidelines, [American Society of Clinical Oncology (ASCO)] guidelines, things of that nature, and that predominantly relates to dosing or selection of stage of disease versus treatment.

Generally, the oncologist knows what regimen they want to use. There are times where they might possibly be out of sync with the NCCN guideline—not often, but it could happen—but generally speaking, our pharmacists are part of the process of making sure that when a decision is made to treat, that the treatment is coherent with established guidelines, be it from ASCO or the NCCN, and that the therapies are optimal in terms of the quality oncology initiative called [Quality Oncology Practice Initiative].

But then also too, there's the time-honored and well-demonstrated role of the pharmacist in terms of alerting the physician when there's organ dysfunction that would impact and necessitate dose adjustments, and that's a constant. It's a very collaborative process in that regard.

Alana Hippensteele: Yeah. How does your participation and communication with oncologists as a part of the care team affect a patient's care in the short and long term?

Dwight Kloth: Well in the short term, if there's a change in a laboratory value that has not been made known to the physician—let's say a change in creatinine clearance as reflected by the serum creatinine, or a change in liver function capability as reflected by liver function tests—that's a very vivid example of a short-term impact. That then can relate to long-term impacts by avoiding toxicities and helping to ensure the success of the therapy that's being administered.

Alana Hippensteele: Right. What is your direct involvement with patients like as a part of their care team, and how has that involvement been affected by the pandemic?

Dwight Kloth: That question has multiple answers as well. On the inpatient setting, when there's inpatient clinical rounding, we try to minimize the amount of people we cram into a patient room, and that's one change that's due to the pandemic. I think after 11 and a half, 12, 12 and a half months of the ordeal of SARS-CoV-2, and with the arrival of vaccines, I think that's relaxing a bit. But that's been one manifestation on the inpatient side.

On the infusion room side, the patients are arriving for in-person therapy to receive infusions or injections, and that needs to be in person, you can't do that remotely. But for other things, telehealth has really played a role. Some physician appointments are now telehealth rather than in-clinic, and there's assessments that can be done remotely by telehealth, and there are others that require the physical presence of the patient to be examined by the physician.

Alana Hippensteele: Right. What are some of the primary challenges when treating patients with cancer today, such as problems that have arisen in relation to delays in care, treatment, or diagnosis?

Dwight Kloth: That's a tough question that I'm not sure I can answer. Fox Chase is a tertiary care referral center, so I and my pharmacists are not seeing directly if there's a delay in getting a patient referred from a family practitioner in the community for testing here—we don't see that directly.

I think that things are better now than they were a year ago, as we in society—to the degree we can deal with the coronavirus and the pandemic—have gotten more skilled at working around some of the immediate constraints that happened back in February of 2020 when we were all trying to figure out just how worried we needed to be, what levels of caution we needed to take, and what levels of PPE we couldn't get back then, and all of those things. So, I may not have answered your question, and if I haven't, I'm sorry, but it is very complicated and multifactorial.

Alana Hippensteele: I can imagine. Since the future of care for patients with cancer is likely to include more telehealth and mobile communication platforms, how might this impact care moving forward?

Dwight Kloth: Boy, that's an interesting question. I wish I was smart enough to know the answer to that. I would suggest, as you said, that telehealth will continue to be a part of our processes and that patients who are not in acute treatment conditions or in acute distress will continue to be seen remotely. I didn't think, in January of 2020, of Zoom as either a verb or an adjective for doing things that we are doing right now. Likewise, for our patients, likewise, for our medical oncologists, and even to a degree for our phone triage when patients might call in at 9 at night, or the spouse or other caregiver might call in at 9 or 10 pm and say, ‘I or the patient is having this situation that is new. Is this worrisome? Can this wait till tomorrow? Should we call 9-1-1? Should we drive in?’

The technology that we have now has made some of those capabilities tremendously more powerful to the degree where if there was, let's say, a skin rash, if the equipment is up to the task, a physician could look at a skin rash over Zoom, Webex, or any one of the platforms—Skype, Facetime—those capabilities are tremendous.

When I think about trying to survive the COVID-19 pandemic as practitioners without these capabilities, it's hard for me to fathom it actually.

Alana Hippensteele: Yeah, absolutely. Do oncology pharmacists have a role in clinical trials, and if so, what does that look like, and has this role been affected by the pandemic?

Dwight Kloth: Well, first of all, absolutely oncology pharmacists have roles to play in clinical trials. Here at Fox Chase, we have 5 pharmacists involved in clinical trial support. We have an investigational drug studies coordinator in a full-time position, an [full-time equivalent], devoted to overseeing our support of our clinical trials. We have over 200 clinical trials, and that individual does not do routine patient care, he is devoted to clinical trials.

We have other pharmacists who serve on the [Institutional Review Boards (IRBs)]. We have 2 IRBs—because of the workload, we split them up. We have team a, team b. We have a total of 5 pharmacists serving those different functions.

We also have a pharmacist on what we call here the research review committee—other institutions call it the scientific review committee—we have one pharmacist on that committee, that's me. So that's a total of 6 people who contribute to the scientific endeavor either at the initial assessment of a protocol before it gets to IRB or to the IRB review process, and that's just at the committee level.

Then when you get into implementing a study, there's the site initiation visits, the conduct of the trial itself, the support and administration of the treatment in the trial, and the pharmacists are involved in every phase of that component, ensuring compliance with the study protocol, ensuring compliance with FDA and NCI requirements for conduct of a trial, study drug accountability, etc.

Alana Hippensteele: What is the value of the pharmacist within the cancer care continuum?

Dwight Kloth: Well, I have a biased answer to that, of course. But as you think about all the things that could go wrong, the role of the pharmacist is vital. One of our oncologists is leaving Fox Chase to go to assume an important position at the NCCN, and she said—and I took it as a compliment to my whole team—your team is fabulous, and I sleep well at night knowing that your pharmacists are part of our patient care process. That warms your heart to hear that.

But it's not just quality of patient care, there's all the other things that we become involved with due to some of the issues related to insurance company restrictions, drug shortages, occasionally we have to switch care because of a shortage related issue. So, there's many roles to play.

Alana Hippensteele: Yeah, absolutely. Thank you so much for taking the time to speak with me today.

Dwight Kloth: Oh, it's my pleasure completely. Thank you very much.