The Role of the Pharmacist as Part of a Multidisciplinary Cancer Care Team

More patients are diagnosed with cancer today than ever before, but the 5-year and overall survival rates for patients with cancer continue to improve. With new advancements in cancer treatment, specifically as they relate to self-administered medications, more patients with cancer are self-managing their care. As patients move through their cancer treatment regimen into long-term survivorship, it is likely that they will develop and manage comorbidities concomitantly with their cancer diagnosis.

As such, it is vital that self-managing oncology patients, especially those receiving anticancer care outside a cancer center, are adequately monitored. The high-level monitoring required for patients with cancer becomes a challenge when patients are seen less frequently by their provider. Extensive training and experience with these medications and how they affect patients leave pharmacists, as an extension of the health care team, well positioned to assist in the clinical management of patients with cancer.

The barriers to cancer treatment adherence are many, and more problematically, multifaceted. These barriers may be related to socioeconomic conditions, the patient’s treatment regimen, the misconceptions associated with starting a self-administered anticancer treatment regimen, or the increasingly varied gaps within the health care system. Often, patients with cancer who begin a self-administered regimen don’t fully comprehend the severity of the consequences of nonadherence or the need to remain compliant to a newly prescribed anticancer medication. This is particularly true for patients who may also have a prior medical history of comorbidities in which they also self-administered the medication.

For example, patients typically don’t experience a real consequence if they periodically miss a couple of doses of a statin for hypercholesterolemia. However, studies show a significant impact in patient outcomes when nonadherence is as low as 10% for oral anticancer therapy. For example, a study published in the Journal of Clinical Oncology showed that long-term adherence to imatinib, a tyrosine kinase inhibitor (TKI), was vital to achieve a complete molecular response for patients with chronic myelogenous leukemia. Adherence to imatinib was monitored in 87 patients over 3 months. Patients who were less than 90% adherent had a significant decrease in achieving a complete or even a major molecular response. One can expect the same outcome for second- and third-generation TKIs. Nonadherence was also found to be higher in the younger population.¹

Adherence rates over time are of particular concern for patients with cancer who require long-term self-administered treatment. A cohort of 492 patients with breast cancer showed a decline in adherence rates in years 1 through 4 after starting tamoxifen as adjuvant therapy for early-stage breast cancer. After a year, patients were 83% adherent, but by year 4, patients were only 50% adherent. In this particular study, many of the participants did not fully understand the intent of the adjuvant therapy with tamoxifen and that it was curative.²

It is certainly not a new discovery that nonadherence is a link to an increased risk in mortality for cancer patients. A retrospective cohort study of 1633 patients prescribed tamoxifen after breast cancer surgery between 1993 and 2002 found that those who were less than 80% adherent had a 10% increase in risk of death (95% CI, 0.1%-21%). Retrospective data suggest that nonadherence over extended periods increased the patient’s risk of death.³

Alternatively, some patients with cancer believe that taking more of their anticancer medication than prescribed may be more effective at treating the disease. This overadherence can cause greater toxicities that ultimately disrupt therapy and potentially lead to decreased outcomes.

Historically, the cancer care team has consisted of doctors and nurses in medical oncology, radiation oncology, and surgery. These medical specialties were frequently sufficient for patient care when the overwhelming majority of anticancer treatment was infusion-based, as much of this treatment was managed within the cancer center. However, as there are more than 50 different oral medications currently used to treat cancer, the treatment paradigm is shifting. As these additional treatment options typically involve self-administered medications, the cancer care team must expand to include pharmacists as key members, given their responsibilities as both the medication and clinical management provider.

In many cases, pharmacists are the de facto frontline provider in the current medical environment. Pharmacists are more accessible to the patient than physicians, as consultations with pharmacists most often do not require a co-pay or appointment. Additionally, with oral chemotherapy regimens, the patient will visit the pharmacist more often (for medication refills, supporting medications, augmentation from over-the-counter products, etc) than the oncologist or oncology nurse. Patients may also develop a level of trust with their pharmacist regarding medication adherence that is different than the relationship they have with their provider. Patients will often have less fear of judgment from the pharmacist about their adherence level and the progression of their illness, which is information the pharmacist does not generally possess. Generally, patients are also able to have longer conversations with their pharmacist, who can plainly infer their adherence based on their refill history and through consultation to ensure that patients are taking their medication correctly.

Specialty pharmacists—specifically those with a clinical focus on the oncology disease state—also receive additional education around the cancer topics that are commonly encountered with patient self-administered medications. The use of a clinical platform allows pharmacists to effectively assist in the management of adverse effects related to cancer and its treatments. The pharmacist typically engages monthly, at a minimum, with each patient with cancer. During these monthly (and at times more frequent) assessments, the pharmacist reviews treatment adherence. Additionally, the pharmacist reviews any barriers that may impact adherence, including adverse effects.

It is vital that adherence be assessed at various stages of treatment, especially when a patient with cancer is on a more chronic self-administered therapy. In the case of chronic myelogenous leukemia, for example, patients may feel normal and do very well on treatment. As a result, they may assume that there is no need to continue with treatment and will discontinue their medication without seeking the guidance of their physician. Consultation with a specialty pharmacist can easily correct this misconception and emphasize the importance of adherence to the patient, providing a critical and unique aspect of treatment guidance in conjunction with those of physicians, nurses, and oncology social workers.

Distress of varying types (emotional, physical, and financial) among patients with cancer may lead to poor adherence and decreased quality of life. Most patients with cancer will experience some level of distress. According to the Cancer Experience Registry, nearly half (47%) of patients with cancer reported clinically significant distress associated with their diagnosis.⁴ Evidence suggests that psychological distress is frequently underreported, although it is commonly associated with patients with cancer.⁵

In addition to health-related adverse effects, the specialty pharmacist also is able to evaluate the financial impact of cancer treatments, a growing area of concern that relates directly to adherence and positive outcomes. With a cost-shift in the form of co-pays made by patients for their cancer treatment, many patients now suffer from significantly negative financial implications. Data suggest that cancer patients are 2.5 times more likely to become bankrupt than noncancer patients. Consequently, these patients and their caregivers experience a significant amount of distress, which has been linked to decreased quality of life and increased mortality.⁶

Pharmacists are in a unique position to detect financial stress in patients and how they might attempt to modify their regimen to a more financially palatable scheme. They observe how patients may attempt to stretch their medication by taking less than the prescribed dosage in order to prolong their daily supply, and they are able to speak with such patients about additional resources and connect them to advocacy groups and oncology social workers.

As cancer treatment continues to evolve and new regimens require a greater amount of patient responsibility outside the treatment center, the health care team must be able to adjust in order to best provide care in this environment. The pharmacist plays a critical role as medication expert, counselor, and frontline care provider, and pharmacists’ value in the health care team, alongside doctors, nurses, and oncology social workers, continues to increase as the needs of patients change.

References

• Marin D, Bazeos A, Mahon FX, et al. Adherence is the critical factor for achieving molecular responses in patients with chronic myeloid leukemia who achieve complete cytogenetic responses on imatinib. J Clin Oncol. 2010;28(14):2381-2388. doi: 10.1200/JCO.2009.26.3087.
• Partridge AH, Wang PS, Winer EP, Avorn J. Nonadherence to adjuvant tamoxifen therapy in women with primary breast cancer. J Clin Oncol. 2003;21(4):602-606.
• McCowan C, Shearer J, Donnan PT, et al. Cohort study examining tamoxifen adherence and its relationship to mortality in women with breast cancer. Br J Cancer. 2008;99(11):1763-1768. doi: 10.1038/sj.bjc.6604758.
• Research and Training Institute of the Cancer Support Community. Insight into the patient experience: Cancer Experience Registry Index Report. Cancer Support Community website. cancersupportcommunity.org/sites/default/files/uploads/our-research/2017_Report/registry_report_final.pdf?v=1. Published 2017. Accessed March 8, 2018.
• Jacobsen PB, Donovan KA, Trask PC, et al. Screening for psychological distress in ambulatory cancer patients. Cancer. 2005;103(7):1494-1502.
• Bansal A, Ramsey SD, Fedorenko CR, et al. Financial insolvency as a risk factor for mortality among patients with cancer. J Clin Oncol. 2015;33(15 Suppl; abstr 6509). doi: 10.1200/jco.2015.33.15_suppl.6509.