In October 2023, the Ontario College of Pharmacists was invited by Ontario Health (Cancer Care Ontario) to present at the Systemic Treatment Incident Learning Community of Practice quarterly meeting. We provided an overview of the AIMS Program and shared data on events involving oral anti-cancer drugs. This led to a rich discussion on best practices and improvement opportunities to prevent errors. Dispensing oral anti-cancer drugs in a community pharmacy setting comes with an increased risk of medication events. This article highlights steps pharmacists can take to mitigate these risks and improve patient safety.
Cancer continues to be a significant health concern – the number of new cancer cases in Canada is expected to increase by approximately 40% between 2015 and 2030.1 Accordingly, the field of oncology is constantly advancing. One of the recent major changes in cancer care is the shift from intravenous treatments to oral anti-cancer drugs (OACDs). The increasing use of OACDs has not only transformed the way in which cancer treatment is delivered, but also redefines the role of pharmacists in oncology care.
What are oral anti-cancer drugs?
OACDs are used to treat a variety of solid tumors, including breast, prostate, and lung cancers, as well as hematologic cancers like lymphomas, myelomas, and leukemia. While traditional intravenous chemotherapy is administered by healthcare providers in institutional settings, such as hospitals, OACDs are medications that patients can administer themselves at home.
Since 2017, OACDs have represented at least 50% of the oncology market share in Canada, marking a significant shift from the previous dominance of traditional intravenous chemotherapy.2 This is explained by the prominence of OACDs currently in drug development, their establishment as a standard treatment option for various cancers, and the convenience and patient preference associated with oral intake.
Why should community pharmacists care about oral anti-cancer drugs?
While OACDs are convenient, their ability to be dispensed and administered on an outpatient or community basis introduces new challenges to both patients and the oncology team, such as drug interactions, polypharmacy, side effects, adherence, storage, safe handling, and ultimately, patient safety.
OACD INCIDENTS RECORDED IN AIMS
Data from the Assurance and Improvement in Medication Safety (AIMS) Program show an upward trend in the number of medication incident and near miss (good catch) reports involving OACDs between August 2018 and September 2023. The most common event category was “incorrect quantity,” followed by “incorrect concentration” and “incorrect drug,” likely in part because of the more complex medication regimens associated with these drugs. Medication incidents and near misses (good catches) involving OACDs most commonly occur at the data input/order entry stage, followed by the dispensing/preparation stage.
Given these considerations, community pharmacists are uniquely positioned to collaborate with patients and their oncology team to optimize OACD safety and therapy.
Oncology patients may choose to get their treatment-related medications from pharmacies located within their oncology treatment centres rather than their regular pharmacies. In these cases, it’s imperative for community pharmacists to develop robust patient assessment strategies to identify polypharmacy and to collaborate with the pharmacist or appropriate oncology team member to ensure a comprehensive and integrated approach to patient care.
However, patients may also choose to fill their OACD prescriptions at their regular pharmacies. Therefore, community pharmacists must be prepared to assist OACD-treated patients and trained to handle these hazardous agents.
Assessment and Recommendations
Consider the following discussion points to optimize their quality of care.
If your patient is receiving their cancer treatment-related medications from another pharmacy:
- Inquire about medications that might be filled at another pharmacy: Regularly ask patients whether they are obtaining medications from other pharmacies or institutions to ensure holistic medication management.
- Recognize cancer-treatment related symptoms: Anti-cancer treatments may induce various adverse effects, including nausea and vomiting, mucositis, diarrhea, and constipation. Recognize and triage these symptoms promptly and refer the patient to the appropriate oncology team member when necessary. Consider referencing the drug’s Ontario Health (Cancer Care Ontario [CCO]) monograph and patient handouts to identify the most common side effects associated with treatment.
- Check in to confirm any changes to treatment plans: Given that treatment plans can change unexpectedly, check in regularly for any changes.
- Understand supportive care medications: Patients undergoing anti-cancer treatment are likely to be on supportive care medications like antiemetics, erythropoietin-stimulating agents, granulocyte colony-stimulating factors (GCSF), bone health medications, and antibiotics/antivirals. These should be carefully considered before dispensing any home medications or recommending any over-the-counter products.
If your patient is receiving their cancer treatment-related medications from your community pharmacy:
- Ensure proper training: Train pharmacy team members on how to handle hazardous drugs, such as OACDs, throughout the storing and dispensing processes to mitigate inadvertent exposure.
- Allocate dedicated storage: Establish a separate storage area for OACDs, with signage indicating that these are hazardous agents that need to be handled accordingly.
- Emphasize key counselling points: Pharmacists should ensure they cover the key counselling points of OACDs with patients (e.g., what the drug is for, how to take the drug, how to safely handle and store the drug, side effects and how to manage the side effects) at the initial and subsequent OACD communications.
- Implement independent check systems: It is crucial to develop systems in which the individual entering an OACD prescription is not the same as the one verifying it and in which double checks are conducted; these independent reviews minimize the risk for error.
- Address drug interactions and polypharmacy diligently: Actively identify and manage OACD drug interactions and polypharmacy.
- Foster interprofessional collaboration: Work closely with patients’ oncology teams to ensure routine follow-ups and necessary lab work for those on OACDs.
- Pursue continuous education: Proactively seek further training and education on oncology-related topics and stay updated with new OACDs entering the market.
The prevalence of cancer in Canada, compounded by continuous advancements in oncology treatments and the expansion of OACDs, underscores the significant role community pharmacists play in the evolving landscape of cancer care. The transition from traditional intravenous chemotherapy to OACDs offers convenience and flexibility to patients but also brings forth many challenges that can compromise patient safety.
Whether patients receive their OACDs from their regular community pharmacy or another pharmacy, pharmacists in both practice settings must be vigilant in addressing the unique challenges posed by OACDs and proactive in acquiring knowledge about new agents and advancements in this field.
In doing so, pharmacists affirm their commitment to optimal medication therapy and safety for oncology patients, bridging the gap between innovation in cancer treatment and the actualization of its benefits in patients’ lives.
References
- Canadian Cancer Society. Cancer statistics. Accessed November 3, 2023. https://cancer.ca/en/research/cancer-statistics#:~:text=2%20in%205%20Canadians%20are,to%20die%20of%20the%20disease.
- Patented Medicine Prices Review Board. Oncology medicines in Canada: trends and international comparisons, 2010–2019. Government of Canada. Updated October 27, 2023. Accessed November 3, 2023. https://www.canada.ca/en/patented-medicine-prices-review/services/npduis/analytical-studies/oncology-medicines-trends-international-comparisons.html