The ISOPP symposium in Prague was the latest in a series which began in New Zealand a decade and a half ago. For a regular attendee at these meetings, such as myself, it is fascinating to see how the interests and concerns of delegates evolve over the years. Some do not change - therapeutic reviews to reassure delegates that their attempts to improve cancer treatment have not been entirely in vain and information on new therapies, to give them hope that progress will be just a little bit quicker in the future, are a constant. Other topics, like the safe handling of cytotoxic drugs, are cyclical. Just when most people think that the last word has been said on the subject, new studies are published suggesting that problems still remain, prompting a flurry of renewed interest. This was signified by several well-attended presentations of studies which have already been presented elsewhere and reported in The Journal.
Of particular interest were those speakers who gave an indication of changing roles and attitudes among oncology pharmacists. It is fascinating to speculate on how much these changes represent the maturation of oncology pharmacy as a specialism and the extent to which they represent changes in society as a whole.
It is unlikely that an early ISOPP meeting would have featured a mainstream oncology pharmacist like Dr Rowena Schwarz (University of Pittsburgh, US) talking in a serious and balanced way about complementary and alternative medicines (CAMs).
She began her lecture by emphasising the difference between complementary therapies, which were used as an adjunct to conventional treatments (often to help with the side effects these induced), and alternative therapies, which were a substitute for orthodox medicine. The latter were potentially more problematic since they might prevent patient access to conventional treatments of proven worth. Dr Schwarz said that CAMs included a wide range of therapies (many of which, relaxation and visualisation techniques, for example, were not drug-related), supported by varying levels of evidence. Use of CAMs was now so widespread that they could no longer be considered separately from "mainstream" medicine. To illustrate this, Dr Schwarz cited a study reported at last year's American Society for Clinical Oncology annual meeting, which showed that 83 per cent of a large sample of cancer patients reported using CAMs. This was a substantially higher level of use than that reported in a similar survey published in 1994, suggesting that the popularity of CAMs was increasing rapidly. Dr Schwarz commented that, despite her natural scepticism, she herself was not immune to this trend and tended to select cough drops with added herbs when visiting her local pharmacy.
The appeal of CAMs to cancer patients could be attributed to a number of factors, said Dr Schwarz. They were something over which the patient had full control at a time when they were forfeiting their independence in many other areas; they provided hope when conventional medicine might be demonstrably failing to provide a cure; they permitted patients' friends and families to contribute to treatment decisions by suggesting or providing favourite remedies; and they allowed personal beliefs in such things as the healing powers of nature or prayer to be integrated into treatment.
Dr Schwarz said that the bewildering array of CAMs currently in use presented a challenge to pharmacists, who could not possibly be an expert on all of them. To claim such expertise would be to mislead patients. However, there were several reasons why pharmacists should take an interest in and discuss CAMs with patients.
First, understanding why patients resorted to CAMs might be useful in optimising conventional drug therapy. If it emerged that they were self-medicating in an attempt to ameliorate previously undisclosed disease symptoms or treatment side effects, remedial action could be taken.
Secondly, some CAMs did have well documented interactions with conventional medications, the recently publicised interactions between St John's Wort and various drugs being an example.
Finally, patients rightly perceived pharmacists as a reliable source of impartial information about their therapy. Dr Schwarz said that the skills in information retrieval and evaluation that pharmacists possessed could be helpful to patients considering whether or not to use a particular CAM. Pharmacists were trained to identify deficiencies in information sources, and could cast an educated eye over the methods involved in any trials used to support claims made for the effectiveness of CAMs. They also understood the limitations of anecdotal reports of therapeutic efficacy, however sincerely these may have been made.
Dr Schwarz concluded by considering several myths about CAMs, which she said should be dispelled. One was that the only professional approach was to counsel against the use of any treatment until its safety and efficacy had been established beyond doubt. Such an approach would be asking for a higher level of proof than that demanded from conventional medicines, as illustrated by the number of women with breast cancer who had been treated with high-dose chemotherapy and stem cell rescue in recent years on the basis of scanty and dubious clinical data. It was also misguided to believe that increased regulation of CAMs would, in itself, ensure that all possible questions about their toxicity and effectiveness could be answered - such certainty was not an automatic consequence of the regulation of conventional pharmaceuticals, so why should CAMs be any different? Neither, said Dr Schwarz, should pharmacists delude themselves that the information sources available to professionals were automatically superior to those available to patients. With almost universal access to on-line information, this was almost certainly untrue, although pharmacists were still better trained than most members of the public in interpreting the information available.
The final misconception considered by Dr Schwarz was the assumption that cancer patients who put their trust in complementary therapies must be unaware of their prognosis and in need of education. This, she said, was patently untrue. By using CAMs they were indicating their understanding of the limitations of conventional treatment. It was important for pharmacists and others advising patients on CAM usage to understand this in order to avoid inadvertently demolishing part of their mechanism for coping with their condition.
The importance of preserving hope while ensuring that patients were adequately informed was also discussed by Dr Jiri Simek (Czech Republic) during a session on ethical controversies in cancer treatment. He extended a familiar analogy to describe the differing perceptions of patients and professionals. He said that patients tended not only to see their half-empty glass of life as being half-full but also understood that even an almost empty glass still had a little water in it.
Such an ultra-optimistic outlook could lead patients to seek out and demand treatments of unproven or very limited efficacy. This could pose an ethical dilemma for those using limited resources to treat cancer patients. In such circumstances, satisfying the demands of individual patients for treatments of doubtful utility could prevent therapies of proven value being offered to others.
In many places, this dilemma is being addressed by the establishment of evidence-based treatment guidelines which move decisions on the use of expensive drugs away from the bedside. It was encouraging to hear that pharmacists from several countries are at the forefront of this process, bringing the analytical skills mentioned by Dr Schwarz to bear on data affecting populations of patients as well as individuals.
Ms Alison Hodgetts (South & West regional drug information centre, Bristol, UK) described her work for the Peninsular Cancer Drug Forum. This multidisciplinary group was set up to deal with the introduction of expensive anticancer drugs and to ensure equity of access to evidence-based treatment in the Devon and Cornwall cancer services steering group area, which contained three health authorities, two cancer centres and three cancer units.
The forum approached the regional drug information centre to provide evaluated information to support its work. Ms Hodgetts explained that subjects for review were selected by the steering group. Usually, reviews covered disease states rather than specific drugs, since this more closely reflected the therapeutic decision-making process.
Ms Hodgetts reviewed each subject using both published sources and consultation with expert clinicians before compiling a report, which included information about the epidemiology of the condition in question, a clinical overview of the disease, a summary of current treatments and the evidence supporting the use of these and any new treatments under consideration, along with information about any important clinical trials still under way.
Finally, a recommendation was made about standard treatment. After a consultation period, the report was formally adopted by the steering group and an application made to the health authorities for any additional funding needed to facilitate introduction of the recommendation. Ms Hodgetts pointed out that not all recommendations came with a large price ticket attatched. A recent report from the forum recommended that all women with early breast cancer should be considered for three to six months' adjuvant chemotherapy post-surgery. This recommendation would have little financial impact since it accorded with the current practice of most clinicians, but should ensure that the few not already offering such treatment would review their prescribing, especially as each report was followed by an audit to determine compliance with its recommendations.Ms Hodgetts said that, so far, the process had produced seven reports, two of which had been updated as part of an ongoing review process, and that the system of reporting appeared to have been successful in aiding difficult discussions on treatment provision.
In Canada, too, pharmacists are at the forefront of the rational introduction of new anticancer treatments. Dr Suzanne Malfair-Taylor (Vancouver, Canada) described her work for the British Columbia Cancer Agency (BCCA) which pays cancer centres to provide treatment to standards defined by the agency.
To help the agency in the formulation of treatment guidelines, a pharmacist-led pharmacoeconomics group had been established. Initially, the group carried out a detailed data collection exercise to compare the economics of paclitaxel and docetaxel in the treatment of advanced breast cancer. The results obtained were compared with estimates made using a spreadsheet model, which was subsequently modified to remedy flaws exposed by the data collection study. The resulting template allowed the group to assess the economic impact of any proposed change in the drug treatment of cancer in their area.
Dr Malfair-Taylor explained that specialist tumour groups now submitted bids for proposed changes to standard drug therapy to the pharmacoeconomics group on an annual basis. Economic modelling was then carried out and the proposed treatment changes were ranked according to the value for money that they represented. The annual cost to the Province of introducing each change was also calculated and used as the basis of a request for funding from the Provincial Health Ministry.
If funding was forthcoming, the treatment was introduced, with treatment centres reimbursed on a case-by-case basis, in return for detailed information on patients and their treatment. This was possible because of a sophisticated data collection system, which ensured that the BCCA had a database containing information on all British Columbia cancer patients and their treatment from 1992 onwards.
The database was now extremely valuable both as a research tool and as a means of forecasting the economic and therapeutic impact of changes in practice. Dr Malfair-Taylor commented that, because pharmacists were the gatekeepers between researchers and the database, the local profile of the profession had been enhanced significantly.
Declaration: As an invited speaker, expenses incurred by my attendance at this meeting were met by the congress organisers.