Cancer care: policies and practice
The risks associated with oral chemotherapy was one of the topics discussed at the policies and practice cancer care session. Harriet
Adcock (on the staff of The
Journal) reports the main themes
Increase in oral chemotherapy use will raise risk management and safety
issues
Pharmacy services would like to see industry take on “big
business” specials manufacturing |
Systems that deal safely with oral chemotherapy in National Health
Service hospitals need to be better developed, Tim Root, London specialist
pharmacist,
clinical governance and technical services, Chelsea and Westminster,
told conference participants.
He explained that prescriptions for parenteral chemotherapy are guaranteed
to be routed via specialist staff. “For oral chemotherapy there
is a chance that an oncology pharmacist will not go near the prescription,” he
said.
The financial and clinical risks involved with administering oral chemotherapy
need to be addressed since, in the next few years, tens of thousands
of patients will be treated with oral anti-cancer drugs. Mr Root added
that there is enforced reliance on patients in terms of administering
oral chemotherapy. Oral therapy is no more or less safe than parenteral
chemotherapy, he warned. “We need to rethink our systems of work,” he
said.
Mr Root went on to discuss issues surrounding clinical trials in cancer
care and called for more specialist pharmacy involvement early in the
planning of trials. “We could all reap the benefits if the right
pharmacists had input to trial design,” he said.
Risk management of unlicensed and off-label medicines use also needs
to be tackled, Mr Root said. He cited the example of thalidomide, for
which an “onerous” patient registration and monitoring scheme
was about to be imposed.
He warned that if more drugs required this sort of monitoring the system
would find itself in difficulties. “The principle is perfectly
sound, but there has been no pragmatic consideration of how the system
should cope,” he warned.
Another issue raised by Mr Root was the modernisation of National Health
Service medicines manufacturing. He reminded participants that the £42m
allocated by the Government was for “traditional manufacturing”,
not for compounding.
Part of the strategy in London is to show the Department of Health that
the new manufacturing money has been spent wisely, he said, but that
further monies would then be needed. He hoped these could be sought from
a second phase of funding.
He added that there was an ongoing debate about the role of the pharmaceutical
industry in specials manufacturing. Pharmacy services in the NHS would
like to see industry take on the manufacturing of “big business” specials
as fully licensed products. However, the industry seems more interested
in taking on the whole specials markets and not just the relatively few
high-volume products for which there is a real need but which may appear
to them commercially uninteresting, he said.
Mr Root went on to discuss priorities for action for pharmacists working
in cancer care. He called for better data collection on workforce and
workload and improved liaison with national cancer organisations. “We
need to learn how to market pharmacy and pharmacists,” he said.
Another priority was to look at the way in which chemotherapy doses are
calculated. There could be a lot to be gained by all disciplines from
rationalising how doses are calculated, he said. Use of body surface
area to calculate doses was time-consuming and error-prone and there
is no strong evidence that it is the best way to determine doses. The
method originated with early animal studies and has simply been used
ever since.
Dose rationalisation, by use of dose banding for instance, would give
greater opportunities for prescribing and preparing chemotherapy in advance,
a system that has been shown to help streamline the pharmacy workload
and reduce patient waiting times.
Network pharmacists highlight pharmacy’s role
The role of the “Network” pharmacist in cancer services was
mapped out to conference participants by Dermot Ball, network lead pharmacist,
Avon, Somerset and Wiltshire Cancer Services.
Primarily, the role of the Cancer Network is to oversee the local delivery
of the Government’s Cancer Plan. The network pharmacist is involved
in those aspects which have an impact on, or are influenced by, the pharmacy
services. “Although there is no standard job description for the
role, the main priorities for network pharmacists involve the funding
and prescribing of drug treatment, clinical trials and network pharmacy
development,” he said.
Network pharmacists work closely with both primary and secondary care
to facilitate the funding and introduction of new oncology treatments
in an equitable manner. Mr Ball said it was important that patients and
clinicians could see how the network arrives at decisions and that all
treatments were available to everyone, irrespective of where they lived.
With this in mind, Avon, Somerset and Wiltshire Cancer Services has made
information about chemotherapy protocols and funding decisions available
via its website.
The information helps commissioners, clinicians and patients understand
what drugs are available and where they are used. “We are trying
to use the web to improve efficiency,” he said.
In terms of clinical trials, Mr Ball said that network pharmacists are
becoming increasingly involved when trials are drawn up. “There
have been instances when trial protocols have contained some pharmaceutical
aspect that is completely unworkable,” he added.
Other areas being looked at by network pharmacists are trial costings
and expanding the role of technicians, beyond just preparing medicines
for trials. He added that impending European legislation would have a
significant, but currently unknown, impact on all clinical trials within
the National Health Service, and work is under way to ensure that oncology
trials can continue in the new climate.
Mr Ball explained that for network pharmacy development, good relationships
are crucial. “The role of existing oncology pharmacists is key
to maintaining and improving services. Network pharmacists don’t
have a formal management role but they have a professional responsibility
to the oncology pharmacists in the trusts,” he said.
Mr Ball concluded by saying that the contribution of pharmacy to cancer
care had not always been adequately acknowledged in the past. “One
significant thing network pharmacists do is to highlight this and make
people realise that without pharmacy there wouldn’t be any chemotherapy,” he
said. |
