British Oncology Pharmacy Association
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Educating patients and health professionals about oral chemotherapy is critical for patient safety, a recent meeting was told. Joanna
Lumb reports
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The meeting was organised by the British
Oncology Pharmacy Association and took place at the Royal Marsden Hospital in London on 10 December.
It was supported by an unrestricted educational grant from Roche
Products Ltd
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How to achieve
safe implementation of oral chemotherapy for cancer
Cancer chemotherapy by the oral route has been available for many years
but has been confined to small scale use. With the introduction of
new drugs, and positive National Institute for Clinical Excellence
guidance,
this is set to change. By 2005, tens of thousands of patients could
be receiving oral anticancer treatment.
The British Oncology Pharmacy Association is developing a position
statement on safe practice and the pharmaceutical care of patients
receiving oral
anticancer chemotherapy. This will emphasise that although oral therapy
has perceived advantages to patients and to the NHS, it also presents
new challenges as home-based treatment may continue for weeks at a
time without direct professional supervision. Education of patients
and primary
care professionals about the use of oral chemotherapy is critical for
patient safety. Not a soft option
“Oral chemotherapy is no more or less safe than IV chemotherapy.
It is not a soft option,” said Neil Watson, chief pharmacist, Royal
Marsden NHS trust. “It is an important and expanding area of practice,
and centres need to look at how they are going to introduce the new drugs
into routine practice.”
At the Royal Marsden NHS Trust, oral capecitabine is now approved for
use but Nicky Browne, general manager, common cancers, explained that
switching from IV 5-fluorouracil to capecitabine had not been an easy
process.
From a management perspective, she said, there initially appears to be
no debate: infusional 5FU involves inpatient admission and insertion
of a Hickman line, which takes up theatre time and is associated with
quality of life and safety issues. Oral therapy appears much more straightforward.
But the financial aspects to the trust are less positive, with increased
drug costs and loss of income. The main driver for change has been NHS
breast cancer targets, which have proved difficult to meet because of
insufficient theatre time. Clinicians were keen to switch drugs. The
NICE guidance on capecitabine, in March 2003, substantially influenced
PCTs’ decision to fund the oral treatment.
“We took a huge financial risk on capecitabine. But we have managed to
offer patients a much improved service and we have met targets,” Ms Browne
commented.
Caroline Waters, directorate pharmacist, gastrointestinal unit, Royal Marsden
NHS Trust, said that, historically, oral chemotherapy has had widest use in
lymphomas and leukaemias. There has been some prejudice that IV therapy is
more effective but the recent success of two drugs — imatinib and capecitabine — has
raised the profile of oral treatment. Capecitabine in particular has had a
major impact because of its use in two common cancers: breast and colorectal.
Support procedures essential
Ms Waters said that it is essential that procedures are in place to
support the implementation of oral chemotherapy. Most patients prefer
oral
treatment provided this is not at the expense of efficacy. It is more
convenient and the patient has increased control over treatment. It
is sometimes assumed that treatment is less toxic “because it
is just a tablet” but this is not the case: toxicity could be
the same or greater than with IV therapy (for example, the incidence
of hand-foot syndrome is higher with capecitabine than with infusional
5FU).
Patients need to be able to recognise side effects and to know when
treatment should be interrupted to prevent toxicity
becoming more serious. Compliance is critical, with particular risk from
over-compliance. “The patient may forget whether they have already
taken a tablet or they may decide to carry on despite side effects.”
Ms Waters added: “The responsibility for administration of the
drug lies with the
patient but it is the responsibility of all members of the multidisciplinary
team to provide appropriate support to ensure patients are well informed
about their treatment and understand when they need to seek advice from
a health care professional. We are relying
on patients to recognise and act on their
toxicity.”
As well as patient education, it is important to educate primary health
care professionals, principally so they can recognise side effects, especially
unusual ones, such as chest pain with capecitabine. Shared care is not
appropriate in such cases but it is vital that GPs are aware of a patient’s
treatment.
Introduction of capecitabine at the Royal Marsden Hospital involved development
of protocols and clinical guidelines. It had an important impact both
on the pharmacy’s aseptic services and its dispensary services.
Prescriptions for oral chemotherapy are screened by accredited pharmacists
using the same process as for any other type of chemotherapy.
Hospitals that have switched to capecitabine need systems for monitoring
patients taking the drug.
At the Beatson Oncology Centre, Glasgow, a pharmacist/nurse-led clinic
has been set up. Mary Maclean, regional cancer care pharmacist from the
West of Scotland Cancer Network, said that the clinic gave patients more
time for counselling and a smooth, planned journey with minimal waiting
times. Patients are routinely seen by a nurse or pharmacist but there
are structured protocols on when to refer to the doctor, eg, for any
toxicity greater than grade 2 or if the patient reports disease-related
symptoms.
Pharmacist assessment and co-ordination of prescribing/dispensing helps
to streamline the process. “For pharmacists, benefits of the clinic
include having more time to counsel and plan patients’ care, and
the opportunity to intervene prospectively and to take a more active
role in the multidisciplinary team,” Ms Maclean said. The service
enables doctors to allocate more time to complex cases.
Karen Harrold, clinical nurse specialist at Mount Vernon Centre for Cancer
Treatment, agrees that multidisciplinary involvement is essential. “Nursing
and pharmacy intervention is needed for all oral chemotherapy. It is
a risk management issue,” she said. The amount of education needed
to help the patient decide between oral and IV therapy and, if oral therapy
was chosen, to enable them to understand how to use the drug safely,
required a team approach.
Thalidomide risk management
Thalidomide provides an extreme example of the precautions needed for
safe use of oral chemotherapy. The drug is currently available on
a compassionate-use basis but a licence application has been submitted
for multiple myeloma and it is being evaluated in several other cancers.
With the main aim of preventing exposure of an unborn child, manufacturer
Pharmion has set up a risk management programme based on managed distribution.
Stephen Slack, Pharmion general manager, said that the programme involves
registration and education of doctor, pharmacist and
patient. Pregnancy testing is required before each monthly prescription
for women of childbearing potential. To date, over 1,000 patients in
the UK are registered for
thalidomide.
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The
Pharmaceutical Journal