British Oncology Pharmacy Association
Major progress since launch of NHS cancer plan has greatly improved care
Mike Richards: aiming to make the NHS a global platform of excellence |
In the mid-1990s, England had a high cancer mortality rate, inadequate
drug and equipment provision, long waiting times for treatment and a
fragmented cancer care workforce. The publication of the cancer plan
has significantly changed this situation.
So said Mike Richards, national cancer director at the Department of
Health, when he gave a keynote speech on progress made nationally in
cancer care.
He said that the mortality rate from cancer continues to fall by two
percentage points per annum in people younger than 75 years, with increased
survival rates from the most common cancers. Progress on waiting times
has been excellent, with the standards set in the cancer plan all currently
met. Professor Richards added that the pharmacy-chemotherapy stage is
currently delivering on waiting times.
Cancer networks have brought together primary, secondary and tertiary
services across the NHS. Thanks to the 1,500 multidisciplinary teams
in England, around 80 per cent of cancer patients now receive co-ordinated
care, the highest number globally.
The UK has historically been slow to incorporate new anticancer treatments
into clinical practice because of funding constraints within the NHS
and clinical caution regarding new developments. In 2004, a report by
the national cancer director confirmed this, and all cancer networks
have had to develop action plans to ensure appropriate local usage of
drugs.
A new publication in September 2006 showed major improvement. Over an
18-month period, the usage of 14 anticancer drugs approved by the National
Institute for Health and Clinical Excellence has increased by between
11 per cent and 120 per cent and, although not yet eliminated, differential
prescribing between networks has decreased.
Professor Richards touched upon the Herceptin story and how it catalysed
the formation of NICE’s new rapid appraisal process. It took just
nine months from the drug’s application for licence to full NICE
approval. This was in part due to the media interest in the drug and
the controversial intervention of the Secretary of State for Health,
but he warned that “the Herceptin story is very likely to happen
again”. Although NICE appraisal mechanisms are now much faster,
cost per quality-adjusted life year is still the key factor in decision
making.
The new NHS Chemotherapy Advisory Group is currently reviewing workforce
issues and is keen to have the input of pharmacists. An electronic capacity
and demand planning tool for chemotherapy (C-PORT) has been developed.
Intended for use by both NICE and local services, six networks have been
trained in its application to date. Professor Richards strongly advocated
the use of electronic prescribing systems to minimise errors, and thanked
pharmacists for their role in intercepting prescribing errors.
He concluded with a summary of progress in cancer research: “Our
aim is to make the NHS a global platform of excellence.” The National
Cancer Research Network has ensured a 9 per cent rise in the number of
patients going into clinical trials over the past five years. This is
because of a renewed interest in both industry-led and investigator-led
research, and he thanked the pharmacy community for its contribution
to both.
Cancer hotels: how the future might look for cancer management
According to the Office for National Statistics, one in three people
in England will develop cancer at some point in their lives. Karol
Sikora, medical director at CancerPartnersUK, discussed how the future
will look for cancer management.
Most cancers are incurable, but technological advances and a better
understanding of molecular biology is set to change this. Invasive
surgical treatment
is expected to be replaced over the next 50 years by robotic biopsies
and nanotechnology, allowing conservation of tissue and organs. Single
doses of radiotherapy targeted to the tumour will be delivered at units
based within the community. Over the next 20 years, traditional infusional
therapy will change to targeted monoclonal antibodies, gene therapy and
cancer vaccines, with chemotherapy reserved for metastatic disease.
Because of an ageing population and better early detection schemes, the
global cancer market is set to triple by 2010. Drug companies are heavily
investing in marketing targeted biological therapies and the challenge
to the NHS will be how to keep costs down.
One way is to invest in cancer diagnostic tools. Predisposition screens
of tissue banks, for example, could identify patients in advance of tumour
development and enable the use of chemoprevention, said Professor Sikora.
Patient risk assessments, as undertaken for cardiovascular disease, will
become an essential component of cancer prevention.
Clinical monitoring of chemotherapy could be undertaken by pharmacists
in the same way as blood pressure and cholesterol are monitored. Pharmacodynamic
biomarkers and patient-specific toxicity prediction could advise accurate
dosing to minimise toxicity and wastage, with surrogate markers of clinical
efficacy providing early indicators on the value of continuing treatment.
Such diagnostic tools will be non-invasive, easy and cheap to run, thus
revolutionising cancer management.
The new expert patient will also be an important driver to reducing costs,
as an increasing number will buy cancer treatment online. Consumerism
will thus remove ineffective drugs and force companies to price cancer
treatment in accordance with efficacy.
By 2026, we can expect to see personalised cancer prevention programmes
using biomarkers within consumer-driven environments. We may see the
emergence of “cancer hotels” as a partnership between the
private sector and the NHS. Before long, clinical pharmacists will be
managing cancer therapy entirely, as it becomes a chronic, controllable
condition. The pace of change for health care professionals is only set
to increase.
Clinical update on success of bone marrow transplants and lung cancer research
“Bone marrow transplant” as a term used loosely to describe
the source of haematopoietic stem cells (HSC) has now expanded to include
peripheral red blood cells, umbilical cord blood cells and even embryonic
liver. Kim Orchard, consultant haematologist and director of the Wessex
blood and marrow transplant programme, explained some applications and
future developments of HSC transplantation.
Research into the immunological events occurring following HSC transplantation
has led to a greater understanding of conditions such as graft-versus-host
disease (GvHD), viral infections and graft rejection. It is now clear
that long-term disease control following transplant is not dependent
on conditioning treatment alone, but relies on the potent graft-versus-tumour
(GvT) effect invoked by the immune cells of the donor, particularly T-lymphocytes
and NK cells. Current research is focusing on how to eliminate the GvHD
cells but retain the GvT cells in an effort to exploit the antitumour
effect.
Sanjay Popat, specialist registrar at the Royal Marsden Hospital NHS
Foundation Trust, highlighted the main developments in the treatment
of non-small cell lung cancer (NSCLC), small cell lung cancer (SCLC)
and mesothelioma. Several trials have looked at new chemotherapy combinations
in the management of NSCLC. One added erlotinib to paclitaxel and carboplatin
for patients with advanced NSCLC but found that it caused higher rates
of toxicity without increasing survival rates. Oral topotecan was trialled
against intravenous docetaxel in patients with advanced pre-treated NSCLC.
The outcomes were equivalent although docetaxel had a higher survival
rate. This places topotecan as a potential alternative for patients intolerant
of intravenous therapy or with symptoms of docetaxel neuropathy.
A recently published meta-analysis showed that cisplatin-based adjuvant
chemotherapy improves overall and disease-free survival in NSCLC patients
compared with no chemotherapy or with radiotherapy alone; vinorelbine
plus cisplatin was the most promising combination. Advanced NSCLC patients
on cisplatin who also tested positive for ERCC1 were found to have significantly
reduced odds of survival. ERCC1 is an enzyme that repairs malignant cells
by removing cisplatin-DNA adducts.
The gold standard chemotherapy regimen for treating chemotherapy-naive
extensive-stage disease SCLC remains etoposide plus cisplatin. A trial
investigating the use of irinotecan plus cisplatin found no difference
in overall survival but increased toxicity. An alternative regimen of
ifosfamide, carboplatin, and etoposide with mid-cycle vincristine showed
survival benefits compared with standard non-platinum chemotherapy, but
also an increased rate of septicaemia.
In relapsed, resistant SCLC, oral topotecan is the first agent to show
survival benefits compared with best supportive therapy alone. The regimen
was well tolerated and conferred a positive effect on quality of life.
Dr Popat reviewed phase II data on the new drug amirubicin in SCLC. He
expects to see it more in the next few years, since its efficacy is equivalent
to etoposide plus cisplatin, without the cardiotoxicity of doxorubicin.
Continued benefit of chemotherapy in elderly
Ageing is an individualised process and the use of chemotherapy in
elderly patients must be considered on a case-by-case basis, according
to Tamas
Hickish, consultant in medical oncology at the Royal Bournemouth Hospital.
Chemotherapy is indicated when a patient’s potential life expectancy
exceeds his or her predicted survival from cancer. The presence of additional
co-morbidities, tumour sensitivity and reduced tissue reserves can all
affect the success of treatment. Altered pharmacokinetics in the elderly
and the greater propensity towards polypharmacy can either increase toxicity
or reduce the efficacy of chemotherapy.
Clinical trials generally under-represent elderly patients despite the
high incidence of cancer in this patient group. Dr Hickish summarised
some of the evidence that is currently available.
Elderly patients are as likely to respond to chemotherapy as younger
patients, including palliative and adjuvant treatment; however, they
are less likely to complete an adjuvant therapy course.
When considering starting adjuvant chemotherapy, online tools such as www.adjuvantonline.com can
be used to calculate risk-benefit ratios for individual patients. Evidence
suggests that the group least likely to
benefit from
chemotherapy are the octogenarian, said Dr Hickish.
He concluded by saying that chemotherapy is generally safe for use in
older patients, with similar toxicity profiles seen in those aged older
and younger than 75 years, although the incidence of neutropenia is higher
in those over 65. A reduced white cell count between the first and second
chemotherapy cycles has been shown to predict increased toxicity in further
cycles. Mucositis should be aggressively managed and there may be a role
for the routine use of growth colony-stimulating factors.
New opportunities
Advances in molecular biology have opened up many opportunities for
targeted therapies in the treatment of cancer. Nicola Stoner, lead cancer
pharmacist, Oxford Radcliffe Hospitals NHS Trust, outlined what is required
of pharmacy services handling such products. Monoclonal antibodies should
be prepared in a pharmacy’s aseptic facility; however, it is recognised
that this option may not always be available. Existing hospital aseptic
facilities can be used as long as adequate
separation is maintained from other products and standard validated cleaning
procedures are applied.
Gene therapy, however, presents a significant biological hazard to staff
and the environment. It is strictly regulated and must be manipulated
in aseptic units — plasmid DNA and DNA complexes can be handled
in non-cytotoxic facilities, but viral vectors require negative pressure
or Class 2 microbiological safety cabinets in a dedicated room.
Such technologies present new hope in the treatment of cancer, but also
pose many challenges to pharmacy services. Ms Stoner concluded by stressing
the importance of good documentation, standard operating procedures and
staff training when handling new biological therapies.
Future influences
Tim Dowdall, chief pharmacist at Surrey Heath and Woking Primary Care
Trust discussed the impact of changes in NHS policy on oncology services.
He said the views of patients and people who use cancer services will
be an important part of reviewing service provision and managing performance.
Practice-based commissioning is currently driving PCTs to target high-impact
changes, such as treating patients at home. What chemotherapy services
will look like in the future is currently unknown, as it depends on patient
choices and how much money is locally available.
Payment by results is currently restricted to non-elective surgery, outpatient
and accident and emergency departments, but full roll-out is expected
in 2008. Most oncology treatments and services are currently excluded
and it is not known when tariffs will be included or how the expensive
NICE-approved drugs will be reflected. Other questions to be resolved
include: will there be any unbundling — a redistribution of acute
and chronic oncology services between primary and secondary care? What
elements of
redesign are possible? Will there be any plurality in service provision
via the introduction of third party organisations?
Enabling patient choice could require different options from those currently
available, and this may affect existing cancer network structures, Mr
Dowdall said.
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The
Pharmaceutical Journal