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I have been an oncology and haematology pharmacist since 2002, and one
of the goals of my job has been to develop services for patients receiving
oral chemotherapy. As a result, I set up a clinic, where I would meet
patients before they started chemotherapy to discuss side effects, answer
any questions they had and obtain their informed consent for treatment.
It
was a natural progression to become a prescriber and manage the follow-up
of these patients as well.
I was fortunate to have the full support of my manager, chief pharmacist
and oncology and haematology consultants, and during my prescribing course,
I began prescribing capecitabine for colorectal and breast cancer. I
felt comfortable with this because most of the patients I had been seeing
in the oral chemotherapy consenting clinic had been taking capecitabine.
However,
my first consultation was nerve-racking and, although the patient was
doing well on chemotherapy and had no major problems, I spent hours
that evening wondering if I had missed any of the “red flag” symptoms
that we had learnt so much about on the prescribing course.
I am glad
I decided to allow myself 30 minutes per consultation because, for each
patient, I need to assess side effects, quality of life, compliance issues,
any new symptoms, blood results and, sometimes, computer tomography scan
reports, before deciding whether the patient should proceed with the
next course of capecitabine or if any adjustments are needed.
After each
consultation, I dictate a letter to be typed and sent to the patient’s
GP (the skill of dictating in a particular order, ie, patient’s
name and identifiers, diagnosis, treatment, outline of any problems,
took some getting used to), write in the notes and prepare for the next
patient.
Tricky situations
I have had some tricky situations with capecitabine patients but these
have been great learning experiences — reflecting on them will
enable me to deal with other situations more confidently in the future.
For
example, cancer patients are at increased risk of venous thromboembolism
and one of my patients presented with a red, swollen leg. I had to
organise a Doppler scan (for the first time), which revealed multiple
deep vein thromboses. This presented a further challenge because warfarin
interacts with capecitabine. I had to make sure the patient understood
how important it was to have her international normalised ratio monitored
frequently.
Another patient described chest pain. Angina is a rare side effect
of capecitabine and can be difficult to diagnose. I obtained a good
history
by asking relevant questions (eg, what type of pain, any precipitating
factors, what relieved the pain) and was able to make a differential
diagnosis. I was fairly sure that the patient had angina, but did not
feel confident enough to make the decision to stop capecitabine without
consulting a doctor. However, the doctor agreed with my diagnosis and
treatment was stopped.
Two patients have presented with incisional hernias, which can sometimes
occur following colorectal surgery. I was able to diagnose these easily
but still had the patients’ abdomens examined by a doctor in case
I was overlooking anything more serious. Physical examination of patients
is still one of my weak areas because I do not feel I have had enough
practice at feeling for abnormal signs.
Another difficult situation with patients who have cancer is dealing
with the inevitable question “How long have I got?”, and
other questions like this. Having deliberated over the answer many times,
I do not believe there is a right one. I try to tailor my response to
what, I believe, are the needs of the patient. Some people obviously
want a straightforward answer in terms of weeks, months or years, while
others are happy with reassurance that the chemotherapy is shrinking
their cancer and “keeping things at bay for now”.
In addition to these more complicated scenarios, I have diagnosed several
minor ailments, such as urinary tract infection, chest infection, thrush
and conjunctivitis, during clinics. I felt competent to prescribe appropriate
treatments for these problems because part of my prescribing course focused
on developing treatment plans for minor ailments, following local and
national prescribing
guidance.
New challenges
A few months into my prescribing role, I felt ready for a new challenge.
A consultant specialising in breast cancer had expressed an interest
in me helping with his overbooked clinic, so I began to review and
prescribe for patients receiving adjuvant chemotherapy for early
breast cancer.
This group of patients brought along a whole new set of issues, with
questions about radiotherapy, lymphoedema, trastuzumab, hormone therapy
and breast reconstruction, to name but a few. It has been a steep learning
curve but I am well supported and now feel able to deal with most of
these.
Once patients start on trastuzumab for early breast cancer, I review
their echocardiograms (the drug can reduce cardiac function) and blood
results every three months and authorise ongoing prescriptions.
Another clinic I am involved with is prescribing hydroxycarbamide for
patients with essential thrombocythaemia or polycythaemia. With a haematology
nurse specialist, I established a telephone clinic for these patients
in 2005, so instead of attending the hospital every two or three months
they have a full blood count (FBC) at their GP surgery and we review
the results in hospital. I can decide whether to make dosage changes
and when the patient needs to have his or her next FBC. I then issue
prescriptions for the ongoing hydroxycarbamide.
I communicate with
the patient by telephone and this system means that patients now
only need
to visit the hospital once a year. The service now manages 120 patients. The future
The oncology and haematology consultants are keen to extend my prescribing
into other chemotherapy regimens, such as docetaxel for prostate cancer,
oxaliplatin de Gramont for colorectal cancer and imatinib for chronic
myeloid leukaemia so the next step for me is to expand my prescribing
role. However, this is not possible at the moment because of lack of
funding to fill my post while I carry out new functions.
I would also like to improve the inpatient chemotherapy pathway by
setting up a clinic for these patients where I write their medicine
charts and
order their antiemetic discharge medicines before their admission. This
would facilitate a smoother admission and discharge process.
At present patients have to attend hospital twice, which can be difficult
for them in terms of both cost and time. In the future, I hope to establish
a community-based chemotherapy pre-assessment clinic, so that patients
can be reviewed and have their chemotherapy prescribed at an appointment
nearer to their homes, and then only attend the hospital to have their
chemotherapy
administered.
I meet regularly with other members of the hospital’s non-medical
prescribers group, which is made up of nurse prescribers
(although I hope to be joined by another pharmacist soon). At present,
our focus is on auditing our prescribing. I believe audit is important
to enable me to reflect on my work, and also to prove the impact and
worth of pharmacist prescribing within the hospital. Peer review will
be used to demonstrate that I can prescribe safely and effectively.
Prescribing chemotherapy and responding to individual patients’ problems
is rewarding and no two consultations are the same.
Becoming a pharmacist prescriber has been the most exciting career move
I have made, and I am embracing the challenges it provides me with. |
The
Pharmaceutical Journal