ORAL
CHEMOTHERAPEUTIC AGENTS AND HOW THAT KNOWLEDGE HELPS US OPTIMIZE ONCOLOGY OR
ONCOLOGIC PHARMACOTHERAPY
Oral chemotherapeutic agents, how will they transform the
practice of pharmacy and oncology?
You're listening to ReachMD. Welcome to Focus on
Pharmacy. I am Dr. Charles Turck, PharmD, your host, and with me today is Dr.
Susan Goodin, PharmD, the Director of the Division of Pharmaceutical Services
at the Cancer Institute of New Jersey, a board-certified
oncology pharmacy specialist and fellow of the American College of Clinical
Pharmacy. Dr. Goodin is also an Associate Professor of Medicine at the
University of Medicine and Dentistry of New Jersey.
DR. CHARLES TURCK:
Dr. Goodin, welcome to the program.
DR. SUSAN GOODIN:
Well, thank you Dr. Turck.
DR. CHARLES TURCK:
Now as I mentioned before, you're the director of
pharmaceutical services of the Cancer Institute of New Jersey. I was wondering
if you could give the listeners a sense of what that job entails.
DR. SUSAN GOODIN:
Certainly, the Cancer Institute is a
relatively new Cancer Center. We are an MCI designated comprehensive Cancer
Center based in central New Jersey and we have only been in existence for just
about 15 years, and I was happy to say that early on our director recognized
the value of clinical pharmacy services and I was the third person recruited to
the Cancer Institute some 15 years ago, so it was really here at the ground
level to get pharmacy services started, which was an enormous opportunity for
me as well as I think for the patients that we take care of here at the Cancer
Institute and as such was able to deal with that pharmaceutical services and
actually pharmaceutical sciences department into what we do today, which is
typically the idea that folks have about what pharmacists do, certainly we
provide dispensing of medications, but in our center, we have the opportunity
to do quite a bit more than that. We interact with all of our patients that
come in to our ambulatory clinic every day. Every patient that comes in to see
or to receive chemotherapy or to receive treatment, actually does see a
clinical pharmacist, who reviews their medication profile, who goes through
their treatments, counsels the patients on their medications, side effects. We
also do a great deal of side effect management from nausea and vomiting to pain
management to anti-coag, as well as a thorough review of what's become, I
think, a very challenging area is drug interactions because not only of the
complicated nature of the therapies that we are giving, but also because of all
of the supplemental or complementary medicines that we know our cancer
patients are taking. I think probably the final area where we play a role in
the patients at our center is in the area of clinical trials. We certainly fulfill
that standard role of investigational drug dispensing, but again we go sort of
that extra step and again all of those patients have thorough med histories,
medication reviews with the pharmacist. They also go through the informed
consent with the patient to make sure they understand the agents that are under
investigation and are there again and available for consultation throughout
that whole drug development process. So we probably are providing somewhat of
a different role, but somewhat similar to many institutions around the country.
DR. CHARLES TURCK:
You mentioned that pharmacist spend what sounds like a good
portion of time with patients, I just want to get a sense of how long the
pharmacists session typically lasts with patients?
DR. SUSAN GOODIN:
We probably follow that similar format that
many practices do and physician practices in that, you know, the initial
patient visit when they come in prior to starting their treatment, a pharmacist
will spend anywhere from 15 to 20 minutes really focusing on drug therapy,
getting a full med history, getting a history of any over-the-counter
alternative, complementary medications that the patients are taking, reviewing
for drug interactions, and then counseling the patient on the trial or the
treatment that the patient is going to receive. So that initial visit probably
is somewhere 15 to 20 minutes. Followup visits can certainly take half that
time because these patients are in sometimes on a weekly basis, sometimes on an
every 3 week basis and it certainly depends upon the schedule of treatment, but
on those followup visits we probably spend anywhere 5-10 minutes or more as
needed and then our patients do have access to the pharmacist even once they
have gone home to call or to ask questions and many of our patients do call
back and either, you know, certainly seek clarification because it's an
overwhelming process or have some sort of symptom or side effect that they need
some input on as to what would be appropriate therapy.
DR. CHARLES TURCK:
Changing tracks just for a moment, you've had years of
experience in oncology-pharmacy practice. One of your interests in particular
is oral chemotherapeutic agents. I was interested in getting sense of what it
is that attracts you to that side of patient care?
DR. SUSAN GOODIN:
The paradigms of managing cancer patients is
continuously changing and when I came into practice a few years ago, the
concept of putting patients in the hospital to treat their cancer was really
the way we managed them and we were really just transitioning into that
ambulatory treatment making sure that the patients could continue working,
quality of life, all those things associated with the ambulatory care patients,
and you know what I noticed, and probably more because of our interest here as
a center in the drug development process, because we certainly here in New
Jersey sit right in the heart of the drug cabinet if you want it to look at it
that way, what we saw and what I realized very early on is that changing
paradigm that we are getting away from these even IV therapies and moving into
oral therapies, and I was fortunate enough to be interviewed some 10 years ago
where at that time someone asked me what do I feel the future of chemotherapy
was and I sort of tongue-in-cheek said that, well, you know, I thought that we
would be moving towards a day where we were managing patients with all oral
therapy and today here we are and it creates a different challenge in oncology
than we've ever seen in the past, the transition from the inpatient to the
outpatient was really a change in settings, and we had to get better delivering
care in a timely fashion and getting patients out the door and more importantly
managing their side effects, but this transition from getting out of our, you
know, our infusion suites to where they take them at home has created a great
deal of concern for me because in oncology we've never worried about
adherence. We always knew when our patients showed up, but that paradigm has
changed because with oral therapy we are not sure about adherence and it's
probably a bigger challenge for us because we are so new to thinking about the
concept. It also brings in a different issue of who is managing these patients
because with the advent of specialty pharmacy is that are really changing the
way we manage patients, that management is being transitioned over for better
or worse to specialty pharmacists, who know very little about our patients and
then sort of that final pieces of side effect management because while they are
oral, they are not without their side effects, and I think without appropriate
counseling by pharmacists or by a nurse or whoever it happens to be, patients
have often times, and I've seen this, they want to tough it out. They want to
do well for their healthcare provider, they want to do well for their family,
so they can start with something as benign as just some diarrhea, which very
rapidly could progress and have them hospitalized because they don’t speak to
anyone about that side effect or may be they go to their refill pharmacy and
ask for suggestion of how to manage that and our retail pharmacist are really
going to be coming into that frontline in the management of these patients
because that's where we know most of our consumers, most of our patients are
going to the retail pharmacy to try to manage those side effects.
DR. CHARLES TURCK:
For those of you, who are just tuning in, I am Dr.
Charles Turck and I am speaking with Dr. Susan Goodin from the Cancer Institute
in New Jersey. We've been discussing several aspects associated with oral
chemotherapeutic agents, old and new, how they work and how that knowledge
helps us optimize oncology or oncologic pharmacotherapy.
Now, Dr. Goodin, you had mentioned several
challenges, one of which was monitoring adherence to therapy, what do you think
is the best way, if there is such a best way?
DR. SUSAN GOODIN:
I wish we knew the best way. I think what we
are all trying to do is learn from the cardiovascular folks and psychiatric
groups as well as those that manage HIV patients and how to educate patients
and how to maintain that contact with them so that patients continue to be
compliant with their therapy and you know in oncology as well as in these other
disease states, it brings into that issue of is it adherence issue or is it a
persistence issue, do we need them to take a note. Do we say, well if you take
80% of your doses, we think you are doing well, and we are not really sure what
that right answer is and as such we are not sure the best way to help
patients. When I look at sort of the literature and when I looked what's out
there, this is a prime area for research that needs to be conducted as well as
an opportunity for us to do a better job to manage our patients so while
certainly the traditional pill counts that we've done in the past, diaries,
those sorts of things are certainly somewhat helpful, we are still struggling
with what the best model is in order to assure that our patients are taking the
medications as directed first of all and then secondly are taking and
continuing to take them or even modifying their dose when side effects occur.
So there is no great model. We are still trying to find, I think define the
best model, and I am not sure I could define that for you today, but what I can
say is that it's a fantastic opportunity for research for a pharmacist or
nurses and for physicians to better understand what makes their patients decide
to take or to not take their therapies.
DR. CHARLES TURCK:
What are some of the characteristics you look for, are there
any tell tale signs of adherence or nonadherence or predictors?
DR. SUSAN GOODIN:
You know the biggest thing that we know of at
this point are side effect management, again an opportunity for pharmacists,
for nurses to really help our patients. We know and there has been in oncology
the biggest area where we looked at this is in long term treatment or the
5-year followup of women with breast cancer. We know that the use of a drug
like tamoxifen or one of the newer agents, Anastrozole or Letrozole both can
result in a decrease in recurrence of the disease if these patients take these
medications for the 5-year period and what the recent data is telling us is the
reasons why patients don’t take them or not compliant with their therapy really
have to do with side effects, and so I think that's where we as healthcare
professionals have to sit with our patients and spend that time helping them to
understand what we expect to occur, meaning the side effects and having a
discussion with them and then also talking with them about managing or coping
with those side effects because it really becomes a risk versus benefit profile
that I think our patients have to understand. I think too often in oncology
with intravenous agents, we often talk amongst ourselves as healthcare
professionals about the risk-benefit profile and then we try to articulate that
to our patients, but I don’t think we do as good a job with oral therapy
because it's so easy to write a prescription and send the patient out the door
and we have to spend that time at the time of writing the script or at
somewhere in that process having a discussion about that risk benefit profile,
about the side effects that are going to occur and then provide them with
mechanisms or therapies that might help them manage or cope with those side
effects, but I think in regards to sort of globally the side effect management
is the biggest piece. Other areas the people have talked about is certainly
the cost. These newer agents are extremely expensive. Now, are they more
expensive than the IV agents that we give in our clinics?, not clear. There are
some small pharmacoeconomics studies that have been performed and it appears
that they actually while they are expensive to the patient, they actually are
cheaper than bringing the patient into an infusion clinic and giving them an IV
medication, so it's really a shift in who is paying is really where the cost is
being, I think more shocking to the patients, but cost has certainly been
listed as another barrier to dealing with compliance in this patient
population.
DR. CHARLES TURCK:
Dr. Susan Goodin has been our guest in our discussion of
oral chemotherapeutic medications. Susan, thank you so much for joining us.
DR. SUSAN GOODIN:
Thank you Dr. Turck.
DR. CHARLES TURCK:
I am Dr. Charles Turck, and you've been listening to
Focus on Pharmacy on ReachMD, The Channel for Medical Professionals.
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