Oral Chemotherapy Program at THP

Dr. Katherine Enright MD, MPH, FRCPC

What is Oral Chemotherapy?

Oral Chemotherapy is…

Classic Chemotherapy Drugs:• Capecitabine (Xeloda)• Hydroxyurea (Hydrea)• Melphalan• Chlorambucil

…The evil we know

Oral Chemotherapy is also…..Ibrutinib (Imbruvica)Palbociblib (Ibrance)

Imetelstat

Crizotinib (Xalkori)Sunitinib(Sutent)

Sorafenib (Nexavar)Regorafinib (Strivaga

Olaparib (Lynparza)

Gefitinib (Iressa)Erlotinib (Tarceva)Afinitib (Gilotref)

Oral Chemotherapy is…Imatinib (Gleevec) in Chronic Myelogenous Leukemia

Oral Chemotherapy is…- Ibrutinib in Chronic Lymphocytic Leukemia

Oral Chemotherapy is…Gefitinib in EGFR + NSCLC

Oral Chemotherapy is…Crizotinib in ALK + NSCLC

Oral Chemotherapy is the future

Oral vs. IV Chemotherapy

Parenteral (IV) Medications

Patient's role is passive

Patient is recipient of treatment

Provider dictate treatments

Provider monitors and manages side effects

Potential for non-adherence low (and self evident)

Provider responsible for procurement (storage, safe handling and disposal)

Oral Medications

Patient’s role is active

Patient self-administers the medications

Provider collaborates with patient about the treatment

Patient is actively involved in early symptom recognition and management

Potential for medication non-adherence is high

Patient is responsible for medication procurement (safehandling, storage, disposal)

Oral Chemotherapy Delivery Process

Treatment Decision Prescribing Dispensing Medication

AdministrationPatient

Monitoring

Safe handling, patient education and incident reporting

Safe Labelling

Partnering with the Patient

Improving patient education

“The belief in one’s capability to organize and execute the courses of action required to manage positive situations”

Self – EfficacyAlbert Bandura (1986)

Oral Chemotherapy Care Plans

Partnering with Oncology Pharmacists

Oral Chemotherapy Care Pathway Pilot

Cycle 1

Cycle 2

Cycle 3

RN

Pharmacist

•Education•Care Plan Review

•“Teach Back”•Toxicity Assessment•Adherence Assessment

•Rx verification•Drug-drug interactions•Counselling

•“Teach Back”•Toxicity Assessment•Adherence Assessment

• Pilot: March 2, 2015 – May 30, 2015

• Who: 2 Physician/RN Teams at CVH Site (GI/Breast/Lung/GU) (N = 20)

• Inclusion : All new starts on oral chemotherapy (Hormones excluded)

• Pilot Team: Oral Chemotherapy Pharmacist & Nurse Practitioner

Oral Chemotherapy Care Pathway Pilot

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

Dose Modification for toxicity

Drug Discontinuation

CPOE Prescriptions

Pharmacy Interventions

Adherence Assessment

MOATT Assessment

Pilot Baseline

Oral Chemotherapy Care Pathway Pilot

3 3

4

0

2

4

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

Discontinuation Dose Delay Dose reduction

Baseline Pilot

Type of Dose Modification due to Toxicity

Partnering with Retail Pharmacy

Oral Chemotherapy Pharmacist

• Specialty knowledge of oncology• Access to drug

• Community pharmacy may not have in stock (delay in treatment)

• Access to necessary information to double check the Rx

• (blood work, other tests, history, intention, course of treatment, etc.)

• Ease of access to the prescriber

• Drug-Drug Interactions• CYP P450 system

• Drug-Food interactions• Patient Monitoring • Cost

• Out of pocket, 3rd party, special funding programs, ODB access

• Adherence

Advantage over community pharmacist

Main Focus of Oncology Pharmacist

Pharmacy Pilot – CVH Site

Critical Interventions

(4)

Interventions requiring a

change to Rx (78)

Potential Drug

interactions (126)

Herbal/CAM interventions

(116)

Adherence Interventions

(33)

Problem: Identified patient not taking anticoagulant as previously prescribed before starting agent with pro-thrombotic potential

Intervention: Patient educated as per risk, started both

Problem: Irbesartan / enzalutamide interaction

Intervention: PCP contacted to change irbesartan to olmesartan

Problem: Dose not adjusted for decreased CrCl.

Intervention: Dose adjusted

Problem: Patient on combination regimen confused drug schedules

Intervention: Dose Calendar provided

Next Steps for Oral Chemotherapy

- Partnering with Patients• Pilot of various tools to enhance self efficacy underway (Q-site hematology group)• Care plan usability review with PFAC planned

- Partnering with Pharmacy• Sustainability plan to integrate oncology pharmacy at CVH site and expand across THP in

development

- Partnering with Primary Care Physicians ?• Communication of Care Plans to PCP• Toxicity management• Enhance care coordination / communication