Preventing Errors! Oral Chemotherapy Challenges …...Adherence to Oral Chemotherapy: New Challenges and Roles for Oncology Pharmacists Rick Abbott, Rick Abbott, BSc.Pharm BSc.Pharm

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Adherence to Oral Chemotherapy:Adherence to Oral Chemotherapy:Adherence to Oral Chemotherapy:Adherence to Oral Chemotherapy:

New Challenges and Roles for Oncology Pharmacists

Rick Abbott, Rick Abbott, BSc.PharmBSc.PharmRegional Pharmacy Manager, Systemic TherapyRegional Pharmacy Manager, Systemic TherapySt. John’s, NLSt. John’s, [email protected]@easternhealth.ca

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Adherence to Oral ChemotherapyAdherence to Oral ChemotherapyAdherence to Oral ChemotherapyAdherence to Oral ChemotherapyAdherence to Oral ChemotherapyAdherence to Oral ChemotherapyAdherence to Oral ChemotherapyAdherence to Oral Chemotherapy::::::::

New Challenges and Roles New Challenges and Roles for Oncology Pharmacistsfor Oncology Pharmacists

1. Identify how oral chemotherapy marks a fundamental change in contemporary oncology practice

2. Are cancer patients adherent to oral therapy? A review of the published literature

3. Review the factors that influence patient adherence to oral chemotherapy

4. Discuss the challenges with respect to improving adherence to oral chemotherapy

5. Discuss how pharmacists can improve patient adherence to oral chemotherapy and how to incorporate this into your existing practice

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Preventing Errors!Preventing Errors!To prevent medication errors:To prevent medication errors:

1.1. Physician must prescribe correctlyPhysician must prescribe correctly

2.2. Pharmacist must understand and dispense the Pharmacist must understand and dispense the order correctlyorder correctly

3.3. The Nurse must administer the drug correctlyThe Nurse must administer the drug correctly

Taylor, J.A., Winter, L.; Cancer, Sept 15, 2006, Volume 107, Number 6

We know that our systemsWe know that our systemssometimes fail!sometimes fail!

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Chemotherapy Gone Wrong!Chemotherapy Gone Wrong!

2424--yearyear--old woman with brain cancer died old woman with brain cancer died as a result of a lomustine overdoseas a result of a lomustine overdose

–– Physician had written a poorly legible prescription; 190 mg q 6 wksPhysician had written a poorly legible prescription; 190 mg q 6 wks

–– Pharmacist misunderstood the directions as “daily for 6 weeks”Pharmacist misunderstood the directions as “daily for 6 weeks”

–– Patient’s physician had not explained how to take the medicationPatient’s physician had not explained how to take the medication

Hospitalized with severe bone marrow Hospitalized with severe bone marrow suppression and acute bleeding and died a month suppression and acute bleeding and died a month later later

http://www.ismp.org/Newsletters/acutecare/articles/20040715.asp?ptr=y

Oral Chemotherapy ChallengesOral Chemotherapy Challenges

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Oral Chemotherapy Oral Chemotherapy [2003][2003]

Accounts for less than 5% of all drugs used for Accounts for less than 5% of all drugs used for cancer treatmentcancer treatmentThey are expected to represent up to 25% in They are expected to represent up to 25% in the next decadethe next decadeNearly one quarter of the 200 antiNearly one quarter of the 200 anti--neoplastic neoplastic drugs in development are oral agentsdrugs in development are oral agents

Birner A. Safe administration of oral chemotherapy. Clin J Oncol Nurs. 2003;7:158-162

20062006--2009:2009:13/25 (52%) of drugs reviewed by JODR 13/25 (52%) of drugs reviewed by JODR

have been oral agentshave been oral agents(Cancer Drug Access for Canadians, Can. Cancer Society, Aug 2009)

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Advantages:Advantages:Oral vs. IV ChemotherapyOral vs. IV Chemotherapy

Patient convenience / preferencePatient convenience / preference

Flexibility in dosing and schedulingFlexibility in dosing and scheduling

Prolonging drug exposureProlonging drug exposure

Decreased resource utilizationDecreased resource utilization

Altered toxicitiesAltered toxicities

Improved quality of lifeImproved quality of life

Am J Health-Syst Pharm—Vol 64 May 1, 2007 Suppl 5

PDF Created with deskPDF PDF Writer - Trial :: http://www.docudesk.com

http://www.docudesk.com

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Oncologists Preference: Oncologists Preference: Oral vs IVOral vs IV

Efficacy with no increase in toxicities– especially N-V and diarrhea

Concerns – Bioavailability of oral agents

– Compliance was also cited as a concern

– Communication between health provider and patient.

REVIEW: Oral Cancer Treatment: developments in chemotherapy and beyondO’Neill, VJ., Twelves, CJ., British Journal of Cancer, 2002, 933-937

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Patient Preference: Patient Preference: Oral Oral vsvs IVIV

Reasons:– treatment at home – 57%

– avoidance of venepunctures – 55%– greater sense of control over t eir tx – 33%

> 80% of pts prefer oral chemotherapy> 80% of pts prefer oral chemotherapy–– NOT at the expense of efficacy

REVIEW: Oral Cancer Treatment: developments in chemotherapy and beyondO’Neill, VJ., Twelves, CJ., British Journal of Cancer, 2002, 933-937

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Compliance/AdherenceCompliance/Adherence

What is Adherence?What is Adherence?

Extent to which a patient’s behaviour Extent to which a patient’s behaviour corresponds with agreed upon corresponds with agreed upon recommendations from a healthcare recommendations from a healthcare providerprovider

Often referred to as Often referred to as compliancecompliance ..

Am J Health-Syst Pharm. 2007; 64(Suppl 5):S25-32

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Compliance/AdherenceCompliance/Adherence

Noens et al. Blood.2009; 0: blood-2008-12-196543v1

The The ADAGIO studyADAGIO study aimed to aimed to –– Assess prevalence of Imatinib nonadherence in CML patientsAssess prevalence of Imatinib nonadherence in CML patients

–– Examine relationship between treatment response and adherence Examine relationship between treatment response and adherence levelslevels

Results:Results:–– OneOne--third of patients were considered to be nonthird of patients were considered to be non--adherentadherent

–– Only 14.2% of patients were perfectly adherentOnly 14.2% of patients were perfectly adherent

–– Patients with suboptimal response had significantly Patients with suboptimal response had significantly higher mean percentages of Imatinib not takenhigher mean percentages of Imatinib not taken

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NonNon--Adherence: Adj Hormonal TxAdherence: Adj Hormonal Tx

2414 women, 2005 to 2008 2414 women, 2005 to 2008

Methods Methods -- refill historyrefill history

NonNon--adherence adherence -- < 80% of days covered with a < 80% of days covered with a prescriptionprescription

Tamoxifen and AI’sTamoxifen and AI’s

Median age Median age –– 64 yrs (4064 yrs (40--98)98)

Chan, A., Speers, C., O’Reilly, S., Pickering, R., Adherence of adjuvant hormonal therapies…Abstract #36, 32nd San Antonio Breast Cancer Symposium, Dec 2009


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NonNon--Adherence: Adj Hormonal TxAdherence: Adj Hormonal TxResults:Results:

NonNon--adherence rate: adherence rate: -- 40%40%–– Tamoxifen 42% & AI’s 37%Tamoxifen 42% & AI’s 37%

Factors Associated with nonFactors Associated with non--adherenceadherenceOlder ageOlder ageSmaller Tumor sizeSmaller Tumor sizeLower Grade of TumorLower Grade of TumorLower Rate of Adj ChemotherapyLower Rate of Adj Chemotherapy

NonNon--Adherence Rates by Physician GrpAdherence Rates by Physician GrpMedical Onc Medical Onc –– 34%34%

Radiation Onc Radiation Onc –– 47%47%

Chan, A., Speers, C., O’Reilly, S., Pickering, R., Adherence of adjuvant hormonal therapies…Abstract #36, 32nd San Antonio Breast Cancer Symposium, Dec 2009

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Studies of Studies of AdultAdult Adherence to Oral ChemotherapyAdherence to Oral Chemotherapy

CANCERCANCER NO.NO. ORAL TXORAL TXADHERENCE ADHERENCE

MEASUREMEASUREADHERENCE ADHERENCE

RATERATETIME TIME

FRAMEFRAME STUDYSTUDY

HematologyHematology 108108PrednisonePrednisoneAllopurinolAllopurinol

Serum metabolitesSerum metabolites 20%20% 6 mon6 monLevine 1987Levine 1987Richardson 1988Richardson 1988

Breast CancerBreast Cancer 5151 CyclophosphamideCyclophosphamide Self ReportSelf Report 53%53% 6 mon6 mon Lebovits 1990Lebovits 1990

LymphomaLymphoma 2121ChlorambucilChlorambucil

PrednisolonePrednisolone

DexamethasoneDexamethasoneMEMSMEMS 100%100%

852 852 daysdays

Waterhouse 1993Waterhouse 1993

Breast CancerBreast Cancer 5353 TamoxifenTamoxifen Self ReportSelf Report 76%76% 6 mon6 mon Murthy 2002Murthy 2002

Breast CancerBreast Cancer 23782378 TamoxifenTamoxifen Rx Refill RecordsRx Refill Records77% Rx filled 177% Rx filled 1stst yryr

50% Rx filled 450% Rx filled 4thth yryr4 yrs4 yrs Patridge 2003Patridge 2003

Breast Cancer Breast Cancer 28162816 TamoxifenTamoxifen Rx Refill RecordsRx Refill Records78% Rx filled 178% Rx filled 1stst yryr

65% Rx filled 3.5 yr65% Rx filled 3.5 yr3.5 yrs3.5 yrs Barron 2007Barron 2007

Breast CancerBreast Cancer 16331633 TamoxifenTamoxifenClinical Notes; Audit Records; Clinical Notes; Audit Records;

Cancer Registry Data;Cancer Registry Data;

Rx Refill RecordsRx Refill Records93%93% 2.4 yr2.4 yr Thompson 2007Thompson 2007

Breast CancerBreast Cancer 12,39112,391 AnastrazoleAnastrazole Rx Refill RecordsRx Refill Records 7878--86% 186% 1stst yearyear

6262--79% 379% 3rdrd yearyear3 yrs3 yrs Patridge 2008Patridge 2008

Breast CancerBreast Cancer 161161 CapecitabineCapecitabine MEMSMEMS76% took76% took

80% doses80% doses6 cycles6 cycles Patridge 2008Patridge 2008

A Cancer Journal for CliniciansRuddy, K. et al, 2009; 59; pp 56-66

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Studies of Studies of PediatricPediatric Adherence to Oral ChemotherapyAdherence to Oral Chemotherapy

CANCERCANCER NO.NO. ORAL TXORAL TX ADHERENCE ADHERENCE MEASUREMEASURE

ADHERENCE ADHERENCE RATERATE

TIME TIME FRAMEFRAME STUDYSTUDY

Leukemia or NHLLeukemia or NHL 5252 PrednisonePrednisone Urinary metabolitesUrinary metabolitesOverall 67%Overall 67%

Adolescent 41%Adolescent 41%NANA Smith 1979Smith 1979

ALLALL 3131 PrednisonePrednisone Urinary metabolitesUrinary metabolites 58%58% NANA Lansky 1983Lansky 1983

ALLALL 327327 66--MPMP Two metabolites in Two metabolites in RBC’sRBC’s

90%90% > 7 days> 7 days Lennard 1995Lennard 1995

ALLALL 496496 66--MPMPTwo metabolites in Two metabolites in RBC’sRBC’s 98%98% NANA Lancaster 1997Lancaster 1997

VarietyVariety 4646 VarietyVarietySelf report of missed > 1 Self report of missed > 1 dosedose 65%65% 50 wks50 wks Tebbi 1986Tebbi 1986

ALL and HLALL and HL 5050

Prednisone Prednisone or or

prophylactic prophylactic penicillinpenicillin

Serum Serum dehydroepiandrosterone dehydroepiandrosterone sulfate suppressionsulfate suppression

50%50% NANA TamaroffTamaroff 19921992


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ConcernsConcernsOne of the biggest areas of concern:One of the biggest areas of concern:

�� Patient AdherencePatient Adherence

Journal of the National Cancer Institute , 2002, Vol 94, No 9

Drugs don’t work in patients Drugs don’t work in patients who don’t take them!who don’t take them!

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Adherence ExampleAdherence Example

Case StudyCase StudyG.W. is a 63 year old male diagnosed with G.W. is a 63 year old male diagnosed with Stage III rectal cancer.Stage III rectal cancer.

Currently taking Capecitabine 825 mg/m2 = Currently taking Capecitabine 825 mg/m2 = 1500 mg po bid x 6 weeks with radiation.1500 mg po bid x 6 weeks with radiation.

During the weekly toxicity assessment clinic on During the weekly toxicity assessment clinic on week 5, he complains of diarrhea over the past week 5, he complains of diarrhea over the past week. He decided 4 days ago to stop the drug week. He decided 4 days ago to stop the drug himself due to this adverse event.himself due to this adverse event.


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Adherence ChallengesAdherence Challenges

Which patients will not adhere to therapy?Which patients will not adhere to therapy?

Over adherence is a concern, pts often have the Over adherence is a concern, pts often have the misconception more is better.misconception more is better.

Toxicities and drug related problems can be a deterrent to Toxicities and drug related problems can be a deterrent to adherence.adherence.

Treatment OutcomesTreatment Outcomes–– Bonadonna and Valagussa Bonadonna and Valagussa (1981, N Eng J Med), (1981, N Eng J Med),

–– Pts who received < 85% of their prescribed adjuvant therapy had a shorter Pts who received < 85% of their prescribed adjuvant therapy had a shorter relapse free survival and overall survival timesrelapse free survival and overall survival times

Journal of the National Cancer Institute , 2002, Vol 94, No 9Patridge, A. et al

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Model of AdherenceModel of Adherence

Treatment Factors• reason for therapy• dosing schedule• immediacy of benefit• side effects• costs

Interaction With Systems• relationship with providers• satisfaction with care• insurance coverage• convenience of clinics

Personal Factors• emotional state• health benefits• social supports• feelings about disease,self-efficacy & outcome • expectations• socioeconomic status

ADHERENCEADHERENCE

A Cancer Journal for CliniciansRuddy, K. et al,2009; 59; pp 56-66

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Interventions for AdherenceInterventions for AdherenceCochrane review by Cochrane review by BeneyBeney et al revealed et al revealed improved pt outcomes in 10 of 13 studies improved pt outcomes in 10 of 13 studies

–– Due to Pt education by physicians, nurses Due to Pt education by physicians, nurses and pharmacistsand pharmacists

–– Continuous dose observation is the most Continuous dose observation is the most precise way to monitor adherence.precise way to monitor adherence.

EgEg. IV therapy. IV therapy

Adherence should never be assumed, even Adherence should never be assumed, even in oncology; in oncology; every pt is at risk for nonevery pt is at risk for non--adherenceadherence

A Cancer Journal for CliniciansRuddy, K. et al,2009; 59; pp 56-66

Every pt is at risk for nonEvery pt is at risk for non--adherenceadherence

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Methods for Monitoring Adherence

Direct MethodsDirect MethodsDirectly Observe Therapy

Pharmacokinetic Measurement

Indirect MethodsIndirect MethodsPatient Self ReportPatient Diaries

Pill CountsPt. Refill HistoryElectronic Medication Monitoring

American Society of Clinical Oncology JULY 2008 • jop.ascopubs.org Weingart SN, Brown E, Bach PB, et al: NCCN task force report: Oral chemotherapy. J NCCN 6:S1-S15, 2008

Authors of the NCCN report write –“Regardless for the method used to assess adherence , clinicians must realize that lack of adherence typically refle cts the complexity of the regimen rather than willful or manipulative beh aviour from the patient.”

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Two types of nonTwo types of non--adherent behavioursadherent behaviours

1. Unintentional non-adherence– due to forgetfulness or inability to follow directions – poor understanding, regimen complexity, or physical

problems.

2.2. Intentional or intelligent nonIntentional or intelligent non--adherenceadherence– the patient decides not to take the medication as instructed, – due to adverse events and perceptions about the risks and

benefits. – Health beliefs, experiences and behaviour are associated

with non-adherence in patients with chronic conditions.

THE AUSTRALIAN JOURNAL OF PHARMACY VOL.88 OCTOBER 2007 Adherence assessment tools: Drugs don’t work when they’re not taken Debbie Rigby*


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2525A Cancer Journal for CliniciansRuddy, K. et al, 2009; 59; pp 56-66

Signs and Predictors of Poor AdherenceSigns and Predictors of Poor Adherence

�� Missed Appointments, Inadequate FollowMissed Appointments, Inadequate Follow--upup�� Poor PatientPoor Patient--Provider RelationshipProvider Relationship�� Unfilled PrescriptionsUnfilled Prescriptions

�� Adverse Effects from Medication, Medication CostAdverse Effects from Medication, Medication Cost�� Lack of belief in TreatmentLack of belief in Treatment

�� Psychologic Problems, Particularly DepressionPsychologic Problems, Particularly Depression

Interventions for Improving AdherenceInterventions for Improving Adherence

� Increased Accessibility to HealthcareIncreased Accessibility to Healthcare�More convenient follow –up appointments�Access to Pharmacists and Nurses

��Improved Dosing PlanImproved Dosing Plan� Simplified schedule� Supply dose dispensers or blister packs� Reminders to take medications

� Education: Increase Pts UnderstandingEducation: Increase Pts Understanding� Disease Characteristics� Risks and benefits of treatment� Proper use of medication

� Physician InitiativesPhysician Initiatives� Simplify oral regimen� Increase the pts understanding of disease� Listen to the patient� Learn about drug cost� Reinforce adherent behaviors

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Technology

Angela DeMichele: Interventions to boost adherence

Technology– cell phone programs & computerized pill boxes, remains

an untapped resource

– 2008 study, found that adolescents who played a video game called "Re-Mission“ were more adherent to their oral chemotherapy

Angela DeMichele, Compliance And Cost: Bitter Pills To Swallow In

The Age Of Oral Chemotherapy. Science Daily, June 1st, 2009

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Assessing AdherenceAssessing AdherenceMoriskyMorisky scalescale

been used in research on adherence for more than two decades.

four simple close-ended questions with binary response options (yes/no)

The theory: non-adherence can occur because of forgetfulness, carelessness, stopping the drug when feeling better or when experiencing an adverse event.

THE AUSTRALIAN JOURNAL OF PHARMACY VOL.88 OCTOBER 2007 Adherence assessment tools: Drugs don’t work when they’re not taken Debbie Rigby* 2828

Assessing AdherenceAssessing AdherenceMoriskyMorisky scalescale

THE AUSTRALIAN JOURNAL OF PHARMACY VOL.88 OCTOBER 2007 Adherence assessment tools: Drugs don’t work when they’re not taken Debbie Rigby*

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AdherenceAdherence MonitoringMonitoring

1.1. Tell me how you take your medications (i.e. what Tell me how you take your medications (i.e. what time of day and how many pills per dose?) time of day and how many pills per dose?)

2.2. Do you ever forget to take your medications?Do you ever forget to take your medications? (What (What do you do when you forget to take your do you do when you forget to take your medications?) medications?)

3.3. How many doses, if any, were missed last cycle?How many doses, if any, were missed last cycle?

When you feel better, do you sometimes stop taking your When you feel better, do you sometimes stop taking your medications?medications?

If you feel worse when you take your medications, do If you feel worse when you take your medications, do you stop taking them? you stop taking them?

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MASCC teaching toolMASCC teaching tool

Tool kit includes:Tool kit includes:4 Key Elements4 Key Elements1.1. Key assessment questionsKey assessment questions

2.2. Generic education discussion pointsGeneric education discussion points

3.3. Drug specific educationDrug specific education

4.4. Evaluation questions to help ensure pt Evaluation questions to help ensure pt

understandingunderstanding

Support Cancer Care;Sultan, K., Schulmeister, L., et alPublished online: 10 July 2009


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Survey: Community PharmacistsSurvey: Community Pharmacists

Pt Counselling by Community PhC’sPt Counselling by Community PhC’s–– Initial fill: 47% of respondents counsel ptsInitial fill: 47% of respondents counsel pts

–– Upon refill: 5.9% of respondents counsel pts Upon refill: 5.9% of respondents counsel pts –– Only 25% of respondents felt comfortable Only 25% of respondents felt comfortable

counselling pts on oral chemotherapycounselling pts on oral chemotherapy

Good News Good News –– Bad NewsBad News–– Top Two topics discussed with patientsTop Two topics discussed with patients

–– Medication Directions & ComplianceMedication Directions & Compliance

Good News – Bad News!

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The Future:The Future: What’s Needed?What’s Needed?The success of a home service depends on the communication between the team and the patientAn effective home chemotherapy program will require increased resources and stronger linkages to the community.


Pt selection is crucialPt selection is crucialfor regimens that are plannedfor regimens that are planned

for home deliveryfor home delivery

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A Field of Dreams!A Field of Dreams!

Policies / GuidelinesPolicies / Guidelines

�� Broad Selection CriteriaBroad Selection Criteria

�� Assessment for Patient EligibilityAssessment for Patient Eligibility

�� Mini Mental Status ExaminationsMini Mental Status Examinations

�� Consent to Home ChemotherapyConsent to Home Chemotherapy

�� Patient Learning AgreementPatient Learning Agreement

�� Patient Teaching GuidePatient Teaching Guide

�� Checklist for EligibilityChecklist for Eligibility3636

Home Infusion ProgramsHome Infusion ProgramsLearning AgreementsLearning Agreements

��Patients are taught the followingPatients are taught the following

�� Drug information and SEDrug information and SE�� Monitoring of Medication AdministrationMonitoring of Medication Administration��Safe Handling and disposalSafe Handling and disposal�� Home Chemotherapy PrecautionsHome Chemotherapy Precautions��Contact numbers if problems ariseContact numbers if problems arise

This document is reviewed and signed by bothThis document is reviewed and signed by boththe Health Care Provider and the Learnerthe Health Care Provider and the Learner


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The “IDEAL” Oral Chemo Pt.The “IDEAL” Oral Chemo Pt.

Possess good communication skills or Possess good communication skills or have a reasonable committed care have a reasonable committed care givergiver

Can demonstrate a willingness and Can demonstrate a willingness and ability to comply with instructionsability to comply with instructions

Intellectual discipline and emotional Intellectual discipline and emotional wherewithal to commit to the oral wherewithal to commit to the oral chemo treatment programchemo treatment program

Barefoot, J., Blecher, C., Emery, R.Oncology Issues, May/June 2009

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Pts should be assessed with regards to:Pts should be assessed with regards to:

�� understanding of the importance of understanding of the importance of txtx

�� side effects of the side effects of the txtx

�� how they will integrate the therapy intohow they will integrate the therapy into

their scheduletheir schedule

�� whether they can swallow the tablets or liquidwhether they can swallow the tablets or liquid

�� the number of medication doses normally the number of medication doses normally

missed on a weekly basismissed on a weekly basis

�� where they obtain & how they pay for their Rxwhere they obtain & how they pay for their RxBarefoot, J., Blecher, C., Emery, R.Oncology Issues, May/June 2009

The “IDEAL” Oral Chemo Pt.The “IDEAL” Oral Chemo Pt.

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Keeping Pace with Oral ChemoKeeping Pace with Oral Chemo

Need to develop new infrastructures that Need to develop new infrastructures that include:include:

–– a system for patient selectiona system for patient selection

–– a robust educational component to a robust educational component to address safety and adherenceaddress safety and adherence

–– pt followpt follow--up to ensure up to ensure toxicity toxicity managementmanagement , , adherenceadherence and and treatment treatment efficacyefficacy

Barefoot, J., Blecher, C., Emery, R.Oncology Issues, May/June 2009

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Which statement best describes the practice at your Which statement best describes the practice at your center pertaining to patient safety and toxicity center pertaining to patient safety and toxicity

management in regards to IV and Oral therapy?management in regards to IV and Oral therapy?

1.1. Patients receiving IV chemotherapy have a Patients receiving IV chemotherapy have a better standard of care. better standard of care.

2.2. Patients receiving oral chemotherapy have a Patients receiving oral chemotherapy have a better standard of care.better standard of care.

3.3. Patients receiving IV and Oral chemotherapy Patients receiving IV and Oral chemotherapy are both getting the same standard of care.are both getting the same standard of care.

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Do you have Pharmacists in your Do you have Pharmacists in your chemotherapy suite doing toxicity chemotherapy suite doing toxicity

assessments and teaching for patients assessments and teaching for patients receiving IV therapy?receiving IV therapy?

1.1. YesYes

2.2. NoNo


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Are the patients you see in your Are the patients you see in your chemotherapy suite being assessed by the chemotherapy suite being assessed by the oncology nurse with respect to toxicities?oncology nurse with respect to toxicities?

1.1. YesYes

2.2. NoNo

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Questions / Comments / ExperiencesQuestions / Comments / ExperiencesQuestions / Comments / ExperiencesQuestions / Comments / ExperiencesQuestions / Comments / ExperiencesQuestions / Comments / ExperiencesQuestions / Comments / ExperiencesQuestions / Comments / Experiences

[email protected]@easternhealth.ca 709709--777777--85768576


Documents

Preventing Errors! Oral Chemotherapy Challenges …...Adherence to Oral Chemotherapy: New Challenges and Roles for Oncology Pharmacists Rick Abbott, Rick Abbott, BSc.Pharm BSc.Pharm