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