The expanding availability of oral drugs for the treatment of a number of tumor types has increased their use as chemotherapy. Patients prefer the convenience of oral drugs as long as they are as effective as intravenous (IV) drugs, but the increasing use of oral chemotherapy has brought new challenges to the oncology community in terms of prescribing, dispensing, safe handling, and monitoring.
How best to address these challenges was explored by Monika Krzyzanowska, MD, MPH, FRCPC, of Princess Margaret Cancer Centre in Toronto, Ontario, Canada, at the recent American Society of Clinical Oncology (ASCO) Quality Care Symposium.1
“We have created a safe environment for IV chemotherapy, but we need to extend the safety of parenteral chemotherapy to oral chemotherapy,” she stated.
“Oral chemotherapy has unique challenges,” Krzyzanowska continued. “There are new prescribers and community pharmacists filling prescriptions. Data suggest they have little training and experience to dispense these medications. Oral chemotherapy changes the roles for existing caregivers and increases the responsibility for patients and caregivers while reducing responsibility among oncologists.”
The benefits versus harm of oral chemotherapy need to be considered. It is possible that oral chemotherapy could have decreased efficacy because of incorrect prescribing, underadherence, and drug/food interactions, as well as an increased risk because of incorrect prescribing, overadherence, and drug/food interactions, she said.
“We have done a good job with parenteral chemotherapy regarding setting prescribing standards, preprinted orders, dispensing in a controlled environment, safe handling, and standardized assessment for follow-up. But the situation for oral drugs is different,” Krzyzanowska stated.
By contrast, restrictions on who can prescribe oral chemotherapy are few, and there is variable use of computerized physician order entry or preprinted orders, lack of standardization in education, poor-quality educational materials, and lack of education for new “players.” Dispensers of oral chemotherapy are a mixture of community and cancer pharmacies, and community pharmacies have minimal verification standards and few if any safety checks. Also, there are no standardized processes and effective tools for monitoring patients on oral chemotherapy.
Moving forward to address these gaps, Krzyzanowska commended the joint ASCO/ Oncology Nursing Society updated prescribing standards that now include guidelines for oral chemotherapy.2 However, more effort is needed to implement these standards, she told the audience, noting that a small study suggests that implementing them reduces prescribing errors by two-thirds.
More education is needed about oral chemotherapy, she continued, including clarifying the roles of dispensers, identifying effective approaches and tools, and training providers as well as evaluating the effectiveness of such training. She suggested that audience members review a teaching tool about oral chemotherapy developed by the Multinational Association of Supportive Care in Cancer.3
“The area of dispensing probably needs the most attention for patient safety,” she said.
Dispensing standards are needed, and dispensers should be educated about safe handling and chemotherapy verification. She suggested limiting those who can dispense oral chemotherapy within the cancer clinic.
Recommendations for safe handling of oral chemotherapy should be developed for manufacturers, healthcare providers, patients, and caregivers.
Policies and procedures are needed for monitoring patients on oral chemotherapy. “We need to identify effective tools, assess effectiveness, and promote incident reporting,” Krzyzanowska noted.
Many methods are available for measuring adherence, such as self-reports, medication diaries, and pill count. But few studies have evaluated adherence tools specifically for oral chemotherapy.
“I would recommend that you ask your patients about whether they are taking their oral medicines and whether there are issues. You might be surprised what you find,” she advised.
Key ingredients for optimizing adherence include regular assessments, counseling and education, individualized monitoring plans, reminders to take medications (eg, pill boxes, alarms, smartphone applications, text messages).
“We need to learn from experience about which methods work and which ones don’t. Bring the lessons you learn to meetings and share with your colleagues,” she said.
“The next frontier is oral chemotherapy support programs, specialized clinics, and telephone support. Think about your own practice and hospital and the biggest gaps. Figure out which ones to address first. I suggest you start with safe prescribing, leverage existing guidelines, metrics, and lessons from previous initiatives; remember to evaluate the impact of these measures, and don’t be afraid to innovate,” Krzyzanowska concluded. l
References
1. Krzyzanowska M. Extending the quality & safety agenda from parenteral to oral chemotherapy. Presented at: ASCO Quality Care Symposium; October 17-18, 2014; Boston, MA.
2. Neuss MN, Polovich M, McNiff K, et al. 2013 updated American Society of Clinical Oncology/Oncology Nursing Society chemotherapy administration safety standards including standards for the safe administration and management of oral chemotherapy. J Oncol Pract. 2013;9(suppl 2):5s-13s.
3. Kav S, Schulmeister L, Nirenberg A, et al. Development of the MASCC Teaching Tool for Patients Receiving Oral Agents for Cancer. Support Care Cancer. 2010;18:583-590.