Throughout this series, we have evaluated various challenges and barriers to optimizing care for patients with cancer. While it is evident that we have a long way to go with regard to making cancer therapy logistically easy, better tolerated, and less emotionally exhausting, the past decade has arguably brought us closer to achieving these goals. New oral chemotherapy drugs have freed some patients from the restraints of treatment within a cancer center’s infusion suite. New targeted therapies have increased survival and treatment-related efficacy while reducing adverse events.
Our growing understanding of cancer biology has led to the identification of new druggable targets and novel therapies for diseases for which survival benefit had never been achieved (ie, metastatic melanoma). Better supportive-care medications have increased tolerance to therapy and resulted in significant improvements to patient quality of life. However, with each success comes new challenges, and we are left with the question of “Where do we go from here?” or “What issues will oncology providers confront in the future?”
It seems obvious that the movement toward the development of drugs that can be delivered in oral dosage forms will continue long into the future. In fact, as Dr Hansen reports, approximately 25% of investigational agents currently undergoing clinical trials for the management of cancer will be available for oral administration, and in 2011 oral medications represented more than half of all new drug approvals from the FDA. As a result, patient medication adherence will become even more of an issue for oncology providers.
Proactive consideration of the risk factors and potential solutions Dr Hansen presents should be a standard of practice. Never should we assume that patients will be adherent with prescribed medications. In fact, conservative management would have us assume that patients will not be adherent with oral medications and therefore should be monitored closely and re-educated routinely as to the value and goals of continuing with oral versus intravenous (IV) therapies. When doubt exists regarding a patient’s pattern of adherence, providers should carefully consider substitution of IV therapies, but only in scenarios in which suitable alternatives exist.
Research and development of novel cancer therapies such as imatinib have already demonstrated long-term control of disease states like chronic myelogenous leukemia (CML). This “wonder drug” represents our ability to treat and maintain a patient’s cancer much like hypertension, diabetes, or any other chronic disease state. It is highly conceivable that the future offers the promise of many more medications that target driver mutations in key oncogenic pathways that can be modulated to offer sustained benefit and survival similar to the success of imatinib in CML.
As we shift the treatment paradigm of cancer from acute to chronic disease, new opportunities will undoubtedly emerge for oncology pharmacists. The longevity of patients on oral therapies will require, in addition to patient education, continual re-evaluation of a patient’s medications for clinically significant drug interactions, continual assessment of adverse events, further consideration and recommendation for sequencing of therapies, provision of information regarding clinical trials and the emergence of new oral and IV therapies, and close observation of survivorship issues that patients have historically not experienced with many of these disease states.
Furthermore, as Dr Hansen has identified in this series, tightening regulations by third-party payers requiring these unique and expensive medications to be dispensed by specialty pharmacies argues for the role of the clinic-based oncology pharmacist to be involved in the patient’s ongoing care so that fragmentation of care becomes less of an issue and safe medication use by our patients is ensured. Overall, while we are able to overcome many barriers and challenges to the care of patients with cancer, each new development brings with it new questions and issues that must be addressed so that patients are effectively treated. For these reasons, the practice of oncology medicine, nursing, and pharmacy remain intellectually stimulating and will continue to challenge us to solve the puzzles that each individual patient represents.