Austin, TX—Cancer survivors with chronic diseases are falling through the cracks, said Sarah Scarpace, PharmD, MPH, BCOP, at the 11th annual Hematology/Oncology Pharmacy Association conference. When oncologists are no longer managing chronic diseases like diabetes and hypertension, a window of opportunity exists for pharmacists to become involved in multidisciplinary cancer survivorship team models.
Opportunities for Innovation and Entrepreneurship
There is a general lack of information about survivorship clinics, particularly in relation to the role of the pharmacist, said Dr Scarpace, Assistant Dean for Pharmacy Professional Affairs and Associate Professor at the Albany College of Pharmacy and Health Sciences, NY. The lack of survivorship care standardization has become an important talking point within cancer care, she stated.
“Everybody is doing something a little bit differently, and not every institution has these clinics,” explained Dr Scarpace. “We’re trying to figure out what survivorship care should look like because there is so much variability.”
“In the National Comprehensive Cancer Network and American Society of Clinical Oncology guidelines, which looked at the survivorship care team, the pharmacist was blatantly missing from the list of providers who could be helpful to survivors; this is very disturbing,” she emphasized. Furthermore, “pharmacists” were mentioned only once in the National Academies Press 535-page report, From Cancer Patient to Cancer Survivor: Lost in Transition. “Pharmacists are certainly underrepresented,” Dr Scarpace added.
Physicians currently provide approximately 73% of all survivorship care, but pharmacists are not the only underrepresented cohort. “Only about a quarter of survivorship care is provided by other mid-level providers, not pharmacists,” Dr Scarpace stated. “So again, there is this opportunity for the oncologist to get back to diagnosing patients [with cancer] and coming up with treatment plans, and having mid-levels take on more of a role.”
Coordinating with Primary Care Providers
“We talk about how to integrate care with primary care physicians, but what about the primary care pharmacist?” she queried. “As oncology pharmacists, we can play a very important role in making sure that patients, throughout their cancer treatment program, are interacting with the community-based pharmacist they are still seeing for their diabetes and hypertension, and other disease states. Patients should understand the need to have that conversation [about their cancer plan] with their primary care pharmacist. So that’s another really important opportunity for the oncology pharmacist—not just the interaction with the physicians, but also with the primary care pharmacists who are taking care of our patients once they get into surveillance.”
Fragmentation of care is a noted concern in the realm of cancer survivorship; therefore, long-term follow-up is crucial. Follow-up can be executed through surveillance care plans, proper documentation of cancer treatment history, interventions to manage ongoing problems and toxicities resulting from cancer treatment, and ensuring that patients still get their age-/sex-appropriate healthcare and screenings. General health promotion is another important facet of long-term follow-up. “Those initial consultations with your patients in which you discuss how to manage and prevent side effects from chemo[therapy], those still need to continue once they complete treatment,” Dr Scarpace stated. Adherence to vaccination schedules should be promoted, and tobacco cessation should be encouraged, as the efficacy of oral therapies can be reduced from smoking, she added. Contributing to patients’ end-of-treatment consultation notes is another opportunity for pharmacist involvement.
“It’s obviously very important for pharmacists to be involved right at the beginning—at diagnosis—to make sure that we’re a part of the conversation in coming up with the initial treatment plan,” she emphasized. “And it’s just as important at the end, during the discharge component and the celebration of their last dose of chemo. We want to make sure that we know what the plan is afterwards, because we can’t assume that other people are going to be as detailed as we are.”
One research opportunity for pharmacists in the scope of cancer survivorship includes evaluating patterns of supplementary/complementary alternative medicine use among different populations of cancer survivors. “Once somebody goes through a cancer diagnosis, they will sometimes scramble for ways to boost their immune system and prevent cancer from coming back,” Dr Scarpace noted. “They’ll do a lot of research on their own, and they’ll experiment with different therapies, so that’s an opportunity for us to get involved, monitor these patients, track their outcomes, and publish [information about] it.”
Evaluating adherence behaviors to medications and nonpharmacologic recommendations among cancer survivors is another opportunity for research. “Some people have significant problems coping with the significance of having a cancer diagnosis,” she explained. “So they sometimes go through periods of experimentation and noncompliance.” Monitoring and reporting late toxicities from long-term use of targeted therapies has the potential to improve future patient outcomes, Dr Scarpace suggested, and the effectiveness of survivorship programs—particularly those involving pharmacists—should be appraised.
Although practice and research opportunities exist for pharmacists in survivorship care, the pharmacist’s role is yet to be defined. According to Dr Scarpace, the key needs lie in the pharmacist’s coordination with primary care providers, as well as the management of long-term medical problems related to cancer treatment.