Tracey Walker

Oncologists recognize the potential of artificial intelligence (AI) in improving the quality of care and patient outcomes according to new research.

, a research-based report series analyzing the views of more than 180 U.S. oncologists, from Cardinal Health Specialty Solutions, found that overall, participating oncologists are optimistic AI will improve both patient care and practice operations.

When asked about the future impact of AI on the oncology industry, 53% of participating oncologists said they are “excited.” More than half of oncologists said they anticipate AI will help enhance the quality of care (53%), improve clinical outcomes (57%), and drive operational efficiencies (58%) in three or more years. Nearly half (47%) also expect it to lower the cost of care.

“The potential of AI-based tools to improve care and lower healthcare costs is significant,” says Bruce Feinberg, DO, vice president and chief medical officer for Cardinal Health Specialty Solutions.

As evidence of this, public and private investment in healthcare AI is expected to reach $6.6 billion by 2021, according to Forbes.

“Healthcare systems will play a key role in the early adoption and use of this technology,” Feinberg says. “Our research may help healthcare executives better understand the expectations and concerns oncologists have about these tools, and identify potential barriers that will need to be addressed as new technology is introduced into practice.”

One in three oncologists (36%) said AI will have a significant impact on oncology care over the next few years.
	When asked to identify the most valuable benefit that AI could provide to their practice, 37% said automating administrative tasks to allow oncologists to focus more on patients and 27% said identifying best treatment paths to help them choose the right drug the first time.
	Oncologists also cited the potential to predict patients most at risk of complications and the ability to enhance the accuracy of diagnostics as key opportunities for AI to improve oncology care.
	Top concerns about using AI in practice included the need for clinical trial data to show effectiveness (29%), the potential for bias in algorithms (27%), and oncologists’ own lack of familiarity with the technology (27%).
	“The potential breakthroughs in oncology treatment make this the most exciting time in history to provide care to cancer patients,” Feinberg says. “At the same time, oncologists face unprecedented challenges including growing patient volumes, rising costs, increasing regulatory pressures, increasing industry consolidation, and changing reimbursement models. Emerging tools such as AI have the potential to help ease some of these burdens for oncologists-but, if not understood and used effectively, they could also add to the complexity.”

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Optimism for AI in Cancer Care

The expected spending and growth in the oncology market is growing, according to a new report.

Oncology is the largest therapy area in biopharmaceuticals characterized by a large number of recently launched therapies, significant clinical benefits, the largest pipeline of any therapy area and significant potential breakthroughs in new mechanisms in the next few years, according to IQVIA Institute’s “

Global Oncology Trends 2019: Therapeutics, Clinical Development and Health System Implication

The report found that in 2018, a record number of 15 new active substance oncology treatments with 17 indications, including one tissue-agnostic therapy, launched in the U.S. Those 2018 debuts bring the total number of new oncology therapeutics launched since 2013 to 57 covering 89 approved indications for 23 different tumor types.

Consumer Reports Says Imported Drugs Are “Risky”

However, despite extensive pipeline activity, oncology remains the most challenging area for research and development, facing significant risk of failure and long, costly development, according to the report.

Other unique findings from the report include:

31% of the new drug launches treat non-solid tumors (leukemias/lymphomas/multiple myeloma)

Overall pipeline up 63% in the past five years with over 100 next-generation biotherapeutics (including cell, gene, and nucleotide therapies), examples already launched include CAR T therapies

Clinical trials remain risky but the overall numbers are high and large numbers of launches are expected through 2023

Biomarkers are a key success factor for future drugs and a wide range of them are already in use across a range of tumors, but a range of barriers persist that delay or limit patient access to medicines.

Spending reached nearly $150 billion globally in 2018 and is projected to exceed $200 billion by 2023 growing at 9% to 12%.

New oncology drugs launched in 2018 took a median of 10.5 years from the time of first patent filing to regulatory approval and launch, an acceleration of more than four years from the 2017 level


	“The future looks robust with a large and varied pipeline, a focus on biomarkers and overcoming logistical and technological hurdles to identifying and managing patients, and extremely promising mechanisms in development promising improved patient response and survival across a range of tumors with large populations and small,” says Michael Kleinrock, research director, IQVIA Institute.

The 2018 oncology drug market had a record number of new treatments and continued a trend of growth.

Oncology Market Remains Robust, Says Report

Precision medicine or “targeted therapy” is said to be the pathway to improved cancer treatment.In fact, UC San Francisco recently opened a $275-million cancer center which is set to provide adult patients with immunotherapy, genetic counseling, molecular profiling of tumors, fully integrated clinical trials, and advanced imaging.Â Â The Bakar Precision Cancer Medicine Building, part of the university's Helen Diller Family Comprehensive Cancer Center, focuses on a range of cancer services including medical care provided by surgical, medical, and radiation oncologists who work with an expanded care team to support the whole patient and their family with specialized psychosocial support, cancer specific nutrition expertise, hereditary cancer care, and wellness programs such as exercise counseling.Related: Precision Medicine Cutting-Edge Developments: What Health Execs Should KnowJeremy Schafer, PharmD, MBA, senior vice president, director, Access Experience, Precision for Value, views precision medicine as a potential game-changer. Here, Schafer offers four ways that he believes precision medicine will change cancer treatment:

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How targeted therapy could be the pathway to improved cancer treatment.

4 Ways Precision Medicine Impacts Cancer Treatment

A pharmacist-driven intervention program can reduce readmissions, according to a study published in the American Journal of Health-System Pharmacy.

Rates of 30-day readmissions were substantially lower with pharmacist involvement and collaboration with other healthcare team members during patient transitions from the hospital to home, according to the study.

Deborah Hauser, RPh, MHA, network director of pharmacy, outpatient pharmacy, Einstein Medical Center, and her colleagues conducted a quality-improvement cohort study of 1,059 admissions of 667 patients at an inner-city hospital. Einstein is the largest independent academic medical center in the Philadelphia area.

The study compared rates of unplanned readmissions within 30 days of discharge in the full- and partial-intervention groups and in patients who received standard discharge care.

Among patients who received the full intervention, 30 of 305 admissions (9.8%) resulted in unplanned readmissions within 30 days, compared with a readmission rate of 20.4% (110 of 538 patients) among patients who received standard discharge care.

The findings demonstrate the role and value of pharmacists in reducing hospital readmissions using a standard intervention that includes medication reconciliation, patient-centered education, resolution of access-to-care issues, and follow-up counseling and communication with healthcare providers, says Hauser.

“When a pharmacist is deployed with a structured intervention as a part of the multidisciplinary discharge process, readmissions can be reduced,” she says. “This study was conducted as a quality improvement program to improve hospital readmissions.”

Patients in the intervention groups received some or all components of Einstein’s multifaceted “Medication REACH” intervention, which includes:

Reconciliation of the patients’ medication lists making sure they are accurate and complete at discharge. At this step, the pharmacist contacts the prescriber to optimize therapy and clarify any medications for safety and accuracy.

Patient-centered education by the pharmacist.

Access, where the pharmacist works closely to ensure the patient has access to medications through insurance and assists with prior authorizations or therapy changes to formulary products. “Many patients were able to gain access through our discharge pharmacy, so medications are readily available at discharge,” Hauser says.

Counseling, with post-discharge follow-up phone calls, which can be done by a delegate or pharmacy personnel. “In our study, we teamed with the Philadelphia Corporation for Aging and had a bridge coordinator who did visits to homes and calls,” Hauser says. “The pharmacist is then deployed if further clarifications about medications are needed. Post-discharge counseling can reinforce medication adherence, verifying that patients are not experiencing any side effects and making sure the patient sees a primary care physician for follow up.”

Healthy patient at home. “If the prior steps are fully implemented, we strive for a healthy patient at home, and not being readmitted,” Hauser says.

Pharmacists are best suited to review and optimize patient therapies to improve patient care outcomes, Hauser says. “Pharmacists play very close attention to medication details to ensure an optimal discharge for the patient as it pertains to medication therapy management beyond the hospital as part of a larger population health strategy.”

Pharmacists are often underutilized in hospitals, according to Hauser. “There is tremendous opportunity to improve the discharge process and continue to build on the use of pharmacists to improve medication therapy management beyond the hospital as part of a larger population health strategy.”

Einstein Medical Center is developing a role for pharmacists in an accountable care organization as a follow-up expansion to its current program.

Tracey Walker is content manager of Drug Topics’ sister publication, Managed Healthcare Executive

Study validates benefits of pharmacists on healthcare teams.

Pharmacist-Driven Intervention Program Reduces Readmissions

The closest exposure most pharmacists have to medical marijuana products in their day-to-day practice is likely to be with cannabinoids, such as dronabinol (Marinol, Syndros, THC) or the newly approved cannabidiol (CBD; Purified CBD, Epidiolex), according to William Kirchain, PharmD, CDE, Wilbur and Mildred Robichaux Endowed Professor at Xavier University of Louisiana College of Pharmacy. True medical marijuana, he says, refers to herbal products, which are sold through either marijuana dispensaries or specialty permitted marijuana pharmacies.

CBD and tetrahydrocannabinol (THC) are two natural compounds found in Cannabis, the marijuana plant. CBD does not cause the “high”; that comes from THC, which is the primary psychoactive component of marijuana.

While pharmacists must counsel patients thoroughly when they dispence Epidiolex or Marinol, all pharmacists should also be discussing medical and recreational use of marijuana with all their patients because marijuana can interact poorly with certain prescription medications and over-the-counter medications.

Studies indicate that more Americans are trying marijuana for recreational use and medicinal purposes as laws surrounding marijuana use have become more liberal. At press time, 31 states, and Washington, DC, allow comprehensive public medical marijuana and cannabis programs. Of those, nine have approved marijuana for recreational use.

Each state has its own laws about how patients can access medical marijuana.

Related: No Matter the Law, Pharmaciists Need to Know About Cannabis

In a controversial move, back in June 2018, Oklahoma voters voted to made it legal to use, sell, and grow marijuana for medicinal purposes in a referendum  (State Question 788). The referendum passed despite pushback from conservative politicians and law enforcement groups.

Estimates of past-year marijuana use has increased for middle-aged and older adults, according to a study published in Drug and Alcohol Dependence. The analysis comes from data gathered in the National Survey on Drug Use and Health from 2015 and 2016. About 9% of U.S. adults between ages 50 and 64 used marijuana in the previous year, according to survey results. About 3% of people over 65 used the drug in that time period.
	In the 2016 study, almost one-quarter of Americans over age 65 who had used marijuana in the previous year said they received permission from their physicians. A January 2017 research overview published by the National Academies of Science, Engineering, and Medicine, showed that a still small but growing number of studies suggest that marijuana may be helpful in treating pain, nausea, and spasticity.

Medical marijuana can be marketed and sold in a variety of forms, as the properties of THC and CBD are used to produce a desired therapeutic response, Scott Tomerlin, PharmD, APhA spokesperson. Some of the latest trends in medical marijuana include the use of CBD oil in a variety of topical and oral preparations, he says.

“Other products that have gained popularity over recent years have included the use of hemp seed oil as well as the use of products containing CBD for veterinary use. E-cigarettes and other products which allow CBD to be inhaled in a vapor form, otherwise known as ‘vaping,’ are becoming increasingly popular on the marketplace as well,” he says.

There are more than 40 compounds in common CBD oils and extracts, and these products may vary in potency by a substantial amount even batch to batch. Some states allow use of “low THC, high CBD” products for medical reasons in limited situations. 

Marijuana is metabolized through the liver, primarily through the CYP450 enzyme system, specifically 2C9, and 3A4 pathways, according to Deborah A. Pasko, PharmD, MHA, senior director for Medication Safety and Quality with ASHP.

“Drugs that undergo these same metabolic pathways are at risk of having a drug-drug interaction with marijuana. If the non-THC drug is an inducer it will lower concentrations of THC. If the non-THC drug is an inhibitor then it will elevate concentrations of THC,” Pasko says.

Knowing if a patient is being treated with medical marijuana establishes the opportunity for pharmacists to identify any potential drug interactions, especially if the patient may present with adverse effects that could be attributed to any recent changes in medication or over the counter use,” says Tomerlin. “It is always a good plan for the pharmacist to be fully equipped with as much information that is necessary to provide optimal patient care.”

Shital Mars, CEO of Progressive Care Inc., a healthcare and technology company with services that include medication therapy management, prescription pharmaceuticals, and compounded medications, says marijuana is generally well-tolerated in patients with mild to moderate risks of serious adverse side effects and/or dependence.

However, marijuana does have some notable drug interactions to consider before use. They include:

Just because there is a drug interaction, however, does not mean that the two substances cannot be used in combination, Mars says. With drug interactions, “it’s important that the doctor and pharmacist monitor harmful side effects or therapy inefficiencies. In many cases with the medications listed above, medical marijuana acts on the enzymes that either inhibit or induce the metabolic rate of the medication, meaning that interaction with medical marijuana can either increase the potency and effectiveness of the medication or decrease it.”

Kirchain says pharmacists should be aware of adverse reactions associated with marijuana use. These include: central nervous system depression, worsening of depression and other psychiatric illnesses, weight gain, and xerostomia.

Read More: Making the Case for Regulated Marijuana

There can be interactions with contaminates of marijuana products. “Smoked products may increase the risk of respiratory illness, and there have been reports of food-borne illness such as salmonella,” Kirchain says.

Other serious but rare adverse events associated with marijuana use include cannabis hyperemisis syndrome, characterized by recurrent nausea, vomiting, and crampy abdominal pain; cannabis-associated arteritis; and Takotsubo cardiomyopathy (also known as Takotsubo syndrome), a serious condition that includes sudden onset cardiovascular symptoms,” says Kirchain.

Smoking is the most common method of consumption of marijuana, but eating food products that contain marijuana (known as edibles) is quickly becoming a popular way to consume the drug. Although still illegal under federal and many state statutes, food products containing marijuana or marijuana extracts are currently common in states that either permit or that have declined to prosecute medical or recreational marijuana, according to the DEA.
	“The differences of these products vary considerably based upon who and how the end product is manufactured,” Pasko says. “Marijuana scientists can alter the potency depending upon the section of the plant that is used, and also the total dose of THC in the compound.”
	The marketplace for edible and smoked medical marijuana products is continuing to expand, with a plethora of options for patients to consider for use, according to Tomerlin. “Edible marijuana products may have the potential to be more potent than inhalable versions, but these products and the concentrations of THC and CBD can vary widely,” he says.
	Smoked/vaped products will produce a more immediate effect on the body because the route through the lungs provides direct access to the blood, Mars says. “However, these effects should generally wear off much quicker than edible products and produce a less-intense psychologic effect even though the absorption of cannabinoids is higher than in edible products.”
	Edibles take longer to achieve an effect because of the route through the gastrointestinal tract, according to Mars.
	“Generally speaking, the issue is less that the person may die from ingesting too much through an edible, but rather they will be more impaired and may feel ill and experience nausea, vomiting, diarrhea, headaches, dizziness, etc.,” she says. “Pharmacists and physicians should be on the lookout for these side effects so that they can counsel their patients on how to avoid or handle them safely.”
	Beyond the inhalable or edible route, topical preparations such as creams containing CBD oil, as well as other products-including lip balms and aromatic incense wicks to name a few-are readily available, according to Tomerlin.

Epidiolex is first FDA-approved drug comprised of an active ingredient derived from marijuana. It was approved in June 2018 for treatment of two rare severe forms of pediatric epilepsy.
	The DEA gave a Schedule 5 classification to the antiseizure drug, the classification with the lowest degree of restriction, indicating the DEA believes it has a low potential for abuse.
	Epidiolex is a purified CBD oil extract, says Kirchain.

Read More: What Pharmacists Need to Know About Epidiolex


	Pharmacists should use the same approach with THC that they would counseling for any other medication, including discussing risks associated with impairment, toxicities, and long-term side effects, Pasko says.

When counseling patients who are using medical or recreational marijuana, pharmacists should also:

Tell patients that it should not be used by pregnant women or women who are breastfeeding.

Warn patients about the use of marijuana, medical or otherwise, in minors.

 “In some cases, medical marijuana has been prescribed to children with certain nervous system conditions,” Mars says. “In children, it is important to use medical marijuana with proper supervision and medical professional follow up. Used without such controls can subject a child to risk of psychotic and cognitive impairment conditions later in life.”

Be wary of promises that are too good to be true.

 “It’s not magic,” Mars says. “There are many places that talk about the medicinal benefits or marijuana; however, one should be wary of promises that are too good to be true. Marijuana does have medicinal benefits that are now being confirmed through controlled clinical trials, but it should not be used a cure-all or catch-all for any condition a patient may have.”

Keep a complete medication profile for patients including all OTC, herbal, illicit, and prescription medications.

 “Medication management services should be conducted when dispensing any medication,” Pasko says. “There should be a discussion about any other medication that they may be taking that could interact with the medical marijuana.” 

Pharmacists should prepare to advise patient consumption methods and THC drug interactions as use and manufacturing models continue to grow and legalize.