Of the estimated 1.7 million new cases of cancer that will be diagnosed in the United States this year, the most fortunate patients will have a board certified oncology pharmacist (BCOP) ontheir care team to help them. In addition to being cancer medication experts, BCOPs deliver a broad range of expertise and unique levels of practice, skills, and responsibilities to their patients.
The pharmacist’s critical role in the care of oncology patients was underscored in a recent retrospective review of transitional care management (TCM) conducted at Boston Medical Center. The study concluded that pharmacist intervention reduced the average 30-day unplanned readmission rate among patients who had an inpatient oncology service. The readmission rate was 18.7% among patients who completed the TCM process; it was 37% for patients who did not. Pharmacists in the study were credited with identifying errors in more than half the discharge medication reconciliations completed by physicians. The authors concluded that pharmacists’ subsequent intervention with patients helped to reduce harm and optimize patient care.
“The oncology pharmacist is often one of the few team members who fully understands the safety, efficacy, pharmacologic, and financial components of patient care,” says Michael Bourisaw, executive director of the Hematology/Oncology Pharmacy Association. “The changing landscape of healthcare and evolving approach to cancer care—including oral therapies, targeted therapies, and personalized medicine—emphasizes the need for the oncology healthcare team to include an oncology pharmacist.”
Resource for Staff and Patients
The Cancer Care Center at Baptist Health Lexington in Kentucky sees about 100 patients each day. On-staff clinical oncology pharmacy specialists Megan May and Jeannie Patrick—who are both PharmD and BCOP—consider education to be one of their primary roles there.
They provide in-services and up-to-date information to their fellow interdisciplinary team members in addition to counseling every new oral chemotherapy patient. They also facilitate drug acquisition and patient management, working off treatment plans to help streamline the way products are ordered and treatment plans are entered.
May and Patrick are the only two clinical specialists in the Baptist Health Lexington Cancer Care Center; two to three other pharmacists compound IV chemotherapies, and two pharmacists are responsible for oral chemotherapy dispensing.
May says her work begins before a new patient starts chemotherapy. Once the oncologist has made a diagnosis and recommended treatment with her assistance, she sits down with the patient to do a medication reconciliation. She reviews their list of at-home medications and double checks it for accuracy with their local pharmacy to ensure there will be no interactions with the patient’s chemotherapy.
“Then we go over with the patient what we’re prescribing, what it’s for, how to take it, how long they’re going to take it, any side effects they might have from that, and we also touch on adherence,” she explains. This step includes drawing up a meticulously detailed schedule that shows precisely when the patient should take the various medications.
Almost all of the oral chemotherapy medications prescribed at the cancer center are considered specialty drugs, and most are available from the in-house pharmacy. When medications are in limited distribution, or when drug manufacturers require the use of a specific specialty pharmacy, they are ordered from outside.
May and Patrick help the cancer center’s financial navigator find ways to reduce high out-of-pocket costs for the specialty medications. One recent case involved a 71-year-old with prostate cancer whose oncologist wanted to start on abiraterone (Zytiga). The insurance company approved the prescription, but the copay was $2,196 per month. “Obviously, there was some sticker shock,” recalls Patrick.
The financial navigator started a search, and two days later found a $6,500 grant that the patient was qualified for and received. After the patient’s first copay, Patrick estimates that his monthly cost dropped to about $500.
“We keep a running log, and as that grant money starts to trickle down and run out we start the same process all over, looking at grants to see if anything has opened up that we can apply for. If not, we’ll reach out to the manufacturer for assistance,” Patrick explains.
At Smilow Cancer Hospital at Yale New Haven in Connecticut, Darren Luon, PharmD, BCOP, clinical pharmacy specialist in medical oncology, still recalls a case he handled as a P4 student that led to his decision to specialize in oncology. It involved a young patient who only spoke Cambodian, which Luon had learned as a child.
“She and her family had no idea what was going on because there was such a language and cultural barrier,” he says. “The team let me sit down with [the patient’s family] and talk about everything to see how they were doing. It really affected me greatly, and after that I wanted to go into oncology 100%.”
Today, counseling patients is a major part of Luon’s role at Smilow. While the oncologist talks to patients about their cancer diagnosis, prognosis, and the treatments that are available, his role is to explain the drugs. “We have the most experience in being able to guide our patients in terms of how to manage side effects and supportive care in general,” he says.
Luon’s colleague, Kristen Rychalsky, PharmD, BCOP, BCPS, oncology clinical pharmacist II, also relishes the role of counselor, which she first experienced while working at a VA hospital. She recalls one patient who was suffering from a medication-related rash on his hands and feet. His physician hadn’t talked to him yet about side effects, so Rychalsky addressed the issue by holding the medication until the rash resolved and reducing the dose.
“The next time I was able to talk to him, the patient simply expressed his gratitude in such a touching way,” she recalls. “I was not only working to the top of my ability, but I knew the appreciation that the patient felt for me and my role. It was an amazing experience to have as any type of healthcare professional.”
Luon admits that a cancer clinic is not the easiest or happiest place to work. With many patients moving towards the end of life, conversations often center on difficult topics. Still, he appreciates all the hard work and experience that got him to this point. That, and a large dose of compassion, keeps him going day to day.
“We’re basically fighting an uphill battle a lot of times. We want to make patients get better, but there’s only so much you can do sometimes,” he says. “In order to keep doing this, you need to have that drive and love this field.”