Unbranded, long-form, Q&A-styled article
- Role of Pharmacists in Oncology Care:
- Discuss the evolving role of clinical pharmacists in the multidisciplinary oncology team.
- Highlight the specific responsibilities pharmacists have in managing targeted cancer therapy treatments and the evolving role of specialty pharmacists within a rapidly changing landscape.
Title Options:
- The Role of Pharmacists in Oncology Care (40 characters)
- The Role of Pharmacists in the Oncology Care Community Setting (62 characters)
- Enhancing Cancer Care: The Essential Role of Specialty Pharmacists (66 characters)
- Navigating Targeted Therapies: The Role of Pharmacists (54 characters)
The role of clinical pharmacists in multidisciplinary oncology teams has evolved over the years, particularly in non-small cell lung cancer (NSCLC), according to Whitney Lewis, PharmD, clinical pharmacy specialist at The University of Texas MD Anderson Cancer Center. Pharmacists collaborate with oncologists, nurses, and other healthcare professionals to provide comprehensive care plans for patients.
Physician’s Weekly (PW) spoke with Dr. Lewis to better understand the role of pharmacists in oncology care and how they are a proactive source of advocacy for patients with NSCLC.
PW: How has the role of clinical pharmacists in multidisciplinary oncology teams evolved over the past few years, particularly in NSCLC?
Dr. Lewis: In lung cancer, we’ve been blessed the last several years to have an explosion of new drug approvals and indications. When they’re on my service, I always tell learners that we don’t treat a single thing the same now as when I was doing my residency training a decade ago. Watching these new drugs and combinations become available to help the patient population has been amazing. Watching this population’s overall survival trends get slightly longer has been great. However, keeping all these new combinations and approvals straight can be difficult.
As a clinical pharmacist, I keep up with all the literature with a lot of granularity because my input is often solicited to help decide on the patient’s pharmacotherapy.
With many of these approvals, that’s changed. We’re more involved with that now, especially given all the new targeted therapies available for patients. A lot of these mutations are rare, so there’s not always a lot of robust experience with them, especially at first. As a clinical pharmacist in a large academic medical center, I work with two to three medical oncologists five days a week. In contrast, my physicians may have clinic anywhere from one to three days a week. So, the pharmacy team may have more experience treating these patients than some physicians because we are involved with more patients. This puts pharmacists in a unique position to help counsel patients on unexpected adverse effects and how to manage them. We’ve seen how these things are managed and how they may present. We’ve also collaborated with the team to participate in some of these high-level discussions to help select the best therapy and dose for a patient.
We also get involved by educating both providers and patients. We do a lot with patient safety, including reviewing anticancer orders and monitoring for drug interactions. We help with patient care. We often serve almost as an internal medicine consult. We often help pick therapies for nononcologic issues like urinary tract infections or pneumonia. We do a lot with pain management with NSCLC. As you might imagine, we can assist with drug information and dose adjustment questions based on a patient’s organ dysfunction. We do a lot with the EHR system in terms of developing ordering tools. We’re, for example, an epic institution, so clinical pharmacies are involved in developing all the treatment plans for standard-of-care medications. And we also help participate in multidisciplinary validations for all our clinical trial treatment plans. We can also help contribute to developing institutional guidelines and policies to help with cost savings, both from an institutional standpoint and for the patients, like helping get them screened for patient assistance programs.
This is happening even outside of oncology. If we know that a patient needs something for venous thromboembolism, we may be helping select the best, most effective, and cost-effective medication to help manage that for patients. One service we’d like to implement that has been adopted by some other disease states at the institution is an oral chemo clinic run by the clinical pharmacist to kind be an additional touch point for the patients, make sure they started on their oral therapy, they’ve got it in hand, they’re tolerating it, okay, do we need to talk about any side effects? Are they getting all the proper monitoring recommended by the drug manufacturer? It just helps manage these patients in conjunction with the primary team and provider.
Our roles have changed; we continue to do a lot, but it’s also exciting and rewarding.
How do pharmacists collaborate with oncologists, nurses, and other healthcare professionals to provide a truly comprehensive care plan for patients with NSCLC in a community setting?
I think everything’s a little bit less siloed and more deconstructed. In a community setting, you’re more likely to have multiple pharmacists involved in the patient’s care at different steps. There may or may not be a clinical pharmacist collaborating in the workroom with the physician when these decisions are being made. The pharmacist can provide broader coverage across many more disease states. These pharmacists are still involved in patient education and toxicity management and have conversations with the teams about managing some of these side effects. They often provide or play a larger role in assisting with medication acquisition in the community setting.
Many of my colleagues in the community may be doing more prior authorizations, helping write letters of medical necessity to get these drugs acquired for the patient. We’re lucky to have those resources. We have additional people specializing in that, but that may only sometimes be the case in the community and then in the community. For example, we have a specialty pharmacy on site; that may be different in the community. A lot of time, that’s going to be mail order. So again, different providers are involved in the patient’s care at different times. Retail pharmacists may also help supplement some of this education and be involved in prior authorizations for the specific oncology drug—I would say for some of those supportive care medications.
Pharmacists and specialty pharmacies are often very proactive in coordinating between patients. They may even initiate medication requests as soon as molecular profiling comes back and start submitting test claims to see if prior authorizations are likely to be needed and provide a lot of patient counseling. They follow up. When patients have started therapy, they often keep patients on track by filling refills and screening for those drug interactions while filling the patient’s concomitant medications. It’s a little more challenging, with more moving pieces, but there’s still a large opportunity in the community for pharmacy to be involved in the patient’s care and collaborate with the multidisciplinary team.
What specific responsibilities do pharmacists have in managing NSCLC targeted therapy treatment options and how do they contribute to patient care?
Although clinical pharmacists do not own these items, we participate heavily in educating patients about potential adverse effects and how to help manage them. In my experience, it can be frustrating for patients to feel like all of this is happening to them, and they’re not able to exert much control over their disease or their situation. I talk to patients about the adverse effects and how to manage them because that helps them feel more empowered to be proactive in managing these side effects so that the patient can feel like they’re regaining a little bit more of that control. Still, they can try to exert over the disease.
I may not be able to avoid nausea completely, but I can try to control and stay ahead of it. It makes the patient feel better sooner if they’re already prompted to know how to do that rather than wait for the medical team to reply to those patient messages. As pharmacists, we debate the relative merits of different targeted treatment options with physicians. We talk about the data, the response rate duration, and the intracranial response with this agent. We also look at the unique side effect profiles of the drugs. Maybe one has more cardiotoxicity or the other one’s more nauseating; perhaps it’s a higher pill burden, or you must take it more often, and this patient may or may not be compliant with that.
We look at those things and the drug interaction profile to help select the best therapy and dose for the patient. As pharmacists, we often apply the treatment plan and review those orders. Our chemotherapy requires two signatures, so I frequently provide one of the signatures and send that to the physician to co-sign or be the co-signer. I mentioned before that we’re lucky to have an onsite specialty pharmacy, which helps handle many prior authorizations in conjunction with our apps. They also proactively screen patients for patient assistance programs. Then, the clinical pharmacy can also connect these various teams as we screen patients for the patient assistance program, make sure everybody’s paperwork gets done, and help to mastermind all of that.
How do pharmacists provide that emotional and practical support to patients and their families throughout this treatment journey?
One of the most obvious ways is during those patient education counseling sessions. I always find that a rewarding part of the job. You can see people relax sometimes and feel more comfortable thinking about having to have some of those side effects during their follow-ups. I may also see the same patients for toxicity management and help them redesign a plan to help manage whatever those toxicities are or help manage them better with their pain. Pharmacists also help discuss if patients have questions about complementary or alternative medications, which is becoming more frequent. We often come with literature to support for or against some of these therapies and use it as a general touchpoint for the patient.
We know that we’re not their only provider, and they may be started on other medications. By being that touchpoint for drug interactions and knowing if there are any pharmacotherapeutic changes, pharmacists involved in oral chemo clinics can provide more continuity for patients. Those relationships build, and seeing a patient progress always breaks your heart. But if they’ve met you before, you can go in and present the next option. ‘I know how you did with your previous treatment, so tell me more in person.’ Then, try to tailor that to their specific new regimen and help decide what more to emphasize based on how the patient tolerated their previous therapy. Patients respond well to that, and although it’s not always their favorite thing to have to see the pharmacist, it’s usually needed when they’re either starting to do therapy or having a toxicity. In these cases, at least, it’s a familiar person who is a trusted source for medication information with that they already have a relationship with.
In what ways do pharmacists advocate for the needs and preferences of patients in treatment decisions in the community setting?
Much of this happens behind the scenes before the pharmacist sees the patient. A lot of times, at least in an academic medical setting, the provider’s already seen the patient and then, so we’re discussing the best plan for the patient, including that patient’s needs and preferences like oral versus IV frequency of visits, what’s the toxicity profile and side effects that the patient’s anxious about? That happens even in community settings if there is a pharmacist there, too. That plan’s already being created. In the community, if there’s not a clinical pharmacist, retail specialty pharmacists can also help advocate for the patients when they obtain financial clearance. They still help with patient safety, like ensuring safe transitions of care if they’re going from an inpatient to an outpatient setting, helping patients avoid polypharmacy, and reviewing those orders again just for accuracy.
Helping with patient safety, drug-drug interactions, and drug over-the-counter interactions often gets overlooked. Patients don’t necessarily think about over-the-counter treatments when making their medication lists, new medication approvals, or patient adherence. This could help get to the root of why patients aren’t being adherent. Is it a cost issue, and they’re trying to stretch their pills, or are they self-dose-reducing because they’re having side effects and things like that? There are many ways that you can advocate for the patients and help manage their toxicities while working with the team.
In your opinion, how can the advocacy efforts of pharmacists be further supported and integrated into the broader healthcare system for these patients?
Although pharmacy organizations have advocated for this, perhaps retroactively, we should have been pushing to obtain provider status. One of the things to overcome is that we can only bill for the services we’ve discussed. We need to be able to bill, particularly for direct patient education, to help generate income instead of just being a cost that justifies more positions. A more direct, tangible way for the pharmacist to help with cost savings and patient safety, as well as indirect things, may help open up more positions, allowing pharmacists to become more integrated into the oncology patient’s care.
Particularly with NSCLC, these patients often don’t have the best, most robust performance status at baseline. They’re often more complicated medically. The average age of a lung cancer patient is in their seventies so that they may be on a lot of medications, they may have organ dysfunction, or they may just have other complicated medical problems. In a disease state where we’re making headway, patients are moving into survivorship, and we’re having a long-term response. And then we also see these young people who are on these targeted therapies with sometimes some unusual side effects. It’s not just EGFR inhibitors anymore. We have over half a dozen categories of targeted therapies with unique side effects to help manage. And these patients can be on these drugs for a long time. We want to make sure that they can tolerate it and stay on a dose of intense therapy to get the best, most durable response. So I think pharmacists could maybe bill, we could have more pharmacists broaden that scope, and ideally, I believe a clinical pharmacist should be involved in the care of everyone. I think it’s the goal for all of us.
