Carole R Chambers

Gastric Acid Suppression Is Associated With Decreased Erlotinib Efficacy in Non–Small-Cell Lung Cancer

BACKGROUND Erlotinib is a key therapy for advanced NSCLC. Concurrent AS therapy with TKIs might reduce TKI plasma levels. Because of gastroesophageal reflux disease prevalence, this retrospective analysis was undertaken to determine if coadministering erlotinib with AS therapy affected NSCLC outcomes. PATIENTS AND METHODS Records of advanced NSCLC patients who received erlotinib from 2007 to 2012 at a large, centralized, cancer institution were retrospectively reviewed. Pertinent demographic data were collected and concomitant AS treatment was defined as AS prescription dates overlapping with ≥ 20% of erlotinib treatment duration. Records of patients who received erlotinib for ≥ 1 week were analyzed for progression-free survival (PFS) and overall survival (OS). RESULTS Stage IIIB/IV NSCLC patients (n = 544) were identified and 507 had adequate data for review. The median age was 64 years and 272 were female. Adenocarcinoma (n = 318; 64%) and squamous (n = 106; 21%) were predominant subtypes; 124 patients received concomitant AS therapy. In this unselected population, median PFS and OS in AS versus no AS groups were 1.4 versus 2.3 months (P < .001) and 12.9 versus 16.8 months (P = .003), respectively. Factoring sex, subtype, and performance status in multivariate Cox proportional hazards ratios for PFS and OS between AS and no AS groups were 1.83 (95% confidence interval [CI], 1.48-2.25) and 1.37 (95% CI, 1.11-1.69), respectively. CONCLUSION This large population-based study suggests erlotinib efficacy might be linked with gastric pH and OS could be adversely affected. To our knowledge, this is the first study demonstrating a possible negative clinical effect of coadministration of erlotinib with AS therapy. Further prospective investigation is warranted.

Antineoplastic agent workplace contamination study: the Alberta Cancer Board Pharmacy perspective

Objective. To continue with workplace contamination monitoring in the Alberta Cancer Board (ACB) pharmacy practice environment. Setting. The ACB in the Canadian province of Alberta which includes two public tertiary centers and 19 associated community satellite sites based around the province in existing hospitals. Methods. After the completion of a Phase 1 and Phase 11 study,1 which investigated the feasibility of routine monitoring of antineoplastic agent contamination in the pharmacy practice environment, it was decided to launch a Phase III study. The Phase III study would be done at the Cross Cancer Institute in the main pharmacy department as well as at a brand new satellite pharmacy within the CCI hospital. Samples would be taken in these areas as well as on the outer exterior of latex gloves worn to prepare cyclophosphamide and other antineoplastics. Results. The result determined that the area in front of the biological safety cabinet in the main CCI pharmacy department as well as the exterior of the latex gloves showed evidence of cyclophosphamide contamination. The results from the sample taken in the new satellite pharmacy showed no evidence of cyclophosphamide contamination. Conclusion. Results from this study prompted a decision to launch a Phase IV study to determine the feasibility within our network, for routine monitoring as well as sampling throughout the clean room beyond the BSC.

A feasibility study to assess the integration of a pharmacist into neurooncology clinic

Objective. A multidisciplinary approach is increasingly used in NeuroOncology clinics. Although this model has several advantages, patients report feeling overwhelmed by the complexity of their treatment protocol and staff feel rushed because each provider must evaluate the patient within the limited clinic hours. We hypothesized that the presence of a pharmacist in clinic could address these concerns by (1) reviewing all treatment protocols and side-effect management with patients, (2) being available to address questions outside of clinic and (3) answering staff related medication questions. Methods. The pharmacist met with consenting patients at the initial clinic visit and followed up by telephone two additional times. The pharmacist was available to answer questions outside of clinic hours. Surveys were developed and given to patient and staff to evaluate their experience. Results. Over 4 months, 13 patients were enrolled. The pharmacist interacted with each patient an average of 9 times with 55% of interactions occurring outside scheduled visits and two-thirds of pharmacist interventions directly involving patient care. A total of 85% of patients and staff responded to the evaluation survey and 90% of respondents indicated that the pharmacist should remain part of the NeuroOncology team. Patients reported less stress related to their treatment and clinical staff experienced improved clinical efficiency directly as a result of the presence of the pharmacist. Conclusion. Based on these results, a clinical pharmacist should become a permanent member of the outpatient NeuroOncology clinic. J Oncol Pharm Practice (2009) 15: 79—85.

Adherence to adjuvant endocrine therapy in women with breast cancer

Purpose: To determine how many breast cancer patients who initiated adjuvant endocrine therapy discontinued early and to evaluate adherence in patients who persisted with therapy. Secondary objectives were to explore possible trends to see if certain factors may correlate to early discontinuation of therapy. Methods: A retrospective review of charts and pharmacy dispensing records was conducted, including patients who initiated adjuvant endocrine therapy for breast cancer at the Cross Cancer Institute from 1 January to 31 December, 2006. Results: Out of 346 patients, 81 (22%) discontinued therapy within 2 years. Adherence rates calculated for the 265 patients who remained on therapy beyond 2 years showed that 247 (93%) of these patients had 80% or better adherence. Patients who did not undergo chemotherapy and patients with Cross Cancer Institute follow-up times of less than 1 year were significantly more likely to discontinue therapy early. Conclusions: The majority of patients who were prescribed adjuvant endocrine therapy for breast cancer at the Cross Cancer Institute remained on therapy for at least 2 years and were adherent. Longer follow-up by Cross Cancer Institute practitioners may help decrease discontinuation rates.

Medication adherence among adults prescribed imatinib, dasatinib, or nilotinib for the treatment of chronic myeloid leukemia.

Background Oral tyrosine kinase inhibitors are the standard of care for chronic myeloid leukemia. Tyrosine kinase inhibitors are administered in an outpatient setting for an indefinite period which may negatively impact adherence. Non-adherence to tyrosine kinase inhibitors is associated with disease progression. Objectives To evaluate the need for adherence-enhancing interventions, this study was designed to determine the proportion of chronic myeloid leukemia patients non-adherent to their tyrosine kinase inhibitor regimen. The secondary objective was to identify the influence of patient characteristics on tyrosine kinase inhibitor adherence. Methods Cross-sectional retrospective chart and dispensing record reviews were performed to identify patients receiving a tyrosine kinase inhibitor from 1 June 2010 to 31 January 2012. Adherence was evaluated using the medication possession ratio. Results A total of 124 patients were included. Thirty-eight (31%) patients were non-adherent to their tyrosine kinase inhibitor regimen. Patients not receiving concurrent medications were more likely to be non-adherent (odds ratio (OR) 2.33, 95% confidence interval (CI) 1.05–5.13, p = 0.04). The median medication possession ratio was 0.95 (IQR = 0.83–1.07). Median medication possession ratio was lower in patients receiving imatinib compared to dasatinib or nilotinib (0.95 vs. 1.00, p = 0.01) and in those less than 50 years old compared to those greater than 50 years old (0.92 vs. 0.97, p = 0.02). Conclusions Optimal tyrosine kinase inhibitor adherence in chronic myeloid leukemia patients poses a significant obstacle in achieving best possible outcomes while reducing healthcare costs. In this study, one in three chronic myeloid leukemia patients treated with a tyrosine kinase inhibitor were non-adherent to their regimen. Those at higher risk of non-adherence were on no concurrent medications, less than 50 years old, and those treated with imatinib. Active intervention to improve tyrosine kinase inhibitor adherence should be developed, implemented, and evaluated to improve patient outcomes at our center.

Optimizing pain relief in a specialized outpatient palliative radiotherapy clinic: Contributions of a clinical pharmacist

Purpose. Bone metastases are the most common cause of cancer pain, with palliative radiotherapy (RT) the mainstay of treatment. However, relief from RT may be delayed, incomplete, or short-lived and therefore optimized pharmacologic therapy is essential. Our objective was to describe the contribution of the clinical pharmacist (CP) to an outpatient palliative RT clinic. Methods. The Edmonton Symptom Assessment System, an 11-point scale for measuring nine symptoms, and other validated screening tools were administered, and a medication history performed by the CP. Baseline CP assessment also included opioid toxicity, need for supportive medications, and drug interactions. Anonymized clinical information was collected prospectively and descriptive statistics were compiled including themes of counselling performed by the CP. Results. The CP reviewed 114 patients over 140 clinic visits (01/2007–12/2008). Median age was 68.3 years, 68.4% were male and 36.8% had prostate cancer. All symptoms improved or stabilized in ≥80% by 4 weeks. Median pain score was 6/10 (SD 2.6) at baseline, and 2.1/10 (SD 2.4) by week 4. Average morphine equivalent daily dose was 76.8 mg at baseline and 44.5 mg at week 4. CP assessment included screening for opioid toxicity (87.9%), recommending a change in analgesic (28.9%), and liaison with the community pharmacy (17.1%). Medication counselling took place in 84.3% of visits, on bowel routine (85.6% of the time), opioids (82.2%), and hydration (40.7%). Conclusions. The CP plays a key role in holistic patient assessment and optimization of pharmacologic therapy, contributing to improved symptom control of patients receiving palliative RT.

Oncology medication safety: A 3D status report 2008

Background. The safe use of medications is a major concern in oncology practice. Three organizations collaborated on a survey to determine if practitioners had implemented current recommended safe practices for IV vincristine administration, general oncology safe practices, and safe practices for oral chemotherapy. Methods. A survey was distributed to members of the Hematology Oncology Pharmacy Association (HOPA) and the International Society of Pharmacy Practitioners (ISOPP) using Survey Monkey TM. The Institute of Safe Medication Practices (ISMP) also solicited readers of its Medication Safety Alert! ® to respond to the survey. A comparison to results from a survey conducted by ISMP in 2006 on safe practices for IV vincristine was also conducted. Results. The majority of respondents were aware of the WHO recommendations for IV vincristine, although the rate of implementation of the guidelines ranged from 24.1 to 53.6%. When compared to the ISMP 2006 survey there was a 25.8—37.4% improvement in following many of the safe practice guidelines. Administering IV vincristine via a minibag showed the lowest rate of adoption (less than 40%). Of the 35 survey items on general chemotherapy safety strategies, 80% of respondents had implemented at least 21 items in the survey. Overall 32.4% of respondents did not consider oral chemotherapy as requiring the same safety concerns as parenteral therapy. Conclusions. The results of this survey will provide a new baseline for the adoption rate of safe medication practice recommendations related to oncology. Further work on addressing barriers in adopting identified safe practice recommendations needs to be conducted.

Evaluation of clinical pharmacists' follow-up service in an oncology pain clinic.

Background: Patients who present with pain in an oncology setting are often complex and require a multidisciplinary approach for symptom control. The Pain and Symptom Control Clinic at Tom Baker Cancer Center includes two pharmacists who participate in weekly multidisciplinary clinics and provide a follow-up service to patients. Objective: This study will assess the impact of the pharmacists’ follow-up service with respect to activities performed as well as patient and health care professional satisfaction. The activities performed will also be compared to defined objectives for pharmacy practice in a hospital setting. Methods: Activities performed by the pharmacists over a 10-week period were recorded and tabulated. Online surveys were completed by health care professionals and telephone surveys were completed by patients 1 month post clinic visit. Results: Over 6 weeks, 44 patients assessed in clinic required follow-up from a pharmacist. There was an average of 2.3 interactions per patient and an average time of 85 min was spent on each patient outside of clinic. The three activities that occurred most frequently included: (1) interacting with other health care professionals, (2) making alterations to patients’ medication regimens, and (3) organizing refills. All health care professionals surveyed felt that the pharmacists’ follow-up service was a valuable component of the Pain and Symptom Control Clinic and nearly all patients surveyed reported a positive experience with the service received. Conclusion: The inclusion of pharmacists in the Pain and Symptom Control Clinic is favored by patients and health care professionals and provides increased efficiency to the clinic.

Temozolomide plus radiotherapy for glioblastoma in a Canadian province: Efficacy versus effectiveness and the impact of O6-methylguanine-DNA-methyltransferase promoter methylation

Background: Radiotherapy with concomitant and adjuvant temozolomide has been the standard of care for newly diagnosed glioblastoma in adults since the pivotal trial by Roger Stupp and colleagues. The effectiveness of this regimen has not been evaluated in Canada. Additionally, the impact of O6-methylguanine-DNA-methyltransferase (MGMT) promoter methylation on patient survival has not been confirmed. Hence, survival outcomes and MGMT predictive value were compared for the patients in Alberta versus the Stupp trial population. Methods: Retrospective chart review of 215 adult glioblastoma patients who started radiotherapy and temozolomide between January 2007 and December 2010 at the Cross Cancer Institute (Edmonton, Alberta) or the Tom Baker Cancer Centre (Calgary, Alberta). Results: In the Alberta population, median overall survival was 14.3 months (vs. 14.6 months in trial, p = NS) and median progression-free survival was 5.8 months (vs. 6.9 months in trial, p = NS). However, unlike the trial, the Alberta MGMT subgroup analysis for overall survival was not statistically significant, despite a hazard ratio of 0.65 in favor of the methylated group. More Alberta patients received corticosteroids (p < 0.0001) and fewer underwent complete resection (p = 0.0001) or a postprogression second surgery (p = 0.01) than the Stupp population, but characteristics were otherwise similar. Conclusion: Current practice in Alberta enables patients to achieve overall and progression-free survival similar to the clinical trial. Further follow-up is required to confirm the predictive value of the MGMT assay. Until that is clarified or better treatments are developed, it is reasonable to continue offering this treatment regimen to patients regardless of MGMT methylation status.

Look-alike, sound-alike drugs in oncology.

Background. Medication errors with oncology drugs can place cancer patients at risk for adverse events or death. Look-alike, sound-alike (LASA) drug names may increase the risk for errors. Published lists of LASA drug names are generally a result of voluntarily reported medication incidents. This study performed a proactive review of the oncology drug formulary from the Cancer Services of the Alberta Health Services for LASA drug pairs. Methods. The Levenshtein Distance and Bigram Similarity algorithms, same first and last letters, and Lexi-CompR on-line alerts were used to review the outpatient oncology formulary to identify potential LASA generic drug name pairs. Results. Results indicate there are more potential LASA generic drug name pairs in the oncology formulary than are published in the literature. The risk detection methods used in this study identified unique and common LASA drug pairs. The Bigram Similarity algorithm identified 186 LASA drug pairs from 3320 possible pairs. The Levenshtein Distance algorithm, same first and last letters, and Lexi-CompR methods identified 42, 75, and 38 LASA drug pairs, respectively. Five generic LASA drug pairs were identified in common by all four of the risk determination methods. Discussion. LASA drug pairs identified by three or four methods were considered to provide the highest risk for errors. A step-wise approach to risk reduction, dependent on the number of detection methods identifying a pair, is presented. Conclusion. For specialty areas of practice, a proactive system of reviewing LASA drug name pairs may be warranted for increasing medication safety. J Oncol Pharm Practice (2011) 17: 104— 118.