Christine Carrington

The development of a competency framework for pharmacists providing cancer services

Background: Health practitioners should possess relevant, up to date skills and be able to perform within their required scope of practice to ensure that they are competent. Maintaining the competency of health care professionals is a key principle of clinical governance and risk management. The aim of this project was to develop a competency framework for pharmacists providing pharmaceutical care to cancer patients. Methodology: An initial draft framework was developed based on existing documentation and adapted to the needs of Queensland Health (QH) facilities. Pharmacists in QH and interstate were asked to review the framework for content and applicability. Cancer care pharmacists in QH were invited to evaluate and score the usefulness and relevance of the final framework. Results: The framework consists of competency clusters, which describe core activities within three areas: patient care competencies, knowledge competencies, and advanced level competencies. The characteristics of the levels of practice at foundation, advanced, and consultant are defined. Twelve pharmacists evaluated the framework by self-assessing their own practice. Respondents reported that the framework was very to somewhat reflective of what they usually do and gave overall support for the content and applicability to practice. Discussion: The framework has been developed using national and international documents and the input of experienced practitioners across Australia. It represents a set of key competencies for the pharmaceutical delivery of cancer care. The next essential step of the competency framework is to implement and integrate the framework into practice and to develop accompanying training tools.

The Clinical Oncological Society of Australia (COSA) guidelines for the safe prescribing, dispensing and administration of cancer chemotherapy.

The issue of medication safety is highly significant when anti‐cancer therapy is used as a treatment modality due to the high potential for harm from these agents and the disease context in which they are being used.

Development of guidelines for the safe prescribing, dispensing and administration of cancer chemotherapy

Aim:  The issue of medication safety is highly significant when anti‐cancer therapy is used due to the high potential for harm from these agents and the disease context in which they are being used. This article reports on the development of multidisciplinary consensus guidelines for the safe prescribing, dispensing and administration of cancer chemotherapy undertaken by a working group of the Clinical Oncological Society of Australia (COSA).

To Cap or Not to Cap: Chemotherapy Dosing in Obese Adult Hematology Patients

Obesity, defined by the World Health Organization (WHO) as a body mass index (BMI) of ≥30 kg/m2, is a risk factor for many cancers and may be associated with higher cancer-related mortality.1 In comparison to solid tumors, the influence of obesity on the prevalence, pathophysiology, treatment, and disease outcomes of hematological cancers such as lymphoma, leukemia, and plasma cell disorders is less well defined. As the incidence of obesity increases (according to WHO projections, by 2015 more than 700 million adults worldwide will be obese),1 clinicians treating blood cancers are increasingly aware of the uncertainties and disparities with drug treatment within this group, especially in determining the most appropriate chemotherapy dosing algorithms that take into account the changes in anticancer drug pharmacokinetics and pharmacodynamics to optimize outcomes.

A systematic review of treatment outcomes with weight-based dosing of chemotherapy in obese adult patients with acute leukemia or lymphoma.

High dose chemotherapy for acute hematological malignancies is usually prescribed with curative intent. However, treatment-related toxicities such as infection, prolonged myelosuppression, neurotoxicity, renal impairment, gastrointestinal toxicity and cardiovascular complications cause significant morbidity and in some instances mortality. Balancing efficacy and toxicity is a constant challenge. Between 1980–2013, the worldwide prevalence of overweight or obese adults rose by 28% [1]. Body mass index (BMI), defined as weight in kilograms divided by square of height in meters, is used to define overweight as a BMI 25 kg/m and obese as a BMI 30 kg/m [2]. Weight-based chemotherapy doses have been commonly reduced in overweight and obese hematology and oncology patients [3]. This is due to concerns regarding altered chemotherapy pharmacokinetics and an excess of toxicity in this population. Whilst there are numerous publications reviewing treatment outcomes in patients of increased weight, most do not capture information regarding weightbased dose modifications. Consequently, results cannot be adequately interpreted to guide future patient dosing. This systematic review of the literature was performed to collate treatment-related toxicities and outcomes in overweight and obese adult patients compared to normal weight patients with acute leukemia or aggressive lymphoma. The aim was to determine the appropriateness of dosing chemotherapy according to actual body weight (ABW) in this population. Dosing of novel targeted therapies was not addressed in this review. A literature search of four databases (PubMed, EMBASE, Web of Science and Cochrane Central Register of Controlled Trials) was conducted for English language articles published between 1995 and the end of 2014. The PubMed search terms were (obes* AND acute myel* leukemia) OR (overweight AND acute myel* leukemia) OR (obes* AND acute lymph* leukemia) OR (overweight AND acute lymph* leukemia) OR (obes* AND lymphoma) OR (overweight AND lymphoma). The EMBASE search used combinations of the Emtree terms ‘‘obesity’’, ‘‘lymphoma’’, ‘‘acute lymphoblastic leukemia’’ and ‘‘acute granulocytic leukemia’’, the latter being the database’s search term for acute myeloid leukemia. For the Web of Science and Cochrane Central Register of Controlled Trials searches we used the same search terms and combinations as for the PubMed search. Two authors (SM, GS) independently screened titles, collated potentially relevant articles and then read them in full in order to determine their eligibility for this review. Discrepancies were resolved by consensus. Published articles were only included in this review if treatment outcomes were detailed (including toxicities, disease response and/or survival), currently accepted chemotherapy regimens were used and a comment was made that doses were weight-based with no, or specified, modification of doses in a minority of patients of increased weight (except vincristine). Studies in stem cell transplantation were excluded because doses in conditioning chemotherapy regimens are often intentionally myeloablative and treatment-related toxicities could be confounded by total body irradiation, immunosuppression and stem cell dose. Furthermore, a comprehensive literature review in this population had been published recently [4]. Pediatric (defined as below 16 years of age) studies, literature reviews, small case series and case reports, abstracts and editorials were similarly excluded. A total of 861 acute leukemia studies and 1098 lymphoma studies were identified using this search strategy [Fig. 1]. Upon screening titles and evaluating the articles for potential relevance, only five articles for acute myeloid leukemia and four for lymphoma fulfilled

Application of the Repertory Grid Technique to explore medication understanding in patients receiving cancer therapy for breast cancer

Abstract of a poster presentation presented at the Joint Meeting of the COSA 39th Annual Scientific Meeting and IPOS 14th World Congress of Psycho-Oncology, 13-15 November 2012, Brisbane Convention and Exhibition Centre.

Study to support the standardization of the prescribing, dispensing and labeling of etoposide formulations in Australia

Aim:  Etoposide is used in a wide variety of solid and hematological tumors. It is available in Australia in two intravenous formulations; etoposide base and the etoposide phosphate salt with 113.6 mg of etoposide phosphate being equivalent to 100 mg of the etoposide base. Variances between the etoposide dose prescribed and that actually given have been reported recently in Australia with patients receiving either too much or too little of the intended dose of etoposide. We carried out a review of national practices of prescribing, dispensing and labeling of etoposide and etoposide phosphate.

Preventing chemotherapy errors: Implementing system changes

The multiple pathways and personnel involved in providing chemotherapy services offer many opportunities for failures to occur in the delivery pathway. As treatment regimens become more complex and reliant on multiple services, the risk of iatrogenic injury increases, often due to the tightly coupled nature of healthcare organizations. If a system is interactively complex, independent failure events may occur in ways that cannot be predicted by users of the system. Therefore, any intervention aimed at reducing adverse incidents and improving safety needs to be targeted at several points in the system. Systems approach to safety recognizes that safety is a property of the system as a whole, not a property of individual system components. The introduction of protocols and specific training help to reduce complexity and the use of system constraints place limitations on behavior that can prevent unsafe behavior or unsafe interactions among system components. Errors related to the use of chemotherapy that result in patient harm are well publicised. The consequence of any error involving these agents can be devastating due to the low therapeutic index and minimal safety margin of these drugs. Errors can occur at any step of the medication pathway from prescribing and preparation to distribution and administration as well as at a more complex level related to the competency, knowledge and skills of those involved in the process. Patient safety is now high on the agenda for all areas in health care and the application of specific strategies and safeguards clearly reduces the incidence of chemotherapy errors. The issue of safe administration is becoming more critical in oncology, with an increasing number of new agents and combinations, and it is a challenge to medical oncologists, hematologists, pharmacists, nurses and managers to ensure there are safe administration systems in place as every new drug is introduced to the clinic. The article by Gilbar and Dooley in this issue defines both procedural and system strategies that can be implemented to enhance safety and minimise the occurrence of errors from the inadvertent administration of vincristine by the intrathecal route. These errors have occurred worldwide in a variety of settings but usually with the same devastating fatal outcome. The strategy of placing the drug vincristine in a mini-infusion bag is a relatively easy safeguard to implement and is a clear example of a “stop sign” in preventing medication administration errors. The occurrence of inadvertent intrathecal administration is not limited to vincristine, with similar errors occurring with other chemotherapy agents. When such errors occur, they are usually multifactorial, related to the many complex steps built into the chemotherapy delivery process. It is unlikely that any single safeguard will completely eliminate the occurrence of all errors. Many other potential errors are intercepted or prevented on a daily basis by medical, nursing and pharmacy staff involved in the chemotherapy process by the application of preventative strategies within the complex system of prescribing, supply and administration. A multidisciplinary systems approach should be taken to miminize the possibility of errors such as those highlighted by Gilbar and Dooley. The principles of a wellgrounded medication safety system include: 1 Simplify and standardize. Systems that are complex with excessive redundancy are more likely to be inherently error-prone. The use of protocols to eliminate unnecessary variance in practices is a hallmark of a good quality assurance system. 2 Independent dose verification processes by the doctor, nurse and pharmacist. 3 Provide an environment that enhances concentration and communication, and miminizes distractions and interruptions. 4 Use forcing functions, features of a system that only permit a task to be done the correct way. The use of mini-infusion bags for vincristine administration is a good example of this principle. 5 Minimize transfers between people or groups. Handovers or gaps are inevitable but their number can be minimized and system safety improved by attention to systems design. Asia–Pacific Journal of Clinical Oncology 2007; 3: 57–58 doi:10.1111/j.1743-7563.2007.00098.x