The Role of the Pharmacist in Treating the Cancer Patient

Cincinnati—Historically, care for a patient with cancer was managed by just a physician and the patient. In the current clinical environment, care for a patient with cancer is managed by a healthcare team that includes the patient, primary care physician, oncology nurse, oncologist, home care provider, social worker, and pharmacist. The model also includes the patient’s caregiver, family and friends.

At a Contemporary Issues session at the AMCP meeting, Rowena N. Schwartz, PharmD, BCOP, senior director, clinical content and services, at McKesson Specialty Health, gave a presentation titled Clinical Issues in Oncology Management.
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Dr. Schwartz began her presentation by noting that advances in the care of the individual with cancer increasingly focus on the evolving role of the pharmacist. She said that pharmacists have several opportunities to optimize care, including playing a role in prevention, early detection, cancer treatment, survivorship care, and palliative care.

She then cited a case study of a premenopausal 45-year-old woman diagnosed with stage II B breast cancer. At that early stage, the treatment goal is a cure. Treatment could include surgery, radiation, chemotherapy, hormonal therapy, and/or trastuzumab.

Criteria for the use of adjuvant chemotherapy for early stage breast cancer include the size of the tumor, the axillary lymph node status, and the tumor biology. Chemotherapy options involve which agent to use, at what dose, for what duration, and in what sequence.

Dr. Schwartz then discussed the complexities in managing the individual with cancer that arise from the use of pharmacotherapy. Comorbidities associated with cancer treatment such as gastroesophageal reflux disease, depression, pain, hypertension, and insomnia create a need for the management of polypharmacy. Areas of concern include possible drug/drug and drug/food interactions.

Pharmacists can manage possible drug interactions in a cancer patient by being aware of the potential for unrecognized and/or under-reported drug interactions associated with the patient’s use of dietary and nutritional supplements, herbal medications or food, complementary and alternative medicine, and over-the-counter medications.

In some patients, bone loss may be induced from therapies that are associated with estrogen or androgen deprivation, Dr. Schwartz continued. Cancer treatment-induced bone loss (CTIBL) can lead to osteoporosis, increasing the risk of fractures in patients treated with androgen-deprivation therapy, estrogen-deprivation therapy, or who have treatment-related menopause as a result of chemotherapy or surgery. The risks associated with CTIBL can be reduced with a combination of nondrug therapy (promoting lifestyle changes), assessment and monitoring of bone mineral density, and calcium and vitamin D supplementation.

Dr. Schwartz then turned her attention to the role of the pharmacist vis-à-vis management of a cancer survivor. According to the National Coalition for Cancer Survivorship, an individual is considered a cancer survivor from the time of diagnosis, through the balance of his or her life. Based on 2005 data, there are an estimated 11 million cancer survivors in the United States. Of those, 60% are ≥65 years of age.

Dr. Schwartz cited several recommendations for the management of cancer survivors [From Patient to Cancer Survivor: Lost in Transition; 2006; Maria Hewitt, ed]. The recommendations include (1) healthcare providers, advocates, and other stakeholders should raise awareness of the needs of cancer survivors, establish cancer survivorship as a distinct phase of cancer care, and act to ensure the delivery of appropriate survivorship care; (2) patients completing primary cancer treatment should be provided with a comprehensive care summary and follow-up plan written by the healthcare providers(s) who provided cancer treatment; and (3) systematically developed evidence-based clinical practice guidelines, assessment tools, and screening instruments should be developed to manage late effects of cancer and its treatment.

She noted clinicians should be aware of the psychological effects of cancer, including late psychological effects (psychological or emotional response that emerges following completion of treatment) and long-term effects (psychological or emotional response that emerges after a cancer diagnosis or during cancer treatment and persists for at least 5 years). There is often an overlap between psychological and physical effects (fatigue, sexual dysfunction, sleep disturbances), Dr. Schwartz added.

Finally, Dr. Schwartz outlined the evolving role of pharmacists in optimizing care for the individual cancer patient. She noted that for patients treated with oral anticancer therapy, the pharmacist has a role in modifying dosage, facilitating patient access to medications, increasing adherence, and monitoring drug interactions.