Traditionally the majority of anticancer therapies for solid tumours were only available as intravenous products prepared and administered in secondary care. Recent years have seen a huge growth in the number of oral anticancer medicines, which can be dispensed by community pharmacy.
This article discusses the potential impact of these changes on the role of the community pharmacist and explains what community pharmacists need to know about chemotherapy and anticancer medicines.
Impact on community pharmacy
It is probably too early to assess the impact of these planned changes but we can be sure that community pharmacists will have more contact with cancer patients as more and more cancer patients are treated with oral anticancer medicines that can be taken at home.
As well as the growth in oral anticancer medicines, there is also the impact of more effective treatment to consider, with management of some cancers now similar to that for long-term conditions. For example, patients receiving oral imatinib (Glivec) for chronic myeloid leukaemia (CML) have a 95 per cent five-year survival rate and may continue on the medicine for many years. Breast cancer patients now have an 80 per cent five-year survival rate.
The most common UK cancers are breast, lung, colorectal and prostate, so it follows that these are the patients most likely to be seen by community pharmacists. Of these, lung cancer has the poorest prognosis, with average five-year survival of only 7 per cent and only 25 per cent of patients alive after one year.
Early diagnosis of lung cancer is critical, and community pharmacists have an important role in referring patients with symptoms such as a new cough that does not go away after 2-3 weeks, worsening of a longstanding cough, longstanding chest infection and other symptoms listed in the national guidance lung cancer guidance.
Even if community pharmacists are not directly involved in the supply of anticancer medicines, patients taking these medicines still need to access community pharmacy for OTC medicines to manage side-effects and potentially supplement their treatment with complementary preparations.
There is little hard evidence on the potential for interactions and benefits of complementary medicines, such as herbal supplements, but cancer patients often want to take something that they believe will help.
Generally, advice is to be cautious about taking these medications while receiving anticancer medicines. The Royal College of Radiologists Faculty of Clinical Oncology provides an excellent advice sheet that gives links to sources of information on these medicines.
There are concerns over the safe management of anticancer medicines in secondary care. The National Patient Safety Agency (NPSA) issued an alert to all healthcare professionals in January 2008 entitled Risks of Incorrect Dosing of Oral Anticancer Medicines. The report highlights the potential for fatal outcomes if incorrect doses of oral anticancer therapy are prescribed, dispensed or administered.
The NPSA data indicated that 6,099,989 dose units of oral anticancer medicines were dispensed in primary care in 2006-07. The most common of these were chlorambucil, cyclophosphamide, hydroxycarbamide, imatinib, mercaptopurine and methotrexate.
While many of these medicines have non-cancer indications, we can see that significant numbers of cancer patients are already treated by community pharmacy. Table 1 lists the oral anticancer medicines available in the UK.
Clearly safety issues must be considered before expanding chemotherapy services into primary care, but there are also barriers to the successful and safe transmission of chemotherapy dispensing from secondary to primary care.
However, frameworks and good practice examples are emerging to facilitate this move. It is essential that community pharmacists taking on dispensing of anticancer medicines are supported by their colleagues in secondary care, in particular by their local Cancer Network.
The NPSA alert required all patients to be issued with a copy of their treatment plan, which should contain details of drug doses and frequencies. Community pharmacists can use these treatment plans and patient-held records as a way of finding out what medicines are needed.
It may be that community pharmacists will be asked to dispense and counsel chemotherapy patients. This could present some training issues as oral anticancer medicines are quite specialised.
Pharmacists should be aware of counselling patients on the safe handling and storage of anticancer medicines and of common side effects of chemotherapy such as sickness and diarrhoea, mouth problems, hair loss, skin side-effects and bone marrow suppression.
The frequency and severity of these side-effects will vary between drug regimens, making access to the regimen protocol (which contains advice on management of side-effects) vital.
Pharmacists should counsel patients receiving anticancer medicines to be particularly aware of symptoms of infection such as sore throat, raised temperature, pain passing urine, cough or breathlessness. Patients with bone marrow suppression can often develop serious infections with only slightly raised temperature.
As well as traditional cytotoxic medicines, many new anticancer medicines act in novel ways, such as targeting epidermal growth factor receptor (EGFR) for example. Erlotinib (Tarceva) in lung cancer or tyrosine kinases e.g. imatinib (Glivec(r)) in CML work in this way.
These newer agents have different side-effect profiles, such as severe skin reactions, which need specialist management. Side-effects are part of the treatment with anticancer medicine and to be expected, patients need to be well informed and supported to manage these side-effects. As well as specific drug-related advice, community pharmacists are in an ideal position to reinforce lifestyle advice (see box ‘Lifestyle advice for patients on anticancer medicines’).
Lifestyle advice for patients on anticancer medicines
- Tell doctor immediately if they get a fever (temperature over 38°C) or notice any bleeding or bruising.
- Keep as clean as possible, washing hands before preparing food for instance.
- Try to eat a healthy diet – lots of fresh fruit and salads.
- Make sure any cooked food is properly heated through to kill off bacteria.
- Avoid injury e.g. wear thick gardening gloves.
- Keep away from animals to avoid infection, especially cat litter trays and bird cages.
- Put pressure on cuts for longer than usual to stop bleeding.
- Rest when feeling tired.
- Avoid doing too much in the middle of each course of chemotherapy, as this is when blood counts will be lowest.
- Avoid any contact with people who have, or may have been in contact with, chicken pox.
Sources of information
We can see that is useful for the average community pharmacist to have some knowledge of how common cancers are treated and, more importantly, how they can help cancer patients.
When managing cancer patients it is not expected that community pharmacists should become experts in cancer medicines, but rather that they are able to apply their skills as medicines experts to help cancer patients.
Indeed, oncology pharmacy is a well-developed speciality within hospital pharmacy. The British Oncology Pharmacy Association has over 1,400 members and recently established a Faculty of Cancer Pharmacy within the College of Pharmacy Practice to accredit its members.
Part of the challenge for the community pharmacist is knowing where to look to get quick information on cancer patients’ medicines. The BNF, while an admirable source of medicines information, is not very helpful when it comes to cancer treatments.
This is because most chemotherapy regimens are given as combinations of drugs with doses often very different from those quoted in the BNF. Following its safety alert into oral chemotherapy, the NPSA has recognised this and is working with the BNF to update sections 8.1 and 8.2 to provide more useful information.
The Cancerbackup website (www.cancerbackup.org.uk/Treatments) provides some excellent patient information sheets on combination regimens. Your local hospital trust or Cancer Network will have regimen protocols for all the drugs in use.
My own organisation has published the Oral Anticancer Medicine Handbook, which offers a quick reference guide to oral chemotherapy and oral anticancer medicines, including advice on safe prescribing, handling and administration.
There is an increasing policy move for cancer patients to be treated in primary care, which means community pharmacists will be asked to provide pharmaceutical care. It is not expected that community pharmacists become experts in anticancer medicines but they should know where to look and who to ask for information and guidance on these medicines.
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- Cancer Research UK patient information sheet: Your blood, bone marrow and chemotherapy (www.cancerhelp.org.uk/help/default.asp?page=314).
- Williamson S, Polwart C. The Oral Anticancer Medicine Handbook. North of England Cancer Network, 2008 (available from www.lulu.com/content/2528296).
Steve Williamson is Consultant Pharmacist in Cancer Services at Northumbria Healthcare and North of England Cancer Network.