Clinical outcomes of a pharmacist-managed anticoagulation service for breast cancer patients.

PURPOSE: Report descriptive outcome measures related to the quality of pharmacist-managed anticoagulation care with warfarin in patients with breast cancer since the formation of the anticoagulation management service (AMS). METHODS: Retrospective review of 145 patients with breast cancer (median age 54 years) receiving warfarin therapy for venous thromboembolism (VTE) managed by the pharmacist-run AMS between 1998 and 2005. RESULTS: The median time followed by the AMS was 151 days. Fifty three percent (n = 1651) of total lab draws (n = 3129) were within the target therapeutic INR range 2-3. Recurrent thrombosis occurred in 4.1% of patients. Minor bleeding occurred in 18.6% of patients and major bleeding occurred in three patients (2.1%, gastrointestinal, intra-abdominal, and subdural hematoma). CONCLUSION: To date, this is the largest known published database of cancer patients receiving anticoagulation in a pharmacist-managed anticoagulation service. Recurrent VTE rates, major and minor bleeding rates, and percentage of time spent within the therapeutic range are slightly different in our patient population compared to an oncology population receiving warfarin and a non-oncology population with warfarin managed by AMS. Oral anticoagulation with warfarin is an effective, albeit complicated, treatment for venous thromboembolism in the oncology population. Although low-molecular weight heparin (LMWH) therapy is now the preferred treatment for thrombosis in malignancy, warfarin is still relevant in patients who are unable to receive treatment with LMWH. This report provides valuable information supporting coordinated anticoagulation therapy with a pharmacist-managed service in a breast cancer-specific population, and contributes to the growing data supporting the challenging nature of maintaining warfarin anticoagulation in patients with cancer.

Approaches for administering chemotherapy in the intensive care unit.

Guidelines on how to treat cancer patients receiving cytotoxic chemotherapy in the intensive care unit (ICU) are very limited. Recognizing the severity of the patient, their disease may require the need for chemotherapy whether for localized, metastatic, or hematological malignancies. It may be given alone or in combination with other cancer treatments such as radiation, or hormonal therapies. Nevertheless, the toxicities associated with chemotherapy serve as the driving force for managing complications and safe handling in the ICU. Tumor lysis syndrome, nausea and vomiting, pain management, and adverse medication effects requiring antidotes are complications for patients receiving chemotherapy in the ICU. The administration and safe handling of chemotherapy by nursing is emphasized to provide additional safety precautions. A basic understanding of cytotoxic chemotherapy is reviewed for patients requiring therapy in an ICU.

Evolving novel anti-HER2 strategies.

The approval of trastuzumab for use in metastatic breast cancer marked a breakthrough in the understanding of the biology of the disease. However, like most cancer therapies, the disease finds a way to advance despite the treatments developed to eradicate it. Although trastuzumab has had a large effect on the treatment of early and advanced-stage disease, a substantial proportion of patients with HER2-positive breast cancer still progress after receiving the drug. Potential mechanisms of resistance to trastuzumab include bypass mechanisms, mutations of the HER2 target, masking of HER2 proteins, inhibition of insulin-like growth factor, and phosphatase and tensin homologue (PTEN) deficiency. Many therapies are being developed to target these mechanisms in patients with HER2-positive, trastuzumab-resistant breast cancer. Additionally, treatment strategies other than trastuzumab with unique mechanisms of action are being assessed in this specific group of patients. In this review, we discuss the emerging data assessing therapeutic approaches in the management of trastuzumab-resistant HER2-positive disease.

Comparison of chemotherapy education and patient preferences in community versus academic gynecology oncology clinics.

PURPOSE: To evaluate and compare patients' preferences in receiving chemotherapy education from health care teams in community versus academic clinics. METHODS: Results from a 13-question questionnaire about the chemotherapy education preferences of patients in three community gynecology oncology clinics were compared to the results from a similar study previously conducted in an academic gynecology oncology clinic. RESULTS: A total of 57% of the 203 community-clinic respondents (116) and 67% of the 282 academic-institution respondents (189) who completed questionnaires had previously received chemotherapy. Of the patients treated in community clinics, almost 60% preferred chemotherapy education to be provided in written form and directly by a health care professional compared to 87% of the patients in academic clinics. Overall, 88% of the patients in the community clinics believed they received adequate information, compared to 63% of the patients in the academic setting. Patients in the community clinics wanted to get more in-depth answers to questions such as 'What is chemotherapy?' (54%) and 'How it is given?' (55%). In addition, community patients also wanted to know more about 'Why chemotherapy stops working?' (72%) and 'What to do and who to call about side effects?' (60%). In the academic setting, patients were less likely to want to know more about these chemotherapy related questions (42, 35, 57, and 49, respectively). CONCLUSIONS: Patients preferred to receive written chemotherapy education that was reviewed with a healthcare professional and that gave more detailed information about the chemotherapeutic drugs themselves and how to prevent and manage side effects. As a result of this questionnaire, the patient education materials used at our institution will be revised to better address patients' preferences in both treatment settings.

Dietary supplements in patients with cancer: risks and key concepts, part 1.

PURPOSE: The risks and key concepts regarding the use of dietary supplements in patients with cancer are described. SUMMARY: There are six common characteristics of dietary supplements that must be addressed when used by patients with cancer. Clinicians must establish if the supplement is an antioxidant, is an anticoagulant or procoagulant, has immunosuppressive or immunomodulating properties, has hormonal properties, has known safety issues, and has known or theoretical drug interactions. These six characteristics of the dietary supplements commonly used by patients with cancer are reviewed to aid in the analysis of the scientific data and communication of the results with the patient or family members. A framework upon which clinicians can adequately help patients make informed decisions regarding the use of complimentary and alternative medicine and dietary supplements is also described. When evaluating the appropriateness of a supplement for use by a patient with cancer, clinicians must conduct a safety review (evaluate the six characteristics). If the supplement is considered safe, an efficacy review must be conducted, after which the clinicians can recommend the supplement's use, accept the patient's decision to use the supplement if no or inconclusive evidence exists, or discourage use if there is conclusive evidence supporting inefficacy. Available resources for locating information regarding dietary supplements are also discussed. CONCLUSION: Counseling patients with cancer about dietary supplements requires a systematic thought process that considers the available theories and data, as well as the patients' views about the agents.

Dietary supplements in patients with cancer: risks and key concepts, part 2.

PURPOSE: The risks and key concepts regarding the use of dietary supplements in patients with cancer are described. SUMMARY: There are six common characteristics of dietary supplements that must be addressed when used by patients with cancer. Clinicians must establish if the supplement is an antioxidant, is an anticoagulant or procoagulant, has immunosuppressive or immunomodulating properties, has hormonal properties, has known safety issues, and has known or theoretical drug interactions. These six characteristics of the dietary supplements commonly used by patients with cancer are reviewed to aid in the analysis of the scientific data and communication of the results with the patient or family members. A framework upon which clinicians can adequately help patients make informed decisions regarding the use of complimentary and alternative medicine and dietary supplements is also described. When evaluating the appropriateness of a supplement for use by a patient with cancer, clinicians must conduct a safety review (evaluate the six characteristics). If the supplement is considered safe, an efficacy review must be conducted, after which the clinicians can recommend the supplement's use, accept the patient's decision to use the supplement if no or inconclusive evidence exists, or discourage use if there is conclusive evidence supporting inefficacy. Available resources for locating information regarding dietary supplements are also discussed. CONCLUSION: Counseling patients with cancer about dietary supplements requires a systematic thought process that considers the available theories and data, as well as the patients' views about the agents.

A review of adjuvant hormonal therapy in breast cancer.

Breast cancer is the most common carcinoma diagnosed in women today excluding non-melanoma skin cancers. It has been well documented that estrogen plays a critical role in its development and is a major target for treatment. For many years, tamoxifen has been the gold standard for adjuvant hormonal therapy in breast cancer patients. With newer products targeting different mechanisms to suppress estrogen production, patients now have many decisions regarding their care. Agents such as luteinizing hormone releasing hormone (LHRH) agonists can suppress ovarian function in premenopausal patients and have been shown to be as effective and even better than chemotherapy (CMF--cyclophosphamide, methotrexate, fluorouracil-containing regimens) in certain patient populations. Tamoxifen continues to be an option as well as toremifene, a similar selective estrogen receptor modulator. With the advent of newer third generation aromatase inhibitors (anastrozole, letrozole and exemestane) toxicities have been documented to be less and in some cases they are more efficacious than the standard, tamoxifen. This article reviews the current data regarding ovarian suppression, ovarian suppression plus tamoxifen, tamoxifen, toremifene, anastrozole, letrozole, and exemestane in the treatment of adjuvant hormonal-sensitive breast cancer.

An assessment of the utilization of complementary and alternative medication in women with gynecologic or breast malignancies.

PURPOSE: To describe and assess the current utilization of complementary and alternative medicines (CAMs) in women with a diagnosis of either gynecologic or breast cancer and evaluate their reasons for use. PATIENTS AND METHODS: This study included 250 female patients from the Multidisciplinary Breast Center and 250 patients from the Gynecologic Oncology Center of The University of Texas M.D. Anderson Cancer Center (Houston, TX). Patients were selected by having an odd-numbered medical record number, and they were contacted before their clinic visit. The goals of the study were explained, and verbal consent was obtained. Patients who agreed to participate were asked to bring a written list and the medication bottles of all over-the-counter prescriptions and CAMs with them to clinic. In clinic, the investigator obtained a written informed consent and administered the survey. All patients and surveys were assessable. RESULTS: The most frequently used herbal products and megavitamins/minerals were identified from the patient medication histories. Overall, we found the proportion of patients using CAM to be 48% (95% CI, 44% to 53%; 241 of 500 patients). CAM use was related to patients' educational status: 62% had postgraduate degrees, 50% had college degrees, 56% had some college, and 33% had a high school education or less. Also, among patients using CAMs, only 53.5% had spoken to a healthcare provider regarding CAM therapy. CONCLUSION: The use of CAM is common among women with cancer. Studies need to be conducted to establish if there are any potential drug interactions and/or therapeutic benefit of CAM products. Moreover, there is a need to educate patients and healthcare providers on appropriate and safe use of CAM products.

Capecitabine-induced pancreatitis.

A 47-year-old woman with metastatic breast cancer developed acute pancreatitis while receiving capecitabine. She had been receiving capecitabine 2000 mg/m2/day; however, when the dosage was increased to 2500 mg/m2/day (the maximum dosage approved by the Food and Drug Administration) she experienced abdominal pain and cramping. These symptoms were followed by nausea and vomiting, palmar-plantar erythrodysesthesia (hand-foot syndrome), and mucositis, resulting in admission to the hospital. Laboratory tests for liver function showed elevated levels of alkaline phosphatase and lactate dehydrogenase. The patient's lipase and amylase levels were also elevated, but an abdominal ultrasound was normal. After bowel rest and intravenous hydration, the patient's liver function tests and lipase and amylase levels returned to normal. Many chemotherapeutic agents have been documented to cause pancreatitis; however, we found no previously described reports of capecitabine-induced pancreatitis. Clinicians should be aware of this potential adverse effect, particularly in patients with preexisting risk factors for pancreatitis who are prescribed capecitabine.