The Expanding Role of the Oncology Pharmacist.

Although oncology pharmacists have been involved in the care of cancer patients for over 50 years, the role of the oncology pharmacist continues to expand. Initially, pharmacists were primarily based within either an inpatient or outpatient pharmacy setting and their work focused on providing the necessary safety checks to dispense cancer-related medications. With technology freeing up pharmacists from dispensing functions and advanced training in direct patient care (e.g., oncology residency, oncology fellowship), the oncology pharmacist was able to provide direct patient care at the bedside or within the clinic where treatment decisions are made by the healthcare team. In fact, they have become integral members of the healthcare team. This Issue describes several expanding roles of oncology pharmacists in stem cell transplant, hematology, gastrointestinal oncology, and precision genomics, as well as oncology pharmacists preventing a reduction in cancer patient visits as the oncology physician shortage occurs. Oncology pharmacists are an integral part of the cancer care team; their value has been documented in several studies, and is highlighted in this Issue. We encourage the profession to continue to document their value so that one day each patient can have an oncology pharmacist as part of their cancer care team.

The Role of Pharmacists in Managing Adverse Events Related to Immune Checkpoint Inhibitor Therapy.

OBJECTIVE: To provide an overview of immune checkpoint inhibitor (ICI) therapy-associated immune-related adverse events (irAEs) and their management, focusing on the key responsibilities for pharmacists in recognizing, distinguishing, and treating irAEs and in educating patients about irAEs and their management. DATA SOURCES: Literature published from January 2000 to March 2018 available from online sources. STUDY SELECTION AND DATA EXTRACTION: Relevant English-language studies, guidelines, and articles. DATA SYNTHESIS: ICI therapies have been approved for the treatment of several cancers as single-agent therapies, combined ICI therapies, or in combination with other agents. ICI therapies increase the activity of the immune system and consequently can have autoimmune-like adverse effects that are often termed irAEs. irAE management can be challenging as irAEs can vary in their frequency and severity among patients, according to the specific agent, and can occur at any time during treatment or after therapy discontinuation. Additionally, for patients treated with ICI therapies in combination with other therapies, ICI-associated irAEs must be distinguished from adverse events associated with chemotherapy or targeted therapies, which often require different management. Pharmacists can provide essential support to diagnose and manage irAEs. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE: Early and accurate diagnosis and prompt management of irAEs by pharmacists are critical to reduce the risk of severe or life-threatening complications and prevent premature ICI discontinuation. CONCLUSIONS: Pharmacists have a key role in the recognition, monitoring, and management of irAEs and in educating patients about irAEs associated with ICI therapies and the agents used to manage them.

Demonstrating the value of the oncology pharmacist within the healthcare team.

INTRODUCTION: Although many oncology pharmacists are embedded members within the healthcare team, data documenting their contributions to optimal patient outcomes are growing. The purpose of this paper is to demonstrate the value of the oncology pharmacist within the healthcare team and describe the knowledge, skills, and functions of the oncology pharmacist. METHODS: A systematic literature review of articles that were published on PubMed between January 1951 and October 2018 was completed. Identified abstracts were reviewed and included if they focused on measuring the value or impact of the oncology pharmacist on provider/patient satisfaction, improvement of medication safety, improvement of quality/clinical care outcomes, economics, and intervention acceptance. Review articles, meta-analysis, and studies not evaluating oncology pharmacist activities were excluded. Studies were thematically coded into four themes (clinical care, patient education, informatics, and cost savings) by 10 oncology pharmacists. RESULTS: Four-hundred twenty-two articles were identified, in which 66 articles met inclusion criteria for this review. The selected literature included 27 interventional and 38 descriptive studies. The value of the oncology pharmacist was demonstrated by published articles in four key themes: clinical care, patient education, informatics, and cost savings. CONCLUSION: With an expected shortage of oncology physicians and the ongoing development of complex oncology therapies, the board-certified oncology pharmacist is well suited to serve as a physician extender alongside nurse practitioners and/or physician assistants as the medication expert on the oncology care team. The demonstrated value of the oncology pharmacist supports their role as frontline providers of patient care.

Development of a Practice Standard for Monitoring Adult Patients Receiving Bone-Modifying Agents at a Community Cancer Center.

The purpose of this study is to develop a standard for monitoring outpatients starting bone-modifying agents (BMAs) at a community cancer center. The National Comprehensive Cancer Network (NCCN) and American Society of Clinical Oncology (ASCO) guidelines recommend the monitoring of serum magnesium and phosphorus during BMA therapy but do not define a standard interval. The risk of hypomagnesemia and hypophosphatemia was assessed for the BMAs denosumab, pamidronate, and zoledronic acid. Compliance with dental clearance was also evaluated. Adult cancer outpatients newly started on BMAs between January 1, 2016, to December 31, 2016, were evaluated. Patients with hypercalcemia of malignancy were excluded. Primary endpoints were the composite rates of grade 3 and 4 hypomagnesemia and hypophosphatemia. Secondary endpoints included all-grade hypomagnesemia, all-grade hypophosphatemia, charges for laboratory draws, rate of dental clearance, and rate of osteonecrosis of the jaw (ONJ). Among 61 patients, 4.3% experienced grade 3 and 4 hypophosphatemia. No cases of grade 3 and 4 hypomagnesemia occurred. The annual cost for serum magnesium and phosphorus lab draws totaled $9,144.80. Dental clearance was obtained in 100% of patients, with 67% of clearances obtained from a dentist. No patients developed ONJ. Composite rates of grade 3 and 4 hypomagnesemia and hypophosphatemia were lower than reported in the literature. We propose to monitor magnesium and phosphorus levels at baseline, and then every 6 months. More frequent laboratory draws may be indicated based on clinical judgment. This recommendation will reduce laboratory draws and provide cost savings for patients. Compliance with dental clearance was fully achieved.

Assessment of Initial Febrile Neutropenia Management in Hospitalized Cancer Patients at a Community Cancer Center.

Fever may be the only sign of an underlying infection in neutropenic cancer patients. Unrecognized fever and untreated infections can lead to progressive sepsis and possibly death. The importance of early recognition, timely antibiotics, and treatment is crucial to favorable outcomes. The primary objective of this study was to evaluate the treatment of adult cancer patients with febrile neutropenia for compliance with National Comprehensive Cancer Network (NCCN) febrile neutropenia guidelines at our institution, UCHealth Memorial Hospital. Secondary objectives were to examine antibiotic selection, culture results, time to antibiotics, all-cause mortality, and length of hospital stay. This was a single-center, retrospective chart review of hospitalized neutropenic patients undergoing active chemotherapy. Neutropenia and fever were defined based on NCCN Guidelines. A total of 223 neutropenic patients were hospitalized between October 15, 2015, and December 31, 2016. Overall, 16 patients met the inclusion criteria for chemotherapy-induced neutropenia with fever. Compliance with the NCCN guideline standards was seen in seven (43.8%) patients. Antibiotics administered within 60 minutes of presentation was the lowest standard with adherence in eight (50%) patients. Empiric monotherapy antibiotic regimens were initiated in 11 (68.8%) patients; eight (50%) received cefepime and three (18.8%) received meropenem. At our institution, full compliance with the NCCN febrile neutropenia guidelines is not optimal. This study demonstrates the need for process improvement initiatives, including the addition of an electronic health record alert to flag patients undergoing active chemotherapy. It also warrants promoting the use of our institution's emergency department febrile neutropenia treatment pathway to providers to improve overall compliance.