Noha El Baghdady, M.Sc.

Oncology Clinical Pharmacy from Practice to Research

Cancer was first described by the ancient Egyptians

The earliest description of cancer was found in the Edwin Smith Papyrus dating back to 1600 B.C. The document describes breast tumours removed by a tool called the fire drill. However, it states that "there is no treatment".

10 FACTS ON CANCER

• Fact 1There are more than 100 types of cancers; any part of the body can be affected.• Fact 2In 2008, 7.6 million people died of cancer - 13% of all deaths worldwide.• Fact 3About 70% of all cancer deaths occur in low- and middle-income countries

• Fact 4Worldwide, the 5 most common types of cancer that kill men are (in order of frequency): lung, stomach, liver, colorectal and oesophagus.• Fact 5Worldwide, the 5 most common types of cancer that kill women are (in the order of frequency): breast, lung, stomach, colorectal and cervical. In many developing countries, cervical cancer is the most common cancer.

• Fact 6Tobacco use is the single largest preventable cause of cancer in the world causing 22% of cancer deaths• Fact 7One fifth of all cancers worldwide are caused by a chronic infection, for example human papillomavirus (HPV) causes cervical cancer and hepatitis B virus (HBV) causes liver cancer.• Fact 8Cancers of major public health relevance such as breast, cervical and colorectal cancer can be cured if detected early and treated adequately.• Fact 9All patients in need of pain relief could be helped if current knowledge about pain control and palliative care were applied.

• Fact 10More than 30% of cancer could be prevented, mainly by not using tobacco, having a healthy

diet, being physically active and moderating the use of alcohol.

In developing countries up to 20% of cancer deaths could be prevented by immunization

against the infection of HBV and HPV.

• The Lowest income countries have a survival rate for oncology patients of 25% compared with 56% in wealthiest.

Role of The Clinical Pharmacist

Symposium on Clinical Pharmacy and Clinical Pharmacology,1981

• The purpose of the Symposium is to describe the present and future

functional roles of clinical pharmacists and clinical pharmacologists in drug research, professional

education, and patient care.

RUSSELL R. MILLER Pharm.D., Ph.D, 1981

Clinical Pharmacists’ role

Drug research

Patient careProfessional education

Level of Action of Clinical Pharmacists(ESCP)

Before The Prescription

During The Prescription

After The Prescription

1- Before the prescription• Clinical trials• Formularies• Drug information• Clinical pharmacists have the potential

to implement and influence drug-related policies’ national and local formularies’, which prescribing policies and treatment guidelines should be implemented.

• Clinical pharmacists are also actively involved in clinical trials at different levels.

2- During the prescription• Counseling activity• Clinical pharmacists can influence the attitudes and priorities

of prescribers in their choice of correct treatments.• The clinical pharmacist monitors, detects and prevents

harmful drug interaction, adverse reactions ad medication errors through evaluation of prescriptions' profiles.

• The clinical pharmacist pays special attention to the dosage of drugs which need therapeutic monitoring.

• Community pharmacists can also make prescription decisions directly, when over the counter drugs are counseled.

3 -After the prescription

• Counseling• Preparation of personalized

formulation• Drug use evaluation• Outcome research• Pharmacoeconomic studies

1 -patient Care

Oncology Pharmaceutical Care Plan

• Cancer therapy• Side effects or consequences of the cancer

therapy• Complications of the problems associated with

the cancer (e.g. pain)• Comorbidities

Pharmaceutical Care Plan Issues

PCP

Disease

Medications Patient

B - Side effects or consequences of the cancer therapy

1-Recognition 2-Prevention strategies3- Management strategies (CTC grading system) 4- Patient counseling

B- Side effects or consequences of the cancer therapy

• Hematological.• Gastrointestinal.• Mucocutaneous.• Hypersensitivity• Renal Toxicity• Bladder Toxicity• Hepatotoxicity• Nervous System Toxicity• Gonad Dysfunction• Extravasation• Infusion related reactions

Principles for the Prevention and Management of CINV

1 .Evaluate each patient individually2- Evaluate the emetogenic potential and pattern of the chemotherapeutic regimen to be given3- Antiemetics are most effective when given prophylactically4. Flexibility is the keya. There are many “right” answers for anti emetic regimens.‐b. Remember that every patient has a different “threshold” for nausea/vomiting; cost effective therapy does not mean being ‐stingy with antiemetics.c. Institution specific guidelines standardize therapy, ‐facilitate tracking of outcomes, and reduce costs.

C- Complications of the problems associated with the cancer

• Pain Management.

2 -Patients Issues

1 -Performance status (ECOG)2 -Health status

a)Organ functionb)Nutritional status

3 -Comorbidities

Comorbidities

Cancer

Other Medical Problems

Cancer Treatment

3- Concurrent medications

Oncology PCP

Disease

Cancer issue

Disease

Therapy

Response

Side effects

1-Recognition

2-Prevention strategies

3- Management strategies

4- Patient counseling

Complications

Patient

PerformanceHealth status Comorbidities

Concurrent Medications

Communicate to apply your recommendations

Follow up

Talk to your patient about his medications and if he has any concerns or queries

Talk to the nurse about drug administration (especially new drugs and high alert medications)

Study updated guidelines

Guidelines

1- NCCN (National Comprehensive Cancer Network)2- ASCO (American Society of Clinical Oncology)3- ESMO(European Society of Medical Oncology)4- MASCC guidelines

Start your organization guidelines and polices

Continue updating your self

2- Research

1960 “ University of Michigan, US “

1996

Evidenced based practice guidelines often recommend enrollment in a clinical trial when

other standard therapies fail and a treatment or cure is not possible.

-

Pharmacists as PI • 1983, U.S. Food and Drug Administration (FDA)

Associate Commissioner for Health Affairs, who

stated, “It has long been FDA policy to accept

Doctors of Pharmacy as principal investigators of

studies of investigational drugs within their

expertise.”

ACCP, Update: The Clinical Pharmacist as Principal Investigator American. Pharmacotherapy, 2010

www.ClinicalTrials.gov

• Use of www.ClinicalTrials.gov provided a stronger

picture of clinical pharmacist research, with 523

studies performed by those with a Pharm.D.

degree when searched in 2009.

ACCP, Update: The Clinical Pharmacist as Principal Investigator American. Pharmacotherapy, 2010

Egyptian Clinical Pharmacist Research

Eur J Clin Pharmacol (2013)

ACCP, Evidence of the Economic Benefit of Clinical Pharmacy Services

1979, the first cost- benefit analysis of a clinical pharmacy service was published.

ACCP, Evidence of the Economic Benefit of Clinical Pharmacy Services: 1996–2000. (Pharmacotherapy 2003;23(1):113–132)

Evaluation of Clinical Pharmacy Services in a Hematology/ Oncology Outpatient

Setting

• A clinical pharmacist in outpatient hematology - oncology clinics can potentially result in overall decreased health care costs and in an improvement in the quality of patient care (Wong and Gray 1999).

Breast cancer risk assessmentThe first study assessed the impact of breast

cancer risk assessment and education provided by a community pharmacist.

• The pharmacist provided direct patient care to 140 women.

• There was a positive correlation to adherence of breast self-examination by the patients after patient education was performed by the clinical pharmacist (Giles et al. 2001).

Interventions documentation • In another study, Where Washington DC

Medical Center.• Over an 8 month period, the pharmacy staff

reported 503 interventions, the 2 most common being clinical consultation (33%) and correction of prescribing errors (17%).

• There were 129 supportive care services provided by pharmacists, including nausea/vomiting, hematologic toxicity, pain control, mucositis, allergy, and other general issues. Overall interventions by oncology pharmacists resulted in a medication cost avoidance of $23,091 (Waddell et al. 1998).

1996

Documentation

Make it Loud!

Journal Publications 1 -Original Research

(Clinical trials – pharmacy practice )

2 -Review3 -Short Report

Original Research• Original research articles are

primary sources of scientific literature and present an original study.

• Authors have to conduct research on a particular topic through experiments, surveys, observation, etc. and report the findings of their study through original research articles.

Literature Review

• In writing the literature review, your purpose is to convey to your reader what knowledge and ideas have been established on a topic, and what their strengths and weaknesses are.

Case Study (Short Report)

Where ??? • ACCP virtual poster symposium. • International Oncology

Pharmacy Conferences.• Pharmaceutical conferences. • Cochrane collaboration

Increase the acceptance!!

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THANK YOU!