Abstract
Abstract 1
Type: Poster
Category: Audit
Pre-hydration in high dose methotrexate chemotherapy
Pre-Registration Pharmacist, Newcastle upon Tyne Hospitals NHS Foundation Trust
Northern Centre for Cancer Care (NCCC) gives high dose methotrexate (HDMTX) to treat several diseases, often as part of a trial. HDMTX is high risk treatment requiring careful management. Pre-hydration and urinary alkalinisation is required to increase urine pH to facilitate rapid excretion. NCCC guideline1 states a minimum 6 h pre-hydration with 2 l of fluid, concurrent with sodium bicarbonate to raise urinary pH. Methotrexate infusion can only commence when urinary pH > 7 (or as specified in the trial protocol), ideally in the morning after overnight hydration, no later than 2 pm.
Project arose from nursing concerns that the pH rise was taking longer to achieve than expected.
• Undertake a retrospective service evaluation of pre-hydration in HDMTX cycles
• Is practice in keeping with guideline, and vice versa? Are guidelines practical?
• Determine whether changes required to practice or guidelines
• Prescriptions demonstrating administration records
• Fluid balance charts for urinary pH measurements
• Electronic and paper notes where applicable
• HDMTX protocols from London Cancer Network and BC Cancer Alliance
• Time hydration commenced
• Time required pH achieved, and value recorded
• Time methotrexate infusion commenced
• Fluid and sodium bicarbonate volumes to achieve required pH
• Achieving urinary pH took an average of 7.32 h
• A large difference was observed between cycles with different pH requirements
• Cycles requiring pH ≥ 7 took an average of 6.28 h
• Cycles requiring pH ≥ 8 took an average of 10.59 h
Incidental finding: A gap of 1–2 h between urinary pH achievement and methotrexate infusion. Ideally, methotrexate infusions should commence immediately upon achievement of required pH.
39% HDMTX infusions started before 2 pm.
19.5% HDMTX infusions started between 9 pm and 6 am. This is potentially dangerous; appropriate specialist support may not be readily available in the event of a complication.
Average hydration fluid volume was 2362 ml.
• Documentation ambiguity
• Recording not always clear
• Times and dates, sometimes absent or ambiguous
• Chemocare prescription format did not facilitate clear recording or retrospective interpretation of hydration given after the 6 h minimum (not recorded electronically at time of audit)
HDMTX protocols from London Cancer Alliance and BC Cancer Agency similar to NCCC guideline. Oral bicarbonate was sometimes included alongside IV to raise the urinary pH.2,3 A 2012 American study examined oral bicarbonate use pre-admission in HDMTX therapy, finding it facilitated a faster urinary pH rise and could shorten inpatient stay.4
Adapt guidelines and improve communication and nursing education with regards to clinical trials and higher pH requirements
Consider oral bicarbonate to accelerate pH rise.
Ensure clearer documentation – use Chemocare to record administration, particularly volumes of fluid and bicarbonate.
Consider prospective evaluation to allow the investigator to follow sequentially and clarify with staff where documentation unclear.
References
Abstract 2
Type: Poster
Category: Audit
Investigating antifungal prescribing in haematology at Oxford University Hospitals NHS Foundation Trust – An audit analysing compliance with trust guidelines
Consultant Cancer Pharmacist, Oxford University Hospitals NHS Foundation Trust
Invasive fungal infections carry significant risk in patients suffering with a haematological malignancy. The neutropenic effect of chemotherapy along with the nature of the cancer results in the patient lacking the required neutrophils to prevent infection.1 The Antifungal Medication in Haematology Guideline at Oxford University Hospitals NHS Foundation Trust was written to aid prescribers in selecting the most effective antifungal for prophylactic and treatment purposes taking into account factors such as local resistance patterns. It also contains additional prescribing and monitoring requirements for each antifungal specified in the guideline.2 It is important that clinical guidelines are adhered to as they maximise both clinical efficacy and cost effectiveness thus setting the standard of how all patients in the trust should be cared for.
1. To create an extra section on the guideline defining the extra prescribing/monitoring requirements for each antifungal.
2. To create a reminder on the electronic prescribing system for the prescriber so that they prescribe a test dose of Ambisome® and to include the dose in mg/kg.
3. To create a reminder on the electronic prescribing system when a patient is due a review following commencement of antifungal therapy.
4. To educate staff on the importance of documenting information both electronically and in paper records.
Results were obtained while the Trust was moving to electronic prescribing. It is advised that a future audit should be undertaken to determine whether compliance with the guideline improves once paperless prescribing is implemented.
Additional material is available in the supplementary online file published with this supplement.
References
Abstract 3
Type: Poster
Category: Audit
Audit of year one: Post implementation of national intrathecal chemotherapy (ITC) policy
Senior Oncology and Haematology Pharmacist, University Hospital Waterford
• Was the procedure successful?
• Did the patient have IV Chemotherapy on the same day?
• Was the prescriber on the Intrathecal Register?
• Was the prescription verified by a pharmacist on the IT register?
• Was the IT Chemotherapy collected by the administering doctor?
• Was the IT Chemotherapy checked by a nurse checker who is registered on the Intrathecal register?
• Was the administering doctor on the Intrathecal Register?
• Was the IT Chemotherapy in a designated area for IT use only?
• Were the patient’s bloods appropriate for treatment?
• Was the prescription issued by a pharmacist on the IT register and endorsed appropriately?
• Was the completed prescription and administration record faxed to the pharmacy department upon completion of the procedure?
• 91% of procedures were successfully administered (N = 41)
• No patients had cytotoxic chemotherapy on the same day of IT chemotherapy (N = 0)
• 100% of prescriptions were prescribed by doctors on the IT register (N = 45)
• 100% of prescriptions were verified by pharmacists on the IT register (N = 45)
• IT chemotherapy was collected by the administering doctor in 100% of cases (N = 45)
• IT chemotherapy was checked by a nurse on the IT register in 100% of cases (N = 45)
• The administering doctor was on the Intrathecal register in 100% of cases (N = 45)
• IT chemotherapy was administered in a designated area in 100% of cases (N = 45)
• Patients’ blood results were appropriate for treatment in 76% of cases (N = 34)
• 100% of IT chemotherapy prescriptions were issued by pharmacists on the IT register and endorsed appropriately (N = 45)
• The completed prescription and administration record was faxed to the pharmacy department in 53% of cases (N = 24)
In the 24 % (N = 11) of cases where blood results were deemed inappropriate this was primarily due to APTT/PT not being requested (N = 7), APTT/PT sample unsuitable for analysis (N = 3) or no blood sample analysed in preceding 72 h (N = 1).
This audit has led to a review of the policy with the Haematology team and we have now modified our policy to only require APTT/PT in patients where clinically indicated.
This audit shows that the introduction of a local policy for the safe administration of Intrathecal chemotherapy provides a platform for the medical, nursing and pharmacy team to provide a safe service in an area of high clinical risk.
References
Abstract 4
Type: Poster
Category: Audit
Audit of antiemetic prophylaxis in systemic anticancer treatment patients in University Hospital Waterford
Senior Oncology and Haematology Pharmacist, University Hospital Waterford
• What percentages of patients suffer from acute vomiting?
• What is the extent of acute vomiting that is suffered by patients?
• What percentages of patients suffer from acute nausea?
• What is the extent of acute nausea that is suffered by patients?
• What percentages of patients suffer from delayed vomiting?
• What is the extent of delayed vomiting that is suffered by patients?
• What percentages of patients suffer from delayed nausea?
• What is the extent of delayed nausea that is suffered by patients?
This is an internationally validated tool to quantify the degree of acute and delayed nausea and vomiting experienced by patients receiving chemotherapy.
The patients were educated on the use of the tool and completed it after receiving their chemotherapy. The scoring tool was then returned to the HODW upon completion. Forty patients returned forms that had sufficient data for evaluation.
When the forms were returned the following data were gathered:
• Chemotherapy regime
• Cycle of chemotherapy
• Day of current cycle
• Did the patient have acute vomiting?
• Number of acute vomiting episodes
• Did the patient experience acute nausea
• Nausea score out of 10
• Did the patient experience delayed vomiting?
• Number of delayed vomiting episodes
• Did the patient experience delayed nausea
• Delayed nausea score out of 10
• No patient experienced acute vomiting
• 17.5% of patients experienced acute nausea (N = 7)
• 2.5% of patients experienced delayed vomiting (N = 1)
• 25% of patients experienced delayed nausea (N = 10)
• The average score for acute nausea was 3.14/10
• The average score for delayed nausea was 4.7/10
• The average number of delayed vomiting episodes was 5
• Oxaliplatin- and Paclitaxel-containing regimens were the most frequent causes for delayed nausea
• Oxaliplatin, Irinotecan and oral Fludarabine caused the most severe cases of delayed nausea
• Oral Fludarabine was responsible for acute nausea and delayed vomiting
The need to amend our local policy to introduce novel agents such as Palonosetron/Netupitant for moderately emetogenic regimens containing Oxaliplatin in combination with other moderately emetogenic chemotherapeutic agents, as well as all highly emetogenic regimens is a step taken on foot of this audit.
Continuing this audit and comparing the results six months post implementing this change to current levels of acute and delayed nausea will indicate how successful the novel approach to dealing with this therapeutic challenge has been.
References
Abstract 5
Type: Poster
Category: Audit
An audit of Aprepitant for the prevention of nausea and vomiting after chemotherapy
Consultant Pharmacist, University Hospital Birmingham NHS Foundation Trust
Aprepitant (a neurokinin 1-receptor antagonist) is widely used for prevention of nausea and vomiting in patients receiving moderately and highly emetogenic chemotherapy. Due to interest in using an alternative agent (Akynzeo®) in this setting, it was felt important to first obtain data on the efficacy of our current standard of care – aprepitant plus ondansetron.
The aim of this audit was to evaluate the effectiveness of aprepitant against the following audit standards based (where available) on relevant clinical trial literature1–3:
• 40% of treatment cycles will result in a CTC nausea score of 0 (i.e. no nausea)
• 70% of treatment cycles will result in a CTC nausea score of 0–1 (i.e. no significant nausea)
• 75% of treatment cycles will result in a CTC vomiting score of 0
• 90% of patients will not need to contact the Trust chemotherapy helpline because of issues relating to nausea and/or vomiting
• 95% of patients will avoid readmission to hospital because of uncontrolled nausea and vomiting
• 95% of patients will avoid chemotherapy dose delays or dose reductions related to nausea and vomiting
Data relevant to the audit standards were collected from the Trust electronic prescribing and clinical noting systems for all cycles of chemotherapy received by eligible patients and were then analysed using Microsoft Excel®.
If missing data are excluded, aprepitant was effective at preventing emesis in 82% of treatment cycles. Similarly, no nausea was reported for 55% of cycles and no significant nausea for 93% of cycles.
The Trust 24-hour chemotherapy helpline received 23 calls from 17 patients (22% of audit population) who were suffering from nausea/vomiting at home. All calls occurred after cycle 1 or 2 of chemotherapy only. Twelve patients (16%) were admitted to hospital for reasons either partially or wholly related to nausea and vomiting. Three patients (4%) required a dose reduction because of nausea and vomiting but there were no treatment delays due to this complication.
Additional material is available in the supplementary online file published with this supplement.
References
Abstract 6
Type: Poster
Category: Audit
Is the use of GCSF justified in patients receiving docetaxel for castrate resistant prostate cancer?
Specialist Pharmacist EP, The Christie Manchester
Docetaxel plus prednisolone has been a standard treatment for castrate-resistant prostate cancer patients since results published in the TAX327 trial.1 This trial did not use prophylactic GCSF and 32/332 patients had grade 3 or 4 neutropenia whilst the actual rate of Febrile neutropenia (FN) was low with 3/332.
GCSF has been used at The Christie with Hormone sensitive docetaxel treatment since the publication of the upfront docetaxel data from the Stampede trials.2 This study demonstrated much higher rates of FN (15%) than TAX327. Prophylactic GCSF in this setting is appropriate.
Reduction of FN is key to ensure patient safety, reduce hospital admissions, maintain dose intensity and to allow completion of treatment.3
Incidence of FN was collected from the electronic notes system to give overall rates of FN for each population. Dose reductions and treatment discontinuation were noted as further outcomes.
The rate of NS seen here is similar to the rate seen in the stampede trial however much higher than what was seen in the TAX327 trial. A 12% chance of FN is considered intermediate risk4; however, patient factors in this group (such as age over 65 and advanced disease) increase risk to high. It is justified to strongly consider the use of prophylactic GCSF in this population in order to maintain dose intensity and improve patient’s safety whilst considering cost, the palliative nature of treatment and patient outcomes.
Additional material is available in the supplementary online file published with this supplement.
References
Abstract 7
Type: Poster
Category: Audit
A retrospective audit to assess if outpatient prescribing of oral antiemetic(s) complies with antiemetic guidelines for adult patients receiving chemotherapy and/or radiotherapy at the Macmillan Dispensary
Pharmacist, University College London Hospital and The Cancer Centre for Medicines Optimisation, Research and Education (CMORE)
Chemotherapy and radiotherapy induced nausea and vomiting (CINV/RINV) is the most frequently experienced side effects encountered by chemotherapy patients1 and can lead to unnecessary prolonged hospital admissions.2 North Central London & UCL Partners published evidence-based and cost-effective local guidance on treatment of CINV/RINV according to emetogenic risk associated with patients’ chemotherapy regimen.2 This is the first audit to assess compliance of outpatient prescribing of antiemetic therapy for adult patients experiencing CINV/RINV against these guidelines, as they were published in 2016.
• 100% of adult patient’s prescribed antiemetic therapy on outpatient prescriptions should be prescribed in line with the NCL Antiemetic guidelines for adult patients receiving chemotherapy and radiotherapy
• Documentation of the management of failed antiemetic therapy should be fully logged on Chemocare or LaunchPad by either doctor/pharmacist, in 100% of the cases
• 100% of patients starting new antiemetic therapy as an outpatient should be fully counselled on how to take their medication by a member of the pharmacy team
• 100% of prescriptions are legible and clearly written in line with general prescription requirements
• Audit registered within trust audit log and approved at Chemotherapy governance January 2017.
• Data collection tool designed and piloted on 10 patients presenting with an outpatient prescription containing antiemetics to MCC dispensary.
• Areas of improvement identified; data collection tool improved
• Screening pharmacists at MCC dispensary asked to identify scripts consisting of antiemetic therapies, over three weeks and complete data collection tool.
• All dispensary staff handing out prescriptions noted down whether counselling was provided to patients starting the antiemetic for the first time.
• Data input into Microsoft Excel
• Launchpad, Chemocare and CDR used retrospectively to research patient, e.g. the Chemotherapy/Radiotherapy regimen, any notes regarding specific changes or failed antiemetic therapy.
• Patients prescribed Dexamethasone as an antiemetic on an outpatient prescription. (All prescribing of Dexamethasone as an antiemetic should be strictly on Chemocare).
• Any patients prescribed antiemetics not due to CINV/RINV.
• Paediatric patients (<18 years).
• Clinical Trial patients
Fifty-three prescriptions met the inclusion criteria and were included in the audit.
Prescribers often incorrectly opted third-line therapies, e.g. Ondansetron 8 mg BD-TDS, without attempting second-line therapy, e.g. Cyclizine 50 mg TDS. Based on 2016 NHS Tariff a typical 14-day course of Ondansetron will cost more than four times the equivalent course of Cyclizine, showing a lack of awareness of the NCL guidance. Three audit standards were not met; implying lack of awareness of the NCL guidance. Improvements in documentation by pharmacists and medical staff are key to ensure accurate follow up and improve patient’s confidence in therapies.
Additional material is available in the supplementary online file published with this supplement.
References
Abstract 8
Type: Poster
Category: Audit
A retrospective clinical audit evaluating anti-fungal treatment approaches in high risk haematology patients
Lead Haematology Pharmacist, Oxford University Hospitals NHS Foundation Trust
Patients with haematological malignancies are at high risk of invasive fungal disease (IFD) including patients with prolonged neutropenia especially during induction chemotherapy for acute myeloid leukaemia or myelodysplastic syndrome and allogeneic haematopoietic stem cell transplant; other risk factors include prolonged steroid use and graft versus host disease 1. IFDs are classified as possible, probable or proven based on host, clinical and microbiological features using the EORTC/MSG criteria 2. Recommendations for prophylaxis, diagnosis and treatment of invasive fungal infections, vary across national and international guidelines (ECIL5 3, GSHO 1, IDSA 4).
Antifungal prescribing data for 115 patients were pulled from electronic prescribing records. Additional data collected included primary diagnosis and chemotherapy treatment, risk factors for IFIs and IFI diagnostic data (CT imaging and laboratory fungal tests). Mortality reports and post-mortem records were reviewed for the cause of death.
Further evaluation is required to assess health economics and resource implications of prophylactic and treatment approaches.
Additional material is available in the supplementary online file published with this supplement.
References
Abstract 9
Type: Poster
Category: Audit
A review of incidence of invasive fungal infection and antifungal expenditure post introduction of BHT antifungal guidelines for the prophylaxis and treatment of fungal infections with oral posaconazole in high risk haematology patients
Principle Cancer Pharmacist, Buckinghamshire Healthcare NHS Trust
Posaconazole prophylaxis in high-risk haematology patients has been shown to significantly reduce the risk of invasive fungal infection.1 The BHT guideline for the treatment and prophylaxis of fungal infections in high-risk haematology patients with acute myeloid leukaemia or myelodysplastic syndromes treated with intensive chemotherapy was introduced in June 2015. This guideline recommends posaconazole prophylaxis in this high-risk group. Posaconazole treatment is funded by NHS England provided a trust guideline is in place and appropriate internal audit is undertaken. The premise behind the introduction of this guideline is that there will be less high-risk patients who require management with therapeutic anti-fungal agents and the cost of posaconazole prophylaxis will be offset by the reduced cost of therapeutic anti-fungal agents. Previous network approved prophylaxis in these patients was fluconazole 50 mg daily.
• 29 patients were treated with prophylactic posaconazole in the 12 months post guideline implementation. Cost was £186,000.
• Pre-guideline (12 months) Post guideline (12 months)
• Number of patients identified for inclusion in audit 34 27
• Number of episodes of suspected or proven IFI managed with antifungal agents 47 31
• Cost of IFI treatment £263,000 £74,000
• Table 1 High-risk AML/MDS receiving anti-fungal prophylaxis
Further review of this guidance is now required to compare treatment costs and prophylaxis since the introduction of generic antifungal agents for the management of IFIs (voriconazole and caspofungin).
References
Abstract 10
Type: Poster
Category: Audit
An audit of post chemotherapy antiemetic prescribing pre and post the domperidone MHRA Alert (2014)
Rotational Clinical Pharmacist, University College London Hospital and The Cancer Centre for Medicines Optimisation, Research and Education (CMORE)
In April 2014, the Medicines and Healthcare Products Regulatory Agency (MHRA) issued an alert on the use of domperidone, including reductions in its recommended dose and duration.1 The effect of adopting these restrictions, in relation to the prevention of chemotherapy induced nausea and vomiting (CINV), is one which has remained unknown with little or no research and audit completed in the area.
• 100% of patients audited pre and post the MHRA alert will not experience antiemetic failure.
• No statistical difference will occur between the antiemetic failure observed in the pre and post audit arms.
References
Abstract 11
Type: Poster
Category: Audit
Patient acceptability of national chemo dose banding leaflet
Pre-Registration Pharmacist, North Tyneside Hospital Rake Lane
Patient’s views are traditionally not taken account when introducing changes in how chemotherapy drugs are provided to them. Information on drugs can cause anxiety.1 The national dosing banding project sought to harmonise all prescribing of dose banding chemotherapy within England.2 As part of the project a patient information leaflet was developed and shared with patient groups for feedback and then a real-world evaluation of the leaflet with patients receiving chemotherapy was undertaken.
Explore how much detail on drug dosing should be provided to chemotherapy patients
• Qualitative audit of patients views
• Cohort of 20 patients receiving chemotherapy at a multi-site Hospital Trust in May 2017
• After verbal consent to participate received, patients given leaflet, allowed time to read the interviewed by researcher
• Five structured questions (Likert scale on acceptability) on patients’ opinions on leaflet, followed by in-depth exploration of patients views.
• Themes for questions were:
(1) Easy to read
(2) Understood it
(3) Answered all questions
(4) Necessary
(5) Did it cause any concerns
• 17 patients reported they completely understood information, 3 understanding most
• 18 patients reported they had no concerns about dose banding, 1 was unsure and 1 patient had concerns.
On the whole, there were no significant concerns about dose banding after reading the leaflet. However, one patient was concerned that it would be more difficult to change the dose if he experienced any problems during his treatment. Another would have liked to know a bit more about the amounts that doses are rounded up or down.
The majority of patients thought the leaflet was clearly presented, easy to read and they understood the content. Two patients felt the paragraph explaining that ‘the amount a dose would be changed if a patient experiences problems would be much larger than the amount that it would be changed in dose banding’ wasn’t very clear.
Patients generally did not ask any questions or want to know further information after reading the leaflet, suggesting that it contains all necessary information.
Additional material is available in the supplementary online file published with this supplement.
References
Abstract 12
Type: Poster
Category: Audit
Pilot audit for national chemotherapy delays
Pharmacy Practice, University of Central Lancashire
Delays to chemotherapy treatment have been examined in limited ways, e.g. individual diseases, single centre studies. A recent publication by Gardini et al (2016) looked at this across a number of sites, reviewing retrospectively dose reductions and interruptions over a one-year period and reported a dose reduction rate of 10% and a discontinuation rate of 9%. Whilst there may be debate on the impact of delays on disease outcome there are economic consequences, these include wastage of pre-made chemotherapy, travel expenses for patients and also underused chemotherapy slots and waiting list considerations. It is therefore important to understand the prevalence of chemotherapy delays and cancellations to aid planning of services. In addition to this, national trends may enable adaptation of supportive care guidelines to match the real-world consequences that are observed.
Feedback from both the sites and students were taken and the data collected was analysed using only descriptive methods.
• Interpretation of terminology
• Different processes at each site
• Location of data collection (clinic versus aseptic suite)
These issues meant that the data from each site could not be directly compared although there was consistency in reported rates (20%), which is much higher than previously suggested.
Some data are worth presenting. The most prevalent reasons for delay were non-haematological toxicity and patient choice (43.9 and 31.7%, respectively) from site 1, and admission to hospital and not fit for chemotherapy (25 and 18%, respectively). Site 1 was also able to collect wastage data. Interestingly, despite the use of dose banding and third party purchase 70% of the delays resulted in advance prepared doses being wasted. Some additional data from site 1 suggested that delayed patients were not more likely to have been previously delayed, were more likely not to have received GCSF or anti-infective therapy and, during the data collection period this was their first delay.
The pilot also highlighted that there may be misconceptions about the patients, e.g. impact of previous delays.
References
Abstract 13
Type: Poster
Category: Audit
Incidence of neutropenia in breast cancer patients receiving fixed-dose GCSF: Are we underdosing patients with higher body weights?
Clinical and Chemotherapy Pharmacist, The Royal Marsden Hospital NHS Foundation Trust
The summary of product characteristics of all available filgrastim preparations available in the UK state doses of 5 µg/kg/day should be used in adult and paediatric patients receiving cytotoxic chemotherapy (10 µg/kg/day in patients treated with myeloablative therapy followed by bone marrow transplantation). Additionally, current guidelines establish doses of 300 and 480 µg are to be used in patients below or over 80 kg, respectively. However, the use of flat doses regardless of patients’ weight seems to be standard practice in a number of centres across the UK.
Baseline and treatment characteristics were summarised in Table 1.
A total of 47 patients <80 kg (15.77%) and 23 patients ≥80 kg (23.71%) experienced at least one episode of CTCAE v4 grade 3+ neutropenia (including febrile neutropenia) whilst on treatment.
Fisher’s exact test’s p = 0.053; NNH = 12.6.
Additional material is available in the supplementary online file published with this supplement.
References
Abstract 14
Type: Poster
Category: Audit
SACT dose banding at the Royal Marsden Hospital
Overseas Pharmacists, The Royal Marsden NHS Foundation Trust
One of the objectives set out in the Commissioning for Quality and Innovation (CQUIN)1 guidance and an initiative to improve patient safety and cost savings, is the standardisation of systemic anticancer therapy (SACT) doses across England. A nationally approved set of dose bands have been developed for local adoption which aim to both improve efficiency and reduce wastage.
A local audit was conducted to review the compliance to the national dose bands, to identify causes for discrepancies and to recommend improvement measures accordingly.
Second, two major contributors to non-compliance were the continuation of a legacy dose and failing to dose band a dose reduction. It is understandable that many cases have started SACTs before dose banding standardisation is advocated. Nevertheless, with the implementation of the new national dose banding practice, it is recommended that pharmacists can take a more proactive role in communicating with doctors to reinforce the need to prescribe a nationally approved banded dose, especially during dosage reduction and starting a new chemotherapy regimen (cycle 1).
Moreover, non-banded doses occasionally arose due to the use of extreme doses, which fell beyond the boundaries of the standard dose bands on the E-chemo system. As the Royal Marsden progresses towards a new electronic prescribing system, the aim would be to incorporate a comprehensive dose banding database, which calculates and bands these doses, thereby resolving this problem in the future.
Additional material is available in the supplementary online file published with this supplement.
Reference
Abstract 15
Type: Poster
Category: Audit
Audit of oral anticancer medication prescribing in University Hospital Waterford
Senior Oncology and Haematology Pharmacist, University Hospital Waterford
We aimed to find out how many OAM high tech prescriptions for cycle 1 of a patient’s chemotherapy had sufficient information to allow a non-specialist community pharmacist to safely dispense OAM before specialist pharmacist intervention.
Each patient file in the chemotherapy unit of the UHW Pharmacy Department has a copy of the patient’s pharmaceutical care plan and their high tech OAM Rx. Each Rx was checked for the following:
• Treatment
• Indication for Treatment
• Was the treatment licensed for this indication
• Was the indication documented on the Rx?
• Was the dose as per the licensed instruction?
• Was the dose as per a UHW/NCCP protocol?
• Is the dosing information available in the BNF or drug SPC?
• Is the Rx safe to dispense by a non-specialist community pharmacist?
• If not, would a hospital pharmacist intervention make the Rx safe for a non-specialist community pharmacist to dispense?
• The licensed indication was used in 87.6% of Rxs (N = 114)
• The indication was noted on the Rx in 40.77% of cases (N = 53)
• The licensed dose was used in 53.07% of Rxs (N = 69)
• A UHW/NCCP protocol was used in 90% of cases (N = 117)
• 22.3% OF Rxs had enough information documented on them to allow a non-specialist community pharmacist safely and legally dispense the OAM
• A specialist hospital pharmacist intervention brought this figure up to 97% of Rxs
• Putting the indication on the Rx alone as an intervention would increase the number of safe Rxs to 40%
• The other 60% of Rxs fell into the following cohorts:
• 32% of Rxs were unlicensed use of a medication but used according to a UHW or NCCP Protocol
• 25% of Rxs had a drug interaction or dose reduction that required addressing
• 3% of Rx were Non-protocol doses based on Phase 2 trial
As a result of this audit all dose adjusted high tech Rxs for OAMs are now verified by chemotherapy trained pharmacists as well as OAM Rxs prior to cycle 1.
The hospital pharmacist verification step in the prescribing and dispensing OAM High Tech Rxs improved the safety of OAM High Tech dispensing in community pharmacies from 22.3% to 97%.
A multidisciplinary approach which draws on the medical, nursing and pharmaceutical expertise of all disciplines improves the safety, quality and efficacy of patient care in complex high-risk patient journeys
References
Abstract 16
Type: Oral and Poster
Category: Audit
An audit on waste of adult systemic anticancer therapy at University College London Hospitals NHS Foundation Trust Pharmacy Aseptic Production Unit
Cancer Pharmacist, University College London Hospital and The Cancer Centre for Medicines Optimisation, Research and Education (CMORE)
The NHS has a responsibility to use medicines optimally, cut waste and increase productivity to ensure that the limited funds available may be spent on improving the health service or patient care. In 2016, NHS England implemented a national dose banding system to help standardise and optimise intravenous Systemic Anti-Cancer Therapy (SACT) doses and reduce waste.1
Standards 1–3: 100% paclitaxel, carboplatin and gemcitabine doses dispensed by UCLH PAPU used before there expiry date.
Agents were expected to be banded as per national bands to make this achievable as any cancelled/omitted doses can be reallocated to other appropriate patients.
Standards 4–6: 100% paclitaxel, carboplatin and gemcitabine doses dispensed by UCLH PAPU dosed as per the national dose banding system.
Reference
Abstract 17
Type: Oral and Poster
Category: Audit
Comparison of melphalan administration time post implementation of nurse and pharmacist led autologous pathway in ambulatory care at UCLH
Lead Haematology Pharmacist, University College London Hospital and The Cancer Centre for Medicines Optimisation, Research and Education (CMORE)
At University College London Hospitals NHS Trust (UCLH), nearly 80% of myeloma patients receiving Melphalan autografts are treated in ambulatory care (AC). Cell infusions are administered either 24 or 48 h, in the case of poor renal function after melphalan infusion. The administration start time is essential in assuring adequate medical cover is available for this subsequent cell infusion, due to the risk of infusion reactions and 2 pm is considered the latest start time for melphalan.
In 2015, an evaluation of 32 patients between January and June 2015 attending AC showed that 13% (n = 4) of melphalan was administered by 2 pm, with a total time range of 10:00–17:00. Reasons for late administration were identified as prescribing and consenting occurred on admission (81%, n = 29), of which the most common time was between 12 and 1 pm (43%). Pharmacy verification and aseptic dispensing would follow prescribing, and only after this point could administration commence.
A nurse- and pharmacist-led pathway was implemented in November 2015 to reduce delays in AC.
1. 100% Melphalan prescribed prior to admission
2. 100% Melphalan administered by 2 pm
A total of 74% (n = 34) of patients had melphalan administered by 2 pm. The reasons for late melphalan administration were delays in pharmacy production (n = 9), patient requiring a medical review (n = 1), chemotherapy not prescribed in advance (n = 1) and human error (n = 1).
Further work is required with the medical team as 28% (n = 13) of patients were not prescribed in advance. In addition, a review of the production turnover times is required as pharmacy delays resulted in late administration.
Finally, to identify areas of improvement a prospective audit is planned and will identify patients not following the pathway, and promptly address issues.
One limitation of the audit is the time melphalan was ready in pharmacy was used as the melphalan administration time. Due to the short expiry of the drug the nurses administer the infusion when it is ready.
Additional material is available in the supplementary online file published with this supplement.
Abstract 18
Type: Poster
Category: Innovation, service evaluation or service improvement
Immune checkpoint inhibitors: A multidisciplinary approach to improve practice and patient safety
Senior Cancer Care Pharmacist, Beatson West of Scotland Cancer Centre
Immune checkpoint inhibition is associated with a unique spectrum of side effects termed “Immune-related Adverse Events (irAEs)”. Management of irAEs is unlike that of conventional systemic anti-cancer treatment (SACT) and early identification of adverse events and timely intervention is critical. The majority of irAEs improve or resolve with appropriate management, including interruptions of treatment and administration of corticosteroids and/or supportive care. The development of a guideline will play a key role in the effective and safe delivery of these treatments.
The group will meet at fixed intervals to drive a continuous improvement programme in this developing area of medicine.
Additional material is available in the supplementary online file published with this supplement.
Abstract 19
Type: Poster
Category: Innovation, service evaluation or service improvement
Community pharmacies supporting patients on oral anticancer medication (OAM): A mixed methods study of patient’s needs and views
Darzi Fellow in Leadership in Health, Guy’s and St Thomas NHS Foundation Trust
The use of oral anticancer medication (OAM) for cancer treatment is increasing.1 It is expected that 25% of cancer treatment will be in an oral form in the next decade.2 Community pharmacies are ideally placed to provide additional support closer to home to this patient group.3 It is therefore important to understand what patient’s needs are and what their perceptions of community pharmacy are.
To identify if patients on OAM currently visit their community pharmacy in regards to their cancer and their cancer medication.
To identify cancer patients perceptions and experience of community pharmacies.
Twenty-three per cent (n = 142) of patients required extra support in between their hospital clinic visits requesting a range of supportive issues as detailed in Figure 1 (supplementary material available online). The majority (75%) currently contact their hospital oncology team for these issues.
Seventy-seven per cent (n = 142) have a regular community pharmacy that they visit but only 8% have ever visited with a cancer-related query.
Quotes from the focus group and informal interviews:
When asked about visiting a regular pharmacy participant 3 said:
‘I think it’s important to get, you know, familiar with your pharmacist and they get to know you’
When we asked participant 6 why they would not visit their community pharmacy the response was:
‘Why would it occur to me to call someone that just looks at a prescription, gives you the pills and never says another word?’
On leaving the focus group participant 3 said:
‘We should make more use of our pharmacists. I will do after today.’
Funding was received from the King's Health Partners Pharmaceutical Science Clinical Academic Group.
Additional material is available in the supplementary online file published with this supplement.
References
Abstract 20
Type: Poster
Category: Innovation, service evaluation or service improvement
Qualitative analysis of the multidisciplinary acceptability of the introduction of a band 7 oncology pharmacist into a breast cancer clinic
Lead Gastrointestinal Cancer Pharmacist, Royal Marsden Hospital
Lord Carter’s review recommends that pharmacists spend more time on patient-facing and medicines optimisation activities.1 By integrating a band 7 oncology pharmacist into the multidisciplinary breast clinic, as opposed to remotely screening SACT in isolation on the Medical Day Unit (MDU), it was anticipated that a pharmacist could provide more proactive intervention and support to the multidisciplinary team, improving patient outcomes.
To obtain the perception of members of the multidisciplinary team on the impact and acceptability of introducing an oncology pharmacist into the multidisciplinary clinic
Qualitative comments were given for 24 questionnaires. All of them were positive. Key themes for nurses were the improved efficiency, education and training and organisation of the subcutaneous injection clinic. Medical staff valued the face-to-face interaction and clinical support with drug interaction queries, dose adjustments and electronic prescribing support. Other healthcare professionals valued the improved communication.
Reference
Abstract 21
Type: Poster
Category: Innovation, service evaluation or service improvement
A multidisciplinary approach to chemotherapy prescribing at Newcastle upon Tyne Hospitals NHS Foundation Trust
Lead Clinical Pharmacist-Specialist Haematology, Newcastle upon Tyne Hospitals NHS Trust
Newcastle Upon Tyne Haematology service has made changes in recent years to provide streamlined care for patients, focusing on reduced wait times and improved quality of care. The original pathway was costly in time, involving several waits for the patient: for urgent venepuncture, physician consultation, prescribing of chemotherapy, specialist pharmacist screening of prescriptions and outpatient pharmacy for dispensing. Patients returned home and waited for the Clinical Nurse Specialist (CNS) to ring and confirm if blood results were appropriate for chemotherapy administration. Pharmacy waiting times for oral outpatient prescriptions are approximately 30 min.
Deferred oral chemotherapy can be returned to pharmacy stock, minimising waste. Intravenous chemotherapy is pre-planned and authorised on the day of treatment if patients are fit to proceed.
Patient satisfaction was assessed using a patient questionnaire.
Data for deferred treatments were collated using paper records and Chemocare.
JAC (pharmacy dispensing system) was used to check individual patient dispensing in order to assess potential savings by returning medication to pharmacy.
Results showed 89% of patients noted a reduction in wait times and 89% felt they spent more time in consultations. All patients noted they spent more time with the CNS and benefited from not attending pharmacy. All patients rated the service more efficient.
However, it must be noted that during Jan–June 2015 the cost of wasted drug, due to patients being unfit for treatment on the day, potentially incurred by pre-prescribing was £57,775. It is, therefore, critical to ensure that medication that has not yet been given to patients can be returned to pharmacy if this type of pre-prescribing model is to operate efficiently.
Abstract 22
Type: Poster
Category: Innovation, service evaluation or service improvement
A survey of the pharmaceutical care provided to patients with cancer treated on non-cancer wards
Lead Oncology Pharmacist, Salisbury NHS Foundation Trust
There are professional recommendations concerning the pharmaceutical care of patients with cancer when they are treated on cancer wards but not when they are treated on non-cancer wards. A literature search failed to uncover any publications or formal documentation concerning how this issue has been addressed at other Trusts hence, our local practice could not be compared with any accepted practice or standards. A questionnaire was developed in order to gather these data and aid benchmarking our local practice against other Trusts.
• To identify and describe specialist cancer pharmacy support for the pharmaceutical care of patients with cancer treated on non-cancer wards at other Trusts.
• To compare local service provision of cancer pharmacist support with that provided at other Trusts.
• A draft quantitative, self-administered questionnaire was developed and usability testing carried out.
• The final version, sent out to the BOPA membership, was available for completion over an eight-week period.
• A numerical coding framework was developed and applied.
• Analysis involved generation and interpretation of descriptive statistical information such as number and percentage of responses to each question.
Eight responses were obtained from respondents in specialist hospitals in which all inpatients have cancer. Of these, three provided specialist input to another hospital.
When there was a pharmacist working in an acute oncology team (AOT), the majority (20/28) provided this service during normal working hours with a further five ‘sometimes’ and three providing a ‘24 hour service’.
With the exception of Scotland in which seven out of 15 reported pharmacy involvement with an AOT, not having a pharmacy staff on the AOT was the most frequent response in each geographical area.
Where a hospital has an AOT, the majority (91/134), like my Trust, did not include a pharmacist reviewing patients.
When asked if there were any arrangements for cancer pharmacy support for the team on non-cancer wards, 48% (59) said there were whilst 52% (63) said there was not. For both groups, the most frequent description of their local situation was ‘we would deal with each situation on an individual basis’.
Those who did not have cancer pharmacy review arrangements reported a lack of resources more often (21/63) than those who did provide a service (3/59). No one responded that there was ‘no need for the service’.
The results implied that if there were resources available then more pharmacies would offer this service. The impact of providing a service has not been studied.
Abstract 23
Type: Poster
Category: Innovation, service evaluation or service improvement
Patient satisfaction with a clinical pharmacy service to chemotherapy day treatment units
Cancer Consultant Pharmacist, Oxford University Hospitals NHS Foundation Trust
A previous service evaluation for clinical pharmacy services at the chemotherapy day treatment units (DTUs) at Oxford University Hospitals NHS Foundation Trust (OUH) reported on the patient experience, staff satisfaction and cost savings. It focussed on the oncology and haematology DTUs at the Oxford site but not the Horton unit in Banbury, which covers all cancers. In addition, although patient experience was reported to be positive, the data collection questionnaire was not validated and did not focus on satisfaction with the process and outcome of the pharmacy service. No validated instrument exists to measure patient satisfaction with clinical pharmacy interactions on chemotherapy DTUs. This provided the rationale for adapting an existing, validated patient satisfaction questionnaire (PSQ) focussing on pharmacy consultations for use in the current study.
Abstract 24
Type: Poster
Category: Innovation, service evaluation or service improvement
Service evaluation of a myeloma pharmacist non-medical prescribing service
Specialist Cancer Pharmacist, Oxford University Hospitals NHS Foundation Trust
The non-medical prescribing (NMP) role undertaken by pharmacists is increasingly extended to cancer patients. Oxford s Cancer Centre has 5 prescribing pharmacists working in colorectal, urology, breast and myeloma. The myeloma service quality meeting identified the need for a myeloma NMP service evaluation.
Five questionnaires per week for 4 weeks were issued to patients attending the myeloma clinic. Patient selection took place during the myeloma pre-clinic meeting. Suitable patients were those who previously underwent review or were currently undergoing review, by the pharmacist prescriber. To ensure neutrality and anonymity, questionnaires were handed out by and returned to the myeloma service co-ordinator at the outpatient reception.
Patients reported the overall rating of their experience as follows: excellent (42%), very good (37%), good (11%), fair (0%), poor (0%), no rating issued (10%). Only seven of 19 patients reported what went well during the consultation, as follows: “very informative and helpful”, “thorough and not rushed”, “all problems addressed”, and “relaxed, caring and personable pharmacist”. Only four of 19 patients answered the question on aspects that could be improved; two patients stated “none”, one highlighted the need to improve time keeping of appointments, and one suggested to discuss myeloma paraprotein results at the beginning of the consultation. One patient raised the issue of repeated drug delivery delays to their home address.
Additional material is available in the supplementary online file published with this supplement.
Abstract 25
Type: Poster
Category: Innovation, service evaluation or service improvement
An overview of the implementation of year 1 of the dose banding of chemotherapy CQUIN at Sheffield Teaching Hospitals
Oncology pharmacist and Leadership fellow, Sheffield Teaching Hospitals
Following on from the publication of the Carter report in 2016, NHS England to date has developed several commissioning for quality and innovation (CQUIN) initiatives to deliver quality improvements and drive transformational change within the NHS in England. One of the CQUINs for the year 2016/17 was the implementation of dose banding intravenous chemotherapy. Sheffield Teaching Hospitals (STH) signed up for year 1 of the CQUIN. My role as a leadership fellow secondment for one year with the project of the dose banding CQUIN was to analyse data and to see what the advantages of the CQUIN were in practice and what this means for STH going forward.
During quarter one, the CQUIN was taken to the Drugs and Therapeutics committee (D&T) for approval, quarterly targets were set, a dose banding implementation group was formed and a plan for the implementation was created. Drugs were dose banded in separate stages, on a weekend where the system was not been actively used, over the whole year. Following the implementation of the dose bands, some of the products were then outsourced to pharmaceutical manufacturers as per the North of England chemotherapy tender. Throughout quarters 2 and 3 the number of doses prescribed in line with the dose banding tables was analysed and submitted to NHS England using the Excel spread sheets supplied from NHS England. At the end of quarter 4 as well as submitting the quantitative data to NHS England further analysis over the year using Excel, looked into the number of doses prescribed and expenditure of the seventeen dose banded drugs.
Throughout the year a decrease in expenditure of the 17 dose banded drugs was seen from £347 128.80 in April 2016 to £273 576.60 in March 2017. There was also a slight increased in number of doses prescribed over the year from 1936 doses in April 2016 to 2074 in March 2017. In comparison to the beginning of the financial year to the end there has been just short of £100 000 savings in the expenditure of the dose banded drugs per month. A graph showing the trends over the year in relation to expenditure and number of doses prescribed can be seen in the supplementary online file published with this supplement. Some products were outsourced to pharmaceutical manufacturers prior to the dose banding CQUIN but this number has increased to free up isolator time and increase capacity of the cytotoxic aseptic unit at STH during the course of the year. From the data analysed above it was decided more work into chemotherapy waste and how to improve our pathways surrounding waste and chemotherapy re-utilisation was required.
In conclusion it is clear to see that the dose banding CQUIN does reduce expenditure and may increase capacity of aseptic units, however there are many further service improvements which can all contribute to increasing efficacy, reducing cost and ultimately increasing patient safety.
Additional material is available in the supplementary online file published with this supplement.
Abstract 26
Type: Poster
Category: Innovation, service evaluation or service improvement
A patient satisfaction survey of a new cancer satellite pharmacy
Consultant Cancer Pharmacist, Oxford University Hospitals NHS Foundation Trust
A satellite pharmacy was built in the Churchill Hospital Cancer and Haematology Centre in October 2015 to prevent patients having to walk 1 km to the main pharmacy to collect their medicines and enable patients to receive information and counselling from specialist pharmacy staff.
Thirty-four per cent (12/35) of patients had used the pharmacy less than a month or for 3–6 months. Forty-one per cent (15/37) had previously used the main pharmacy at the Churchill hospital with patients reporting better distance from the cancer centre and less waiting times at the satellite in comparison. Over 80% of patients had been asked by the pharmacy staff if they had the medication before and if they had any allergies. Only 61% (17/28) of patients said they were given information about their medicine. For patient satisfaction, 91% (32/35) were satisfied/very satisfied with the time taken to be seen by staff. Over 80% satisfaction was obtained for being told when the prescription would be ready and how they could find out it was ready. Less than 80% satisfaction was achieved with waiting times, being told how to take their medicines, an opportunity to raise any concerns (although 26% ticked ‘not applicable’) and the waiting area space (60%; 21/35).
Abstract 27
Type: Poster
Category: Innovation, service evaluation or service improvement
Evaluating a pharmacist prescriber role in haematology and oncology clinics
Consultant Pharmacist, University Hospital Birmingham NHS Foundation Trust
In June 2016, as part of a 12-month pilot of a consultant pharmacist post, the post-holder started working in four different outpatient clinics in haematology and oncology at University Hospitals Birmingham NHS Foundation Trust, reviewing patients (who would previously have been seen by a doctor) and prescribing relevant medication, including chemotherapy.
The aim of this piece of work was to evaluate the impact of this service development, focusing on activity data and levels of satisfaction with the service amongst patients and colleagues.
A total of 76 completed patient questionnaires were received (50% response rate). Key findings are summarised below:
• 59% of respondents felt that waiting times in clinic were shorter when they saw the pharmacist (this figure was 81% for the CML/MDS clinic)
• 100% of respondents stated that the pharmacist spent adequate time with them
• 100% of respondents stated that they had confidence and trust in the pharmacist
• When asked to evaluate the consultation with the pharmacist, 65% of respondents rated it as “excellent”, 28% as “very good” and 5% as “good”.
• 86% of respondents stated that they would definitely be happy to see the pharmacist when they came to clinic again. Only one respondent stated that they would not want to see the pharmacist on future visits.
Fifteen colleagues responded to the staff survey (eight doctors, seven nurses/HCAs) – a 62% response rate. Ninety-three per cent of respondents felt that the presence of the pharmacist reduced clinic waiting times. One hundred per cent of respondents stated that they had complete confidence in having the pharmacist seeing patients in clinic. All respondents rated the clinic service provided by the pharmacist as either excellent (67%) or very good (33%).
Abstract 28
Type: Poster
Category: Innovation, service evaluation or service improvement
Development of a dose banding table for oral temozolomide
Advanced Clinical Pharmacist Oncology, Queen Elizabeth Hospital Birmingham
Temozolomide is unusual in that it is an oral chemotherapy drug dosed on a body surface area basis. It is available in six capsule strengths to allow flexibility in dosing and provide a wide range of doses. The smallest dose unit is 5 mg, so all doses at Queen Elizabeth Hospital Birmingham (QEHB) are rounded to the nearest 5 mg by the electronic prescribing system (EPS).
However, this does not take into account;
• The number of capsules necessary to make the dose
• How this dose is made up. (This is important to reduce the risk of patients taking the incorrect dose due to confusion over different capsule strengths/numbers).
Reducing risks of incorrect dosing is paramount in this patient group because;
• Patients are required to self-medicate at home on a cyclical basis
• Throughout treatment patients may receive up to three different dosing schedules
• A diagnosis of a brain tumour may bring cognitive impairment increasing the risk of administration errors.
Rounding to the nearest 5 mg gives 67 possible doses. Pharmacists clinically checking these prescriptions are therefore permitted to “round the dose within 5% to achieve a dose that can be more easily dispensed”. However, there is currently no specific guidance on how to do this.
There was a recent an error at QEHB whereby a patient muddled up the capsule strengths leading to a significant under dose. Therefore, the aim of this work was to improve patient safety through development of a dose banding table.
• Low Risk – 1 capsule of 1 strength OR 2+ capsules of all the same strength
• Medium Risk – More than 1 strength, but only 1 capsule of each strength
• High Risk – Multiple strength capsules where the patient has to take different numbers of each strength.
By applying a 6% variance to each dose (as per the current NHS England dose banding tables) bands of doses were then created. Where a dose could fall into more than one band it was included in the one with the lowest risk. The table was circulated within pharmacy and neuro-oncology.
• Doses available reduced from 67 to 19
• No manual dose rounding, resulting in reduced ambiguity/increased consistency of prescribed doses.
• Clear guidance for pharmacy staff in how to make up each dose
• Defining risks of the doses allows staff to be vigilant to those doses that carry more risk, namely 110 and 220 mg.
This is a simple change to improve the safety of temozolomide prescribing. It is due to be programmed into the EPS at QEHB to bring prescribing of temozolomide in line with NHS England dose banding recommendations for intravenous chemotherapy.
Additional material is available in the supplementary online file published with this supplement.
Abstract 29
Type: Poster
Category: Innovation, service evaluation or service improvement
Overcoming e-prescribing challenges in the implementation of automated national SACT dose-banding tables in MOSAIQ® at Guy’s and St Thomas’ NHSFT
Lead cancer e-prescribing pharmacist, Guy’s & St Thomas’ NHS Foundation Trust
In undertaking a local project to implement the NHS England national SACT dose-banding tables1 on our MOSAIQ® e-prescribing system, a number of challenges were generated which had to be overcome.
1. Dose banding configuration at the order-set level rather than drug formulary level
MOSAIQ® requires dose tables to be entered at the order-set, rather than the drug formulary level. This increased the volume of manual data entry from 19 drug formulary entries to 270 order-sets, representing over 8000 rows of data that also required an accuracy check.
Workaround: None.
2. System rounding of banded doses
MOSAIQ® uses hard-coded background rounding rules in addition to optional user-configurable rounding rules. The user-configurable rounding rules were removed as part of the implementation to prevent a “double rounding” effect. The hard-coded rules round to three significant figures and cannot be removed. In certain circumstances this caused a successfully banded dose to be rounded to a non-banded dose, e.g. bendamustine calculated dose of 149.4 mg, successfully banded to 157.5 mg and then rounded to 158 mg (not a banded dose).
Workaround: manual dose banding at individual patient level.
3. Dose calculation to more decimal places than displayed on-screen
MOSAIQ® displays calculated doses ≥1 and < 10, and dose-banding tables to a maximum of two decimal places. It was subsequently identified that the system calculates doses ≥1 and <10 in the background to a greater number of decimal places than it displays on the screen. A situation can therefore arise where the calculated dose falls above the upper limit of one band and below the lower limit of the next band and so fails to be banded by the system.
Workaround: configuring affected banding tables to four decimal places.
4. Regimen dose capping to non-banded doses
Some protocols were identified that utilised a dose cap that was not itself a banded dose.
Workaround: review of dose capped order-sets.
5. Dose-banding data lost when subsequent changes made to order-sets
Changes to the name or category of an order-set cause the previously entered dose-banding rules to be lost from the order-set.
Workaround: process redesigned to prevent issue.
Reference
Abstract 30
Type: Poster
Category: Innovation, service evaluation or service improvement
Using a collaborative approach to optimise data quality for billing of cancer drugs to NHS England
Cancer Pharmacist, County Durham & Darlington NHS Foundation Trust
Access to funding for Cancer Drugs through both NHS England and the Cancer Drugs Fund is subject to strict rules about timeliness of billing and data quality. NHS England is unable to state the value of Cancer Drugs Fund invoices that are rejected due to billing issues; however, it is likely to be several hundred thousand pounds per year or more.
Hospitals have identified a number of different approaches to billing. Much of this has required either manual intervention from pharmacy staff at the time of issue of the drugs, at month end or both. This intensive intervention is distracting to clinical care of patients.
Developing solutions in individual organisations in isolation is not in keeping with the principles of the Carter Report. We therefore sought to develop a collaborative solution that required the minimum of support from Pharmacy Staff that would maximise data quality while minimising risk of financial loss.
Minimise human input in the billing process to both reduce the risk of error and maximise efficiency
Reduce the frequency of contested invoices from NHS England and the Cancer Drugs Fund
Version 2 is being developed to allow a more sophisticated rules engine which will better allow identification of responsible commissioner.
Reduced contested bills will avoid NHS Provider Organisations loosing income which would otherwise have resulted in a reduction in available resource to treat patients.
Abstract 31
Type: Poster
Category: Innovation, service evaluation or service improvement
Development of a program for validation of pharmacist carrying out SACT verification in small private hospitals
National Lead Pharmacist Chemotherapy e-Prescribing, BMI Healthcare
BMI Healthcare is a national private hospital group with 22 oncology centres providing SACT services. Patient numbers at these SACT units range from 5 to 30 per week. Most BMI pharmacists are sole practitioners in their pharmacy covering all specialities including oncology.
Verification of SACT prescriptions is a high-risk activity and as such all prescriptions for chemotherapy should be checked by an Oncology Pharmacist, who has undergone specialist training, has demonstrated competence and is locally accredited for the task.1
A competency validation programme incorporating the BOPA Standards for Pharmacy Verification of Prescriptions for Cancer Medicines was needed for all BMI SACT pharmacists.
In June 2016 a comprehensive competency assessment programme incorporating the BOPA standards was developed by national BMI pharmacy team.
The programme is delivered through a combination of remote recording of validated prescriptions with documentation of issues addressed, face to face, scenario-based discussion and completion of mock prescriptions tailored to the Pharmacist’s local practice.
Each participant is issued with specific feedback including recommendations for areas for development. Where a candidate is deemed not meeting the requirements for validating SACT prescriptions then recommended remedial actions would be outlined with guidance and a further assessment would be made as necessary.
“The commissioning of this programme provided adherence to RPS standard 10.2.e ‘… to ensure competency is maintained and developed to meet changing service needs, patient expectations and the introduction of new technologies’.
Anne Iveson, Group Chief Pharmacist, BMI Healthcare.
We feel that there may be other smaller organisations that could benefit from delivery of such a programme to Pharmacists performing this activity. This programme can also be adapted for community pharmacists providing SACT services. We are currently looking to develop a competency programme for SACT accuracy checking for pharmacy technicians.
Additional material is available in the supplementary online file published with this supplement.
Reference
Abstract 32
Type: Poster
Category: Innovation, service evaluation or service improvement
Adverse event and efficacy monitoring in patients receiving oral tyrosine kinase inhibitors (TKIs) for chronic myeloid leukaemia (CML)
Consultant Pharmacist, University Hospital Birmingham NHS Foundation Trust
Long-term therapy with oral tyrosine kinase inhibitors (TKIs) has revolutionised management of CML in the past 15–20 years. Patients can now be offered the prospect of a functional cure of their cancer but require long-term oral therapy to achieve this outcome with a requirement for regular molecular monitoring to assess disease status. In recent years, there has been an increasing awareness of the adverse event profile of these TKIs, and this led to the publication in 2016 of European-wide guidelines on the identification, management and prevention of a wide variety of potential toxicities.1 For patients at UHB NHS Foundation Trust currently receiving treatment with a TKI, concerns had been raised that monitoring of both efficacy and toxicity parameters was suboptimal – too frequent for PCR testing for BCR-ABL transcripts and not frequent enough for toxicity monitoring.
Consequently, as part of an enhanced pharmacist role in the CML clinic, a greater emphasis was to be placed on appropriate patient monitoring. The aim of this service evaluation was to compare monitoring strategies before and after the introduction of a pharmacist into the CML clinic.
Data on toxicity monitoring were available for 42 patients and are summarised in Table 1 (attached):
Additional material is available in the supplementary online file published with this supplement.
References
Abstract 33
Type: Poster
Category: Innovation, service evaluation or service improvement
Pharmacists role in promoting and supporting the use a Health Care App in an oncology setting
GI/Supportive care pharmacist, The Christie NHS Foundation Trust
As part of the Cancer Vanguard Medicines Optimisation programme, uMotif (a smart phone or tablet app to track symptoms) is being piloted at The Christie. It allows patients to track their symptoms while on chemotherapy, between clinical appointments.
This company has provided similar apps in other healthcare settings around the world. A randomised controlled trial in Parkinson’s disease across seven UK centres showed an improvement in adherence to treatment and perception of quality of life.1 A study reported at ASCO found that an app to encourage self-reporting of symptoms actually extended the median overall survival by five months.2
Assess the uptake of the uMotif app in colorectal cancer patients
• Identify patient opinions towards healthcare apps
• Assess usage of uMotif app in this patient group
Participants will fill out questionnaires regarding their opinions of healthcare apps and the uMotif app prior to using the app and then after 30 days and 60 days.
• Approximately 55% of participants do not regularly use any kind of healthcare app despite 90% of participants stating that they use general apps at least weekly.
• The majority of participants believe that using the app will help them to manage their symptoms and improve their consultations.
• Thirty-seven patients have downloaded the app (of 62 patients offered).
• The main reason cited by patients for not participating is the lack of access to a smart phone or tablet device. Sixty per cent of those patients who declined to take part cited the lack of hardware or other fundamental technology barrier as the reason why.
• The demographic spread of participants shows a diverse patient group.
○ Ages range from under 40 years to 70 years old
○ Male and female participants
○ Various stages of disease.
• Preliminary results show the number of participants with minimum expected engagement is at least 45% of those who agree to participate. This means that almost half of users use the app at least every three days.
This may be the first time these patients are using a healthcare app so care must be taken to ensure they understand how to use it in order to receive the maximum benefit (potentially extended overall survival).
Further investigation is required into clinician opinions and support of symptom tracking apps as patients may be less likely to engage if their team do not understand or are unable to use the technology.
References
Abstract 34
Type: Poster
Category: Innovation, service evaluation or service improvement
Implementation of guidelines for the management of immune-related adverse reactions of immuno-oncology agents
Specialist Cancer Pharmacist, Oxford University Hospitals NHS Foundation Trust
Immuno-oncology (I-O) agents are fast becoming standard treatment for a variety of oncology and haematology indications.
These I-O therapies have unique immune-related adverse effects (IrAE), which are very different to traditional anti-cancer agent toxicities.
Patients with IrAEs can present with a wide range of symptoms. Therefore, clinicians working in many specialities will encounter these patients.
The guideline was presented in the format of algorithms covering individual organ systems such as gastrointestinal and endocrine and gives guidance on how to manage toxicities.
Collaboration with experts in different specialities was crucial in the guideline development process. The guideline gives advice on when patients should be referred to these specialities and recommends joint management of any patients with severe or persistent moderate IrAEs.
One challenge in the implementation of the guideline was that some treatments, such as Infliximab, are not specifically licensed for immune-related conditions secondary to I-O agents and hence agreement needed to be sought from governance and drug and therapeutic committees. Funding for Infliximab has also been challenging, as there have been debates about meeting NICE criteria for colitis,1 and extra funding agreements needed to be sought from NHS England.
The use of the guideline will be audited in six months to assess whether the suggested treatment algorithms have provided the desired patient outcomes.
A specialist I-O subcommittee is being developed, which will include a consultant, specialist pharmacist and specialist nurse, focussing on issues surrounding the use of I-O agents across all tumour types.
Reference
Abstract 35
Type: Poster
Category: Innovation, service evaluation or service improvement
Biosimilars adoption – Getting it right 1st time
Drug Resource Manager, The Royal Marsden NHS Foundation Trust
The Cancer Vanguard Pharma Challenge1 provided the opportunity for the pharmaceutical industry to submit proposals for collaborative projects with the Cancer Vanguard. One of the successful proposals was from Sandoz Ltd which focused on the process of biosimilar adoption.
Biosimilars represent a significant opportunity for the NHS to save money; however, they are not universally understood or accepted. Despite being set by the EMA in 20052, the biosimilar regulatory process remains unfamiliar to many healthcare professionals; this has led to considerable variation in biosimilar adoption processes and subsequent usage in the NHS3. Due to this unfamiliarity, an education and evidence generation program was devised to build confidence amongst healthcare professionals to facilitate safe and timely adoption of biosimilars across the NHS in a standardised fashion. The overall approach and outcomes are described here.
To produce resources to improve the rate of safe and timely adoption of biosimilars across the NHS
• Address concerns of key stakeholders through education and training
• Develop materials to assist NHS trusts in safe and timely biosimilars adoption
• Quantify the service impact of biosimilar adoption
• Evaluate the efficacy of the project
Objective 1. An education and training package was piloted followed by a content gap analysis with a control group of nurses/pharmacists. Package updated and sessions carried out across Vanguard sites. A short, validated questionnaire was completed by participants’ pre and post session to quantify impact on biosimilar perceptions.
Objective 2. Materials available within the NHS were reviewed. The most suitable materials that could be developed within the scope of the project were agreed and developed.
Objective 3. A tool to measure the service impact of introducing a biosimilar at trust level was developed, taking into consideration all areas impacted.
Objective 4. Throughout the project, data collected included education and training package effectiveness, service evaluation pre and post biosimilar adoption, service impact of switch, web site education and training materials (usability and usefulness), adoption of biosimilars across London and the wider NHS and savings generated (via procurement data).
Objective 1. Healthcare professionals have completed the training to date across two of the Cancer Vanguard Trusts (>100 participants). The results of the training impact shown to be positive with significant improvement in understanding of the concept of biosimilars following the sessions (full summary available for poster).
Objective 2. Areas agreed to focus on; adoption timeline tool, Trust Policy Template, data collection tool to evaluate service impact of a switch, development of a web-based interactive training package, a Q&A document and PIL. All were developed and uploaded onto the Cancer Vanguard site to allow easy access. Availability was advertised and communicated to all key stakeholders.
Objective 3. Results from two of the Cancer Vanguard sites will be available by September 2017 (and available for poster).
Objective 4. Results will be reported from July 2017 (and available for poster).
Reference
Abstract 36
Type: Poster
Category: Innovation, service evaluation or service improvement
How chemotherapy is delivered closer to home: A national scoping survey
Lead Pharmacist Applied Health Research, University College London Hospital and The Cancer Centre for Medicines Optimisation, Research and Education (CMORE)
The delivery of chemotherapy closer to home is a priority area for many cancer delivering organisations. Nationally the pace of progression in this area is variable with many organisations adopting different strategies for various types of treatment and patient groups. A Scoping exercise was planned as part of the National Cancer Vanguard, NHS England and NHS Scotland work-streams to enable the understanding of models of care employed in this area.
When asked which patients were to be excluded from treatment closer to home the majority (n = 17) excluded trial patients, followed by patients receiving cycle 1 (n = 15) and the administration of drugs causing hypersensitivity (n = 13). The majority of respondents (n = 15) note that they operate from a set list of suitable regimens.
Answers relating to the key challenges when initiating the service were primarily financial (n = 10) and the chemotherapy manufacturing pathway (n = 12), e.g. transport and logistics. E prescribing was noted as a challenge for six respondents. Only two felt that the management of acute complications were a key challenge.
Nine respondents note that patient surveys and feedback have either supported the pathway or resulted in changes to the services delivered.
Thirty respondents answered the question regarding whether there were safety concerns regarding the delivery of chemotherapy in patients’ homes. The majority (n = 27) believed there to be safety issues but these could be managed and overcome with appropriate standards and monitoring. Comments followed themes of delivering the right treatment to the right patient in this setting.
Abstract 37
Type: Poster
Category: Innovation, service evaluation or service improvement
DPD deficiency testing – An overview of current variations in practice
Senior Oncology Pharmacist, University College London Hospital and The Cancer Centre for Medicines Optimisation, Research and Education (CMORE)
The fluoropyrimidines, fluorouracil (5FU) and capecitabine have been used routinely in upper and lower gastrointestinal (GI), head and neck and breast oncology patients since the 1960s. The enzyme dihydropyrimidine dehydrogenase (DPD) is responsible for the detoxifying metabolism of both drugs commonly used within these areas of practice. A recent paper published by Guys and St Thomas’s hospital estimated that the incidence of DPD deficiency within the UK population can be up to 5%.1 Other studies have found the incidence to be significantly higher.2
Both heterozygous and homozygous deficiencies can cause severe and often life-threatening side effects resulting in prolonged hospital stays with associated costs. Several recent publications demonstrate economic value in routine testing and this is now recommended as standard by the FDA.3 Viapath, the pathology partner of Guys and St Thomas’s Foundation Trust, who carry out the test in London and the south of England provide this test at a cost of £57.56. Viapath also recommend a dose reduction of 20–75% and in some cases complete avoidance depending on the results.4
Additional material is available in the supplementary online file published with this supplement.
References
Abstract 38
Type: Poster
Category: Innovation, service evaluation or service improvement
Development of a parenteral systemic anticancer therapy (SACT) dispensing service funded by savings generated from implementation of national dose banding tables and switching to readymade doses
Service Lead Pharmacist in Cancer, Barts Health
The Pharmacy Chemotherapy Unit at St Bartholomew’s Hospital supplies over 40,000 doses of parenteral SACT each year. In 2015–16 approximately 27% of this was supplied in a readymade format purchased from various specialist suppliers. Use of readymade products is more efficient than manufacturing from scratch, releasing much needed manufacturing capacity for doses that cannot be outsourced. In addition, unused doses often have a longer shelf-life and when used in conjunction with dose banding can allow reuse of doses and reduced wastage.
In 2016–17 a national CQUIN for implementation of dose bands for various anti-cancer drugs was issued by NHS England with a view to standardise dosing of SACT and reduce wastage.
• Agree and implement the doses bands outlined by NHS England
• Explore opportunities for purchasing readymade doses within these bands and to review and optimise the current readymade range to reduce manufacturing burden, improve patient experience and reduce wastage
A business case to switch supply of these drugs in this format was produced. In order to facilitate delivery additional staffing (2 x band 5 Medicines Management Pharmacy Technicians) and equipment was requested and approved by the Cancer directorate.
As of June 2017, four of the planned readymade drug ranges have been implemented along with a full review of the existing supplies. In May 2017, 46% of parenteral SACT doses were supplied in this format, an increase of 19% from the 2015 to 2016 average.
Reference
Abstract 39
Type: Poster
Category: Innovation, service evaluation or service improvement
Review of pharmacist interventions during the verification of haematology chemotherapy, following the implementation of a bespoke chemotherapy electronic prescribing system
Highly Specialist Pharmacist Haematology, Wirral University Teaching Hospitals NHS Trust
NHS England introduced penalties for the non-delivery of electronic chemotherapy prescribing from March 2017.1 Wirral University Teaching Hospitals NHS Trust (WUTH) uses Cerner Millennium for non-chemotherapy prescribing and pre-printed paper prescriptions for haematology chemotherapy prescribing. In 2016 WUTH collaborated with Cerner to design/build an integrated electronic prescribing system (EPS) for haematology chemotherapy, which was implemented in January 2017. This enabled the implementation of targeted solutions to reduce frequent pharmacist intervention types. Clinical trials and some newer regimens remained on paper prescriptions.
The aim of this work was to identify whether the implementation of a bespoke chemotherapy EPS reduced the average number of pharmacist interventions per prescription, and the 10 most frequent pharmacist intervention types required when verifying chemotherapy prescriptions.
Reduction in the average number of interventions per prescription required when verifying chemotherapy prescriptions results in an increased amount of pharmacist time, which could be used for counselling patients, improving patient care or as an NHS cost saving. Prescribing errors may be reduced, hence patient safety increased.
Before implementation of a chemotherapy EPS, consideration should be made regarding the potential benefits of developing a bespoke, rather than generic, system.
The introduction of the EPS introduced different pharmacist intervention types when verifying chemotherapy prescriptions. These are fewer in number and will guide further service improvement, which will be re-evaluated quarterly. The post EPS implementation review utilised a small sample size as this is the first evaluation. This will be built upon with future quarterly evaluations.
Additional material is available in the supplementary online file published with this supplement.
References
Abstract 40
Type: Poster
Category: Innovation, service evaluation or service improvement
A review of the advice provided to patients who wish to self-medicate with complementary supplements during cancer treatment, by the Medicines Information department at The Royal Marsden NHS Foundation Trust
Lead Lung Cancer and Clinical Commissioning Support Pharmacist, The Royal Marsden NHS Foundation Trust
There is a paucity of published evidence on the concomitant use of complementary supplements (particularly herbal supplements) with cancer treatments. Currently, Medicines Information (MI) looks in depth for information to support clinicians and patients in decision making. It was perceived that the majority of answers provided in this category were that these supplements should be avoided, particularly for patients receiving Systemic Anticancer Chemotherapy (SACT). There was an opportunity to utilise the time spent answering these queries on other more impactful patient facing activities. This project stems from local priorities which focus on enhancing operational performance in a sustainable manner as well as UKMi Quality Standards in driving efficiency and resource optimisation.1
• To assess the need and relevance of comprehensively answering every individual query
• To identify groups whereby standardised information could be provided
• To develop a position statement and an information leaflet
• Out of 279 enquiries, 78 queries (28%) contained 238 supplements; 39% (median time for complementary supplements 102 min) of the total time was spent on answering them (Figure 1)
• The majority of supplements (92%) related to patients receiving SACT
• It was advised that 62% of supplements investigated were avoided
• Supplements categorised as vitamins, minerals and homeopathy (VMH) were allowed within safe daily limits
• For patients on anti-oestrogens only (e.g. Tamoxifen), additional supplements other than VMH were also permitted
For patients taking anti-oestrogens alone (i.e. not on SACT or RT), more supplements were permitted. Therefore, there is a potential positive impact in continuing to review them as they also form a small part of the overall workload (7% in this study).
Evidence on complementary supplements is unlikely to be updated to the same standard as licensed conventional medicines. Answering ‘yes’ for some supplements with ‘other mechanisms’, only resembles a lack of an identifiable interaction.
A position statement has been agreed and a leaflet has been developed to support patients for whom a comprehensive review is not warranted.
Additional material is available in the supplementary online file published with this supplement.
Reference
Abstract 41
Type: Poster
Category: Innovation, service evaluation or service improvement
Developing specialist chemotherapy pharmacy services in Mbarara, Uganda: A project supported by Mbarara University of Science and Technology, University Hospitals, Bristol and The Uganda Cancer Institute
Lead pharmacist for Oncology Clinics and TYA, Bristol Haematology and Oncology Centre
The UCI and the Department of Medicine at MUST developed an oncology clinic in Mbarara in 2012. Chemotherapy is supplied by UCI and doses calculated by clinicians. Nurses with short-term training initially reconstituted cytotoxic drugs on bench tops without robust procedures governing safety and accuracy. The risks to patients and staff were recognised, and in 2015, clinicians at MUST and UHB developed a partnership project to strengthen processes in chemotherapy delivery.
Improve knowledge of nursing and pharmacy staff in relation to safe chemotherapy preparation and disposal procedures
Introduce a prescription template for chemotherapy prescribing within the clinic and add a pharmacist screening step into the chemotherapy delivery process
Provide teaching on cytotoxic agents available in Mbarara including indications, usual doses and toxicities
Update the protocol folder in the clinic to allow clinicians to be following the most up to date advice.
Training was also provided on how to use the medical notes, chemotherapy protocols and blood results to clinically check the prescription as well as encouraging the team to challenge any prescribing they are unsure about.
A one-month fellowship was organised in Bristol for both the Intern Pharmacist from Mbarara and the lead Chemotherapy Pharmacist from UCI who oversees the service in Mbarara including attendance at annual BOPA symposium as well as shadowing pharmacists and technicians working in the oncology centre in Bristol.
Abstract 42
Type: Poster
Category: Innovation, service evaluation or service improvement
Service impact assessment of new immunotherapy agents at Guy’s and St Thomas’ Foundation Trust
Lead Pharmacist for Cancer Services, Guy’s & St Thomas’ NHS Foundation Trust
GSTFT is a large cancer centre, serving a population of over two million, in South East London and Kent. In response to the introduction of novel immunotherapy agents a multidisciplinary immunotherapy working group (IWG) was set up to oversee use within the Trust. The IWG prospectively manages a database of patients on treatment across all relevant tumour types (including trials). Adverse events triggered by immunotherapy drugs are different to traditional chemotherapy and the IWG aims to ensure patients are appropriately triaged and toxicities managed consistently across all tumour types. The IWG also reviews usage, for clinical and financial implications.
Patients are seen in tumour-specific clinics. The treatment is dispensed by the pharmacy aseptics unit and delivered by cancer nurses in the newly opened Cancer Centre, at the Guys site.
To assess the service impact of new immunotherapy agents at Guy’s and St Thomas’ Foundation Trust (GSTFT)
• Identify usage of immunotherapy drugs.
• Assess capacity implications for outpatients, pharmacy and cancer day unit (CDU).
• Assess impact on Trust financial expenditure for National Health Service England (NHSE) indications.
As a result of the findings, the IWG have recommended:
• Standardised immunotherapy blood order sets.
• Ongoing education to raise awareness within the Trust and regional hospitals
• Review of delivery models and alternative opportunities to resolve capacity.
• Regular review of Trust performance for future NHSE budgeting/forecasting.
Abstract 43
Type: Poster
Category: Innovation, service evaluation or service improvement
Use of undergraduate pharmacy students to support a national chemotherapy audit
Senior Lecturer in Pharmacy Practice, University of Central Lancashire
It is not always possible to deliver cancer chemotherapy as intended. There is a paucity of data for chemotherapy delay rates for individual hospitals although there are data related to individual diseases. Gardini et al. (2016) found that 9.7% of patients in their survey in Italy were affected by treatment delays. Pharmacists play an important role in patient care and their time to undertake audit and research is limited. Cancer teaching in undergraduate courses is varied in content and focus. Pharmacy undergraduate exposure to the cancer speciality during summer and other placements is also limited.
Feedback from students and centres was recorded and described. A data collection protocol was provided in addition to a background document.
The results collected, although valuable, were not consistent and raised many questions regarding accuracy and interpretation of terminology. Differences in local procedures also impacted on the consistency.
In addition, feedback from the host hospitals and students involved which was positive.
Quote from student: “I would like to thank you for providing me with the opportunity to work experience for the BOPA Clinical Audit at Leicester Royal infirmary. It was a wonderful experience and made me even surer that I would like to pursue a career in Hospital Pharmacy. I truly appreciate the confidence you showed in me by providing me with this opportunity.”
Quote from NHS Trust mentor: “Also it was really helpful to have the students, it really speeded up the data collection. We also had positive feedback from {the student} which was great to feedback to the team.”
Reference
Abstract 44
Type: Poster
Category: Innovation, service evaluation or service improvement
Managing oral systemic anti-cancer therapies – Quantifying current waste and implementing strategies to reduce waste
Lead Cancer Pharmacist Barts Health NHS Trust
NHS England spends around £400 m per year on oral Systemic Anti-Cancer Therapy (SACT) (and rising). It is estimated 1% is wasted = £4 m.
Barts Health NHS Trust (BH) signed up to the Oral SACT CQUIN 2015/16, described as “Implementation of improved prescribing practice aimed at achieving reduction in the level of Oral SACT that is wasted” (i.e. issued to patients but not taken by patients), informed by the (draft) national Policy on Management of Oral formulations of SACT.
Q1 milestones included;
• Confirming completion of review of the draft policy and confirm the implementation plan to meet compliance with the policy.
• Submission of the Trust policy.
• Completion of a spot audit review and set the baseline.
• Define a methodology for tracking improvements in Q1.
• Performance will then be measured in each quarter using the proposed methodology
The financial cost of oversupply was calculated to form the baseline.
The cancer MDT were presented with the results of the baseline audit and informed of the following changes to the prescribing, confirmations and supply process:
• Each patient on a high cost oral SACT would be asked how many they had at home by pharmacy.
• Any member of the MDT confirming oral SACT prescriptions were requested to ask patients how many they had at home
• Pharmacy would adjust the quantity prescribed to take into account the supply the patient already had (1–2 week buffer supply was allowed for long-term targeted therapy, e.g. imatinib).
• A simple leaflet would be produced requesting patients to bring in their oral SACT to each appointment.
Defining a methodology for tracking improvement: to record each time a pharmacist intervened and adjusted the quantity supplied, the interventions database (used by pharmacists to record all interventions) was thought to be the best platform. An additional intervention category “Oral SACT quantity adjustment” was added.
The proactive quantity adjustment during 2015/16 showed the following savings:
Q2 = £19,950, Q3 = £30,217, Q4 = £26,744, Total = £76, 913
This study shows there is always room for improvement.
The practice of simply asking patients how many tablets or capsules they have at home is now embedded in practice by the MDT. The pharmacy team continue to record the adjustment of oral SACT supplies.
Abstract 45
Type: Poster
Category: Innovation, service evaluation or service improvement
Proposal for the reduction in observation time post administration of subcutaneous herceptin
Advanced Clinical Pharmacist in Oncology, Weston Park Hospital
Administration-related reactions (ARRs) with Herceptin are historically considered as common. Roche clinical trials with SC Herceptin reported “no serious ARRs”.1 However, the MHRA imposed the same safety precautions for license, as those observed post IV Herceptin administration. Roche states: Patients should be observed for 6 h from administration of first dose and 2 h on subsequent administration.1 Patients are observed in chemotherapy chairs at WPH.
• Review the local incidence of ARRs with Herceptin
• Review wider practice of administration of SC Herceptin
• Calculate the impact that SC Herceptin observation times has on chair capacity
• Review published data of ARRs with Herceptin
• Review SC Herceptin protocols
• Review time saving with proposed reduced observation times
Audit of ARRs post administration SC Herceptin at North East & Cumbria (NE&C) and South East: post-injection reactions are infrequent and mild in nature.3 NE&C reduced observation times: 30 min post first dose, and no monitoring thereafter. Conclusions from audit at Great Western hospital ‘a minority of patients experienced mild adverse reactions to Trastuzumab, a review of the administration duration and observation period is warranted’.4
Variance was seen in administration protocol across several sites. No continuity in premedication or observation times, which ranged from 0.5 to 6 h post 1st dose, 0–2 h post 2nd dose.
Current allocated chair time for administration of SC Herceptin; 6 h first dose, 2 h second dose, 30 min third dose. Total 8.5 h. Proposed observation times: 2 h first dose, 30 min second dose, no observation thereafter. Total 2.5 h.
References
Abstract 46
Type: Poster
Category: Innovation, service evaluation or service improvement
Pharmacist-led myeloproliferative neoplasm clinic – An audit of current practice
Haematology Pharmacist, Countess of Chester NHS Foundation Trust
The management by pharmacists of patients with chronic haematological malignancies including Myeloproliferative Neoplasms (MPNs) has become commonplace. Locally, patients can remain in pharmacist-led clinic indefinitely, often with no clinician input into their care. Additionally, increasing numbers of patients are being referred to pharmacist-led clinic, putting pressure on the service.
Having recently taken over an MPN clinic a prescribing pharmacist undertook an audit of existing patient care against local guidelines1 to assess current performance and investigate whether improvements could be made to the way patients were managed.
Local guidelines state:
• Patients with an MPN should be on aspirin or alternative antiplatelet.
• Patients with polycythaemia vera (PV) should have a target Haematocrit (HcT) of less than 0.45.
• Patients on cytoreductive therapy should have U + E and LFTs monitored every three months.
• Patient’s GPs should be asked to address primary risk factors for atherosclerosis.
The secondary objective was to identify inefficiencies in the assessment process and recommend ways in which patients could be seen more effectively by auditing:
• How often patients being treated with venesection were receiving this intervention compared to how often they were attending clinic.
• How many patients on cytoreductive therapy had been stable and on the same dose of therapy for 12 months.
• Whether patient’s diagnoses were correct.
• Whether aspirin status and target Haematocrit were regularly documented.
• 81% with an MPN were on aspirin or equivalent, or had a contraindication to antiplatelet therapy (antiplatelet status documented in 19% patient’s notes in last 12 months).
• 100% with PV had a target HcT of less than 0.45 (target HcT documented in 22% patient’s notes in last 12 months).
• 21% on cytoreductive therapy had had U + Es and LFTs monitored in the last three months
• 0% had evidence in their notes that GPs had been asked to address primary risk factors for atherosclerosis.
• 39% being managed with venesection alone had been venesected less than half the time they attended clinic.
• 50% on cytoreductive therapy had been on the same dose for more than 12 months.
• Five patients had possible incorrect diagnoses and were referred back to consultant-led clinic.
• Patients to be discussed with consultant annually to agree management. Clinical management plan template developed and introduced to facilitate this. Target Hct, antiplatelet status and primary prevention advice to be included in clinic letter after each yearly review.
• Telephone clinic introduced to manage:
○ Patients stable on cytoreductive therapy
○ Patients not requiring regular venesections
• Shared care agreement for hydroxycarbamide developed to enable telephone clinic patients to have their hydroxycarbamide prescribed by their GP.
• Education programme for non-medical prescribers introduced.
• To re-audit biennially.
Reference
Abstract 47
Type: Poster
Category: Innovation, service evaluation or service improvement
The administration of immuno-oncology agents in UK clinical practice: Exploration of the patient benefits derived from the home-infusion service
Cancer Consultant Pharmacist, Churchill Hospital
The field of immuno-oncology represents a new era in the treatment of cancer; immuno-oncology agents diminish the immunosuppressive capacity of tumours and enable participation of the immune system in tumour eradication.1 Pembrolizumab, a programmed death-1 (PD-1) inhibitor, has demonstrated potent anti-tumour activity and is currently indicated for the treatment of advanced (unresectable or metastatic) melanoma, locally advanced and metastatic non-small cell lung cancer, and relapsed/refractory classical Hodgkin-lymphoma.2 Despite their efficacy, the frequent administration of immuno-oncology treatments in day units increases the pressure on health services and requires additional resources.
In an attempt to minimise the demand on the NHS that may accompany the availability of immuno-oncology therapies, MSD designed a service evaluation programme for patients who were receiving pembrolizumab for advanced melanoma. The objective of this pilot evaluation was to explore the potential impact of this service, considering both the benefits and challenges that may arise.
In the post-hospital-based infusion questionnaire, 77% of patients reported that having the infusion in the clinic caused an added financial worry, primarily in terms of travel and parking costs. Twenty three patients agreed that home infusion reduced personal financial implications of the treatment (Figure 1). Overall, 93% of patients preferred to have their infusions at home rather than hospital-based treatment. Ninety-seven per cent of patients would recommend the home-infusion service to other patients.
Additional material is available in the supplementary online file published with this supplement.
References
Abstract 48
Type: Oral and Poster
Category: Innovation, service evaluation or service improvement
Assessing the safety of an increase in validity of full blood counts from 72 to 96 h in our breast cancer chemotherapy patients
Cancer Services Pharmacist, University College London Hospital and The Cancer Centre for Medicines Optimisation, Research and Education (CMORE)
An increase in the number of breast cancer patients at UCLH has meant that in order to accommodate patients in day care, the breast pathway has moved to a different day pathway. The majority of breast cancer patients are now being reviewed in clinic on a Thursday and returning for treatment the following Monday. Patients returning on the Monday require a repeat blood test on arrival due to a maximum validity of 72 h for full blood counts, namely neutrophils and platelets, to verify chemotherapy. It was suggested that extending the validity to 96 h would remove the requirement of repeat blood tests and improve the experience for our patients (reducing the need for re-bleeding and waiting for chemotherapy to be released by pharmacy) whilst reducing expenditure on unnecessary blood tests.
Review data from eligible patients and treatment cycles, and identify how many patients who had acceptable blood results on the Thursday were subsequently unacceptable on the day of treatment, the following Monday.
Of those eligible to be included (n = 155), neutrophil and platelet results were manually extracted from Chemocare© and compared to the critical tests for their respective chemotherapy regime (see Table 1).
Additional material is available in the supplementary online file published with this supplement.
Abstract 49
Type: Oral and Poster
Category: Innovation, service evaluation or service improvement
Impact assessment of cancer drug changes at Guy’s and St Thomas’ Foundation Trust, since introduction of the new Cancer Drugs Fund
Clinical Lecturer in Medical Oncology, Guy's and St Thomas' NHS Foundation Trust and King's College London
Since introduction of the new Cancer Drugs Fund (CDF) process on 29 July 2016, there have been several commissioning changes. These relate to 37 new drugs/indications during 29 July 2016–29 March 2017, which have resulted in significant challenges for the CDF and National Health Service England (NHSE) billing processes.
• Review real-time data to evaluate:
○ Actual versus estimated patient numbers receiving baseline-commissioned drugs
○ Financial implication on drug expenditure
• Sub-analysis of the impact of new drugs – previously not available via the CDF – on Cancer Centre capacity.
The actual patient numbers receiving each drug by indication were recorded and compared to the estimated totals from the horizon scanning process. Drug cost from the pharmacy system was used to estimate financial implications.
A sub-analysis of new drugs, not previously available via the CDF, was reviewed to assess impact on Cancer Centre capacity in terms of outpatient appointments and Cancer Day Unit (CDU) administration times.
Cost of drug/patient was known for 15/19 drugs/indications predicted as part of the contracting process. The predicted cost implication for the year 17/18 was £15,434,038, compared to the actual cost of £19,860,929, resulting in a deficit of £4,426,891.
Of the 37 commissioned changes, 12 drugs were not previously available via the CDF. Based on current and predicted numbers of patients treated with these drugs, the additional CDU chair capacity was calculated as 4492/year and the additional number of outpatient appointments as 5045/year.
The learning from this evaluation will allow:
• improved planning and performance for the introduction of new drugs to inform the contracting process for GSTFT
• more detailed, collaborative service review extending across a wider population across South East London (SEL) Sustainability and Transformation Plan (STP) to translate impact and better inform decision making.
Abstract 50
Type: Oral and Poster
Category: Innovation, service evaluation or service improvement
Exploring the assessment skills required by pharmacist independent prescribers for the safe prescribing of systemic anti-cancer therapy
Advanced Pharmacist Cancer Clinical Trials, Edinburgh Cancer Centre
Assessment of a patient’s toxicities, well-being and treatment response are essential for the safe prescribing of systemic anti-cancer therapy (SACT). With the emergence of pharmacist prescribing of SACT the specific skills required to undertake such assessments should be well defined.
NHS Research Ethics Committee approval was unnecessary as the study involved NHS employees only.
Abstract 51
Type: Oral and Poster
Category: Innovation, service evaluation or service improvement
Denosumab self-administration: A pilot for breast cancer patients
Lead Pharmacist in Applied Health Research, University College London Hospital and The Cancer Centre for Medicines Optimisation, Research and Education (CMORE)
Denosumab is approved for use in the prevention of Skeletal Related Events (SREs) in patients with solid tumours excluding prostate. It is commonly used for breast cancer patients. We reviewed our patient pathway and found that patients were having long waits to have denosumab administered by a nurse in our supportive care unit and this impacted negatively on patient experience. This was a driver in establishing a working group to develop new models of care. Furthermore, in February 2016 we undertook a financial mapping exercise that identified that CCGs in north central London were being charged £1.5 million in delivery tariff (inclusive of market forces factor). Thus, a new model might result in potential savings overall for the NHS together with improvements in patient experience. Patients had expressed an interest in self-administration. Local reimbursement of drug costs from the CCGs would be agreed if the pilot was successful.
To understand whether self-administration was a suitable and acceptable option for breast cancer patients receiving denosumab and its impact on patient experience.
• To evaluate the numbers of patients that would consider moving to this option.
• To evaluate the patient experience benefits using this model.
• To evaluate wastage of medication for all patients.
Patients that were eligible to self-administer denosumab were invited to join the pilot by their clinician. These patients were trained by a nurse on the supportive care unit and given instructions on how to administer denosumab and given any equipment needed. Initial data from all patients were collected by RM to understand the patient preference to self-administration, using a self-developed questionnaire using validated rating scales. This was repeated and patient experience was additionally captured after three months of self-administration by PC. Wastage was recorded throughout.
In total eight patients joined the self-administration pilot. A repeat patient preference survey showed that all patients were confident and happy with their chosen pathway. Two patients moved back to hospital delivery, one due to injection site preference and one due to disease progression. In total 80% of patients (6/8) believed that they had reduced trips to the hospital and (7/8) patients believed their quality of life to be improved as a result of self-administration. The pilot has been running for nine months and there has been no wastage of denosumab.
Abstract 52
Type: Oral and Poster
Category: Innovation, service evaluation or service improvement
Preliminary results of a specialist pharmacist led medicines optimisation service (polypharmacy clinic) for prostate cancer patients
Cancer Pharmacist, University College London Hospital and The Cancer Centre for Medicines Optimisation, Research and Education (CMORE)
Polypharmacy has been described as the use of multiple medications by a patient and generally occurs in older adults aged 65 and over. The increasing number of treatment options and an aging population has meant that anecdotally we are seeing more patients with co-morbidities. The multiple specialisms involved in various aspects of cancer patient care can lead to no one taking responsibility for the patient as a whole which may result in poorer therapeutic outcomes and in-appropriate polypharmacy. Prostate cancer is a condition that is prevalent in older men and therefore a Pharmacist-led optimisation service for this cohort of patients was developed.
• To evaluate changes in the medicines usage and adherence of Prostate Cancer patients
• To evaluate change in quality of life and well-being of the Prostate cancer patients
• To understand service implications and time taken to conduct the MUR
References
Abstract 53
Type: Poster
Category: Research
National systemic anti-cancer therapy regimen-specific consent forms – Uptake and feedback survey
Oncology Pharmacist - CRUK Information Lead, Guy’s and St.Thomas’ NHS
The UK Chemotherapy Board issued guidance on consent for SACT1 in July 2016. National regimen-specific consent forms were published on the Cancer Research UK website in July 2016, starting with breast cancer and a generic form. Forms for other tumour groups (oncology and haematology) continue to be published throughout 2017.
• To evaluate the uptake of the national forms in England, N. Ireland, Scotland and Wales.
• To obtain feedback on the forms.
• To identify challenges related to introducing the forms.
• To use feedback to inform future developments of the project.
Ninety-two per cent and 74% of all responders stated that they were aware of the national consent forms and guidance on consent for SACT, respectively.
Responses revealed that a variety of methods are used to consent adult patients to treatment with SACT: Figure 1.
Thirty hospitals/Trusts stated that they were using the national forms; 17 others confirmed plans for implementation.
Reasons given for not using the forms included:
• Prefer existing method
• Resistance from key stakeholders
• Forms not approved for use in the hospital/Trust
• Too much paper to give to patients
• Time and motivation to implement
• Awaiting regional steer
• Use of electronic systems and processes
• Queries regarding legality of the forms
• Forms not being available for all tumour groups
Seventy-three per cent (22) of hospitals/Trusts using the national forms stated that they were preferred to the previous method; 60% (18) stated that the forms were very easy or easy to use.
Key themes identified from 38 responses in the feedback/comment sections or free text areas were:
• Legal review/endorsement of the forms
• Length of forms
• Availability of forms for all tumour groups
• Local processes for use, i.e. printing, copying and storage
• Need for paediatric forms
• Electronic versions
Recommendations for the project, in view of the survey results, are:
• Continue to publish forms for remaining tumour groups
• Outline some options for local processes for use of the forms, as guidance
• Issue a reminder regarding the national guidance document for consent for SACT
• Continue to send regular updates and communications in relation to the forms and project
• Request a legal review of the forms
• Develop and publish paediatric forms
• Scope the feasibility of electronic forms
• Repeat the survey in one year when all adult forms have been published and more hospitals/Trusts will have experience of using the forms.
Additional material is available in the supplementary online file published with this supplement.
Reference
Abstract 54
Type: Poster
Category: Research
Comparing the chemotherapeutic drug loading processes of two types of drug-eluting embolisation microspheres
Section Leader, Licensed Cytotoxics, The Newcastle upon Tyne Hospitals NHS Foundation Trust
Hepatocellular carcinoma (HCC) is an increasingly common tumour with a poor prognosis and limited treatment options, approximately 80% of patients die within a year of diagnosis.1 Trans-arterial chemoembolisation (TACE) is the most used treatment for patients with unresectable HCC because it improves median survival and tumour response.2 TACE is the administration of embolic particles mixed with chemotherapeutic drugs and produces a shutdown of the blood flow and the simultaneous release of the drugs.3
Several types of embolic particles or drug-eluting embolisation microsphere devices are available, each displaying diverse properties. Although in vitro properties which vary by device type have been presented,4 there is little data available in the wider literature that compares the drug loading processes of the different microspheres in an aseptic pharmacy environment. Furthermore, evaluating and optimising the loading processes could offer potential time and cost savings for the pharmacy.
Additional material is available in the supplementary online file published with this supplement.
References
Abstract 55
Type: Poster
Category: Research
Observing outcomes of carboplatin treatment in lung and breast cancer patients
Specialist Pharmacist in Haematology and Oncology, The Mid Yorkshire NHS Trust
Carboplatin is unique as a chemotherapy drug due to its systemic effect being directly correlated to an individual’s renal function. Carboplatin dosing is based on the Calvert formula which relies on accurate glomerular filtration rate (GFR). The conventional way to measure GFR is the Cockcroft and Gault (CG) equation. As CG equations are based on body weight as a muscle mass, it is important to dose according to ideal body weight (IBW) in obese patients (classed as >20% above ideal body weight.1 It is estimated that using CG-IBW there was a 48.6% discordance of carboplatin doses being >20% under-dosed versus measured glomerular function values.2 Renal function calculations used for carboplatin-based regimens at Mid Yorkshire NHS Trust have anecdotally been variable. The aim of the study was to attain whether variation in dosing calculations result in different clinical outcomes for lung/breast cancer patients.
Regression analysis was performed using key input variables (Method of Renal Function, Gender, Performance Status, Previous Therapy, Overweight, AUC, Charlson Comorbidity, Albumin and Age 70 +) versus 1-year mortality and 30-day mortality to observe if these variables were related to poorer mortality outcomes.
The study was ethically approved by Leeds University Ethics Committee.
References
Abstract 56
Type: Poster
Category: Research
Outcomes of treatment for obese patients with advanced hodgkin lymphoma in the RATHL Trial (CRUK/07/033)
Lead Divisional Pharmacist Oncology and Haematology, University Hospitals Bristol NHS Foundation Trust
With obesity levels increasing,1 optimal chemotherapy (CT) dosing for overweight patients (pts) is a significant issue. Although guidelines recommend obese patients should be dosed on full body weight,2 clinicians continue to cap doses through fear of excess toxicity.3 It is not clear whether this affects treatment outcomes, particularly in diseases treated in anticipation of cure, such as Hodgkin Lymphoma (HL), where the role of body mass index (BMI) on survival is unknown.
Additional material is available in the supplementary online file published with this supplement.
References
Abstract 57
Type: Poster
Category: Research
Healthcare professionals attitudes of implementing a chemotherapy electronic prescribing system: A mixed methods study
Pharmacy Manager, Springfield Hospital
Chemotherapy prescribing is a highly complex and specialised area. Recent research has investigated the attitudes of healthcare professions by studying perceived barriers and facilitators of implementing different electronic healthcare systems such as electronic medical records1 or eP in primary care.2 At present there are only eight published studies exploring the barriers and facilitators to implementation of eP in secondary care,3 and no studies looking at either attitudes or perceived factors of healthcare staff when implementing eP in chemotherapy.
The first phase was a qualitative exploration of attitudes of healthcare professionals towards the implementation of a chemotherapy eP system. This consisted of a focus group with five healthcare professionals from different healthcare areas within the same trust. A questionnaire was then developed based on these findings.
This was followed by a quantitative second phase where the results from the questionnaire were used to assess if the qualitative results could be generalised to a larger population. The questionnaire was sent to all relevant staff within four hospital trusts (122 participants).
Further progression of the study in phase three looked at developing recommendations based on the factors found in order to aid future implementations for hospitals.
Nine of these factors were also cited as factors by researchers when implementing electronic medical records or generic eP system in primary or secondary care. However, four factors seemed to be specific to chemotherapy eP implementations.
Finally, we have suggested six broad recommendations which can be broken down into 19 specific recommendations when implementing a chemotherapy eP system within healthcare based on these findings (Table 1).
Additional material is available in the supplementary online file published with this supplement.
References
Abstract 58
Type: Poster
Category: Research
The use of common information sources by UK pharmacists to support prescribing
Industrial trainee in Medical Affairs, Pfizer Ltd
The definitive data source for a marketed medicine is the Summary of Product Characteristics (SmPC). A number of other, derived sources also exist, including the abbreviated prescribing information (PI), required on all promotional materials produced by pharmaceutical companies in the UK.
Accessing information online was most common across all sources.
With practice defined in this study, it would be useful to explore the reasons why the PI was not used for prescribing, and consider whether there would be value in replacing this with a link to an updated SPC on promotional materials.
Additional material is available in the supplementary online file published with this supplement.
Abstract 59
Type: Poster
Category: Research
Investigation of community pharmacists input to the pharmaceutical care of patients prescribed systemic anticancer therapy. Results of a focus group and questionnaire
Medical Scientist, Gilead Sciences
Patients with cancer who receive systemic anticancer therapy (SACT) are mostly community based. Community pharmacists can support patients by providing local and accessible high quality healthcare. Electronic referral of patients from hospital to community pharmacy would enable directed care but lack of access by community pharmacists to patients’ health records can be a barrier to providing pharmaceutical care. An evaluation of how community pharmacists’ deliver pharmaceutical care to patients with cancer was undertaken to inform health board primary care and e-health service developments.
• To identify access to patient’s clinical information, preferred methods of receiving information and training needs of community pharmacists to enable them to support patients having SACT
• To explore current and future uptake of e-health technologies to support the delivery of pharmaceutical care by community pharmacists to patients with cancer
An electronic questionnaire with 19 questions and covering letter was emailed by Community Pharmacy Scotland (CPS) to their members (1800). Qualtrics software was used to collate and analyse responses.
Forty-six questionnaires were completed from across Scotland. No pharmacist received clinical information about their patients. Email was the preferred method of transferring patient’s data. Four pharmacists (11%) were confident in providing pharmaceutical care to patients prescribed SACT. Reasons for lack of confidence included not knowing that the patient has cancer and limited knowledge of cancer. The pharmacists wanted training on cancer to include common side effects of SACT, drug interactions and contact details for specialist clinicians.
Post-study initiatives implemented in NHSGGC include e-referral from hospital to GP-based pharmacists as step one and e-referral to community pharmacists as step two once their access to patient records is granted; clinical vignettes to support community pharmacists in providing advice and development of nationally agreed pharmaceutical care bundles for community pharmacists to enable local delivery of pharmaceutical care.
Abstract 60
Type: Poster
Category: Research
Safety of extended temozolomide regimes in brain tumour patients
Clinical and Chemotherapy Pharmacist, The Royal Marsden Hospital NHS Foundation
Evidence supporting the routine use of adjuvant monotherapy with temozolomide (TMZ) beyond six cycles (with or without previous radiotherapy and concomitant TMZ ± debulking surgery) is limited and somewhat controversial (Urgoiti et al, 2012). In spite of this, its use is relatively common in many centres. This study aimed at assessing the safety and tolerability of an extended TMZ regimen given until disease progression or unacceptable toxicity, in a cohort of patients who showed initial response to six cycles of adjuvant TMZ, post radiotherapy or post chemo-radiotherapy.
References
Abstract 61
Type: Poster
Category: Research
The use of granulocyte colony stimulating factors (G-CSFs) in UK haematology centres – A survey of practice
Consultant Pharmacist, University Hospital Birmingham NHS Foundation Trust
Granulocyte colony-stimulating factors(G-CSFs) have been widely used in haematology since the early 1990s. Although the more recent introduction of biosimilar G-CSFs has led to a move away from the originator products for a number of clinical indications, their use for mobilisation of stem cells, particularly in the setting of normal donors, has remained controversial due to concerns about both efficacy and safety.1,2 As data have begun to emerge from UK haematology centres on the use of biosimilar G-CSF for stem cell mobilisation in both patients3 and normal donors4 it was felt to be timely to undertake a survey with the aim of investigating current practice, both in this area and more widely within haematology.
• Choice of G-CSF for stem cell mobilisation, post-transplant count recovery and 1ry or 2ry prophylaxis in patients receiving conventional chemotherapy.
• Starting and stopping criteria for G-CSF in the post-transplant setting
Results were collated and analysed using Microsoft Excel®.
Data relating to the choice of G-CSF for stem cell mobilisation are presented in Table 1 (attached):
In the post-transplant setting, 13 centres (52%) routinely used G-CSF for all patients and two centres (8%) did not give it to any patients. The remaining 10 centres used G-CSF in specific clinical circumstances. For example, five centres routinely used G-CSF in autograft recipients but not in allograft recipients. In those centres that used post-transplant G-CSF, the start date was most commonly 5–7 days after stem cell return but ranged from one to 14 days. The majority (77%) of respondents stopped G-CSF once the absolute neutrophil count (ANC) was >1 × 109/l for 1–3 days although the cut-off ranged from 0.5 to 3 × 109/l. Eighty-seven per cent of centres used biosimilar G-CSF in this setting.
For 1ry or 2ry prophylaxis in patients receiving conventional chemotherapy, all but one adult centre used biosimilar filgrastim for some or all of their patients. The three paediatric centres all used Granocyte® and two adult centres used pegfilgrastim in some patients.
Additional material is available in the supplementary online file published with this supplement.
References
Abstract 62
Type: Poster
Category: Research
The stability of plerixafor (Mozobil) in pre-filled syringes for patient administration in an ambulatory setting
Undergraduate Student, Kingston University London
Plerixafor (Mozobil 20 mg/ml) is used in conjunction with Granulocyte-colony stimulating factor (G-CSF) to aid in the mobilisation of haematopoietic stem cells out of bone marrow into peripheral circulation.1 Upon migration, the cells are harvested by apheresis and used in autologous transplantation back to the patient after receiving their chemotherapeutic regimen. This helps to ensure the recovery and regeneration of cells of the bone marrow and hence aid in a patient’s rehabilitation.
Administration of a high cost drug such as Plerixafor can prove a clinical challenge due to patient wait times and the high-pressure burden of an increasing pharmacy workload, coinciding with the limited availability of drug stability data.
Drug stability testing is paramount in ensuring reliable and safe data to optimise how the drug is handled beyond the manufacture guidance. It is important to provide stability data on Mozobil and evaluate storage of the drug in pre-filled syringes for administration in an ambulatory setting and hence support the streamlining of the patient care pathway. Previous studies have shown Plerixafor to be stable at and 25°C over longer periods of time (84 days)2; however, there was a gap in the literature regarding higher temperatures.
The stability at 25 and 33°C throughout a 48 h period was comparable, with minimal variance between the concentrations under both conditions.
References
Abstract 63
Type: Poster
Category: Research
Awareness and compliance with pharmacovigilance requirements amongst UK pharmacists
Scientific Advisor, Pfizer
Understanding the true safety profile of new medicines requires rigorous adverse event (AE) reporting. Post licence, a new medicine is labelled with a black triangle indicating all AEs should be reported. Once regulatory bodies are satisfied that a medicine has an established safety profile, the black triangle is removed and only serious and unexpected AEs should be reported. Despite regulatory recommendations, it is recognised that AEs are often underreported.1 With a particular increase in the number of oncology drugs being licenced for use, there is a need to identify further the real world understanding of the black triangle and engagement with AE reporting programme.
Reference
Abstract 64
Type: Poster
Category: Research
Pilot study: Incidence of hyperbilirubinaemia in sarcoma patients receiving single agent doxorubicin
Cancer Services Pharmacist, University College London Hospital and The Cancer Centre for Medicines Optimisation, Research and Education (CMORE)
University College London Hospital (UCLH) is a tertiary referral centre for sarcoma patients. With a large catchment area, the Trust is committed to making patient pathways streamlined to ensure patients receive high quality treatment with minimal disruption. Doxorubicin is used in the palliative treatment of sarcomas, with patients receiving up to a total of six cycles. Biochemistry evaluation is required prior to chemotherapy as 50% of doxorubicin is excreted via the biliary tract.1
Dose reductions are advised in patients with a bilirubin >/=20 due to the increased risk of toxicity, including myelosuppression.2 Bloods must be <72 h old and therefore can be taken either locally or on the day of chemotherapy. Same day results may not be available for up to 6 h, causing delays to chemotherapy administration.
• Identify the number of patients with hyperbilirubinaemia (>/=20) at baseline and prior to each cycle of chemotherapy
• Evaluate the incidence of hyperbilirubinaemia during treatment in patients with a baseline bilirubin <20
Of those with hyperbilirubinaemia, 40% (n = 2) of these patients saw their levels normalise from cycle 2 onwards. Of the 14 cycles, 14.3% (n = 2) were dose reduced in line with recommendations, 41.7% (n = 5) had no dose reduction applied and 50% (n = 7) of patients were given a dose above that advised within the Summary of Product Characteristics.1 Eighty per cent (n = 4) of the patients with hyperbilirubinaemia were prescribed gCSF as prophylaxis or secondary to myelosuppression, compared to 32.6% (n = 42) of those with a bilirubin <20 throughout treatment.
Additional material is available in the supplementary online file published with this supplement.
References
Abstract 65
Type: Poster
Category: Research
Using meta-analysis to develop an audit standard for the rapid infusion of bio-similar rituximab
Durham, Darlington & Tees Valley Cancer Pharmacist, County Durham & Darlington NHS Foundation Trust
Rapid Rituximab for haematological malignancies has been published in several audits, a single randomised trial and as part of the evidence base of a further clinical study. While now licenced in the US, this is not part of the European Marketing Authorisation. Bio-similar Rituximab has been licenced in Europe with a licence mirroring the originator.
There is a clear requirement from NHS England to migrate to using Bio-similar Rituximab.
As organisations move from the originator to Bio-similar Rituximab there is a desire to audit the rate of adverse infusion events with the unlicensed rate of administration to ensure this is no different. However, there is a difficulty in determining a suitable audit standard to compare this with.
We have therefore undertaken a meta-analysis of all published data on rapid rituximab infusions within haematology, allowing development of an audit standard.
• Develop an audit standard for the Rate of Infusion Reactions to Rapid Infusion Rituximab based on a literature review
• Develop a common dataset for sharing of audit data between organisations to support a collaborative approach to auditing of Bio-similar Rituximab infusion rates
Likely factors influencing reaction rates were determined by literature review and brainstorm. The symptoms associated with individual grades of cytokine and allergic reactions were identified. A dataset, including data format was developed.
In addition, we have developed a dataset of 52 fields, with clear definitions which we hope will enable better sharing of audit data between centres to allow rapid collation of data in meaningful numbers.
Additional material is available in the supplementary online file published with this supplement.
Reference
Abstract 66
Type: Poster
Category: Research
Impact of education programme on biosimilar attitudes and beliefs
Head of Medical Science Liaison, Sandoz
Biosimilars represent a significant opportunity for the NHS to save money, and pharmacists frequently lead the adoption process.
Although set in 2005 by the EMA, the biosimilar regulatory process remains unfamiliar to many healthcare professionals. Despite a leading role in adoption, biosimilar science did not feature to any extent in the teaching of most currently practicing pharmacists, creating a potential knowledge gap.
As part of developing a standardised adoption process, the Cancer Vanguard and Sandoz developed an education programme that focused on the scientific rationale for the biosimilar licensing process to address this gap. The development of the materials and the results of the education program are described here.
Using the subsequently modified material, sessions were carried out across two Vanguard sites incorporating the questionnaire. Questionnaire analysis used parametric statistical methods.
Prior to training, biosimilar understanding varied considerably. Eighty-six per cent of nurses and 43% of doctors had not heard the term “biosimilar/biosimilarity” in the prior month.
This figure was only 17% amongst pharmacy staff.
Following the training, understanding of biosimilar principles universally improved as shown in Table 1. Paired t-tests showed high significance.
Expectations of clinical response also changed. Initially 40.1% of participants responded “not sure” altering to 95% of participants responding “very much the same” or “somewhat the same”.
Participants confidence in using a biosimilar in their patients changed from mean (SD) scores of 3.1 (3.2) to 7.1 (2.1) p < 0.000.
Those with initially low scores on the biosimilar principles were more likely to be initially unsure in the clinical response and have low scores of confidence in use. This relationship was not seen in the post-training results demonstrating.
Areas of further training were identified in the questionnaire and these were used to develop a train-the-trainer programme.
Additional material is available in the supplementary online file published with this supplement.
Abstract 67
Type: Poster
Category: Research
A survey of the oncology pharmacy workforce and assessment of capability to undertake advanced roles in the cancer setting
On behalf of BOPA and the UK Chemo Board
The prevalence of Cancer in the UK population is projected to rise from two million in 2015 to 3.4 million in 2030.1 This represents a significant challenge for commissioners and providers of cancer care. The Royal Colleges of Radiologists2 and Physicians3 have highlighted increasing shortfalls of medical staff supporting SACT services. It is imperative that a flexible and resilient workforce model is employed, utilising the skills of the non-medical workforce to alleviate these pressures. With increased demand coupled with downward workforce pressure on nursing numbers4 there is an opportunity and challenge for the pharmacy workforce to undertake ‘advanced roles’ in the cancer setting on a larger scale.
• To evaluate the current level experience of the oncology pharmacy workforce.
• To establish the percentage of the workforce registered as an independent prescriber (IP) and the frequency of practice.
• To qualitatively explore barriers to additional/advanced roles.
• Out of a total BOPA membership of 943, there were 152 surveys questionnaires completed (16% response rate).
• The majority were employed in the hospital sector (n = 149, 98%).
• 103 (68%) were AFC equivalent Band 8, and 35 (23%) AFC band 7.
• 108 (72%) had been working within oncology for 5+yrs, of which 62 (57%) for >10 yrs.
• 140 respondents answered the question related to IP, of which 65 (46%) were existing IPs. Of the 75 (54%) who were not IPs, 12 (16%) were undertaking the course and 23 (31%) indicated they planned to do so in the next 2 yrs.
• Of respondents who were IPs (n = 65), 24 (37%) were not prescribing, 30 (46%) were prescribing 1–2 sessions a week, with 11 (17%) prescribing in excess of 2 sessions a week. A session was defined as a half day period.
• Lack of support staff and workload were supported as the top concerns for undertaking advanced roles. Seventy-five per cent of respondents agreed that better skill mix would be positive for cancer services at their place of work.
References
Abstract 68
Type: Poster
Category: Research
Optimising the care of patients receiving oral systemic anti-cancer treatments: The health professional perspective
Doctoral Research Student, Oxford Brookes University
Patients prescribed oral systemic anti-cancer treatments (SACT) need to be managed in accordance with national guidance (1–2) to ensure safe and effective care.
To address these requirements, a regional cancer centre implemented a pharmacist and nurse-led oral SACT education clinic (OEC) providing individually tailored patient education about drug administration and side effect management. Evidence indicates patient satisfaction with oral SACT education services3 but the views of health professionals involved in managing this patient group have not yet been reported.
The OEC was perceived as effective for providing education to patient’s receiving oral SACT, but the education needed to be individually tailored and should be delivered on more than one occasion. Participants recommended that professionals providing the OEC service should be aware of ‘information overload’ and the important role of family, friends and carers in ensuring safe administration. Some patients were perceived to be higher risk of adverse outcomes, highlighting the need for accurate assessment to stratify patients into risk groups to identify patients requiring closer monitoring. The use of a patient diary was also suggested to help adherence and toxicity assessment. The GP was viewed as having a significant role, but there was a sense that utilisation of GP services was dependent on patients’ confidence and trust in their GP. Future recommendations included increased education to GPs and incorporating technology into monitoring patients remotely.
Additional material is available in the supplementary online file published with this supplement.
References
Abstract 69
Type: Poster
Category: Research
Compared efficacy of palbociclib versus ribociclib in advanced breast cancer
Clinical and Chemotherapy Pharmacist, The Royal Marsden Hospital NHS Foundation Trust
Palbociclib and ribociclib are highly selective, reversible cyclin-dependent kinases (CDK) types 4 & 6 inhibitors involved in multiple signalling pathways which lead to cellular proliferation. Early results of the phase III PALOMA-2 trial showed clinical benefits in terms of progression-free survival (PFS) of palbociclib + letrozole versus letrozole in monotherapy, which granted accelerated FDA and EMA approval as first-line therapy for the treatment of ER+, HER2−, locally advanced or metastatic breast cancer (ABC) in post-menopausal women.1 Likewise, a pre-planned interim analysis from the phase III MONALEESA-2 trial suggested there is clinical benefit derived from the use of ribociclib in a similar cohort, thus raising questions as to which of the two drugs provides the best efficacy outcomes, as well as to determine their future role in the treatment of ABC.2
Additional material is available in the supplementary online file published with this supplement.
References
Abstract 70
Type: Poster
Category: Research
Predictors for deferrals and dose reductions with oxaliplatin modified de Gramont chemotherapy for colorectal cancer
Specialist Clinical Pharmacist, The Christie NHS Foundation Trust
Colorectal cancer is the second most common cause of cancer death after lung and the third most common cancer in the United Kingdom affecting approximately 41,000 people in 2012.1 Cancer treatment is costly so savings resulting from minimising treatment wastage could alleviate cost pressures. Side effects of chemotherapy can cause treatment deferrals and/or dose reductions. When indicators of treatment deferral are not identified, the chemotherapy may be discarded but the cost is still incurred. It is therefore important to determine factors that predict treatment deferrals or dose reductions. Using characteristics reported in the literature as factors affecting tolerability of chemotherapy the study reported here investigated the risk of changes to chemotherapy treatment that could be used to initiate risk-reducing strategies within a chemotherapy unit, saving the NHS the cost of discarded treatment.
• To establish patient factors associated with frequency of deferrals.
• To establish whether it is possible to identify predictors for deferral.
Reference
Abstract 71
Type: Poster
Category: Research
Is there value in using patient recorded outcome measures to improve toxicity management patients receiving chemotherapy for breast cancer?
Senior Cancer Pharmacist, University College London Hospital and The Cancer Centre for Medicines Optimisation, Research and Education (CMORE)
It has been documented that PROMs can improve the quality of life (QoL) for patients receiving chemotherapy and reduces admissions for chemotherapy-related toxicity management.1
Owise2 in an app developed to help breast cancer patients monitor their symptoms and feelings during treatment as well as incorporating a diary function. Results are collated into graphs to show patients how they have been feeling physically and mentally over a set time period.
To assess patient satisfaction with the app
To assess if patients thought the app helped their management of toxicities
Patients were asked to use the app for one month then invited to complete an online questionnaire through the Qualtrics website which used the Likert Scale to rate patients’ satisfaction.
Anonymised data were extracted to understand whether the real world data could enable improvements in the service that would result in less suffered toxicity for patients.
No patients routinely used the app during clinician consultations.
Although this project did not provide clinical data, that patients were accepting of the app is a positive step forward in improving how we can manage patients’ toxicities and enable patients to take a greater role in their care.
There is a place in practice for the use of this app; however, further study is required in order to derive benefit for patients and practitioners:
• Understanding why the patients did not use the app in clinician consultations
• Should clinicians prompt patients to discuss their data in consultations?
• Did patients understand they could use the app in consultations?
• Did patients not feel the need to openly consult the app in consultations?
• Practitioners need to understand how to use these data to support their patients in clinics
• Practitioners will need access to collective data from the app in order to implement changes to practice in supportive care for specific patient populations
Going forward, this research has provided the basis on which to build a larger-scale, outcome-driven project with the opportunity to assess actual toxicity data and would be easy to run across multiple participating Trusts.
Additional material is available in the supplementary online file published with this supplement.
References
Abstract 72
Type: Poster
Category: Research
Observational study of skin toxicity with Afatinib
Senior Cancer Pharmacist, University College London Hospital and The Cancer Centre for Medicines Optimisation, Research and Education (CMORE)
Afatinib tyrosine kinase inhibitor (TKI) indicated for the treatment of epidermal growth factor (EGFR) -mutation non-small cell lung cancer (NSCLC). Inhibition of the EGFR pathway causes an inflammatory response which can manifest as skin toxicity. The summary of product characteristics (SPC) lists rash, acne, pruritus and dry skin as very common, and palmar-plantar erythema as common.1 It has been anecdotally noted at UCLH that a high proportion of patients on afatinib experience some degree of skin toxicity. There are no formal guidelines for the management of these side effects resulting in variation in practice.
Califano et al.2 published guidance in 2015 but this has not been adopted locally. It was decided to retrospectively look at the prevalence and management of skin toxicities historically at UCLH, and see if there was any common theme for management.
All patients are provided topical emollients at baseline and counselled on the importance of keeping their skin moisturised.
• Evaluate the proportion of patients who experienced skin toxicity
• Describe the severity of skin toxicity
• Compare interventions for skin toxicity management
Thirty-eight per cent of patients received two or more interventions at the same time, e.g. topical clindamycin with oral antibiotics.
Prophylactic antibiotics are not endorsed at UCLH but two patients with ongoing Grade 3 skin toxicities both started long-term courses of minocycline during their treatment to some avail.
Overall the following interventions were made, with no single option being favoured: dose reduction 47.6%; topical steroids 42.9%; topical clindamycin 33.3%; oral antibiotics 42.9%; treatment break 42.9%.
Additional material is available in the supplementary online file published with this supplement.
References
Abstract 73
Type: Oral and Poster
Category: Research
A focus group to explore the experiences and opinions of generalist pharmacy staff providing pharmaceutical care to patients with cancer on non-cancer wards
Lead Oncology Pharmacist, Salisbury NHS Foundation Trust
When a patient is admitted to any ward at Salisbury NHS Foundation Trust (SFT), their pharmaceutical care is provided by the ward-based pharmacy team. On our specialist cancer ward, this care is provided by a pharmacist with specialist cancer and chemotherapy training however, patients with cancer may be admitted to other wards depending on their medical needs. A focus group was carried out to explore how other pharmacy team members felt about caring for patients with cancer.
• To explore the experiences and opinions of the pharmacy team at SFT concerning the provision of pharmaceutical care to patients with cancer on non-cancer wards.
• To investigate if further support from a specialist cancer pharmacist is required by the local pharmacy team.
The project pharmacist transcribed the digital recording, coded the transcript and carried out thematic analysis using a framework method to develop themes and sub-themes. A descriptive analysis of the themes was carried out.
A number of themes were common throughout the discussion and reflected the dissatisfaction that individuals felt with the current situation of ad hoc advice. Some felt uneasy that they did not know when to ask for advice possibly due to lack of relevant educational background and a poorly defined process for providing specialist input. It was acknowledged that in an ideal world, all patients would be referred to a specialist pharmacist but it was recognised that this was not practicable and hence, other options were explored.
Three main themes were identified from the discussion: pharmaceutical care of patients, robust systems to support their care and the provision of education and training.
An initial action plan has been drafted and includes:
• Development of a training package for the general pharmacy team on how to use our chemotherapy prescribing system.
• Develop guidance on sources of drug history information when patients are on chemotherapy.
• Update our oral chemotherapy policy to provide more explicit guidance for generalists.
• Devise a rolling educational programme for generalists on the pharmaceutical care of patients with cancer.
Abstract 74
Type: Oral and Poster
Category: Research
How do local demographics influence outcomes for metastatic castration resistant prostate cancer (mCRPC) patients prescribed abiraterone?
Clinical Effectiveness Pharmacist Cancer Care, NHS Greater Glasgow and Clyde
Abiraterone was accepted for use within NHS Scotland in 2012 for men with mCRPC who have progressed on or after docetaxel-based chemotherapy. Subsequently in 2015 it was accepted for use after failure of androgen deprivation therapy in men whom chemotherapy is not yet clinically indicated. This retrospective study was planned to provide real world experience of abiraterone in NHS Greater Glasgow & Clyde as part of the Cancer Medicines Outcome Programme (CMOP). Overall survival (OS) in pivotal studies was 15.8 months1 and 34.7 months2 in the post and pre chemotherapy cohorts. Limited outcomes in the real world are known, particularly in the pre-chemotherapy setting which appear to show inferior results.3
Fifty-seven per cent of patients (n = 93) and 41% (n = 67) received abiraterone post- and pre-chemotherapy with median age 73 and 75 years, respectively. Two per cent (n = 4) received abiraterone for mCRPC post upfront docetaxel for newly diagnosed metastatic prostate cancer.
Median duration of treatment was 6.7 and 11.1 months post- and pre-chemotherapy compared to 7.4 months and 13.8 months in the respective pivotal trials.
Median OS was 10.9 and 20.4 months post- and pre-chemotherapy compared to 15.8 and 34.7 months in the respective pivotal trials. HR for each variable were calculated, stratified by pre or post chemotherapy; Table 1. Higher PS significantly increased the death hazard.
Median OS was shorter in our patients. PS correlated with OS, a finding which was also reported in the post chemotherapy pivotal trial. The pre chemotherapy pivotal study excluded patients with PS >1, so no comparison can be made. The study reinforces the importance of PS in determining treatment eligibility and suggests that outcomes in trials may not be reflective of those in ‘real-life’.
Further analysis on OS by additional variables is planned and will be available late summer as is analyses of the PSA response rate, time to PSA progression and next treatment.
Additional material is available in the supplementary online file published with this supplement.
References
Abstract 75
Type: Oral and Poster
Category: Research
New treatments for advanced (unresectable or metastatic) melanoma: What do they mean for patients? Real world experience from NHS Greater Glasgow and Clyde
Clinical Effectiveness Pharmacist, Cancer Care, NHS Greater Glasgow and Clyde
Treatment options for advanced (unresectable or metastatic) melanoma have radically changed over the past few years with the introduction of targeted treatments such as vemurafenib; dabrafenib and trametinib and immunotherapies including ipilimumab, nivolumab and pembrolizumab. The Cancer Medicines Outcomes Programme (CMOP) is a collaborative three-year programme between NHS Greater Glasgow and Clyde (NHSGGC) and the University of Strathclyde aiming to evaluate the effectiveness of cancer medicines used in the real world, providing further information for clinicians and patients for shared decision making. Despite an increasing amount of clinical trial evidence including updates of pivotal trials, real world outcome information is lacking.
Univariate analysis found only M status (American Joint Committee on Cancer 7th Edition) had an impact on OS; those who were M1c had an unadjusted hazard ratio of 2.27 compared to those M0-M1b. No other clinical variable had a statistically significant impact on OS. Duration of therapy was similar for patients in NHS GGC and clinical trials.
Limitations of our study include small patient numbers and challenges reporting progression-free survival in the real world. The next phase of the study will expand the patient cohort to whole West of Scotland to increase patient numbers. Further analysis will also be carried out to determine the influence of baseline demographics on outcomes with all treatments and the impact of other treatments on survival.
Additional material is available in the supplementary online file published with this supplement.
References
Primary Author Index
Ahmed, Rahil Abstract 31, Page 28
Baillie, Kelly Abstract 74, Page 67
Bayliss, Katherine Abstract 64, Page 57
Breen, David Abstract 46, Page 42
Bruggink, Rosanne Abstract 58, Page 53
Buijtenhuijs, Bastiaan Abstract 6, Page 6
Burnett, Bruce Abstract 43, Page 39
Chambers, Pinkie Abstract 36, Page 33
Chambers, Pinkie Abstract 51, Page 46
Chauhan, Rena Abstract 53, Page 48
Clarke, Julie Abstract 75, Page 68
Coe, Faye Abstract 70, Page 63
Cortez, Lillian Abstract 20, Page 19
Coupe, Joseph Abstract 2, Page 2
Cracknell, Netty Abstract 57, Page 52
Dalby, Melanie Abstract 19, Page 18
Davies, Louisa Abstract 37, Page 34
Djebbari, Faouzi Abstract 24, Page 22
Duncan, Nick Abstract 5, Page 5
Duncan, Nick Abstract 27, Page 25
Duncan, Nick Abstract 32, Page 29
Duncan, Nick Abstract 61, Page 55
Elkonaissi, Islam Abstract 40, Page 36
Elliott, Ben Abstract 50, Page 45
Evans, Mark Abstract 67, Page 60
Finch, Milly Abstract 25, Page 23
Ford, Natalie Abstract 71, Page 64
Ford, Natalie, Abstract 72, Page 65
Fraser, Brendan James Abstract 55, Page 50
Gabriel, Sumantha Abstract 21, Page 19
Gibson, Jennifer Abstract 39, Page 35
Gregory, Kate Abstract 41, Page 37
Hamilton-Tanner, Natasha Abstract 9, Page 9
Hogdson, Beth Abstract 11, Page 11
Josephs, Debra Abstract 49, Page 44
Lister, Stephanie Abstract 62, Page 56
MacLean, Fiona Abstract 59, Page 53
Maguire, Áine Abstract 16, Page 15
Maouche, Nadjoua Abstract 8, Page 8
Mateo-Carrasco, Hector Abstract 13, Page 13
Mateo-Carrasco, Hector Abstract 60, Page 54
Mateo-Carrasco, Hector Abstract 69, Page 62
Mawhinney, Michael Abstract 68, Page 61
McCarthy, Tim Abstract 35, Page 32
Moorhouse, Kristen Abstract 34, Page 31
Moyse, Nicholas Abstract 54, Page 49
Murphy, Philip Abstract 66, Page 59
Nijjar, Rajinder Abstract 44, Page 40
Nobrega, Robert Abstract 10, Page 10
O’Donohgue, Róisín Abstract 18, Page 17
Paton, Nina Abstract 33, Page 30
Polwart, Calum Abstract 30, Page 27
Polwart, Calum Abstract 65, Page 58
Preston, Andrea Abstract 56, Page 51
Robertson, Debra Abstract 22, Page 20
Robertson, Debra Abstract 73, Page 66
Shah, Bansi Abstract 7, Page 7
Shah, Raakhee Abstract 17, Page 16
Shaunak, Nisha Abstract 42, Page 38
Stoner, Nicola Abstract 23, Page 21
Stoner, Nicola Abstract 26, Page 24
Stoner, Nicola Abstract 47, Page 43
Tew, Alice Abstract 28, Page 25
Thorne, Rebecca Abstract 63, Page 57
Thwaites, Benjamin Abstract 48, Page 44
Tipping, Anna Abstract 12, Page 12
Walsh, Darren Abstract 3, Page 3
Walsh, Darren Abstract 4, Page 4
Walsh, Darren Abstract 15, Page 14
Warner, Marcus Abstract 29, Page 26
Watson, Christopher Abstract 38, Page 34
Watson, Helen Abstract 1, Page 1
Williams, Joseph Abstract 52, Page 47
Wood, Kate Abstract 45, Page 41
Yiu, Brian Abstract 14, Page 13
Yuen, Amy Abstract 14, Page 13
Supplemental Material
sj-pdf-1-opp-10.1177_1078155217729776 - Supplemental material for Abstract
Supplemental material, sj-pdf-1-opp-10.1177_1078155217729776 for Abstract by in Journal of Oncology Pharmacy Practice
Supplementary Material
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