Administration
01
Workload and Utilization Impact of a Pharmacy-Led Intervention to Electronic Ordering of Subcutaneous Rituximab
Curtis Kellett, Carla Pensack, Marc Geirnaert, Pamela Skrabek, Oliver Bucher
CancerCare Manitoba, Winnipeg, Canada
Objective/Purpose: To determine if a pharmacy-led change to electronic order sets increased the rate of prescribing of subcutaneous rituximab to eligible lymphoma patients, and to assess what impact this forced function had on pharmacy workload.
Study design/Methods: Patient data will be abstracted from the electronic record to identify patients that were eligible to receive subcutaneous rituximab for the first-line treatment of Non-Hodgkin's lymphoma between the funding date for the formulation and 90 days following the implementation of the forced function. Descriptive statistics will be performed to characterize patients according to formulation received, frequency of formulation change, and specialty performing the change. An interrupted time series analysis will be performed upon completion of data collection. Pharmacist intervention and workload will be measured through the presence of a pharmacy note termed an ‘eDOC’.
Results/Key findings: Preliminary data for 57 patients has been gathered. Findings for this subset show that the percentage of patients receiving subcutaneous rituximab at Cycle #2 increased from 59% to 94% (p = 0.011), and a decreased number of eDOCs were required (5/39 vs 0/18) after the changes to electronic ordering were implemented.
Conclusion/Recommendations: This study is ongoing. Final results and analysis will be provided in advance of the conference.
02
A Real-World Data Approach to Determine the Optimal Usage of Pembrolizumab
Ashley Jang1, Lynne Nakashima2, Tonya Ng2, Mayo Fung2, Samarah Jiwani2, Kimberly Schaff2, Jennifer Cowie2, Randy Goncalves2, Dennis Jang2, Kimberly Kuik2, Sylvie Labelle2, Alison Pow2
1University of British Columbia, Vancouver, Canada
2BC Cancer, Vancouver, Canada
Objective/Purpose: Analyze pembrolizumab data at all six BC Cancer Centres over one year to optimize its use through:
Actual vs estimated calculations of usage, wastage, and cost
Alternative cost-effective dosing regimens
Study design/Methods: Part One: Actual amounts of drug used to manufacture doses prescribed were calculated from dispensing data and wastage logs. Estimated calculations of usage and wastage were calculated from dispensing data assuming smallest number of vials used to minimize waste, without and with vial sharing assumptions. Costs were calculated based on wholesale acquisition prices. Part Two: Drug usage costs for dosing strategies mg/kg dosing (max: 200 mg), rounding down within 5 and 10%, and 200 mg flat dosing were performed, with 50 and 100 mg vials.
Results/Key findings: There were a total of 172 non-small cell lung cancer and melanoma patients with 937 doses administered. Percentage of documented drug wasted was highest at the center dispensing the least amount of drug (17.31%). For all centres, documented drug wastage amounted to $492,709.80 and vial sharing theoretically saved $378,400.00. The least expensive dosing strategy was rounding down within 10% using 50 mg vials costing $6,899,200.00.
Conclusion/Recommendations: Further investigation into pharmacy practices and other dosing strategies may improve usage of pembrolizumab.
03
The Effectiveness of Ontario's Generic Pricing Polices for Intravenous Chemotherapy
Rohini Naipaul, Jaclyn Beca, Scott Gavura
Cancer Care Ontario, Toronto, Canada
Objective/Purpose: Cancer Care Ontario's generic pricing policy for IV cancer drugs is based on a competitive tendering model. In 2014, we evaluated the effect of this policy on reimbursement prices for drugs funded by the New Drug Funding Program and found substantial price reductions over time. We updated this analysis to examine the current impact and effectiveness.
Study design/Methods: New Drug Funding Program reimbursement prices were reviewed between 2004 and 2018 for 13 generic drugs to examine initial and cumulative price reductions, time to price reduction, and to estimate cost savings. Formulary prices, listing dates, and market dates were sourced from administrative databases.
Results/Key findings: The 13 drugs reviewed were on the New Drug Funding Program formulary for an average of 17 years (range, 8.6–23.8). Reimbursement prices initially decreased by an average of 60 ± 26% over 0.5 ± 0.4 years from the date the first generic equivalent was marketed in Canada. Reimbursement prices at the end of 2018 were on average 12% of the New Drug Funding Program list price prior to the first generic entry.
Based on 17/18 utilization volumes, this model delivered an estimated $138 million in savings in the 17/18 fiscal year.
Conclusion/Recommendations: Cancer Care Ontario's generic drug pricing policies continues to deliver substantial price reductions for generic drugs.
04
Trends in Costs and Use of Publicly-funded Oncology Biologics in Ontario
Rohini Naipaul1, Jaclyn Beca1, Rebecca Mercer2, Scott Gavura1
1Cancer Care Ontario, Toronto, Canada
2Canadian Centre for Applied Research in Cancer Control, Toronto, Canada
Background: In Canada, biosimilars, drugs that are highly similar to regulatory approved biologics, are expected to be increasingly available for oncology uses. To inform system planning, we examined trends in costs and utilization of biologics funded by Cancer Care Ontario's New Drug Funding Program for IV cancer drugs.
Study design/Methods: All drugs funded by New Drug Funding Program (n = 46) were classified as ‘biologic’ or ‘non-biologic’ based on Health Canada and FDA definitions. Claims and costs data were obtained from the New Drug Funding Program database, for claims approved between April 2013 and March 2018.
Results/Key findings: Over the past five years, the number of biologic drugs funded by the New Drug Funding Program almost doubled. In that timeframe, spending on biologics increased by 81% while spending on non-biologics decreased by 35%. By FY2018, biologics accounted for 82% of annual New Drug Funding Program expenditures with trastuzumab, rituximab, and bevacizumab incurring expenditures of $180M (48% of the annual New Drug Funding Program expenditure). During this five-year period, treatment volumes increased by 33% for biologics.
Conclusion/Recommendations: In Ontario, the majority of spending on IV cancer drugs has shifted from non-biologics to biologics, which now represent the majority of the growth in use and expenditure. These findings suggest an opportunity for significant cost-savings from the introduction of oncology biosimilars.
05
Le Mode Continu D'évaluation des Médicaments Aux Fins D'inscription À L'inesss: Impact Sur Les Délais D'émission des Recommandations Pour Les Anticancéreux
Valerie Cote
Inesss, Montreal, Canada
Situation: En 2017, le Québec publiait la Stratégie québécoise des sciences de la vie qui souhaitait notamment rendre accessible plus rapidement les médicaments avec une valeur ajoutée. L'INESSS a donc modifié son processus d'évaluation afin que ses recommandations soient publiées dans un délai rapproché avec l'ACMTS, permettant au Québec de s'engager dans la négociation d'une entente simultanément aux autres provinces membres de l'Alliance pancanadienne pharmaceutique.
Objectif: Pour les anticancéreux, mesurer le délai entre l'avis de conformité (AC) de Santé Canada et le dépôt d'une soumission à l'INESSS, et le délai entre l'AC et l'envoi d'une recommandation au ministre avant et après l'implantation du mode continu.
Devis: Évaluation rétrospective des soumissions déposées entre 26/05/2016 et 30/05/2017 (avant l'implantation) et du 10/10/2017 au 10/10/2018 (après l'implantation).
Résultats: Avant et après, 23 et 30 soumissions ont été déposées (dont 2 et 22 pré-AC). Le délai médian entre l'AC et la soumission a été de 97 contre 46,5 jours. Le délai médian entre l'AC et la recommandation a été de 254 contre 94,5 jours.
Conclusion: L'implantation d'un mode continu d'évaluation a permis de répondre aux objectifs de la Stratégie québécoise des sciences de la vie pour les anticancéreux.
06
An Analysis of Quality and Savings Post-Implementation of Extended Beyond Use Dating of Single Dose Vials with PhaSeal
Alicia Wall, Lynn Hartery, Rick Abbott
Eastern Health, St. John's, Canada
Objective/Purpose:
To determine the rate of microbial contamination detected through a quality assurance program
To evaluate the cost savings associated with extended beyond use dating of single dose vials
Study design/Methods: Partial single use vials of cancer drugs that had been used in preparation of patient-specific compounded sterile products using PhaSeal were segregated and tested for microbial contamination at hours 24, 48, 72, 96, 120, 144, and 168 after initial puncture for quality assurance. The value of partial single use vials of cancer drugs discarded on a daily basis was recorded for one month prior to implementation of extended beyond use dating and for six months after implementation.
Results/Key findings: In all, 18 vials were tested for quality assurance, yielding 79 samples. The rate of microbial contamination identified by standard plate count was 0%. The value of waste decreased 51% from baseline, realizing over $155,000 in savings in six months.
Conclusion/Recommendations: Extended beyond use dating of single dose vials of cancer drugs using PhaSeal results in cost savings while maintaining product sterility and quality.
07
Humber River Hospital Oncology Pharmacy - Vial Optimization Sterility Study (VOSS)
Mihir Patel, Deo Bahadur, Jennifer Singh, Subuddhi Kulkarni, Albert Karas
Humber River Hospital, Toronto, Canada
Objective/Purpose: According to the NAPRA sterile compounding standards, a single-use vial must be discarded six hours after puncture. We sought to validate the aseptic sterile compounding techniques of pharmacy technicians preparing hazardous medications while using a closed system transfer device to extend this beyond-use dating from 6 hours to 120 hours (5 days), where chemical stability is available.
Study design/Methods: To simulate daily compounding practice, vials containing Tryptic Soy Broth were used as a growth medium. GroMed™ vials were punctured using PhaSeal® P55 adapters and 1 mL doses were withdrawn using PhaSeal® syringe adaptors. Two doses were withdrawn from the TSB vial daily for 5 days. All syringes and partial GroMed™ vials were incubated at 30 °C–35 °C for 14 days in a Pharmacy incubator. Results were read daily.
Results/Key findings: Over the eight-week study period, there was a total of 16 punctured vials and 154 syringes totaling 170 samples. There was no visible turbidity to indicate microbial growth in any of samples and the goal of 0% contamination rate was achieved.
Conclusion/Recommendations: A closed system transfer device, such as PhaSeal®, can be used to demonstrate aseptic compounding techniques that maintains the sterility of punctured single-use vials for up to 5 days.
08
Old Habits Die Hard … Updating Policies to Reflect Current Evidence-Based Antiemetic Guidelines at a Regional Cancer Centre
Jordan Stinson, Ivan Tyono, Mark Pasetka, Carlo DeAngelis, Flay Charbonneau
Sunnybrook Odette Cancer Centre, Toronto, Canada
Objective/Purpose: The objective of this project was to transition our centre's antiemetic policies to the current evidence-based guidelines introduced by ASCO and MASCC in 2017.This involved updating the antiemetic links in our computerized physician order entry system from Hesketh levels to highly-emetogenic chemotherapy, moderately-emetogenic chemotherapy, and low-emetogenic chemotherapy classifications.
Study design/Methods: A complete review of chemotherapy regimens in our centre's computerized physician order entry system was conducted between January 2017 and December 2018. New regimen classifications, antiemetic links, and adherence calendars were required.
Results/Key findings: A total of 595 chemotherapy regimens were reviewed. Each regimen was classified based on the most emetogenic agent involved: 61 (10%) highly-emetogenic chemotherapy, 174 (29%) moderately-emetogenic chemotherapy, and 101 (17%) low-emetogenic chemotherapy regimens were identified. Regimens were divided by disease site group and reviewed with the site group lead for approval.
Conclusion/Recommendations: Updating antiemetic prescribing policies requires significant time and dedicated staff to organize, create, and meet with interprofessional team members to gain consensus and approval of changes.
09
From Guidelines to Practice: Patient-Focused and Evidence-Informed Update of Antiemetic Recommendations in Ontario
Kathy Vu1,2, David Warr3, Leta Forbes1,4, Daniela Gallo-Hershberg1,2, Carlo De Angelis2,5, Stephanie Brule6, Dayna Comfort7, Lisa Randall8, Julie Williams9, Sarah Salama1
1Cancer Care Ontario, Toronto, Canada
2Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
3Princess Margaret Cancer Centre, Toronto, Canada
4R.S. McLaughlin Durham Regional Cancer Centre, Oshawa, Canada
5Odette Cancer Centre, Toronto, Canada
6The Ottawa Hospital, Ottawa, Canada
7London Health Sciences Centre, London, Canada
8North Bay Regional Health Centre, North Bay, Canada
9Kingston General Hospital, Kingston, Canada
Objective/Purpose: Cancer Care Ontario last updated their guidance for the management of chemotherapy-induced nausea and vomiting in 2013. Since then, new evidence emerged which changed antiemetic recommendations internationally. The Cancer Care Ontario Antiemetic Working Group reviewed the current literature and aimed to update existing recommendations for the prevention and management of chemotherapy-induced nausea and vomiting in adult patients.
Study design/Methods: Ontario subject matter experts consisting of oncologists, pharmacists, and nurses formed the Group. Relevant guidelines published from prominent jurisdictions were assessed. A literature search was done to incorporate the latest evidence. All chemotherapy regimens in the Cancer Care Ontario Drug Formulary were reviewed. Ontario Cancer Leads for each disease site were consulted to ensure emetic classifications for all regimens and antiemetic recommendations reflected both the evidence (including gaps in the literature) and clinical practice (including gaps between evidence and practice).
Results/Key findings: Recommendations for antiemetic agents for highly, moderately, low and minimal emetic risk intravenous and oral chemotherapy are outlined. Chemotherapy regimens in the Cancer Care Ontario Drug Formulary were reviewed and emetic risks updated. Recommendations differed from those of major international guidelines around olanzapine dosing, cannabinoids, and emetic risk classification.
Conclusion/Recommendations: A systematic approach to updating antiemetic recommendations resulted in evidence-informed recommendations that are patient-focused and clinically feasible.
10
From Dose Rounding to Dose Banding: Development of Dose Banding Tables for Oral Chemotherapy Medications
Vian Cheng, Mario de Lemos, Dennis Jang, Carrie Kung, Ricky Dhemi
BC Cancer, Vancouver, Canada
Objective/Purpose: BC Cancer prescribers currently use preprinted orders on paper and manually calculate oral chemotherapy doses, using a target dose (mg/m2) normalized to body surface area and the patient's body surface area, then rounded to accommodate available dosage strengths. BC Cancer is transitioning from preprinted orders to computerized physician order entry, whereby prescribers use a programmed dose calculator to calculate doses using the target dose and patient's body surface area, follow by dose rounding. To automate the dose rounding process, a dose banding table is needed to standardize the dose rounding approach in the programmed dose calculator.
Study design/Methods: A literature search was performed to identify ideal features from dose banding approaches in various cancer centres. These features should maintain similar clinical efficacy and toxicity, ensure patient acceptance, minimize pharmacy dispensing burden, and minimize cost, as compared to precise dosing.
Results/Key findings: Dose banding tables for capecitabine and temozolamide were created by: (1) keeping each dose band within a minimal variance; (2) using the minimum number of pills; (3) using the minimum number of dosage strengths; and (4) minimizing cost.
Conclusion/Recommendations: Dose banding tables were created for two oral chemotherapy medications. Similar approach can be applied to dose banding for other oral chemotherapy medications.
11
Implications of Endotoxin in Defining Nivolumab Infusion Volume
Anne Dar Santos1, Mario de Lemos1, Nadine Badry2
1BC Cancer, Vancouver, Canada
2BC Cancer, Victoria, Canada
Objective/Purpose: Nivolumab follows fixed-dose and weight-based dosing. In 2018, the manufacturer specified that the fixed-dose nivolumab infusion volume should not exceed 120 mL to stay within the endotoxin exposure limit in low body weight patients. At BC Cancer, nivolumab follows weight-based dosing for patients below 80 kg. We sought to define the nivolumab infusion volume in this setting, considering both endotoxin and drug concentration-dependent stability limits.
Study design/Methods: Using 1 mg/kg, 3 mg/kg (max 240 mg), and 6 mg/kg (max 480 mg) dosages, we applied a range of weight and infusion volumes to determine the endotoxin level and drug concentration of nivolumab preparations. The endotoxin limit was 5 EU/kg (nivolumab plus infusion bag). The drug concentration limit was 1–10 mg/mL.
Results/Key findings: Iterations of weight, dosing, and infusion volume showed that endotoxin levels would stay within limits using 100 mL infusion bags, irrespective of body weight. To stay within drug concentration limits, smaller doses may require 50 mL infusion bags.
Conclusion/Recommendations: Preparing weight-based nivolumab doses using 100 mL infusion bags enables most preparations to stay within endotoxin and drug concentration limits.
Pharmacy Practice
12
The Stopwatch Trial – Oral Systemic Therapy Monitoring Program: Pharmacist Workload Assessment
Jonathan Stevens1, Kyia Hynes2, Courtney Blue3
1Horizon Health, Saint John, Canada
2Alberta Health Sciences, Calgary, Canada
3Dalhousie College of Pharmacy, Halifax, Canada
Objective/Purpose: This workload assessment sought to quantify pharmacist time allocated to clinical and non-clinical duties in the Oral Systemic Therapy Monitoring Program to optimize clinical interventions associated with improved patient outcomes.
Study design/Methods: This quality improvement project included Oral Systemic Therapy Monitoring Program workload statistics in two phases (19–30 June 2017 and 28 May–8 June 2018) at the Saint John Regional Hospital. Data extraction was completed during clinic hours analyzing the following variables:
Time allocated to clinical responsibilities (blood-work assessments, toxicity assessments, clinical problems, and miscellaneous)
Time allocated to non-clinical responsibilities (technical problem management, treatment calendars, and scheduling appointments).
Charts reviewed/day, average time/chart, and interruptions.
Results/Key findings: The two phases included 114.79 hours overall with non-clinical duties accounting for 44% of hours in phase 1 and 52% in phase 2. The relationship between both values was quantified using Clinical Care Ratios. Miscellaneous duties comprised the largest proportion of clinical responsibilities in both samples.
Conclusion/Recommendations: In the Oral Systemic Therapy Monitoring Program the majority of pharmacist time is allocated to non-clinical duties. This study provides valuable insight regarding pharmacist workload distribution and identification of tasks that may be altered or delegated to optimize time allotted to clinical interventions associated with improved patient outcomes.
13
Do Oncology Exceptional Treatments Warrant the Special Treatment?
Tonya Ng, Lynne Nakashima, Helen Anderson, Karen Janes, Mario de Lemos, John Larmet, Adeline Markarian, Yvonne Miller
BC Cancer, Vancouver, Canada
Objective/Purpose: Increasing demand to use new cancer treatments in exceptional cases poses pressures on healthcare resources. Compared with routine treatments, fewer patients are affected, thus fewer resources are assigned to support delivery. Limited available information and infrequent use of exceptional treatments increase risk for operational inefficiencies and medication errors. A BC Cancer interdisciplinary task group was formed to recommend a provincial process to maintain quality care and safety in the delivery of exceptional treatments.
Study design/Methods: Environmental scan, medication error report review and gap analysis were performed comparing the delivery of routine vs exceptional cancer treatments at BC Cancer. Recommendations were reviewed by key interdisciplinary committees.
Results/Key findings: Processes and resources needed to address the gaps in exceptional treatment delivery were identified. The ethical dilemma of responsible fiscal allocation vs patient safety was debated but BC Cancer's core value of patient-centred quality care focused the intent of the work. The final report was used as foundational piece for resource development, oncology module design for the new electronic healthcare system and guidance for future direction of BC Cancer Systemic Therapy Program.
Conclusion/Recommendations: A value-driven, patient-focused combination of clinical, safety, operational, and fiscal knowledge is required to design an effective cancer treatment delivery process.
14
Evaluation of Pharmacists' Clinical Interventions and Systematic Documentation in Oncology Practice
Shirin Abadi
1,2
1BC Cancer, Vancouver, Canada
2University of British Columbia, Vancouver, Canada
Objective/Purpose: To evaluate the impact of pharmacists' interventions on identifying and resolving drug therapy problems in patients with cancer.
Study Design: Prospective, Quality Assurance Project
Methods: Pharmacists working in all patient-care areas within or outside the pharmacy department were asked to use a systematic approach, in order to capture their clinical interventions in an Excel spreadsheet. The types of interventions were standardized and clearly defined. Each intervention required patient-validation and regular review by the project leader.
Results/Key findings: More than 20,000 clinically important drug therapy interventions were captured for each year in 2015, 2016, 2017, and 2018 for the benefit of patients with cancer, thus leading to significant improvements in patient health outcomes and patient safety, while reducing healthcare costs.
Conclusion/Recommendations: This project has enabled pharmacists to capture their clinical interventions to optimize patient care, by preventing and resolving drug therapy problems, including drug interactions and adverse events related to medications. The results have enabled the organization to be better informed about patient safety concerns with regards to medication therapy (chemotherapy and otherwise), and the steps needed to optimize the provision of patient care in the context of drug therapy.
15
Descriptive Analysis of Filgrastim use in children in Québec's University Teaching Hospitals, Canada
Ghislain Bérard1,6, Cathy Quirion2, Chantal Guévremont2,6, Jean-François Delisle3, Élaine Pelletier3,6, Nathalie Marcotte4,6, Marie-Claude Michel4,6, France Varin5,6, Paul Farand1,6, Raghu Rajan2,6, Philippe Ovetchkine3,6, Louise Deschesne4,6, Daniel Froment5,6, Monia Marzouki3
1CIUSSS de l'Estrie – CHUS, Sherbrooke, Canada
2McGill University Health Centre, Montréal, Canada
3Centre hospitalier universitaire Sainte-Justine, Montréal, Canada
4CHU de Québec-Université Laval, Québec, Canada
5Centre hospitalier de l'Université de Montréal, Montréal, Canada
6Programme de gestion thérapeutique des médicaments, Canada
Background: Filgrastim use in primary prophylaxis of febrile neutropenia in children is generally guided by specific research protocols. Its use in febrile neutropenia treatment for this population is also common.
Objective/Purpose: Describe filgrastim use in the pediatric population.
Study Design/Methods: Retrospectively, 175 episodes of care in 148 patients who received filgrastim between 1 August 2014 and 31 July 2015 were chosen randomly and reviewed.
Results/Key findings: Filgrastim was used in 79 episodes for primary prophylaxis, 6 for secondary prophylaxis and 42 for febrile neutropenia. In all but four episodes of primary prophylaxis, filgrastim was given as part of a clinical study or a protocol identical to a closed study. All were for patients that received chemotherapy at high or moderate risk of febrile neutropenia. In the 42 episodes of febrile neutropenia, mean hospitalisation stay was 25.9 days and mean filgrastim use was 5.7 days. At least one factor for poor clinical outcome was identified in 30 of these episodes. Absolute neutrophil count was above 1.9 x 10e9/L in 14 episodes when filgrastim was stopped.
Conclusion/Recommendations: Tools to help clinicians with filgrastim prescription outside of clinical research protocols (pre-printed order, febrile neutropenia guidelines, standardised absolute neutrophil count for filgrastim discontinuation) should be developed to optimize its use.
16
Stem Cell Mobilization with Filgrastim in Patients Prior to Autologous Stem Cell Transplant; a Comparison of Biosimilar Filgrastim to the Originator
Melanie Trinacty1,2,3, Jason Wentzell1,2,3, Tiffany Nguyen1,2,3
1The Ottawa Hospital Pharmacy Department, Ottawa, Canada
2Ottawa Hospital Research Institute, Ottawa, Canada
3The Oncology Pharmacist Research Collaboration, Ottawa, Canada
Objective/Purpose: To compare mobilization outcomes between a historical practice cohort receiving Neupogen® mobilization (1 July 2016 to 30 June 2017) and current practice with Grastofil ®mobilization (1 October 2017 to 30 September 2018) in patients receiving autologous stem cell transplants.
Study design/Methods: Retrospective chart review of the above two cohorts. This is a quality assurance project post institutional practice transition from Neupogen® to Grastofil® use in autologous stem cell transplants.
Results/Key findings: There were 122 and 136 patients in the Grastofil® and Neupogen® cohorts, respectively. Overall, there were no statistically significant differences in the: number of transplants requiring greater than one collection day (19.2% vs. 12.5%, p = 0.14), total dose of filgrastim per patient (5870.0 mcg vs. 5938.2 mcg, p = 0.79), use of plerixafor (5.0% vs. 5.2% p = 0.96), or average stem cell count at initial day of transplant (7.22 CD34+/kg vs. 6.96 CD34+/kg, p = 0.80) in the Grastofil® and Neupogen® groups, respectively. Based on Ontario Drug Benefit pricing, Grastofil® use was associated with an average direct drug cost savings of $608 per patient.
Conclusion/Recommendations: The use of biosimilar filgrastim (Grastofil®) prior to autologous stem cell transplants did not result in significant differences in stem cell mobilization outcomes compared to the originator filgrastim, but did yield drug cost savings.
17
Evaluation of Chemotherapy Administration Sequence in BC Cancer Chemotherapy Protocols Against Literature Recommendations
Sally Waignein, Victoria Kletas, Mario de Lemos
BC Cancer, Vancouver, Canada
Objective/Purpose: To evaluate concordance of chemotherapy administration sequences at BC Cancer with those recommended by Mancini 2011 literature review. To develop guiding principles to inform appropriate chemotherapy administration sequences not included in the Mancini review.
Study design/Methods: BC Cancer chemotherapy protocols were reviewed to determine the concordance of drug administration sequences. Supporting evidence from the Mancini review was evaluated to ascertain if discordance and concordance should lead to revisions and strengthening of BC Cancer recommendations, respectively. Guiding principles were developed to determine threshold of evidence required to make these changes.
Results/Key findings: The Mancini review recommended specific administration sequences for 21 chemotherapy combinations. Discordance was identified with fluorouracil-methotrexate. This did not lead to revision of BC Cancer recommendations because the evidence was weak and irrelevant to the treated patient populations at BC Cancer. Evidence supporting concordant recommendations was insufficient to warrant strengthening of current BC Cancer recommendations. In general, BC Cancer requires at minimum supportive clinical data to recommend a particular administration sequence. Additional guiding principles were developed to inform future practice.
Conclusion/Recommendations: No revisions were deemed necessary for the BC Cancer recommendations on administration sequences of chemotherapy protocols. Guiding principles were developed to aid future protocol development at BC Cancer.
18
Financial Implications for Patients Associated with the Out-Of-Pocket Costs for Oral Anticancer Medications
Alia Thawer, Susan Singh, Kim O'Connor, Samantha Jenkins, Alison Chambers, Deana Slater, Denise Bilodeau, Flay Charbonneau
Sunnybrook Health Sciences Centre, Toronto, Canada
Background: Evidence suggests that cancer patients are affected by treatment-related financial harm. Given the way Oral Anticancer Cancer Medications are reimbursed in Ontario, patients may experience financial toxicity due to out-of-pocket costs in the form of insurance copayments and deductibles.
Objective/Purpose: To describe the frequency of patients using public, private, or manufacturer patient support programs to access Oral Anticancer Cancer Medications and to quantify the turnaround times to secured funding.
Study design/Methods: Fifty consecutive patients who were starting an Oral Anticancer Cancer Medication prospectively had the date of treatment decision, funding access and method of access documented as part of routine care within the Oral Anticancer Cancer Medication program at the Sunnybrook Odette Cancer Centre.
Results/Key findings: Twenty five different Oral Anticancer Cancer Medications were included in this analysis. Of this subset, 72% of patients had private insurance as their primary payer, 40% required public drug approval as either a primary or secondary payer, and 44% had patient support program assistance for deductibles/copays. Median time to access was 15 and 14 days for private versus public payer respectively, and 40% of patients started treatment on supply provided by patient support programs.
Conclusion/Recommendations: Oral Anticancer Cancer Medication drug access is complex and requires specialized support. Patient support programs lessen financial toxicity experienced by patients and provide timely access while securing funding.
Research – Clinical
19
Oncology Personalized Medicine and Pharmacists' Role: A Scoping Review
Riley (Min Ji) Kim, Thomas McFarlane
University of Waterloo School of Pharmacy, Kitchener, Canada
Objective/Purpose: To (1) map the current literature on the state, and evaluate the practicality and utility of oncology pharmacogenomic practices, (2) investigate pharmacists' role, and (3) identify any barriers in translation into a clinical practice model.
Study design/Methods: This project consists of two parts – (1) a scoping review analyzing the current literature on oncology pharmacogenomic tests from PubMed, EMBASE, and IPA and (2) a literature review investigating barriers of implementation and pharmacists' role.
Results/Key findings: A total of 54 studies were included. Most common cancers with pharmacogenomic analyses were breast, lung, and colorectal. Key findings were pooled and categorized based on study interventions. Emerging evidence supports the role of pharmacogenomic tests in predicting treatment response from various chemotherapy and targeted therapies. Polymorphisms in genes encoding drug-metabolizing enzymes, drug transporters, and drug targets are of particular relevance. Studies also showed significant overall cost reduction with pre-emptive pharmacogenomic testing, leading to several initiatives being undertaken by other institutions involving pharmacogenomic testing.
Conclusion/Recommendations: Cancer pharmacogenomics is evolving and has the potential to significantly impact patient care. Ongoing translation into standard patient care will require the availability of practitioners, suitable institutional practices, as well as restructuring of current clinical trial designs and reimbursement models.
20
Optimizing Patient Education of Oncology Medications: A Quantitative Analysis of the Patient Perspective
Kristin Kaupp1, Samantha Scott1, Laura Minard1, Tessa Lambourne2
1Department of Pharmacy, Nova Scotia Health Authority, Central Zone, Halifax, Canada
2Department of Pharmacy, Nova Scotia Health Authority, Northern Zone, New Glasgow, Canada
Background: With the ever-increasing complexity of cancer treatments, oncology medication patient education is becoming a progressively important component of cancer care. Despite this, cancer patients frequently report that they receive inadequate information and feel that their education needs have not been met.
Objective/Purpose: To explore patients' perspectives of optimal oncology medication education across Nova Scotia.
Study design/Methods: A descriptive survey of adult medical, hematological, and gynaecological oncology outpatients who received intravenous chemotherapy between 26 January and 30 April 2018.
Results/Key findings: Eighty-seven percent of respondents reported being satisfied or very satisfied with the education they received. In all, 30% percent and 43% of respondents would like to receive education or follow-up from a hospital pharmacist, respectively. Respondents with post-secondary education were found to have 2.82 higher odds of wanting to make an appointment for education with a hospital pharmacist.
Conclusion/Recommendations: Patients were generally satisfied with their oncology medication education despite the majority not receiving education from a hospital pharmacist. Patients with a higher level of formal education were more likely to want the opportunity to schedule an appointment with and/or receive follow-up from a hospital pharmacist. Findings from this research can be used to optimize oncology medication patient education and improve patient-centered care.
21
Exploring the Perspectives of Healthcare Professionals in Delivering Optimal Oncology Medication Education
Allison Lively1, Laura Minard1, Samantha Scott1, Heidi Deal2, Tessa Lambourne3, Jenn Giffin4
1Department of Pharmacy, Nova Scotia Health Authority, Central Zone, Halifax, Canada
2College of Pharmacy, Dalhousie University, Halifax, Canada
3Department of Pharmacy, Nova Scotia Health Authority, Northern Zone, New Glasgow, Canada
4Nova Scotia Health Authority, Central Zone, Halifax, Canada
Background: To optimize patient education, it is important to understand what healthcare professionals perceive to be ideal oncology medication education for patients to receive. Few studies have explored the roles of healthcare professionals in delivering oncology medication education.
Objective/Purpose: To explore the perspectives of healthcare professionals working in medical, gynaecological, or hematological oncology at the Nova Scotia Health Authority, Central Zone, to identify what they perceive to be optimal oncology medication education for patients.
Study Design/Methods: Physicians, nurses and pharmacists working in oncology at Nova Scotia Health Authority were invited to participate in semi-structured, one-on-one interviews which were audio-recorded, transcribed and analyzed using thematic analysis.
Results/Key findings: Five physicians, four nurses, and six pharmacists were interviewed from February to April 2018. Four major themes were identified: Delivery of oncology medication education, Facilitating the patient learning process, Multidisciplinary Approach, and Understanding barriers to the healthcare professional in providing education.
Conclusion/Recommendations: Identified themes uncovered previously unknown ideas about how healthcare professionals felt education could be delivered to patients, and also supported findings in the literature. The data obtained will inform the design of any new models for oncology medication education at Nova Scotia Health Authority and potentially other sites.
22
Delayed CINV in FOLFOX Chemotherapy: A Retrospective Chart Review Comparing Two Ontario Hospitals
Naushin Hooda1, Elizabeth Quinn3, Carlo DeAngelis2,4, Mark Pasetka1,2, Tom McFarlane1,2
1University of Waterloo, Kitchener, Canada
2Sunnybrook Health Sciences Centre, Toronto, Canada
3Cambridge Memorial Hospital, Cambridge, Canada
4University of Toronto, Toronto, Canada
Background: Moderately emetogenic chemotherapy has a broad definition which encompasses rates of chemotherapy induced nausea and vomiting of 30–90% attributed to moderately emetogenic chemotherapy regimens. Cancer Care Ontario published recommendations for single day use of dexamethasone in moderately emetogenic chemotherapy regimens in 2014 which not all hospitals adopted. We conducted a retrospective analysis comparing patients receiving FOLFOX and multiple day dexamethasone at Odette Cancer Centre (n = 154) with patients receiving FOLFOX and single-day dexamethasone at Cambridge Memorial Hospital (n = 56) to determine whether there were differences in rates of chemotherapy induced nausea and vomiting between the two institutions.
Results/Key findings: Patient demographics in the two cohorts were well balanced. The adherence to single day dexamethasone in FOLFOX regimens as outlined by Cancer Care Ontario was 100% in the Cambridge Memorial Hospital cohort of patients compared to 0% in the Odette Cancer Centre patients. Overall patient reported rates of chemotherapy induced nausea and vomiting were 19% at OCC and 42% at Cambridge Memorial Hospital which was a statistically significant difference (p=0.013). Risk of CTCAE Grade 2 nausea was significantly reduced in the Odette Cancer Centre patients compared to the Cambridge Memorial Hospital patients (RR 0.33, p = 0.0084).
Conclusion/Recommendations: Multiple day dexamethasone appears to be more protective against chemotherapy induced nausea and vomiting in patients on FOLFOX. A prospective trial is needed to validate these findings.
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CDK 4/6 Inhibitors in Hr-Positive, Her2-Negative Metastatic Breast Cancer: A Knowledge Synthesis Project
Julia Gomes, Tom McFarlane
University of Waterloo, Kitchener, Canada
Objective/Purpose: Cyclin dependent kinase 4/6 inhibitors have recently been introduced as an effective means of overcoming resistance to endocrine therapy in hormone receptor positive breast cancer patients. There are multiple agents available for use, each with slightly different characteristics, however to date there are no head-to-head trials between the various agents. We sought to undertake a knowledge synthesis project in order to come up with a practical tool to help practitioners choose the most appropriate agent for a given patient.
Study design/Methods: A primary literature search was undertaken to delineate pharmacokinetic, toxicity, and metabolic profiles of palbociclib, ribociclib, and abemaciclib in order to determine differences that might impact on choice of therapy. Product monographs for each of the three agents were also mined for information of this type. This information was then used to inform the creation of an infographic which could be used as a tool by clinicians.
Results/Key findings: Although all three agents are considered to be relatively equivalent clinically, there were differences noted that could impact choice of treatment, including increased liver function tests and QTc prolongation with ribociclib, and differences in metabolic pathway and availability of renal dosing. These were accounted for in the infographic.
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Assessing the Impact of a Layered Learning Practice Model on the Delivery of Clinical Pharmacy Key Performance Indicators within an Inpatient Oncology Unit of a Tertiary Care Centre
Jason Yung1, Tiffany Nguyen1,4, Bob MacLean1, Jason Wentzell1,2,3,4
1The Ottawa Hospital, Ottawa, Canada
2University of Waterloo School of Pharmacy, Kitchener Waterloo, Canada
3The Ottawa Hospital Research Institute, Ottawa, Canada
4The Oncology Pharmacist Research Collaboration, Ottawa, Canada
Background: Within a layered-learning practice model, pharmacist preceptor(s) supervise multiple pharmacy learners (residents and students) on clinical rotations. A Canadian collaborative of hospital pharmacists established consensus on eight clinical pharmacy key performance indicators, associated with improved patient outcomes. Implementation of layered-learning practice models and concurrent measurement of clinical pharmacy key performance indicators offers opportunities to evaluate pharmaceutical care delivery in the presence of pharmacy learners, compared to standard practice.
Objective/Purpose: To quantify clinical productivity, as measured by the proportions of eligible patients receiving clinical pharmacy key performance indicators and the absolute number of completed clinical pharmacy key performance indicators, across scenarios during which pharmacists work with, or without pharmacy learners.
Study design/Methods: In this retrospective observational study, clinical productivity was described across three practical scenarios: (i) pharmacist(s) with student(s) and a resident (‘P-R-S’); (ii) pharmacist(s) with student(s) (‘P-S’); (iii) pharmacist(s) alone (‘P’).
Results/Key findings: Generally, scenarios with pharmacy learners present provided clinical pharmacy key performance indicators to similar proportions of patients compared to standard practice. Standardized to 20 pharmacist work days, the total number of clinical pharmacy key performance indicators 1,2,3,5,6,7 (‘P-S’=281; ‘P-R-S’=255; ‘P’=258) and resolved drug therapy problems (‘P-S’=180; ‘P-R-S’=153; ‘P’=149) were similar across the scenarios.
Conclusion/Recommendations: Compared to standard practice, integration of pharmacy learners within an oncology unit does not appear to impair clinical productivity, as measured by clinical pharmacy key performance indicators.
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Use, Response and Outcomes of Second-Line Chemotherapy in Patients with Advanced Biliary Tract Cancers
Brittney Mathers, Shirin Abadi, Janine Davies, Cheryl Ho, Connor McIntyre
BC Cancer, Vancouver, Canada
Objective/Purpose: Biliary tract cancers include gallbladder, ampullary, and bile duct cancers. First-line chemotherapy for advanced biliary tract cancer has been established as gemcitabine and cisplatin; however, there is currently no recognized standard second-line treatment for advanced biliary tract cancers. The purpose of this study is to review and evaluate the outcomes of second-line chemotherapy for advanced biliary tract cancers.
Study design/Methods: Patients who received chemotherapy for unresectable or metastatic biliary tract cancers at BC Cancer between 1 August 2009 and 31 December 2015 were retrospectively studied to identify second-line chemotherapy regimens and to determine OS, time-to-treatment discontinuation, and characteristics predicting for use of second-line chemotherapy.
Results/Key findings: Of 326 patients who received chemotherapy for advanced biliary tract cancer, 93 (29%) received second-line chemotherapy. Median OS for patients who received only first-line chemotherapy was 10.8 months vs. 21.3 months for patients who received second-line chemotherapy. Median time-to-treatment discontinuation for second-line chemotherapy was 2.0 months. Common second-line treatments included capecitabine (27%), 5-FU and irinotecan (16%), and 5-FU monotherapy (14%).
Conclusion/Recommendations: Patients who are fit enough to receive second-line chemotherapy may benefit in terms of OS, however; the longer median OS for patients who received second-line chemotherapy may be impacted by independent patient-specific factors. Time-to-treatment discontinuation for second-line chemotherapy was comparable to PFS previously reported in the literature.
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Optimizing Pharmacy Learner Rotations to Improve Clinical Productivity: A Study Assessing Three Pharmacy Layered Learning Practice Models within an Inpatient Tertiary Care Oncology Unit
Lauren Salsbury1, Jason Yung2, Stephanie Lovering1, Tiffany Nguyen1, Jason Wentzell1,3,4
1Department of Pharmacy, The Ottawa Hospital, Ottawa, Canada
2Department of Pharmacy, University Health Network, Toronto, Canada
3Ottawa Hospital Research Institute, Ottawa, Canada
4School of Pharmacy, University of Waterloo, Kitchener/Waterloo, Canada
Objective/Purpose: Prior exploration of layered-learning practice models, comprising pharmacists and pharmacy learners (residents and students), revealed the presence of pharmacy learners completing inpatient oncology rotations does not impair overall clinical productivity when compared to standard practice, as measured by clinical pharmacy key performance indicators. This project serves to explore three structured pharmacy layered-learning practice models, which are organized differently from the previous layered-learning practice models, to determine if clinical capacity can be improved during learner rotations versus standard practice. The goal is to optimize experiential learning and improve patient care.
Study design/Methods: This retrospective study will interpret and analyze data collected during three different 8-week layered-learning practice models intervention periods that were performed on an inpatient oncology unit in Ottawa, Canada. Each block comprised two pharmacists, a pharmacy resident, a post-baccalaureate PharmD student, and variably one, two, or three final-year PharmD students respectively. Completion of seven different key performance indicators was recorded for longitudinal assessment and comparison between groups.
Results/Key findings: This is an ongoing pharmacy residency project with anticipated completion in advance of the conference. We plan to report the percentage of eligible clinical pharmacy key performance indicators received per patient compared across intervention groups and standard practice and describe the impact of three structured layered-learning practice models on clinical oncology practice.
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Impact of Tacrolimus Levels on the Day of Allogeneic Hematopoietic Stem Cell Transplant on Graft Versus Host Disease
Tiffany Nguyen1,3, Michelle Boyce1,2, Melanie Trinacty1,3, Jason Wentzell1,3, Jacky Cheung1, Pierre Giguere1,3
1The Ottawa Hospital, Ottawa, Canada
2Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
3Ottawa Hospital Research Institute, Ottawa, Canada
Background: It is currently unclear if a patient's likelihood of developing graft versus host disease is associated with a subtherapeutic tacrolimus level (<5 ug/L) on transplant day 0; the day of allogeneic hematopoietic stem cell transplant.
Objective/Purpose: To determine if subtherapeutic tacrolimus levels on the day of hematopoietic stem cell transplant and the early period post-hematopoietic stem cell transplant impacts the incidence of graft versus host disease in patients receiving allogeneic hematopoietic stem cell transplant. This study will also determine the proportion of time in therapeutic range from the day of transplant to day +7 post-transplant for each patient, and the subsequent impact on the incidence of graft versus host disease within 100 days of transplant.
Study design/Methods: This retrospective chart review will include patients who received an allogeneic hematopoietic stem cell transplant at the General Campus of The Ottawa Hospital between 1 November 2015 and 1 September 2018 (approximately 200 patients).
Results/Key findings: This is an ongoing pharmacy residency research project with the anticipated completion prior to the CAPhO conference. Results will be reported and made available to the CAPhO Research Committee for review in advance of the conference.
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Biosimilar Grastofil® (Filgrastim) Versus Historical Control Neupogen® (Filgrastim) in the Primary Prophylaxis (PPx) of Febrile Neutropenia (FN): Experience at the Sunnybrook Odette Cancer Centre (SOCC) in Canada
Katie Wang1, Jordan Stinson1, Flay Charbonneau1, Mark Pasetka1, Rashi Asthana2, Edward Chow3, Carlo DeAngelis1,2
1Department of Pharmacy, Sunnybrook Odette Cancer Centre, Toronto, Canada
2Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
3Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Canada
Objective/Purpose: The aim of this study was to compare the incidence of febrile neutropenia in breast and lymphoma cancer patients who received primary prophylaxis with Grastofil® versus Neupogen® at our centre. Secondary endpoints included dose-delays and dose-reductions.
Study design/Methods: A retrospective chart review of all eligible breast and lymphoma cancer patients receiving primary prophylaxis with Grastofil® during January 2017 to September 2018 and Neupogen® during 2013–2017 was conducted. Patient, disease, and treatment characteristics were collected along with Grastofil® and Neupogen® usage, incidence of febrile neutropenia, dose-delays, and dose-reductions.
Results/Key findings: 120 Grastofil® and 202 Neupogen® patients were included in the present study. Overall, 10 (8.3%) Grastofil® patients experienced febrile neutropenia during treatment, 21 (17.5%) experienced a dose-delay and 65 (54.2%) received a dose-reduction. In comparison, 17 (8.4%) Neupogen® patients experienced febrile neutropenia, 44 (21.8%) experienced a dose-delay, and 112 (55.4%) received a dose-reduction.
Conclusion/Recommendations: The incidence of febrile neutropenia in patients who received primary prophylaxi with Grastofil® was comparable to patients who received primary prophylaxiswith Neupogen®. Moving forward, Grastofil® and Neupogen® patients will be case-matched for chemotherapy regimen, planned dose intensity, age at treatment, hemoglobin, sex, and bone marrow involvement (for lymphoma patients only), in a 1:1 ratio to compare the rates of febrile neutropeni with an equivalence statistical design.
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Bendamustine-Based (BeEAM) Conditioning for Autologous Stem Cell Transplant in Hodgkin and Non-Hodgkin Lymphomas: A Single Center Experience
Xue Feng, Amelie Veilleux, Meggie Thuot, Mariline Tardif
CIUSSS Nord-de-l'Île-de-Montréal: Hôpital du Sacré-Coeur de Montréal, Montreal, Canada
Background: Autologous stem cell transplantation is the standard of care for patients with relapse/refractory lymphoma. One of the most widely accepted conditioning regimens is BEAM (carmustine, etoposide, cytarabine, melphalan). Recently, a price increase of carmustine has led to the use of alternative bendamustine-based regimen (BeEAM) at our institution.
Objective/Purpose: This study aims to evaluate the safety of BeEAM regimen at our institution.
Study design/Methods: We conducted a descriptive, retrospective, observational, single-center study. Data were collected for 17 patients who received BeEAM (bendamustine 200 mg/m2, cytarabine, etoposide, melphalan) between 2015 and 2017.
Results/Key findings: Nephrotoxicity (grade ≥ 2) was reported in 10 patients (59%), of which 7 (41%) had an early onset between days –6 and –4. Median hydration volume prior to autologous stem cell transplantation was 2028 mL/24 h, and was significantly higher in those without nephrotoxicity when adjusted for BSA (1188 mL/m2/24 h vs 942 mL/m2/24 h p = 0.008). Clinically documented infections were observed in 41% of patients. Other recorded toxicities include: mucositis (76%), nausea (65%), gastritis (35%), enterocolitis (35%). Twelve patients (71%) received TPN. Three patients experienced tachyarrhythmias. Diabetes insipidus was reported in three patients.
Conclusion/Recommendations: Other studies are required to optimize supportive therapies for BeEAM. Notably, the ideal hydration regimen remains to be defined.
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Impact of Pharmacy Interventions in Patients Receiving Chemotherapy for Breast Cancer at the Odette Cancer Centre
Victoria Rico, Madeleine Lao, Shannon Goodall, Rashi Asthana, Katie Wang, Rhea D'Souza, Ronald Chow, Edward Chow, Carlo De Angelis
Department of Pharmacy, Sunnybrook Odette Cancer Centre, Toronto, Canada
Objective/Purpose: To determine the success of over-the-phone pharmacy interventions throughout the course of treatment in patients with breast cancer receiving adjuvant or neoadjuvant chemotherapy.
Study Design/Methods: We retrospectively reviewed patients from 2010 to 2015 with breast cancer receiving adjuvant or neoadjuvant chemotherapy at the Odette Cancer Centre. Information on patient characteristics and pharmacy interventions was collected through electronic charts and records.
Results/Key findings: A total of 1593 over-the-phone pharmacy interventions were implemented for 441 patients and were retrospectively reviewed: 458 were baseline interventions to be implemented before the start of a new chemotherapy cycle, and 1135 were cycle interventions to be implemented during the current cycle. The outcomes of 677 interventions (42.50%) were not documented. There were 455 interventions documented as successful or partially successful (28.56%) and the other interventions were either unsuccessful or immeasurable for various reasons (n = 461, 28.94%). In each cycle, an average of 2.19 attempts were made by the pharmacy to contact the patient, and an average of 0.0054 phone calls from patients were missed by the pharmacy.
Conclusion/Recommendations: Pharmacy interventions throughout chemotherapy can reduce side effects experienced by patients. A prospective study should be undertaken to determine a more accurate measurement of the impact of these interventions.
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Are we Doing Enough for Our High-risk Patients? Incidence of CINV in Head and Neck Cancer Patients Receiving Single-Agent Cisplatin with Concurrent Radiation
Jordan Stinson, Flay Charbonneau, Carlo DeAngelis
Sunnybrook Odette Cancer Centre, Toronto, Canada
Objective/Purpose: Cisplatin remains one of the highest emetogenic chemotherapy agents administered today. Although head and neck radiation is considered low emetogenic (30–60%), the location and burden of disease can cause a multitude of issues surrounding nutrition and nausea.
Study design/Methods: A retrospective chart review was conducted between March and December 2018. Eligibility criteria included cisplatin-naive patients receiving single-agent treatment and a minimum two cycles of treatment. Incidence of nausea and vomiting was determined by pharmacy follow-up reports in our electronic medical record system.
Results/Key findings: In all, 77 head and neck cancer patients met the eligibility criteria (27 received low-dose cisplatin weekly and 50 received high-dose cisplatin monthly). 50 patients (65%) experienced no nausea after completing their first cycle and 75 patients (97%) experienced no vomiting. Average Visual Analogue Score for nausea for patients receiving low-dose cisplatin was 4.6 compared to 5.4 for patients receiving high-dose cisplatin. Of the 27 patients that experienced nausea/vomiting only five (18%) had changes to their antiemetics for cycle 2.
Conclusion/Recommendations: Incidence of chemotherapy-induced nausea and vomiting was well controlled in patients receiving single-agent cisplatin with concurrent radiation. Nausea continues to be the greatest challenge when managing antiemetic medication.
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Incidence of Edema with Second vs First Generation ALK inhibitors
Alia Thawer, Jordan Stinson, Christina Mychaskiw, Johnathan Shloush, Carmilia Sun, Flay Charbonneau, Parneet Cheema, Susanna Cheng
Sunnybrook Health Sciences Centre, Toronto, Canada
Background: The ALEX trials demonstrated superiority of alectinib over crizotinib in progression-free survival for anaplastic lymphoma kinase-mutated advanced lung cancers. Reduced incidence of any grade peripheral edema in the alectinib-treated patients was also observed. This did not align with clinician observation in the real-word setting.
Objective/Purpose: To understand the real-world incidence of peripheral edema in patients treated with alectinib vs. other ALK inhibitors.
Study design/Methods: A retrospective chart review was conducted for all patients initiated on an ALK inhibitor between Jan 2012 and Jan 2018 at the Sunnybrook Odette Cancer Centre.
Results/Key findings: Eight, six, and 24 patients were treated with alectinib, ceritinib, and crizotinib, respectively. All patients were ALK positive, 50% were male and 50% had CNS disease at treatment initiation. Median follow up was 307 days. The incidence of any grade peripheral edema was 88% with alectinib, 33% with ceritinib, and 33% with crizotinib. Dose reductions for drug-related peripheral edema occurred more frequently with alectinib (43%) versus crizotinib (13%). No treatment discontinuations for peripheral edema were noted.
Conclusion/Recommendations: In this analysis, peripheral edema occurred more frequently with alectinib than with other ALK inhibitors. Peripheral edema should be routinely assessed in practice as it may occur more than reported in clinical trials.
Research – Non-clinical
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Assessing the Impact of an Immune Checkpoint Inhibitor Workshop for Front-Line Pharmacists; a Pre- and Post-Intervention Survey and Recommendations
Jason Wentzell1,2,3,4, Stephanie Lovering1,4, Tiffany Nguyen1,4, Matthew Richler1,4
1The Ottawa Hospital, Ottawa, Canada
2University of Waterloo School of Pharmacy, Kitchener Waterloo, Canada
3The Ottawa Hospital Research Institute, Ottawa, Canada
4The Oncology Pharmacist Research Collaboration, Ottawa, Canada
Background: As the role of immune checkpoint inhibitors therapy in oncology expands, front-line care providers require formal education in these emerging therapies to ensure appropriate and safe delivery of care within the community.
Objective/Purpose: To implement and study a pilot-workshop program designed to provide education surrounding immune checkpoint inhibitor therapies to front-line, non-oncology pharmacists to promote early recognition, treatment, and referral of therapy related toxicities in the community.
Study design/Methods: A group of Ottawa-based front-line pharmacists participated in a two-hour voluntary immune checkpoint inhibitor therapy pilot-workshop. Participants completed an anonymous, voluntary pre-and post-workshop survey.
Results/Key findings: Participant's average self-rated Likert-scale scores indicating comfort-level with identifying immune checkpoint inhibitor-related toxicities increased from 30/100 pre-workshop (n = 13) to 81/100 post-workshop (n = 10). Participant's average self-rated Likert-scale scores indicating comfort-level with recommending treatment of toxicities (where appropriate) to their patients on ICI therapy increased from 16/100 (n = 13) pre-workshop to 81/100 post-workshop (n = 10). Participating pharmacists were better able to recognize ICI agents and appropriately resolve case-based scenarios. One hundred percent of post-survey respondents rated the session as ‘helpful for my practice’, ‘interesting', and recommended the workshop 'be repeated for other similar pharmacists’ (n = 9).
Conclusion/Recommendations: A pilot-workshop on immune checkpoint inhibitor therapy was well received and effective in providing education and awareness to front-line pharmacists.
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Patient Satisfaction Survey Results of take Home Oral Anticancer Medication Pharmacist Counseling at Humber River Hospital
Mihir Patel, Raminder Grewal, Amy Lo, Angela Cacciatore, Deo Bahadur, Subuddhi Kulkarni, Albert Karas
Humber River Hospital, Toronto, Canada
Objective/Purpose: To evaluate patient satisfaction of the teaching, understanding of medication administration, and confidence in managing adverse events for take home oral anticancer medications using a patient survey after the implementation of a pharmacist-led counseling program.
Study design/Methods: A literature review was conducted of patient satisfaction surveys in the oncology population using PubMed and general search engines. Consolidating existing surveys with the Multinational Association of Supportive Cancer Care Oral Agent Teaching Tool, ten questions were selected that focused on evaluating patient satisfaction of counseling and understanding of oral anticancer medications. Patients rated questions on a Likert scale of 1 to 5, 1 representing strongly disagree and 5 representing strongly agree. The survey was anonymous, voluntary, and allowed for open written feedback.
Results/Key findings: A total of 22 patients responded to the survey who received first-dose counseling for a take home oral anticancer medication in October 2018. Patient overall satisfaction with the counseling rated 4.86. Other results included a score of 4.14 for patient confidence on managing adverse effects and a score of 4.5 for recommendation of counseling for future patients.
Conclusion/Recommendations: Administering a patient satisfaction survey indicated the value of one-on-one counseling provided by a pharmacist and identified areas for improvements.
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Real-World Incidence of Side Effects of Chemotherapy in Patients with Breast Cancer at the Odette Cancer Centre
Victoria Rico, Madeleine Lao, Shannon Goodall, Rashi Asthana, Katie Wang, Rhea D'Souza, Ronald Chow, Edward Chow, Carlo De Angelis
Department of Pharmacy, Sunnybrook Odette Cancer Centre, Toronto, Canada
Objective/Purpose: To identify the incidence of chemotherapy induced nausea and vomiting, constipation, diarrhea, mucositis, and pain in patients receiving adjuvant or neoadjuvant chemotherapy for breast cancer who received phone calls and interventions from the pharmacy team throughout their treatment.
Study design/Methods: We retrospectively reviewed patients with breast cancer receiving adjuvant or neoadjuvant chemotherapy at the Odette Cancer Centre from 2010 to 2015. Patient characteristics and side-effect information was collected through electronic charts. Data were analyzed according to chemotherapy regimen and cycle number.
Results/Key findings: A total of 713 chemotherapy cycles received by 444 patients were reviewed. In all, 165 patients received anthracycline plus taxane regimens, 161 received anthracycline plus taxane dose dense regimens, 87 received TC regimens, 11 received paclitaxel regimens, and 20 received other chemotherapy regimens. Across all regimens and cycles, nausea had the highest incidence (39.13%), followed by pain (35.06%), constipation (24.68%), vomiting (11.92%), and diarrhea (8.84%). Cumulatively across all regimens, nausea had the highest incidence during cycle 1 (47.38%) and pain had the highest incidence during cycle 5 (57.45%).
Conclusion/Recommendations: Of all five side-effects, nausea had the highest incidence, most frequently occurring in the AC dose dense group. Pain had the second highest incidence, most frequently occurring at cycle 5.
