Enhancing oncology care: A prospective observational study on counseling practices of hospital pharmacists

Abstract

Introduction

Pharmacists are crucial in oncology and haematology, especially in medication management, patient counselling, and healthcare team collaboration. Their roles differ across institutions and countries. In Italy, where hospital pharmacies distribute oral cancer therapies, there is an emerging need for standardized counselling practices to enhance patient outcomes. This study aims to examine the current counselling practices of hospital pharmacists in Italy's oncology and haematology settings, identifying areas for improvement to better support patient care.

Method

A web-based questionnaire was used for this prospective observational study, distributed through a national oncology pharmacists’ network (Oncofarma). It was organized into three sections covering demographic information, counselling activities for patients and physicians, and communication methods. Data were analysed descriptively, with participants recruited through convenience sampling.

Results

Of the 99 participants from 61 centres surveyed, most were NHS hospital pharmacists. Half provided advice to oncologists or haematologists, and 36% engaged in direct patient counselling. Pharmacists typically advised on drug administration, side effects, and drug interactions, with communication primarily through face-to-face interactions or telephone calls. Counselling often took place at pharmacy counters or on hospital wards, with limited access to dedicated consultation spaces or times.

Conclusion

The study reveals variability in Italian hospital pharmacists’ counselling practices in oncology and haematology. Expanding patient counselling and introducing structured communication protocols may improve care quality. Standardised guidelines and training in communication, clinical knowledge and documentation could improve consistency, improve patient outcomes and support the integration of pharmacists into the healthcare team.

Keywords

Patient counselling clinical pharmacist hospital pharmacist

Introduction

Pharmacists play a critical role in the management of cancer and haematological diseases, contributing to many aspects of patient care, including medication therapy management, patient counselling, and collaboration with other healthcare professionals.^1–3 The complexity of oncology treatments, often with narrow therapeutic windows and significant toxicity profiles, requires specialised knowledge and skills that pharmacists are particularly qualified to provide.^4–7 For example, pharmacists often help the clinician as oncology and onco-haemalogy medicines require dose adjustments based on renal function or drug interactions, while some haematology medicines, like Bruton kinase inhibitors, require careful monitoring for bleeding risks in patients that may already be compromised in their wound-healing potential by basal thrombocytopenia.

Several studies have demonstrated the positive impact of pharmacists on patient outcomes in oncology. For instance, pharmacist-led medication reviews have been shown to reduce medication errors and hospitalization rate, improve management of adverse events and medication adherence, thus promoting overall treatment efficacy and tolerability.^8,9 In addition, pharmacist involvement in patient education has been associated with improved understanding of treatment regimens, better home management of side effects, and increased patient satisfaction.^10,11

Historically, the role of the pharmacist has been confined to the preparation and distribution of chemotherapeutic agents, with the primary responsibility for the quality of the compounded drugs. However, there has been a gradual evolution of this role, with the expansion of its responsibilities to encompass clinical functions such as patient education, medication monitoring, active participation in the selection of therapeutic interventions within a multidisciplinary team setting, and the management of investigational drugs. The findings from Holle et al. (2020) suggest that this is not homogeneous.¹²

Indeed, the responsibility for the compounding of chemotherapy drugs generally still falls to the pharmacist. However, the pharmacist's presence on the ward, direct contact with patients and distribution of oral antineoplastic drugs varies from country to country. In some contexts, their role extends beyond the clinic to include cost forecasting and negotiation with insurance providers, highlighting their diverse responsibilities beyond traditional pharmacy duties.¹³

A recent global survey, promoted by the European Society of Oncology Pharmacy, mapped clinical oncology pharmacy activities, revealing that clinical pharmacy tasks are implemented across Europe, Africa, Asia, and the Americas. While responses highlight the growing role of oncology pharmacists in medication reconciliation, patient counseling, and pharmaceutical interventions, disparities in education, access to electronic medical records, and clinical integration remain.¹⁴Hence, despite these benefits, the integration of pharmacists into oncology care teams is not uniform due to a lack of adequate clinical training during academic education, insufficient staffing and a lack of financial incentives, even though several studies have highlighted the cost-effectiveness of pharmacist interventions.^15,16 To address this issue, a recent systematic review demonstrated a positive impact of the presence of clinical pharmacists on cost saving and a recent US pilot study demonstrated significant reduction of emergency-department visits and economic benefits following introduction of a clinical pharmacist in the oncology department.^8,17,18

Still, there is a lack of robust studies documenting clinical pharmacy activities, both methodologically and in terms of the indicators measured, especially when patient-centred impact indicators are considered.¹⁹ To this end, in France, clinical pharmacy experts from the French Society of Clinical Pharmacy (SFPC) have developed a tool called CLEO to measure the impact of pharmacists’ presence in clinics, taking into account three dimensions: clinical, economic and organisational impact.²⁰ The CLEO tool is a powerful framework for measuring and demonstrating the value of clinical pharmacists in healthcare settings, including oncology care. CLEO provides compelling evidence to support the integration of pharmacists into multidisciplinary teams and it can be utilized to advocate for expanded roles, guide resource allocation, and improve the quality of patient care.

In Italy, oral therapies for cancer patients are provided directly to patients by hospital pharmacies, thus excluding community pharmacies from this therapeutic area.²¹ Despite this specificity, the structure and scope of pharmacist consultations in oncology and haematology are not well documented, leading to variations in practice and potential gaps in care.

This study aims to fill this knowledge gap by providing a comprehensive overview of the current counselling practices of Italian hospital pharmacists in these specialties. The study is a prospective observational study using a web-based questionnaire to collect data from pharmacists within the Oncofarma network, the main association of hospital pharmacists in oncology and haematology in Italy.

This research is the first phase of a broader initiative to standardise counselling practices among Italian hospital pharmacists to ensure consistent and high-quality patient care. The results of this study will provide insights into existing practices and highlight areas for improvement, paving the way for the development of standardised guidelines.

Methods

Study design

The study was a prospective observational study to investigate the counselling activity of pharmacists in the field of oncology and haematology using a web-based questionnaire to investigate pharmacists’ counselling activities. As this research is the first step of a larger project aimed at standardising the counselling activity of hospital pharmacists working in oncology and haematology, most of the questions investigate how this activity is structured in Italian hospitals.

Setting and participants

Data were collected from 1^st April 2023 to 31^st July 2023.

Participation was open and voluntary for all healthcare professionals who received the questionnaire through the Italian oncology pharmacists’ network called Oncofarma.

This network counts 862 associates and it is the main association for hospital pharmacists working in the field of oncology and haematology.Convenience sampling was used to recruit participants, and this can constitute a selection bias. The sample size was determined using the formula for finite population estimation. Considering the number of pharmacists registered in the Oncofarma network (n = 862) as the reference population and applying a 95% confidence interval with a 10% margin of error, a minimum of 87 responses was required to ensure the sample's representativeness. For this reason, the following data presented (N = 99) are sufficient to be considered representative of the association's community.

Questionnaire development and distribution

The questionnaire was developed based on a literature search and consultation with expert pharmacists who have been providing counselling for many years. Expert pharmacists were selected based on the counseling activities promoted over the years at their centers. During the development of the questionnaire, we conducted a literature search to determine if there were other structured questionnaires that examined the organisation of pharmacist consultations in oncology/haematology. It was found that there are some reviews that summarise the types of clinical pharmacist intervention,²² but the studies only partially report information on how the consultation is structured and the organisational characteristics associated with this service. For this reason, we asked expert pharmacists to contribute to the design of a questionnaire that would specifically assess these aspects. The questionnaire was anonymous. It had three sections: demographic information, counselling activities for patients and for physicians and communication methods. ‘In the demographic section, the questionnaire asked participants their area of origin and the type of hospital they worked in (research institutes or university hospitals, tertiary care hospitals, or general primary care hospitals). The questionnaire did not include any question about individual training of participants. In the counselling sections, participants are asked to indicate the topics covered by the pharmacist counselling, the setting, while in the last section participants were asked to explain how this information is shared with patients and clinicians. A copy of the questionnaire is available as supplementary material. The questionnaire was pre-tested with a small group of pharmacists associates of Oncofarma to ensure clarity and relevance. The web-based questionnaire was chosen for its efficiency in collecting data from a large, geographically dispersed sample of pharmacists.

The questionnaire was distributed via email invitations sent through the Oncofarma network newsletter, as well as on the Oncofarma website and social media platforms such as LinkedIn and Facebook. The survey was hosted on GoogleForms.

Data analysis

Data analysis was conducted using Microsoft Excel and R software (v.4.3.0). Descriptive statistics, including frequencies and percentages, were used for data summarization. Incomplete responses were excluded, and data cleaning involved identifying duplicate entries, retaining only the most recent response. No missing data were present, as the questionnaire required all mandatory questions to be completed before submission.

Results

The survey was completed by 99 participants from 61 centres. There were no missing responses from participants. Sample's characteristics are described in Table 1.

Table 1.

Participants’ characteristics.

	N	%
Region
Veneto	19	19%
Emilia Romagna	10	10%
Sardegna	10	10%
Puglia	9	9%
Lazio	7	7%
Lombardia	7	7%
Piemonte	6	6%
Friuli Venezia Giulia	5	5%
Campania	4	4%
Marche	4	4%
Abruzzo	3	3%
Sicilia	3	3%
Trentino Alto Adige	3	3%
Umbria	3	3%
Calabria	2	2%
Toscana	2	2%
Basilicata	1	1%
Molise	1	1%
Valle d'Aosta	0	0%
Liguria	0	0%
Type of healthcare setting
NHS Hospital	55	56%
University Hospital	19	19%
Research Hospital	16	16%
Regional Healthcare office	3	3%
Private Hospital	3	3%
Community pharmacy	2	2%
Unoccupied	1	1%
Workplace
Hospital Pharmacy	88	89%
Oncology/Haematology ward	3	3%
Outpatient pharmacy service	4	4%
Oncology pharmacy	1	1%
Community pharmacy	2	2%
I do not work in a pharmacy	2	2%
Working position
NHS hospital pharmacist	57	58%
Resident	12	12%
Pharmacy Director	17	17%
Other type of contract	6	6%
Private Hospital pharmacist	3	3%
Researcher	2	2%
I am not a pharmacist	2	2%

The survey responses had a good overall distribution across Italy. Veneto, Emilia-Romagna, Sardinia and Puglia were the best represented areas with 48% of responses. The questionnaire was freely accessible to all members of the Oncofarma network, which is mainly composed of hospital pharmacists but also other professions such as nurses, community pharmacists and pharmacists working in regional authorities. The majority of participants were NHS hospital pharmacists (n = 74, 75% including both pharmacists with basic duties and hospital pharmacy directors), 12% were resident in school of hospital pharmacy, 11% were pharmacists with another type of contract: Two hospital pharmacists employed on a research contract, 3 hospital pharmacists working in a private hospital, 3 pharmacists employed on a freelance basis in an NHS hospital, 2 community pharmacists and one resident who did not specify the type of contract. Two participants were non-pharmacists (nurses). Within the group of NHS pharmacists, 17% (n = 17) were hospital pharmacy directors. Most pharmacists worked in a NHS hospital (56%), 19% in a university hospital and 16% in a research hospital. Only a minority of participants worked in oncology or haematology wards (3%), while most were part of the hospital pharmacy department and worked in collaboration with the wards. The two nurses working in oncology wards described whether a pharmacist was present on their ward and how his consultations took place; the two community pharmacists stated that they were not directly involved in providing counselling.

Half of the respondents (50%) reported providing counseling to the oncologist or haematologist on the ward, whereas only 36% indicated that they had counseled the patient (Figure 1). When available, pharmacist counselling was provided for both oncology and haematology specialties. In 11 cases counseling was provided only for oncology, while in 5 cases pharmacist advice was available only for the haematology department

Given the limited human resources available for pharmacist's advice, we asked participants whether they used selection criteria to prioritize patients who would benefit the most from a pharmacist's intervention. (Figure 2).

Half of respondents (48%) reported that they provide advice to the physician for all patients, while 44% reserved advice for selected patients who were candidates for oral therapy (24%) or infusion therapy (20%). Several participants reported that they only provide advice to the physician when specifically requested. Regarding patient counselling, the responses split into two groups: 36% of pharmacists answered to provide counselling to all patients, while 61% reserved this service only for patients receiving oral therapy; a minority reserved counselling only for infusion therapy patients (6%).

Advice to the physician often included instructions for drug administration (84%), drug interactions and possible side effects of the drug (60%) (Figure 3).

Drug-drug interaction analysis frequently reported pharmacodynamic (60%) and pharmacokinetic interactions (64% of cases), while potential drug-disease interactions were reported less frequently (34%). Physicians received information on medication review in 52% of cases and on patient adherence in 44% of cases, while therapeutic drug monitoring was less common (30%). In a more limited number of cases, pharmacists provided advice on access to treatment (eligibility for reimbursement, timing of purchase, substitution with alternative products in case of shortage). In some cases, classified as “other” responses in Figure 3, pharmacists counselled the physician for appropriate prescribing, gave information about the compounding of the therapeutic regimen, provided advice on possible alternative medicines in case of allergy/intolerance to excipients, or reported potential therapeutic errors.

Patient counselling focused on certain aspects in common with physician counselling, such as medication review (67%) and interaction analysis, with a greater focus on pharmacokinetic interactions (47%) than on pharmacodynamic (39%) and drug-disease interactions (33%). When the pharmacist interacts with the patient, much more attention is paid to drug administration instructions (100%), toxicity management (83%) and supply (72%). On the contrary, the results of therapeutic drug monitoring are rarely presented by pharmacists to patients.

One of the aims of the questionnaire was to find out which means of communication were used to give advice to clinician/patient and how the advice was sought by the clinician. In most cases, communication with the physician or patient was face-to-face or by telephone (Figure 4).

A treatment-specific infographic, named “patient information card”, often accompanied patient counselling (58%), but only 36% of participants gave a written consultation report to the patient or filed it in the patient's medical file (39%). The consultation report is patient-specific, and it usually reports the results of pharmacist's counseling. Advice to the clinician was almost always given by telephone or face-to-face (94%), and only a fewer proportion of pharmacists kept a written record of the advice that is included in patient's medical record (24%), while some of them produce a written report that however is not visible in patient's medical file (34%). When there was a written record, in most of the cases, it was sent by informal means such as email (34%). In only 18% of cases, pharmacist's consultation was filed in the patient's medical file. At the same time, most pharmacists received the request for advice from the clinician either by telephone (80%) or by e-mail (42%). Only in 4 cases the request was made via the patient record management system (8%). Finally, we looked at the places and times set aside for counselling (Figure 5).

Most patient consultations took place during the daily dispensing activity (61%) at the pharmacy counter. Only in a minority of cases (19%) it was planned to reserve a place or a specific time for this activity in the pharmacy. In a fifth of cases (19%), there was a dedicated room for consultation, while the remaining 39% of responses indicate that pharmacists met the patient directly on the ward. Consultation with clinicians mainly took place on the ward (50%) or at the pharmacy counter (44%), but only in 14% of cases a working time was reserved for this activity. In 36% of cases, the consultation took place during the multidisciplinary discussion of the case. Some pharmacists did not find any of the answers applicable (14%). In most of these cases, there was no specific place where the counselling took place, as it was done over the phone or at the time of the clinician's validation of the therapy.

Discussion

The results of this study provide important insights into the counselling activities of hospital pharmacists in Italian oncology and haematology settings. The survey responses indicate a widespread involvement of pharmacists in providing advice to both physicians and patients, although the extent and nature of this involvement varies considerably.

Most pharmacists reported providing advice to physicians, particularly on medication administration and managing side effects, which is consistent with previous studies highlighting the critical role of pharmacists in optimising medication use and patient safety.^8,9,23 However, only a minority of hospital pharmacists are involved in direct patient counselling, which suggests a potential area for improvement, as increasing pharmacists’ direct interaction with patients has been shown to improve medication adherence, reduce errors and ultimately improve patient outcomes.^4,5,10,11

A possible explanation for the low prevalence of patient counselling by hospital pharmacists may lie in several factors, such as under-reporting of pharmacists’ work, lack of specific training during hospital pharmacy education, and limited numbers of specialised pharmacists dedicated to this activity.^15,16

In Italy, oncological and onco-haematological medicines are mainly distributed by hospital pharmacies. Therefore, hospital pharmacists have close contact with patients and routinely provide advice to patients on at least two main topics during the daily supply of medicines: how to take the medicines and how to manage side effects²¹; On the other hand, most of the studies describing structured experiences report the experiences of single institutions.⁸ Only a limited number of studies, map the diffusion of clinical pharmacy services across a whole country or investigate the needs expressed by pharmacists.^13,24,25 Most hospital pharmacists express the need for specialised training to develop structured and high-quality clinical services.^16,26 In particular, hospital pharmacists feel the need to acquire communication techniques, knowledge of oncology clinical guidelines, local patient journeys and information exchange with patient associations.

An additional issue arising from our study is about current methods of communication and documentation of counselling activities. The reliance on informal communication methods, such as telephone and email, and the limited use of formal documentation practices may undermine the consistency and reliability of the counselling provided. On the same line, previous research has highlighted several barriers to effective pharmacist-patient and pharmacist-physician communication, including lack of time, inadequate training, and insufficient institutional support.^15,16 Addressing these challenges is essential to optimise the contribution of pharmacists to oncology care. For this reason, the findings presented in our study represent a first milestone in a larger project aimed at implementing a standardised and structured communication and documentation model for patient counselling and medical advice, which will ultimately hopefully improve the effectiveness of pharmacists’ interventions and facilitate better integration with the wider healthcare team.

Our findings imply that structured counselling, through its clarity, consistency, and patient-centered approach, can address key barriers to medication adherence and improve health outcomes. A structured communication model ensures that all pharmacists deliver consistent and clear information to patients and that all relevant information about patient counselling is recorded accurately and comprehensively. This can facilitate better follow-up and monitoring by pharmacists and other healthcare providers, ensuring that any issues with adherence are identified and addressed promptly.

Moreover, structured communication and documentation can improve collaboration between pharmacists and other healthcare professionals. Finally, by addressing specific barriers to adherence (e.g., forgetfulness, side effects, or financial concerns), pharmacists can provide more personalized support, which can enhance adherence and outcomes. The development of a standardized model aims to make these benefits scalable and applicable across different healthcare contexts.

A notable limitation of this study is the use of convenience sampling, which may affect the generalisability of the findings. In addition, the reliance on self-reported data introduces the risk of response bias. Efforts were made to mitigate these limitations by ensuring anonymity and encouraging honest responses. A potential limitation of this study lies also in the possible heterogeneity of the sample. The questionnaire was disseminated through the Oncofarma network, which led to responses from pharmacists involved in oncology and haematology who were not necessarily employed directly by the NHS. Two community pharmacists were included, as they may have been engaged in hospital-related activities or completed training placements in hospital settings. Additionally, two oncology nurses were included to provide insight into the presence and role of pharmacists in their wards. Although the survey was tailored to the hospital context, this inclusion may introduce variability. However, with 98% of respondents working in hospital settings (excluding the two community pharmacists for whom further details were not available), we consider the results to be a reasonable reflection of the hospital pharmacist's professional context, providing valuable baseline data on the counselling practices of hospital pharmacists in Italy and highlighting the need for standardised guidelines to ensure consistency and quality of patient care.

Conclusions

This study examines the role of hospital pharmacists in oncology and haematology in Italy, highlighting their vital contributions to advising on drug administration, adverse effect management, and drug-drug interactions. It reveals variability in counselling practices, emphasizing the need for standardized guidelines to ensure consistent, high-quality care. Despite sampling limitations, the findings suggest that more structured patient counselling could improve medication adherence and outcomes. Furthermore, the reliance on informal methods of communication and documentation suggests that more structured protocols could improve the consistency and reliability of advice given, so that the clinician and patient know what to expect from a pharmacist consultation. Future efforts should focus on developing standardized protocols and robust training programs to enhance the impact, the reproducibility and reliability of pharmacists’ contributions across healthcare settings.

Supplemental Material

sj-pdf-1-opp-10.1177_10781552251351325 - Supplemental material for Enhancing oncology care: A prospective observational study on counseling practices of hospital pharmacists

Supplemental material, sj-pdf-1-opp-10.1177_10781552251351325 for Enhancing oncology care: A prospective observational study on counseling practices of hospital pharmacists by S.A.M. Urru, S. Masucci, P. Baldo, U. Gallo, P. Schincariol, P. Silimbani, S. Vecchia and V. Damuzzo in Journal of Oncology Pharmacy Practice

Footnotes

Acknowledgements

We thank all participants in this study for their valuable contributions.

Author contributions

V.D., S.M., U.G., P.B. designed the study. S.M. collected the data. V.D. performed data analysis. S.A.M.U., S.V., P.Sc., P.Si. discussed the results, S.A.M.U., S.V., P.Si. wrote the first draft of the manuscript. All authors read and approved the final manuscript.

Data availability

The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethics approval

This is an observational study. Participation was voluntary and no ethical approval is required.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

V. Damuzzo

Supplemental material

Supplemental material for this article is available online.

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