Pharmacists will have more contact with cancer patients as more and more of them are treated with oral anticancer medicines that can be taken at home, reports Lisa Offord.

Key points:

  • Recent years have seen a huge growth in the number of oral anticancer medicines, many of which act in novel ways, each with unique side-effect profiles;
  • It’s important for community pharmacists to recognise they will be seeing more of these oral anticancer agents coming into the community and to take the time to learn about them so they can do the best for their patients;
  • It is important to develop networks and relationships with the local hospital to be able to refer back to the medical pharmacy or nursing staff at the institution that is managing that person’s cancer;
  • A lot of targeted therapies have skin side effects/skin rashes and a lot of those can be managed with simple creams; and
  • This is where community pharmacists can assist but again pharmacists also need to recognise when it needs to be referred back to the hospital.

ACCORDING TO THE Cancer Council an estimated 128,000 new cases of cancer will be diagnosed in Australia this year, with that number set to rise to 150,000 by 2020. One-in-two Australian men and one-in-three Australian women will be diagnosed with cancer by the age of 85.

Although cancer is a leading cause of death in Australia, research and medical breakthroughs have lifted the survival rate to the point that today 66% of people living with cancer in Australia are still alive five years after diagnosis.

In fact the survival rate for many common cancers has increased by 30% in the past two decades.

The most common cancers in Australia (excluding non-melanoma skin cancer) are prostate, bowel, breast, melanoma and lung cancer. These five cancers account for more than 60% of all cancers diagnosed.

Even if community pharmacists are not directly involved in the supply of cancer medicines, people affected by cancer will still see community pharmacists for OTC medicines.

The overarching message to community pharmacists from pharmacists who have dedicated their careers to oncology is be prepared.

Pharmacists play a key role in the care of patients with cancer across the continuum of care. Three pharmacists who have specialised in cancer care talked to AJP about their experience and how community pharmacists can strengthen their role in cancer care.

Gail Rowan has spent more than 15 years working in cancer care in both production and clinical services. She worked in hospitals in New Zealand before taking a position managing clinical services for the Peter MacCallum Cancer Centre in Melbourne. Her interests include the treatment of haematological malignancies, minimisation of chemotherapy related adverse effects and education on chemotherapy and safety.

“A lot of it comes back to getting the message to patients on simple terms—we give all our patients diaries and medication plans and tell them when they need to take medications and we give them access to someone they can call if they need to.”

Rowan said it was important for community pharmacists to be aware that these patients required additional time and attention.

“Their doses can often change, their disease can often change and their ability to manage their medications can often change,” she says.

So spending time with the patient each time they present was vital. “The main thing is to focus on the patient… the other is to not work outside your scope,” she says.

“It is important to develop networks and relationships with the local hospital to be able to refer back to the medical pharmacy or nursing staff at the institution that is managing that person’s cancer.”

Knowing when a medication side effect can be managed at home, or when a patient needed to go to hospital, was imperative.

“Diarrhoea is quite common with a lot of the cancer therapies and what might seem to be a simple case of diarrhoea can rapidly escalate and become life-threatening so often that is a situation where you do need to refer back to the hospital.

“Another side effect of neutropenia is fever—if a patient presents with a fever that needs to be referred straight back to the hospital.

“Fever can be the first sign of an infection and requires urgent antibiotic therapy.

“A lot of our targeted therapies have skin side effects/skin rashes and a lot of those can be managed with simple creams… again this is where community pharmacists may be able to assist but again also recognising when it needs to be referred back to the hospital.”

Rowan adds that pharmacists should be cautious about recommending herbal ‘over-the-counter’ therapies to patients who are undergoing active therapy for cancer.

“Herbal medicines can interact with cancer therapy to reduce its effectiveness,” she says.

Rowan stressed the need for community pharmacists involved in cancer care to keep up to date with research.

“Scan the journals, familiarise yourself with what is happening and don’t rely on the pharmaceutical companies to tell you—I think it is important to try to find out yourself what’s current.”

A good source of information, she says, is the Cancer Institute NSW eviQ Cancer Treatments Online which includes the main reference source for chemotherapy protocols in Australia.

John Coutsouvelis is the senior oncology/haematology pharmacist at the Alfred Hospital in Melbourne and is on a two-day-a-week secondment with Monash University as a senior clinical lecturer working in the postgraduate studies department.

“It’s an amazing area oncology and community pharmacists realise that,” he says.

“As we all live longer and therapies move outside hospitals and into the community there is a huge role and opportunity for community pharmacy to focus on cancer services.”

John said that as well as having an understanding of the new therapies coming through, community pharmacists also needed to be aware of what supportive care they could offer.

“An oncology patient might be worried about nausea more than anything, or mouth care, or how treatment affects their health, or their diet and nutrition.

“It’s much easier to access that information at the primary care level—it is a little niche area that community pharmacy can really take on.”

He said patients with cancer were highly receptive to pharmacists and the key to communication was ‘honesty’.

Also, “don’t assume the patients don’t know,” he says.

“Ninety per cent of our patients are well educated and they have done a lot of research into their cancers and tumours and therapies.

“Where they many need help, however, is in interpreting the information and I think that’s where the pharmacist can have a huge role.

“Anyone can Google and find the information but a pharmacist can then put it into context, adding that extra layer of information that the patient needs.”

On the other hand don’t assume that just because the patient is on an oncology drug that they do know everything.

He suggested asking “that next question”—checking the patient is being monitored and followed up.

“It could be something like, ‘you are on a steroid for your cancer, is someone looking after your blood sugar?’

“We see patients all the time who say no-one told them to look after their blood sugars and that could be quite preventable at a community level.”

Ben Stevenson has worked in the private hospital sector since graduating with a pharmacy degree from the University of South Australia in 1998.

Stevenson found himself on a steep learning curve when only two years after graduation he was made head of department.

“I was thrust into the deep end, there isn’t a lot educational opportunities when it comes to specific oncology education in Australia so I trained myself—I sought out the information, joined professional organisations and up-skilled.

He says one of the most important things pharmacists could do was build a support network of colleagues in other workplaces especially if they were not a part of a large organisation.

“I certainly gained more experience and that support from colleagues helped me realise my passion was in the cancer care space,” he says.

He says what he has always valued about working in cancer care was being part of a team.

“You have a team within your own pharmacy but you are also a member of the broader team treating the patient.”

Currently working in a management role as the general manager of pharmacy services for Icon Cancer Care, Ben says he has witnessed a threefold change in this space.

“There have been diseases where historically we felt were chemo naïve that now we give chemo to with great results; there has been a push towards combination therapy in a number of diseases; and there has obviously also been the development and the increase in oral chemotherapy agents where there is a significant crossover between the public hospital sector and the retail pharmacy environment and the private hospital sector and the retail pharmacy environment.

“Many of us in this field are very keen to strengthen the relationships between hospitals and community pharmacists and encourage community pharmacists to learn more about these oral agents… they aren’t run- of-the-mill stuff.”

His message for community pharmacists? Be alert, not alarmed.

“There is a group of patients coming your way—seek out knowledge so you will be better placed to help them on their journey.”

He said he could not imagine another area being as rewarding as it is working in cancer.

“Sure there are moments of sadness and patients do pass away but for the most part you see the very best part of the human spirit on a daily basis working in cancer and it is very rewarding being involved and doing what you can to make that patient’s journey just a little bit smoother.”