7 Ways Oncology Pharmacists Impact Cancer Care
Being an oncology pharmacist is incredibly rewarding. There are many opportunities to impact patient care whether you currently work in oncology or want to transition into this specialty.
If you are new to oncology and looking for where to start, I discuss 7 areas where an oncology pharmacist can have an impact that will give you ideas on how you can contribute to the care of these patients. Which one aligns with your professional talents and goals?
If you are an experienced clinician, which subset of oncology lights you up? Is it where you’re working today? Which area could you double down on or pivot into? Keeping an open mind brings new experiences – I never considered informatics until an opportunity presented itself!
Regardless of your experience, we all need to communicate the value of pharmacists to the greater healthcare community
I sort of stumbled into becoming an oncology pharmacist. I recall some classmates that were full force into this specialty area, but I was not a fan of those courses in pharmacy school. They were challenging – perhaps it was the immunology, perhaps the teaching style, perhaps my lack of personal vested interest to study it intently. Regardless of what I found interesting life has a way of showing you a path when you can’t see it for yourself. That path was illuminated when my maternal grandmother, Barbara (aka Grams), was diagnosed with AML (acute myeloid leukemia) at the beginning of my P4 year; she was 73 years old.
I was the only person in my immediate family in the medical field at the time, so I began a crash course in all things leukemia. I studied leukemia subtypes, her treatment regimen, and expected outcomes. I saw the complications of her induction therapy first-hand – alopecia, nausea, vomiting, diarrhea, anorexia, neutropenic fever, and more. She had residual disease in her bone marrow after induction and received another cycle of chemotherapy which put her into remission. Given the cytogenetics (aka genetic makeup) of her leukemia, her risk of relapse was high enough that hematopoietic cell transplantation (HCT) was recommended to achieve a long-term cure.
Grams and I celebrating her 74 birthday at the start of her induction therapy at Mass General
Oncology pharmacists are vital in the multi-disciplinary care of patients with cancer
I regularly find myself explaining what an oncology pharmacist does. As you have likely experienced, the general public has a single image of a pharmacist (our professional branding needs are a topic for another day). Pharmacists are of course drug experts but not everyone understands the impact we can have on the care of patients with cancer. During my Grams’ treatment, I saw all the places a specialized pharmacist impacted, or could have impacted, her care and our experience with the healthcare system. Being an oncology pharmacist can be challenging, but it matters to our patients, to our colleagues, and to our profession. Here are 7 areas I see oncology pharmacists having the biggest impact.
Clinical Recommendations
Oncology pharmacists can impact a wide range of clinical recommendations. In my experience, once I establish trust with my physicians, I can impact all aspects of a patient’s cancer regimen. This has included selection of chemotherapy and supportive care regimens, chemotherapy dosing, toxicity management, and long-term health maintenance. Our advice is not often needed for the selection of front-line therapies. As the saying goes, the riches are in the niches and our niches are often in the gray areas of cancer treatment such as patients that have progressed on standard therapies or that have organ dysfunction, comorbid conditions, interacting concurrent medications, or pharmacogenomic considerations that preclude the use of certain drugs. It often requires researching the literature for supporting data and presenting conclusions to the oncologist. This isn’t easy - it may be the most challenging part of being an oncology pharmacist. It requires a baseline knowledge of cancer biology, treatments, outcomes, and statistics that is not born overnight as well as refined skills to communicate all this information in a concise and accurate way to the oncologist. It takes dedication to master this, but it absolutely can be done, and I believe pharmacists have the ideal skill set to succeed at it.
Supportive care and toxicity management, important in both the short and long-term, are the backbone of an oncology pharmacist’s role. We are, and should be, the experts in the prevention and treatment of all conditions caused by chemotherapy. This includes common and uncommon toxicities in the short-term setting such as chemotherapy-induced nausea and vomiting (CINV), cytokine release syndrome, venous thromboembolism (VTE), pain, hypersensitivity reactions, and others, to longer-term toxicities in the post-treatment maintenance setting such as osteoporosis, hypertension, hyperlipidemia, diabetes, and many more.
Grams had quite the sense of humor - this is her acting incredulous for the camera at the AM medications I gave her following her HCT discharge (although it was definitely a lot!).
We are the drug experts that can make recommendations when:
A patient is refractory to the standard CINV drugs and who cannot keep any food or liquid down (this was Grams – she couldn’t eat more than a few crackers a day for weeks)
A patient’s triglycerides are through the roof from asparaginase therapy
Pulse dose steroids are wreaking havoc with a patient’s glucose levels and sleep cycle
An oral chemotherapy has a high risk of VTE, but the patient is persistently thrombocytopenic
A patient is having a severe treatment-related reaction, but steroids should be avoided because they blunt the treatment’s effect
The patient is persistently hypokalemic but cannot swallow the giant tablets and cannot stomach the liquid formulations (also Grams – we spent many 4+ hour days in the infusion center for IV potassium)
Pill burden becomes overwhelming (many cancer patients and every HCT patient)
Long-term health maintenance, toxicity monitoring, and survivorship care plans are important post-treatment follow-up that oncology pharmacists can participate in. Oncologists are not experts in areas that are typically in the realm of primary care physicians (nor do they want to be in my experience). The challenge is that our healthcare system is fractured, we often work in silos, and I have lost count how many times I have heard “their PCP will manage that” but it never actually gets managed. Pharmacists can be the thread that stitches this system together because patients shouldn’t have to do it and their outcomes are on the line.
Chemotherapy dosing is a vital component of the oncology pharmacist’s repertoire. We need to know where the standard dosing came from, in which patient populations it was studied, what evidence supports it, and when it’s appropriate to stray from it.
Recommendations we make consider factors such as:
Drug interactions, such as:
Azoles and vinca alkaloids (and so many other drugs!)
Methotrexate and practically everything (okay, a slight exaggeration, but it feels like it!)
NSAIDs and pemetrexed
Comorbid conditions
How much dexamethasone can be used in a patient with diabetes and multiple myeloma?
Baseline organ dysfunction
How well will they metabolize doxorubicin with a bilirubin of 3? And why do they have a bilirubin of 3 anyway – disease related or unrelated?
Tolerability of previous cycles
Has the patient experienced neutropenic fever? Is treatment being delayed for count recovery?
Pharmacogenomics
Alternative hormonal therapy to tamoxifen in poor CYP2D6 metabolizers
Patient weight
Should we use actual, ideal, or adjusted? If adjusted, 25%, 40%, or some equally random adjustment?!
How should we account for patients with amputations?
Implications of under or over-dosing
What are the dose limiting toxicities?
Here are other examples of clinical recommendations an oncology pharmacist makes related to chemotherapy, supportive care, toxicities, health maintenance, and survivorship.
Therapeutic Drug Monitoring
Oncology pharmacists impact patient care by driving the drug use process, and that includes therapeutic drug monitoring (TDM). The goal of TDM is to optimize drug dosing by monitoring relevant molecules (parent drugs, metabolites, etc.) to maintain therapeutic concentrations and efficacy while minimizing toxicity. This is important when drugs have a narrow therapeutic range and wide interpatient variability. Historically, TDM has been commonplace for non-oncology drugs such as antibiotics (vancomycin, aminoglycosides) and more recently antifungals (voriconazole, posaconazole). A common chemotherapy for TDM is busulfan in the context of HCT; supratherapeutic and subtherapeutic levels are associated with increased toxicity and reduced efficacy, respectively. Most transplant institutions utilize an outside lab for busulfan TDM and make treatment dosing decisions based on a report, but a few run these labs internally and the oncology pharmacists calculate the area under the curve and subsequent dose changes.
TDM for immunosuppression (cyclosporine, tacrolimus, sirolimus) is done in HCT and solid organ transplant and is a vital component of follow-up as the degree of immunosuppression in these patients is a very delicate balance. TDM of asparaginase, a crucial part of therapy for acute lymphoblastic leukemia, is used to identify patients who develop neutralizing antibodies since they may not present with traditional hypersensitivities; unidentified “silent inactivation” in this context can lead to worse outcomes.
TDM is a great area for oncology pharmacists to dive into. Clinicians need to understand the ongoing challenges such as differences in assays, sample collection and handling processes, and validation of clinical outcomes. I have heard rumblings in the past about TDM for melphalan and cyclophosphamide and after doing a quick search on clinicaltrials.gov I found several trials listed for TDM with 5-fluorouracil, paclitaxel, sunitinib, pazopanib, and everolimus. Oncology pharmacists are in a perfect position to participate in this important aspect of care - let’s not leave this to another healthcare profession!
Education
Education is one of my favorite parts of being an oncology pharmacist. Oncology has so many drug approvals and new literature published that education is a never-ending need. Patient education is the most challenging, but the most rewarding, in my opinion. We must account for baseline health literacy and the ability to retain information following a cancer diagnosis or news of disease progression. Oncology pharmacists often participate in the education of the treatment regimen, including the regimen selected, treatment schedule, toxicities to expect and how to treat them, when to seek urgent care, how to prevent infections, and the overall expectations of their therapy. More and more cancer therapies are taken by the patient in their home, so education is a critical step in ensuring safety and efficacy of these therapies.
Consider how a typical patient will manage an oral oncolytic regimen that is daily for 21 days followed by 7 days off. Or my favorite, twice daily Monday through Friday for 2 weeks followed by 2 weeks off. What could go wrong?! Perhaps some of these examples:
The drug could be delayed in getting to the patient (happens all the time in the age of limited distribution for specialty drugs)
The patient feels ill and skips doses
The patient forgets to take a dose and doubles up the next day
The patient misses a follow-up appointment due to a snowstorm and slips through the cracks for days/weeks
Accurate and repetitive education is important to achieve good outcomes. The patient is often overwhelmed at the initial visit and may not have a family member with them. They need follow-up touch points to ensure not only compliance but adequate understanding for the safe use of these medications.
Educating our healthcare colleagues is also an important role of the oncology pharmacist and there are endless opportunities to do this. This education can happen in many different settings such as didactic lectures in pharmacy, medicine, nursing, physician assistant, technician, and nurse practitioner classrooms; topic discussions during pharmacy student or resident rotations; orientation for medical interns, residents, and new oncology fellows; presentations at formal continuing education events for various professions; in-services for nursing and pharmacy staff. You have your pick of which groups you enjoy teaching!
There are many topics to educate our colleagues about. Oncology has rapid drug approvals and publication of new data that can benefit all healthcare professionals. The logistics of how new medications will be used in your center need teaching. When liposomal vincristine hit the market there was a huge need for education, particularly to the pharmacy compounding staff, because there are 26 reconstitution steps that had to be accounted for in pharmacy and nursing workflow! When we started using daratumumab, education was needed for nursing, physician, and lab personnel related to hypersensitivity with initial doses, interference with response monitoring in some myeloma patients, and anomalies in blood cross-matching and antibody screening – talk about interdisciplinary! There are also seemingly limitless drug shortages that must be communicated along with recommendations for alternative therapies. Drug formularies are routinely updated, and we will have more and more opportunities to educate on the use of biosimilar drugs that pharmacists are perfectly poised to detail out. The educational opportunities are infinite!
Drug Compounding
Despite the onslaught of oral oncolytics, cancer centers will always need to compound drug products on-site for intravenous, intrathecal, subcutaneous, intravesicular, and other routes of administration. This is a vital sub-specialty of oncology that requires specialized knowledge of drugs, product supplies, sterile compounding, and workflows. These pharmacists and technicians have a keen understanding of how long it take to compound drugs and how laborious it is (complex compounding needs can severely impact pharmacy staffing workflows), in which order drugs should be compounded, how to minimize drug waste, and how to manage drugs with short expiration dates.
I want to give a shout out to our oncology technicians here. If you work in sterile compounding, you know how valuable your technicians are. These colleagues are unsung heroes; they are the rock stars who are proficient at mixing accurately and efficiently. They know when to ask questions (“are you sure this dose is right, it’s higher than I usually mix”) and are the people you want by your side on a heavy 5-fluorouracil pump day; I have great admiration for my technicians who can get all the bubbles out of these cassettes efficiently – not an easy task!
Oncology pharmacists in this setting may work with a single laminar flow glovebox up to a fully USP-compliant clean room. Some large centers may even have a chemotherapy compounding robot! Sterility is of the utmost importance and requires specialized knowledge which is why the Board of Pharmacy Specialties now recognizes board certification in Compounded Sterile Preparations (CSP).
Clinical Trials
If you want to be on the cutting edge, working in an oncology investigational pharmacy is likely right up your alley! I found 80,921 studies listed on clinicaltrials.gov with the keyword of cancer; talk about a need! Oncology pharmacists can participate in clinical trials in many ways, including trial preparation (before the trial opens at an institution) and maintenance of an ongoing trial. If your aspirations are even higher, there are examples of pharmacists overseeing research in a variety of clinical and industry settings, such as R. Donald Harvey who is the director of the Phase I cancer research program at Emory University.
I would advocate for getting involved as early in the clinical trial process as possible. In my experience, pharmacy is notified when the study is ready to open and orders are needed. In the process of creating orders, there inevitably are questions that need to be addressed. If they aren’t specified in the protocol (hard to believe in a document hundreds of pages long, but it happens!), communication must go out to the principal investigator and/or study sponsor which can delay a trial from opening. Time to opening a clinical trial is an important metric in cancer centers and one I think oncology pharmacists can positively impact by thinking through all the steps of treatment and workflows during the preparation phase.
Protocols will detail out all drugs that can or should not be used in a patient on trial. They don’t typically provide order sets so someone will have to create either paper orders or build the treatment plan in your electronic health record (EHR – see the informatics section below). Trust me, if you will interact with these orders, you want to be the person making them – no one is as detailed as a pharmacist!
Specialty Pharmacy
Specialty pharmacies play a huge role in the care of oncology patients. Many oral oncolytics, particularly the new to market ones, are put into limited distribution networks by the manufacturers which drives dispensing to specific pharmacies; rarely can patients pick up these treatments locally. Medications that are not restricted can be filled in a variety of settings such as non-limited distribution specialty pharmacies and local retail pharmacies, including those affiliated or owned by the cancer center.
One of the biggest challenges in this model is the risk of delays in patient care. Most specialty pharmacies are working in a silo relying on information coming from the clinic; they are often independent companies without access to the full electronic health record. Once they receive information, they go through their dispensing steps and physically mail the medication to the patient. Issues that come up are prescriptions:
With unresolved clinical issues such as drug interactions and lab abnormalities that impact dosing (or no lab information)
Without documentation of clinical rationale often needed for insurance approval
That aren’t covered or are copay-prohibitive
Unresolved clinical issues and lack of clinical rationale documentation can be resolved by having an oncology pharmacist proactively review these prescriptions before they are sent to the pharmacy; however, the specialty pharmacist won’t often know if a review has been done so they will still require recent lab results and clinical documentation to perform their own review. Efficient communication of clinical data is vital to a speedy delivery.
Some cancer centers and clinics will have staff to perform a benefit investigation ahead of time; however, smaller cancer centers often don’t so the patient is the first to learn their copay is prohibitive. Some specialty pharmacies offer services around finding patient assistance programs but unless there is a dedicated person moving the patient through the process as quickly as possible, there are likely to be delays. If the oncology pharmacist has information up front about benefits, they can make recommendations with the physician and educate the patient about the process. Knowledge about patient assistance programs can seem like an entire job itself! There are many programs available, but it takes a knowledgeable person to know how to navigate all the available resources and their required deadlines and appeals processes.
I believe there are great opportunities for oncology-trained pharmacists in specialty pharmacies. One way they can impact patient care is by facilitating communication with their cancer center counterparts to get the drug to the patient as quickly as possible. Another way is through patient education. Many cancer centers, even the large academic centers, don’t always have an oncology pharmacist educating every patient that will receive an oral oncolytic. This means the specialty pharmacist plays a key role is delivering needed information to the patient on expected side effects, when to call their doctor, how to handle missed doses, etc. Even if the patient did receive counseling from a clinic pharmacist, the ability to reinforce this information by the specialty pharmacist is highly valuable!
For more information on best practices with oral oncolytics, the Hematology/Oncology Pharmacy Association (HOPA) published their best practices in 2018.
Additionally, the National Community Oncology Dispensing Association (NCODA) is working to address the growing need for dispensing cancer center clinics to improve operations. If you are interested in this area of practice, definitely check them out!
Informatics
Clinical and technical teams are both critical to the success of any oncology program. While these teams typically have very different backgrounds, skill sets, communication styles, and day-to-day responsibilities, their top priority is patient care. To deliver the safest and highest quality care, these teams must work together to develop robust technical solutions to support clinical practice workflows.
The role of the oncology pharmacist in informatics was not readily apparent to me before I found my way here. I worked with many people on the technical team, including pharmacists, when we implemented CPOE in a previous clinical role, but I did not appreciate the specific skills that a pharmacist experienced in oncology can bring to an informatics team.
The ability to effectively communicate requirements, expectations, limitations, and resolutions to both clinical and technical teams is paramount; this is particularly important in oncology with rapidly changing science. With such different perspectives, the teams often don’t speak the same “language,” necessitating a translator who can ensure information shared by each team is well understood by the other. This clinical liaison – who has both a clear grasp of clinical requirements and technology – enables the functional flow and prioritization of information.
An oncology pharmacist is well-suited to serving this critical function of “interpreter” due to the complexity of EHRs, drug systems, treatment regimens, and really, just the vast amounts of drugs and formulations available; we are subject matter experts. Oncology pharmacists are skilled at understanding workflows and how a patient moves through a cancer center. We know what pre-medications, hydration, and PRN medications should be built into a treatment plan. We understand how the treatment plan will be ordered and by whom. We know what kinds of errors may happen and at what stage in the process. We are skilled at education, both to the layperson and the clinician, and are therefore valuable in the training process. As new technology becomes mainstream, including pharmacogenomics platforms that are well on their way, oncology pharmacists are well positioned to assist in their implementation. We have the clinical knowledge that complements the technical team’s knowledge and together we can create systems that are effective and safe for our cancer patients.
There are endless opportunities to get involved in the care of patients with cancer
I loved my direct patient care role for many years and now equally enjoy my system support role. Whatever you are passionate about there is a niche within oncology pharmacy where you can make a difference!
What if you DON’T have oncology experience?
I am often asked if you need residency training to work in oncology and the short answer is no but it definitely helps. It depends on the type of role you are interested in, your location, and how motivated you are to seek out opportunities. I always recommend residency training because it fast track you, but it is not the only path, nor can it be because there are not enough programs for everyone!
Laura Bobolts, PharmD, BCOP has described her path into oncology that didn’t include a PYG2. I have spoken with pharmacists from a variety of settings who saw an opportunity in oncology and jumped at the chance to get their foot in the door. You are not likely to be handed an opportunity so get out there and make it happen yourself – motivation and perseverance gets you far!
There are initial steps you can take, starting with assessing where you are currently and developing a professional development plan. Begin planting seeds through networking. You want others to know what your interest areas are, so they know to share opportunities with you. This can be a conversation with your boss about opportunities in your current system, sharing and interacting on social media or in professional organizations, and attending live conferences or networking events. Networking is vital for any pharmacist but is a must-do for those looking to transition into a new specialty area. Since you want to maximize the benefit as much as possible, you’ll want to have a plan to capitalize on these events.
Lastly, get started learning! Oncology is a vast specialty area and you’ll want to set yourself up for success by starting the learning process early. Pharmacists are lifelong learners and oncology can absolutely be learned, it just takes time, motivation, and hard work (and maybe coffee…). Not sure where to start? Read about how to learn oncology and subscribe to my newsletter to get bi-monthly oncology insights in your inbox 👇!
About The Author
Kelley is a board-certified oncology pharmacist that strongly believes oncology is the best specialty for pharmacists and that anyone can learn it. She founded the ELO (Enjoy Learning Oncology) Program, the only private member network exclusively for oncology pharmacists. Want to get instruction and personalized support to take your oncology knowledge and career to the next level?
