The Pharmacist’s Role in Combination Cancer Treatments
Since the first checkpoint inhibitor was approved (https://news.bms.com/news/details/2011/FDA-Approves-YERVOY-ipilimumab-for-the-Treatment-of-Patients-with-Newly-Diagnosed-or-Previously-Treated-Unresectable-or-Metastatic-Melanoma-the-Deadliest-Form-of-Skin-Cancer/default.aspx) in 2011, we have made tremendous leaps in immunotherapy in a short span of 10 years. Now we see immunotherapy combined with a variety of options, including chemotherapy or other oral and IV targeted therapy.
Untangling such a complex web of care requires an interprofessional approach. I am a clinical pharmacy specialist and work out of interprofessional solid tumor clinics at a National Cancer Institute-designated cancer center. My role with immunotherapy combination products is multipronged.
First, I ensure that the drug selection is appropriate, including the indication, drug, dose, and line of therapy. I consider patient-specific factors, such as their height and weight, organ function, and performance status. Then, I review the patient’s medication profile for any potential drug-drug or drug-herb interactions. Herbal supplements can pose a serious risk to patients on chemotherapy. In one study (https://journals.sagepub.com/doi/10.1177/2374373517706612), almost 40% of prescription drug users reported using concomitant herbal product, so oncology nurses should always ask patients about herbals when reviewing their medications.
Oncology nurses and pharmacists often work together to educate patients about their treatment and care. Our institution implemented virtual education sessions to allow the patient and all of their caregivers to learn about their treatments from the comfort of their homes. Following up with patients on an ongoing basis and reviewing labs, other pertinent tests, and patient adherence are also important functions for pharmacists.
Along with oncology nurses, pharmacists provide other members of the care team and patients with evidence-based information on management of various adverse effects from chemotherapy combinations. Many agents have toxicities that overlap with oral tyrosine kinase inhibitors, which are often combined with immunotherapy. The biggest implication for pharmacists and nurses is to be aware that combining immunotherapy with other chemotherapy or targeted agents can improve efficacy but can also increase toxicity. Nurses should monitor patients closely and be aware of the agents’ correct dosing and frequency.
The pharmacist’s role can vary depending on type of combination. In general, IV chemotherapies undergo a lot more scrutiny. IV treatments require verification by pharmacists and nurses and are prepared and administered at the cancer center, where every step of the process is observed and controlled. In contrast, some oral chemotherapies may be required to be filled at a pharmacy determined by the insurance company, and we don’t have direct oversight when a prescription is sent to an outside pharmacy. Those situations require even closer follow up with the patient to prevent or identify medication errors.
Our institution has pharmacists in our inpatient, infusion, and outpatient areas. We are very involved in patient care and readily available for our nursing, physician, and advance practice provider colleagues when they have questions, whether the concern is related to the management of adverse events such as rash or nausea, drug interactions, or any other considerations. No two days are the same for me, and I am always learning something new.