Oral Chemotherapy Program at THP. Dr. Katherine Enright MD, MPH, FRCPC

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1 Oral Chemotherapy Program at THP Dr. Katherine Enright MD, MPH, FRCPC

2 What is Oral Chemotherapy?

3 Oral Chemotherapy is Classic Chemotherapy Drugs: Capecitabine (Xeloda) Hydroxyurea (Hydrea) Melphalan Chlorambucil

4 The evil we know

5 Oral Chemotherapy is also.. Gefitinib (Iressa) Erlotinib (Tarceva) Afinitib (Gilotref) Ibrutinib (Imbruvica) Palbociblib (Ibrance) Imetelstat Olaparib (Lynparza) Sunitinib(Sutent) Sorafenib (Nexavar) Regorafinib (Strivaga Crizotinib (Xalkori)

6 Oral Chemotherapy is Imatinib (Gleevec) in Chronic Myelogenous Leukemia

7 Oral Chemotherapy is - Ibrutinib in Chronic Lymphocytic Leukemia

8 Oral Chemotherapy is Gefitinib in EGFR + NSCLC

9 Oral Chemotherapy is Crizotinib in ALK + NSCLC

10 Oral Chemotherapy is the future

11 Oral vs. IV Chemotherapy Parenteral (IV) Medications Oral Medications Patient's role is passive Patient is recipient of treatment Provider dictate treatments Provider monitors and manages side effects Potential for non-adherence low (and self evident) Provider responsible for procurement (storage, safe handling and disposal) Patient s role is active Patient self-administers the medications Provider collaborates with patient about the treatment Patient is actively involved in early symptom recognition and management Potential for medication non-adherence is high Patient is responsible for medication procurement (safe handling, storage, disposal)

12 Oral Chemotherapy Delivery Process Safe Labelling Treatment Decision Prescribing Dispensing Medication Administration Patient Monitoring Safe handling, patient education and incident reporting

13 Partnering with the Patient Improving patient education

14 Self Efficacy Albert Bandura (1986) The belief in one s capability to organize and execute the courses of action required to manage positive situations

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16 Oral Chemotherapy Care Plans

17 Partnering with Oncology Pharmacists

18 Oral Chemotherapy Care Pathway Pilot RN Education Care Plan Review Teach Back Toxicity Assessment Adherence Assessment Cycle 1 Cycle 2 Cycle 3 Pharmacist Rx verification Drug-drug interactions Counselling Teach Back Toxicity Assessment Adherence Assessment Pilot: March 2, 2015 May 30, 2015 Who: 2 Physician/RN Teams at CVH Site (GI/Breast/Lung/GU) (N = 20) Inclusion : All new starts on oral chemotherapy (Hormones excluded) Pilot Team: Oral Chemotherapy Pharmacist & Nurse Practitioner

19 Oral Chemotherapy Care Pathway Pilot MOATT Assessment Adherence Assessment Pharmacy Interventions CPOE Prescriptions Drug Discontinuation Dose Modification for toxicity Pilot Baseline

20 Oral Chemotherapy Care Pathway Pilot Type of Dose Modification due to Toxicity Discontinuation Dose Delay Dose reduction Baseline Pilot 4

21 Partnering with Retail Pharmacy

22 Oral Chemotherapy Pharmacist Advantage over community pharmacist Specialty knowledge of oncology Access to drug Community pharmacy may not have in stock (delay in treatment) Access to necessary information to double check the Rx (blood work, other tests, history, intention, course of treatment, etc.) Ease of access to the prescriber Main Focus of Oncology Pharmacist Drug-Drug Interactions CYP P450 system Drug-Food interactions Patient Monitoring Cost Out of pocket, 3 rd party, special funding programs, ODB access Adherence

23 Pharmacy Pilot CVH Site Problem: Dose not adjusted for decreased CrCl. Problem: Patient on combination regimen confused drug schedules Intervention: Dose Calendar provided Intervention: Dose adjusted Critical Interventions (4) Interventions requiring a change to Rx (78) Potential Drug interactions (126) Herbal/CAM interventions (116) Adherence Interventions (33) Problem: Identified patient not taking anticoagulant as previously prescribed before starting agent with prothrombotic potential Intervention: Patient educated as per risk, started both Problem: Irbesartan / enzalutamide interaction Intervention: PCP contacted to change irbesartan to olmesartan

24 Next Steps for Oral Chemotherapy - Partnering with Patients Pilot of various tools to enhance self efficacy underway (Q-site hematology group) Care plan usability review with PFAC planned - Partnering with Pharmacy Sustainability plan to integrate oncology pharmacy at CVH site and expand across THP in development - Partnering with Primary Care Physicians? Communication of Care Plans to PCP Toxicity management Enhance care coordination / communication