Building partnerships in care

During the first week of April, the fourteenth meeting of the International Society of Oncology Pharmacy Practitioners (ISOPP) took place in Montreal, Canada, and attracted over 300 delegates from across the globe. The main theme of the symposium was Building Partnerships in Care, with a focus on both patient factors such as adherence, pharmacokinetic variability and co-morbidities and on inter-professional working, particularly in the area of risk reduction.

The importance of patient engagement was elegantly demonstrated in the opening plenary presentation given by Mike Lang, a cancer survivor, who has spent the past decade working with young adults during and after their cancer treatment, primarily through organising regular ‘adventure’ trips during which participants have the opportunity to talk about their cancer journey with their peers. He emphasised the importance of listening to our patients, trying to put ourselves in their shoes and ensuring that we personalise the patient experience by providing bespoke information in the same way as we are beginning to provide bespoke cancer treatments. As we struggle to get our heads around the latest developments in pharmacogenomics and personalised medicine, it was reassuring to hear that there are other, perhaps simpler, ways of also delivering patient‑centred care.

The second plenary session focused on safety concerns in the use of oncology medications and was a joint presentation by Eric Cropp, a pharmacist from Ohio, USA and David U from the Institute for Safe Medication Practices (ISMP), Canada. Eric’s story had a profound effect on the audience as he described how a preparation error (involving the selection of hypertonic saline instead of normal saline) by a pharmacy technician under his supervision led to the death of a paediatric patient and Eric’s subsequent conviction for involuntary manslaughter and a six-month jail sentence. After that sobering illustration of the impact of a single error, the speakers broadened the discussion by presenting the findings of a study involving three outpatient adult oncology centres and one paediatric centre over a nine-month period. During the study period the authors found that:

David then discussed, in detail, strategies to prevent chemotherapy errors, particularly focusing on ‘Helpful Do’s and Don’ts for Writing Chemotherapy Orders.’ He also presented the web-based medication safety self-assessment tool that has been developed by the ISMP and ISOPP to allow centres to benchmark their practice and identify areas for improvement. It is designed to be completed by a multidisciplinary team and allows for data to be collected in a number of main domains , for example, drug labelling and packaging, drug information, workflow, staffing, staff education, patient information and education, quality processes, etc. Snapshot data from 13 countries were then presented. Unsurprisingly, there was significant variation in levels of adherence to the 180 different elements/standards, ranging from 12% at one extreme (item 116 – when multiple chemotherapy/biotherapy infusions are being administered intravenously, the distal ends of all tubing are clearly labelled with the drug name) to 98% at the other (item 88 – chemotherapy/biotherapy drugs are purchased from authorised distributors or manufacturers who can verify the source of the drug). For those centres who have not yet utilised this tool it struck me as an extremely valuable resource with huge potential to assist in the improvement of our practice at a local level (available at: www.ismp.org/selfassessments/).

At the end of this comprehensive presentation, four key take-home messages were delivered:

Focus on systems failures, not human error

The themes of patient safety and risk reduction flowed into the Friday programme, which started with a fascinating plenary presentation by Rachel White (Human Era @ University Health Network, Canada) entitled Human Factors 201: Human error in Complex Dynamic Systems. After hearing of Eric Cropp’s experiences, it was noteworthy that one of the main messages within Rachel’s talk was contained within the following quote from Lucian Leape, a physician and professor from the Harvard School of Public Health and a leading authority on medical error: “The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes.”

Rachel argued that we should be focusing our attention on failures in systems rather than individual errors and used a case study of a patient receiving chemotherapy to demonstrate how a series of system failures led to an avoidable death. She was able to breakdown the failures into a series of categories: staff and psychological; equipment and surroundings; team, management/organisational and political and professional practice – with each of these functioning as a layer within the classic Swiss Cheese Model of accident causation.  She then encouraged the audience to be more proactive in the area of error prevention by challenging us to:

She closed her presentation with another thought-provoking quote, this time from James Reason, Professor of Psychology, University of Manchester , UK and one of the original developers of the Swiss Cheese Model: “We cannot change the human condition but we can change the conditions under which humans work.”

The closing plenary on the Saturday focused on oral anticancer medicines and featured an eminent panel of pharmacists from Canada, Australia, UK, USA, Singapore and Germany who discussed the similarities and differences in practice around the world when dealing with such agents. Given that more than three-quarters of anticancer drugs in development are oral formulations, this is an area that is becoming increasingly important for oncology pharmacists.

During the session it became apparent that although significant efforts are being made to treat oral agents in the same way as we treat parenteral treatments, we still have a long way to go before we can be confident that our systems for both pathways are equally robust. For example, a number of panellists expressed concern that the majority of oral anticancer drugs that are prescribed in their centres are then dispensed in a community setting by pharmacy staff with limited experience and expertise in screening such prescriptions. There was also a valuable discussion of adherence to oral anticancer medicines and there was general consensus that this is an under-researched area and one in which health professionals are often guilty of assuming (perhaps erroneously) that cancer patients will have much better adherence rates than patients taking long-term oral treatments for other conditions. Lita Chew, Head of Pharmacy at the National Cancer Centre Singapore, presented findings from an adherence study of breast cancer patients that she had been involved with.  Patients taking hormonal therapies were assessed using a modified Morisky Medication Adherence Scale (MMAS) and the non-adherence rate was found to be as high as 60%. There was some debate as to the validity of the MMAS score in the oncology setting but the take-home message was very much that we need to be doing more to both investigate and then, hopefully, improve levels of adherence within our patient populations.

As with previous meetings, there was an interesting and varied selection of posters on display. A number of authors focused on developments in symptom control: topics included aprepitant and palonosetron for chemotherapy-induced nausea and vomiting, minocycline for skin rash in non-small cell lung cancer patients receiving epidermal growth factor inhibitors and rasburicase for prevention of tumour lysis syndrome in the paediatric setting.

Within the technical services arena, groups from Italy, Germany and Saudi Arabia presented their experiences with robotic dispensing of chemotherapy, and there were also stimulating posters on logarithmic dose banding and the use of near infrared spectroscopy to accurately determine concentrations of cytotoxics.

Considering the prominence given to oral anticancer medicines within the main conference programme, it was not surprising to see a large number of posters on this topic. For example, a Canadian group led by Heather Logan surveyed 45 cancer centres to explore current practices in relation to the safe use and handling of oral agents. They found that between 30–40% of centres did not have standard operating procedures in place for prescribing, dispensing or monitoring of these drugs, with the majority of centres using handwritten prescriptions rather than the pre-printed templates or electronic systems that we would expect to be used routinely for parenteral treatments. Their conclusions that standards for intravenous (IV) chemotherapy are less commonly used for oral chemotherapy echoed the sentiments of the participants in the closing plenary and should act as a stimulus to all oncology pharmacists to examine practices at our individual centres with the aim of standardising our approach to oral and parenteral treatments.

One eye-catching poster was presented by Nadia Ayoub and colleagues from Karachi and investigated the use of more dilute gemcitabine solutions to reduce the incidence of infusion-related pain. Their relatively small intervention (reducing the final concentration from 9–10mg/ml to 3–4mg/ml) resulted in a large and statistically significant benefit in terms of patient-reported pain scores and struck me as an extremely simple but effective way of improving the patient experience.

The clinical programme provided a series of updates on the management of a number of common solid and haematological malignancies. Jim Siderov (Senior Pharmacist for Cancer Services at the Olivia Newton-John Cancer & Wellness Centre, Heidelberg, Australia) provided an excellent overview of recent developments in the management of diffuse large B-cell lymphoma. His presentation included encouraging data on the use of mini-R-CHOP in patients over 80 years (with a 50% overall survival rate at two years) and the intriguing suggestion that older males (>60 years) may require higher doses of rituximab (for example, 500mg/m2) than other patients due to enhanced clearance of the drug. He also discussed new targeted therapies, including Bispecific T-cell engagers (BiTE therapy). These are novel bispecific monoclonal antibodies that bind to both antigens on tumour cells and cytotoxic T lymphocytes (via the CD3 receptor). Blinatumumab (which targets CD19 on B cells) is undergoing trials in both non-Hodgkin’s lymphoma (NHL) and acute lymphoblastic leukaemia (ALL) and there is interest in using similar molecules in a variety of other tumour types.

As a haematology pharmacist, I ensured that I attended an update on multiple myeloma given by Steve Stricker (Assistant Professor of Pharmacy Practice at the McWhorter School of Pharmacy at Stamford University in Birmingham, Alabama, US). As treatment options continue to increase for this malignancy, it was instructive to note that newer agents currently in clinical trials or being employed as a third- or fourth-line therapy in the UK are being positioned much higher up the treatment pathway in the US. For example, Professor Stricker presented data on the combination of carfilzomib, lenalidomide and dexamethasone as first-line treatment for newly diagnosed myeloma, which is producing response rates in excess of 95%. In a similar vein, he also discussed the Frontline Investigation Of Lenalidomide + Dexamethasone Versus Standard Thalidomide (FIRST) trial (originally presented at the American Society of Hematology 2013), which demonstrated a 28% relative risk reduction in the primary endpoint of progression or death for a combination of lenalidomide and dexamethasone compared with the current standard of care (MPT – melphalan, prednisolone and thalidomide) in newly diagnosed patients ineligible for stem cell transplantation.

It is difficult within the confines of a short conference report to do justice to the breadth and scope of the ISOPP XIV programme. As a first-time attendee, I found it to be a fascinating meeting with an excellent mix of science and practice and with the unrivalled opportunity to compare and contrast experiences with other oncology pharmacy practitioners from different parts of the world. Roll on ISOPP XIV, which will take place in Chile in 2016.