Journal of Oncology Pharmacy Practice

Background. Recent advances in the molecular biology and genetics of colorectal cancer have led to the identification of potential therapeutic targets such as epidermal growth factor receptor, vascular endothelial growth factor and endothelial receptors.

Objective. This review will examine the major therapeutic advances along with the preclinical basis justifying their combination with conventional therapeutic tools. This review will also critically consider current possibilities offered to identify responding patients.

Data sources. Preclinical and primary clinical trial results published in peer-review journals. The authors examined the relevance and subsequent inclusion of the data.

Conclusions. Cetuximab and bevacizumab provide new benefits in terms of the response rate and survival. There remain, however, important questions concerning, for instance, optimal combinations between conventional cytotoxic agents and targeted therapies and also between targeted drugs themselves. These new targeted treatments are costly and in this context the question of the identification of the right drug for the right patient is particularly relevant. Adequate tools in predicting the efficacy of targeted treatments are still needed.

Aim. The aim of this project was to establish the importance of a pharmacist in the health-care team in improving drug use in an oncology ward in the Department of Oncology, Karolinska University Hospital, Stockholm, Sweden.

Methods and patients. The pharmacist participated in the medical round in the mornings and worked as a member of the health-care team. Drug-related problems (DRPs) were identified by drug chart reviews based on data from medical files, laboratory tests and interviews with patients and/or relatives. A questionnaire to physicians and nurses was used to evaluate their experiences of the pharmacist’s contribution to the oncology ward.

Results. In total, 114 DRPs were identified in 58 patients. For each DRP, the pharmacist gave proposals for solutions. Sixty-eight suggestions out of 114 (59.6%) were implemented by the physician. Two suggestions (1.8%) were partly followed. For 32 suggestions (28.0%) it was unclear if they had caused any change in medication. Twelve suggestions (10.5%) were not followed. Most of the physicians and nurses acknowledged the pharmacist’s contribution to improved drug use in the ward.

Conclusion. A pharmacist can improve drug use in an oncology ward as a member of the health-care team. The pharmacist contributes with a systematic focus on the patient from a drug perspective.

Introduction. Israel is a small country, about the size of Wales, located in the eastern corner of the Mediterranean Sea. The Israel Ministry of Health has responsibility for health matters in Israel. All health matters fall under their jurisdiction.

Hospital and clinical pharmacy in Israel. There are about 50 hospitals in Israel with between 300 and 1200 beds including 12 specialist tertiary care centres (6 have facilities to perform bone marrow transplantations). The total number of hospital beds is around 30 000.

Safe handling of cytotoxics in Israel. Israel’s growing population (rising from half a million in 1948 to about 7 million in 2005) has been matched with an equally rapid rise in the use of cytotoxic drugs. The ministry issued guidelines to standardize and harmonize the level of pharmaceutical oncology services in Israel, and improve the professional level of cytotoxic pharmacy services and acknowledged the need to recognize clinical oncology pharmacy as a speciality.

Discussion. Over the last 25 years, safe handling of cytotoxics has moved forward in Israel in a manner comparable to that seen in the best of the developed “western” countries.

An explicit approach to funding decisions has become increasingly important to ensure fairness and consistency in resource allocation in cancer therapy. Funding decisions are often based on whether a treatment is ‘medically necessary’ and the level of clinical improvement. Currently, there is a lack of consensus on defining different levels of clinical improvement, leading to controversies on the values placed on different outcomes and degrees of clinical improvements during funding evaluation. More information on how clinicians and patients define the levels of clinical improvement can help ensure the evaluation and decision-making processes of funding to become more predictable, consistent, understandable and therefore accountable to providers and consumers of healthcare.

Objective. The aim of this study was to examine the removal and deactivation of cytotoxic contamination from surfaces of a pharmaceutical isolator workstation.

Methods. Three marker cytotoxic drugs were evaluated in three phases using decontamination technologies currently available in the pharmaceutical and healthcare environments. Phase I investigated the physical removal of contamination by detergents. Phase II and III investigated the effectiveness of detergents and Vaporised Hydrogen Peroxide (VHP®) in degrading cytotoxic drugs, respectively.

Results. 5-Flurouracil, doxorubicin and cyclophosphamide were removed from a surface by wiping with detergents. VHP® and alkaline detergents caused degradation of doxorubicin. The observed effect with detergent cleaning was pH dependent, but neither of the technologies applied had any effect on the chemical stability of 5-flurouracil and cyclophosphamide under the conditions tested.

Study objectives. To re-evaluate the cost effectiveness and median overall survival (OS) achieved in patients with recurrent malignant gliomas treated with temozolomide in British Columbia, as compared to previous lomustine use in the same patient population based on updated outcomes data. Results were also compared to temozolomide literature reports.

Methods. A retrospective medical record review was performed to identify patients who received single agent temozolomide or lomustine during successive, prespecified time periods. Data were collected on survival, duration of therapy, drug cost, labour and supplies, and successive or prior chemotherapy.

Results. Forty-one patients in the temozolomide group and 25 patients in the lomustine group were analysed. The median OS was 33.3 weeks (95% CI 28.4, 42.1 weeks) and 37.7 weeks (95% CI 25.0, 88.4 weeks) respectively (P=0.783). Temozolomide patients received a mean of 5.1 cycles of drug treatment, with a mean cost per patient of $10 746 (CAD). In contrast, lomustine patients received a mean of 3.3 cycles of therapy, with a mean cost per patient of $129 (CAD). The cost-effectiveness analysis showed that temozolomide was generally not a cost-effective strategy and that lomustine was the dominant strategy. In the sensitivity analysis, in scenarios where median OS was prolonged with temozolomide as compared to lomustine, the incremental cost-effectiveness ratio for each life year gained ranged from $32,247 to $162,186.

Conclusion. No difference in survival was observed between patients treated with single agent lomustine and temozolomide. Based on the higher cost and lack of additional clinical benefit of temozolomide, lomustine is a more cost-effective treatment strategy.

Study objective. The aim of this retrospective study was to determine the incidence of vinca alkaloid extravasation following administration via syringes or mini-bags.

Methods. An electronic survey was sent to pharmacy departments at hospitals throughout Australia. The survey was designed to collect data on the administration methods of vinca alkaloids (vincristine, vinblastine, vinorelbine) and the corresponding documented incidence of extravasation. The questionnaire requested the following information: how the drugs were prepared for administration (syringe or mini-bag); volume of each product; number of items supplied; and the number of cases of extravasation reported for each product.

Results. Questionnaires were sent to 228 hospital pharmacy departments in Australia. Sixty-eight questionnaires were received (29.8%), including responses from most major cancer centres. Data represented a range of 3 to 120 months (mean: 38 months) of clinical experience. The reported incidence of vincristine extravasation from syringes was 0.03% (11/37 084) and 0.041% (3/7255) with mini-bags. One case of vinblastine extravasation was reported with syringes 0.013% (1/7913), none from mini-bags (0/1421). Vinorelbine data were difficult to interpret as cases may represent phlebitis rather than extravasation. The reported incidence from vinorelbine syringes was 0.029% (2/6914) and 0.146% (8/5475) with mini-bags. Excluding vinorelbine data, the reported vinca alkaloid extravasation episodes from syringes (0.027%) and mini-bags (0.035%) were found to be similar and infrequent.

Conclusion. The data suggest that vinca alkaloids can be given safely as low volume, short infusions via mini-bags. Policies and practices that ensure the same careful monitoring of infusional therapy as is recommended with administration by syringe may further reduce the incidence of untoward effects. Mini-bags should be used for the administration of vinca alkaloids and this practice will prevent the inadvertent intrathecal administration of vinca alkaloids via syringes.

This case report describes the use of palifermin in a multiple myeloma patient with a history of osteonecrosis of the jaw (ONJ) for the prevention of high-dose chemotherapy-induced mucositis. Following the day of autologous stem cell infusion, palifermin was discontinued secondary to adverse events. Specifically, palifermin-associated macroglossia seemed to exacerbate the pain localized in the oral cavity area affected by ONJ, necessitating escalated doses of narcotic analgesics. When contemplating palifermin as a mucosal protectant in a hematopoietic stem cell transplant patient with ONJ, a careful benefit-to-risk assessment is in order to ensure optimal effectiveness without undue harm.