October 31, 2016
Sandra Cuellar, PharmD, BCOP
Dr. Sandra Cuellar is a clinical pharmacist and professor at the University of Illinois at Chicago. She also works at a 500-bed inner-city hospital, where she helps care for elderly oncology patients. One of her recent patients sat home with a neutropenic fever for an entire weekend, even though he had been told to seek treatment if a fever spiked, before finally heading to the clinic on Monday morning. By that time he was hypotensive and his condition had become serious enough to require hospitalization. She also recalled one oncology regimen that required a patient to take 13 tablets daily, with each tablet having its own special instructions. Dr. Cuellar recently said giving complex medication regimens to patients who typically have low health literacies is a formula for failure and discussed ways to improve the care of these high-risk patients.
Why is it so challenging to care for oncology patients?
We give them complicated therapies, and they often don’t have the support system or sufficient health literacy to make the right decisions about their care or recognize potential adverse drug events. In addition, gaps in therapy often occur during transitions of care, and the literature has shown that problems revolve around medication reconciliations at discharge. Medication reconciliation is particularly important for elderly oncology patients. They undergo major changes in therapy during neutropenic events, hospitalizations, and disease progression. That’s where pharmacists are positioned to help. They have the expertise to perform appropriate reconciliations. They’ve also seen patients since hospital admission, and therefore have the advantage of having documented all medication changes, and knowing why those changes were made.
How can pharmacists help improve the understanding these patients have of the drugs they take?
Health literacy is one of the fundamental aspects of patient care that we know is a huge problem in this patient population — I’ve had patients who didn’t eat for 10 hours before taking pills because they were directed to take them on an empty stomach. Patients and their family members need very specific information about the therapies they receive. It’s not enough to tell patients they should take medications twice a day. Pharmacists must engage them in order to determine what twice a day means — the exact times — based on their daily schedules.
How has immuno‑oncology impacted the care of cancer patients?
It’s been a tremendous breakthrough, but it’s also associated with several toxicities, so patients need to know what adverse reactions they might experience. For example, if they present at the emergency room with shortness of breath or colitis, the simple remedy is a dose of corticosteroids, not antibiotics, because the reactions are related to the cancer drugs. That’s why medication lists have to be current and communication during transitions of care must be effective and clear.
How important is ensuring each patient interaction is meaningful?
It’s essential. Oral oncolytics now account for one-third of all cancer treatments. That means the responsibility of medication management shifts to the patients. They’re responsible for taking pills as directed every day, and if they experience adverse events, it’s on them to act. My institution has developed a better process to make sure patients who receive oral oncolytics are counseled about how to take them properly. Health system pharmacists meet with patients to ensure they understand what therapies they’re taking, why they’re taking them, and how to take them.
What’s at stake when caring for cancer patients?
Oral oncolytics cost between $6,000 and $12,000 a month, and patients are using them to prolong life or in some cases with a curative intent. But if they’re taking them incorrectly or stop taking them because of adverse events, the healthcare providers responsible for their care are contributing to poor health outcomes and hospital admissions or readmissions. Oncology pharmacists need to take the time to understand patients’ preconceived notions about the medications they’re prescribed. Pharmacists in our health system are integrated into the patient care team and devoted to ensuring patients take their cancer therapies appropriately. Giving cancer patients medications, asking them if they have any questions, and handing them a drug information pamphlet is unacceptable.