INTRODUCTION
Clinical pharmacists, especially those working in oncology settings, play a pivotal role in medication management for older adults with cancer. Clinical pharmacists conduct structured medication assessments, which can include adverse effect assessment, interaction assessments, adherence monitoring, medication reconciliation, and in certain jurisdictions, prescribing and deprescribing.
Pharmacists offer the Geriatric Oncology MDT suggestions to enhance medication safety, taking multiple factors into consideration, including the patient’s age, comorbidities, and factors influencing drug metabolism and elimination.
The SIOG Nursing and Allied Health Interest Group have recently published a perspective paper highlighting the role of clinical pharmacists in geriatric oncology[1]. We sat down with the lead author, Darren Walsh, pharmacist in University Hospital Waterford (Ireland) to discuss the growing recognition of clinical pharmacy as a key component of a wider multidisciplinary team within Geriatric Oncology.
Roles and Responsibilities of Clinical Pharmacists
Could you discuss the roles and responsibilities of clinical pharmacists in a Geriatric Oncology Multidisciplinary Team (MDT)?
Our role is to ensure that the patients’ medications are optimised. In the Geriatric Oncology Assessment and Liaison (GOAL) clinic in University Hospital Waterford (UHW) our clinical lead is a medical oncologist with a special interest in oncogeriatrics. That affects my role in the team, relative to some of my colleagues with geriatrician clinical leads. I’m responsible for ensuring patient’s systemic therapy and supportive care medications are optimised also.
We are responsible for reviewing a patients medication list, identifying potentially inappropriate medications, assessing pharmacokinetic aspects of medication management, opportunities for deprescribing and reviewing medication safety continuously.
How do you see the role of clinical pharmacists in the broader healthcare ecosystem, and in what ways do you think clinical pharmacists can bridge the gap between different healthcare sectors, specifically between primary and secondary care?
The nature of the disease groups we treat means that unplanned hospitalisation is inevitable. By documenting medication reviews in the outpatient setting we can become that key link for medication management, by cross referencing general practitioner and community pharmacist medication lists we can build relationships with those in primary care. I try to fill the gap between primary and secondary care by communicating to each patients GP and community pharmacy.
I do feel, certainly in the healthcare ecosystem I work in, we still lack the IT infrastructure to do this efficiently. Care is shared between primary and secondary care, yet our means of communication are very inefficient and often ineffective. I could easily see, in an ideal healthcare model, where a clinical pharmacist would become the key stakeholder in the medication management of patients, allowing physicians, nurses and allied healthcare professionals to concentrate on the other key issues facing our patients.
There seems to be a lack of clarity about who is responsible for managing medication for chronic long-term conditions. How do you navigate this issue in your practice?
I believe everyone involved in caring for an older adult with cancer is a stakeholder for their medication management. In our clinic, the chronic long-term conditions are typically managed by the patient’s GP, but ultimately it would be naive to think that the addition of systemic anticancer therapy, supportive care medications and the associated issues around cancer will be completely independent from the long-term conditions.
This question nearly raises more further questions than answers. I see my role as aggregating all of the evidence, for and against each medication, and providing this information to the patient, their oncologist and GP. I typically discuss potential medication changes with patients in clinic, get a feel for their willingness to abide by these changes, and then inform them that their GP or oncologist will prescribe as they feel appropriate, with my recommendations informing that process. We use tools like STOPP/START, Beer’s Criteria, STOPPFrail, ThinkCascades, Anticholinergic Burden Scores to name but a few resources, to identify potential medication related problems.
Each patient I see in clinic is presented at our multidisciplinary team meeting. When I have presented the patient’s medication related issues, as a team we decide whether or not the GOAL team will make the changes, or whether I communicate the recommendations to the patient’s GP. This is then summarised in a concise letter to the patient’s GP and Oncologist.
Many of the issues we identify also lack clarity, and the clinical relevance of them can vary, depending on a patient’s prognosis. In summary, we use tools to inform, common sense and clinical interpretation to make recommendations and allow the physicians to use their clinical judgment to implement these recommendations.
Integration of Pharmacists in Geriatric Oncology
What are the key barriers to incorporating pharmacists into Geriatric Oncology MDTs and how can these be overcome?
We need more pharmacists, certainly in Ireland there is a dearth of pharmacists. We also need more education and training. Increasing the number of pharmacy places in third level education is a key first step. The SIOG NAH group has a team of pharmacists collaborating on a scoping review at the moment, assessing training and education for pharmacists in oncogeriatrics. I believe this is key, having competent professionals who enter a field with a good solid feel for what they are doing. I would love to see a postgraduate qualification in medication management for older adults with cancer develop.
We also need clinical leads who believe that clinical pharmacists are valuable members and will add something worthwhile to the MDT. I am very lucky that our clinical lead Dr. Anne Horgan proactively sought out a clinical pharmacist for our GOAL team. I think if pharmacists working in oncology and/or care of the elderly do a good job in the acute hospital environment, clinical leads will soon see the value of our work.
Specific Practices in Geriatric Oncology Pharmacy
What are some of the challenges faced in conducting a medication review in older adults with cancer?
We don’t have electronic prescribing, so even getting an accurate medication list during clinic preparation can be a nightmare. It’s also difficult at times to ensure patients are truthful about the over the counter and herbal medications they may be taking.
From speaking to friends and colleagues in SIOG, I feel like ascertaining a patient’s adherence to their medication is a challenge. It’s very difficult to measure, but key component to successful pharmacotherapy.
We also use tools, as listed above, that are validated in older adults, but not necessarily older adults with cancer. Indeed, some trials that validated these tools excluded cancer patients from their recruitment. This means we cannot use the tools as absolutes, and that our clinical experience, knowledge and intuition is still a key determinant of the clinical relevance of a medication related recommendation.
I’ve also found a very small minority of patient who themselves are a barrier. In Ireland, there can still be a belief that doctors are infallible, and that questioning a medication that has been prescribed for them is inappropriate. I wish it were so, but then I’d be out of a job! It can be difficult to convince some patients that I work with my excellent physician colleagues, as opposed to in spite of them!
How do pharmacist prescribing privileges enhance the care of older adults with cancer and what are the barriers to implementing these privileges?
In Ireland pharmacists don’t currently have prescribing privileges. It would be very useful, particularly when an issue is clear – such as prescribing supportive care medications as per a chemotherapy protocol. I think as pharmacists we obsess over prescribing, so I think we would make excellent prescribers. I do, however, believe that our prescribing should be within a limited scope of practice.
Where I see the most benefit is speed of access to medication. As a pharmacist, I have an intrinsic knowledge of the medication procurement and supply process in my area, and I have a relatively good knowledge of what medication shortages are affecting the medications we may wish to prescribe. As a pharmacist working with older adults with cancer, I believe I might be better placed to prescribe alternatives in this setting also.
Can you talk about the concept of “deprescribing” and the significance of this process in older adults with cancer?
We know from the literature that the presence of polypharmacy and potentially inappropriate medications cause poorer outcomes in older adults with cancer. What isn’t absolutely clear yet, is what the clinical significance of “deprescribing” potentially inappropriate medications would be. This is a key challenge for pharmacists, to justify their inclusion in the MDT by showing categorically, the benefit of this.
Deprescribing medications that have a clear contraindication – for example NSAID in a patient with poor renal function or an active bleed – is relatively easy. When it is explained to the patient why the medication is no longer appropriate, and potentially doing them harm, in my experience that conversation goes relatively easily.
Deprescribing medications, that may still be appropriate, but the clinical benefit may be minimal with a limited life expectancy is a far more delicate balance. Telling a patient that a medication should be stopped because they will not likely live long enough to gain a benefit from it can be a tough conversation, and needs to be considerate and empathetic.
Ultimately, there is often a benefit to deprescribing medication appropriately, however, ensuring the patient is part of that process is key to its success.
Personal Experience
Can you share a personal experience where you felt your role as a clinical pharmacist made a significant impact on the care of a geriatric oncology patient?
They are a heterogeneous group, and every patient’s individual needs are different, but the ones that stick out for me are the patients with upper gastrointestinal malignancies that are dysphagic or have gastric outlet obstruction. For some of these patients I’ve recommended comprehensive changes to their medications, in particular optimising their dosage form to prevent inadvertent overdosing and to ensure therapeutic efficacy. I’ll also recommend changes to their supportive care protocol, compared to our standard regimen, to ensure their supportive care meds are adapted for their needs. This has actually led me to screening every patient now, regardless of primary tumour site, for patient reported swallowing difficulties.
International Collaboration and Membership Benefits
How does international collaboration among pharmacists working in geriatric oncology help in identifying and addressing knowledge gaps in clinical practice and research? What research collaborations is the group working on?
When I joined the GOAL clinic, initially in 2018 on a referral/remote basis, I felt that I was doing assessments without any peer support to reassure me that what I was doing was appropriate. I joined SIOG in 2019 and eventually the pharmacists in SIOG set up a collaborative group that meets once a month. This was a great development personally. I got to engage with some fantastic peers, and our meetings and discussion have refined and improved my clinical practice.
We share relevant publications we come across, and have discussed the benefits and drawbacks of using tools validated in older adults in the context of both regional and advanced cancer, such as STOPP/START, Beer’s criteria etc.
The group published a perspective piece in the Journal of Geriatric Oncology recently, outlining the current practices in clinical pharmacy, which reflected on the challenges and future research needs for clinical pharmacy in geriatric oncology. We are currently working on a scoping review examining the educational needs of oncology pharmacy professionals to optimise medicines in older adults with cancer. We are also working on a protocol for a multi-site observational study on patient reported medication adherence and the use of adherence aids in older adults with cancer.
As a member of the SIOG NAH pharmacist subgroup, what opportunities and benefits do pharmacists working in, or interested in, geriatric oncology get from joining this group?
The group is full of fantastic people. It is a small group, so everyone gets to know each other quite well. And we have been very productive, publishing our first paper already! The opportunities offered are to work on collaborative projects that will enhance the knowledge and understanding of the role of a clinical pharmacist in the geriatric oncology MDT, and to make good friends. Last year, those of us that attended the SIOG conference met up for lunch together and had a fantastic chat,
The benefits of joining this group, I believe, revolve around professional development. As I said earlier, I’ve learned an awful lot from our peer discussions in our monthly meetings and it is great to have a cohort of pharmacists I can email or call when I have a clinical conundrum.
Guidance and Policies
Can you elaborate on the guidance published by the NAH/Young SIOG in 2022 and its significance for pharmacists new to geriatric oncology?
The medication review guidance, published by Young SIOG in 2022, including three excellent pharmacists in our group, is a fantastic starting point for pharmacists new to geriatric oncology. It offers a structure on which to build your medication review process. When it was published it reassured me that my current practice was adequate, but highlighted some weaknesses is our current medication review process. It therefore is an incredibly useful tool to identify gaps in clinical practice.
REFERENCE:
[1] Walsh DJ, Kantilal K, Herledan C, et al. Medication assessment in older adults with cancer – Current practices in clinical pharmacy. J Geriatr Oncol 2023;14:101531. doi:10.1016/j.jgo.2023.101531