ONA interview: Coordinating with specialty pharmacies

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The development of oral forms of some chemotherapy agents meant some patients could undergo cancer treatment completely at home without hospitalization or frequent trips to their doctor's office, a clinic, or a cancer center. In recognizing this changing paradigm in cancer treatment, Walgreens Specialty Pharmacy developed its cycle management program (CMP). The program not only provides patients with their oral chemotherapy, it helps patients manage and adhere to their treatment regimen, provides support for coping with treatment side effects, and facilitates communication with the physician's office.

Recently, the pharmacy chain announced the addition of six more oncology medications, for a total of nine medications managed within the CMP. Oncology Nurse Advisor spoke with Rhonda Letwin, RN, BSN, OCN, a nurse certified in oncology and Walgreens director of specialty reporting, about the program and the role nurses play in coordinating patient care with specialty pharmacies.

ONA: Please explain how the cycle management program works.

LETWIN: The Walgreens Specialty Pharmacy Cycle Management Program closely monitors patients new to nine oral oncology medications with high drop-off rates. A specially trained nurse contacts the patient prior to initiation of the medication to provide patient education. Patients are then contacted at days 10 and 20 of therapy to assess medication adherence, side effects, and other concerns.

Side effects are graded according to the National Cancer Institute (NCI) grading scale and managed according to drug-specific protocols developed by our oncology advisory board. If side effects are reported during an assessment and protocols advise intervening, the patient's oncology care team is contacted. Working with oncology clinicians, regimens can be adjusted or discontinued mid-cycle without negatively impacting patient care or wasting medication. In addition, prescribers receive a patient adherence report via fax at the end of the first month of therapy.

ONA: What makes this program unique?

LETWIN: This program provides unprecedented clinical management and enhanced support between physician office visits as patients cope with challenging oral oncology regimens.  The first month is so crucial to the success of treatment. Early recognition of adverse events can lead to timely changes in dose, frequency, and medication and prevent the progression of side effects.

The program also offers an optional “split-fill” dispensing system. With this option, only half of the first month's supply of medication is initially provided. The additional first-month follow-ups allow our nurse to assess the patient's treatment response and potential reactions or side effects, avoiding medication waste and the costs associated with early therapy discontinuation. As far as we know, no other specialty pharmacy provider offers this level of close contact with patients and physicians' offices during the course of these therapies.

ONA: What are the most significant benefits of oral chemotherapy?

LETWIN: Patients like the convenience of oral oncology medications. However, patients may also believe oral oncology medicines are safer than intravenous treatment; in reality, the protocol poses added risks. No longer under the watchful eye of clinicians, patients are more likely to take the medication incorrectly, inadequately, or stop taking it altogether due to adverse events. These and other factors lead to waste and less-effective treatment. Our cycle management program was developed to provide better counsel to patients taking these medications, especially those drugs with particularly high drop-off rates.

Treating complex conditions with oral medications can be difficult. Regular in-office treatment visits provide opportunities to monitor patients, so sending patients home with oral oncology medications creates challenges. However, clinicians seek to put their patients first and understand that the advances made with these oral medications can result in better outcomes for patients. Walgreens understands this and it is a big reason why the cycle management program was developed. Nurses and specialty pharmacists in the program do their best to serve as an extension of the oncology care team. They communicate with the physician's office regularly so they can have peace of mind knowing that their patients are being taken care of and are taking their medications.  

ONA: What treatment-related challenges are unique to oral chemotherapy?

LETWIN: The number of oncology medications available in oral form continues to grow. One of the biggest challenges is patient adherence. Although oral oncology medications are convenient, they place the responsibility of understanding and taking the medication correctly on the patient. Also unique is managing the side effects that develop. When a side effect develops in a clinic or hospital setting, immediate counsel can be provided. Unfortunately, that is not always the case for the patient at home.

We may speak with a patient who is experiencing what we know to be minor side effects, but the uncertainty of not knowing lets it get blown out of proportion in the patient's mind. Most patients are nervous and scared about what is happening to them. Conversely, patients may not contact the physician's office between visits. We had one patient who developed blisters on the soles of her feet that almost went unnoted because she did not correlate the condition with her oral chemotherapy.

In our day-to-day role, we help patients understand which side effects are concerning so they have a better understanding from the beginning about what they will experience. Our response to reported side effects follows drug-specific protocols. We counsel and intervene as necessary which may include communication with the physician's team on the patient's behalf.

ONA: Which side effects have the greatest impact, positive or negative, on patient adherence?

LETWIN: The most frequent side effects associated with oral oncology medications managed within the CMP include vomiting, diarrhea, hand-foot syndrome, skin rashes, mouth sores, and fatigue.  These side effects have the potential to progress in severity. If optimized clinical management that allows for early recognition of adverse events and intervention is not available, worsening side effects can result in adverse-event-related hospitalization or the patient may stop taking the medications altogether.

ONA: Which patients may not be candidates for oral chemotherapy or the cycle management program?

LETWIN: Physicians are responsible for determining which patients would not be candidates for oral chemotherapy. Any patient who is new to an oral oncology agent included in our cycle management program would benefit from the enhanced patient support and physician communication this program offers.

ONA: How can nurses facilitate teamwork between patients, cycle management coordinators, and oncology clinicians?

LETWIN: Oncology nurses are the glue that holds this whole team together.  Their support is instrumental in making sure that our team can remain in contact with patients' clinicians to provide the care patients need to manage their cancer. As a nurse at Walgreens Specialty Pharmacy, my job is to take what the cycle management coordinators learn from patients and provide counsel on those issues. If something suggests a shift in treatment approach is needed, our nurses contact the patient's clinician to discuss an action plan or even initiate a phone call from the oncology care provider's office to the patient. Our background in nursing allows us to play the dual role of patient counselor and care coordinator that is critical to keeping care teams in sync, providing the best possible patient care. ONA

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