Responding to the COVID-19 Pandemic—Impact in Oncology Pharmacy Practice

Sylvia Bartel, MPH, RPh
Vice President of Pharmacy
Dana-Farber Cancer Institute
Boston, MA

During the COVID-19 pandemic, healthcare institutions and phar­macies worldwide have experienced significant challenges that have forced them to alter their standard operational and clinical practices. The shortage of personal protective equipment (PPE), which received widespread media attention early on, was merely the beginning. Across the globe, healthcare organizations have reported other con­sequences of the pandemic, including delayed access to cancer, anti-infective, and support­ive care medications, as well as a decrease in clinical trial referrals.¹ Some institutions have also paused certain preventive services and cancer treatments.² For example, breast, colon, and cervical exams decreased by 60% between mid-March and mid-June of 2020.3 Similarly, 44% of breast cancer patients re­ported delayed treatments.³ And like many other businesses worldwide, healthcare in­stitutions have laid off non-critical staff and reassigned others to areas in the organization with which they are less familiar.^1,4

In response to these challenges, and to keep patients and staff safe, healthcare institutions implemented rigorous infec­tion-control practices and altered standard procedures. In addition to wearing face masks and practicing physical distancing—minimal preventive measures endorsed by numerous governmental health agencies—healthcare providers and pharmacies have installed plastic barriers at public ser­vice counters and increased telehealth options to deliver patient care, education, and medication reconciliation services.^1,4,5 Pharmacies have adopted alternative methods for dispensing and administering medications in response to supply shortages and to limit contact between healthcare staff and patients. For example, some oncologists have reduced the number of patients on myelosuppressive medica­tions.¹ They may prescribe smaller doses of medications that cause neutropenia, or delay administration of these medications to limit the number of patients who require follow-up care.⁴ Other oncolo­gists have transitioned patients from intravenous to oral medications whenever possible.^1,4 To further reduce patient and staff contact, pharmacies have created self-service dispensing locations, set up curbside pickup, and mailed medications to patients.⁴

The COVID-19 Response at the Dana-Farber Cancer Institute
Throughout the COVID-19 pandemic, the Dana-Farber Cancer Institute (DFCI), like many other leading cancer centers, has been impacted both clinically and operationally. For example, the orga­nization established a hospital incident command center structure, which included the pharmacy, to disseminate rapid updates (once or twice daily) across all departments through weekly meetings, daily huddles, and email communication. The pharmacy created its own internal command structure to ensure rapid communica­tion between all areas of the pharmacy—infusion services, clinical services, and clinical trials/research pharmacy, outpatient/specialty pharmacy—and the rest of the DFCI healthcare team. Other insti­tution-wide changes that affected pharmacy operations included employee, visitor and vendor screening protocols, staff relocation, and remote work options. New PPE and medication conservation strategies required the pharmacy to closely monitor its stock and work collaboratively with DFCI’s supply chain team.

5 Ways COVID-19 Changed Pharmacy Operations
In addition to adapting to DFCI’s institu­tion-wide changes, the pharmacy revised its own operating procedures to ensure the saf­est protocols for medication preparation and dispensing. For example, we reduced the du­ration and frequency of on-site patient visits and decreased medication turnaround times, which was a goal we achieved early on in the COVID-19 pandemic and have been able to maintain since. To accomplish this, we have:

1. adjusted where and how staff work,
2. increased the number of medications prepared in advance for infusion therapy appointments,
3. maximized use of the automated dispensing cabinet (ADC),
4. used prescription delivery services to minimize contact between patients and staff, and
5. adjusted medication administration—route, frequency, and dosage—to decrease the amount of time patients spend on site and to minimize their need for follow-up care.

Adjusting Where and How Staff Work
Approximately 40% of pharmacy staff have worked remotely since March. While those in leadership roles such as directors and man­agers and a portion of order verification pharmacists are working under a hybrid model that includes both remote and on-site hours, staff in clinical practice, research, informatics, and billing and regulatory compliance work entirely remotely. Clinical pharmacy specialists that have been working remote include those in the anti­coagulation management service, pain and palliative care, and oral chemotherapy teach areas.

While this has been successful overall, there are many challenges associated with remote work. Staff need the necessary technolo­gy—desktop/laptop, multiple screens, internet connectivity—to access to the institution’s clinical and operational systems. Com­munication methods (e.g. Microsoft Teams, Business Skype) with clinical teams and internal pharmacy department staff must remain secure and HIPAA compliance needs to be maintained. Additionally, it is important for remote workers to stay connected and engaged with on-site staff as well as to maintain a work-life balance.

There have been no noted changes in productivity or major issues identified. We have also reassessed and expanded staff roles. While everyone is expected to assist each other with tasks that fall outside of their usual responsibilities, some have taken on signifi­cantly more or different duties. For example, outpatient pharmacy technicians have provided coverage in the infusion pharmacy processing and material management areas.

Increasing the Number of Medications Pre­pared in Advance
Early on in the pandemic, pharmacy staff began to identify additional medications that could be prepared before patients arrived for infusion therapy appointments. Staff selected medications based on the drug’s stability, the likelihood it would be used (i.e., the patient would receive treatment as sched­uled to minimize waste), and the likelihood that physicians would not need to adjust the prescribed dosage. For medications that are weight based, such as trastuzumab and 5-Flu­orouracil, the doses were based on previous weight or body surface area as long as these remained within 10%. And now, we regularly prepare the following medications prior to patient appointments:

• 5-Fluorouracil continuous infusion pumps
• Herceptin Hylecta (trastuzumab and hyaluronidase-oysk)
• Herceptin (trastuzumab)
• Keytruda (pembrolizumab)
• Opdivo (nivolumab)
• Perjeta (pertuzumab)

Using a daily report, pharmacy staff identify infusion therapy patients and prepare medications for them in advance. For morning appointments, the medication is prepped by the end of the previous day; for afternoon appointments, prep is done in the morning of the same day. Pharmacy staff also manages delivery of the medica­tions to the infusion unit. By increasing the number of medications prepared in advance, the pharmacy hopes to reduce the amount of time patients wait for their appointments once on site. Since adding the aforementioned medications to our advance preparation list in August of 2020, pharmacy staff are already seeing a more efficient clean room operation because compounding occurs throughout the day instead of at peak appointment times (i.e., between 10:00 a.m. and 2:00 p.m.). Further, there has been minimal drug waste. The flat dose medications can be used for other patients, and for medications dosed by weight or body surface area, the 10% dose variation threshold has kept waste to a minimum.

In the coming months, we plan to review our metrics to determine preparation time for each medication, the number of physicians signing orders in advance, and patient wait times in the infusion therapy unit. We also continue to identify other medications that might be suitable for advance preparation and are working with physicians to determine whether exams and infusion therapy can occur on different days for certain types of treatments and patients.

Maximizing Use of the Automated Dis­pensing Cabinet
To minimize patient wait time and foot traffic in patient care areas and reduce compounding in the clean room, we have identified additional medications that can be added to our ADC. We have adjusted the periodic automatic replenishment (PAR) levels to reduce the frequency of restocking. Examples of medications we have added to the ADC include 4 mg doses of Zometa (zo­lendronic acid) and 120 mg doses of Xgeva (denosumab).

Using Prescription Delivery Services to Minimize Contact between Patients and Staff
In addition to delivering medications to our infusion therapy unit in advance of patient appointments, our outpatient and specialty pharmacy units are developing a process to dispense oral contrast medications to patients prior to their on-site radiology appointments. The units are also mailing prescriptions to patients both within Massachusetts and in other states.

Adjusting Medication Administration
Patients with cancer are at greater risk of experiencing acute COVID-19 symptoms and dying because cancer treatments often cause immunosuppression.^1,2,3 Therefore, physicians are decreasing the frequency of treatments and prescribing fewer myelosuppres­sive regimens when possible. For example, Keytruda (pembroli­zumab) is often administered in 200 mg doses every 3 weeks, but we have been able to administer 400 mg doses every 6 weeks based on recent approval of an extended dosing interval. Physicians are prescribing Opdivo (nivolumab) in 480 mg doses every 4 weeks as opposed to 240 mg doses every 2 weeks as well. Patients are receiving Kyprolis (carfilzomib) weekly as opposed to twice weekly, and we have been able to substitute darbepoetin alpha (Aranesp) for epoetin alfa, its therapeutic equivalent, to reduce the treatment frequency. The utilization of standardized dosing supports the abili­ty to prepare medications in advance of a patient’s visit as well as avoid any potential medication dosage calculation errors. Explora­tion of other medications that are suitable for dose standardization along with dose banding is being further explored.

Physicians are also prescribing oral or subcutaneous admin­istration routes to reduce the frequency and duration of on-site treatments. Oral medications such as etoposide have been utilized for patients receiving intravenous etoposide on multi-day regimens. In addition, Ninlaro (ixazomib) has been prescribed instead of in­travenous Velcade (bortezomib). Examples of traditionally intrave­nous medications that are now available for subcutaneous delivery include Herceptin Hylecta (trastuzumab and hyaluronidase-oysk), Rituxan Hycela (rituximab and hyaluronidase human), Darzalex Faspro (daratumumab and hyaluronidase human-fihj) and Phesgo (pertuzumab, trastuzumab and hyaluronidase-zzxf). Physicians are also increasing prescriptions of Neulasta (pegfilgrastim) including the on-body injector, to avoid patients needing to return to clinic for an injection and to minimize the risk of febrile neutropenia. Though there has been a reduction in clinical trial referrals, we have been able to mail oral investigational medications to patients already on study therapy.

As DFCI moves into the next phases of its COVID-19 response, we plan to continue practicing some of the changes implemented in our pharmacy areas. We anticipate certain staff will maintain a remote work schedule and that telehealth will remain a convenient and appropriate option for certain patients or certain points in a patient’s treatment plan. Our advance medication preparation protocols have improved workflow in our clean room and, we believe metrics will show, have reduced patient wait times in the infusion treatment unit. Delivering clinical trial investigational and commercial medications to patients by postal mail has proved to be efficient for staff and convenient for patients. Finally, we have re­alized the indispensable value of data analytics for monitoring—in real-time—the effects of our new processes, creating performance targets, and identifying trends that will determine long-term operational changes.

The DFCI pharmacy staff have demonstrated remarkable resil­iency and flexibility during the COVID-19 pandemic; I am humbled by their commitment to our patients. I look forward to working with them as we continue to adapt—and improve—our processes.

REFERENCES

1. Alexander M, Jupp J, Chazan G, et al. Global oncology pharmacy response to COVID-19 pandermic: Medication access and safety. J Oncol Pharm Pract. 2020; 26(5):1225-1229. https://pubmed.ncbi.nlm.nih.gov/32408842/
2. Schrag D, Hershman D, Basch E. Oncology practice during the COVID-19 pandemic. JAMA. 2020; 323(20):2005-2006. doi: 10.1177/1078155220927450.
3. Ducharme J, Barone, E. How the COVID-19 pandemic has changed cancer care, in 4 charts. Time. August 28, 2020. http://www.time.com/5884236/ coronavirus-pandemic-cancer-care.
4. Pourroy, B, Tournamille JF, Bardin, C, et al. Providing oncology pharmacy services during the coronavirus pandemic: French Society for Oncology Pharmacy (Société Francaise de Pharmacie Oncologique [SFPO]) Guidelines. JCO Oncol Pract. 2020; 16(11):e1282-e1290. doi; 10.1200/OP.20.00295.
5. Koster ES, Philbert D, Bouvy ML. Impact of COVID-19 epidemic on the provision of pharmaceutical care in community pharmacies [published online ahead of print July 2, 2020]. Res Social Adm Pharm. 2021; 17(1):2002–2004. doi: 10.1016/j.sapharm.2020.07.001.