Pharmacists Bridging the Gap Between Oncology Care and Primary Care

Emily Mackler, PharmD BCOP
Director, Clinical Quality Initiatives
Michigan Oncology Quality Consortium
Ann Arbor, MI

Amy Thompson, PharmD BCACP
Director, Ambulatory Clinical Pharmacy Practices
Michigan Medicine
Ann Arbor, MI

Over the past several years cancer treatments have changed from classic cytotoxic therapies to molecular targeted treatments. With this change in target, we’ve seen more oral anticancer agents (OAAs) approved and integrated into standard treatment protocols.1 In addition to the type of systemic therapy changing, the duration of treatment has been extended. The average duration of cancer treatment in the late 1990s (1994–1999) was 4 months, with the median duration more than doubling to 9 months just a decade later (2010–2014).¹ Extending the median duration of cancer treatment, and moving to OAAs that are generally taken daily at home, increases the interaction of systemic cancer treatment and comorbid conditions caused by drug-drug interactions and potentially worsening side effects.²

Among Medicare beneficiaries age 65 years and older with cancer, 40% have at least one comorbid condition, and 15% have two or more. The most common of these comorbidities are cardiovascular disease, diabetes mellitus, and mental health disorders.² We know that cancer has effects on comorbidities—particularly related to the worsening of diabetes or cardiovascular disease seen with certain systemic therapies like tyrosine kinase inhibitors, endocrine therapy, and steroids. We also know that comorbidities can affect cancer outcomes, given their impact on treatment toxicities, treatment effectiveness, and overall survival. Given the significant proportion of patients who are managing a chronic condition in addition to their cancer diagnosis, a collaboration between oncologists and primary care providers is necessary to ensure the patient’s overall health.^2-5 Unfortunately, the literature is replete with evidence of lapses in communication between oncology specialty providers and primary care providers. These lapses provide multiple opportunities for improvements in care and, ultimately, in patient outcomes.^3,6,7

We believe that pharmacists are well suited to help bridge the gap between oncology care and primary care. Pharmacists are well versed in adverse-effect management and in identifying and resolving drug-drug interactions. Studies estimate that drug-drug interactions affect one-third of patients treated for cancer. Pharmacists can screen medication lists, assess clinical significance, and recommend alternatives. In addition, pharmacists can also recognize treatment-related adverse effects and arrange for proper management and follow-up.^8-10

In an effort to enhance the collaboration between oncology and primary care, we developed the Primary Care Oncology Model (PCOM) pilot program in the Michigan Oncology Quality Consortium (MOQC).¹¹ The MOQC-PCOM pilot used a primary care pharmacist to conduct comprehensive medication reviews (CMRs) via phone visits for patients with cancer who were receiving active systemic cancer treatment and had at least one of the following pre-existing chronic conditions: diabetes, hypertension, heart failure, depression, and anxiety. Results of the CMR and management recommendations were communicated to the patient’s primary care physician (PCP) and oncologist and/or oncology pharmacist. Although the CMR was the responsibility of the primary care pharmacist in this model, the oncology pharmacist was heavily involved when the primary care pharmacist identified any medication issues related to the patient’s cancer care or when the primary care pharmacist had questions related to the plan for the patient’s cancer treatment. The goals of MOQC-PCOM were to improve management of the chronic disease state, decrease unplanned healthcare utilization, decrease drug-drug interactions, and decrease cancer therapy toxicity.

A total of 96 patients met our inclusion criteria of having a PCP at one Michigan Medicine General Medicine clinic, having an oncologist at the Michigan Medicine Rogel Cancer Center, receiving active cancer treatment, and having at least one of the chronic conditions listed above. Of those 96, a total of 55 had completed CMRs conducted by the primary care pharmacist. The median age was 66 years (range 32–87), 59% were female, 27% were Black, and 67% were White. The median number of medications the patients took was 11 (range 2–23). The following were incidences of comorbid conditions: hypertension, 73%; diabetes, 26%; congestive heart failure, 13%; and psychiatric illness, 42%.

Results from the CMRs included the findings that 77% of patients had changes made to their medication list, 18% were referred to a primary care pharmacist for ongoing chronic disease state management, 22% were referred to a physician for needed follow-up, and 22 medication-related problems (MRPs) were identified.¹² In addition, there were 66 instances of patient education provided related to a medication, disease, or lifestyle. Of the MRPs identified, 32% were related to adherence, 23% to safety, 14% to an indication, and 9% to treatment effectiveness; the remaining 23% were in the “other” category.

The results of this pilot highlight the opportunity that pharmacists have to improve the coordination of care and enhance clinical outcomes for patients with cancer and comorbid conditions. Future work following this pilot will include expansion across the state of Michigan with involvement of other sites, modification to real-time (rather than retrospective) referral, and ultimately the development of a risk model to identify those patients most likely to benefit from the pharmacist’s CMR.

Acknowledgment
The authors wish to recognize and thank the following co-investigators for the MOQC-PCOM pilot: Michelle Azar, PharmD candidate; Karen Farris, PhD; and Emily Joehengen, PharmD.

References

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11. Primary care oncology model overview. Michigan Oncology Quality Consortium website. https://moqc.org/initiatives/pcom/
12. Pharmacy Quality Alliance. PQA Medication Therapy Problem Categories Framework. August 2017. https://www.pqaalliance.org/assets/Measures/PQA%20MTP%20Categories%20Framework.pdf