Candice Gagliardi, PharmD BCOP
Oncology Pharmacist
Cancer Care Partnership
Mount Nittany Medical Center
State College, PA

2018 JADPRO (Journal of the Advanced Practitioner of Oncology) Live, the sixth annual meeting of the Advanced Practitioner Society for Hematology and Oncology (APSHO), took place November 1–4, in Hollywood, FL. Nearly 1,300 participants—physicians, nurse practitioners, nurses, physician assistants, pharmacists, and other advanced-degree practitioners—attended. The theme, “Bringing Clarity to Complexity,” focused on the diversity of practitioners collaborating to bring clarity to the increasingly complicated field of oncology.

In the exhibit hall 22 posters covered topics ranging from quality of care to professional development; more than 50 vendors had displays, with educators available to answer questions; and daily product theaters were held. The APSHO booth illuminated the society’s mission and encouraged attendees to get involved and check out the society’s mentorship program. Attendees could choose from many breakout sessions covering the range and diversity of oncology practice settings. Topics included nausea and vomiting, new cancer therapies approved during the past year, new directions in treating myeloid malignancies, treatment sequencing, risk management, the costs of cancer care, and patient care stories. Close to 8 hours of Board Certified Oncology Pharmacist (BCOP) credit were offered, covering hematologic malignancies, solid tumors, and supportive care in oncology.¹

Kate Jeffers, PharmD MHA BCOP, from UCHealth Memorial Hospital, and Patrick J. Kiel, PharmD BCOP BCPS, from Indiana University Simon Cancer Center, kicked off the meeting with a preconference workshop titled “Ask a Pharmacist.” Several complex cases were discussed, and emerging therapies and their associated safety and efficacy concerns were reviewed. Also covered were drug shortage plans, URAC (formerly the Utilization Review Accreditation Commission) accreditation, and other topics that highlighted the role of the oncology pharmacist and the wealth of information and resources that we can provide to a collaborative practice. Other preconference workshops were “Learning to Present with Confidence” and “Running on Empty: Caring for Yourself While Caring for Others.”

Several other oncology pharmacy colleagues took the stage, including Christopher Campen, PharmD BCOP; Morgane Diven, PharmD BCOP; Donald Harvey, PharmD BCOP; Kimberly Hicks, PharmD; Rebecca Nelson, PharmD BCOP; and Melinda Tran, PharmD BCOP. One review covered recently approved CAR T-cell options, as well as side-effect management for cytokine release syndrome (CRS), presented by Jae Park, MD, and Amber C. King, PharmD BCOP, from Memorial Sloan Kettering Cancer Center.² The session emphasized the need to identify the right candidate for CAR T-cell therapy, considering the length of time for the CAR-T cells to be manufactured and evaluating the patient’s disease burden and estimated life expectancy.

The program “Advances in the Treatment of HER2-Positive Breast Cancer”³ presented by Reshma Mahtani, DO, from Sylvester Cancer Center and the University of Miami, and Lisa Hineman, MS AOCN PHN ANP-C, from LA Cancer Network, highlighted the following trials:

• HERA and PERSEPHONE
  • The trials demonstrated noninferiority with 6 months rather than 12 months of trastuzumab.
  • Despite this benefit, the presenters carefully highlighted the selected patient population included in the study and their previous treatment history.
• APHINITY
  • Subgroup analysis showed that patients with hormone receptor–negative or node-positive disease had the greatest invasive disease-free survival (IDFS) benefit with pertuzumab.
• ExteNET
  • Five-year IDFS analysis showed more benefit in the hormone receptor–positive cohort; overall survival data should be available this year for extended neratinib therapy.
  • In this study, 40% of patients experienced grade 3 diarrhea.
  • The presenters stressed the importance of prophylactically treating patients for tyrosine kinase–associated diarrhea, as we historically have done with antiemetic therapy to prevent nausea and vomiting associated with traditional chemotherapy agents.
  • Prophylactic suggestions include the BRAT (banana, rice, applesauce, and toast) diet and loperamide 4 mg three times daily on days 1–14, then twice daily for weeks 3–8, then as needed thereafter; budesonide 9 mg daily can also be considered if needed.

Keynote speaker Charles Von Gunten, MD PhD FACP FAAHMP, from Ohio Health, presented “Integrating Palliative Care into the Cancer Care Setting: The Role of the Advanced Practitioner.”⁴ Ensuring that concurrent palliative care is given from the time of diagnosis forward should be a collaborative goal among advanced practitioners. A 2010 article in the New England Journal of Medicine demonstrated that early palliative care improved quality of life and that patients who received early palliative care interventions received less chemotherapy and also had prolonged survival of approximately 2 months, compared to patients who did not receive those interventions.⁵ An American Society of Clinical Oncology (ASCO) Clinical Practice Guideline Update titled “The Integration of Palliative Care into Standard Oncology Care” was published in 2017.⁶ This guideline and the keynote address challenged all in attendance to integrate early palliative care into our current cancer care practices.

Sunday’s agenda, though shorter, was still packed with valuable education options. “Preventing and Treating Venous Thrombosis in Oncology,” by Rowena Schwartz, PharmD BCOP, from the University of Cincinnati, reviewed new data on cancer-associated thrombosis and management.⁷ The need to follow the National Comprehensive Cancer Network (NCCN) Venous Thromboembolism (VTE) guidelines for dosing recommendations but also look closely at each individual patient in making treatment decisions was a dominant theme. Cancer patients may be more at risk for VTE, and several factors must be considered: the length of intended therapy, the cancer type, genetic mutations, and the selected cancer treatment. Regarding the selection of an optimal anticoagulant, results from several clinical trials were presented:

• Overview of trials comparing low-molecular-weight heparin (LMWH) to warfarin
  • LMWH products were associated with fewer incidences of recurrent thrombosis and major bleeds.
  • One key reason for these outcomes was the fact that warfarin was in therapeutic range less than 50% of the time.
  • Results from these trials led to the recommendation that LMWH be used as the gold standard for treating cancer patients.
• Hokusai VTE Cancer Trial (edoxaban vs. LMWH; published in the New England Journal of Medicine in February 2018)
  • All patients with cancer-associated VTE were started on LMWH for at least 5 days, followed by edoxaban 60 mg daily versus dalteparin injections daily.
  • At 12 months, recurrent VTE and major bleeding events in the edoxaban group were noninferior to the dalteparin group.
• SELECT-D trial (rivaroxaban vs. LMWH; conducted in Europe)
  • The rivaroxaban arm had lower 6-month VTE recurrence rates but higher rates of major bleeding (mostly gastrointestinal).

2019 JADPRO Live is scheduled for October 24–27 in Seattle, WA. More information can be found at www.jadprolive.com.

APSHO’s mission is to improve the quality of care for patients with cancer by supporting critical issues in educational, clinical, and professional development for advanced practitioners in hematology and oncology. The organization believes that expanding knowledge through an interdisciplinary team approach to cancer treatment allows us to be more productive and more efficient in offering the best care for our patients. APSHO provides advanced practitioners publications, continuing education, and conferences because collaborative teaching and care will shape the future of cancer treatment.⁸

References

1. JADPRO Live 2018, Conference Guide: Bringing Clarity to Complexity. The Annual APSHO Meeting, November 1–4, 2018, Hollywood, FL.
2. Park J, King A. CAR T-cell therapy and the pharmacology of managing cytokine release syndrome. Presented at JADPRO Live, November 2, 2018, Hollywood, FL.
3. Mahtani R, Hineman L. Advances in the treatment of HER2-positive breast cancer. Presented at JADPRO Live; November 3, 2018, Hollywood, FL.
4. Von Gunten C. Integrating palliative care into the cancer care setting: the role of the advanced practitioner. Presented at JADPRO Live, November 2, 2018, Hollywood, FL.
5. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non–small-cell lung cancer. N Engl J Med. 2010;363:733-742.
6. Ferrell BR, Temel JS, Temin S, et al. Integration of palliative care into standard oncology care: American Society of Clinical Oncology Clinical Practice Guideline Update.” J Clin Oncol. 2017;35(1):96-112.
7. Schwartz R. Preventing and treating venous thrombosis in oncology. Presented at JADPRO Live, November 4, 2018, Hollywood, FL.
8. Advanced Practitioner Society for Hematology and Oncology. About the Society. Available at www.apsho.org.