More patients with cancer are being treated with oral anticancer therapies than ever before and, with a multitude of these medicines in development, the number being treated this way is likely to increase further. There are many advantages associated with oral chemotherapy (eg, it is often more convenient and acceptable for patients).However, unlike intravenous chemotherapy, which is administered by qualified healthcare professionals, oral chemotherapy regimens are administered by patients or their carers — this is a great deal of responsibility considering the potential toxicity of these medicines.Between November 2003 and July 2007the National Patient Safety Agency received three reports of patient deaths associated with oral chemotherapy. In response it issued a rapid response report stating that patients should be fully informed about their treatment and should receive up-to-date verbal and written information about their oral anticancer medicines from the initiating hospital. Effective counselling is vital to ensure patients are able to use their oral chemotherapy in a safe and effective way —this is a clear role for pharmacy staff.
When and where
Patients with cancer receive huge amounts of information, which can often be difficult for them to process. Ideally, counselling for oral chemotherapy should occur at a separate visit to other outpatient appointments so that the importance of the information is emphasised and information overload is avoided.
Most counselling for oral chemotherapy takes place within the dispensing hospital. However, counselling at home, for example by homecare providers, or over the telephone does occur.
Wherever counselling is provided it should be in an environment free from interruption and where the patient feels comfortable. It is important to consider including carers and relatives in the counselling because they will often be involved in the administration of the medicines; however, this should only happen with the patient’s permission.
It is good practice to provide written information that reiterates what has been discussed during the counselling session.Sometimes dosing reminder charts or patient diaries can be useful, as well as patient information packs provided by manufacturers. Counselling documentation can ensure uniformity of information and act as a record of the consultation. A clear and concise approach to counselling is necessary and the key communication skills of planning and preparation, delivering the message, listening and questioning should be used.
Effective counselling is a vital part of the successful and safe use of oral chemotherapy.
Verbal and written information should be combined and delivered by a healthcare professional with well developed communication skills who has a good understanding of the particular treatment. Pharmacy staff are often well placed to provide such counselling.
For all patients
There are general points that apply to most oral anticancer medicines and should bec overed as a matter of course. Pharmacists should explain:
- The names of the medicines and their indications
- How the medicines should be taken (see Box 1)
- The arrangements for resupply, ie, from the hospital, GP, homecare, etc
- How the medicines should be stored, including the need to keep all medicines out of the reach of children
- Any handling or safety precautions — for example, cytotoxic drugs should not be handled by pregnant women
- Common side effects and how to manage them
- What to do in the event of a fever or other signs of infection
- What to do if the patient misses a dose or vomits shortly after the dose is taken (dose repetition is not usually advisable)
- Any drug or food interactions
- Any issues around fertility
- Where to obtain further information and who to contact if help or advice are required
Some counselling points for specific oral anticancer medicines are outlined below.
Capecitabine Capecitabine should betaken within 30 minutes of a meal.Capecitabine can cause coronary vasoconstriction, so patients should be advised to seek urgent medical attention if they experience chest pain. Common side effects include diarrhoea and palmar-plantar erythrodysesthesia (a hand and foot skin reaction, known as“hand-foot syndrome”). Patients should be advised to use skin emollients on theirhands and feet.
Erlotinib Erlotinib should be taken on an empty stomach, one hour before or two hours after food. It commonly causes diarrhoea, eye irritation and rash, and patients should seek medical advice if they experience such symptoms.
Erlotinib has several clinically significant drug interactions. Patients should be warned of the potential for drug interactions, especially if starting new medicines. Cigarette smoking can increase the metabolism of erlotinib, reducing patient exposure to the drug. Smokers should be advised to stop smoking and pharmacists should offer cessation support.
Etoposide Patients should be advised to take etoposide on an empty stomach. They should also be informed that around two thirds of patients will experience complete hair loss, usually within three to four weeks, but that it is reversible when therapy stops.
Fludarabine Patients who take fludarabine are at risk of transfusion-associated graft-versus-host disease. Therefore patients should be advised to inform all healthcare professionals treating them that they are taking the medicine, since any blood products they require should be irradiated before administration. Bone marrow suppression is common and can last up to four weeks after stopping therapy.
Gefitinib Patients should be instructed to avoid antacids two hours before and one hour after taking gefitinib because these can reduce bioavailability. Warn patients to report any suddenly worsening dyspnoea because this may be a sign of interstitial lung disease.
Lapatinib Lapatinib should be taken on an empty stomach — one hour before or one hour after food. Lapatinib is largely metabolised by cytochrome P450 3A4 ands o patients should be advised to avoid consumption of grapefruit juice. Rash and diarrhoea are common side effects.
Lenalidomide Because lenalidomide is structurally related to thalidomide there is a risk that it is teratogenic. Therefore, all patients must be enrolled in a “pregnancy prevention programme”. The risk of thrombosis is increased with lenalidomide so patients should be educated to report any signs of pulmonary embolism or deep vein thrombosis. Peripheral neuropathy and fatigue are common side effects.
Mitotane Mitotane tablets should be taken at the end of a high-fat meal. Patients should be advised that blood levels of the drug need to be monitored and the dose adjusted according to the results. Mitotane causes adrenal insufficiency so patients should receive corticosteroid replacement therapy. Mitotane should be stopped and advice sought in the case of shock, severe stress or trauma. Gynaecomastia is a common adverse effect in men.
Procarbazine Procarbazine is a mild monoamine oxidase inhibitor and so patients should be advised to avoid tyramine-rich food and drinks and be made aware of the potential for serious drug interactions.
Box1: Clear instructions for complex regimens
Many oral chemotherapy regimens are complex, so require a clear and thorough explanation.
One example is “CTD”, which is used for the treatment of multiple myeloma(ClinicalPharmacist2012;4:123). This regimen involves taking:
- Cyclophosphamide 500mg (10 x 50mg tablets) on days 1, 8 and 15
- Thalidomide 50–200mg every night
- Dexamethasone 40mg (20 x 2mg tablets) on days 1–4 and 12–15
Each cycle lasts for 21 days and patients usually have four to six cycles.When counselling patients about such regimens, pharmacists should state clearly how many tablets or capsules are to betaken, when this should occur and whether they should be taken with food or on an empty stomach. It can be useful to have the medicines present when counselling so that they can be used as a visual aids. This information should also be supplied for any supportive therapies.
Sorafenib Hand-foot skin reaction and rash are common with sorafenib treatment. Chest pain requires urgent medical attention because the use of sorafenib has been associated with cardiac events.Patients should be advised that their blood pressure will be monitored regularly because sorafenib can cause hypertension.Any unusual bleeding should be reported.
Sunitinib Sunitinib can cause hypertension, so pharmacists should explain the need for regular monitoring of blood pressure. Grapefruit juice should be avoided because sunitinib is metabolised byCYP3A4. Hand-foot skin reaction, fatigue, stomatitis and diarrhoea are common.Patients should be educated about the symptoms of hypothyroidism and asked to report such symptoms because they can be caused by sunitinib.
Temozolomide Temozolomide should betaken one hour before food. If a patient’s treatment regimen includes bothradiotherapy and temozolomide, the drugshould be taken one hour beforeradiotherapy. Common adverse effectsinclude loss of appetite, taste disturbancesand nausea.
Thalidomide Thalidomide can cause drowsiness so is usually taken at night. Patients should be made fully aware of the potential effects of thalidomide on an unborn child and all patients must be enrolled in the thalidomide “pregnancy prevention programme”. Women of childbearing potential must undergo monthly pregnancy tests, and sexually active females should use effective contraception for four weeks before, during and for four weeks after treatment. Men should use condoms because thalidomide passes into semen.
Thalidomide increases a patient’s risk of thrombosis and patients are often also prescribed a low molecular weight heparin.Patients should be advised to report immediately any signs that might indicate thromboembolism, peripheral neuropathy or Stevens-Johnson syndrome.
Vinorelbine Vinorelbine is taken once weekly, preferably with a light meal, and antiemetics are usually taken before a dose. Vinorelbine should not be taken with a hot drink because this will make the capsule dissolve too quickly. Pharmacists should explain to patients or carers how to open the blister pack containing vinorelbine, which has to be cut with scissors then the backing pealed off. The liquid contained within vinorelbine capsules is an irritant so patients should be told what to do if a capsule breaks. Oral vinorelbine can cause diarrhoea or constipation. Patients should be advised that peripheral neuropathy is a potential side effect of vinorelbine treatment (and can be a reason for dose reduction).
- National Patient Safety Agency. Risks of incorrect dosing of oral anti-cancer medicines. January 2008. www.nrls.npsa.nhs.uk/resources (accessed 22 February2012).
- Neilson E. Pharmacists can help patients take oral cancer drugs and stick with them. Pharmaceutical Journal 2010;284;632.
- Hartigan K. Patient education: the cornerstone of successful oral chemotherapy treatment. Clinical Journal of Oncology Nursing 2003; Supp 6:21–4.
- Wiffen P, Mitchell M, Snelling M, et al. Oxford handbook of clinical pharmacy. Oxford: Oxford University Press; 2007.