Is there a place for cancer therapy provided from community pharmacy?

New guidance, “A report on the dispensing and supply of oral chemotherapy and systemic anticancer medicines in primary care”, published last week spells out a new role for pharmacists in this specialist area (PJ, 29 January 2011, p89). It has been developed as part of collaborative work between the NHS, pharmaceutical professional bodies and special interest groups.

But, as the document lands on the desks of NHS service commissioners and providers for consideration, it will become apparent that the case for involving community pharmacists is not clear cut. 

Summing up the challenge, associate director of the National Cancer Action Team Jane Whittome says: “We need to recognise that oral chemotherapy can be as dangerous as intravenous therapy, and wherever oral chemotherapy is delivered, the safety of patients has to be paramount.”

For the author of the report, Steve Williamson, consultant pharmacist in cancer services, Northumbria Healthcare/North of England Cancer Network, the publication of his report is timely; less than a month ago, the Department of Health published its revised Cancer Reform Strategy (CRS), which has spelt out the need for cost-effective and patient-centred services to be established at every stage of the cancer journey, from prevention and earlier detection, to treatment and end-of-life care. 

Noting the NHS’s current focus on extending choice for patients and cutting bureaucracy, Mr Williamson’s report concludes: “Extending the choice of chemotherapy service providers from secondary care to include community service providers builds upon previous NHS initiatives.”

On the agenda

Community pharmacy’s role in the delivery of systemic anticancer therapy has been openly on the Government’s agenda for pharmacy since at least 2008, when the White Paper “Pharmacy in England building on strengths — delivering the future” concluded that “oral chemotherapy … dispensed in the community … saves patients’ time, is more convenient for those who may have difficulty getting to their clinic and enables patients to have easier control of their therapy”.

This then suggests that “with very careful prescribing, dispensing, administering and monitoring, it is possible within a multidisciplinary clinical network for oral chemotherapy to be safely dispensed in the community”.

No easy win

But, as Mr Williamson’s report and articles published on the subject make clear, safe and effective service development in this area is no easy win. In an article published in the European Journal of Oncology Pharmacy (2008;2:29–32), the authors (including community pharmacist Jackie Lewis, of Lewis Pharmacy in Exmouth) conclude that there are at least 10 issues that community pharmacists and their contract negotiators will have to address: 

• Patient numbers per locality
• The pharmacist’s competence in chemotherapy regimens
• Availability of the drug
• Origin of the prescription — according to NFP Synergy research, only 8 per cent of GPs specialise or have a particular interest in cancer
• Requirement for shared care documentation 
• Training
• Continuity of community pharmacy workforce
• Handling and disposal of cytotoxic drugs and associated waste
• Out-of-hours support
• Remuneration

For its part, the Pharmaceutical Services Negotiating Committee sees the impact of such service delivery on the average community pharmacy as a key area to address. Among its early concerns are that any contract for the delivery of oral chemotherapy should be sufficiently flexible to allow for some services to be delivered by all pharmacies, as an essential service, and others by only some pharmacies, via a local enhanced service.

However, despite concerns, head of pharmacy practice Barbara Parsons says the PSNC has been and remains keen to see pharmacies involved in this area of care. She says: “Getting pharmacies integrated in cancer care pathways will give us a better feel for what pharmacies can and can’t do.”

Chemotherapy delivered closer to home has also been endorsed by the 2009 report of the National Chemotherapy Advisory Group, “Chemotherapy services in England: ensuring quality and safety”.

This recommends that: 

• Cancer Networks should consider whether there are further opportunities to devolve chemotherapy delivery from cancer centres to cancer units (or closer to home) while still maintaining safety and quality. 
• Service commissioners monitor the proportion of treatment cycles given at a cancer centre, cancer unit or closer to home, and the introduction and expansion of nurse-led and pharmacist-led chemotherapy. 

Welcomed by the Department of Health, the recommendations will be considered for inclusion in the draft chemotherapy measures for the “Manual for cancer services”, which is open for consultation until 10 February 2011.

Mrs Whittome comments: “The use of chemotherapy and other systemic agents for cancer is rapidly changing — treatment is improving steadily, the rate of introduction of new drugs is accelerating and the number of patients benefiting from such treatments is increasing; patients are increasingly being treated in settings closer to and including home.

“Our hope is that the  report and its recommendations will allow services to develop in a safe way.”

Box 1 gives examples of oral anticancer therapies currently available in the UK. Conditions covered by these drugs include chronic myeloid leukaemia, breast, colorectal, lung, renal, liver and upper gastrointestinal cancers, myelomas, lymphomas, gliomas and adrenocortical carcinoma.

Use of chemotherapy agents in the home will also be buoyed by the recent increase in VAT, and the current VAT provision that drugs dispensed for administration in patients’ own homes (or residential homes) are zero-rated.

(Secondary care pharmacies currently pay VAT on oral anticancer medicines. Oral anticancer medicines dispensed by community pharmacists are not subject to the same VAT.) 

Since drug costs for care in this field can run into tens of thousands of pounds delivery via this route is likely to accrue substantial savings and appeal to the quality, innovation, productivity and prevention agenda, says Mr Williamson.

Other views

Grass-roots pharmacists, as well as recipient patients, are likely to have their own opinions on a more developed role for community pharmacies in oral chemotherapy. Starting with pharmacists, views were polled during the creation of the oral chemotherapy report and Mr Williamson admits that although there was enthusiasm, reservations were expressed about the prospect of additional involvement or the need for additional training.

He says: “I accept that some pharmacists will think twice about this work when they see what is involved and particularly the likely low volume of patients for whom this care delivery route is both suitable and acceptable. Some may be keen simply to develop their role in early detection.”

Work continues on detection and screening roles for community pharmacists (see Box 2).

Patients might have reservations as well. In a survey proposing a home chemotherapy offer to patients only 50 per cent of patients said they wanted to take up the option, preferring instead the reassurance of hospital, and the high level and continuity of care available in hospitals. 

Mr Williamson thinks that the likelihood is that a community pharmacy based service will prove most desirable in areas where there are supporting reasons, such rurality, or a population of patients who are stable and on maintenance therapy, and for whom cancer can be treated like a long-term condition.

Speaking on behalf of cancer patients, Ciarán Devane, chief executive at Macmillan Cancer Support, says that the theme of patient-centred care, which runs through both Mr Williamson’s report and the CRS review, is to be welcomed. 

Responding to the CRS review, he said: “We welcome the strategy’s detail and commitment to improving early diagnosis and aftercare services for cancer patients. This should lead to cancer patients feeling less abandoned after treatment. Instead they are more likely to cope with their diagnosis, to manage the long-term effects of cancer and to get their lives back on track. That is all good news.”