BOSTON -- Few of the safeguards routinely used for infusion chemotherapy have been adopted for oral chemotherapy at major U.S. cancer centers, according to an analysis.
BOSTON, Jan.12 -- Few of the safeguards routinely used for infusion chemotherapy have been adopted for oral chemotherapy at major U.S. cancer centers, found a 2005 analysis
In a survey of pharmacy directors at 42 of the 54 National Cancer Institute comprehensive cancer centers, safety practices for prescribing, coordinating, monitoring, and educating patients about oral chemotherapy, were scattershot and left considerable room for improvement, according to an online report in the Jan. 13 issue of the BMJ.
Although some common malignancies can be treated with oral medications, offering patients newly found convenience compared with infusion therapy, 23 of the centers had no required elements for oral chemotherapy prescriptions, said Saul Weingart, M.D., Ph.D., of the Center for Patient Safety at the Dana-Farber Cancer Institute here, and colleagues.
Yet given the potential toxicities of oral therapy, the investigators said that the findings of this study emphasize the importance of forging a consensus on standardized safeguards and practice for prescribing and monitoring the use of these drugs.
Surprisingly, Dr. Weingart and his colleagues said, few of the safeguards in routine use for infusion chemotherapy have been adopted for oral chemotherapy. Only one in three organizations required a clinician to note the surface area or calculation of dose on the prescription for six commonly used oral drugs and only one in four required a patient's diagnosis or protocol.
Only about half the institutions coordinated oral with intravenous chemotherapy, and most centers provided little infrastructure to support adherence to treatment.
Dr. Weingart's team focused on six non-hormonal oral agents with a risk of serious toxicity. The drugs included Xeloda (capecitabine), Cytoxan (cyclophosphamide), Iressa (gefitinib), Gleevec (imatinib), oral Rheumatrex (oral methotrexate), and Temodar (temozolomide).
The findings were as follows:
Thirty-four centers had an on-site pharmacy for patients receiving oral chemotherapy who were not on research protocols. Respondents estimated, however, that 38% of eligible patients did not use this facility.
Failure to use an on-site pharmacy may be problematic, as respondents at 17 centers rated communication between community pharmacies and cancer centers as fair or poor.
At most centers physicians shared responsibility with other health professionals for educating patients about oral chemotherapy.
On-site pharmacies and consultation with a pharmacist were widely available to patients, but both were underused.
Finally, the researchers reported that clinicians from various professions shared responsibility for educating patients about oral chemotherapy, but few centers provided clinicians with relevant formal training.
One in five organizations required a second clinician to double- check the prescription, and fewer than one in 10 required the clinician to record the treatment cycle.
Finally, half of the centers required no safeguards for prescription writing, the researchers said.
The study had several limitations, the investigators said. For example, the results may have overemphasized the perspective of pharmacy directors relative to other oncology clinicians. Similarly, respondents' evaluation of safety practices reflected their best- but potentially biased- judgments.
The oral agents considered here had significant toxicity risks, but the respondents may not have shared this definition. In addition, it may have been difficult for respondents to characterize medication practices in organization with practice patterns that varied across clinicians and treatment regimens.
In summary, the investigators wrote that despite clinicians' concern about oral chemotherapies, there is no apparent consensus among oncology professionals about safe practices for these drugs.
"Safeguards used for infusion chemotherapy cannot be abandoned for oral treatment. The oncology community must define safe medication practices appropriate for oral chemotherapy, develop practice guidelines, and accelerate their adoption," they concluded.