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 TEDMED 2012 Feature Presentation

 Pharmacodynamic Elegance: Combination of BRAF and MEK Inhibitors

Greetings!

I just re-read what I wrote in last year's Summer e-newsletter, and unfortunately weather was on my mind then, as it is now, and for the same reason - it is raining in Calgary and has stopped for just a moment in Vancouver, but it is blistering hot out East. If anything, our chatter about weather unites us from coast to coast!

From a very busy spring into a very busy fall, I hope you are enjoying your summer. This e-newsletter provides you mainly with news from our travel grant winners, but we also get introduced to Kim Hugel, who is now a member of the Communications Committee, in our 'Member Spotlight' and to C17 in our 'Get to Know' section, and President Jennifer Jupp provides a great update on what CAPhO and certain members are up to.

Behind the scenes, the Communications Committee has been busy. Stay tuned - as the summer draws to a close, we will be announcing a contest that will increase member interaction. We are also slowly building up CAPhO's social media presence on platforms such as Facebook and Twitter. While we realize these sites are often not allowed to be used during work hours, they are another way to keep up with CAPhO happenings. Perhaps more importantly, they serve to promote CAPhO to other organizations, associations and individuals. For instance, take a look at who is already following us on Twitter. Give us a "like" on Facebook and "follow" on Twitter!

If you have any questions about the association, its past activities and its future endeavours, contact me or one of the Executive members and we will be happy to respond.

 

Sincerely,

Christopher Ralph
Communications Committee Chair
communications@capho.org

Roxanne Dobish has accepted the position of Membership Chair. Her three-year term will start at the 2012 AGM held during NOPS 2012 in Saskatoon. Roxanne has over twenty-four years of experience working in complex healthcare environments, and specializes in patient and medication safety, healthcare management and oncology pharmacy. She is employed by Alberta Health Services as the Pharmacy Manager for the Cancer Network in Alberta, based out of Edmonton. CAPhO looks forward to working with Roxanne to continually engage our membership in all of CAPhO's current and future endeavours.

Ing Collins, Pharmacist, Juravinski Cancer Centre, Hamilton, Ontario

Similar to the National Oncology Pharmacy Symposium (NOPS), the Hematology/Oncology Pharmacy Association (HOPA)'s 8th Annual Conference was jam packed with scheduled educational events of lectures, poster sessions and symposia. Surprisingly, there was even a yoga event to raise funds for the HOPA foundation which sponsored the "Give Hope Foundation." The latter is a non-profit organization that provides support to children and families in Central Florida who are battling childhood cancer.

In addition to educational updates on cancer treatments, the conference presented on many issues that concern our American counterparts which are similar to what we are facing in Canada. Three prominent themes were drug shortages, drug coverage or reimbursement issues and the management of toxicities from oral chemotherapeutic drugs.

A discussion panel of three pharmacist speakers addressed the issue of drug shortage from different perspectives. One speaker provided the statistics that in 2011, there were 267 drugs on the short list of which 26 were chemotherapeutic drugs. So far, in 2012, there is already greater than 267 drugs on this list. It is not just the chemotherapeutic agents that are in short supply but many others including opiates. This was a very hot topic that drew much participation from the audience. Many questions were directed to the pharmacist from the FDA about how FDA is handling and planning to resolve this shortage. A twist as result of this topic that I did not think of was how the drug shortage may affect the consent process for treatment. Many talked about incorporating a statement about this issue in the consent. Others warn the physicians in advance, so that alternatives can be found. The pharmacists were told to avoid hoarding so that the supply can be stretched to accommodate the demands. The clinical manager spoke of increasing labour costs as well. Staff is being re-deployed or resources are added to address the drug shortages by re-doing treatment plans or order sets; and the manager, herself is also occupied dealing with the supply issues. Usage reports are being generated in an attempt to project how long the current inventory will last. Does this sound familiar to you?

The drug coverage or reimbursement practices were a bit foreign to me as the American system is different than that of ours in Canada. However, the bottom line is still the same: how do we seek financial support or funding to cover the increasing cost of chemotherapy agents in this age of targeted therapies or personalized medicine.

The theme of oral chemotherapy toxicity management was reflected in many of the educational lectures and in the posters posted by the pharmacy residents. Often clinics were set up by pharmacists / pharmacy residents to manage patients on oral chemotherapy. Initially, these were pilot projects that were tried and were found to be very much successful. However, sustainability by pharmacists is a big question. How much workload can a pharmacist do as call back programs are labour intensive and require a fine tuned scheduling of calls to patients? How can pharmacists collaborate with other health care professionals to manage this practice? I even met a pharmacist from a Walgreens pharmacy (an American retail pharmacy chain) who was sent to the conference seeking education on this topic. It is definitely an area of concern for both hospital and retail pharmacists. Likewise, at our cancer centre and I am sure yours as well, this is a common issue that we are all trying to manage. Currently, we are at the initial stage of looking into the logistics of pharmacist-managed program. Ideas from this conference can be used as a jump start to our own practice at the centre.

I sat in at the HOPA annual members meeting facilitated by the president of the association, Donald Harvey III. He listed the organization's achievements from the previous year. They were aimed to align with their strategic plan to support pharmacy practitioners and promote and advance the profession which are not unlike that of the CAPhO organization. I was also quite impressed with their high profiling.  Here are some highlights: 

• Oncology Boot Camp was added for the first time in this year's agenda for pharmacist new to the field or for those who would like a refresher. Unfortunately, due to time conflicts I could not take advantage of this opportunity.
• The organization is also in the midst of developing a comprehensive scope of practice document. Similarly, CAPhO has developed a set of standards of practice in Canada.
• I was quite impressed that the HOPA organization not only embarked on advocacy for pharmacy with those outside of the profession, but  they have hired and are partnered with an advocacy company to lobby on the behalf of the organization on Capitol Hill.
• The HOPA organization also has other external collaboration activities. For an example, HOPA contributed to ASCO (American Society of Clinical Oncology) on the topic of REMS (Risk and Evaluation Mitigation Strategies which are programs assigned to ensure that drugs with a specific toxicity are utilized properly), and they were one of the stakeholders that presented to the FDA on the topic of drug shortages.   

Donald spoke of more than 1900 members in the HOPA organization and that their membership is increasing by 10% annually. Their annual operational budget is around $2 million dollars.  WOW!

Another notable impression was Susan Goodin's acceptance speech of the award of HOPA excellence. She quoted from Albert Einstein that in middle of difficulties, opportunities arise. She spoke about the changes to the pharmacists' role in order to provide the best care for the patients. Her motto was Service above Self which are worthy words to live by in spite of the daily challenges that we all faced at work. In addition, she encouraged all pharmacists to become more involved in research opportunities within their practice and to educate the patients about the importance of research as one of the options of cancer treatments. It is through research that standard of care treatments are found. How inspirational!

I would like to end by thanking the CAPhO organization and the Awards Committee for initiating a HOPA Conference Travel Grant this year. I would also like to express my gratitude to the Awards Committee for generously awarding me this grant. I have found the experience to be very insightful and a great oncology educational opportunity. I would encourage all eligible members to apply for next year's travel grant.  The 9th annual HOPA conference will take place in Los Angeles, California from March 20 to 23, 2013. 

Crystal Amos, Pharmacy Professional Practice Leader, BC Cancer Agency, Vancouver, BC

There was a general theme of safety at the thirteenth International Society of Oncology Pharmacy Practitioners (ISOPP) Conference this year in Melbourne, Australia. Not only was patient safety a focus, but also occupational safety. Many lectures described the hazardous nature of oncology drugs, and how our manufacturing and delivery processes could be improved. In fact one lecture described how our processes may be causing an increased exposure of hazardous drugs. The results of a study were described which showed that after manufacturing hazardous drugs in an isolator, wipe samples revealed chemotherapy residue on the outside of syringes and bags that were dispensed to nursing staff. Interestingly, the effect was more pronounced with colourless chemotherapy agents such as 5-Fluorouracil as compared to red-coloured Epirubicin. It is hypothesized that it is because the red colour of the Epirubicin enabled the technician to see droplets or residue on the outside of the bag or syringe more easily and therefore would wipe it clean prior to dispensing. The results of this study demonstrate another reason why implementation of a Closed Drug Transfer System helps improve occupational safety.

Another topic discussed related to safety is the importance of utilizing human factors principles in healthcare. A lecture provided by Rachel White of the University Health Network team provided some important guidelines to use when considering ways to improve safety within our workplaces.

Human factors looks at the way people interact physically and psychologically with devices and processes. This becomes important when considering the purchase of a new device, implementing a process, or understanding how to improve a process to reduce the incidence of errors.

There are many factors that can lead to an error, and some human factors principles can shed light on why certain errors occur. For example, inattentional blindness leads a person to miss something that is plainly obvious because his/her attention is focused on something else. As a human, our attentional resources are finite, and focusing so closely on one task can lead us to miss something that is obviously right in front of our eyes, such as an error.

There are other human limitations that can lead us to make an error, such as cognitive biases. These lead us to make short-cuts in our decision making. For example, confirmation bias occurs when our brain favours information that confirms our beliefs or expectations of what we are expecting to see. This type of error occurs with look-alike sound-alike drug names, when an unfamiliar drug is read as a more familiar one. Or an unfamiliar vial size and colour is chosen as a more familiar one.

A framing effect is our tendency to draw conclusions in a situation depending on how a situation is presented to us. This type of bias is often seen when presenting study results. Drug companies often report the relative risk of study results because they often "appear" to be more favourable, rather than the absolute risk. Relative risk compares the risk between two groups (e.g. treatment vs placebo), however absolute risk describes the magnitude of risk (in comparison to your risk of dying, for example) and is often considered to be more clinically meaningful. (#1)

These are a few examples of how human factors can influence behaviours in healthcare. Considering these factors when implementing processes or choosing a medical device can greatly affect the success of that endeavour. Rachel White encourages healthcare professionals to learn more about human factors and to utilize them to improve safety in our workplaces. (#2, #3)

1. Malenka, DJ, Baron JA, Johansen S, et al. The Framing Effect of Relative and Absolute Risk. J Gen Intern Med 1993;8:543.

2. Vicente, K. The Human Factor: Revolutionizing the Way We Live with Technology. Publisher: Vintage Canada, July 2004.

3. Sessink PJM, White RE, Easty AC, et al. Safety Considerations in Oncology Pharmacy. Publisher: PPM (www.ppme.eu), Fall 2011

The needs of our patients should be a top priority within our oncology pharmacy practice. We chose the theme of "Patients First!" for NOPS 2012 to reflect our responsibility of providing patient centered care. Our patients want us to be competent providers of cancer care and an important foundation of our NOPS meetings has always been about presenting current cancer treatment information, partnered with how we provide oncology pharmacy services in a safe and efficient manner. This year, a number of presentations will focus directly on our patients - their desire for safe care, their thoughts on the ever changing landscape of drug review and access, their transition between oncology specialists and their primary care providers, and their need for effective communication. It is our hope that you enjoy NOPS 2012 in Saskatoon and come away energized, educated and re-focused on what is most important - our patients.