The Evolving Role of the Hematology/Oncology Pharmacist

As the treatment of hematologic conditions and cancer has evolved to include more personalized, targeted agents, the demand for comprehensive pharmacist services has risen. Oncology pharmacists engage in all aspects of cancer care, from preparing chemotherapy and related medications to answering patient and caregiver questions.

This month, three members of Emory University’s oncology pharmacy team describe the expanding role of the oncology pharmacist and the importance of ongoing patient education and communication.

Danielle Schlafer, PharmD, and Elyse Hall Panjic, PharmD, are hematology/oncology clinical pharmacy specialists at Emory University Hospital in Atlanta, Georgia. R. Donald Harvey, PharmD, is associate professor of hematology/medical oncology and pharmacology at Emory University School of Medicine and director of the Phase I Clinical Trials Section and Unit at the Winship Cancer Institute of Emory University.

What are the typical responsibilities of the hematology/oncology pharmacist?

Oncology pharmacists play a critical role in the provision of safe, effective treatment for patients in both ambulatory and inpatient environments. We work alongside the physician and other clinicians to provide optimal medication management.

An average day involves preparing chemotherapy orders and medications, as well as assessing patients for dose adjustments for organ dysfunction or toxicities. We also work with other members of a patient’s health-care team to ensure the patient is receiving comprehensive therapies for managing or mitigating any treatment-related adverse events (AEs; e.g., infection prophylaxis, venous thromboembolism prophylaxis, anti-emetic agents, and prevention of skeletal-related events).

We see many patients enrolled in clinical trials because many treatments are administered in the context of a blended clinical and research environment. To optimize patient care while maintaining protocol requirements, we assess patients for eligibility, assist with preparing clinical trial orders, evaluate patients’ organ function, and monitor other lab parameters.

Education and training (for ourselves, health-care providers, and patients) also fall under our purview.

What types of education efforts do hematology/oncology pharmacists engage in?

Our mandate is to ensure we are fully educated on new medications and their associated AEs, overall clinical use, and monitoring. With the relative flood of new anti-cancer agents in recent years, including targeted therapies and immune checkpoint inhibitors, it is challenging to stay current. We do so by reading primary literature, reviewing summaries from the U.S. Food and Drug Administration approval process, and attending professional conferences for hematology/oncology pharmacists to gather information relevant to new agents’ clinical use.

We provide education in clinics and hospitals and through formal mechanisms, such as lectures, Pharmacy and Therapeutics Committee meetings, journal clubs, and e-newsletters.

Patient education is a critical component of our day-to-day responsibilities, reflected by the amount of time we spend on it prior to new treatment initiation.

“Our numbers continue to grow, and, as more pharmacists graduate from specialty residency programs, we expect to see even higher numbers of us in clinics in disease-specific practices.”

In a typical day, how much time is spent interacting with patients?

Hematology/oncology pharmacists provide continuity of care for patients transitioning between inpatient and outpatient environments. This means we are often the main points of contact for patients – and caregivers – when they have questions about medications.

A member of our pharmacy team meets with every patient before he or she starts a new chemotherapy regimen to provide medication counseling. While patients are on treatment, we check in periodically during a clinic visit (or hospitalization for inpatient chemotherapy) to answer any new medication-related questions or provide recommendations for symptom management.

The conversation does not end after prescriptions are filled. We educate and counsel patients on chemotherapy and supportive-care medications both during their visit to the clinic or infusion center and after they head home. This entails reviewing home medications for potential drug-drug interactions, providing written materials detailing treatment regimens, and recommending options for nausea and pain management. We call patients to address questions or concerns that occur between appointments, and relay information to other health-care providers as necessary.

As one might expect, the most common questions concern side effects: How will I feel while I’m on this treatment? Are there any restrictions to my diet or activities? What should I do if a given side effect occurs? It is our goal to inform patients and their caregivers about treatment and how to manage potential side effects, while also conveying the importance of adhering to medications.

Myeloma regimens, as an example of one condition for which multiple drugs are given on differing schedules, can be particularly complex. To ensure that patients are prepared to follow these regimens, we work with our nursing colleagues to create treatment calendars as visual aids. We then discuss potential common and serious AEs, along with our game plan for managing them.

How has the introduction of newer, targeted therapies affected the oncology pharmacists’ responsibilities?

We know more information about cancer biology now than ever before, and we are finding more opportunities to specialize within cancer subtypes.

The new agents available in the clinic have more specificity. As a result, our training in specialties such as multiple myeloma is no longer relegated to specializing in hematopoietic cell transplantation. We have dedicated pharmacists in the areas of myeloma, lymphoma, and leukemia, and each is frequently called on by other clinicians.

Because of the recent advances in novel agents and combination therapies in myeloma (including the introduction of pomalidomide, elotuzumab, ixazomib, and daratumumab), along with an active clinical trial portfolio, we established a dedicated pharmacist who has updated treatment and education protocols, expanded patient counseling activities, and ensured all supportive care for agents and regimens are up-to-date.

We have also witnessed a greater acceptance of pharmacist input and independence. Our numbers continue to grow, and, as more pharmacists graduate from specialty residency programs, we expect to see even higher numbers of us in clinics in disease-specific practices.