The prevalence of individuals living with cancer continues to rise, largely because of an aging and growing population along with advances in oncology care. More than 16.9 million US individuals with a history of cancer were alive on January 1, 2019.1 On January 21, 2020, the United States reported its first case of coronavirus disease 2019 (COVID-19).2 Especially hard hit were patients with cancer who depended on regular visits to their cancer centers for infusions, follow-up care, procedures, radiation, and other forms of oncology care. 

The increasing prevalence of oral oncolytics use, further accelerated by COVID-19, heightens the need for strong patient-pharmacist treatment coordination, especially as drug pipelines and patient preferences move away from intravenous (IV) drugs. Cancer is an exceedingly complex disease with complex treatments that require a care team with diverse roles and responsibilities. Specialty oncology pharmacists play a wide range of roles in meeting patient needs, including care coordination, insurance approval assistance, financial assistance for high out-of-pocket co-pays, drug interaction checks, patient education, and adverse effect monitoring. 

Making Adjustments to Provide Critical Care 
The oncology team at Partners HealthCare Specialty Pharmacy (PHSP) is now playing these critical patient care roles remotely. PHSP is an integrated specialty pharmacy servicing patients of Partners’ multiple academic centers. PHSP is located off campus from the cancer centers and comprises a care center and a fulfillment center. The transition to a work-from-home model was seamless for the oncology team at PHSP, with few changes to the daily workflow. The oncology pharmacists conduct all patient care interactions via the telephone or electronically. These include initial counseling and tolerability and adherence checks, as well as clinical reassessments. Delivery services from our fulfillment center provide oncology drugs to the patient. 

The patient’s electronic medical record (EMR) is integral to the provision of PHSP services. The EMR provides PHSP with the orders for oncology medications, which are e-prescribed to the final dispensing pharmacy based on patient preference, insurance requirements, and access to the drug. The EMR is largely used as a communication method among PHSP staff, patients, and providers. PHSP documents the progress of the prescription, including insurance approvals in the EMR. As COVID-19 presented itself and forced staff to quickly move and adapt to working in the safety of their homes, the resiliency of the PHSP model was demonstrated with minimal impact on operations and quality of services. 

Increasing Options With Oral Oncolytics 
PHSP has seen an increase in the volume of oral oncolytics prescribed since COVID- 19. If an oral form of an IV medication is available, as with etoposide, for instance, oncologists have been switching patients to the oral form. Multiple chemotherapy options with equal efficacy or ranking by the National Comprehensive Cancer Network (NCCN) guidelines are often available. Since the COVID-19 pandemic began, many oncologists and patients have preferred oral chemotherapy if available, as it is the safer option. Even among oral chemotherapy options, providers suggest oral chemotherapy with less immune suppression when discussing treatment options with their patients. 

Along with cisplatin, etoposide is an NCCN category I recommendation for the primary or adjuvant treatment of limited small cell lung cancer.3 Although cisplatin is dosed intravenously on day 1, etoposide is dosed on days 1, 2, and 3 of a 21-day cycle. As such, PHSP switched patients from IV etoposide on days 2 and 3 to oral etoposide on days 2 and 3. PHSP also uses the patient’s EMR to determine day 1 of the cycle to ensure timely delivery of the oral etoposide. Careful attention was given to the therapeutic interchange because the conversion is 1:2 from IV etoposide to oral etoposide. 

Another example of the impact of the COVID-19 pandemic on cancer care is the extended use of CDK4/6 inhibitors, which include abemaciclib (Verzenio), palbociclib (Ibrance), and ribociclib (Kisqali). In select patients with nonmetastatic breast cancer who refuse chemotherapy, CDK4/6 inhibitors may replace traditional neoadjuvant chemotherapy. Typically, once resectable, the patient proceeds to surgery. The COVID-19 pandemic has led to delays in surgeries, and as such, patients have remained on a CDK4/6 inhibitors longer. Out of fear, some patients refused to switch to chemotherapy upon signs of clinical progression, opting to remain on a CDK4/6 inhibitor longer. Some patients starting treatment with a CDK4/6 inhibitor for treatment of metastatic breast cancer, as well as providers, have preferred abemaciclib if appropriate because it is the least immunosuppressive agent compared with the other CDK4/6 inhibitors. 

Patients with cancer have a weakened immune system because of either their current cancer treatment or past treatment. To minimize patient visits to hospitals and clinics, the Partners cancer center established a weekly committee with the goal to move as many patient injections from in clinic to the patient’s home as expeditiously as possible. A home infusion nurse administers the injections. 

Partners cancer center requested PHSP support in this transition. PHSP expanded our services to include injectable agents that were commonly administered in the clinic, such as hormonal injections used to treat breast and prostate cancers. This required increased communication and coordination with the clinic staff to arrange home nursing services. PHSP worked quickly to support these efforts, allowing patients to receive their treatments uninterrupted and in the care of their own homes or local clinics, with greatly reduced exposure to COVID-19. 

A Possible New Normal 
The pandemic has demonstrated that today’s medical infrastructure largely supports remote clinical visits and reduced requirements for patients for in-person clinic visits. During the pandemic, patients quickly became accustomed to telemedicine, including videoconferences and telephone-only visits from the comfort of their own home. Patients were consented to treatments verbally, and the clinical staff quickly adopted standardized language to document verbal consents and the televisit. Could this be the new norm? Many patients drive to our centers from surrounding states, such as Maine and Vermont, often preparing as early as 4 am for the commute. Patients who were required to visit the hospital for labs, scans, or clinical visits that could not be deferred reported shorter clinic wait times. Telemedicine eliminates the commuting stress and reduces the exposure to potentially harmful pathogens that may lead to serious illness in these immunocompromised patients. 

The value of oral oncolytics and their importance to cancer treatment is on full display during this pandemic. Patients can receive treatment for their cancer with minimal disruption, avoiding hospital clinics to allow for home quarantine and thus minimizing their exposure to COVID-19. 

Conclusion 
COVID-19 and the resulting global pandemic led to a great disruption in cancer care. Patients were unable to return to Massachusetts for their cancer care follow-up visits, many were unable to take advantage of the public transportation to their cancer appointments or participate in clinical trials, biopsies and physical exams were deferred, and the trajectory of many patients’ cancer treatment was taken off course. Through it all, PHSP was able to increase its services to support the cancer center and patients’ needs while maintaining the quality of care and services that patients have come to expect and depend on. 

Partners HealthCare Specialty Pharmacy is a member of the Excelera Network, a nationwide network of leading US health systems with owned specialty pharmacies. For more information about Excelera, visit www.excelerarx.com. 
 
AMANDA MANOOGIAN, PHARMD, BCOP, is clinical manager, Specialty Pharmacy- Clinical Services at Partners HealthCare in Burlington, Massachusetts; CLAUDIA CASTRO, PHARMD, MS, BCOP, BCGP, is clinical oncology/hematology coordinator, Specialty Pharmacy - Clinical Services at Partners HealthCare. 


REFERENCES
  1. Miller KD, Nogueira L, Mariotto A, et al. Cancer treatment and survivorship statistics, 2019. CA Cancer J Clin. 2019;69(5):363-385. doi:10.3322/caac.21565
  2. Borresen J. What to expect if you are being tested for the coronavirus. USA Today. April 1, 2020. Accessed May 25, 2020. https://www.usatoday.com/in-depth/news/2020/04/01/coronavirus-testing-what-expect-if-youre-tested/5077039002/
  3. NCCN. Clinical Practice Guidelines in Oncology. Bone cancer, version 3. 2020. Accessed May 25, 2020. https://www.nccn.org/professionals/physician_gls/pdf/sclc.pdf