Consistent toxicity management and education reinforcement can improve the patient’s treatment management strategy.
Lisa M. Holle, PharmD, BCOP, FHOPA, FISOPP, Clinical Professor, University of Connecticut School of Pharmacy, Storrs, Connecticut, discusses treatment guidelines for metastatic renal cell carcinoma (mRCC) with Pharmacy Times at the Hematology/Oncology Annual Conference 2023 in Phoenix, Arizona.
PT Staff: How do you interpret current guidelines (and patient characteristics) when selecting a therapy for a patient with mRCC (metastatic renal cell carcinoma)?
Lisa M. Holle, PharmD, BCOP, FHOPA, FISOPP: Well, there are several guidelines within the United States and internationally for the treatment of mRCC. They have a variety of options that are available, some with more evidence to support them than others. But it really is important to think about the patient, their comorbidities, their medications, their social determinants of health (SDOHs), what their goals of care are, and take all of those things into consideration when selecting a therapy.
PT Staff:What are the most common toxicities associated with approved mRCC treatment options, and how do you approach creating a toxicity management strategy?
Lisa M. Holle, PharmD, BCOP, FHOPA, FISOPP: Alright, so the main 2 types of treatments that are used in mRCC are checkpoint inhibitors or immunotherapy. And as most folks know, immunotherapy can cause immune-related adverse events (AEs), so it can affect any organ of the body. We have, again, several guidelines to help us manage toxicity, but what's really important about that is that not all the immune-related AEs are included in the guidelines. And since they can happen at any point in the body, we need to really think about what's available in the literature and how we might be able to treat those with the other main group of agents that are used in mRCC, the vascular endothelial growth factor receptor (VEGF) receptor inhibitors also can cause a host of AEs. So they include things like high blood pressure, proteinuria, fatigue, gastrointestinal (GI) symptoms like nausea, diarrhea, mucositis, but also anorexia or a loss of appetite, hand-foot skin syndrome, wound-healing changes (or delays in wound healing). And all these side effects need to be managed appropriately. There are general guidelines that we've used to treat those side effects with the other therapies, and we can apply them to VEGF inhibitors, But it's really important to make sure that we are managing those patients and their toxicities.
PT Staff: So vascular endothelial growth factor (VEGF) receptor inhibitors can cause anorexia- how so?
Lisa M. Holle, PharmD, BCOP, FHOPA, FISOPP: Anorexia just means loss of appetite and not wanting to eat, which then often results in weight loss. And it's because these medications change the GI tract and some of the pathophysiology of it or how it works. Sometimes people lose taste, or they feel crummy, so they just don't feel like eating. It's all those thing’s kind of together.
PT Staff: Could there be a medication management strategy that is more universally applicable?
Lisa M. Holle, PharmD, BCOP, FHOPA, FISOPP: Well, that's an excellent question. So it's hard to make sort of a universal treatment plan, because each individual patient has a variety of characteristics that you have to take into consideration. And so it's really understanding where to find information, how to manage these patients, and then think about the individual patient and what will work for them. So what I do for 1 patient with the same side effect or toxicity would not be what I would do with another patient, because they may not be able to follow the directions we provide them, or they don't have the ability to communicate well with the healthcare team if they're having a toxicity and how it's being managed.
PT Staff: How can oncology pharmacists provide better patient education to improve treatment adherence?
Lisa M. Holle, PharmD, BCOP, FHOPA, FISOPP: So 1 of the things that improves outcomes with patient care is making sure that they understand the patient understands what you are, what information you're giving them that can help improve their side effects or manage their overall care. So education is something that is very important, but you also do have to understand that it needs to be reinforced over and over. Sometimes you can't just do it in the clinic. When you see the patient, it can be beneficial to follow up with them a telephone call and reiterate that information. Provide written information all depends on what and how the patient may respond best to the information that you're giving them.
PT Staff: What is a common misconception that patients with mRCC have about the role of clinical oncology pharmacy and pain management services?
Lisa M. Holle, PharmD, BCOP, FHOPA, FISOPP: A common misconception that patients have, especially if they haven't met their clinical oncology pharmacist yet, is that the pharmacist is someone that they see in a community pharmacy who gives them the prescription that their doctor wrote for them. But in fact, clinical oncology pharmacists, they actually can have many roles; a common role might be that they work with the healthcare team to help identify the most appropriate anti-cancer regimen for the patient and then manage that patient as they might be experiencing toxicity, [such as] how to take the medication the correct way and overall help with their care.