The New Norm in Oncology Pharmacy

Directions in Pharmacy, November 2020, Volume 2, Issue 5

How has COVID-19 impacted our professional lives in providing care to patients with cancer, who are at even greater risk of contracting the virus and more likely to have higher morbidity and mortality should they be infected?

The outbreak of coronavirus disease 2019 (COVID-19) has had an impact on many aspects of life. First appearing in China in late 2019, the virus quickly spread throughout the world.

In mid-January I traveled to Finland, and in February, I was up and down the East Coast for business. I recall only a handful of people wearing masks in the airports and on the planes. My first reaction was to avoid these people, as they may be affected with some virus. Today, however, is it just the opposite. When we see an individual without a mask, we give them a wide berth.

How has COVID-19 impacted our professional lives in providing care to patients with cancer, who are at even greater risk of contracting the virus and more likely to have higher morbidity and mortality should they be infected?

Because of COVID-19 and its prevalence throughout the globe, patients undergoing cancer treatment have suffered great disruptions in their care. They are often unable to return to cancer centers to resume their program for a number of reasons. Often those individuals rely on public transportation that might have or has been suspended. Participants in clinical trials often are unable to continue to participate. Procedures such as biopsies or physical exams have been cancelled or rescheduled, resulting in great alterations in care and potential recovery.

Undiagnosed Patients

Our health care system relies greatly on routine cancer screenings to identify patients who may be at risk or have cancer. Routine visits to our physicians or annual checkups are key. Screenings and traditional office visits have declined steeply, and it is commonly known that since the start of the COVID-19 pandemic, there has been a significant reduction in cancer diagnoses.

I can speak from personal experience because I had my annual physical conducted over Zoom. Although I had my lab work done prior to my online physician visit, I missed out on a real exam. It was more of a check-in, feel-good visit but certainly not the same depth as being there in person. I am one of the lucky ones, as most individuals have skipped health care this year unless they are involved in a serious accident or fall ill.

People are avoiding hospitals whenever possible. When our authorities shut down many businesses due to COVID-19, people were advised to stay home, including avoiding health care settings to reduce their exposure to the virus. We were bombarded with the risks of getting the virus, and health care providers and patients both lacked adequate supplies of personal protective equipment (PPE). Health care providers were more focused on treating the acutely sick rather than those with chronic diseases or potentially undiagnosed cancers.

Quest Diagnostics, one of 2 national laboratories, reported that screenings for breast, cervical, and colon cancers dropped by approximately 90%, and the number of newly identified patients with any of the 6 major cancer types fell by 46%, including a 25% decrease for pancreatic cancer and a 52% decrease for breast cancer.

Changes in Oncology Practice

Through the current adversity, several guidelines have been changed or improved for the pharmaceutical care of the oncology patient. The first area of focus was to educate health care providers, patients, and their caregivers on hygiene and safety. Patients with cancer are at greater risk of contracting COVID- 19, and if they do, it is more likely to develop faster, be more severe, and often be fatal.

Pharmacists and staff should be well equipped with PPE including masks and gowns, both of which should be frequently changed. Disposable gloves must be immediately changed with each patient interaction. Additionally, the area where care is provided should be decontaminated frequently using the appropriate cleaning supplies. Barriers should be erected wherever possible and should be respected. Hands should be washed frequently and personal contact kept to a minimum. Any computer equipment such as keyboards, tablets, and smartphones should be regularly cleaned. When wearing protective goggles or a prescription lens, care should be given to sanitize regularly.

If an oncology patient is diagnosed with COVID- 19, they should continue to obtain medical care, and adjustments need to be made depending on the severity of their symptoms. Health care providers need to take even more significant measures to minimize their exposure.

Shift in Cancer Therapy to Orals or Home Infusion

The pharmaceutical industry has been hard at work in shifting infusion therapies to orals the past several years. Specialty pharmacists have been especially active in transitioning to oral equivalent therapies for patients who can use an oral therapy and do self-monitoring at home.

By using orals over intravenous (IV), patients can be treated at home instead of having to travel to an infusion clinic or hospital. With the advent of COVID-19, the volume of oral oncolytics prescribed has increased.

Our publication has worked closely with the National Comprehensive Cancer Network, which has many guidelines that often provide alternatives to IV therapy.

Unfortunately, not all cancer diagnoses with available IV therapy have oral alternatives. In many cases, however, clinics have been able to shift to home infusion so the drugs are administered in the relative safety of the patient’s own home—reducing the potential exposure to COVID-19 for all parties. Centers for Medicare & Medicaid Services (CMS) earlier in the year issued an interim final rule that allows for infused or injected Medicare Part B drugs to be administered at home. These services can be reimbursed by CMS if administered by a home health agency as long as a provider is present, including via telehealth.

The Shift to Telehealth

Consultations by oncology pharmacists contribute to the optimal management of a patient with cancer. To reduce the risk of a patient contracting COVID-19, there has been a dramatic shift to telephone consultations or teleconsultations. With wide access to technology, a positive shift has taken place. Based on that shift, our health care infrastructure can support many fundamental aspects of remote clinical visits, reducing the need for oncology patient exposure to in-person office visits.

Cancer care is serious business, and oncology patients and providers rapidly shifted to telemedicine, via videoconferencing, and telephone. Patients and their health care team can be found making these visits from the safely of their own home. Many specialty pharmacies and hubs have adapted to having the bulk of their staff connected to their colleagues and patients via technology. The pharmacy maintains a physical presence of staff for inventory management, dispensing, and logistics from the pharmacy location. This could very well be the new norm for our industry.

Another benefit of remote visits is increased productivity, as telemedicine eliminates the commuting stress and reduces the exposure to COVID-19 for health care providers and potentially immunocompromised patients.

Boards of health and pharmacy have adopted many emergency rules facilitating these shifts in care. 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 copays, drug-interaction checks, patient education, and adverse effect monitoring.

The New Norm Post—COVID-19

Adversity has forced oncology pharmacists to shift their behaviors and practices, and many of these changes have been well received by the health care community. Patients have adapted, and data show they are generally satisfied with telemedicine. I anticipate that telemedicine will become an entrenched part of health care in the future.

As a society, we are very connected to our smartphones, social media, iPads, and laptops. Talking to friends and family using Skype and Messenger already was commonplace. Those in business have been entrenched in conference calls for years. It only stands to reason that a shift to leveraging technology would work, particularly in pharmacy.

Specialty pharmacy has been using technology since its inception. Now oncology pharmacy is filling gaps in care during this time of ongoing crisis, working with patients remotely, and in many cases, even more effectively than before. Given pharmacy services are primarily reimbursed based on product dispensing, our next challenge is provider status. Nondispensing activity should be reimbursed, as is the case with other providers.

Dan Steiber, RPh, operates Genesis Pharma Consultants, a consulting practice responsible for commercial operations and trade-supply chain strategy development. Steiber has served in several senior positions in pharmacy, distribution, and industry over the course of his 40- year career. Steiber is a licensed pharmacist in Texas, Washington, California, and Pennsylvania. He is affiliated with several professional associations and publications and a frequent speaker on behalf of many professional organizations. Steiber graduated from Washington State University College of Pharmacy. He has participated in a variety of postgraduate programs in law and business development/marketing at Harvard University and Northwestern University.