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Brokaar EJ, Visser LE, van den Bos F, Portielje JEA. Medication optimization in older adults with advanced cancer and a limited life expectancy: A prospective observational study. J Geriatr Oncol 2023; 14:101606. [PMID: 37603957 DOI: 10.1016/j.jgo.2023.101606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 07/14/2023] [Accepted: 08/14/2023] [Indexed: 08/23/2023]
Abstract
INTRODUCTION Polypharmacy is common in older adults with cancer and is associated with drug related problems (DRPs) and potentially inappropriate medication (PIM). We introduced a medication optimization care pathway for older adults with advanced cancer and a limited life expectancy and studied the prevalence of DRPs and PIMs as well as the adherence to medication-related recommendations and the patient satisfaction. MATERIALS AND METHODS A medication review was performed in patients aged ≥65 years with polypharmacy and a life expectancy of <24 months. Recommendations on adjustments of medication were discussed in a multidisciplinary team including a pharmacist, an oncologist, and a geriatrician. Implementation of the recommendations was left to the discretion of the oncologist. Four weeks after the implementation, the patient filled a questionnaire to assess satisfaction. RESULTS One hundred twenty patients were included. The mean age was 75 years and 39% were female. A mean of 12 medications was used. The median number of DRP was 6.0 per patient and median number of PIMs was 3.0 per patient. Overtreatment accounted for 26% of DRP and the most frequently involved drug classes were antihypertensive medication (22%), non-opioid analgesics (22%), and antilipemics (12%). The multidisciplinary team accepted 78% of the recommendations of the pharmacist and the oncologist implemented 54% of the recommendations. Overall, patients were satisfied or very satisfied with the intervention. DISCUSSION DRPs and PIMs are highly prevalent in this population and can be reduced by a multidisciplinary medication optimization intervention. Patients appreciate the medication optimization intervention and are satisfied with the intervention.
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Affiliation(s)
- Edwin J Brokaar
- Department of Pharmacy, Haga Teaching Hospital, PO Box 40551, 2504 LN The Hague, the Netherlands.
| | - Loes E Visser
- Department of Pharmacy, Haga Teaching Hospital, PO Box 40551, 2504 LN The Hague, the Netherlands; Department of Hospital Pharmacy, Erasmus Medical Center, PO Box 2040, 3000 CA Rotterdam, the Netherlands; Department of Epidemiology, Erasmus Medical Center, PO Box 2040, 3000 CA Rotterdam, the Netherlands.
| | - Frederiek van den Bos
- Department of Gerontology & Geriatrics, University Medical Center Leiden, PO Box 9600, 2300 RC Leiden, the Netherlands.
| | - Johanneke E A Portielje
- Department of Internal Medicine - Medical Oncology, University Medical Center Leiden, PO Box 9600, 2300 RC Leiden, the Netherlands.
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Strassl I, Windhager A, Machherndl-Spandl S, Buxhofer-Ausch V, Stiefel O, Weltermann A. TOP-PIC: a new tool to optimize pharmacotherapy and reduce polypharmacy in patients with incurable cancer. J Cancer Res Clin Oncol 2023; 149:7113-7123. [PMID: 36877279 PMCID: PMC10374723 DOI: 10.1007/s00432-023-04671-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 02/26/2023] [Indexed: 03/07/2023]
Abstract
PURPOSE Polypharmacy is a significant problem in patients with incurable cancer and a method to optimize pharmacotherapy in this patient group is lacking. Therefore, a drug optimization tool was developed and tested in a pilot test. METHODS A multidisciplinary team of health professionals developed a "Tool to Optimize Pharmacotherapy in Patients with Incurable Cancer" (TOP-PIC) for patients with a limited life expectancy. The tool consists of five sequential steps to optimize medications, including medication history, screening for medication appropriateness and drug interactions, a benefit-risk assessment using the TOP-PIC Disease-based list, and shared decision-making with the patient. For pilot testing of the tool, 8 patient cases with polypharmacy were analyzed by 11 oncologists before and after training with the TOP-PIC tool. RESULTS TOP-PIC was considered helpful by all oncologists during the pilot test. The median additional time required to administer the tool was 2 min per patient (P < 0.001). For 17.4% of all medications, different decisions were made by using TOP-PIC. Among possible treatment decisions (discontinuation, reduction, increase, replacement, or addition of a drug), discontinuation of medications was the most common. Without TOP-PIC, physicians were uncertain in 9.3% of medication changes, compared with only 4.8% after using TOP-PIC (P = 0.001). The TOP-PIC Disease-based list was considered helpful by 94.5% of oncologists. CONCLUSIONS TOP-PIC provides a detailed, disease-based benefit-risk assessment with recommendations specific for cancer patients with limited life expectancy. Based on the results of the pilot study, the tool seems practicable for day-to-day clinical decision-making and provides evidence-based facts to optimize pharmacotherapy.
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Affiliation(s)
- Irene Strassl
- Division of Hematology With Stem Cell Transplantation, Hemostaseology and Medical Oncology, Department of Internal Medicine I, Ordensklinikum Linz, Fadingerstrasse 1, 4020 Linz and Seilerstätte 4, 4010, Linz, Austria.
- Doctoral Programme MedUni Vienna, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria.
- Medical Faculty, Johannes Kepler University Linz, Altenberger Strasse 69, 4040, Linz, Austria.
| | - Armin Windhager
- Department of Cardiology and Intensive Care Medicine, Kepler University Hospital Linz, Krankenhausstrasse 9, 4021, Linz, Austria
| | - Sigrid Machherndl-Spandl
- Division of Hematology With Stem Cell Transplantation, Hemostaseology and Medical Oncology, Department of Internal Medicine I, Ordensklinikum Linz, Fadingerstrasse 1, 4020 Linz and Seilerstätte 4, 4010, Linz, Austria
- Medical Faculty, Johannes Kepler University Linz, Altenberger Strasse 69, 4040, Linz, Austria
| | - Veronika Buxhofer-Ausch
- Division of Hematology With Stem Cell Transplantation, Hemostaseology and Medical Oncology, Department of Internal Medicine I, Ordensklinikum Linz, Fadingerstrasse 1, 4020 Linz and Seilerstätte 4, 4010, Linz, Austria
- Medical Faculty, Johannes Kepler University Linz, Altenberger Strasse 69, 4040, Linz, Austria
| | - Olga Stiefel
- Division of Hematology With Stem Cell Transplantation, Hemostaseology and Medical Oncology, Department of Internal Medicine I, Ordensklinikum Linz, Fadingerstrasse 1, 4020 Linz and Seilerstätte 4, 4010, Linz, Austria
- Medical Faculty, Johannes Kepler University Linz, Altenberger Strasse 69, 4040, Linz, Austria
| | - Ansgar Weltermann
- Division of Hematology With Stem Cell Transplantation, Hemostaseology and Medical Oncology, Department of Internal Medicine I, Ordensklinikum Linz, Fadingerstrasse 1, 4020 Linz and Seilerstätte 4, 4010, Linz, Austria
- Medical Faculty, Johannes Kepler University Linz, Altenberger Strasse 69, 4040, Linz, Austria
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Brotzman LE, Zikmund-Fisher BJ. Perceived Barriers Among Clinicians and Older Adults Aged 65 and Older Regarding Use of Life Expectancy to Inform Cancer Screening: A Narrative Review and Comparison. Med Care Res Rev 2023; 80:372-385. [PMID: 36800914 DOI: 10.1177/10775587231153269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Abstract
While cancer screening guidelines increasingly recommend incorporating life expectancy estimates to inform screening decisions for older adults, little is known about how this happens in practice. This review summarizes current knowledge about primary care clinician and older adult (65+) perspectives about use of life expectancy to guide cancer screening decisions. Clinicians report operational barriers, uncertainty, and hesitation around use of life expectancy in screening decisions. They recognize it may help them more accurately weigh benefits and harms but are unsure how to estimate life expectancy for individual patients. Older adults face conceptual barriers and are generally unconvinced of the benefits of considering their life expectancy when making screening decisions. Life expectancy will always be a difficult topic for clinicians and patients, but there are advantages to incorporating it in cancer screening decisions. We highlight key takeaways from both clinician and older adult perspectives to guide future research.
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Whitman A, Fitch E, Nightingale G. The role of oncology pharmacists and comprehensive medication reconciliation in informing treatment plans for older adults with cancer and downstream outcomes. Curr Opin Support Palliat Care 2023; 17:3-7. [PMID: 36695863 DOI: 10.1097/spc.0000000000000634] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
PURPOSE OF REVIEW Proper medication management is an essential part of older adult cancer care. An aging population, an increase in anticancer treatment options, and high rates of comorbid conditions make navigating general medication reconciliation complicated. This review will highlight the recent literature describing the roles of the oncology pharmacist in caring for older adults with cancer. RECENT FINDINGS The body of literature highlighting oncology pharmacist roles in this population is mainly focused on polypharmacy and potentially inappropriate medication assessments, deprescribing nonessential therapies, drug-drug interaction reviews, and immunization optimization. Outcomes associated with oncology pharmacist interventions are still lacking as well as the development of benchmarks for appropriate pharmacy-based care in the older adult oncology population. SUMMARY Oncology pharmacist interventions in older adults with cancer have the potential to improve patient care. Future randomized studies in this area of practice are warranted in order to clearly define the optimal impact of oncology pharmacists.
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Affiliation(s)
- Andrew Whitman
- Department of Pharmacy Services, University of Virginia Health, Charlottesville, Virginia
| | - Emily Fitch
- Virginia Commonwealth University School of Pharmacy, Richmond, Virginia
| | - Ginah Nightingale
- Department of Pharmacy Practice, Jefferson College of Pharmacy, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Zeng J, Wu H, Huang Q, Li J, Yu Z, Zhong Z. Dihydropyrimidine dehydrogenase (DPYD) gene c.1627A>G A/G and G/G genotypes are risk factors for lymph node metastasis and distant metastasis of colorectal cancer. J Clin Lab Anal 2021; 35:e24023. [PMID: 34612540 PMCID: PMC8605172 DOI: 10.1002/jcla.24023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 09/07/2021] [Accepted: 09/13/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Dihydropyrimidine dehydrogenase (DPD) acts as the key enzyme catabolizing pyrimidines, and may affect the tumor progression. DPYD gene mutations affect DPD activity. The relationship between DPYD IVS14+1G>A, c.1627A>G, c.85T>C and lymph node metastasis (LNM) and distant metastasis (DM) of colorectal cancer (CRC) was investigated. METHODS A total of 537 CRC patients were enrolled in this study. DPYD polymorphisms were analyzed by polymerase chain reaction (PCR)-Sanger sequencing. The relationship between DPYD genotypes and clinical features of patients, metastasis of CRC was analyzed. RESULTS About DPYD c.1627A>G, A/A (57.7%) was the most common genotype, followed by A/G (35.6%), G/G (6.7%) genotypes. In c.85T>C, T/T, T/C, and C/C genotypes are accounted for 83.6%, 16.0%, and 0.4%, respectively. Logistic regression analysis revealed that DPYD c.1627A>G A/G and G/G genotypes in the dominant model (A/G + G/G vs. A/A) were significant risk factors for the LNM (p = 0.029, OR 1.506, 95% CI = 1.048-2.165) and DM (p = 0.039, OR 1.588, 95% CI = 1.041-2.423) of CRC. In addition, DPYD c.1627A>G polymorphism was more common in patients with abnormal serum carcinoembryonic antigen (CEA) (>5 ng/ml) (p = 0.003) or carbohydrate antigen 24-2 (CA24-2) (>20 U/ml) level (p = 0.015). CONCLUSIONS The results suggested that DPYD c.1627A>G A/G, G/G genotypes are associated with increased risk of LNM and DM of CRC.
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Affiliation(s)
- Juanzi Zeng
- Department of OncologyMeizhou People’s Hospital (Huangtang Hospital)Meizhou Academy of Medical SciencesMeizhouChina
- Guangdong Provincial Key Laboratory of Precision Medicine and Clinical Translational Research of Hakka PopulationMeizhou People’s Hospital (Huangtang Hospital)Meizhou Academy of Medical SciencesMeizhouChina
| | - Heming Wu
- Guangdong Provincial Key Laboratory of Precision Medicine and Clinical Translational Research of Hakka PopulationMeizhou People’s Hospital (Huangtang Hospital)Meizhou Academy of Medical SciencesMeizhouChina
- Center for Precision MedicineMeizhou People’s Hospital (Huangtang Hospital)Meizhou Academy of Medical SciencesMeizhouChina
| | - Qingyan Huang
- Guangdong Provincial Key Laboratory of Precision Medicine and Clinical Translational Research of Hakka PopulationMeizhou People’s Hospital (Huangtang Hospital)Meizhou Academy of Medical SciencesMeizhouChina
- Center for Precision MedicineMeizhou People’s Hospital (Huangtang Hospital)Meizhou Academy of Medical SciencesMeizhouChina
| | - Jiaquan Li
- Department of OncologyMeizhou People’s Hospital (Huangtang Hospital)Meizhou Academy of Medical SciencesMeizhouChina
- Guangdong Provincial Key Laboratory of Precision Medicine and Clinical Translational Research of Hakka PopulationMeizhou People’s Hospital (Huangtang Hospital)Meizhou Academy of Medical SciencesMeizhouChina
| | - Zhikang Yu
- Guangdong Provincial Key Laboratory of Precision Medicine and Clinical Translational Research of Hakka PopulationMeizhou People’s Hospital (Huangtang Hospital)Meizhou Academy of Medical SciencesMeizhouChina
- Center for Precision MedicineMeizhou People’s Hospital (Huangtang Hospital)Meizhou Academy of Medical SciencesMeizhouChina
| | - Zhixiong Zhong
- Guangdong Provincial Key Laboratory of Precision Medicine and Clinical Translational Research of Hakka PopulationMeizhou People’s Hospital (Huangtang Hospital)Meizhou Academy of Medical SciencesMeizhouChina
- Center for Precision MedicineMeizhou People’s Hospital (Huangtang Hospital)Meizhou Academy of Medical SciencesMeizhouChina
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