This week I’m sharing a review article looking at optimising medicines for people living with cancer and coexisting chronic conditions. It’s published in Clinical Oncology, so is written with a specialist oncology audience in mind, but there is a lot that is relevant to GPs and community pharmacy. The article is behind a paywall so if you can’t get access to it but would like to read it, send me a message.
Full disclosure - medication management to enhance integration of care for people living with cancer and chronic conditions is the topic of my PhD and one of the author’s is my supervisor. So I have some strong (but I like to think reasonably well informed) opinions on this.
I want to bring your attention to this bit which is talking about potential drug drug interactions (PDDIs):
Fragmentation of care and lack of co-ordination and communication between specialists and primary care providers often results in PDDIs going unnoticed. Oncologists may underestimate the risk of PDDIs, and may be unaware of interactions of anticancer or supportive care medications with medications used to treat comorbidities or over-the-counter medications . Primary care practitioners, including community pharmacists, may not have a comprehensive medication record for cancer patients and, therefore, may not be able to detect PDDIs. This could result in unintended consequences, such as prescribing additional medications, treatment failure or increased healthcare utilisation
As I said, they’re talking from an oncologist perspective so they are focusing on identifying the drug interactions with chemotherapy, which is why they are dismissive of the role of primary care practitioners. But I would suggest that the role of primary care providers isn’t to identify the PDDI, it’s to ensure that the cancer care providers are provided with complete and accurate information regarding the patient’s medication taking behaviour and current medication regimen.
Most people with cancer have a lag time of at least four to six weeks between the initial detection of what might be cancer and their appointment with their oncologist to have their chemotherapy prescribed for a definite diagnosis. During that time they have lots of appointments where they are asked repeatedly what medications they’re taking. Many also have surgical procedures and might need to hold medications peri-operatively. Why wait until the patient visits the specialist to have this information? Do it early so that all of the care providers have access to it along the way.
The other bit that I think is key for primary care relates to the discussion around considerations for deprescribing. Again, this is written for oncologists so they suggest that deprescribing should occur as a collaborative process within the cancer multidisciplinary team. But again I ask - why should this wait for the specialist? Considerations regarding deprescribing and initiating conversations with the patient can happen with the GP (with support of a pharmacist) and continue throughout the cancer journey. I actually think this is much more appropriate as it helps to maintain continuity of care and sits within the scope of the GP.
My key messages here for GPs and primary care pharmacists - you don’t have to be an expert in chemotherapy to optimise medicines for people with cancer and multimorbidity. In fact, a generalist approach can be just what these patients need.
I have more ideas (so many more ideas) about how this can be achieved, but I’ll save them for if anybody is actually interested. If you are interested, please do reply below. I love talking about this subject.
Now, back to actually writing my thesis!