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Transitions of Care in Patients With Cancer
Brandon R. Shank, PharmD, MPH, BCOP; Phuoc Anh (Anne) Nguyen, PharmD, MS, BCPS; and Emily C. Pherson, PharmD, BCPS
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Transitions of Care in Patients With Cancer

Brandon R. Shank, PharmD, MPH, BCOP; Phuoc Anh (Anne) Nguyen, PharmD, MS, BCPS; and Emily C. Pherson, PharmD, BCPS
Pharmacists play an integral role in enhancing transitions of care in patients undergoing cancer treatment through medication reconciliation, education, and post-discharge follow-up to ensure optimal, safe, and effective medication use.
Models of Cancer Care Delivery
Cancer treatments are administered in a variety of settings, ranging from a small private practice to a large academic comprehensive cancer treatment center. Clinical outcomes may differ for certain disease states based on setting; for example, patients with a rare hematologic malignancy, multiple myeloma, who were treated at a high-volume center were found to have higher overall survival to those treated in community settings.33 The volume-outcome relationship is well known for surgical management of solid cancers.34 Some patients may not have access to a high-volume cancer treatment center given their geographical location, insurance network, or financial feasibility. Co-management is a potential solution, in which the patient receives treatment recommendations from a higher-volume center but visits a local physician to have the treatment plan implemented.33 Whether cancer care is delivered in a small community hospital or a large academic medical center, a multidisciplinary team that includes a hematologist/oncologist, surgical oncologist, radiologist, palliative care providers, midlevel providers, pharmacists, social workers, case managers, and spiritual care providers is essential to meet patients’ needs.35,36

Of the total 69 NCI-designated cancer centers, 47 are comprehensive cancer centers that perform laboratory, clinical, behavioral, and population-based research. Fifteen of the 69 cancer centers perform basic, population sciences, and clinical research.37 Many additional academic medical centers are not NCI-designated. Regardless of the shortfalls of respective models, cancer treatment teams need to identify the shortfalls of their models and adapt their approach to account for the diversity in practice settings where cancer care is delivered, although it may be challenging to coordinate the various fragmented services to ensure provision of comprehensive care. A primary cancer treatment team should be established to ensure care coordination, with the pharmacists involved in all pharmacotherapy aspects throughout the patient’s transitions within the healthcare system.

Cancer Treatment Challenges
Antineoplastic medications can be administered in the outpatient or inpatient setting depending on the type of regimen, insurance coverage, and center where the drug is being administered. Starting cancer treatment requires careful coordination with the patient’s insurance carrier to obtain pre-approval for high-cost antineoplastic medications, and G-CSF if clinically indicated. Additionally, care teams can help patients enroll in patient financial assistance programs to help cover high-cost medications.38 Some chemotherapy regimens that require an infusion pump, such as continuous-infusion fluorouracil, may require working with outside infusion companies; patient education must also be provided. Furthermore, long commutes to clinics for patients undergoing cancer treatment can be strenuous on patients and caregivers. Coordinating patients’ schedules to combine appointments can minimize trips and decrease the patient’s stress.

Cancer treatments range from simple once-a-day oral medications to multiple inpatient and outpatient infusion treatments with variations in “on” and “off” periods, further complicating the administration of cancer care. Regimens of such medications as hyperfractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone require an initial inpatient infusions followed by outpatient infusions.39 Patients need to be informed of complex drug dosing frequencies such as weeks off treatment, as with regorafenib or dexamethasone pulses to prevent overdoses.39,40 Certain supportive-care medications like azole antifungals may need to be taken around the time of each chemotherapy session to prevent drug interactions, which adds to the complexity of the treatment.

Managing Care Transitions During Cancer Treatment
Managing complications of cancer treatment may require hospital admission and holding treatment. EHRs need to have the capability to put treatment plans on hold to prevent the administration of chemotherapy and biotherapy during the period when toxicities are being managed. Patients may need to continue intravenous antibiotics in the outpatient setting, requiring careful coordination with the case manager to set up home infusion services. Some large institutions have the ability to administer intravenous antibiotics, intravenous fluids, blood products, or G-CSF in the outpatient setting through an infusion center. In addition to medications, patients may have other needs such as setting up home oxygen, outpatient physical/occupational therapy, medical equipment, and home health services. Certain infusional chemotherapies, such as continuous infusion doxorubicin, require central line access; in such cases, patients must be provided with line care supplies and trained to care for their own lines.

Depending on the chemotherapy regimen, patients may need to have laboratory blood monitoring in the outpatient setting, in time patterns ranging from once a cycle to several times a week. Communication is essential when multiple physicians are involved in the management of a patient. Fortunately, EHRs are making those transitions easier. However, providers must still communicate among one another about a co-managed patient’s cycles of chemotherapy, laboratory values, and changes in condition between cycles. These communications can be meaningfully achieved through physical or electronic letters sent to the co-managing physician. Sample orders including chemotherapy and biotherapy as well as supportive care medications may be provided for physicians taking over care for subsequent cycles. Pharmacists at large cancer centers with experience with the regimens can collaborate with smaller centers to ensure optimal delivery of the regimens. Patients may need to go to skilled nursing, long-term acute care, rehabilitation, or hospice facilities. It is important for care teams to provide clear medication, laboratory, and monitoring support to these facilities, as they may not be accustomed to monitoring these types of patients.

Conclusions
Cancer care is complex and requires an interdisciplinary approach with careful coordination of many specialties. While cancer treatment providers and supportive professionals have been providing these services, they are adapting care delivery to enhance quality and reduce cost, based on incentives provided by health plans. TOC models are being evaluated to enhance the transitions of patients undergoing cancer care. Coordination by the primary treatment team and thorough medication reconciliation and education provided by pharmacists, in conjunction with appropriate follow-up, is essential to ensure optimal outcomes and minimize AEs.

AUTHOR INFORMATION
Brandon R. Shank, PharmD, MPH, BCOP, is a clinical pharmacy specialist, Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX.
Phuoc Anh (Anne) Nguyen, PharmD, MS, BCPS, is a clinical pharmacy specialist, Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX.
Emily C. Pherson, PharmD, BCPS, is a clinical pharmacy specialist, Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD.

ADDRESS FOR CORRESPONDENCE
Brandon R. Shank, PharmD, MPH, BCOP
Clinical Pharmacy Specialist, Division of Pharmacy
The University of Texas MD Anderson Cancer Center
1515 Holcombe Blvd - Unit 377
Houston, TX 77030.
E-mail: BShank@mdanderson.org.

DISCLOSURES
None
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