What additional safety practices should be followed when providing oral cancer therapy?

From Cancer Guidelines Wiki


Oral cancer therapies include cytotoxic agents, targeted and/or biological therapies which are increasingly being used for cancer treatment. Oral cancer therapy carries the same risks in terms of potential for error and toxicities as cancer therapies administered by other routes.[1][2]

While the oral route of administration is often preferred by patients, the self-administration of oral cancer therapies introduces additional risks of error and also the risk of non-adherence.[3][4][5][6]

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Evidence Summary

Oral cancer therapies are often complex to understand. Patients and/or caregivers may misinterpret instructions and inadvertently take an incorrect dose or continue therapy beyond that prescribed. The intermittent treatment that is characteristic of cancer chemotherapy may be difficult for some patients to understand. Fatal outcomes have been associated with patient misinterpretation of dosage instructions.[7][8][9][4]

Oral cancer therapies may continue for weeks at a time without direct professional supervision and therefore medication, dose or scheduling errors are less likely to be detected.[5]

Note: Further information on prescribing, dispensing and administering oral cancer therapy is provided under the medical, pharmacy and nursing sections of these guidelines.

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Consensus-based recommendationQuestion mark transparent.png

Oral cancer therapies should be subject to the same standards for prescribing, verification, dispensing and administration as cancer therapies via other routes, with additional safeguards to support safe self-administration by patients and their caregivers in the home setting (Carrington, 2015; Carrington, 2013).

All healthcare professionals involved in prescribing, dispensing and administering oral cancer therapies need to be appropriately trained to assist patients and/or caregivers with issues pertaining to adherence, toxicity management and safety issues in the home setting (NHS National Patient Safety Agency UK, 2008; Taylor et al, 2006; Parsad and Ratain, 2007; Society of Hospital Pharmacists of Australia Committee of Specialty Practice in Cancer Services, 2007; Scottish Executive Health Department, 2005; Halfdanarson and Jatoi, 2010; Moore, 2010).

Practice pointQuestion mark transparent.png

Online resources such as eviQ (Cancer Institute NSW) are available to assist community pharmacists on safety issues around oral therapy. EviQ education online provides a useful resource on oral antineoplastic therapy (Cancer Institute NSW).

Institutions should consider implementing adequate support and education programs to facilitate patient understanding of how to take medication, when to take medication, what to look out for in terms of potential side effects and when to report problems (Winkeljohn, 2010; Halfdanarson and Jatoi, 2010; Neuss et al, 2017).

(Carrington, 2015)[10] ;(Carrington, 2013)[11] ;(NHS National Patient Safety Agency UK, 2008)[4] ;(Taylor et al, 2006)[5] ;(Parsad and Ratain, 2007)[12] ;(Society of Hospital Pharmacists of Australia Committee of Specialty Practice in Cancer Services, 2007)[13] ;(Scottish Executive Health Department, 2005)[14] ;(Halfdanarson and Jatoi, 2010)[15] ;(Moore, 2010)[16] ;(Cancer Institute NSW, 2016)[17] ;(Winkeljohn, 2010)[18] ;(Neuss et al, 2017)[1]

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  1. 1.0 1.1 Neuss MN, Gilmore TR, Belderson KM, Billett AL, Conti-Kalchik T, Harvet BE, et al. 2016 Updated American Society of Clinical Oncology/Oncology Nursing Society Chemotherapy Administration Safety Standards, Including Standards for Pediatric Oncology. Oncol Nurs Forum 2017 Jan 6;44(1):31-43 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/28067033.
  2. Carrington C, Stone L, Koczwara B, Searle C, Siderov J, Stevenson B, et al. The Clinical Oncological Society of Australia (COSA) guidelines for the safe prescribing, dispensing and administration of cancer chemotherapy. Asia Pac J Clin Oncol 2010 Sep;6(3):220-37 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20887505.
  3. Kav S, Johnson J, Rittenberg C, Fernadez-Ortega P, Suominen T, Olsen PR, et al. Role of the nurse in patient education and follow-up of people receiving oral chemotherapy treatment: an international survey. Support Care Cancer 2008 Sep;16(9):1075-83 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/18197437.
  4. 4.0 4.1 4.2 NHS National Patient Safety Agency UK. Rapid Response Report (NPSA/2008/RRR001). Risks of incorrect dosing of oral anti-cancer medicines. [homepage on the internet]; 2008 Jan 22 [cited 2016 Sep]. Available from: http://www.nrls.npsa.nhs.uk/resources/?entryid45=59880.
  5. 5.0 5.1 5.2 Taylor JA, Winter L, Geyer LJ, Hawkins DS. Oral outpatient chemotherapy medication errors in children with acute lymphoblastic leukemia. Cancer 2006 Sep 15;107(6):1400-6 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16909415.
  6. Weingart SN, Toro J, Spencer J, Duncombe D, Gross A, Bartel S, et al. Medication errors involving oral chemotherapy. Cancer 2010 May 15;116(10):2455-64 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20225328.
  7. Phillips J. FDA Safety Page: Fatal medication errors associated with Temodar. [homepage on the internet]; 2003 Apr 7 [cited 2016 Sep]. Available from: http://drugtopics.modernmedicine.com/drug-topics/content/fda-safety-page-fatal-medication-errors-associated-temodar.
  8. Institute for Safe Medication Practices. ISMP Safety Alert. With oral chemotherapy, we simply must do better! [homepage on the internet]; 2014 Jul 17 [cited 2016 Sep]. Available from: https://www.ismp.org/newsletters/acutecare/showarticle.aspx?id=84.
  9. Institute for Safe Medication Practices. ISMP Safety Alert. Lowdown on lomustine: We’d hate CeeNU make this mistake. [homepage on the internet]; 2004 Jul 15 [cited 2016 Sep]. Available from: http://www.ismp.org/Newsletters/acutecare/articles/20040715.asp.
  10. Carrington C. Oral targeted therapy for cancer. Aust Prescr 2015 Oct;38(5):171-6 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26648656.
  11. Carrington C. Safe use of oral cytotoxic medicines. Australian Prescriber 2013;36(1):9-12.
  12. Parsad SD, Ratain MJ. Prescribing oral chemotherapy. BMJ 2007 Feb 24;334(7590):376 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17322214.
  13. Society of Hospital Pharmacists of Australia. Committee of Specialty Practice in Cancer Services. Standards of Practice for the Provision of Pharmaceutical Care of Patients Receiving Oral Chemotherapy for the Treatment of Cancer. J Pharm Pract Res 2007;37,147-150.
  14. Scottish Executive Health Department. Guidance for the Safe Use of Cytotoxic Chemotherapy.; 2005 [cited 2016 Sep] Available from: http://www.sehd.scot.nhs.uk/mels/HDL2005_29.pdf.
  15. Halfdanarson TR, Jatoi A. Oral cancer chemotherapy: the critical interplay between patient education and patient safety. Curr Oncol Rep 2010 Jul;12(4):247-52 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20437116.
  16. Moore S. Nonadherence in patients with breast cancer receiving oral therapies. Clin J Oncol Nurs 2010 Feb;14(1):41-7 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20118025.
  17. Cancer Institute NSW. eviQ Cancer Treatments Online. [homepage on the internet]; [cited 2016 Sep]. Available from: https://www.eviq.org.au.
  18. Winkeljohn D. Adherence to oral cancer therapies: nursing interventions. Clin J Oncol Nurs 2010 Aug;14(4):461-6 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20682501.

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