Dr. Edwin Brokaar
Older patients with cancer and a limited life expectancy often use many medications that expectedly do not contribute to the quality of life or future health benefits any more. In a multidisciplinary meeting, the medication are discussed with the aim to optimize pharmacological treatment and to reduce unnecessary pill burden.
More than half of incident cancers are in patients of 65 years or older. Polypharmacy is common in this group but is infrequently addressed, even in the case of advanced cancer with a poor prognosis. Many medications have treatment goals that lie in the distant future, but adverse drug events can occur at any moment. A larger number of comorbidities and of medications increase the probability these patients experience adverse drugs reactions or are at risk for relevant drug-drug interactions. A medication review to address these issues is even more relevant in our patient group than in the general population, as quality of life should be an increasingly important aspect of the treatment as death approaches. Therefore, a thorough medication review focussing on patient preferences is essential in older patients with advanced cancer to improve quality of life and to reduce the medication burden.
In the Haga Teaching Hospital, patients aged 65 years and older with cancer, polypharmacy and an estimated life expectancy of <24 months are offered a medication review. This medication review starts with a face-to-face interview to find out the patients’ preferences, expectations and drug-related problems. Next, the pharmacist thoroughly analyses the medication to propose improvements. Concurrently, patients are screened for frailty and referred for a comprehensive geriatric assessment (CGA) if needed.
In a multidisciplinary team (MDT) meeting consisting of pharmacists, medical oncologists, clinical geriatricians, and advanced nurse specialists, the pharmacists’ proposals and findings of the CGA are discussed until consensus is reached about the preferred medication-related interventions. The consensus-based recommendations are entered into the electronic file as an advice to the patient’s oncologist. The oncologist finally discusses the recommendations with the patient and the medication is adjusted accordingly. When the procedure has finished, the patients receive a survey to evaluate their satisfaction with various parts of the medication review. Satisfaction is measured using a five point Likert scale.
On average, 3 to 4 patients are reviewed monthly. An interim analysis of the first 70 patients showed that the mean number of medications was 12.0 (range 5-25), the mean number of drug-related problems (DRP) was 6.0 (range 1-14), and the mean number of possibly inappropriate medications (PIM) was 3.5 (range 0-13). As a result of the medication reviews, the mean number of DRPs decreased from 6.0 to 2.8 per patient and the PIMs from 3.5 to 1.7. Almost half of the recommendations was to discontinue a drug, thus reducing the medication burden significantly. The surveys revealed that overall patient satisfaction was high or very high in 90% of the respondents. This approach is unique in the integration of knowledge and expertise of pharmacists, oncologists and geriatricians when evaluating the medications of older patients with cancer. The method has been incorporated as a best practice in the care path Oncology of the Dutch Society for Clinical Pharmacy (NVZA) and the pharmacists involved have lectured across the Netherlands. In the Haga Teaching Hospital, similar medication review activities were initiated on the requested of medical specialists in other patient groups.