Community pharmacy and support for patients who take oral anticancer medication

The NHS must provide an integrated cancer service, particularly because improvements in diagnosis and treatment position the management of many cancers similarly to other long-term conditions^[1]
,[2]
. Drugs used to treat cancer are increasingly being developed as oral treatments, rather than as traditional intravenous treatments^[3]
. Around 1.6 million people visit community pharmacy each day^[4]
; community pharmacists must ensure they have the required competencies to support a range of patients, including those prescribed oral anticancer medication (OAM)^[5]
— drugs with direct anti-tumour activity, targeted therapies and hormonal treatments.

A study was conducted to investigate community pharmacists’ experience of interacting with people who have cancer, and associated training requirements. The study also aimed to gauge their level of interest in supporting patients who take an OAM.

A survey was sent to 133 community pharmacists in two London boroughs during an eight-week period (3 February 2017 to 31 March 2017), to which 23 staff members responded. A semi-structured focus group was then held in March 2017 with seven community pharmacists. The focus group was facilitated by an oncology pharmacist and a cancer nurse, and explored responses to the survey in more detail. The focus group was recorded, transcribed and coded through thematic analysis. Four common themes emerged from the data:

1. Experience of interacting with cancer patients

The majority of survey participants (57%) indicated that they interacted with patients who asked questions related to their OAM. However, this was not supported by findings from the focus group: “I’d have to say very, very rarely or very little. None of my patients tell me they have cancer… on the occasion they have told me, I suppose I have been taken a bit aback.” The survey data show that 63.6% of pharmacy staff felt very confident (13.6%) or reasonably confident (50%) to provide support to patients on OAM, while 36% were not confident. The focus group participants discussed their confidence and indicated that this was reduced because of infrequent involvement with patients in relation to OAM: “It’s because we don’t have that depth of knowledge that we do with other things we do on a daily basis.”

2. Support provided by community pharmacies

The survey showed around 57% of pharmacy staff provide some support to patients who take OAM. The main types of support provided were reassurance and signposting to other healthcare professionals. The focus group thought they could also provide side effect management advice if they were trained: “There’s nothing much we could do but just reassuring that there is someone in the community to look after [them].”

3. Training

The majority of cancer-related training for community pharmacy staff came from undergraduate training (45%). Three survey respondents had received no cancer training. The focus group conversation was similar — attendants had varied experience with training in this area. The survey results showed a variety of preferred learning methods: away days (0%), mentor support (9%), assessments (26%), shadow specialist pharmacist (35%), workshop (43%), evening meetings (61%), reading materials (65%) and online training packages (87%). Self-directed learning was a popular option for survey participants. During the focus group, community pharmacists also discussed the potential benefits of direct learning through shadowing specialist oncology pharmacists, nurses and patients: “Maybe even talking to a patient who has been treated here about how they feel, what they expect, how they want to be treated.”

4. Integration of secondary care with community pharmacy

The final questions of the survey and focus group asked if and how integration of secondary cancer care and community pharmacies could better support patients taking OAM. Discussions focused on how patients would be referred; the majority of survey respondents preferred email (65%), followed by a referral system (48%) and fax (43%). Around 82% of community pharmacists surveyed said they would find it acceptable to receive referrals from the hospital for patients taking OAM who require extra support. Barriers were time, staffing, incomplete information and a lack of commission. There was engagement from the focus group attendees; they realised the importance and opportunities of connecting with secondary care and creating a network among themselves: “It would help us to break down barriers with the patients and break down that myth of it being a taboo subject… to stop me being afraid of helping and it will help me to gain more confidence and hopefully gain trust with that patient.”

Integration between the hospital cancer team and community pharmacy is important. A network of community pharmacies within each borough, with contacts to the hospital, seemed the most popular way of working. Email was the most preferable referral route, but not all community pharmacies have NHS email accounts to ensure secure transfer of patient data. Referral using an electronic system was discussed. Nazar et al. have shared their successes with the use of this technology^[6]
.

There are opportunities for hospital pharmacists to work with their community counterparts to develop seamless care of patients taking OAM. For this to happen, there needs to be assurance that community pharmacy staff have the required training and access to the resources and the contacts they require to support this patient group.

Melanie Dalby, highly specialist oncology pharmacist, Guy’s and St Thomas’ NHS Foundation Trust

Catherine Oakley, chemotherapy nurse consultant, Guy’s and St Thomas’ NHS Foundation Trust

• This short communication was updated on 3 May 2018 to correct an error.