Oncology Fundamentals Day 2021

Learning Objectives:

1. Recognize features of multiple myeloma, its treatment challenges and the impact of the evolving treatment landscape on patient care;
2. Assess how the administration and dosing of novel agents can enhance the patient experience and benefit health care; and
3. Appreciate how to optimize the patient experience through a focus on improving health-related quality of life and supportive care.
    

Learning Objectives:

1. Discuss the most common adverse events associated with antibody-drug conjugates & tyrosine kinase inhibitors to help educate healthcare professionals & patients;
2. Recognize the importance of adverse events of “special interest”, including interstitial lung disease/pneumonitis & gastrointestinal events; and
3. Describe recommendations for monitoring & management of adverse events.
    

Navigating the process of accessing a medication for a patient can be confusing and tricky, there’s several different funding bodies and pathways and it’s not always a straightforward process. This presentation will provide an overview of the various pathways of drug access as well as some of the challenges faced along the way. By understanding the drug access process, Pharmacists and Pharmacy Technicians can play an important role in patient care by learning how to access medications when patients need them and reduce mental and financial burden.

Learning Objectives:

1. Describe the different pathways that can be explored for drug coverage;
2. Understand some of the challenges of each pathway;
3. Know the role that Patient Support Programs can have; and
4. Understand how Pharmacy Technicians can play a role in drug access.
    

Ovarian cancer is the eighth leading cause of all deaths in Canadian women, and the fifth leading cause of cancer related death. The majority of women diagnosed with ovarian cancer will be diagnosed with advanced (stage III or IV) disease and are, unfortunately, faced with the reality of high recurrence rates and poor outcomes.

The 1990’s saw the addition of paclitaxel to standard platinum-based therapy, and the 2000’s brought addition of bevacizumab for some select high risk patients. A lack of therapeutic advances clearly highlights the need for new and additional treatment options following standard surgery, chemotherapy, and active surveillance in advanced ovarian cancer.

The identification of gene mutations and subsequent emergence of poly (adenosine diphosphate [ADP]-ribose) polymerase (PARP) inhibitors serving as maintenance treatment, in both the upfront and recurrent platinum sensitive setting, has changed the treatment approach in advanced ovarian cancer.

This learning activity aims to provide an introductory knowledge of ovarian cancer, concentrating on the role of PARP inhibitors in treatment, and the pharmacist’s role in the management of these patients.

Learning Objectives:

1. Review introductory concepts of ovarian cancer including general treatment approach;
2. Describe the role of PARP inhibitors in treatment of advanced ovarian cancer;
3. Discuss the mechanism of action, safety and efficacy of PARP inhibitors through review of best available evidence; and
4. Outline the pharmacist’s role in toxicity assessment, monitoring and management of adverse events related to PARP inhibitors.

CAR T-Cell Therapy is a type of immunotherapy where a patient's T-Cells (a type of white blood cell that is a part of the immune system) are first collected via leukapheresis, then genetically engineered and expanded in a laboratory to express chimeric antigen receptors (CARs) on their surface to recognize, bind to and kill cancer cells. Patients receive three days of lympho-depleting chemotherapy prior to the infusion of the CAR T-cells to make room in the immune system. 

Possible adverse effects from CAR T-Cells include: cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). Pharmacists play an important role in managing these adverse effects as well as educating patients prior to the CAR T-Cell infusion. 

The Ottawa Hospital (TOH) is one of few cancer centers in Canada that provide CAR T-Cell Therapy. At TOH we currently use two commercially available products (Axicabtagene ciloleucel and Tisagenlecleucel) that are Health Canada approved, in addition to a clinical trial product (Canadian-Led Immunotherapies in Cancer - CLIC-01 Study). All of the above are CD19-directed CAR T-Cell Therapy products.

CAR T-Cell Therapy is a developing area of research with several ongoing clinical trials for solid tumors and various types of blood cancers.

Learning Objectives:

1. Provide a general overview of what CAR T-Cell Therapy is (i.e. the structure of a CAR, how it works, target antigens, etc.) and the overall process; 
2. Identify the available CAR T-Cell products in Canada and their approved indications;
3. Briefly summarize the lympho-depleting chemotherapy regimens prior to CAR T-Cell infusion and the most common chemotherapy associated side effects; 
4. Discuss CAR T-Cell related side effects and their management, with a focus on cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS); and
5. Outline the prophylactic medications associated with CAR T-Cell Therapy.

In this session, we will re-activate our prior knowledge of basic genetics and explore the impact genetics, both inherited and acquired, have in cancer pharmacotherapy.  With a case based approach, we will discuss genetic polymorphisms that can impact oncology drug efficacy and safety and strategies to mitigate the risks of poor outcomes.  A review of important concepts of selecting targeted therapies based on the genetic profile of the malignancy will also be provided. 

Learning Objectives:

1. Differentiate between germline and somatic genetic mutations and appreciate their relationship to personalized medicine;
2. Describe the implications of polymorphisms in drug metabolizing enzymes in oncology drug efficacy and toxicity;
3. Explain the various mechanisms by which polymorphisms in drug transport genes can impact oncology drug efficacy and toxicity; and
4. Explain the relevance of acquired gene mutations within a malignancy in the selection of individualized cancer therapy.    

The Oncotype DX test looks at individual tumor biology by measuring the expression of 21 genes.  The testing is used to help determine whether women with HER2 negative, ER positive early breast cancer would benefit from chemotherapy.  

At the Saskatchewan Cancer Agency, funding for the Oncotype DX testing is sourced from the pharmacy budget, therefore pharmacy is involved in determining eligibility of patients to receive testing.

This role was initially fulfilled by a Senior Pharmacist; however, it was quickly noted that a Senior Pharmacy Technician would certainly be able to fulfill this roll. 

This presentation will describe Oncotype DX testing and how the Pharmacy Technician roll has evolved to include reviewing patient eligibility for testing.

Learning Objectives:

1. Describe Oncotype Dx testing and it’s importance in determining breast cancer treatment;
2. Describe criteria required to meet funding for Oncotype Dx at the Saskatoon Cancer Centre; and
3. Describe the evolution of the pharmacists and pharmacy technicians role in Oncotype Dx; and testing at the Saskatoon Cancer Centre.

Children are not small adults and cancers affecting pediatric patients are very different from adult cancers.  Dosing of chemotherapy regimens for children is complex for multiple reasons.  The effects of chemotherapeutic agents on infants and young children can be different than in adolescents or adults because of developmental physiological changes that occur throughout childhood affecting pharmacokinetics.  This can result in variable chemotherapy exposure and clearance in children and unpredictable efficacy/toxicity profiles, thus making dosing of chemotherapy challenging, especially in infants and younger children.  While it is standard practice to use body surface area (BSA) to calculate adult chemotherapy doses, this method can greatly overestimate dosing for infants and younger children, thus weight-based dosing is preferred in patients with BSA < 0.6 m2.  The number of orally administered chemotherapy agents continues to increase but pediatric appropriate dosage formulations (i.e. oral liquids or low-dose mini tablets) are limited and extemporaneous liquid formulations are not always available, creating further obstacles for accurate and safe dosing of these medications in children.  Supportive care medications may also vary between pediatric and adult cancer patients due to differences in chemotherapy intensity or toxicities.  Some medications considered standard of care in adults may not be tolerated in children due to side effects or lack of appropriate formulations.  Understanding the factors that impact chemotherapy dosing and supportive care strategies in children will enable better care and monitoring of pediatric patients with cancer.  

Learning Objectives:

1. Understand the multiple factors influencing chemotherapeutic agents in pediatric patients; 
2. Understand how chemotherapy dosing in children may differ from adults;
3. List pediatric specific chemotherapy formulations, alternative dosing regimens when extemporaneous formulations unavailable and other special considerations in children; and
4. Describe similarities and differences in supportive care medications for pediatric and adult cancer patients.

​​​​​​As patients continue to have increasing ease of access to health related information, there is a higher proportion turning to Complementary and Alternative Medicine (CAM) for cancer treatment or symptom management. For the purposes of this presentation, CAM will refer to biologically-based practices, which focuses on consuming things found in nature, including vitamins, botanicals, or special foods. 

While high quality evidence regarding the safety and efficacy of such interventions is often lacking, patient values and goals of care often play a role in their decision to use such therapy and should be incorporated into patient discussions. During this presentation we will discuss factors which impact the use of CAM and how to address these during conversations with patients. We will also review evidence of commonly requested CAM therapies in patients with lymphoproliferative disorders and discuss how to navigate resources with credible information on these agents. 

Learning Objectives:

1. Describe the use of complementary-alternative medicine (CAM) in patients with a diagnosis of cancer,  specifically CLL and lymphoma; 
2. Discuss considerations and concerns regarding CAM use in patients with B-cell malignancies;
3. Review the evidence of commonly requested biologic CAM therapies in this patient population, including vitamin C, green tea (EGCG) and turmeric (curcumin); and
4. Discuss the importance of engaging in conversations regarding CAM with our patients and review methods to facilitate this dialogue.