Survey Reveals Need For Standardized Oral Chemotherapy Prescribing Practices, Safeguards

In the Jan. 13 issue of the British Medical Journal, Saul N. Weingart, MD, PhD, vice president for patient safety at Dana-Farber, and his colleagues report that a survey of National Cancer Institute-designated comprehensive cancer centers found few organizations with standardized prescribing practices for oral chemotherapy.

"Given how quickly oral chemotherapies have become standard care for a growing number of cancers, we were not surprised to find variations in how organizations prescribe and monitor the use of these agents," said Weingart. "It was surprising, however, that few of the safeguards used with infusion chemotherapy have been adopted for oral chemotherapy."

The researchers sent a survey on the current practices for prescribing, coordinating and monitoring, dispensing, and educating patients about oral chemotherapy to 54 NCI-designated comprehensive cancer centers, of which 42 centers responded.

Weingart said the survey revealed significant variations in the manner prescriptions were generated at most centers and in the amount of information required to complete them.

Nearly 70 percent of the centers (29) used handwritten orders for the majority of oral chemotherapy prescriptions, five percent (2) used pre-printed paper prescriptions, and 14 percent (6) used computed-based prescription order entry systems.

An analysis of the information required to order prescriptions for six oral chemotherapies found that few centers mandated the inclusion of the patient's diagnosis (26 percent), the treatment's schedule and duration (9 percent), or the patient's body surface area (BSA) calculation, which is used to determine appropriate and safe drug dosage level, and only 21 percent of the centers required a second physician to review and approve the chemotherapy order. More than half of the centers had no required elements for oral chemotherapy prescriptions, noted Weingart, who is an associate professor of medicine at Harvard Medical School.

The respondents also reported that between 2004 and 2005 at least one serious adverse drug event related to oral chemotherapy occurred at 10 centers, and 13 centers experienced a 'serious near miss.'

"The growing availability of effective oral chemotherapy, especially the new class of 'targeted biologic therapies,' is one of the wonderful recent advances in cancer care, as it has given cancer patients unprecedented convenience compared to intravenous infusion therapy," said paper co-author Lawrence Shulman, MD, chief medical officer at Dana-Farber and an associate professor of medicine at Harvard Medical School. "However, these findings underline the importance of forging a consensus in the oncology field on standardized safeguards and practices for prescribing and monitoring the use of these drugs."

The paper's other authors are Daniela Brouillard, Laurinda Morway, EdM, Ann Partridge, MD, MPH, Sylvia Bartel, RPh, MHP, and Maureen Connor, RN, of Dana-Farber; and Jonathan Flug, Tufts University School of Medicine, Boston.

The research was supported by the Center for Patient Safety at Dana-Farber and the Agency for Healthcare Research and Quality.