Dec 1, 2015 - The elderly patient with cancer is exposed to a high medication risk: treatment for ... alized care project in geriatric oncology. However, this ...
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34
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2015
JOURNAL OF CLINICAL ONCOLOGY
C O R R E S P O N D E N C E
Polypharmacy and Potentially Inappropriate Medication Use Among Senior Adults With Cancer: What Is the Best Approach? TO
THE
EDITOR: In the original report by Nightingale et al,1 a
pharmacist-led comprehensive medication assessment demonstrated a high prevalence of polypharmacy (PP) and potentially inappropriate medication (PIM) use among ambulatory senior adults with cancer. For at least 234 patients, the mean number of medications used was 9.23. The prevalence rates of PP and PIM use were 41% and 51%, respectively. PP and increased comorbidities were associated with PIM use. The elderly patient with cancer is exposed to a high medication risk: treatment for comorbidities, cancer treatment, supportive treatments, and self-medication. Evaluation of medicine-related illness and of medication risk seems essential to the development of a personalized care project in geriatric oncology. However, this factor currently may seem neglected. The study by Nightingale et al1 leads to a certain number of remarks. As stressed by Lichtman et al,2 gerontologic evaluation is an indispensable tool in any geriatric oncologic approach. All patients enrolled onto the study reported by Nightingale et al1 received gerontologic evaluation at inclusion. However, the principal tools used and the results of the evaluation are not given by the authors. This raises several problems. Notably, because there is no information on the patients’ cognitive statuses, we cannot be certain that data collection on medication was exhaustive and relevant. (The authors do not specify how the aid of the caregiver was enlisted.) Without knowledge of the cognitive profile of the patient, it is also difficult to determine the ability of the patient to take treatment. Several elements need to be taken into account to adapt and prioritize treatments: polymedication, the risk of drug interaction, the risk of inappropriate prescriptions (treatment not indicated or contraindicated), the risk of overtreatment, and the risk of undertreatment. Treatment adaptation requires full knowledge of the disease context and comorbidities of the patient. In this study, although the prevalence and type of comorbidities are well described by the authors, there is no evaluation of their potential seriousness. Use of a comorbidity evaluation scale, such as the Cumulative Illness Rating Scale for Geriatrics, would seem to be an indispensable tool for prioritizing treatments.3,4 Conversely, the risk of inappropriateprescribingandofovertreatmentiswelltakenintoaccount, in particular through the 2012 combined Beers, Screening Tool of Older Persons’ Prescriptions, and Healthcare Effectiveness Data and Information Set criteria. Thanks to these criteria, in the study by Nightingale et al,1 pharmacistsidentified173occurrencesofPIMspresentin40%,38%,and 21% of patients, respectively. However, the risk of underuse is probably underestimated by the authors, because the Screening Tool to Alert Doctors to the Right Treatment criteria were not used.5 Also, the risk of
interactions with cancer treatments, and with chemotherapies in particular, did not seem to be considered. To identify PIM use in nursing home residents, Cool et al6 used a specific indicator, which was based on the Summary of Product Characteristics, on the Laroche list and on residents’ clinical data. PIM use was defined as the presence of at least one of the following criteria: drug with an unfavorable benefit-to-risk ratio; drug with questionable efficacy according to the Laroche list; absolute contraindication; or significant drug-drug interaction. The advantage of this method lies in the use of multiple reference tools, which yields a more overall view of these drug prescriptions and drug-drug interactions. By using this method, a higher proportion of PIMs would probably be identified. Cool et al6 identified PIMS among 71% of the 974 patients included. Nevertheless, the study by Nightingale et al1 is still an interesting one. In particular, it underlines the key role of the pharmacist in the adaptation of treatment in the elderly patient with cancer. Adaptation should be a collegial process that involves all those who care for the patient, such as the oncologist, the geriatrician, and the patient’s general practitioner. This study does not show whether the findings of the pharmacists’ assessments are put into practice, nor whether they are effective: Do the assessments result in fewer adverse events or fewer and shorter hospital admissions? Prospective studies could usefully analyze adverse outcomes or adverse events and could examine whether a strategy of cleaning up patients’ prescriptions is effective and how it can affect patient welfare.
Marie-Eve Rougé Bugat Institut Universitaire du Cancer–Oncopole, Université Paul Sabatier Toulouse III, and Institut National de la Santé et de la Recherche Médicale–UPS, Toulouse, France
Delphine Bréchemier and Laurent Balardy Centre Hospitalo-Universitaire de Toulouse, Toulouse, France
AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST
Disclosures provided by the authors are available with this article at www.jco.org. REFERENCES 1. Nightingale G, Hajjar E, Swartz K, et al: Evaluation of a pharmacist-led medication assessment used to identify prevalence of and associations with polypharmacy and potentially inappropriate medication use among ambulatory senior adults with cancer. J Clin Oncol 33:1453-1459, 2015 2. Lichtman SM: Polypharmacy: Geriatric oncology evaluation should become mainstream. J Clin Oncol 33:1422-1423, 2015 3. Beloosesky Y, Weiss A, Mansur N: Validity of the medication-based disease burden index compared with the Charlson Comorbidity Index and the Cumulative Illness Rating Scale for Geriatrics: A cohort study. Drugs Aging 28:1007-1014, 2011 4. Wedding U, Roehrig B, Klippstein A, et al: Comorbidity in patients with cancer: Prevalence and severity measured by Cumulative Illness Rating Scale. Crit Rev Oncol Hematol 61:269-276, 2007 5. O’Mahony D, O’Sullivan D, Byrne S, et al: STOPP/START criteria for potentially inappropriate prescribing in older people: Version 2. Age Ageing 44:213-218, 2015 6. Cool C, Cestac P, Laborde C, et al: Potentially inappropriate drug prescribing and associated factors in nursing homes. J Am Med Dir Assoc 15:850 e1-e9, 2014
DOI: 10.1200/JCO.2015.62.8149; published online ahead of print at www.jco.org on September 8, 2015
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Journal of Clinical Oncology, Vol 33, No 34 (December 1), 2015: pp 4123-4124
© 2015 by American Society of Clinical Oncology
Downloaded from jco.ascopubs.org on December 28, 2015. For personal use only. No other uses without permission. Copyright © 2015 American Society of Clinical Oncology. All rights reserved.
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Correspondence
AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST
Polypharmacy and Potentially Inappropriate Medication Use Among Senior Adults With Cancer: What Is the Best Approach? The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I ⫽ Immediate Family Member, Inst ⫽ My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO’s conflict of interest policy, please refer to www.asco.org/rwc or jco.ascopubs.org/site/ifc. Marie-Eve Rougé Bugat No relationship to disclose
Laurent Balardy No relationship to disclose
Delphine Bréchemier No relationship to disclose
© 2015 by American Society of Clinical Oncology
JOURNAL OF CLINICAL ONCOLOGY
Downloaded from jco.ascopubs.org on December 28, 2015. For personal use only. No other uses without permission. Copyright © 2015 American Society of Clinical Oncology. All rights reserved.
