Elazzazy, Shereen (2023) Optimising cancer supportive care in Qatar. (PhD thesis), Kingston University, .
Abstract
According to the 2022 World Health Organisation (WHO) statement, cancer was the world's leading cause of death in 2020, accounting for up to 10 million deaths, close to one in every six. Whereas, the 2020 UK Cancer Research report showed that in England and Wales, more than 375,000 cases are diagnosed with cancer every year during the period of 2016 - 2018, with 167,147 cases of fatalities over 2017-2019 (Cancer Research UK, 2020). A cancer diagnosis and its following treatment can have an overwhelming effect on a patient's QoL, as well as on the life of their family (NICE, 2019). Regardless of their individual circumstances, cancer type, stage, or anti-cancer medication, all cancer patients have a fundamental right to supportive care (NICE, 2019). Hence, it is crucial to optimise cancer supportive care, in order to improve patients' clinical outcomes, compliance with therapy, QoL, and cost effectiveness of cancer care, as well as to ensure that cancer patients get the most out of their anticancer treatments. Real-world studies enable oncology healthcare professionals to comprehend regional variances in clinical practise and the reported real-world outcomes. RCTs frequently exclude participants with co-morbid conditions, advanced age, and low performance status. This leaves a gap in the body of knowledge regarding the effectiveness and safety of cancer therapy for this cohort of patients. Therefore, it is necessary to have a deeper knowledge of Real-World Evidence (RWE) to better understand therapy outcomes in real practice (Banerjee and Prasad, 2020). The Multidisciplinary Team (MDT) approach has been proven to improve patients’ clinical outcomes. The oncology pharmacist is a core member of cancer MDTs in Qatar. Over the last 15 years, oncology clinical pharmacists have been showing a significant independent role in cancer supportive care in Qatar, which significantly reflects on clinical, economic, and psycho-social outcomes of cancer patients. This thesis contributes to cancer supportive care real-world research, and different approaches towards improvement of therapeutic outcomes. It includes six studies, with a considerable representation of different real-world research methodologies, including a retrospective cohort study, a prospective cohort study, a healthcare survey, a Point Prevalence Survey (PPS), a systematic review, and a mixed method study. The aim of the KP1 study was to assess the impact of the oncology pharmacists' interventions during the discharge reconciliation process in the outpatient pharmacy. This study included a total of 4293 orders of medications for 591 patients/prescriptions. The results revealed a sum of 278 (47%) prescriptions required pharmacists’ interventions. Plus, 32% (190/591) of the prescriptions had medication discrepancies, and 21% (122/591) had medication errors, as detected by the pharmacists. In KP2, the purpose was to assess how different healthcare providers (HCPs) perceived the oncology clinical pharmacy service in NCCCR. The results showed that different oncology HCPs in Qatar perceived a growing need for the clinical pharmacy profession in the following proportions: 96% for pharmacists, 90% for doctors, and 64% for nurses, with statistical significance (p=0.002). The majority of respondents noted that the clinical pharmacy service has the greatest influence with detecting medication errors (85%), patients’ education (82%), and participation in clinical rounds (82%). Focusing on cancer drugs related complications, KP3 aimed to assess the safety of Bone-Targeting Agents (BTAs) in bone metastasis. This study included 271 patients who received 1141 doses of BTAs (denosumab and zoledronic acid). The results showed – with statistical significance – that in Qatar’s population hypocalcaemia was more frequent in denosumab patients than zoledronic acid patients. Whereas, about 60% of hypocalcaemia patients on both drugs did not receive calcium or vitamin D supplements. KP4 was a systematic review, aimed to identify the most popular techniques for diagnosing and managing the haematological Immune Related Adverse Events (irAEs) with the use of Immune Checkpoint Inhibitors (ICIs) by analysing the published data from case reports and case series. This study included 49 articles in total, with 118 cases reported haematological irAEs with ICIs. It concluded that, the most frequent irAEs were thrombocytopenia, haemolytic anaemias, and aplastic anaemias. Furthermore, steroids were used in 68% (80/118) of the reported events for the management of haematological irAEs, with a failure rate of 20% (16/80). KP5 and KP6 are two studies focused on Antimicrobial Stewardship (AMS). KP5 was a PPS conducted to identify the prevalence of antimicrobial use for oncology patients in Qatar. It showed that by including 58 inpatients, the overall prevalence of antibiotic use was 43% (25/58). However, the compliance with the regional prescribing restriction requirements fell short of expectations, as only 58% (19/33) of prescriptions were issued by privileged prescribers. While in KP6, the study's aim was to assess the level of AMS knowledge, outcomes, and barriers among Qatar's cancer management team. This study included a total of 219 prescriptions during the course of the 6 PPSs. The results showed that the compliance continued to be low as 60% (similar to KP5). Yet, educational interventions resulted in significant improvement, with an overall compliance rate of 96%. In conclusion, this thesis will address the published real-world studies conducted using a variety of methodologies on cancer supportive care in Qatar, and shed light on recommendations and strategies for improving the outcomes of this type of care, as well as how they relate to clinical practise.
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