Non-communicable diseases, according to data, in 2015, low and middle income countries (LMICs) had 78% deaths of global death burden, among which 50% were considered premature. The disease burden of cancer in LMICs equates to 70% of the global proportion. 1 Additionally, cancer registries’ data indicates that in 2018, 18.1 million new cases were confirmed, and 9.6 million deaths were reported. 1 The World Health Organization has forecasted a dire picture, estimating a rise in disease burden to 29.5 million new cases, and annual deaths will rise to 16.5 million people. Furthermore, in 2012, LMICs had 65% of the global share of cancer-related deaths which is forecast to increase to 75% by 2030. 2
Chemotherapy is a treatment modality for cancer patients in a curative or palliative setting. Yet, it is also worth discussing that the chemotherapy agents, as part of chemotherapy protocol, can also be involved in adverse drug events (ADE), which have financial implications, amounting to such significant proportionality where the existing cost of therapy is far less than the burden of managing the ADE itself.3,4 Regarding providing safe and effective healthcare services to cancer patients, data from von Grünigen et al., 5 shows that the median level of safe handling practices was quite favorable (63%). The study also revealed significant disparities in practices between healthcare facilities in LMICs. 5 Furthermore, as chemotherapy is the most common treatment modality, the major challenge observed is chemotherapy preparation. Aseptic preparation of the chemotherapy involves the riskiest steps in delivering treatment to the patient. Any calculation, dosing, or sampling error made during the chemotherapy preparation process may have potentially severe consequences for the patient. Furthermore, chemotherapy preparation poses a significant risk of occupational exposure, as it involves handling potent cytotoxic drugs. 5 Therefore, standardizing and regulating safety procedures in this domain should be one of the LMIC's top priorities.
Oncology stewardship is a new concept in LMICs, which can help reduce errors during chemotherapy and the cost of medication used for cancer treatment. Forecasted disease burden on LMICs, related to cancer, poses a financial threat to an already weak healthcare and economic infrastructure. We recommend implementing oncology stewardship programs, as they will add to the safety and quality of patient care. However, there is no standard definition available. Ochs et. al. 2022, defined oncology stewardship as a “set of coordinated strategies to improve the use of antineoplastic agents with the goal of enhancing patient outcomes while reducing financial toxicity.” 6 The key recommendation is the placement of pharmacists at the helm of the affairs. Aseptic compounding and clinical pharmacy services are necessary for oncology care settings and are being practiced in many nations, including LMICs. The American pharmacist board certification related to oncology pharmacy and sterile compounding preparation pharmacy is the cornerstone of trained pharmacist board certification. Patient safety should be covered comprehensively with trained pharmacy staff and integrated into the oncology stewardship team. This should be more focused on pharmacy staff associated with verifying, preparing, and dispensing chemotherapy. Currently, there are 48 Board Certified Oncology Pharmacist (BCOP) in LMICs and 7 Board Certified Sterile Compounding Pharmacist (BCSCP), as shown in Table 1. 7 Encouraging pharmacy staff to gain board certification will promote and ensure that the next generation of pharmacists is equipped with the requisite knowledge, core competencies and attitudes to ensure optimal patient safety in oncology pharmacy practice.
Table 1.
The number of pharmacists certified by board of pharmacy specialties in LMICs with BCOP and BCSCP.
| Name of LMIC | Number of pharmacists with BCOP | Number of pharmacists with BCSCP |
|---|---|---|
| Arab Republic of Egypt/ | 5 | 1 |
| Jordan | 3 | 2 |
| Kenya | 1 | 0 |
| Lebanon | 1 | 1 |
| Malaysia | 7 | 0 |
| Pakistan | 1 | 2 |
| Philippines | 0 | 1 |
| Sudan | 1 | 0 |
| Thailand | 29 | 0 |
To initiate the stewardship program, a BCOP pharmacist or head of the department can take a secretarial role of a subcommittee of the pharmacy and therapeutics committee, titled as chemotherapy council (CC), headed by a medical director or chief oncologist. Other members will include oncologists, hematologists, and oncology specialty nurses. The goals of CC will be to approve chemotherapy protocols and forecast the procurement of materials for the patients of a given diagnosis determined to receive the plan. Furthermore, based on in-house or National Comprehensive Cancer Network (NCCN) criteria, assess the suitability of approval of therapy lines, given published randomized control trials, compared to other chemotherapy protocols and address factors such as evidence, cost, quality survival benefit, and feasibility.
A BCSCP pharmacist should design each approved chemotherapy protocol's preparation, dispensing, and administration protocol. Steps should be taken to ensure the safe and effective use of chemotherapy. Some examples include dose rounding and reusability of chemotherapy vials. Others include designing cost-effective pre- and post-medication protocols. Special initiatives should be taken to dispense continuous intravenous infusions where there is an example of blinatumomab which was designed for 48 h of infusion dispensing by pharmacists’ leading to cost-effective initiatives. 8 The pharmacy team can share the impact of cost saving and in long run, return on investment, to focus on the financial implication of resource allocation and utilization. Economic impact carries an essential element for stewardship programs in LMICs.
Though oncology stewardship is new in LMICs, introducing oncology stewardship programs may reduce chemotherapy-related errors and the cost of medications. Implementing a successful oncology stewardship practice in LMICs requires a collaborative approach that includes all multidisciplinary team members.
Footnotes
Authors Contributions: AS and SS conceived the idea and drafted the manuscript. AA and OB made a substantial contribution to the literature review and critically reviewed the manuscript. All authors reviewed and approved the final version of the manuscript.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
ORCID iD: Sunil Shrestha https://orcid.org/0000-0002-9174-7120
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