Use of prescription and nonprescription medications and supplements by cancer patients during chemotherapy: questionnaire validation

A case study of a patient-centered reverse translational systems-based approach to understand adverse event profiles in drug development

Adverse drug reactions (ADRs) of targeted therapy drugs (TTDs) are frequently unexpected and long‐term toxicities detract from exceptional efficacy of new TTDs. In this proof‐of‐concept study, we explored how molecular causation involved in trastuzumab‐induced cardiotoxicity changes when trastuzumab was given in combination with doxorubicin, tamoxifen, paroxetine, or lapatinib. The data analytical platform Molecular Health Effect was utilized to map population ADR data from the US Food and Drug Administration (FDA) Adverse Event Reporting System to chemical and biological databases (such as UniProt and Reactome), for hypothesis generation regarding the underlying molecular mechanisms causing cardiotoxicity. Disproportionality analysis was used to assess the statistical relevance between adverse events of interest and molecular causation. Literature search was performed to compare the established hypotheses to published experimental findings. We found that the combination therapy of trastuzumab and doxorubicin may affect mitochondrial dysfunction in cardiomyocytes through different molecular pathways such as BCL‐X and PGC‐1α proteins, leading to a synergistic effect of cardiotoxicity. We found, on the other hand, that trastuzumab‐induced cardiotoxicity would be diminished by concomitant use of tamoxifen, paroxetine, and/or lapatinib. Tamoxifen and paroxetine may cause less cardiotoxicity through an increase in antioxidant activities, such as glutathione conjugation. Lapatinib may decrease the apoptotic effects in cardiomyocytes by altering the effects of trastuzumab on BCL‐X proteins. This patient‐centered systems‐based approach provides, based on the trastuzumab‐induced ADR cardiotoxicity, an example of how to apply reverse translation to investigate ADRs at the molecular pathway and target level to understand the causality and prevalence during drug development of novel therapeutics.

Prevalence of potential interactions of medications, including herbs and supplements, before, during, and after chemotherapy in patients with breast and prostate cancer

BACKGROUND

The use of herbs and supplements (HS) is common among patients with cancer, yet limited information exists about potential medication interactions (PMIs) with HS use around chemotherapy.

METHODS

Patients with breast or prostate cancer who had recently finished chemotherapy at 2 academic medical centers were surveyed by telephone. Interviewers inquired about all medications, including HS, before, during, and after chemotherapy. Micromedex, Lexicomp, and Natural Medicines Comprehensive Database interaction software programs were used to determine PMIs.

RESULTS

A total of 67 subjects (age range, 39-77 years) were evaluated in this study. Participants were primarily White patients (73%) with breast cancer (87%). The median number of medications was 11 (range, 2-28) during the entire study and was highest during chemotherapy (7; range, 2-22). Approximately four-fifths (84%) used HS. A total of 1747 PMIs were identified, and they represented 635 unique PMIs across all 3 timeframes, with most occurring during chemotherapy. Prescription-related PMIs (70%) were the most common type, and they were followed by HS-related (56%) and anticancer treatment-related PMIs (22%). Approximately half of the PMIs (54%) were categorized as moderate interactions, and more than one-third (38%) were categorized as major interactions. Patient use of HS increased from 51% during chemotherapy to 66% after chemotherapy, and this correlated with an increased prevalence of HS PMIs (46% to 60%). HS users were more likely to be at risk for a major PMI than non-HS users (92% vs 70%; P = .038).

CONCLUSIONS

The use of HS remains prevalent among patients with cancer and may place them at risk for PMIs both during chemotherapy and after the completion of treatment.

LAY SUMMARY

This study evaluates the risk of potential medication interactions for patients with breast or prostate cancer undergoing chemotherapy. The results show that patients often use herbs and supplements during treatment. Prescription medications are most often associated with medication interactions, which are followed by herb and supplement-related interactions. More than one-third of potential medication interactions are considered major. Patients should be educated about the risk of herb and supplement-related medication interactions during treatment.

New tricks of old drugs: Repurposing non-chemo drugs and dietary phytochemicals as adjuvants in anti-tumor therapies

Combination therapy has long been applied to enhance therapeutic effect and deal with the occurrence of multi-drug resistance in cancer treatment. However, the overlapping toxicity of multiple anticancer drugs to healthy tissues and increasing financial burden on patients emerged as major concerns. As promising alternatives to chemo agents, repurposed non-chemo drugs and dietary phytochemicals have been investigated as adjuvants to conventional anti-tumor therapeutics, offering a safe and economic strategy for combination therapy. In this review, we aim to highlight the advances in research about combination therapy using conventional therapeutics and repurposed drugs or phytochemicals for an enhanced anti-tumor efficacy, along with the mechanisms involved in the synergism. Beyond these, we outlined the potential challenges and solutions for clinical translation of the proposed combination therapy, providing a safe and affordable strategy to improve the reach of cancer therapy to low income regions with such new tricks of old drugs.

Shared Care During Breast and Colorectal Cancer Treatment: Is It Associated With Patient-Reported Care Quality?

There is growing evidence that shared care, where the oncologist, primary care physician, and/or other specialty physicians jointly participate in care, can improve the quality of patients' cancer care. This cross-sectional study of breast and colorectal cancer patients (N = 534) recruited from the New Jersey State Cancer Registry examined patient and health system factors associated with receipt of shared care during cancer treatment into the early survivorship phase. We also assessed whether shared care was associated with quality indicators of cancer care: receipt of comprehensive care, follow-up care instructions, and written treatment summaries. Less than two-thirds of participants reported shared care during their cancer treatment. The odds of reporting shared care were 2.5 (95% CI: 1.46-4.17) times higher for colorectal than breast cancer patients and 52% (95% CI: 0.24-0.95) lower for uninsured compared with privately insured, after adjusting for other sociodemographic, clinical/tumor, and health system factors. No significant relationships were observed between shared care and quality indicators of cancer care. Given a substantial proportion of patients did not receive shared care, there may be missed opportunities for integrating primary care and nononcology specialists in cancer care, who can play critical roles in care coordination and managing comorbidities during cancer treatment.

Oncology pharmacist-led medication reconciliation among cancer patients initiating chemotherapy

BACKGROUND

Pharmacist-led medication reconciliation (PMR) ensures adequate recording and use of medications by patients. PMR may be important for cancer patients initiating new therapies, as they have a high burden of medication use and are more susceptible to inadvertent medication discrepancies. To describe medication changes (additions, discontinuations, and modifications) made to the electronic health record during a PMR among cancer patients initiating chemotherapy.

METHODS

From October 2011 to March 2012, 397 cancer patients initiating chemotherapy underwent a PMR at the University of North Carolina Cancer Hospital. Self-reported medications and those in the patients' electronic health record were reviewed. Log-binomial regression models were used to estimate adjusted prevalence ratios and 95% confidence intervals for the associations between patient characteristics and medication changes made to the electronic health record.

RESULTS

Mean age at time of the PMR was 58. Median number of medications taken prior to the PMR was 10 and median time to PMR completion was 11 min. Vitamins and herbal supplements accounted for the largest proportion of medication additions (38%) and modifications (20%). Antimicrobials accounted for the largest share of discontinuations (15%). After adjustment for all other covariates, patients aged 60-69 years were more likely to have additions than those aged 50 and under (aPR = 1.47, 95%CI: 1.10-1.97). Patients 70 years and over were more likely to have modifications (aPR = 1.74, 95%CI: 1.07-2.82).

CONCLUSION

Our results show that most cancer patients had a medication change in the electronic health record. A brief oncology PMR can accurately capture and improve medication safety by preventing prescribing and administration errors.

Adherence to Lenalidomide in Older Adults With Newly Diagnosed Multiple Myeloma

INTRODUCTION

One of the most common orally administered antimyeloma agents, lenalidomide, has significantly improved outcomes in multiple myeloma, including in older patients. However, despite its utilization and cost, the rates and factors related to adherence to lenalidomide in older adults with newly diagnosed multiple myeloma remain unknown.

PATIENTS AND METHODS

Data were collected from adults with newly diagnosed multiple myeloma over age 65 years being treated with lenalidomide therapy between the years 2007 and 2014 in the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked databases. Adherence was measured as medication possession ratio (MPR), which was defined as the ratio of the number of days the patient had pills in their possession to the number of days in the observation period in the first year after myeloma diagnosis. MPR of < 90% was considered poor adherence.

RESULTS

A total of 793 patients were included in the analysis. The mean MPR in our cohort was 89.5 ± 9.3%. Overall, 38% (n = 302) of the patients were considered to have poor adherence. Factors associated with poor adherence included increasing age (adjusted odds ratio [aOR] = 1.03 per year; 95% confidence interval [CI], 1.00-1.05; P = .024), black race (aOR = 1.72; 95% CI, 1.08-2.73; P = .022), and polypharmacy (aOR = 1.04 per medication; 95% CI, 1.01-1.08; P = .008).

CONCLUSION

Over a third of older adults with newly diagnosed multiple myeloma were considered to have poor adherence to lenalidomide, using the MPR as a surrogate for adherence. This highlights the need to further understand factors and devise strategies to support adherence in this patient cohort.

Polypharmacy in Patients with Ovarian Cancer

OBJECTIVE

Polypharmacy has been associated with morbidity and mortality in patients with cancer. Data about polypharmacy among patients with ovarian cancer are limited. The primary objective of this study was to evaluate polypharmacy in a cohort of patients with ovarian cancer and to assess the evolution of polypharmacy from initial presentation to 2 years posttreatment. A secondary objective was to evaluate differences in polypharmacy between a subset of patients primarily treated in our comprehensive cancer center (CCC) and our safety net hospital (SNH).

METHODS

Women treated for ovarian cancer between January 1, 2011, and December 31, 2016, were included. Data were abstracted from the electronic medical record. Medication safety was assessed using the established Anticholinergic Burden (ACB) scale and the Beers criteria. Statistical analyses were performed using paired t tests and Cox proportional hazards models, with significance set at p < .05.

RESULTS

The study included 152 patients. The majority of patients had high-grade serous carcinoma. Hypertension was the most common medical problem. The mean number of medications at the time of diagnosis was 3.72. Paired testing demonstrated significant patient-level increases in the number medications at 2 years following initial diagnosis (4.16 vs. 7.01, p < .001). At the CCC, 47.4% of patients met criteria for polypharmacy at diagnosis compared with 19.4% at the SNH (p < .001). By 2 years postdiagnosis, 77.6% of patients at the CCC met criteria for polypharmacy compared with 43.3% at the SNH (p = .001). The use of any medications on the ACB scale (p < .001) increased significantly between initial diagnosis and 2 years for the entire population. Polypharmacy was not a significant predictor of overall survival.

CONCLUSION

Polypharmacy worsens as women go through ovarian cancer treatment. Both at initial presentation and at 2 years postdiagnosis, rates of polypharmacy were higher at the CCC. Polypharmacy did not have an effect on survival in this cohort.

IMPLICATIONS FOR PRACTICE

Awareness of escalating numbers of medications and potentially adverse interactions is crucial among women with ovarian cancer, who are at high risk for polypharmacy.

Metabolomics Approach for Validation of Self-Reported Ibuprofen and Acetaminophen Use

Over-the-counter analgesic use is common and is typically assessed through self-report; therefore, it is subject to misclassification. Detection of drug metabolites in biofluids offers a viable tool for validating self-reported analgesic use. Thus, the aim of this study was to determine the utility of a metabolomics approach for the validation of acetaminophen and ibuprofen use in blood samples. Untargeted mass spectrometry-based metabolomics analysis was conducted in serum samples from 1547 women and plasma samples from 556 men. The presence of two metabolites each for acetaminophen and ibuprofen at levels at or above a defined cutoff value was used to determine concordance with self-reported use. For acetaminophen use based on the presence of both acetaminophen and acetamidophenylglucuronide, concordance was 98.5–100% among individuals reporting use today, and 79.8–91.4% for those reporting never or rare use. Ibuprofen use based on the presence of both carboxyibuprofen and hydroxyibuprofen resulted in concordance of 51.3–52.5% for individuals reporting use today and 99.4–100% for those reporting never or rare use. Our findings suggest that an untargeted metabolomics approach in blood samples may be useful for validating self-reported acetaminophen use. However, this approach appears unlikely to be suitable for validating ibuprofen use.

Use of prescription drugs among women diagnosed with epithelial ovarian cancer in Denmark

INTRODUCTION

Epithelial ovarian cancer patients often suffer from chronic diseases requiring drug treatment. We assessed temporal patterns of drug use among women with ovarian cancer.

MATERIAL AND METHODS

We identified all postmenopausal women with epithelial ovarian cancer in Denmark 2005-2012 and a comparison cohort of age-matched women without cancer. We calculated rates of new drug treatment and total drug use and examined use of new and prevalent drugs before and after diagnosis. Analyses were stratified by histological type and stage of epithelial ovarian cancer.

RESULTS

We identified 2742 patients. The rate of new drug treatment increased from 3 to 5 months before diagnosis and peaked in the first month after diagnosis at 99 new types of drug therapy per 100 individuals (mainly antiemetics, proton-pump inhibitors, hypnotics, and opioids). Although declining, the rate of new drug use remained substantially higher among epithelial ovarian cancer patients than among controls throughout the 3-year postdiagnosis follow-up period. The number of prevalent drugs increased slightly from a median of 4 drugs (interquartile range 2-7) before diagnosis to 5 drugs (interquartile range 2-8) shortly after the diagnosis. The use of preventive drugs decreased only slightly after diagnosis. In stratified analyses, we found limited variation according to histological type, whereas patterns were slightly more pronounced among women with nonlocalized disease compared with localized disease.

CONCLUSIONS

Drug use among postmenopausal women with epithelial ovarian cancer was substantial and varied considerably in relation to the time of cancer diagnosis, although only limited changes were seen in the use of preventive medicines.

Multimorbidity patterns in relation to polypharmacy and dosage frequency: a nationwide, cross-sectional study in a Japanese population

In the present study, we aimed to identify multimorbidity patterns in a Japanese population and investigate whether these patterns have differing effects on polypharmacy and dosage frequency. Data was collected on 17 chronic health conditions via nationwide cross-sectional survey of 3,256 adult Japanese residents. Factor analysis was performed to identify multimorbidity patterns, and associations were determined with excessive polypharmacy [concurrent use of ≥ 10 prescription or over-the-counter (OTC) medications] and higher dosage frequency ( ≥ 3 doses per day). Secondary outcomes were the number of concurrent prescription medications and the number of concurrent OTC medications. We used a generalized linear model to adjust for individual sociodemographic characteristics. Five multimorbidity patterns were identified: cardiovascular/renal/metabolic, neuropsychiatric, skeletal/articular/digestive, respiratory/dermal, and malignant/digestive/urologic. Among these patterns, malignant/digestive/urologic and cardiovascular/renal/metabolic patterns showed the strongest associations with excessive polypharmacy and the number of concurrent OTC medications. Malignant/digestive/urologic, respiratory/dermal, and skeletal/articular/digestive patterns were also associated with higher dosage frequency. Multimorbidity patterns have differing effects on excessive polypharmacy and dosage frequency. Malignant/digestive/urologic pattern may be at higher risk of impaired medication safety and increased treatment burden, than other patterns. Continued study is warranted to determine how to incorporate multimorbidity patterns into risk assessments of polypharmacy and overall treatment burden.

Integrated safety analysis of rolapitant with coadministered drugs from phase II/III trials: an assessment of CYP2D6 or BCRP inhibition by rolapitant

BACKGROUND

Rolapitant, a long-acting neurokinin (NK)1 receptor antagonist (RA), has demonstrated efficacy in prevention of chemotherapy-induced nausea and vomiting in patients administered moderately or highly emetogenic chemotherapy. Unlike other NK1 RAs, rolapitant does not inhibit or induce cytochrome P450 (CYP) 3A4, but it does inhibit CYP2D6 and breast cancer resistance protein (BCRP). To analyze potential drug-drug interactions between rolapitant and concomitant medications, this integrated safety analysis of four double-blind, randomized phase II or III studies of rolapitant examined adverse events (AEs) by use versus non-use of drug substrates of CYP2D6 or BCRP.

PATIENTS AND METHODS

Patients were randomized to receive either 180 mg oral rolapitant or placebo ∼1-2 h before chemotherapy in combination with a 5-hydroxytryptamine type 3 RA and dexamethasone. Data for treatment-emergent AEs (TEAEs) and treatment-emergent serious AEs (TESAEs) during cycle 1 were pooled across the four studies and summarized in the overall population and by concomitant use/non-use of CYP2D6 or BCRP substrate drugs.

RESULTS

In the integrated safety population, 828 of 1294 patients (64%) in the rolapitant group and 840 of 1301 patients (65%) in the control group experienced at least one TEAE. Frequencies of common TEAEs were similar in the rolapitant and control populations. Overall, 53% of patients received CYP2D6 substrate drugs, none of which had a narrow therapeutic index (like thioridazine or pimozide), and 63% received BCRP substrate drugs. When grouped by concomitant use versus non-use of CYP2D6 or BCRP substrate drugs, TEAEs and TESAEs occurred with similar frequency in the rolapitant and control populations.

CONCLUSIONS

The results of this study support the safety of rolapitant as part of an antiemetic triple-drug regimen in patients receiving emetogenic chemotherapy, including those administered concomitant medications that are substrates of CYP2D6 or BCRP, such as ondansetron, docetaxel, or irinotecan.

The impact of pharmacist telephone calls after discharge on satisfaction of oncology patients: A randomized controlled study

Purpose

The aim of the study was to determine the impact of telephone follow-up calls on satisfaction in oncology patients after hospital discharge.

Method

A randomized controlled study, in which patients were randomized into two groups: The experimental group with the telephone follow-up (TFU) calls (intervention) and the control group (no intervention). The telephone follow-up call was conducted within 72 h after discharge. During the call, patients were asked about their medications, namely, whether they received them, understood how to take them, and whether they developed any medication-related adverse effect. Both groups were contacted by phone two weeks later to assess their satisfaction with the discharge medication instructions and the provided pharmaceutical services, using the 5-point Likert scale. In addition, hospital records were reviewed for emergency room visits and hospital readmissions within 30 days after discharge.

Results

There was no difference in the percentage of patients who reported being very satisfied between both the intervention and the control groups (45% intervention vs. 48% control, P = 0.68). The mean time of the intervention phone call was 3 ± 1.7 (SD) min. During the telephone follow-up call, medication-related problems were identified in 20% of the patients. There was no significant difference in emergency room visits and hospital readmissions in the intervention group vs. control (44% vs. 53%, P = 0.123) and (37% vs. 43%, P = 0.317), respectively.

Conclusion

Telephone follow-up calls conducted by a pharmacist to discharged oncology patients did not improve patients' satisfaction, emergency room visits or hospital readmissions; however, they helped to identify medication-related adverse effects in the oncology patients.

Polypharmacy and potentially inappropriate medication use in geriatric oncology

Polypharmacy is a highly prevalent problem in older persons, and is challenging to assess and improve due to variations in definitions of the problem and the heterogeneous methods of medication review and reduction. The purpose of this review is to summarize evidence regarding the prevalence and impact of polypharmacy in geriatric oncology patients and to provide recommendations for assessment and management. Polypharmacy has somewhat variably been incorporated into geriatric assessment studies in geriatric oncology, and polypharmacy has not been consistently evaluated as a predictor of negative outcomes in patients with cancer. Once screened, interventions for polypharmacy are even more uncertain. There is a great need to create standardized interventions to improve polypharmacy in geriatrics, and particularly in geriatric oncology. The process of deprescribing is aimed at reducing medications for which real or potential harm outweighs benefit, and there are numerous methods to determine which medications are candidates for deprescribing. However, deprescribing approaches have not been evaluated in older patients with cancer. Ultimately, methods to identify polypharmacy will need to be clearly defined and validated, and interventions to improve medication use will need to be based on clearly defined and standardized methods.

Potential drug interactions and chemotoxicity in older patients with cancer receiving chemotherapy

PURPOSE

Increased risk of drug interactions due to polypharmacy and aging-related changes in physiology among older patients with cancer is further augmented during chemotherapy. No previous studies examined potential drug interactions (PDIs) from polypharmacy and their association with chemotherapy tolerance in older patients with cancer.

METHODS

This study is a retrospective medical chart review of 244 patients aged 70+ years who received chemotherapy for solid or hematological malignancies. PDI among all drugs, supplements, and herbals taken with the first chemotherapy cycle were screened for using the Drug Interaction Facts software, which classifies PDIs into five levels of clinical significance with level 1 being the highest. Descriptive and correlative statistics were used to describe rates of PDI. The association between PDI and severe chemotoxicity was tested with logistic regressions adjusted for baseline covariates.

RESULTS

A total of 769 PDIs were identified in 75.4% patients. Of the 82 level 1 PDIs identified among these, 32 PDIs involved chemotherapeutics. A large proportion of the identified PDIs were of minor clinical significance. The risk of severe non-hematological toxicity almost doubled with each level 1 PDI (OR=1.94, 95% CI: 1.22-3.09), and tripled with each level 1 PDI involving chemotherapeutics (OR=3.08, 95% CI: 1.33-7.12). No association between PDI and hematological toxicity was found.

CONCLUSIONS

In this convenience sample of older patients with cancer receiving chemotherapy we found notable rates of PDI and a substantial adjusted impact of PDI on risk of non-hematological toxicity. These findings warrant further research to optimize chemotherapy outcomes.

Drug interactions and the pharmacist: focus on everolimus

OBJECTIVE

To evaluate everolimus drug-drug and drug-food interactions, with an emphasis on patients with cancer.

DATA SOURCES

Literature was accessed through PubMed (1990-March 2013) using Boolean combinations of the terms drug interactions, herb-drug interactions, food-drug interactions, everolimus, antineoplastic agents, hormonal, and breast neoplasms. In addition, reference citations from publications and the prescribing information for everolimus were reviewed.

STUDY SELECTION AND DATA EXTRACTION

All articles published in English, including human, animal, and in vitro studies, identified from the data sources were included.

DATA SYNTHESIS

Patients with cancer are at increased risk for drug interactions because of the multiple medications they are prescribed to treat their disease and comorbid conditions. Everolimus, an oral mammalian target of rapamycin (mTOR) inhibitor, is indicated for the treatment in adults with progressive neuroendocrine tumors of pancreatic origin that are unresectable, locally advanced, or metastatic; adults with advanced renal cell carcinoma after failure of treatment with sunitinib or sorafenib; and, recently, postmenopausal women with advanced hormone receptor-positive, human epidermal growth factor receptor 2-negative breast cancer in combination with exemestane after failure of treatment with letrozole or anastrozole. As its use increases among patients with cancer, clinicians must be knowledgeable about potential drug and/or food/nutrient interactions and the mechanisms by which these interactions occur, to mitigate and prevent unwanted reactions and ensure patient safety.

CONCLUSIONS

Everolimus is a widely used oral mTOR inhibitor that has the potential for drug interactions that may affect therapeutic outcomes, produce toxicities, or both. This article provides a review of evidence-based literature, along with the prescribing information, to educate clinicians on the significance of these drug interactions and their impact on management with everolimus.

A pilot study of website information regarding aromatase inhibitors: dietary supplement interactions

OBJECTIVES

Patients who have hormone receptor-positive breast cancer and who are taking aromatase inhibitors (AIs) should understand the benefits and risks of concomitant dietary supplement (DS) use. The International Society for Integrative Oncology (SIO) encourages patients to discuss DS use with their health care practitioners. The objective was to conduct a pilot study rating Internet websites from the perspective of health care practitioners for information about AI-DS interactions.

DESIGN

Five (5) Internet websites suggested by SIO were evaluated using the DISCERN instrument rating tool. The available AI-DS information on these websites was rated by 4 evaluators: 2 naturopathic doctors, 1 oncology pharmacy resident, and a pharmacy student.

RESULTS

The overall rankings ranged from 1.6 to 3.9, with considerable variability in the type of information available from the websites. The interevaluator rankings of the websites ranged from 0.44 to 0.89. The evaluators consistently found the most reliable, unbiased, and comprehensive information on AI-DS interactions at the Natural Medicines Comprehensive Database and Memorial Sloan-Kettering Cancer Center websites. However, more than one database was needed for provision of optimal patient information on AI-DS interactions.

CONCLUSIONS

In order to effectively advise patients regarding AI-DS interactions, more than one website should be evaluated to assess the potential efficacy and safety of DS in women whose breast cancer is being treated with an AI.

Polypharmacy in elderly patients with cancer: clinical implications and management

More and more elderly people with cancer are treated in oncology clinics worldwide every year, many of whom have comorbid disorders treated with one or more drugs. Moreover, these patients might also take self-prescribed over-the-counter drugs or complementary and alternative medicines, which they might not tell their doctor about. Initiation of chemotherapy with one or more cytotoxic or targeted agents and drugs for treatment of cancer symptoms or toxic effects related to treatment can result in polypharmacy. We examine the clinical implications of polypharmacy. Challenges for the medical teams who treat elderly patients with cancer include identification of what drugs are actually being taken by the patient, avoidance or management of any adverse effects or drug interactions, and reassessing the patient's overall treatment. We address these issues and propose practical recommendations for management of treatment for elderly patients with cancer.

Optimizing chemotherapy: concomitant medication lists

Identifying sources of variability in the response to cancer chemotherapy requires knowledge of all variables, including concomitant medications, that can alter the metabolism and pharmacokinetics of chemotherapy. This study investigated the accuracy of the lists of concomitant medications in the charts of cancer patients. Information collated from a questionnaire, patient interview, and the patient's medical chart was used to obtain validated medication lists. Patients took an average of 4.8 prescription drugs, 1.6 nonprescription drugs, and 1.6 other remedies within the 3 days prior to chemotherapy. Of the concomitant drugs actually taken, the medical records did not report 24% of prescription drugs, 84% of nonprescription drugs, and 83% of other remedies. Electronic medical records (EMRs) were more complete than paper charts, but even these omitted >75% of nonprescription drugs and other remedies. Potential drug interactions were noted in this study. This study documents the extent and complexity of the concomitant drugs taken by patients undergoing chemotherapy and the deficiencies in recording this information in medical charts.