October is American Pharmacists Month. The American Pharmacists Association has declared this year’s theme “Caring for Our Communities.” This theme leads us to the role of the pharmacist in community oncology.

The role of pharmacists in the Community Oncology Alliance (COA) member practices is expansive, and they do much more than just dispense medication. Each day, they work directly with the entire health care team from diagnosis to survivorship to source the most effective treatments and provide support, educate patients, and navigate the complexities of pharmacy benefit managers, payer mandates, insurer policies, and prior authorizations to ensure patients with cancer have access to the proper medication in a safe and timely manner throughout their cancer care journey.

COA’s Director of Patient Advocacy and Education Rose Gerber, MS, was joined by Judy Alberto, MHA, RPh, BCOP, COA’s director of clinical initiatives, and Lisa Sowinski-Raff, PharmD, MS Pharm, BCPS, BCOP, OneOncology’s vice president of pharmacy services, to discuss pharmacists’ day-to-day activities in a community oncology practice. Attendees learned how pharmacists ensure patients receive the most effective treatment with minimal side effects and advocate for patients by working to lower prescription costs and address pharmacy benefit manager (PBM) issues.

The Role of Pharmacists  

Judy’s role as a pharmacist and director of clinical initiatives is focused on education. She oversees the Community Oncology Pharmacy Association (COPA), the launch of our new COA Advanced Practice Provider Network (CAPP), and the clinically integrated network (CIN). This includes a good deal of PBM and policy issues.

Lisa leads pharmacy services at OneOncology, a national network of leading oncology practices. She oversees a clinical arm that includes pharmacy and therapeutics committees and pathways, clinical decision tools to help providers determine the available treatment options, and an operational arm that offers practice support when dealing with PBMs, in-office dispensing, practice operations issues, and advocacy.

Pharmacists’ Changing Role Over the Past Decades

Most people are familiar with the pharmacist behind the counter at their local drugstore. That individual typically has a doctorate and often has done additional study and training before completing his or her education. He or she may even have additional certification in various specialty areas, such as oncology. Historically, pharmacists were in retail settings where they were thought to be limited to counting pills as determined by a physician’s prescription or stuck in the basement of a hospital preparing prescriptions for patients. The pharmacist’s role expanded with the advent of in-office dispensing (IOD).

Their advanced training makes the pharmacist in an IOD oncology practice a critical part of the care team when it comes to matters such as dosing or tailoring drug therapy to accommodate a patient’s cancer, as well as other conditions that may compromise the liver or kidneys, for example. The pharmacist is often involved in modifying treatment in cases of blood count changes, adverse side effects like nausea or fatigue, and other conditions that arise during treatment. The pharmacist often educates the patient, the caregivers, and/or family members so that everyone involved understands the nature of the treatment. They have become an integral part of the cancer care team, allowing all members to practice at the top of their license.

Though part of the team, pharmacists have played a background role. With the development of biomarkers and the increased complexity of infused therapies, pharmacists’ roles have become more complex. Often, their role makes them the cancer care team expert in medication management.

The IOD pharmacist is also responsible for developing and maintaining the practice’s inventory so when physicians prescribe drugs, the appropriate drugs and doses of those drugs are available. These pharmacists will also monitor patients in ongoing treatment to ensure compliance, check for adverse events, and continually review the drug treatment’s efficacy.

Pharmacists are also key participants and drivers of the Expanded Access Program (EAP). The EAP is a Food and Drug Administration (FDA) program allowing patients with serious or life-threatening conditions to access investigational medical products outside of clinical trials. This program is also known as “compassionate use.” EAPs are for patients who do not qualify for clinical trials or have other alternative therapies. This could be because they live in a remote area, do not meet the entry criteria, or there is no ongoing trial for their disease.

The Pharmacists’ Role in Practice Dynamics 

Oral oncolytics are the future of cancer care, and having IOD and a pharmacist as part of the practice has become increasingly valuable. Though the newest form of care and highly effective, they can often be no less toxic than infused drugs. Monitoring by the pharmacist is important. Unlike infusion treatment, the patient is not physically in the practice, so knowing their status is equally important but more complicated. This falls to the pharmacist who monitors such factors as:

• When did the patient receive the drug?
• When did they begin taking the drug?
• Is the patient dose compliant?
• If toxicity develops, when did it develop?
• What was the dose at the occurrence of the toxicity?

The pharmacist will review all this information and how to modify treatment relative to the toxicity. This is particularly important when practices are forced to use external pharmacies.

IOD pharmacies tend to be more judicious about dispensing oral drugs that are often extremely expensive. For example, they are more likely to avoid dispensing a 90-day supply when the patient’s ability to tolerate the drug is not known. They are more likely to dispense a drug sooner, getting it to the patient sooner, thus allowing the patient to begin treatment sooner. Finally, internal pharmacies do not auto refill expensive drugs without knowing the patient’s status, thereby decreasing the financial toxicity caused by supplying no longer necessary, high-cost drugs.

How Prior Authorization and External Pharmacies Affect Patient Care 

For the patient, receiving a prescription via mail may sound like a better option than getting it at the practice – “I don’t have to do anything.” However, this does not consider the monitoring and support necessary when taking powerful oral cancer drugs.

Mail-order prescriptions may take as much as two weeks to get to the patients, delaying the onset of care. Once receiving a diagnosis, patients are nearly universal in their desire to begin treatment as quickly as possible. That delay can be the difference between disease control and disease progression or could cause a delay that precludes curative treatment. There’s not a pharmacist from the mail-order pharmacy that monitors weekly or monthly labs, making the patient’s status unknown. They are unaware if the drug needs to be dose reduced or what adverse events may be occurring. Automatically arriving refills can confuse patients about what they are supposed to take or when they should be taking that dose. These are issues an IOD pharmacist monitors when a drug is dispensed within the practice.

Auto refills sent by PBMs can create problems beyond actual treatment. Once a refill has been dispensed, patients cannot return a drug they no longer need because of treatment changes. The cost of oral drugs can run up to $15,000 per month. This auto refill creates waste and increases the cost of these expensive drugs to both the patient and the health care system. The financial toxicity caused by this waste drives up the cost of care for the individual patient and the health care system.

Q&A: How does What method of communicatgion is available to a patient communicate with their IOD pharmacist?

Patients can call or email their IOD pharmacist when they have problems or questions. The pharmacist, in turn, has access to the patient’s medical record, as do the other members of the care team. Patient access to their pharmacist, who often knows them on a first-name basis, is immediate.

Q&A: How can a practice dispense in-house?

Patients treated in a community oncology practice have access to an IOD pharmacy and its pharmacist(s). Patients treated in a hospital-based cancer center get their drugs through the hospital’s specialty pharmacy, which may or may not be located on campus..

Q&A: What is the role of the in-house pharmacist with IV drugs?

The in-house pharmacist can manage and adjust dosing on infused (IV) drugs. They are also available to manage toxicity and adverse events as they occur during chemotherapy in the office or later once the patient has left the office. This frees up physician, nurse, and advanced practitioner time while still giving the patient access, through the pharmacist, to contribute to their care decisions.

Q&A: What are brown, white, and clear bagging?

Brown bagging is the shipment of IV drugs to the patient’s home for the patient to bring to the practice for IV treatment. This should never occur. In this case, the proper handling of the drug can never be authenticated because the chain of custody is unknown.

White bagging is where drugs are sent to the practice for dispensing to a specific patient in the office and is only slightly less problematic. Again, chain of custody can be difficult to maintain and determine.

Clear bagging occurs when a cancer center is in a hospital system, and the specialty pharmacy sends the drug to the cancer center.

Many practices, in the interest of patient safety, have established policies to refuse brown and white bagging of drugs.

Q&A: Is COA involved in action to make co-pay accumulators illegal?

Yes. COA’s 2025 policy initiatives involve federal and state actions to make co-pay accumulators illegal.

Q&A: What role does the pharmacist play in checking biomarker results?

Pharmacists are well versed in reading next-generation sequencing (NGS) reports, which reveal cancer biomarkers. They can look at NGS reports and identify therapies for which a patient might potentially qualify for, depending on where they are in their treatment journey.

Summary

Advocacy Chats are regular virtual 30-minute educational conversations about cancer advocacy and policy. Each month features a new topic and special guests joining us. Patients, survivors, caregivers, and other cancer care advocates are all invited to join us for these no-charge and interactive virtual events. Summaries of previous Advocacy Chats are available on the CPAN website.