in Nigeria

U.S. Hem/Onc Pharms Teach, and Learn, in Nigeria

By Dave Doolittle

Cindy O’Bryant, PharmD, didn’t know quite what to expect in the days leading up to a trip to Nigeria late last year that was designed to help strengthen cancer treatment and care in the African nation.

Although she has met several Nigerian healthcare professionals and students as a clinical pharmacy professor at the University of Colorado Anschutz Medical Campus in Aurora, she had no firsthand knowledge of how her colleagues there treated cancer patients.

“They have a wide variety of facilities and resources for oncology pharmacists throughout Nigeria. Some work in modern hospitals that have clean rooms and hoods to make chemotherapy and personal protective equipment,” Dr. Bryant told Pharmacy Practice News. “But in some of these areas, I found that they don’t have any resources: We saw people mixing chemotherapy on a table with no protective equipment, no hood, no anything. It’s pretty amazing the things that they do without to be able to provide care.”

Dr. O’Bryant spent two weeks in Nigeria along with R. Donald Harvey, PharmD, a professor of hematology and medical oncology at Emory University School of Medicine, in Atlanta, Ga., meeting healthcare workers and officials, hosting training sessions and sharing best practices in oncology pharmacy.

The trip was sponsored by the U.S. Embassy’s Fulbright program and organized by Project Pink Blue, a Nigerian nonprofit dedicated to raising cancer awareness and providing resources and support to patients.

“We were brought in to help educate the country’s pharmacists on disease states and to help them learn how to make chemotherapies and sterile techniques—the best way to use protective equipment to do that—and to model what we do as oncology pharmacists here in the United States,” Dr. O’Bryant said. “We also met with the Nigerian health ministry to talk with them about the resources that were needed and the things that would help improve the ability to provide oncology pharmacy services in the country.”

Overcoming Challenges Brings New Ones

Nigeria sits along the western coast of Africa approximately 700 miles north of the equator. It is about twice the size of California with a population of almost 200 million people, making it Africa’s most populated country and the sixth most populated nation in the world. Its healthcare system has faced numerous challenges over the years, exacerbated by climate problems, overpopulation, crumbling infrastructure and a shortage of healthcare professionals, including pharmacists.

Although responding to infectious diseases continues to be a major healthcare struggle, the country has made notable strides in recent years to control outbreaks, facilitated in part by the establishment of the Nigerian Centre for Disease Control in 2011. As a result, “Nigeria has gotten a handle on infectious disease issues that people might have died from earlier,” Dr. O’Bryant said. However, as these patients live longer, “they are developing cancer. So right now, you’re seeing cancer rates going up in Nigeria.”

Since 2013, Project Pink Blue has worked to change how cancer is treated and perceived in Nigeria. It is specifically focused on rural and hard-to-reach areas, which typically do not have the same facilities and resources found in major cities like the capital, Abuja, and Lagos, Nigeria’s largest city. In addition to screenings, Project Pink Blue offers patient support and education as well as fundraising for patient care, research and oncology training. (For more details, see sidebar, page 11.) “[Project Pink Blue is] very savvy about what they have and where they want to be, and they’re very tactical to get there,” Dr. Harvey told Pharmacy Practice News. “They’ve used Fulbright, they’ve used other mechanisms internationally—the [World Health Organization], the UICC [Union for International Cancer Control]—and other international cancer consortium resources to help get them what they need.”

Meeting of the Minds

In Abuja, Drs. O’Bryant and Harvey met separately with members of the Federal Ministry of Health and the U.S. Embassy to discuss overall cancer care in Nigeria, how it is treated in the United States, and how oncology pharmacists from both countries can build relationships and partnerships with organizations like Project Pink Blue. “There were a lot of concerns about what could be done there,” Dr. Harvey said. “A lot of their questions were, ‘What’s our aspirational place to be, and how do we get there?’”

The pair also toured the city’s medical university hospital, where they saw a variety of care procedures, including nurses making chemotherapies at patients’ bedsides and then administering the treatment via drip, Dr. O’Bryant said. “So, again, not a lot of the more modern things we have here with pumps, and relatively limited access to protective equipment,” such as closed system drugtransfer devices, she said. “But they’re doing some very cool things. They have a tumor board where they meet with a multidisciplinary group of physicians and they bring in pharmacists to talk about how to manage their cancer patients.”

In Lagos, Drs. O’Bryant and Harvey toured several hospitals and spent a day with 34 oncology pharmacists from across the country, giving lectures and providing hands-on training on sterile procedures, drug therapies and disease states. “The pharmacists really had the desire to continue to grow their knowledge, and to learn how to handle relationships in all aspects of cancer, not just chemotherapy but also supportive care such as nausea and pain management and other things that have to go along with the care of the patient,” Dr. Harvey said. “The passion was there. There was a deep desire for pharmacists in the country to continue to grow in their work and be the drug expert for cancer patients.”

Problems Persist

Both Drs. O’Bryant and Harvey said their trip was an important step in improving cancer care in Nigeria and in building relationships among pharmacists and other healthcare professionals from both countries. But they also acknowledged that the country has many challenges it must overcome—structurally, politically, economically and socially.

For example, cancer treatment is not covered by insurance in Nigeria, Dr. O’Bryant said, so patients tend to have to pay out of pocket for therapy, unless they work with foundations such as Project Pink Blue. “That can really limit the ability for patients to get care because they’re having to raise money to pay for their own medications,” she said. “There are some government programs that can help them get those at a discounted price, but the weight of that is still falling on the patient.”

In addition, asking family and friends to help pay for medications and treatment can be difficult because of prevalent social stigmas regarding a cancer diagnosis, both pharmacists said. “There are still a lot of thoughts that if you get cancer, that means you’ve done something bad or you’ve been cursed, and the best way to treat your cancer is to go to your religious leader and have

Cancer Care In Nigeriaa 206,139,590

Population

124,815

New cases

233,911

Prevalent cases (5-year)

78,899

Deaths

From left: Jenny Foltz with the U.S. Embassy in Nigeria; R. Donald Harvey, PharmD; Project Pink Blue Executive Director Runcie Chidebe; Cindy O’Bryant, PharmD; and Gloria Olkwu with Project Pink Blue.

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Extravasation Gap

continued from page 1

María Asunción Albert-Marí, PhD, a clinical oncology pharmacist at the Hospital Universitario y Politécnico La Fe, in Valencia, Spain, presented the working group’s proposals at the International Society of Oncology Pharmacy Practitioners (ISOPP) Virtual Symposium in early March.

“Extravasation is a medical emergency because, if not properly and timely managed, [it] can lead to severe consequences,” Dr. Albert-Marí said. “It can impact safety but also can adversely affect quality of life, and if there is a need for cycle delays, it can [degrade] the effectiveness of a therapeutic plan.”

Antineoplastic extravasation is rare, occurring in up to 6% of peripheral infusions and up to 4.7% via the central route (Memo 2016;9[4]:226-230) and has been declining to between 0.05% and 0.5% of all infusions (Tumori 2016;102[3]:290-293), the working group said. But the risks posed still is cause for vigilance, they noted.

The most common symptoms are edema and swelling, which occur in 60% of cases, but serious complications can occur, such as ulceration, necrosis and death.

There are many patient- and administration-based risk factors that can lead to antineoplastic extravasation, from patients with phlebitis or sclerosed veins to multiple venipuncture attempts, mechanical cell compression, inexperienced staff and high workloads, Dr. Albert-Marí said.

Additionally, there are drug-related risk factors for direct cellular toxicity, including concentration and volume extravasated of the medication, she said. For example, cisplatin is classified as a vesicant in doses greater than 0.4 mg/mL and as a high-risk irritant in concentrations lower than 0.4 mg/mL. The working group recommends diluting cisplatin and administering it in minibags to avoid a concentration that can cause potentially fatal extravasations.

Another known drug-related risk factor for extravasations is whether a therapy is a DNA-binding or non–DNA-binding vesicant, Dr. AlbertMarí said. DNA-binding vesicants, such as anthracyclines, amsacrine, dactinomycin and mitomycin, are absorbed locally and cause apoptosis of cells, she noted. “They are not metabolized, and they are liberated again in the extracellular space and also can destroy healthy cells. They produce continuous, chronic and progressive tissue damage.”

Non–DNA-binding vesicants, such as vinca alkaloids, have less necrotizing capability, she said.

Based on data from eight reference documents (guidelines, databases and reference papers), the working group classified various antineoplastic drugs based on their risk for tissue damage, Dr. Albert-Marí said (Table 1).

Table 1. Classification of Antineoplastics Based On Extent of Tissue Injury

Vesicant

amsacrine carmustine dactinomycin daunorubicin doxorubicin epirubicin idarubicin mitomycin mitoxantrone paclitaxel trabectedin vinblastine vincristine vincristine liposomalc vindesine vinflunine vinorelbine bendamustine busulfan cisplatina dacarbazine daunorubicin liposomalc dexrazoxane docetaxel doxorubicin liposomalc (pegylated/ nonpegylated) melphalan oxaliplatin paclitaxel albumin-bound streptozocin trastuzumab emtansine treosulfan arsenic trioxide cabazitaxel carboplatinb etoposideb etoposide phosphate fluorouracilb fotemustine gemcitabine ifosfamide irinotecan irinotecan liposomalc ixabepilone topotecan aflibercept aldesleukin asparaginase azacitidine bleomycin bortezomib brentuximab vedotin carfilzomib cladribine clofarabine crisantaspase cyclophosphamide cytarabine eribulin fludarabine gemtuzumab ozogamicin inotuzumab ozogamicin methotrexate monoclonal antibodies (non-conjugated) nelarabine pegasparaginase pemetrexed pentostatin raltitrexed temsirolimus thiotepa

High-Risk Irritants Low-Risk Irritants Non-Irritant

see EXTRAVASATION, page 10

Table 2. Recommended Extravasation Treatment Guidelines (Peripheral Routea)

Nonpharmacologic Measures

Apply local dry cold compresses (dry cold packs, refrigerated saline bags, or closed bags filled with water to 0°Celsius) as much as tolerated for erythema relief • For LRIs: apply topically for first hour • For vesicants and HRIs: apply for first hour as much as tolerated and then in cycles of 15-20 min 3-4 times daily for 2 to 3 d • Do not apply directly to skin; loss of sensitivity can facilitate cold burns; remove in case of burning sensation, pruritus, or increasing pain • Contraindications: epipodophyllotoxins, hyaluronidase, and vinca alkaloids Apply local dry heat compresses (dry heat packs, electric pads, steam-free iron-heated cloths) • Recommended for vinca alkaloids, etoposide and oxaliplatin; exception: liposomal vincristine • Apply topically for 15-20 min 3-4 times daily for 2 d • Do not apply directly to skin; loss of sensitivity in the area can facilitate burns; remove in case of burning sensation, pruritus, or increasing pain • Contraindications: anthracyclines, bleomycin, carmustine and cisplatin Photoprotection for photosynthesizing drugs, such as cisplatin, dacarbazine, fluorouracil, and mitomycin • Wear long sleeves and avoid sun exposure; do not use OTC creams

Pharmacologic Measures

Apply 99% DMSO to gauze and cover the affected area • Recommended for amsacrine, conventional anthracyclines, dactinomycin, mitomycin, mitoxantrone, carboplatin (C>5 mg/mL), cisplatin (C>0.4 mg/mL or V>20 mL), fluorouracil (high C caused by infusion error, or

V>20 mL) • Apply two 4-cm2 drops of DMSO to 7.5-cm2 gauze and cover the affected area; allow to air-dry 15-20 min and remove; repeat 3-4 times daily for at least 7 d (preferably 14 d) • Avoid applying pressure or bandages • Reduce application times if itching or intolerance occurs • Apply on dry and intact skin because an exothermic reaction can happen with water • Contraindications: not recommended for extravasation of liposomal anthracyclines Administer subcutaneous hyaluronidase around the periphery of the affected area • Recommended for vinca alkaloids, docetaxel, paclitaxel, etoposide (C>10 mg/mL or volume >20 mL); exception: liposomal vincristine • Administer in subcutaneous punctures (25-gauge needle), around the periphery of the affected area, according to the concentration used: –1,500 IU/mL for punctures of 0.1-0.2 mL –150 IU/mL for punctures of 0.2-0.5 mL • Maximum dose: 1,500 IU, usually 5-6 punctures • Administer heat 30 min after hyaluronidase, if needed • Reconstitute formulation of 150 and 1,500 IU with 1 mL • Administration can cause pain; analgesic may be needed Intravenous dexrazoxane for 1 or 2 h within the first 6 h after extravasation for 3 consecutive days • Days 1 and 2: 1,000 mg/m2 (maximum dose, 2,000 mg) • Day 3: 500 mg/m2 (maximum dose, 1,000 mg) • Administer once daily through a large vein located in the contralateral affected arm; if creatinine clearance is >40 mL/min, administer 50% of the dose • Monitor renal, hepatic, and hematologic function; availability depends on institutional or corresponding PTC approval • Contraindicated with simultaneous DMSO and cold; not recommended for use with liposomal anthracyclines • If institutional or PTC approved, dexrazoxane can be used in central or severe extravasation by peripheral route (eg, large volume and concentrated solution)