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Purpose: To track and analyze the growth of 12 Board of Pharmacy Specialties (BPS) specialties from 2008 to 2020 and, subject to criteria, to project specialty numbers through 2025. The analysis considered residency data and Bureau of Labor Statistics projections., Methods: BPS data were used to determine numeric growth, growth rates, and trends for 12 BPS specialties from 2008 to 2020. Specialties begun after 2008 were analyzed from their start date. For specialties with more than 2 data points and coefficients of determination greater than 0.80, we calculated projections through 2025. We also estimated the percentage of BPS-certified pharmacists with postgraduate year 1 training., Results: BPS-certified pharmacists grew in number from 3,004 (2008) to 41,802 (2020), an over 13-fold increase. Currently, 4 of the 5 largest specialties (pharmacotherapy, ambulatory care, oncology, and critical care) continue to grow at a fast rate. Pharmacotherapy experienced the largest numeric growth (20,624) despite the ongoing introduction of new specialties. Critical care and infectious diseases had the highest growth rates (both 32%). We were able to make projections for 10 of 12 specialties, with greater than 62,000 certifications projected by 2025. Growth to these projected levels will require more residencies and more certification preparation opportunities. Residency-trained BPS specialists currently constitute slightly less than 50% of the BPS-certified population., Conclusion: Specialization in the pharmacy profession is growing at a rapid pace. As more clinical privileges are approved, the demand for more specialized pharmacists will likely continue to increase. Data from this study document the growth of the pharmacy specialty workforce. The data and analysis can be used to estimate potential pharmacist contributions across the healthcare spectrum in clinical areas where BPS-certified pharmacists practice., (© American Society of Health-System Pharmacists 2022. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: The purpose of this study was to identify trends in oncology care that allow one to forecast workforce supply and demand, the training and skills needed by the oncology pharmacist for the likely future of oncology care., Methods: Interviews were conducted with experienced oncology pharmacists in leadership roles at 20 organizations balanced by geographic region and type of practice site (academic or community/ambulatory). Results were analyzed using descriptive statistics and theme identification., Results: Practice sites differed widely in numbers of patient visits, practitioner/patient ratios, residency program presence, and other structural features. Despite this, the majority reported an expectation of growth in cancer patients, oncology physicians, oncology pharmacists, pharmacy technicians, oncology nurses, and advanced practice practitioners in the next two to five years. Fifty percent of sites currently support Post Graduate Year 2 (PGY2) oncology residencies. At least 50% reported routine pharmacist involvement in 12 clinical functions. More future involvement was predicted for immunotherapy (80%) and oral oncolytic therapy (90%). Interprofessional involvement was reported for a broad variety of practice-related committees and patient education teams. Limited pharmacist involvement in credentialing, quality measurement, and value-based reimbursement systems was found., Conclusion: Anticipated increases in demand for oncology pharmacists strongly suggest the need for more PGY2 oncology residency programs and on-the-job oncology training programs. Oncology pharmacists are currently involved in many clinical and administrative functions including multidisciplinary management. While a core set of clinical functions has been identified, oncology pharmacists must prepare for the increased use of oral oncology agents and immunotherapy. Pharmacist involvement in value-based reimbursement and other data-based quality outcome measurements should be increased to optimize involvement in team-based patient care.

Purpose: Guidelines have been constructed to optimize the management of patients at risk of developing postoperative nausea and vomiting or postdischarge nausea and vomiting (PONV/PDNV), including the 2002 American Society of Anesthesiologists (ASA) recommendations, the 2006 guidelines assembled by an American Society of PeriAnesthesia Nurses task force (ASPAN), and another set published in 2007 with the support of the Society for Ambulatory Anesthesia (SAMBA). The recommendations set forth are reviewed., Summary: Patient risk factors have been identified that are associated with higher incidences of PONV. For prophylaxis of PONV in high-risk patients, combinational and multimodal therapies with as many as three interventions, including a 5-HT(3)-based therapy and other antiemetic agents with different mechanisms of action, were advocated by guidelines and systematic reviews; specific pharmacotherapies and other interventions were recommended, as well as a treatment algorithm. The number of antiemetic agents prescribed should be appropriate for the individual's risk level, once again emphasizing the importance of patient risk stratification. Prophylaxis for PONV should be maintained throughout the period of risk., Conclusion: Evidence from the Prospective Observational Study of Treatments, Outcomes, and Patterns of Care study indicates that the use of guideline recommended PONV and PDNV prophylactic treatments leads to improved outcomes.

Purpose: The objectives of this study were (1) to describe the usage of topical oral solutions in patients experiencing chemotherapy-induced oral mucositis (CIOM); and (2) to survey the care of oral mucositis provided to patients by clinical oncology pharmacists in institutional settings., Methods: Surveys were distributed to institutional pharmacists in the US, who were asked to provide the components of their 'magic mouthwash'. Other questions included whether an institutional mucositis management guideline is available and what is the involvement of clinical pharmacy in mucositis care., Results: Forty institutions returned surveys during the study period. The top five ingredients used to compound the magic mouthwash are diphenhydramine, viscous lidocaine, magnesium hydroxide/aluminum hydroxide, nystatin and corticosteroids. Most institutions administer the mouthwash every 4 hours (36%) or every 6 hours (36%). Of the surveyed institutions, 33% currently possess guidelines for the management of CIOM., Conclusions: Most institutions in the country formulate their topical solution, or magic mouthwash, with a variety of ingredients. There is a need to standardize the ingredients used to compound the magic mouthwash, in order to fully evaluate the efficacy of the solution to manage CIOM.

Purpose: The pharmacology, pharmacokinetics, preclinical and clinical experience to date, and clinical concerns in monitoring patients receiving bevacizumab, recombinant humanized monoclonal antibody to vascular endothelial growth factor (VEGF), are described., Summary: Preclinical research revealed that bevacizumab specifically inhibits VEGF, has activity in multiple cancer cell lines, and is synergistic with several cancer chemotherapeutic agents. In humans, bevacizumab has a long half-life, allowing intravenous administration once every two to three weeks. Dose-limiting toxicities, the formation of antibodies to bevacizumab, and problems with wound healing after surgery have not been observed in clinical trials. A phase II study of bevacizumab in combination with 5-fluorouracil and leucovorin in patients with metastatic colorectal cancer showed promising results (i.e., therapeutic response rate and disease-free progression of survival), although a clear dose-response relationship was not demonstrated and concerns were raised about the potential for thromboembolic events, bleeding, hypertension, and proteinuria. In a phase III study in patients with refractory metastatic breast cancer, bevacizumab doubled the response rate from capecitabine but it did not affect survival. First-line use of bevacizumab with irinotecan, orouracil, and leucovorin produced significant improvements in response rate, duration of response, and survival in a phase III study of patients with metastatic colorectal cancer. Bevacizumab was associated with hypertension, which was readily managed with mild antihypertensive agents, and possibly with gastrointestinal (GI) perforation, but not with serious bleeding, thromboembolism, or proteinuria. Nevertheless, patients receiving bevacizumab should be monitored for GI perforation, bleeding, thromboembolism, hypertension, and proteinuria, especially if they have a condition that predisposes them to these problems (e.g., a history of unusual bleeding or clotting, hypertension, or proteinuria; use of anticoagulants or other medications that affect clotting or coagulation)., Conclusion: In clinical trials, bevacizumab has shown promise in promoting synergism with other chemotherapeutic agents in the treatment of various cancers.

Objective: To evaluate the effect of telephone follow-up on the physical well-being dimension of health-related quality of life in patients with cancer., Design: Randomized, controlled trial., Setting: Public teaching hospital., Patients: One hundred fifty patients with cancer who were discharged to home from the hospital., Intervention: Patients received a telephone follow-up call 48-72 hours after discharge. Information was solicited regarding drug-related (and other) problems. Problems were addressed, and advice and support were given., Measurements and Main Results: Analysis of variance revealed no differences in the physical well-being dimension of health-related quality of life between patients who received telephone follow-up and a control group who did not. Sixty-eight percent of the follow-up group and 40% of the control group (p = 0.007) reported having had at least one contact with a health professional., Conclusion: One possible explanation for the lack of effect of the intervention is that high-risk patients in the control group received a similar intervention from other health care professionals. We suggest that telephone follow-up be coordinated among health professionals.

The evolution of and rationale for fluorouracil-based strategies in the treatment of metastatic colorectal cancer are discussed, and the role of the new oral fluoropyrimidines is described. Although fluorouracil is one of the most widely used drugs in the United States for colorectal, head and neck, bladder, and breast cancer, response rates and survival times have been disappointing. Dihydropyrimidine dehydrogenase (DPD), a rate-limiting enzyme in the catabolism of fluorouracil, indirectly determines the drug's anticancer efficacy by regulating the availability of fluorouracil for anabolism. Recently, investigators have identified at least five compounds -capecitabine, UFT (tegafur plus uracil), eniluracil, S-1, and BOF-A2-that inhibit, destroy, inactivate, or bypass DPD's activity. Capecitabine, a prodrug of fluorouracil, circumvents DPD. UFT, S-1, and BOF-A2 contain prodrugs of fluorouracil in combination with compounds that alter DPD's activity. Fluorouracil must be administered in combination with eniluracil, an inactivator of DPD. These compounds, classified as fluoropyrimidines, can be administered orally. Oral fluoropyrimidines appear to be at least as active against metastatic colorectal cancer as conventionally administered intravenous fluorouracil, with significantly less toxicity, improved quality of life, and less expense. New oral fluoropyrimidines may ultimately provide enhanced antitumor activity to fluorouracil-containing regimens for advanced colorectal cancer.

Docetaxel is a taxane that disrupts the equilibrium in the polymerization and depolymerization of microtubules, thus inhibiting cell growth. This agent is indicated for the treatment of anthracycline-resistant metastatic breast cancer. The dose-limiting adverse effect is neutropenia, but febrile neutropenia is uncommon. Like paclitaxel, docetaxel is very active in patients with both chemotherapy-resistant and refractory metastatic breast cancer. Although the mechanism of action, spectrum of activity, and side effect profile of this agent are similar to those of paclitaxel, docetaxel may be efficacious in patients with metastatic breast cancer who have become resistant or refractory to paclitaxel therapy. However, more studies are warranted before the role of docetaxel is defined in patients with paclitaxel-resistant breast cancer.

Granisetron is the second agent in the 5-HT3 receptor antagonist class to be approved for the prophylaxis of acute emesis caused by cancer chemotherapy. It is equally effective to ondansetron as a first-line agent in the prevention of acute chemotherapy-induced emesis and has a similar low toxicity profile. Granisetron will be marketed in early 1994, according to SmithKline Beecham. Additional studies will be needed to determine the role of granisetron in the current management of chemotherapy-induced emesis.

In the patient with cancer, malnutrition may result from the disease itself or from its treatment. Total parenteral nutrition (TPN) has been used for many years to treat or prevent malnutrition in the patient with cancer. There have been few studies, however, that demonstrate significant benefit from TPN therapy in these patients. Patients receiving high-dose chemotherapy (as in bone marrow transplantation), and patients with solid tumors who have documented malnutrition (cachexia, weight loss) prior to cancer surgery, may benefit from TPN. No other groups of patients with cancer appear to derive significant benefit from TPN, and some groups may actually be harmed by its use. Practical considerations in the use of TPN include periodic calorie-protein assessment, electrolyte management, and monitoring for drug-TPN interactions.

The pharmacokinetics of moderate doses of methotrexate administered via the hepatic artery were studied in ten patients with cancer metastatic to the liver. Intra-arterial methotrexate showed two-compartment characteristics with a clearance of 79 ml/min/m2 and an apparent volume of distribution of 21.2 l/m2 body surface area. The average half-life of the early phase was 1.9 h and the terminal half-life was 14.4 h. The data were not different from those observed in similar patients after IV administration of equivalent doses of methotrexate.

In summary, there are several ways to manage chronic pain with pharmacologic agents. The clinician should consider adjunctive agents such as antidepressants, stimulants, and antianxiety drugs as well as the standard narcotic analgesics. It is important to consider various modalities in treating the patient. A greater likelihood of successful pain control will be realized if the clinician determines a patient's pain pattern and the factors that appear to impact upon the pain cycle. With these aspects in mind, the rational application of these various analgesics will bring about the eventual goal, preventing of severe, agonizing pain.

A mathematical description of the dose-response curve of heparin to the activated coagulation time is applied retrospectively to 20 patients treated with continuous heparin infusion. The adjusted heparin dose was compared with a calculated prediction using the theoretical mathematical model. The main actual dose was 28 U/kg/h, and the mean predicted dose was 25.8 U/kg/h. The correlation coefficient was 0.862 (p3 0.05). These data are used to develop a dosing adjustment chart. Special considerations prior to using the calculation or dosing adjustment chart are discussed. The use of this model may allow the clinician to determine more rapidly a therapeutic heparin dosage than previous empiric approaches.

In 1983, the Northern California Oncology Group (NCOG) instituted a randomized trial of intravenous (IV) versus intraarterial (IA) floxuridine (FUDR) administered via an implantable pump for patients with colorectal cancer metastatic to the liver. The study objectives were to compare the hepatic response rate, time to hepatic progression, and toxicity for the two treatment arms. The study design, which allowed patients failing IV FUDR to crossover to the IA arm, prevents a meaningful comparative analysis of survival. Patients with liver-only metastases (N = 143) were randomized, 76 to the IV arm and 67 to the IA arm, and 115 patients (65 IV, 50 IA) were fully evaluable. Of the 65 patients in the IV arm, 28 crossed over to IA treatment after failing IV FUDR. The dose-limiting toxicity of IV FUDR was diarrhea, whereas biliary toxicity limited both the dose and duration of IA FUDR therapy. Of the first 25 patients treated with IA FUDR at a dose of .3 mg/kg/day, 10 developed radiographically evident biliary strictures, and three developed permanent jaundice. With reduction of the initial IA FUDR dose to .2 mg/kg/day, and adoption of a policy of early dosage reduction, treatment interruption, or termination of therapy for persistent elevations in alkaline phosphatase, only two further cases of serious biliary toxicity occurred. However, 26 of the 50 IA FUDR patients ultimately had therapy terminated because of drug toxicity rather than disease progression. When compared with systemic infusion, infusion into the hepatic artery greatly enhanced the antitumor activity of FUDR against colorectal liver metastases. Although biliary toxicity is the most serious limitation of this form of therapy, biliary stricture and jaundice usually can be averted through careful monitoring of liver enzymes and early dosage reduction.

Sequential methotrexate (MTX) and 5-FU plus leucovorin and mitomycin (MMC) was given to 52 patients with disseminated, measurable colorectal cancer. Complete and partial responses were seen in 19 of 49 (39%) evaluable patients. Nine additional patients achieved a minimal response. Median overall survival was 8.8 months, while that for patients objectively responding was 13.6 months. This study utilized a MTX exposure period of 12 hours prior to 5-FU. In comparison to other trials utilizing sequential MTX and 5-FU, the addition of MMC to the regimen may improve the response rate but increases the incidence of adverse effects, particularly myelosuppression and renal toxicity. This phase II trial suggests that sequential MTX and 5-FU plus leucovorin and MMC is an active combination therapy and warrants further comparative trial in patients with large bowel cancer.

Toxicities and complications were prospectively analyzed in patients with liver metastases receiving hepatic intra-arterial (IA) and systemic intravenous (IV) floxuridine (FUDR) with the Infusaid (Intermedics-Infusaid Corp., Norwood, MA) implantable pump. Among 55 patients treated with IA FUDR (0.3-0.1 mg/kg/day X 14, every 28 days), elevations in liver enzyme values, not attributable to disease progression, developed in 96% of patients. Serious biliary toxicity occurred in 31 patients (56%). In 16, biliary sclerosis was documented radiographically and was diagnosed clinically in 15 additional patients. Ten patients were hospitalized for biliary toxicity, including five who required cholecystectomy for acalculous cholecystitis. Because of the high reported incidence of serious gastroduodenal toxicity after IA FUDR infusion, our procedure for hepatic arterial cannulation was designed to eliminate misperfusion of the stomach and duodenum with drug; none of our patients experienced FUDR-associated gastroduodenal ulceration or bleeding. Cyclic IV FUDR (0.05-0.15 mg/kg/day X 14, every 28 days) was administered to 31 participants of the Northern California Oncology Group trial (3L-82-1) of IV versus IA FUDR. Dose-limiting toxicity was diarrhea. Serious toxicities were: protracted diarrhea (three), dermatitis (two), tear duct stenosis (two), and stomatitis (two). Three patients were hospitalized for toxicity. No hematologic or biliary toxicity occurred. The optimal route for treatment of hepatic metastases with continuous FUDR infusion has not yet been established. Systemic IV infusion has low morbidity, but preliminary response data need to be substantiated in controlled clinical trials before there can be widespread clinical application. High response rates for IA infusion have been previously documented. Morbidity due to acalculous cholecystitis and gastroduodenal ulceration can now be avoided. Despite significant progress in characterization of hepatobiliary toxicity, it remains dose-limiting. Continuous IA FUDR infusion should remain under the aegis of dedicated treatment centers until standardized protocols with diminished toxicity are established.

Hepatic metastases of colorectal origin are resistant to radiation and immunotherapy. Traditional intravenous chemotherapy produces responses in 10% to 30% of patients, and surgical resection is feasible in approximately 20% of patients who have a solitary or unilobar lesion. Infusion of cytotoxic agents into the hepatic artery, introduced 2 decades ago, is the most promising form of therapy for unresectable hepatic metastases. Fluorouracil, floxuridine, and mitomycin have been most commonly administered by hepatic arterial infusion. The recent development of a totally implantable pump has allowed prolonged ambulatory infusion of chemotherapeutic agents into the hepatic artery. We review the recent data on the pharmacology, therapeutic outcome, administration techniques, and complications of hepatic arterial chemotherapy. Future trials in this area should use uniform stratification variables and standardized criteria for evaluating response, time to progression, and survival.