25 Impact of clinical pharmacy in oncology and hematology centers - A systematic review

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Review Article
Impact of clinical pharmacy in oncology
and hematology centers: A systematic
review
Cynara S Oliveira1, Mauriele P Silva1, Íngara K S P B Miranda1,
Rodrigo T Calumby2 and Renata F de Ara�ujo-Calumby1,3
Abstract
Background: Oncology and hematology is a complex and specific area that requires monitoring by a multidisciplinary
team capable of personalizing the treatment of each patient. Clinical pharmacy services have the potential to contribute
significantly to the effective and economical care of cancer patients.
Objective: To evaluate, synthesize and critically present the available evidence on the impact of the Clinical Pharmacy in
the treatment of patients with hematological cancer.
Method: A review was carried out on the bases PubMed/MEDLINE, LILACS and Google Scholar. The included studies
were: studies that evaluated the effects of pharmaceutical interventions in clinical in oncology and hematology services
and having as a population patient with hematological cancer.
Results: 17 studies were selected among 745 identified. 4.771 patients were included, with an average follow-up time of
15.3months. Patients affected by some type of hematological cancer, undergoing chemotherapy treatment, showed
better adherence and continuity when accompanied by a clinical pharmacist, added to this professional in carrying out
interventions, provides control of symptoms such as cancer pain, nausea and constipation and, thus, contributes to
decrease the length of hospital stay.
Conclusion: The implementation of a Clinical Pharmacy service in oncology and hematology centers contributes
significantly to the effectiveness of pharmacotherapeutic treatment, treatment costs reduction, safety increase in the
use of medications and the patient’s quality of life.
Keywords
Hematology, oncology, clinical pharmacy, pharmaceutical care, drug-related problem
Date received: 27 May 2020; revised: 2 November 2020; accepted: 3 November 2020
Introduction
Cancer is one of the leading causes of death and dis-
ability in the world. Hematological Malignancies (HM)
represent an important group of tumors originating
from mutations in cells of the hematological tissue or
in the Lymphatic System. The three main types of HM
are: Leukemia (originating in the bone marrow and
divided into myeloid or lymphoid); Lymphoma
(which do not originate from the lymphatic system
and are divided into Hodgkin and non-Hodgkin);
and Multiple Myeloma (developed from plasma
cells).1 Worldwide estimates of HM incidence and mor-
tality in 2018 were: Leukemia (437.033 new cases and
309.006 deaths); Hodgkin’s Lymphoma (79,990 new
1Department of Health, Pharmacy College, Unidade de Ensino Superior
de Feira de Santana – UNEF, Feira de Santana, Brazil
2Department of Exact Sciences, University of Feira de Santana, Feira de
Santana, Brazil
3Federal University of Bahia – UFBA, Salvador, Brazil
Corresponding author:
Renata F de Ara�ujo-Calumby, Av. Lu�ıs Eduardo Magalh~aes, Suba�e, Feira de
Santana – BA 44079-002, Brazil.
Email: farm.renata@hotmail.com
J Oncol Pharm Practice
0(0) 1–14
! The Author(s) 2020
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cases and 26.167 deaths); Non-Hodgkin’s Lymphoma
(509.590 new cases and 248.724 deaths); and Multiple
Myeloma (159.985 new cases and 106.105 deaths).2
The oncology and hematology is a complex area in
healthcare that requires monitoring by a multidiscipli-
nary team capable of personalizing the treatment for
each patient. Therapeutic choices will depend on the
patient’s disease and clinical aspects such as age, pres-
ence of other diseases and ability to tolerate chemo-
therapy. There are many therapeutic protocols, which
include the association of chemotherapeutic agents,
immunotherapeutic agents, radiotherapy and, in some
cases, bone marrow transplantation.3,4 Most of the
antineoplastic drugs used in these protocols have high
toxicity and narrow therapeutic indexes, requiring dose
adjustments and supportive care to control infectious
and hemorrhagic complications. Beyond it, some
patients do not respond to treatment or are unable to
adhere to treatment.5,6
The oncology pharmacist plays an essential role in
the treatment of clinically complex patients.7,8 The
main contributions of clinical pharmacists in assisting
onco-hematological patients include: evaluating the
medical prescription regarding quantity, quality, com-
patibility, stability and interactions; supportive care
management, such as managing anti-infectious thera-
pies; assistance in the transition of care; evaluation of
patients regarding the toxicity of chemotherapies and
treatment effectiveness, in addition to tracking iatro-
genic effects; educating patients, caregivers, as well as
health professionals and interns; monitor, evaluate and
report results related to treatment to help improve clin-
ical practice.9–13 Such activities are essential to promote
patient safety when using antineoplastic agents and to
avoid unnecessary expenses with the use of ineffective
drugs for the patient or hospitalizations caused by
complications resulting from medication errors that
could be avoided.14–16
The implementation of a clinical pharmacy service
in oncology care units has been described as an impor-
tant strategy for reducing incorrect prescriptions, drug
interactions, negative effects, in addition to reducing
the number of hospitalizations and, consequently,
treatment costs and negative impacts on the patient’s
life and health.17,18 In the onco-hematology context,
many works have evaluated the impact of clinical phar-
macy services based on several outcome measures.
However, in current literature, there is an absence of
evidence-based research that analyzes and summarizes
clinical studies which assessed the impact of the clinical
pharmacy service in onco-hematology centers. To
address this gap, the objective of this work was to eval-
uate, synthesize and critically present the available evi-
dences of the impact of the Clinical Pharmacy in the
treatment of patients with hematological cancer.
Materials and methods
Search strategy
The research question was formulated based on the
PICO strategy: population, intervention, control and
outcome.19 The following aspects were considered: i)
patients with hematological cancer; ii) the practice of
pharmacotherapeutic monitoring by pharmacists as the
intervention of interest; iii) not performing the service
as baseline; and iv) the results of the applied interven-
tions as outcome. Hence, this systematic review was
guided by the following question: What is the impact
of the implementation of Clinical Pharmacy services in
onco-hematology centers?
The PROSPERO and Cochrane databases were
used to identify any relevant systematic reviews on
the field. A comprehensive literature search was per-
formed using the PubMed/MEDLINE, Latin
American and Caribbean Literature in Health
Sciences (LILACS) and Google Scholar databases
from July 1999 to May 2020. Additional articles were
identified from the reference lists of the included stud-
ies. The research strategy included the use of terms:
{“Clinical Pharmacy” OR “Pharmaceutical care” OR
“Pharmacotherapeutic Follow-up”} AND
{{“Oncology” AND “Hematology”} OR “Onco-
hematology”}.
Selection criteria
The articles were considered for the study based on the
following inclusion requirements: i) original research
articles (e.g., regarding randomized controlled trials,
non-randomized controlled studies, cohort studies,
cross-over studies, and before-and-after studies) pub-
lished between 1999 and 2019; ii) published in
Portuguese, Spanish or English; iii) having evaluateda clinical pharmacy service at an onco-hematology
center; and iv) having patients with hematologic
cancer as a population. The exclusion requirements
were: i) studies that did not consider the treatment of
onco-hematologic tumors; ii) articles with study
designs out of interest such as cases studies and litera-
ture review.
Data collection and analysis
The screening for the selection of eligible articles was
carried out considering the titles and abstracts to iden-
tify and exclude those that presented out of scope
methodological approaches, study interruption, results
without statistical data, or that dealt with themes
repeated by other articles as in literature reviews. The
articles of interest were tabulated by chronological
order of publication and type of study, in addition to
2 Journal of Oncology Pharmacy Practice 0(0)
specifying the sub-types of onco-hematological cancer,
country of origin and venue of publication.
The articles were investigated according to the out-
comes, such as: Drug-Related Problems (DRPs) and
interventions, humanitarian impacts (improvement of
quality of life and patient education and counseling)
and economic impacts (reduction of hospitalization
costs and cost of inappropriate therapies). All findings
were considered by three independent reviewers to
ensure consistency in execution of the review process.
Results
Study characteristics
By using the selected search terms, 745 articles were
found. Based on the inclusion and exclusion require-
ments adopted, 17 papers were selected for analysis.
The selection of the papers found, according to the
PRISMA protocol – Preferred Reporting Items for
Systematic reviews and Meta-Analysis), is outlined in
Figure 1. Table 1 provides a summary of the character-
istics of the selected studies and the main results
achieved in each of the studies.
The selected studies were carried out between 1999
and 2020 and evaluated patients of different national-
ities, such as: United States (n¼ 5); Canada (n¼ 3);
Spain (n¼ 2); France (n¼ 2); Singapore (n¼ 1);
Taiwan (n¼ 1); Morocco (n¼ 1); Finland (n¼ 1)
and Brazil (n¼ 1). Few studies have presented
detailed patient1999 and 2020 and evaluated patients
of different nationalities, such as: United States
(sel3months, ranging from 1 to 72months. The
age of the patients was 0.6 to 63.9 years. Notice that
four studies did not report the age or other clinical
characteristics of the patients. The main types of
tumors presented by the patients being monitored
were: Chronic Myeloid Leukemia (CML) and
Lymphomas.
The selected studies had the common purpose of
describing and evaluating the impact of clinical phar-
macy services in onco-hematology clinics, but they also
discussed: the patients’ needs related to medications;
the role of the clinical pharmacist in the onco-
hematology service; the contributions of implementing
a face-to-face and remote pharmaceutical care model;
the adverse drug reactions; the medication adherence
profile and the patients’ quality of life and economic
impact of clinical pharmacist intervention.
Total articles found (n = 2217)
Google scholar
(n = 1220)
Records screened on titles and abstracts
(n = 74)
Inclusion criteria: (i) an original full-text article published between
1999 and 2020; (ii) be published in Portuguese, Spanish or
English; (iii) to have evaluated a clinical pharmacy service at an
oncology and hematology center (iv) to have patients with
hematological cancer as a population
Exclusion criteria: (i) articles repeated or that were not presented
with the researched theme: (ii) studies that did not consider the
treatment of onco-hematological tumors: (iii) articles with study
designs that do not fit the proposals, such as cases and review
studies.
Articles selected according inclusion criteria (n = 30)
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Figure 1. PRISMA flow for study selection through literature search in this work.
Oliveira et al. 3
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%
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a
an
d
n
au
se
a
/
vo
m
it
in
g,
re
sp
o
n
si
b
le
fo
r
7
8
%
o
f
th
e
to
ta
l
su
p
p
o
r,
2
3
.8
%
),
fa
ilu
re
to
re
ce
iv
e
d
ru
g
o
r
im
p
ro
p
e
r
ad
m
in
is
tr
at
io
n
(8
9
,
1
7
%
),
u
n
tr
e
at
e
d
in
d
ic
at
io
n
(9
2
,1
7
.5
%
),
su
b
th
e
ra
p
e
u
ti
c
d
o
sa
ge
(5
7
,1
0
.9
%
),
su
p
ra
th
e
ra
p
e
u
ti
c
d
o
sa
ge
(6
5
,
1
2
.4
%
)
an
d
d
ru
g
w
it
h
o
u
t
in
d
ic
at
io
n
(7
6
,
1
4
.5
%
).
In
th
e
st
u
d
y,
5
2
5
p
h
ar
m
ac
e
u
ti
ca
l
in
te
rv
e
n
ti
o
n
s
w
e
re
co
lle
ct
e
d
m
ai
n
ly
re
ga
rd
in
g
d
o
se
ad
ju
st
m
e
n
t
(3
3
.1
%
)
an
d
d
ru
g
m
o
n
it
o
ri
n
g
(2
5
.1
%
).
V
al
gu
s
e
t
al
.,
2
0
1
1
,
U
SA
2
0
P
ro
sp
e
ct
iv
e
d
e
sc
ri
p
ti
ve
an
d
q
u
al
it
at
iv
e
st
u
d
y
(1
8
m
o
n
th
s)
8
9
D
e
sc
ri
b
e
th
e
d
ev
e
lo
p
-
m
e
n
t,
im
p
le
m
e
n
ta
ti
o
n
an
d
in
it
ia
l
e
x
p
e
ri
e
n
ce
w
it
h
a
p
ro
gr
am
p
ro
vi
d
-
in
g
cl
in
ic
al
Fo
r
o
n
e
ye
ar
,
th
e
se
rv
ic
e
m
o
n
it
o
re
d
8
9
p
at
ie
n
ts
,
1
8
6
in
te
rv
e
n
ti
o
n
s
an
d
1
3
6
p
re
sc
ri
p
ti
o
n
s.
T
h
e
m
o
st
co
m
m
o
n
in
te
rv
e
n
ti
o
n
s
w
e
re
d
o
se
ad
ju
st
m
e
n
t,
in
d
ic
at
io
n
o
f
m
e
d
ic
at
io
n
,
d
is
co
n
ti
n
u
at
io
n
o
f
in
ap
p
ro
p
ri
at
e
m
e
d
ic
at
io
n
fo
r
th
e
p
at
ie
n
t
an
d
m
an
ag
e
m
e
n
t
o
f
ad
ve
rs
e
re
ac
ti
o
n
s
(a
n
e
m
ia
,
p
ai
n
,
co
n
st
i-
p
at
io
n
o
r
d
ia
rr
h
e
a,
n
au
se
a
an
d
vo
m
it
in
g)
an
d
p
at
ie
n
t
e
d
u
ca
ti
o
n
an
d
(c
o
n
ti
n
u
e
d
)
4 Journal of Oncology Pharmacy Practice 0(0)
T
a
b
le
1
.
C
o
n
ti
n
u
e
d
.
St
u
d
y
ye
ar
/c
o
u
n
tr
y
St
u
d
y
d
e
si
gn
(d
u
ra
ti
o
n
)
P
at
ie
n
ts
O
b
je
ct
iv
e
s
M
ai
n
cl
in
ic
al
o
u
tc
o
m
e
s
p
h
ar
m
ac
e
u
ti
ca
l
se
rv
ic
e
s
in
h
e
m
at
o
lo
gy
-o
n
co
lo
gy
cl
in
ic
s
at
a
u
n
iv
e
rs
it
y
h
o
sp
it
al
.
co
u
n
se
lin
g.
T
h
e
fo
cu
s
o
f
co
u
n
se
lin
g
w
as
to
p
ro
m
o
te
th
e
ra
p
e
u
ti
c
ad
h
e
r-
e
n
ce
an
d
p
ro
vi
d
e
in
fo
rm
at
io
n
to
th
e
p
at
ie
n
t
o
n
:
w
ay
s
o
f
u
si
n
g
th
e
ra
p
e
u
ti
c
ag
e
n
ts
,
p
re
ve
n
ti
o
n
an
d
m
an
ag
e
m
e
n
t
o
f
e
x
p
e
ct
e
d
ad
ve
rs
e
e
ff
e
ct
s,
as
w
e
ll
as
o
n
th
e
d
an
ge
rs
,
si
gn
s
an
d
sy
m
p
to
m
s
o
f
th
ro
m
b
o
si
s.
T
h
u
s,
6
3
e
d
u
ca
-
ti
o
n
al
in
te
rv
e
n
ti
o
n
s
w
e
re
p
e
rf
o
rm
e
d
an
d
m
o
re
th
an
h
al
f
th
e
in
te
rv
e
n
ti
o
n
s
ai
m
e
d
at
th
e
u
se
o
f
an
ti
e
m
e
ti
cs
an
d
th
e
re
so
lu
ti
o
n
o
f
d
o
sa
ge
ca
lc
u
la
ti
o
n
e
rr
o
rs
an
d
ad
ju
st
in
g
p
ai
n
co
n
tr
o
l
re
gi
m
e
s.
C
h
an
e
t
al
.,
2
0
1
2
,
Si
n
ga
p
o
re
2
5
R
e
tr
o
sp
e
ct
iv
e
co
h
o
rt
st
u
d
y
(1
2
m
o
n
th
s)
1
1
6
D
e
sc
ri
b
e
se
rv
ic
e
s
an
d
re
se
ar
ch
ac
ti
vi
ti
e
s
co
n
-
d
u
ct
e
d
b
y
cl
in
ic
al
p
h
ar
-
m
ac
is
ts
fr
o
m
a
ly
m
p
h
o
m
a
te
am
w
ill
b
e
d
is
cu
ss
e
d
.
T
h
e
su
p
p
o
rt
iv
e
h
e
al
th
ca
re
d
ev
e
lo
p
e
d
b
y
p
h
ar
m
ac
is
ts
w
e
re
:
u
se
o
f
gr
an
u
-
lo
cy
te
st
im
u
la
ti
n
g
fa
ct
o
rs
fo
r
(p
re
ve
n
ti
o
n
o
f
fe
b
ri
le
n
e
u
tr
o
p
e
n
ia
ca
u
se
d
b
y
m
ye
lo
su
p
p
re
ss
io
n
re
su
lt
in
g
fr
o
m
th
e
u
se
o
f
ch
e
m
o
th
e
ra
py
);
u
se
o
f
p
ro
-
p
hy
la
ct
ic
an
ti
e
m
e
ti
cs
(t
o
im
p
ro
ve
q
u
al
it
y
o
f
lif
e
an
d
p
re
ve
n
t
u
n
n
e
ce
ss
ar
y
h
o
sp
it
al
iz
at
io
n
s)
;p
re
ve
n
ti
o
n
o
f
tu
m
o
r
ly
si
s
(o
n
co
lo
gi
ca
le
m
e
rg
e
n
cy
o
f
fa
ta
l
p
o
te
n
ti
al
ca
u
se
d
b
y
e
le
ct
ro
ly
te
d
is
o
rd
e
rs
an
d
re
n
al
d
ys
fu
n
ct
io
n
);
th
e
ra
-
p
e
u
ti
c
m
o
n
it
o
ri
n
g
o
f
h
ig
h
-d
o
se
d
ru
gs
(s
u
ch
as
m
e
th
o
tr
e
x
at
e
);
im
p
ro
vi
n
g
th
e
u
se
o
f
re
so
u
rc
e
s;
co
n
tr
o
lle
d
in
fu
si
o
n
o
f
d
ru
gs
(s
u
ch
as
ri
tu
x
im
ab
fo
r
th
e
p
u
rp
o
se
o
f
m
in
im
iz
in
g
th
e
ri
sk
s
o
f
ad
ve
rs
e
re
ac
ti
o
n
s)
an
d
sa
fe
ty
in
th
e
u
se
o
f
d
ru
gs
to
p
re
ve
n
t
D
R
P
s.
A
n
o
th
e
r
fu
n
d
am
e
n
ta
l
ca
re
d
ev
e
lo
p
e
d
b
y
p
h
ar
m
ac
is
ts
w
as
th
e
m
an
ag
e
m
e
n
t
an
d
ev
al
u
at
io
n
o
f
d
ru
g
in
te
ra
ct
io
n
s
b
e
tw
e
e
n
ch
e
m
o
th
e
ra
p
e
u
ti
c
ag
e
n
ts
an
d
th
e
u
se
o
f
al
te
rn
at
iv
e
an
d
co
m
-
p
le
m
e
n
ta
ry
th
e
ra
p
ie
s,
su
ch
as
th
e
u
se
o
f
te
as
an
d
h
e
rb
al
m
e
d
ic
in
e
s.
M
o
st
o
f
th
e
in
te
rv
e
n
ti
o
n
s
p
e
rf
o
rm
e
d
w
e
re
o
n
is
su
e
s
re
la
te
d
to
ch
e
m
o
th
e
ra
py
,
o
p
ti
m
iz
at
io
n
o
f
th
e
u
se
o
f
an
ti
m
ic
ro
b
ia
ls
an
d
su
p
p
o
rt
iv
e
ca
re
th
e
ra
p
ie
s.
T
h
u
s,
as
a
re
su
lt
,
p
h
ar
m
ac
o
th
e
ra
py
w
as
o
p
ti
m
iz
e
d
(3
3
.9
%
),
fo
llo
w
e
d
b
y
th
e
re
so
lu
ti
o
n
o
f
d
ru
g-
re
la
te
d
p
ro
b
le
m
s
(2
6
.2
%
)
an
d
im
p
ro
ve
d
w
o
rk
flo
w
(1
0
.2
%
).
D
e
lp
e
u
ch
e
t
al
.,
2
0
1
5
,
Fr
an
ce
5
P
ro
sp
e
ct
iv
e
d
e
sc
ri
p
ti
ve
an
d
q
u
al
it
at
iv
e
st
u
d
y
(6
m
o
n
th
s)
4
8
9
D
o
cu
m
e
n
t
an
d
ev
al
u
at
e
th
e
ro
le
o
f
cl
in
ic
al
p
h
ar
m
ac
y
se
rv
ic
e
s
in
a
h
e
m
at
o
lo
gy
/o
n
co
lo
gy
D
e
p
ar
tm
e
n
t.
D
u
ri
n
g
th
e
st
u
d
y,
4
8
9
ad
u
lt
ca
n
ce
r
p
at
ie
n
ts
w
e
re
fo
llo
w
e
d
u
p
(m
e
an
ag
e
¼
6
3
ye
ar
s)
.D
u
ri
n
g
th
e
st
u
d
y
p
e
ri
o
d
,5
5
2
d
ru
g-
re
la
te
d
p
ro
b
le
m
s
w
e
re
id
e
n
ti
fie
d
,
in
cl
u
d
in
g:
in
ap
p
ro
p
ri
at
e
m
e
d
ic
at
io
n
(2
0
.6
%
),
u
n
tr
e
at
e
d
in
d
ic
a-
ti
o
n
s
(1
4
.8
%
),
d
ru
g
in
te
ra
ct
io
n
s
(1
4
.3
%
),
in
ad
e
q
u
at
e
ad
m
in
is
tr
at
io
n
s
(1
4
.1
%
),
in
ad
e
q
u
at
e
ad
m
in
is
tr
at
io
n
s
(1
4
.1
%
),
u
n
d
e
rd
o
si
n
g
(1
1
.7
%
),
la
ck
o
f
m
o
n
it
o
ri
n
g
(9
.6
%
),
o
ve
rd
o
se
(8
.9
%
),
ad
m
in
is
tr
at
io
n
o
m
is
si
o
n
s
(3
.5
%
)
an
d
si
d
e
e
ff
e
ct
s
(2
.5
%
).
In
te
rv
e
n
ti
o
n
s
(n
¼
5
5
2
)
le
d
to
tr
e
at
m
e
n
t
d
is
co
n
ti
n
u
-
at
io
n
s
(2
6
.2
%
),
d
o
se
ad
ju
st
m
e
n
ts
(2
1
.5
%
),
ad
d
it
io
n
o
f
d
ru
gs
(1
6
.9
%
),
al
te
rn
at
iv
e
ro
u
te
s
o
f
ad
m
in
is
tr
at
io
n
(1
1
.7
%
),
su
b
st
it
u
ti
o
n
fr
o
m
o
n
e
m
e
d
-
ic
at
io
n
to
an
o
th
e
r
(1
0
.7
%
),
th
e
ra
p
e
u
ti
c
d
ru
g
m
o
n
it
o
ri
n
g
(1
0
.3
%
)
an
d
o
p
ti
m
iz
at
io
n
o
f
ad
m
in
is
tr
at
io
n
(2
.6
%
).
T
h
e
m
aj
o
ri
ty
(9
6
%
)
o
f
th
e
in
te
r-
ve
n
ti
o
n
s
w
e
re
ac
ce
p
te
d
an
d
im
p
le
m
e
n
te
d
b
y
th
e
m
e
d
ic
al
te
am
.
M
o
st
d
ru
g-
re
la
te
d
p
ro
b
le
m
s
in
vo
lv
e
d
an
ti
-i
n
fe
ct
iv
e
ag
e
n
ts
,
w
h
ile
ve
ry
fe
w
co
n
ce
rn
e
d
an
ti
-c
an
ce
r
d
ru
gs
.
T
h
u
s,
th
e
in
te
gr
at
io
n
o
f
th
e
cl
in
ic
al
p
h
ar
-
m
ac
is
t
in
an
o
n
co
h
e
m
at
o
lo
gy
d
e
p
ar
tm
e
n
t
re
su
lt
e
d
in
sp
e
ci
fic
d
ru
g
(c
o
n
ti
n
u
e
d
)
Oliveira et al. 5
T
a
b
le
1
.
C
o
n
ti
n
u
e
d
.
St
u
d
y
ye
ar
/c
o
u
n
tr
y
St
u
d
y
d
e
si
gn
(d
u
ra
ti
o
n
)
P
at
ie
n
ts
O
b
je
ct
iv
e
s
M
ai
n
cl
in
ic
al
o
u
tc
o
m
e
s
in
te
rv
e
n
ti
o
n
s
fo
r
1
2
.6
%
o
f
p
re
sc
ri
p
ti
o
n
s
fo
r
ad
u
lt
p
at
ie
n
ts
h
o
sp
it
al
iz
e
d
w
it
h
ca
n
ce
r.
R
ib
e
d
e
t
al
.,
2
0
1
5
,
Sp
ai
n
1
7
P
ro
sp
e
ct
iv
e
co
h
o
rt
st
u
d
y
(6
m
o
n
th
s)
2
4
9
D
ev
e
lo
p
an
d
ev
al
u
at
e
a
co
m
p
re
h
e
n
si
ve
p
h
ar
-
m
ac
e
u
ti
ca
l
ca
re
p
ro
-
gr
am
fo
r
ca
n
ce
r
o
u
tp
at
ie
n
ts
tr
e
at
e
d
w
it
h
o
ra
l
an
ti
n
e
o
p
la
st
ic
ag
e
n
ts
.
2
4
9
p
at
ie
n
ts
p
ar
ti
ci
p
at
e
d
in
th
e
st
u
d
y,
w
h
o
w
e
re
ev
al
u
at
e
d
in
th
re
e
cl
in
ic
al
in
te
rv
ie
w
s
o
ve
r
6
m
o
n
th
s.
T
h
u
s,
d
u
ri
n
g
th
is
p
e
ri
o
d
2
7
5
m
e
d
ic
at
io
n
e
rr
o
rs
w
e
re
re
co
rd
e
d
,
w
it
h
3
6
2
in
te
rv
e
n
ti
o
n
s
p
e
rf
o
rm
e
d
b
y
th
e
p
h
ar
m
ac
is
t.
T
h
e
re
w
as
a
si
gn
ifi
ca
n
t
in
cr
e
as
e
in
th
e
ra
p
e
u
ti
c
ad
h
e
re
n
ce
in
th
e
gr
o
u
p
o
f
p
at
ie
n
ts
fo
llo
w
e
d
an
d
th
e
p
at
ie
n
ts
in
d
ic
at
e
d
a
d
e
gr
e
e
o
f
sa
ti
sf
ac
ti
o
n
o
f
8
1
.8
%
w
h
e
n
as
ke
d
ab
o
u
t
th
e
se
rv
ic
e
s
p
ro
vi
d
e
d
in
th
e
im
p
le
m
e
n
te
d
P
h
ar
m
ac
e
u
tica
l
C
ar
e
p
ro
gr
am
.
R
u
iz
,
L
e
m
u
s,
E
ch
ev
e
rr
ia
,
2
0
1
5
,
Sp
ai
n
1
8
P
ro
sp
e
ct
iv
e
d
e
sc
ri
p
ti
ve
an
d
q
u
al
it
at
iv
e
st
u
d
y
(5
1
m
o
n
th
s)
1
6
D
e
sc
ri
b
e
th
e
im
p
le
m
e
n
ta
-
ti
o
n
o
f
a
n
ew
m
o
d
e
l
fa
ce
to
fa
ce
an
d
re
m
o
te
p
h
ar
m
ac
e
u
ti
ca
l
ca
re
w
it
h
h
o
m
e
d
e
liv
e
ry
o
f
ty
ro
n
si
n
e
k
in
as
e
in
h
ib
i-
to
rs
m
e
d
ic
in
e
s
fo
r
p
at
ie
n
ts
w
it
h
ch
ro
n
ic
m
ye
lo
id
le
u
ke
m
ia
.
T
h
e
1
6
p
at
ie
n
ts
se
le
ct
e
d
to
u
n
d
e
rg
o
p
h
ar
m
ac
o
th
e
ra
p
e
u
ti
c
fo
llo
w
-u
p
,
o
f
w
h
ic
h
5
o
f
th
e
se
p
at
ie
n
ts
ch
o
o
se
to
m
ak
e
co
n
ta
ct
b
y
e
-m
ai
l
an
d
1
1
b
y
p
h
o
n
e
.
T
h
is
fle
x
ib
ili
ty
al
lo
w
e
d
u
s
to
p
ay
at
te
n
ti
o
n
fo
cu
se
d
o
n
th
e
p
at
ie
n
t’
s
q
u
al
it
y
o
f
lif
e
w
it
h
co
n
ti
n
u
o
u
s
p
h
ar
m
ac
e
u
ti
ca
l
m
o
n
it
o
ri
n
g,
w
h
ic
h
m
ad
e
it
p
o
ss
ib
le
to
d
e
te
ct
in
te
ra
ct
io
n
s,
p
ro
b
le
m
s
re
la
te
d
to
d
ru
gs
an
d
th
e
m
an
-
ag
e
m
e
n
t
o
f
th
e
ra
p
e
u
ti
c
ad
h
e
re
n
ce
in
d
iv
id
u
al
ly
.
O
n
th
e
o
th
e
r
h
an
d
,
th
e
m
o
n
th
ly
d
e
liv
e
ry
o
f
th
e
m
e
d
ic
in
e
at
h
o
m
e
al
lo
w
e
d
to
o
p
ti
m
iz
e
th
e
av
ai
l-
ab
le
re
so
u
rc
e
s
o
f
th
e
p
h
ar
m
ac
y
se
rv
ic
e
,s
u
ch
as
p
hy
si
ca
ls
to
ra
ge
sp
ac
e
an
d
im
p
ro
ve
m
e
n
t
in
th
e
m
an
ag
e
m
e
n
t
o
f
sa
la
ri
e
s.
L
am
,
C
h
e
u
n
g,
2
0
1
5
,
U
SA
2
1
R
e
tr
o
sp
e
ct
iv
e
d
e
sc
ri
p
ti
ve
an
d
q
u
al
it
at
iv
e
st
u
d
y
(7
2
m
o
n
th
s)
5
6
E
va
lu
at
e
th
e
im
p
ac
t
o
f
an
o
n
co
lo
gy
p
h
ar
m
ac
is
t-
m
an
ag
e
d
o
ra
l
an
ti
ca
n
-
ce
r
th
e
ra
py
p
ro
gr
am
o
n
o
ra
l
m
e
d
ic
at
io
n
ad
h
e
r-
e
n
ce
in
C
M
L
p
at
ie
n
ts
ve
rs
u
s
u
su
al
ca
re
.
T
h
e
p
h
ar
m
ac
is
t
h
e
lp
e
d
p
ro
m
o
te
ad
h
e
re
n
ce
(8
8
.6
%
)
an
d
re
su
lt
s
b
y
b
u
ild
in
g
a
cl
o
se
an
d
tr
u
st
in
g
re
la
ti
o
n
sh
ip
w
it
h
th
e
p
at
ie
n
t
an
d
fa
m
ily
,
ge
n
e
ra
te
d
th
ro
u
gh
th
e
im
p
le
m
e
n
ta
ti
o
n
o
f
th
e
tr
e
at
m
e
n
t
p
la
n
,
w
h
ic
h
co
n
si
st
s
o
f
a
vi
si
t
w
it
h
a
p
h
ar
m
ac
is
t
o
n
co
lo
gy
,
w
h
e
re
th
e
p
at
ie
n
t
w
ill
re
ce
iv
e
e
d
u
ca
-
ti
o
n
al
in
fo
rm
at
io
n
ab
o
u
t
th
e
d
is
e
as
e
an
d
m
e
d
ic
at
io
n
s,
e
n
ab
lin
g
th
e
m
to
id
e
n
ti
fy
,
so
lv
e
an
d
p
re
ve
n
t
p
ro
b
le
m
s.
A
ss
is
ta
n
ce
to
p
at
ie
n
ts
is
al
so
p
ro
-
vi
d
e
d
vi
a
e
-m
ai
l
an
d
te
le
p
h
o
n
e
ca
ll,
fa
ci
lit
at
in
g
ac
ce
ss
to
gu
id
e
lin
e
s,
an
d
th
e
re
b
y
re
d
u
ci
n
g
ra
te
s
o
f
n
o
n
-a
d
h
e
re
n
ce
to
tr
e
at
m
e
n
t,
w
h
ic
h
is
o
n
e
o
f
th
e
m
ai
n
fa
ct
o
rs
th
at
co
n
tr
ib
u
te
to
tr
e
at
m
e
n
t
fa
ilu
re
.
T
h
e
p
h
ar
m
ac
is
t
p
e
rf
o
rm
e
d
a
co
n
ti
n
u
o
u
s
fo
llo
w
-u
p
o
f
5
6
p
at
ie
n
ts
,
a
to
ta
l
o
f
5
6
7
p
h
ar
-
m
ac
e
u
ti
ca
l
in
te
rv
e
n
ti
o
n
s
w
e
re
d
o
cu
m
e
n
te
d
b
as
e
d
o
n
a
re
vi
ew
o
f
3
4
3
2
p
h
ar
m
ac
is
t
m
e
e
ti
n
gs
o
f
5
6
p
at
ie
n
ts
o
ve
r
a
6
-y
e
ar
p
e
ri
o
d
.T
h
u
s,
m
o
n
it
o
ri
n
g
an
d
m
an
ag
in
g
si
d
e
e
ff
e
ct
s
(1
6
.8
%
),
d
e
te
ct
in
g
d
ru
g
in
te
ra
ct
io
n
s
(1
9
.2
%
),
d
o
se
ad
ju
st
m
e
n
t
(1
4
.5
%
),
la
b
o
ra
to
ry
m
o
n
it
o
ri
n
g
(3
5
.3
%
),
th
e
ra
p
e
u
ti
c
in
d
ic
at
io
n
fo
r
u
n
tr
e
at
e
d
co
n
d
it
io
n
(1
3
.1
%
)
an
d
o
th
e
rs
(1
.2
%
).
K
e
k
al
e
,
P
e
lt
o
n
ie
m
i,
A
ir
ak
si
n
e
n
,2
0
1
5
,
Fi
n
la
n
d
2
2
P
ro
p
e
ct
iv
e
cr
o
ss
-s
e
ct
io
n
al
st
u
d
y
(6
m
o
n
th
s)
1
2
0
E
va
lu
at
e
ad
ve
rs
e
d
ru
g
re
ac
ti
o
n
s
e
x
p
e
ri
e
n
ce
d
b
y
C
M
L
p
at
ie
n
ts
d
u
ri
n
g
p
e
r
o
ra
l
ty
ro
si
n
e
k
in
as
e
in
h
ib
it
o
r
tr
e
at
m
e
n
t
an
d
co
rr
e
la
ti
o
n
o
f
A
D
R
T
h
is
st
u
d
y
ev
al
u
at
e
d
1
2
0
p
at
ie
n
ts
w
it
h
C
M
L
,
w
it
h
a
m
e
an
ag
e
o
f
5
7
.8
ye
ar
s
an
d
5
2
%
w
e
re
m
al
e
.
Fr
o
m
th
e
to
ta
l
n
u
m
b
e
r
o
f
p
at
ie
n
ts
ev
al
u
at
e
d
,
9
7
%
re
p
o
rt
e
d
b
e
in
g
su
ff
e
ri
n
g
fr
o
m
at
le
as
t
o
n
e
ad
ve
rs
e
re
ac
ti
o
n
,
w
h
ic
h
h
ad
a
n
e
ga
ti
ve
in
flu
e
n
ce
o
n
d
ai
ly
ac
ti
vi
ti
e
s
an
d
tr
e
at
m
e
n
t,
th
u
s,
lo
w
ad
h
e
re
n
ce
to
tr
e
at
m
e
n
t
w
it
h
Im
at
in
ib
in
p
at
ie
n
ts
w
it
h
C
M
L
is
lin
ke
d
ad
ve
rs
e
re
ac
-
ti
o
n
s.
A
m
o
n
g
th
e
ad
ve
rs
e
e
ff
e
ct
s,
th
e
m
o
st
ci
te
d
w
e
re
cr
am
p
(8
0
%
),
(c
o
n
ti
n
u
e
d
)
6 Journal of Oncology Pharmacy Practice 0(0)
T
a
b
le
1
.
C
o
n
ti
n
u
e
d
.
St
u
d
y
ye
ar
/c
o
u
n
tr
y
St
u
d
y
d
e
si
gn
(d
u
ra
ti
o
n
)
P
at
ie
n
ts
O
b
je
ct
iv
e
s
M
ai
n
cl
in
ic
al
o
u
tc
o
m
e
s
sy
m
p
to
m
s
w
it
h
m
e
d
i-
ca
ti
o
n
ad
h
e
re
n
ce
an
d
p
e
rc
e
iv
e
d
q
u
al
it
y
o
f
lif
e
.
e
d
e
m
a
(6
9
%
)
an
d
fa
ti
gu
e
(5
0
%
).
M
o
re
th
an
h
al
f
o
f
th
e
p
at
ie
n
ts
fe
lt
th
at
A
D
R
s
h
ad
a
n
e
ga
ti
ve
in
flu
e
n
ce
o
n
th
e
ir
d
ai
ly
q
u
al
it
y
o
f
lif
e
.
A
q
u
ar
te
r
o
f
th
e
p
at
ie
n
ts
re
p
o
rt
e
d
th
at
th
e
sy
m
p
to
m
s
h
ad
a
n
e
ga
ti
ve
in
flu
e
n
ce
o
n
m
o
o
d
,
ge
n
e
ra
l
co
n
d
it
io
n
o
r
p
le
as
u
re
in
lif
e
.
P
at
ie
n
ts
w
h
o
fe
lt
th
at
th
e
ir
sy
m
p
to
m
s
n
e
ga
ti
ve
ly
af
fe
ct
e
d
th
e
ir
q
u
al
it
y
o
f
lif
e
su
ff
e
re
d
fr
o
m
an
av
e
ra
ge
o
f
e
ig
h
t
d
iff
e
re
n
t
sy
m
p
to
m
s.
Fa
ri
as
e
t
al
.,
2
0
1
6
,
B
ra
zi
l2
7
P
ro
sp
e
ct
iv
e
im
p
ac
t
as
se
ss
m
e
n
t
st
u
d
y
(2
4
m
o
n
th
s)
1
8
5
Im
p
le
m
e
n
t
a
cl
in
ic
al
p
h
ar
-
m
ac
y
se
rv
ic
e
fo
cu
se
d
o
n
th
e
co
m
p
re
h
e
n
si
ve
re
vi
ew
o
f
an
ti
n
e
o
p
la
st
ic
d
ru
gs
u
se
d
in
th
e
ra
py
o
f
h
e
m
at
o
lo
gi
ca
l
d
is
e
as
e
s.
1
8
5
p
at
ie
n
ts
an
d
m
o
re
th
an
1
3
th
o
u
sa
n
d
p
re
sc
ri
p
ti
o
n
s
w
e
re
fo
llo
w
e
d
,w
it
h
a
1
0
6
.5
%
in
cr
e
as
e
in
th
e
d
e
te
ct
io
n
o
f
D
R
P
s.
T
h
e
m
ai
n
u
n
d
e
rl
yi
n
g
d
is
e
as
e
s
o
f
p
at
ie
n
ts
w
it
h
D
R
P
w
e
re
n
o
n
-H
o
d
gk
in
’s
ly
m
p
h
o
m
a,
m
u
lt
ip
le
m
ye
lo
m
a
an
d
ac
u
te
ly
m
p
h
o
id
le
u
ke
m
ia
-
p
o
ss
ib
ly
as
so
ci
at
e
d
w
it
h
th
e
co
m
p
le
x
it
y
o
f
th
e
ir
tr
e
at
m
e
n
t
re
gi
m
e
n
s
-
an
d
th
e
m
ai
n
d
ru
gs
re
la
te
d
to
D
R
P
w
e
re
m
e
th
o
tr
e
x
at
e
,
cy
cl
o
p
h
o
sp
h
am
id
e
,
cy
ta
ra
b
in
e
,
as
p
ar
ag
in
as
e
an
d
fil
gr
as
ti
m
.
T
h
u
s,
th
e
m
aj
o
ri
ty
o
f
D
R
P
s
in
b
o
th
p
e
ri
o
d
s
w
e
re
co
n
si
d
e
re
d
cl
in
ic
al
ly
si
gn
ifi
ca
n
t
(5
8
%
in
th
e
p
e
ri
o
d
w
it
h
o
u
t
th
e
C
lin
ic
al
P
h
ar
m
ac
y
se
rv
ic
e
an
d
7
1
%
w
it
h
th
e
C
lin
ic
al
P
h
ar
m
ac
y
se
rv
ic
e
)
an
d
am
o
n
g
th
e
m
ai
n
ch
ar
ac
te
r-
is
ti
cs
o
f
th
e
D
R
P
s,
th
e
ad
ju
st
m
e
n
t
o
f
d
o
se
,
d
u
ra
ti
o
n
tr
e
at
m
e
n
t
an
d
d
ilu
-
ti
o
n
/
co
n
ce
n
tr
at
io
n
o
f
th
e
m
an
ip
u
la
te
d
m
e
d
ic
at
io
n
.
P
h
ar
m
ac
is
ts
in
te
rv
e
n
e
d
m
ai
n
ly
d
u
ri
n
g
th
e
st
u
d
y
b
y
p
e
rf
o
rm
in
g
d
o
se
ad
ju
st
m
e
n
t,
d
ru
g
su
sp
e
n
si
o
n
,a
lt
e
ra
ti
o
n
o
f
d
ilu
e
n
ts
/
co
n
ce
n
tr
at
io
n
o
f
th
e
m
an
ip
u
la
te
d
d
ru
g,
an
d
in
cl
u
si
o
n
o
f
d
ru
g
th
e
ra
p
y.
D
e
fo
e
,
Ju
p
p
,
L
e
sl
ie
,
2
0
1
7
,
C
an
ad
a2
8
P
ro
sp
e
ct
iv
e
d
e
sc
ri
p
ti
ve
an
d
q
u
al
it
at
iv
e
st
u
d
y
(4
m
o
n
th
s)
2
7
2
D
e
sc
ri
b
e
ke
y
ac
ti
vi
ti
e
s
p
e
rf
o
rm
e
d
b
y
a
n
ew
ly
d
e
p
lo
ye
d
cl
in
ic
al
p
h
ar
-
m
ac
is
t
in
an
o
u
tp
at
ie
n
t
p
e
d
ia
tr
ic
h
e
m
at
o
lo
gy
,
o
n
co
lo
gy
,
tr
an
sp
la
n
t
cl
in
ic
.
D
u
ri
n
g
th
e
st
u
d
y,
p
h
ar
m
ac
is
ts
tr
e
at
e
d
2
7
2
p
at
ie
n
ts
an
d
re
co
rd
e
d
1
0
2
1
in
te
rv
e
n
ti
o
n
s
su
ch
as
m
e
d
ic
at
io
n
re
vi
ew
,
ad
vi
ce
,
u
sa
ge
gu
id
e
lin
e
s
an
d
la
b
o
ra
to
ry
m
o
n
it
o
ri
n
g.
It
w
as
al
so
p
o
ss
ib
le
to
o
b
se
rv
e
a
co
n
si
d
e
ra
b
le
in
cr
e
as
e
in
th
e
n
u
m
b
e
r
o
f
m
e
d
ic
at
io
n
re
co
n
ci
lia
ti
o
n
p
e
rf
o
rm
e
d
(4
0
0
%
),
in
th
e
p
ro
vi
si
o
n
o
f
ad
h
e
re
n
ce
as
si
st
an
ts
fo
r
p
at
ie
n
ts
an
d
th
e
ir
fa
m
ili
e
s
(1
3
2
%
)
an
d
ad
h
e
re
n
ce
as
se
ss
m
e
n
ts
(1
2
2
%
).
C
lin
ic
al
p
h
ar
m
ac
is
ts
h
av
e
d
e
m
o
n
st
ra
te
d
an
in
-d
e
p
th
u
n
d
e
rs
ta
n
d
ing
o
f
tr
e
at
m
e
n
t
re
gi
m
e
n
s,
an
d
am
o
n
g
o
th
e
r
in
te
rv
e
n
ti
o
n
s,
ca
n
re
vi
ew
m
e
d
ic
at
io
n
s
w
it
h
p
at
ie
n
ts
,
m
an
ag
e
th
e
ra
p
e
u
ti
c
d
ru
gs
,
id
e
n
ti
fy
d
ru
g
in
te
ra
ct
io
n
s,
h
e
lp
w
it
h
tr
e
at
m
e
n
t
ad
h
e
r-
e
n
ce
,
p
ro
vi
d
e
m
e
d
ic
at
io
n
ad
vi
ce
,
an
d
th
u
s
id
e
n
ti
fy
an
d
ad
d
re
ss
so
m
e
b
ar
ri
e
rs
.
L
u
ce
n
a
e
t
al
.,
2
0
1
8
,
U
SA
3
0
R
e
tr
o
sp
e
ct
iv
e
d
e
sc
ri
p
ti
ve
an
d
q
u
al
it
at
iv
e
st
u
d
y
(2
m
o
n
th
s)
1
1
4
D
e
te
rm
in
e
ri
sk
cr
it
e
ri
a
sp
e
ci
fic
to
th
e
m
al
ig
n
an
t
h
e
m
at
o
lo
gy
an
d
b
o
n
e
m
ar
ro
w
tr
an
sp
la
n
t
p
at
ie
n
ts
an
d
to
ev
al
u
at
e
th
e
d
iff
e
re
n
t
ty
p
e
s
an
d
se
ve
ri
ti
e
s
o
f
in
te
rv
e
n
-
ti
o
n
s
m
ad
e
b
y
p
h
ar
m
ac
is
ts
.
1
1
4
p
at
ie
n
ts
w
e
re
in
cl
u
d
e
d
w
it
h
a
to
ta
l
o
f
7
9
3
in
te
rv
e
n
ti
o
n
s
o
ve
r
th
e
d
u
ra
ti
o
n
o
f
th
e
st
u
d
y.
A
m
o
n
g
th
e
p
at
ie
n
ts
,
8
0
w
e
re
id
e
n
ti
fie
d
as
in
h
ig
h
ri
sk
an
d
3
4
as
n
o
t
in
h
ig
h
ri
sk
.
T
h
e
re
w
e
re
m
o
re
in
te
rv
e
n
ti
o
n
s
d
o
cu
-
m
e
n
te
d
u
p
o
n
ad
m
is
si
o
n
in
th
e
h
ig
h
-r
is
k
gr
o
u
p
(7
3
in
te
rv
e
n
ti
o
n
s)
co
m
-
p
ar
e
d
w
it
h
th
e
n
o
t
h
ig
h
-r
is
k
gr
o
u
p
(3
1
in
te
rv
e
n
ti
o
n
s)
.
H
o
w
ev
e
r,
in
a
p
e
r
p
at
ie
n
t
an
al
ys
is
,
th
e
re
w
as
a
si
m
ila
r
n
u
m
b
e
r
o
f
in
te
rv
e
n
ti
o
n
s
in
b
o
th
gr
o
u
p
s.
Sp
e
ci
fic
al
ly
fo
r
th
e
h
ig
h
-r
is
k
p
at
ie
n
ts
,
th
e
re
w
e
re
a
to
ta
l
o
f
3
2
6
in
te
rv
e
n
ti
o
n
s,
w
it
h
2
1
o
f
th
e
m
m
ad
e
u
p
o
n
ad
m
is
si
o
n
an
d
3
0
5
m
ad
e
d
u
ri
n
g
h
o
sp
it
al
st
ay
.
In
th
is
ca
se
,
th
e
m
o
st
co
m
m
o
n
in
te
rv
e
n
ti
o
n
s
w
e
re
:
th
e
ra
-
p
e
u
ti
c
re
gi
m
e
n
ch
an
ge
(3
6
%
),
th
e
ra
py
d
is
co
n
ti
n
u
at
io
n
(1
6
%
),
an
d
(c
o
n
ti
n
u
e
d
)
Oliveira et al. 7
T
a
b
le
1
.
C
o
n
ti
n
u
e
d
.
St
u
d
y
ye
ar
/c
o
u
n
tr
y
St
u
d
y
d
e
si
gn
(d
u
ra
ti
o
n
)
P
at
ie
n
ts
O
b
je
ct
iv
e
s
M
ai
n
cl
in
ic
al
o
u
tc
o
m
e
s
m
o
n
it
o
ri
n
g
(1
6
%
).
B
ey
o
n
d
it
,
m
e
d
ic
at
io
n
h
is
to
ri
e
s
co
rr
e
sp
o
n
d
e
d
to
o
n
ly
5
%
o
f
th
e
in
te
rv
e
n
ti
o
n
s
an
d
th
e
au
th
o
rs
co
n
cl
u
d
e
d
th
at
it
su
gg
e
st
s
th
at
p
h
ar
m
ac
is
ts
m
ay
n
e
e
d
to
fo
cu
s
m
o
re
o
n
as
se
ss
in
g
an
d
in
te
rv
e
n
in
g
o
n
p
at
ie
n
ts
.
M
o
re
o
ve
r,
in
te
rv
e
n
ti
o
n
s
re
la
te
d
to
m
e
d
ic
at
io
n
h
is
to
ry
w
e
re
th
e
m
o
st
p
re
va
le
n
t
u
p
o
n
ad
m
is
si
o
n
(7
1
%
),
w
h
ile
th
e
m
o
st
fr
e
q
u
e
n
t
d
u
ri
n
g
th
e
h
o
sp
it
al
st
ay
w
e
re
th
o
se
re
la
te
d
to
m
o
d
ify
in
g
a
th
e
ra
p
e
u
ti
c
re
gi
m
e
n
(3
8
%
),
d
is
co
n
ti
n
u
in
g
th
e
ra
py
(1
6
%
),
an
d
m
o
n
it
o
ri
n
g
(1
6
%
).
C
h
e
n
,
W
u
an
d
H
u
an
g
2
0
1
9
,
T
ai
w
an
2
4
R
e
tr
o
sp
e
ct
iv
e
im
p
ac
t
as
se
ss
m
e
n
t
st
u
d
y
(1
2
m
o
n
th
s)
1
4
4
3
E
va
lu
at
e
th
e
cl
in
ic
al
an
d
e
co
n
o
m
ic
im
p
ac
t
o
f
cl
in
ic
al
p
h
ar
m
ac
is
t
in
te
rv
e
n
ti
o
n
in
a
h
e
m
a-
to
lo
gy
u
n
it
.
A
ft
e
r
th
e
im
p
le
m
e
n
ta
ti
o
n
o
f
th
e
C
lin
ic
al
P
h
ar
m
ac
y
se
rv
ic
e
,
th
e
av
e
ra
ge
h
o
sp
it
al
iz
at
io
n
ti
m
e
d
e
cr
e
as
e
d
fr
o
m
1
9
.2
7
to
1
6
.6
9
d
ay
s.
8
2
6
p
h
ar
m
a-
ce
u
ti
ca
l
in
te
rv
e
n
ti
o
n
s
w
e
re
p
e
rf
o
rm
e
d
w
h
ic
h
w
as
si
gn
ifi
ca
n
tl
y
h
ig
h
e
r
th
an
th
e
p
e
ri
o
d
b
e
fo
re
th
e
in
vo
lv
e
m
e
n
t
o
f
th
e
cl
in
ic
al
p
h
ar
m
ac
is
t
(p
<
0
.0
0
0
0
1
).
A
m
o
n
g
th
e
ac
ti
ve
re
co
m
m
e
n
d
at
io
n
s,
th
e
re
w
e
re
re
co
m
-
m
e
n
d
at
io
n
s
fo
r
th
e
p
ri
m
ar
y
p
ro
p
hy
la
ct
ic
u
se
o
f
p
o
sa
co
n
az
o
le
fo
r
p
at
ie
n
ts
w
it
h
ac
u
te
m
ye
lo
id
le
u
ke
m
ia
u
n
d
e
rg
o
in
g
re
m
is
si
o
n
-i
n
d
u
ci
n
g
ch
e
m
o
th
e
r-
ap
y.
A
s
a
re
su
lt
o
f
th
e
se
m
e
d
ic
at
io
n
o
rd
e
r
in
te
rv
e
n
ti
o
n
s,
d
e
te
ct
e
d
p
re
-
ve
n
ta
b
le
ad
ve
rs
e
ev
e
n
ts
in
cr
e
as
e
d
fr
o
m
5
8
in
th
e
ye
ar
p
ri
o
r
to
th
e
in
vo
lv
e
m
e
n
t
o
f
th
e
cl
in
ic
al
p
h
ar
m
ac
is
t
to
2
3
0
th
e
re
af
te
r.
M
o
re
o
ve
r,
th
e
co
st
sa
vi
n
gs
w
as
5
.7
5
ti
m
e
s
h
ig
h
e
r
th
an
th
e
e
st
im
at
e
d
b
e
fo
re
th
e
in
tr
o
-
d
u
ct
io
n
o
f
th
e
se
rv
ic
e
.
W
in
d
e
t
al
.,
2
0
2
0
,
U
SA
3
1
R
e
tr
o
sp
e
ct
iv
e
im
p
ac
t
as
se
ss
m
e
n
t
st
u
d
y
(7
m
o
n
th
s)
2
8
Im
p
le
m
e
n
t
an
d
o
p
ti
m
iz
e
a
p
ilo
t
tr
an
si
ti
o
n
s
o
f
ca
re
m
o
d
e
l
fo
r
sc
h
e
d
u
le
d
ch
e
m
o
th
e
ra
py
ad
m
is
-
si
o
n
s
in
p
at
ie
n
ts
w
it
h
h
e
m
at
o
lo
gi
c
m
al
ig
n
an
ci
e
s.
T
h
e
p
la
n
-d
o
-s
tu
d
y-
ac
t
(P
D
SA
)
q
u
al
it
y
im
p
ro
ve
m
e
n
t
te
ch
n
iq
u
e
w
as
im
p
le
-
m
e
n
te
d
to
p
ro
sp
e
ct
iv
e
ly
m
e
as
u
re
th
e
su
cc
e
ss
o
f
in
te
rv
e
n
ti
o
n
s
re
la
te
d
to
th
e
im
p
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ve
m
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o
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se
rv
ic
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ss
tr
an
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o
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th
at
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cc
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va
ri
o
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ag
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in
cl
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e
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p
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ti
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al
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ce
-
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ct
ro
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ic
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cu
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ta
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o
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m
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d
ic
al
re
co
rd
s
an
d
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ca
ti
o
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r
th
e
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lt
id
is
ci
p
lin
ar
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gr
o
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p
o
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m
al
ig
n
an
t
h
e
m
at
o
lo
gy
.
In
ad
e
q
u
at
e
p
re
sc
ri
p
ti
o
n
o
f
p
ro
p
hy
la
ct
ic
an
ti
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ro
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ia
ls
an
d
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is
ch
ar
ge
an
ti
e
m
e
ti
cs
o
cc
u
rr
e
d
fo
r
7
8
%
an
d
4
4
%
o
f
p
at
ie
n
ts
,
re
sp
e
ct
iv
e
ly
.
In
ad
d
it
io
n
,
th
re
e
P
D
SA
cy
cl
e
s
w
e
re
co
n
d
u
ct
e
d
re
su
lt
in
g
in
im
p
ro
ve
m
e
n
ts
in
m
u
lt
ip
le
as
p
e
ct
s
su
ch
as
:
co
m
-
m
u
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ic
at
io
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re
ga
rd
in
g
st
at
u
s
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f
b
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fit
s
in
ve
st
ig
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s
p
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rf
o
rm
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r
sp
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al
ty
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at
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p
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to
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m
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so
lu
ti
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se
b
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fit
s
in
ve
st
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at
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s
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o
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ti
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o
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p
ro
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ff
ic
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ch
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py
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at
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in
st
ru
c-
ti
o
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fo
r
ap
p
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p
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ls
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G
r� e
go
ri
e
t
al
.,
2
0
2
0
,
Fr
an
ce
2
3
R
e
tr
o
sp
e
ct
iv
e
q
u
al
it
at
iv
e
an
d
d
e
sc
ri
p
ti
ve
st
u
d
y
(1
2
m
o
n
th
s)
5
5
8
E
va
lu
at
e
cl
in
ic
al
an
d
fin
an
-
ci
al
im
p
ac
t
o
f
p
h
ar
m
a-
ci
st
in
te
rv
e
n
ti
o
n
s
in
an
am
b
u
la
to
ry
ad
u
lt
h
e
m
at
o
lo
gy
-o
n
co
lo
gy
d
e
p
ar
tm
e
n
t.
A
to
ta
l
o
f
1
9
7
0
in
te
rv
e
n
ti
o
n
s
w
e
re
p
e
rf
o
rm
e
d
co
rr
e
sp
o
n
d
in
g
to
an
av
e
ra
ge
o
f
3
.5
in
te
rv
e
n
ti
o
n
s/
p
at
ie
n
t.
T
h
e
m
ai
n
D
R
P
s
w
e
re
:
co
n
tr
a-
in
d
ic
at
io
n
/n
o
n
-
co
n
fo
rm
it
y
to
gu
id
e
lin
e
s
(9
8
,
1
5
%
),
d
o
sa
ge
p
ro
b
le
m
(9
0
,
1
4
%
),
d
ru
g
in
te
ra
ct
io
n
(8
0
,
1
2
%
)
an
d
im
p
ro
p
e
r
p
re
sc
ri
p
ti
o
n
(7
8
,
1
2
%
).
T
h
e
m
ai
n
in
te
rv
e
n
ti
o
n
s
ad
o
p
te
d
w
e
re
:
D
is
co
n
ti
n
u
at
io
n
o
r
re
fu
sa
l
to
d
e
liv
e
r
(2
5
6
,
3
9
%
),
d
d
d
it
io
n
o
f
a
n
ew
d
ru
g
(1
9
6
,
3
0
%
),
d
o
se
ad
ju
st
m
e
n
t
(9
5
,
1
5
%
)
an
d
(c
o
n
ti
n
u
e
d
)
8 Journal of Oncology Pharmacy Practice 0(0)
The selected studies presented different methodolog-
ical designs, which made it difficult to match the results
and compare the reported outcomes. Most of the stud-
ies (n¼ 9) were prospective. The studies had as meth-
odological design: the qualitative and descriptive
analysis (n¼ 8), the impact assessment (n¼ 6), the
cohort analysis (n¼ 2) and the cross-sectional
approach (n¼ 1).
All studies used the identification of DRPs and the
evaluation of the performed interventions as clinical
outcome measures. In addition, three studies
approached the humanistic impacts20–22 and two of
them discussed the economic impacts of interventions
carried out by pharmacists.23,24
Pharmacist intervention for Drug-Related problems
(DRPs)
All studies have shown that in the pharmacotherapy
assessment process, the identification of DRPs was
essential to ensure patient safety when using medica-
tions. Pharmacists have played a key role in evaluatingtherapeutic outcomes, promoting therapeutic adher-
ence and identifying DRPs.
The pharmacotherapy evaluation performed by
pharmacists resulted in more than 3,000 therapeutic
interventions and in the identification of approximately
1,500 DRPs. The most frequently reported DRPs
regarded: safety, due to adverse reaction to the medi-
cation, very high dose prescription or drug interactions;
effectiveness, by underdosing or lack of monitoring;
indication, for untreated health condition or adher-
ence.5,6,17,18,20–22,25–28
To handle or avoid DRPs, the main reported inter-
vention performed by the pharmacist was optimization
of administration,5,21,22,26,29 including: dose adjust-
ment; prescription of drugs; prophylaxis of infections;
replenishiment of electrolytes; substitution of medica-
tion; and therapeutic monitoring. The integration of
the clinical pharmacist in an onco-hematology depart-
ment resulted in beneficial interventions to guarantee
safety in the use of medication for 12.6% of the pre-
scriptions of adult patients hospitalized with cancer.5
In that work, most DRPs reported involved anti-
infectious agents, while quite a few were related to anti-
neoplastic therapy.
Treatment adherence and education for Self-Care
The implementation of a clinical pharmacy service in
onco-hematology clinics has contributed to the promo-
tion of therapeutic adherence and education for self-
care. The focus of counseling was to promote therapeu-
tic adherence and provide information on: ways of
using therapeutic agents, prevention and managementT
a
b
le
1
.
C
o
n
ti
n
u
e
d
.
St
u
d
y
ye
ar
/c
o
u
n
tr
y
St
u
d
y
d
e
si
gn
(d
u
ra
ti
o
n
)
P
at
ie
n
ts
O
b
je
ct
iv
e
s
M
ai
n
cl
in
ic
al
o
u
tc
o
m
e
s
o
p
ti
m
iz
at
io
n
o
f
th
e
d
is
p
e
n
si
n
g/
ad
m
in
is
tr
at
io
n
m
o
d
e
(5
2
.8
%
).
T
h
e
co
st
re
d
u
ct
io
n
w
as
e
3
9
0
,4
8
0
.
T
h
e
co
st
-b
e
n
e
fit
ra
ti
o
o
f
th
e
cl
in
ic
al
p
h
ar
m
ac
is
t
w
as
e
3
.7
fo
r
e
ac
h
e
u
ro
in
ve
st
e
d
.
M
o
u
k
af
ih
e
t
al
.,
2
0
2
0
,
M
o
ro
cc
o
3
2
R
e
tr
o
sp
e
ct
iv
e
o
b
se
rv
a-
ti
o
n
al
st
u
d
y
(1
2
m
o
n
th
s)
5
2
6
D
o
cu
m
e
n
t
an
d
ev
al
u
at
e
th
e
ro
le
o
f
cl
in
ic
al
p
h
ar
m
ac
y
se
rv
ic
e
s
in
an
o
n
co
lo
gy
d
e
p
ar
tm
e
n
t.
T
h
e
st
u
d
y
in
cl
u
d
e
d
5
2
6
p
at
ie
n
ts
.
T
h
e
p
h
ar
m
ac
is
t
id
e
n
ti
fie
d
4
5
0
D
R
P
s,
m
ai
n
ly
:u
n
tr
e
at
e
d
in
d
ic
at
io
n
s
(3
1
.3
%
);
o
ve
rd
o
se
(1
7
.1
%
);
d
ru
g
in
te
ra
ct
io
n
s
(1
2
.4
%
)
an
d
u
n
d
e
rd
o
sa
ge
(1
1
.1
%
).
T
h
e
m
aj
o
ri
ty
(9
8
%
)
o
f
th
e
ch
an
ge
s
im
p
le
m
e
n
te
d
b
y
th
e
te
am
h
ad
a
si
gn
ifi
ca
n
t
cl
in
ic
al
im
p
ac
t
o
n
th
e
p
at
ie
n
t:
8
8
(1
9
.6
%
)
w
it
h
a
ve
ry
si
gn
ifi
ca
n
t
cl
in
ic
al
im
p
ac
t
an
d
7
1
(1
5
.8
%
)
w
it
h
a
p
o
te
n
ti
al
vi
ta
l
im
p
ac
t.
Oliveira et al. 9
of expected adverse reactions, and the dangers, signs
and symptoms of thrombosis.
In this context, the work in20 carried out 63 educa-
tional interventions, which more than half were direct-
ed to the use of antiemetics, the resolution of dosage
calculation errors and to the adjustment of pain control
regimens. These interventions contribute to the individ-
ualization and monitoring of therapeutic regimes.
Additionally, it also benefits both the patient and the
health service by reducing hospitalization time and
unnecessary expenses, and helping to achieve the
goals established by the multidisciplinary team.
The treatment adherence of patients with chronic
myeloid leukemia who received Imatinib was described
in the study in.21 They reported that the pharmacist
helped promote adherence (88.6%) and better results
by building a close and trusting relationship with the
patient and family, through the implementation of a
treatment plan. It consisted of an appointment with
an oncology pharmacist, where the patient received
educational information about the disease and medica-
tions, enabling them to identify, solve and prevent
problems. The assistance to patients was also carried
out via e-mails and telephone calls, facilitating access to
guidelines, and thereby reducing treatment non-
adherence rates, which is one of the main factors that
contribute to the failure of therapy.
Another study was carried out in Finland, between
2012 and 2013, in eight hospitals with the aim of eval-
uating the Adverse Drug Reactions (ADRs) experi-
enced by patients with chronic myeloid leukemia
during oral treatment with tyrosine kinase inhibitor.
The authors reported that More than half of the
patients felt that ADRs had a negative influence on
their quality of life. Moreover, a quarter of the patients
reported that the symptoms had a negative influence on
mood, general condition or pleasure in life. Beyond it,
patients who felt that their symptoms negatively affect-
ed their quality of life suffered from of eight different
symptoms on average.22
Economic impact of pharmacist interventions
Two studies demonstrated that, after the introduction
of Clinical Pharmacy services at Oncology and
Hematology Centers, there was a significant increase
in interventions to reduce medication errors, prevent-
able adverse drug events and medication costs. In a
study carried out in France23 in 2020, the value repre-
sented by deprescriptions and exchanges for less expen-
sive drugs was e185,508. In turn, the value represented
by the addition of medicines and the replacement by
more expensive ones was e9,945. Beyond it, 109 (6%)
of all interventions regarded the revision of immuno-
therapy or chemotherapy regimen resulting in the
reduction of e148,032 (84% of the total cost savings).
The total cost reduction represented ss expensive drugs
was e185,508. In turn, the value represented by the
addition of medicines and th average annual savings
produced a net benefit of e223,021 and the cost-
benefit ratio was . The total cost reduction represented
ss expensive drugs was
In another study carried out in Taipei24 in 2019,
reported that, after the implementation of the clinical
pharmacy service, the average hospitalization time
reduced from 19.27 to 16.69 days compared to the
period before the implementation of the service.
Thus, the cost savings was 5.75 times (NT$250,280a)
the estimated before the introduction of the service
(NT$37,080) by considering the switch from parenteral
to oral medications (main contributor) despite only
decreasing doses or frequency of medication.
Reviewed study limitations
The most common limitations of the selected studies
were: the small number of patients, unpaired distribu-
tion among the study groups, lack of standardization
of the instruments used to assess quality of life and the
incidence of adverse reactions, the short period of time
of evaluation. Moreover, the differences in methodol-
ogies hardened the pairing between studies for the
meta-analysis. These factors can result in low represen-
tativeness of the population and statistical and data
interpretation errors.
Discussion
Our findings represent unprecedented results in rela-
tion to the clinical outcomes of patients with hemato-
logical tumors that were evaluated by clinical
pharmacists, the role of the pharmacist in onco-
hematology services and the corresponding economic
impacts for the organizations. The selected articles
demonstrated significant impacts on health care for
patients with hematological tumors. It highlights the
importance of including the pharmacist in the assis-
tance team in the outpatient, hospital or community
environment. It allows addressing fundamental care
for the drug therapy management and monitoring for
the patients, detecting possible adverse reactions and
drug interactions.
Most of the studies selected in this review described
mainly the types of DRPs found as an indicator of the
pharmacy practice.5,6,20,26,27,32 Few studies have
reported the clinical outcomes of the identified DRPs,
the humanistic17,22,28 and economic
outcomes.20,21,23,24,26,28
The selected studies described a large number of
DRPs identified.The work in27 reported that the
10 Journal of Oncology Pharmacy Practice 0(0)
detection and prevention of DRPs increased 106.5%
compared to the period when the clinical pharmacy
service was not offered to patients. The main underly-
ing diseases of patients with DRPs were: non-
Hodgkin’s lymphoma, multiple myeloma and acute
lymphoid leukemia. The related DRPs can be associat-
ed with the complexity of the treatment regimens and
the main drugs associated were: methotrexate, cyclo-
phosphamide, cytarabine, asparaginase and filgrastim.
Most DRPs in both periods were considered clinically
significant. The pharmacists intervened mainly during
the study of dose adjustment, suspension of drugs,
alteration of diluents/concentration of manipulated
medication and inclusion of drug therapy.
The hematological system is one of those affected by
the toxicity of the chemotherapy treatment. As
reported in the selected work, the main ADRs identi-
fied by pharmacists and responsible for 78% of the
interventions, were: anemia, constipation/diarrhea
and nausea/vomiting.6 In addition, the studies also
reported skin toxicity, nephrotoxicity, infection, insom-
nia, mucositis, increased levels of glucose, allergies,
thrombocytopenia and edema.5,6,20,26,27
The supportive health care conducted by pharma-
cists were: use of granulocyte-stimulating factors for
prevention of febrile neutropenia (caused by myelosup-
pression due to chemotherapy); use of prophylactic
antiemetics (to improve quality of life and prevent
unnecessary hospitalizations); prevention of tumor
lysis (potentially fatal oncological emergency, caused
by electrolyte disturbances and renal dysfunction);
therapeutic monitoring of high-dose drugs such as
methotrexate; controlled infusion of drugs such as rit-
uximab (for minimizing the risk of adverse reactions);
and safety monitoring in the use of drugs to prevent
DRPs. Additional fundamental care developed by
pharmacists were the management and evaluation of
drug interactions between chemotherapeutic agents
and the use of alternative and complementary thera-
pies, such as teas and herbal medicines. Hence, as a
result, pharmacotherapy optimization occurred
(33.9%), followed by the resolution of DRPs
(26.2%).25
The Clinical Pharmacy services contributed to the
individualization and monitoring of therapeutic
regimes, in addition to benefiting both the patient
and the health service by reducing hospitalization
time and unnecessary expenses. Consequently, it
helped achieving the goals established by the multidis-
ciplinary team.20,23,31
A study was carried out in Spain on a Clinical
Pharmacy service for patients with Chronic Myeloid
Leukemia, in which the patient received the medication
at home. It was focused on the quality of life, detection
of interactions and DRPs and the management of
adherence therapy individually. The monthly delivery
of the drugs at home allowed to optimize the available
resources of the pharmacy service, such as storage
space and improved management of expiration dates.
At the end of the study period, all participants contin-
ued to be monitored by the service.18 In a similar study,
carried out in the USA, the pharmacist helped in pro-
moting adherence (88.6%) and in the results by build-
ing a relationship of proximity and trust with the
patient and his family, generated through the imple-
mentation of a health care plan. It consisted of a visit
with an oncology pharmacist, where the patient
received information about the disease and medica-
tions, enabling them to identify, solve and prevent
problems.21
The assessment of ADRs experienced by patients
with CML and the correlation of ADR symptoms
with medication adherence and perceived quality of
life was described in a study conducted at eight hospi-
tals in Finland. The study reported 97% percent of
patients were suffering from at least one ADR.
Although, no correlation was found between adherence
and ADRs, half of the patients felt that ADRs had a
negative influence on their quality of life, affecting their
mood, general state or the pleasure of life.22
The research carried out by Ribed and collabora-
tors17 revealed the positive impact of Clinical
Pharmacy services for outpatients who indicated a
degree of satisfaction of 81.8% when asked about the
services provided in the implemented Pharmaceutical
Care program.
Drug reconciliation has been described as an impor-
tant tool in the clinical pharmacy. A study carried out
in Canada demonstrated a significant increase in the
number of medication reconciliation (400%), assis-
tance to patients and their families to promote therapy
adherence (132%) and adherence assessments
(122%).28
Clinical pharmacists have demonstrated an in-depth
understanding of treatment regimens and, among other
interventions, worked on reviewing medication, man-
aging therapeutic drugs, identifying drug interactions,
helping with treatment adherence, and providing med-
ication advice. Although specific data on the clinical
relevance of interventions conducted by pharmacists
have not been collected, the study demonstrated that
the integration of clinical pharmacists in an interdisci-
plinary clinic can improve patient safety in the use of
drugs, in addition to contributing to the reduction of
adverse events, hospitalization occurrences, and hospi-
talization time.21,27,28
The impact of an oncology pharmacist extends
beyond individual patient care, indirectly affecting
patient outcomes through activities such as the devel-
opment and implementation of safety guidelines and
Oliveira et al. 11
policies for the use of medicines.19,33,34 As observed in
the literature described here, the implementation of a
clinical pharmacy service in oncology care units pro-
moted the reduction of errors resulting from incorrect
prescriptions, drug interactions, side effects, in addition
to reducing the number of hospitalizations and, conse-
quently, treatment costs and negative impacts on
patient’s life and health.35–39 In addition, the relation-
ship and trust between pharmacist and patients under-
going onco-hematology treatment was expanded,
through the practice of pharmaceutical care, positively
contributing to the quality of life of patients. Hence, it
allowed the increase of satisfaction, adherence to treat-
ment and the continuous expert guidance on the cor-
rect use of prescribed antineoplastic agents, as well as
the control of side effects and possible
interactions.17,18,40
In summary, the studies have reported the clinical
activities developed by pharmacists, such as: medica-
tion reconciliation, patient education, and economic
assessments, which are fundamental activities for pro-
moting patient safety when using medications.
Moreover, the studies discussed here presented results
that directly impacted the quality of health care, as well
as the quality of life of patients and the reduction of
treatment costs. Finally, the studies reported improve-
ment of symptoms in subsequent clinical appointments
(after intervention by the pharmacist), of therapeutic
adherence and in the prevention of DRPs.
Some limitations were found in the execution of this
review such as: i) the publication bias that can affect
the selection process of articles, since no study was
identified to show the negative impact of clinical phar-
macy services; ii) the selection bias, given some studies
might not be indexed in the researched databases; and
iii) it was not possible to carry out a quantitative sum-
mary analysis of the data due to the heterogeneity of
the population, interventions and results of the selected
studies.
Conclusions
In view of the evidences found in studies carried out in
different countries, the practice of Clinical Pharmacy
and Pharmaceutical Care has shown that cancer
patients accompanied by a clinical pharmacist,
showed higher adherence to treatment, control of
symptoms (e.g, cancer pain, nausea, constipation),
improvement in the quality of life, as well as in the
reductionand/or solution of DRPs. To the best of
our knowledge, this study is the first systematic
review that summarizes the different studies that deal
with the impacts of Clinical Pharmacy services in assist-
ing patients with onco-hematologic cancers.
In general, the studies included in this review, con-
ducted in diverse places and contexts, concluded that
Clinical Pharmacy services contributed to the individ-
ualization and monitoring of therapeutic regimes. In
addition, it also contributed to the patient and the
health service by reducing hospitalization time and
unnecessary expenses, helping to achieve the goals
established by the multiprofessional team. Another rel-
evant care developed by pharmacists was the manage-
ment and evaluation of drug interactions between
chemotherapeutic agents and the use of alternative
and complementary therapies, such as teas and herbal
medicines.
Finally, we suggest that future longitudinal studies
can be carried out in order to clarify the impacts of
Clinical Pharmacy and Pharmaceutical Care on the
survival and quality of life of patients with onco-
hematological cancers. Such studies would be impor-
tant to describe the long-term results of Clinical
Pharmacy services.
Acknowledgements
The authors thank Caroline Argolo Brito Oliveira and
Lorena Silva Oliveira Nunes for the comments and sugges-
tions on the preliminary version of this work.
Declaration of Conflicting Interests
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
Renata F de Ara�ujo-Calumby https://orcid.org/0000-
0003-2475-5953
Note
a. NT$: New Taiwan Dollar.
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