Disclaimer In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Purpose Oral oncolytics come with significant concerns of noncompliance due to complex regimens, adverse effects, and high overall costs. The Geisinger Oral Chemotherapy Clinic is a fully telephone-based medication therapy disease management (MTDM) program designed to integrate pharmacists as advanced practitioners in hematology/oncology clinics for comanagement of oral chemotherapy. Summary To date, Geisinger has 11 oncology clinics and 3 full-time pharmacists designated to the management of oral chemotherapy. Pharmacists receive referrals for comanagement of patients starting oral oncolytics. Under a collaborative practice agreement, they can order laboratory tests as well as supportive care medications and refills. Pharmacists review planned therapies, perform medication reconciliations, and provide medication counseling. Once treatment has been initiated, pharmacists contact patients for laboratory and toxicity assessments. The clinic incorporates the use of customized smart data elements within the electronic medical record to collect data regarding pharmacist interventions and time allocations in the clinic. As of March 31, 2021, the clinic was actively following approximately 1,100 patients, resulting in an average of 80 to 90 encounters per day for new referrals, chemotherapy education, and laboratory and toxicity assessments. Approximately 2,113 patients were followed from December 1, 2019, to March 31, 2021, with 46,929 interventions documented. Conclusion By obtaining provider buy-in for pharmacy services, acquiring enough personnel resources to meet the needs of the growing patient population and respective therapies, and proper utilization of technology, the program has thrived, allowing for increased provider and patient satisfaction. Future goals include expanding collection of pharmacist intervention metrics and analysis of patient perceptions of services provided by the clinic.

Background: Cytoreduction utilizing hydroxyurea to achieve a hematocrit (HCT) <45% has improved clinical outcomes for patients with Polycythemia Vera (PV). Pharmacists, through a collaborative practice agreement with hematologists, are uniquely posited to act as physician extenders and therapeutically dose adjust hydroxyurea (HU). Since 2013, HU therapeutic drug monitoring for PV patients has been transitioned to pharmacists in our oral chemotherapy clinic. We conducted a retrospective cohort cross-over study to evaluate pharmacist versus physician HU management to achieve a therapeutic HCT <45%. Methods: We retrospectively queried our institutional electronic medical record to identify patients diagnosed with PV with a documented ambulatory HU prescription. Additionally, patients' HU must have been managed by a physician (Phys) and subsequently crossed over to a pharmacist (PharmD) with at least two documented encounters by each clinician type. Hematological parameters for therapeutic drug monitoring are outlined in Table 1. Descriptive statistics were used for demographic information and a random effects model was used to evaluate HU management between Phys and PharmD. We fit a generalized linear regression model with random intercepts for each patient, using SAS's PROC GLIMMIX and Laplace approximation method t-test for a significant difference in probability of a therapeutic measurement between PharmD and Phys managed patients. Odd ratios were also calculated and adjusted for age and sex. Statistical analysis was performed using SAS (SAS9.4 SAS Institute, Cary, NC) and R software (The R Group, Vienna, Austria), with p<0.05 considered statistically significant. Results: Between 1/1/2003 and 1/20/2020, 104 patients meet the inclusion criteria. This cohort was primarily female (53%), white (97%), and aged 71 years during PharmD management vs 69 years during Phys management. The median time of a patient's HU management by PharmD was 2.4 years (IQR 1.2-3.8), Phys was 0.7 years (IQR 0.02-4.2), and overall was 3.6 years (IQR 2-6.6). 3154 complete blood count measurements were collected in the PharmD cohort and 2007 were collected in the Phys cohort. HU management by PharmD vs Phys resulted in statistically significant increases of therapeutic HCT measurements (p<0.0001) and platelet (PLT) measurements (p<0.0001) as shown in Figure 1. These outcomes remained significant when adjusted for both age and sex: HCT 87.8% vs 74.7% (p<0.0001) and PLT 78.4% vs 70.1% (p=0.0001). There was no difference white blood cell (WBC) therapeutic measurements between cohorts nor when adjusted for age and sex. Patients in the PharmD cohort had higher odds of achieving therapeutic HCT (OR 2.44; 95% CI [1.92 - 3.10], p<0.0001) and PLT (OR 1.55; 95% CI [1.25 - 1.92], p=0.0001) goals (Table 1). In terms of hematological safety parameters, there was no significant difference in neutropenia (OR 1.30; CI 95% [0.51-3.25]) with PharmD vs Phys HU management. All grade neutropenia occurred in 35 (1.1%) and 18 (0.9%) of patients between the PharmD vs Phys cohort, respectively. Grade 3 neutropenia occurred in 1.1% of patients in both cohorts with no instances of Grade 4 neutropenia. Conclusion: These findings support the efficacy of pharmacist therapeutic drug management of HU for patients with PV. Pharmacists managing HU achieve a target HCT and PLT count more often than physician management. By acting as a physician extender, pharmacist HU management for PV patients can help decrease the clinical burdens on physicians without compromising efficacy. Disclosures No relevant conflicts of interest to declare.

While immuno-oncotherapy (IO) has significantly improved outcomes in the treatment of systemic cancers, various neurological complications have accompanied these therapies. Treatment with immune checkpoint inhibitors (ICIs) risks multi-organ autoimmune inflammatory responses with gastrointestinal, dermatologic, and endocrine complications being the most common types of complications. Despite some evidence that these therapies are effective to treat central nervous system (CNS) tumors, there are a significant range of related neurological side effects due to ICIs. Neuroradiologic changes associated with ICIs are commonly misdiagnosed as progression and might limit treatment or otherwise impact patient care. Here, we provide a radiologic case series review restricted to neurological complications attributed to ICIs, anti-CTLA-4 and PD-L-1/PD-1 inhibitors. We report the first case series dedicated to the review of CNS/PNS radiologic changes secondary to ICI therapy in cancer patients. We provide a brief case synopsis with neuroimaging followed by an annotated review of the literature relevant to each case. We present a series of neuroradiologic findings including nonspecific parenchymal and encephalitic, hypophyseal, neural (cranial and peripheral), meningeal, cavity associated, and cranial osseous changes seen in association with use of ICIs. Misdiagnosis of radiologic abnormalities secondary to neurological irAEs can impact patient treatment regimens and clinical outcomes. Rapid recognition of various neuroradiologic changes associated with ICI therapy can improve patient tolerance and adherence to cancer therapies.

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