Empowering pharmacists to improve health care for oral chemotherapy patients: Establishment of a European best-practice model (EPIC)

The EPIC project targeted pharmacists in community and hospital pharmacies and empowered them to significantly address the issue of patient safety for cancer patients on oral anticancer therapy.

Partners in the EPIC project were:
European Society of Oncology Pharmacy (ESOP), the Coordinator
Deutsche Gesellschaft für Onkologische Pharmazie (DGOP)
Eesti Haiglaapteekrite Selts (EHAS)
Lekarniška zbornica Slovenije (LZS)

The past:

The present:

Educational Programme

The development and implementation of an educational programme in Slovenia and Estonia represents one of the two core objectives of the project. The training program was carefully and precisely planned: First, working groups were established within ESHP and LZS with the aim to develop the training programme for pharmacists. We took into account the input from the survey that we conducted among pharmacists in Europe, to cover the potential topics in the training programme. Specific needs for the training programme were discussed with stakeholders and relevant professionals’ organizations at the national and international level.

The programme was provided for the pharmacists as e-learning course in both countries and as face-to-face one day educational event in Slovenia. The programme is divided to three modules and every part is completed by passing a test. The training programme consists of more than 500 minutes of lectures and case reports.

Main topics covered in the training programme are:

  • etiology, epidemiology, cancer biology (disease development, staging etc.), basic principles of solid cancer and most common haematological malignancies treatment (surgery, radiation, medical therapy, stem cell transplantation)
  • the principles of chemotherapy, hormonal therapy, targeted therapy and immunotherapy
  • overview of most common side effects of cytotoxic drugs, hormonal drugs and other oral anticancer drugs (TKI), counselling and action
  • directions of use, how to find information (both pharmacists and patients), evidence of using alternative medicines, food supplements, herbal medicine
  • drug-drug and drug-food interactions
  • introduction of case reports
  • principles of safe handling of medicines in a pharmacy and at the patient’s home
  • support of patients in the treatment with oncologic medicines by pharmacists, advice to patients
  • presentation of the EPIC- database and instructions for the work
  • 504 pharmacists (28% of all pharmacists working in pharmacies in Estonia) were registered to the Estonian e-training course; most of them are working in the community pharmacies (88%). In Slovenia 268 pharmacists registered to e-training and 40 pharmacists participated at face-to-face lectures, which means that 24% of all pharmacists working in the community and hospital pharmacies took part in the education.

Oralia Data Base

The second core objective was to implement an oral anticancer drug data base for pharmacists in Slovenia and Estonia. The developed database should assist and support pharmacists at dispensing oral anticancer drugs and counselling cancer patients. Such a database already existed in Germany but had to be adapted to two new a different drug markets and in three additional languages (English plus Slovenian and Estonian). The database is web-based and needs to be conform with local practices and legislation. It consists of three modules: a database of side effects, database of oral anticancer drugs monographs and a module dedicated to pharmaceutical care of cancer patients. The most important characteristics of the database are presented below:

Module 1: Drug database

  • we prepared more than 50 monographs of drugs, which are available on national market
  • drug monographs are regularly updated with new information and we are adding monographs of new drugs available on the market
  • structure of monographs is predefined and consist of:
  • basic information for the patients: general information on the drug, common side effects, instructions for use, interactions with other drugs, additional information/warnings for the patient like: safe handling of the drugs, pregnancy/breastfeeding and warning of the effects on the ability to drive and use of the machines
  • information for pharmacist: available strengths and packaging of the drugs, with the pre-entered frequency of drugs to be taken by the patient and instructions for counselling

Module 2: Adverse drug reactions database

  • we prepared information on more than 40 side effects
  • the information is provided for different target groups:
    • more basic and easily understandable version for patients
    • more in-depth information for pharmacists
  • monographs introduce symptoms, severity according to CTCAE classification, information on management for the patient and when to consult a physician
  • side effects monographs are linked to the drug monographs
  • information for patients is ready to be printed by pharmacists when dispensing the drugs to the cancer patients

Module 3: Patients database

  • database is managed by pharmacists of a single pharmacy
  • following actions can be performed:
    • appointments management
    • pharmaceutical care documentation
    • preparation of different print-outs for the patient (including patient’s dairy, information on side effects and drugs)
    • patient‘s adverse effects management and statistics

The oral anticancer drugs database is used in 74 different pharmacies in Slovenia and in 33 pharmacies in Estonia now. It is used in the pharmacies that dispense most oral anticancer drugs. Since the registration is not related to a single pharmacist but to a pharmacy, it is difficult to estimate the proportion of pharmacists who use the database in their work.


For the purposes final evaluation of pilot implementation of the database and the training programme we conducted a survey among pharmacists in Slovenia and Estonia to evaluate the contribution of and satisfaction with education and helping tool.

We collected 164 answers from pharmacists and pharmacy technicians in Estonia and 74 responses from pharmacists in Slovenia. Most of the responders are working in the community pharmacy (82% in Estonia, 87% in Slovenia). In Estonia only 8% of community pharmacists dispense oral anticancer drugs on daily basis, whereas in Slovenia this proportion is slightly higher (18%). When community pharmacists have the best opportunity to counsel chemotherapy patients they usually talk about posology and administration (86% in Estonia, 93% in Slovenia). Other mainly addressed topics are handling drugs at home (55% in Estonia, 60% in Slovenia), side effects (41% in Estonia, 47% in Slovenia) and using antiemetic drugs during their anticancer treatment (37% in Estonia, 41% in Slovenia). Pharmacist educate patient about drug adherence, interactions or what to do if a dose is missed less often. The pharmacists self-assessed that they counsel patients at first dispensing of anticancer drugs usually 2-5 minutes and only 15% of pharmacists in Estonia and 22% in Slovenia consults chemotherapy patients for longer time than 6 minutes.

The responders assessed the satisfaction with the training program on oral anticancer drugs. Many participants prefer online courses as they can fit it to their plans more conveniently and re-listen to parts that might be confusing at first or to make notes. One third of pharmacists in Estonia and one half in Slovenia would have favoured lectures or seminars to be actively involved and have a face-to-face contact with the lecturer.

Most of the participants graded the organizational side (e.g. registration, information, communication about problems) of the online course good or even very good. Most of the participants enjoyed the topics that lecturers covered and knowledge they provided. Participants were satisfied with lecturers. Most of participants admitted that the tests in the end of every module were useful to memorise the material. Some mentioned that questions were difficult.

Most participants felt that their knowledge to counsel patients about oral anticancer medications improved thanks to this online course. On the other hand, some people admitted that they were still not confident in this area but they were better able to explain basics.

The respondents also assessed the satisfaction with the database. All users agreed that information about anticancer medications and their side effects in the databases is useful and necessary. Almost all users said that that kind of database is beneficial while counselling patients with oral anticancer medications. 92% of registered users of Slovenian database who participated in the survey used the database in their work. As advantages of the database participants mentioned that the database is in their native language, all essential information is in one place, it provides quick access to verified professional information and that patient can monitor the adverse effects of the anticancer treatment. As disadvantages participants mentioned that creating a personal treatment regimen for the printout is too long and complex, and that there is too little information about interactions.

Based on the results we could conclude that both training programme and e-tool considerably improved pharmacists’ knowledge about oncology and oral anticancer drugs and support better counselling and pharmaceutical care for cancer patients.

Experience within Estonia and Slovenia from the pilot project, as well as from Germany showed some of issues with the database that needed to be fixed before introduction of the database to other countries (Instead of working with multiple national copies of the data base in parallel that are bound to diverge from each other over time, the future data base is to integrate all national versions into one, different national legislations within the pharmacy and health care sector require the data base to accommodate different login-procedures, access to different languages). To address these, the partners agreed to commission the programming of a data base with the required functions and prepared a programming concept of a new database.

Present Activities

In the participating countries, we will continue providing support to pharmacists and regularly update information about oral anticancer drugs and adverse drug effects in the database. We will also offer the training in the field of oral anticancer drugs and update the current programme.

The introduction of the training programme and the Oralia database helped pharmacists in the participating countries to get more knowledge about oral anticancer drugs. It supports the provision of appropriate pharmaceutical care Thus this valid practice model will be offered for implementation in other EU countries.

We believe that the database has a great potential for adoption in other countries and that the diversity and international approach will enable us even to increase the quality of the database. ESOP also plans to invite stakeholders from other healthcare professions and cancer patient groups to participate in the discussion and to present their opinions and needs. By cooperating, we will achieve better adherence and care for cancer patients.

ESOP plans to harmonize the content of the database on the EU-level. To this end, we will set up an international working group. By including pharmacists from other European countries, we will improve healthcare – both within countries and cross-border – in the specific field of oral anticancer therapy.