Monitoring New Zealand patients on abiraterone

Prostate cancer is the most common cancer among men in New Zealand. In 2012, 3,129 men were diagnosed with prostate cancer and 607 died from metastatic or castration-resistant disease (MoH, 2015).

The Southern District Health Board (DHB) is a publically funded regional health service covering the lower half of the South Island of New Zealand, servicing an estimated resident population of 304,260. It is the largest geographical area of any of the district health boards in New Zealand covering 62,000 km2, which in itself can present barriers to care in terms of distance and accessibility for its large rural population (www.southerndhb.govt.nz).But perhaps, more significantly in the setting of prostate cancer, it has an aging population many of whom live in rural areas.

Introduction of abiraterone
In New Zealand, abiraterone was publically funded for patients with metastatic resistant prostate cancer (mCRPC) in May 2015. Relatively intense monitoring of side effects is required at the start of abiraterone therapy. This includes potential for hepatic toxicity and hypokalaemia, hypertension or fluid retention due to mineralocorticoid excess caused by CYP17 enzyme inhibition (Pointer, 2016).

Within Southern DHB a joint decision was made to place the primary use of abiraterone after bicalutamide and before taxanes for those patients who were chemotherapy naive. This was not a wholly clinical consideration but took into account societal and economic considerations (Pointer, 2016). Care of these patients was centralised within Radiation Oncology at the Dunedin Cancer Centre with a preference for managing patients at home in the primary care setting by making use of existing monitoring systems, including the Oncology- Haematology Assessment Unit (OHAU) and MOSAIQ, an electronic monitoring programme, both described below (Pointer, 2016).

Oncology Haematology Assessment Unit
The Oncology Haematology Assessment Unit is a nurse-led virtual clinic developed at the Southern District Health Board, just over two years ago with the primary aim of promoting appropriate use of services and resources and reducing avoidable hospital admissions. Secondary aims of this project included:
• Improving patient safety and care by monitoring symptoms and side effects of cancer treatment in a timely manner;
• Reducing avoidable treatment delays and dose reductions;
• Standardising the advice given to patients using evidence-based assessment tools;
• Providing a single point of contact for patients from throughout the region; and
• Ensuring calls are triaged safely and appropriately.

A 24-hour a day, free phoning number is given to all patients receiving oncology/haematology therapies when they first present for treatment. Incoming clinial enquiry’s to this number are triaged according to a set protocol and patients are either given advice and education over the phone; the patient may be referred to another health care practitioner, including the patient’s general practitioner, district nurse, emergency department or oncologist, or the patient can be bought into the unit for an advanced nursing assessment and appropriate treatment. Key to the success of OHAU is that nurses are able to proactively monitor high risk patients on treatment; for example those with complex co-morbidities, elderly patients or those with mental health issues. Patients on oral cancer treatments such as abiraterone are also proactively monitored through the unit via scheduled phone calls.

MOSAIQ: Electronic monitoring programme
MOSAIQ is a comprehensive electronic information management system used within OHAU. It can be used to review, prescribe, dispense, treat, and document patient data in a single database solution. Customisable electronic records can be viewed online from multiple sites, with integration from external diagnostic laboratories and pharmacies. Appointments can be scheduled, and letters, reports and documents created (www.elekta.com/softwaresolutionscare-management/mosaiq-medicaloncology).

What happens when a patient is started on abiraterone?
Patients are seen in clinic by a radiation oncologist and abiraterone is electronically prescribed inMOSAIQ. Approval of the prescription automatically generates an electronic memo to OHAU nursing staff to prompt scheduling of abiraterone phone calls. MOSAIQ also automatically prompts the consultant to prescribe Lucrin (a gonadotropin releasing hormone agonist) if appropriate, to apply for a special authority for the abiraterone (required by the New Zealand drug funding agency PHARMAC) and an electronic request for a DEXA bone scan is generated.

Patients are educated either on-site or over the phone not long after they have seen the oncologist and the patient’s general practice nurse is contacted to arrange for recordings of blood pressure, weight and blood tests. This is then followed up by the nursing staff in OHAU initially two weekly and then monthly at the time of phoning the patient, along with screening for other side effects, including oedema, diarrhoea, breathlessness and any other treatment or disease related complications. If the patient has any complex issues such poor mobility or financial constraints, a plan is individualised to their circumstances. Any concerns regarding a patient or their side effects are discussed with their oncologist as they arise.

Strengths and limits of the OHAU Abiraterone Monitoring Programme
It has been a pleasure working with men commencing on abiraterone. The number of patients reporting improved quality of life with reduction in pain and improved mobility is particularly satisfying. Many patients will be on opiates at the start of their treatment and within a few weeks have been able to wean themselves off. It also reassuring to know that a system is in place to ensure patients do not slip through the cracks in terms of follow up.

MOSAIQ has made this process all that much easier for nurses. The monitoring programme is reliant on the team, not an individual, with all patients’ notes available electronically with no requirement for hand-over between staff. OHAU provides early identification of toxicities and has provided remarkable outcomes in providing supportive care to oncology and haematology patients; patients report that they feel well supported. The only real limitation is managing the high volume of patients, which has become easier over time as the process is refined.

I would like to acknowledge the fabulous oncology team I work with, in particular Jo Tuaine, Lynda Dagg and Simon Pointer, who were pivotal in the development of the abiraterone monitoring system.

References
• Ministry of Health, Cancer: New registrations and death 2012.
• Pointer, S. 2016. MOSAIQ to Manage Patients with  Metastatic Castrate-Resistant Prostate Cancer. Unpublished Power Point Presentation.
• www.elekta.com/software-solutions/caremanagement/mosaiq-medical-oncology, retrieved 27 July 2016.
• http://www.southerndhb.govt.nz/index.php?page=654, retrieved 27 July 2016

Kirstin Unahi, Nurse Practitioner, Southern District Health Board, Dunedin (NZ), Kirstin.Unahi@southerndhb.govt.nz