For example: millions of euros are saved by dosing new, very expensive cancer medication smartly and tailored to each individual patient’s needs. Another example: the premedication to prepare patients for chemotherapy was previously administered by infusion. This took 15 minutes. Hospital pharmacist Roelof van Leeuwen critically examined this method and discovered that giving the medication using a bolus injection was just as effective. Time needed: ten seconds.
10,000 infusion bags
Van Leeuwen says: “We used to use more than 10,000 of these infusion bags annually for premedication at Erasmus MC. Multiply that by a 15-minute infusion time and you can calculate how many hours you can use a day-patient treatment chair for other treatments. And you can also calculate how much less plastic infusion bag waste you will need to dispose of.”
Last year, about EUR 220 million was spent on drugs at Erasmus MC, of which a large part, about EUR 34 million, went to cancer therapies in the department of Internal Oncology. After all, new and often expensive therapies are being developed for an increasing number of cancer types.
That’s great for patients of course, emphasize Sleijfer and Van Leeuwen, but it does put lot of pressure on the hospital’s day-patient treatment department, Sleijfer notes.
To give an example: patients with melanoma that has spread to nearby lymph nodes, a severe form of skin cancer, often benefit from immunotherapy after surgery. This brings an additional 150 patients to Erasmus MC Cancer Institute every year. Sleijfer says: “Previously, these patients were treated in their own hospital and were monitored after surgery. They now undergo immunotherapy every four weeks for a year in one of 14 specially designated centers in the Netherlands.”
Responsible and sustainable
Sleijfer recalls that the number of new cancer therapies soared halfway through the last decade. “The costs of these new therapies are now sky high, and they’re rising by 10 percent every year. We physicians and pharmacists are here to develop, research, and administer these new therapies. But it is also our duty to be socially responsible and sustainable, to see to it that therapies are effective and efficient, and to ensure that the burden on patients is kept to a minimum.”
To implement all these missions to the best of their abilities, hospital pharmacist Roelof van Leeuwen was asked to join the department of Internal Oncology parttime five years ago. This is a relatively unique arrangement, ensuring direct links between oncologists and pharmacists.
Van Leeuwen was assigned to investigate, at close hand and from a pharmacological perspective, the effectiveness of cancer therapies prescribed by the department of Internal Oncology. “A hospital pharmacist can critically examine the therapies from a fresh point of view. After all, we look at things from a different perspective than oncologists do”, says Van Leeuwen.
“I started by critically examining the protocols of the 20 most commonly used cancer therapies. Some guidelines were drawn up years ago in response to a scientific publication, and haven’t been amended since. In the meantime, however, new articles that provide new insights have been published. Moreover, we also often conduct our own research on the effectiveness of a specific treatment.”
More efficient dosing regime
This has resulted in a number of remarkable new practices. The greatest gain was obtained with more efficient dosing of drugs such as nivolumab and pembrolizumab, which are immunotherapy therapies that work very well but are extremely expensive. Sleijfer says: “We know, for example, that 6 milligrams per kilogram of body weight works well for various indications. However, the pharmaceutical company recommends a fixed dose of 480 milligrams for each patient. But this means that you assume that patients always weigh 80 kilos.”
The average weight of a patient in the Netherlands is indeed 80 kilos, says Van Leeuwen, but people come in all shapes and sizes. “That’s why we use tailored doses here. A patient who weighs 60 kilos will get 360 milligrams of nivolumab, while a patient who weighs 80 kilos will get the recommended dose of 480 milligrams. We then adjust the number of ampules as precisely as possible to the dosage that best fits the body weight of the patient to prevent spillage.”
Moreover, Van Leeuwen and the oncologists investigated and determined that patients weighing more than 80 kilos can be effectively and safely treated with a maximum dose of 480 milligrams. “Patients who weigh 120 kilos do not require 720 milligrams of the drug. This means that patients are not administered more oncolytics than necessary. In turn, we have already saved many millions of euros by doing this, up to about 7 million euros per year.”
The hospital pharmacist’s critical eye has also generated substantial extra treatment capacity. Van Leeuwen says: “We administer a course of paclitaxel/carboplatin, an effective chemotherapy for various types of cancer, to our patients about 2,000 times a year. We used to administer such an infusion in 3.5 hours. After research, I demonstrated that this can also be done safely in an hour and 45 minutes. This is more pleasant for the patient, as they can go home sooner, but it also means a gain of 3,500 hours of treatment capacity. We can then help other patients in these 3,500 extra hours.”
Another example: If a patient has to cancel their hospital appointment at the last minute, because they have a bad cold or because the blood values are not good, for instance, the prepared bag of chemotherapy used to be thrown away.
Van Leeuwen says: “Thanks to good shelf-life research, oncolytics now have a much longer shelf-life. This is why we now return unused infusion bags to the pharmacy, look for a patient with the same course and dose, and stick a new patient label on the bag so that it can be used by this other patient. We call this relabeling. The savings can be as much as 4,000 to 20,000 euros per bag.
Three hundred thousand euros
Sleijfer and Van Leeuwen are aware that the savings are high. In addition, the toxic content of the infusion bags no longer ends up in surface water. Sleijfer says: “This type of spillage is now practically zero, and the savings for Erasmus MC amount to at least three hundred thousand euros per year. Health insurers do not cover a course of treatment that we do not administer to a patient, after all.”
In the meantime, Van Leeuwen continues to scrutinize the protocols of pharmacists and colleagues, critically examining them in the light of the latest insights and adjusting them where necessary. “Developments take place very rapidly, which is why I check the literature for every new therapy to determine whether the course of treatment can be shortened and whether the dose is effective. This will greatly benefit both the patient and society in general.”