IntroductionEnsuring the safety and quality of cytotoxic drug preparation is a core component of oncology pharmacy practice. In emerging settings, structured audit tools are essential to assess practices and support continuous quality improvement.ObjectiveTo develop a standardized audit tool for assessing compliance with current standards for hospital cytotoxic drug preparation and to apply it in a specialized oncology hospital.MethodsA working group developed a structured audit tool based on 2023 Good Preparation Practices and international recommendations. The tool included domains, subdomains, and explicit compliance criteria. A 15-day audit was conducted using direct observation, document review, and staff interviews. Deviations were classified by criticality. Data were analyzed quantitatively using a standardized Excel-based framework.ResultsA total of 913 criteria were included in the audit tool, of which 289 were deemed not applicable at the hospital level. Consequently, 624 criteria were assessed across seven thematic areas. The overall compliance rate was 70%. Among the evaluated criteria, 23% were non-compliant and 7% were partially compliant. Among the non-compliant criteria, 27.4% were associated with a potential risk of adverse events. The proposed improvement actions were categorized into short-term and long-term measures.ConclusionsThis study provides a structured audit framework for evaluating compliance with current Good Preparation Practices in hospital cytotoxic drug preparation. Its application highlighted priority areas for improving the quality and safety of preparation practices.

IntroductionGuideline-based prophylaxis prevents most vomiting during highly emetogenic chemotherapy (HEC), but nausea remains incompletely controlled, especially where NK1 receptor antagonists and olanzapine are inaccessible or ineffective. Amisulpride, a dopamine D2/D3 antagonist, may add benefit with less sedation than olanzapine.MethodsAdults receiving cisplatin-based or anthracycline-cyclophosphamide HEC were studied during a single cycle in this randomized, double-blind, placebo-controlled group sequential trial. All received intravenous ondansetron and dexamethasone on day 1 plus oral dexamethasone 8 mg twice daily on days 2-4, with oral amisulpride (25 mg before chemotherapy, then 12.5 mg nightly for 3 days) or placebo. The primary endpoint was the 4-day (0-96 h) no-nausea responder rate; the planned sample size of 94 targeted an 18 percentage-point improvement. Two interim and one final analysis used O'Brien-Fleming efficacy and futility boundaries.ResultsThe trial stopped for futility at the second interim analysis (70 participants; 35 per arm). No-nausea response was 65.7% with amisulpride versus 57.1% with placebo (risk difference 8.6 percentage points; 95% CI -14.2 to 31.3; p = 0.461). Complete response (no emesis or rescue medication) was 80.0% versus 68.6% (p = 0.274). VAS, FLIE, rescue medication use, and adverse-event frequency were similar, apart from more frequent constipation with amisulpride.ConclusionsThe 8.6 percentage-point difference favored amisulpride but fell short of the 18-point practice-changing MCID, in a well-controlled placebo arm. Without an olanzapine- or NK1-containing comparator, the trial cannot position amisulpride against those regimens, nor exclude a smaller benefit worth having where they are inaccessible.

BackgroundEducational videos play a crucial role in enhancing healthcare delivery. Developing an educational video designed to improve patient understanding of catastrophic treatment. During the video's creation, two voiceover methods were employed: human voices and artificial intelligence (AI)-generated voices. To date, the impact of voice-over origin-whether human or AI-on patient knowledge acquisition remains unexplored and warrants further investigation. This study aimed to assess the differences in knowledge and practice scores among cancer patients exposed to educational video materials about chemotherapy, comparing human voice with AI-generated voice narrations.MethodsA total of 129 cancer patients participated in this study. Designed as a case-control study, participants were divided into three groups: a control group, a group receiving videos with human voice narrations, and a group receiving videos with AI-generated voice narrations. All participants completed a questionnaire assessing their understanding of chemotherapy. A three-group quantitative comparative analysis was conducted, focusing on topics such as administration procedures, treatment goals, and the management of adverse drug reactions.Key findingsBoth educational videos with human- and AI-generated voiceovers should be incorporated into the oncology healthcare system due to their effectiveness in improving understanding of treatment. Notably, educational videos featuring human-voice narration consistently enrich knowledge and attitude scores among cancer patients across all assessed chemotherapy topics.ConclusionThe educational videos, whether in human or AI voices, were effective in increasing cancer patients' knowledge and attitudes across all key topics. There was a sustained trend toward human-voice videos in knowledge and attitudes among cancer patients; therefore, the human educational video showed significant improvement in understanding of chemotherapy administration, goals, and adverse drug reactions. Although there was no difference between human and AI voice education, trends toward combining human voice with realistic scenario videos should be considered to facilitate deeper patient understanding.

IntroductionEnvironmental monitoring of antineoplastic drug contamination has primarily focused on medication preparation areas and frequently touched surfaces. Consequently, contamination in nonpreparation areas and on infrequently touched surfaces, such as ceilings, remains poorly characterized. This study evaluated fluorouracil contamination on floors and ceilings in preparation and nonpreparation areas.MethodsThis study was conducted at Aichi Cancer Center, Japan. Samples were collected from floor and ceiling surfaces in the hospital pharmacy, outpatient chemotherapy center, and inpatient ward. Cleaning practices at the sampling sites were also assessed. Fluorouracil concentrations were measured using liquid chromatography-tandem mass spectrometry. At the time of sampling, closed-system drug-transfer devices (CSTDs) were not used for fluorouracil preparation or administration.ResultsFluorouracil was detected on all sampled floor and ceiling surfaces, including those in nonpreparation areas where antineoplastic drugs were not handled. The highest contamination levels were detected on the preparation room floor (3.104 ng/cm[2]) and the pharmacy break room ceiling (2.440 ng/cm[2]). In the outpatient chemotherapy center, relatively high contamination levels were detected on the nursing station floor (0.622 ng/cm[2]) and nursing break room ceiling (0.419 ng/cm[2]).ConclusionsFluorouracil contamination was detected in nonpreparation areas and on ceiling surfaces near air-conditioning units that were not routinely touched or cleaned. These findings suggest that contamination may spread through the movement of healthcare workers and materials and may accumulate on infrequently cleaned surfaces. As part of contamination control, the use of CSTDs may need to be implemented and environmental monitoring may need to be extended beyond medication preparation areas.

BackgroundCritically ill patients with cancer are highly vulnerable to medication-related problems (MRPs) because of complex treatment regimens, organ dysfunction, immunosuppression, and extensive antimicrobial exposure.ObjectivesTo determine the prevalence, patterns, and determinants of MRPs; describe antimicrobial utilisation; evaluate clinical pharmacist interventions; and assess clinical outcomes.MethodsA prospective observational study was conducted over 14 months in an oncology ICU of a tertiary cancer centre. Adults admitted for ≥48 h were enrolled. MRPs were identified using the Pharmaceutical Care Network Europe classification V9.1. Antimicrobial utilisation was measured as defined daily doses (DDD) per 100 bed-days and classified according to WHO AWaRe categories. Pharmacist interventions were documented. Multivariate logistic regression identified predictors of MRP occurrence.ResultsAmong 325 patients (mean age 54.6 ± 12.3 years; 58.5% male), 268 (82.5%) experienced at least one MRP, with 612 identified (mean 1.88/patient). Treatment-effectiveness (38.1%) and treatment-safety (28.9%) problems predominated. Antimicrobials were prescribed in 296 patients (91.1%), with consumption of 142.6 DDD/100 bed-days; Watch agents accounted for 54.2%. Pharmacists made 540 interventions, of which 466 (86.3%) were accepted. Polypharmacy, prolonged ICU stay, renal impairment, hematological malignancy, and use of ≥2 concurrent antimicrobials independently predicted MRP occurrence. Mortality was higher among patients with unresolved or severe MRPs than among those without MRPs (34.2% vs 18.6%, p = 0.002).ConclusionMRPs were highly prevalent and associated with medication burden, organ dysfunction, malignancy type, and antimicrobial exposure, while pharmacist interventions showed a high acceptance rate, supporting their potential role in medication safety and antimicrobial stewardship.

IntroductionImmune checkpoint inhibitors (ICI) are widely used in oncology. By stimulating immunity, their mechanism induces immune-related adverse events (irAE). Some studies suggest that certain drugs may exacerbate these toxicities (dysbiosis). This study aims to assess the link between taking chronic medications and the occurrence of immune-related adverse event during ICI treatment.MethodsThis retrospective monocentric study includes adult patients who started an ICI treatment between 06.01.23 and 12.31.23. Clinical characteristics were extracted from medical records. The use of chronic medicines during ICI treatment was screened. The occurrence of an IRAE within 12 months following ICI initiation was monitored.ResultsA total of 76 patients were included, mainly treated with pembrolizumab (88%). Fifty-four patients (71%) suffered from at least one irAE within one year (41% endocrine, 37% hepatic and 20% dermatological). PPI were the most prescribed chronic drug (33%). Taking chronic treatments was not associated with the occurrence of an IRAE (p = 0.19). Toxicity's severity was not significantly associated with having chronic medication (p = 0.43). No association was found between PPI or NSAID use and digestive toxicity (respectively p = 0.29;p = 0.99). Breast cancer treatment was significantly associated with irAE occurrence (p = 0.02).ConclusionIn this cohort, irAE were highly prevalent. Pembrolizumab-treated patients were predominant and chronic co-medications were not associated with the occurrence of irAE. However, the design of the study, short follow-up and limited sample size may have limited the detection of an effect. In order to anticipate irAE consequences, larger prospective studies are needed to clarify the role of co-medications in their occurrence.

IntroductionMetastasis occurs in almost 50% of patients with uveal melanoma. In patients who are HLA-A*02:01 positive, first line treatment is the Immune mobilizing monoclonal T cell receptor Against Cancer (ImmTAC), tebentafusp, which increases overall survival significantly at one year compared to single-agent immunotherapy or chemotherapy. Hypersensitivity reactions (HSR) to cancer therapeutics are well established. When these therapies offer significant benefits over alternatives, drug desensitization protocols are utilized to improve clinical outcomes in those with suspected IgE-mediated HSRs.Case reportWe present a case of an individual with metastatic uveal melanoma who suffered an anaphylactic HSR to tebentafusp. Given the lack of available ImmTAC therapeutic desensitization protocols, this report's purpose was to create a tebentafusp desensitization protocol based on accepted desensitization protocols for other chemotherapeutic drugs.Management and outcomeThe desensitization procedure consisted of pretreatment with cetirizine, famotidine, diphenhydramine, methylprednisolone, and acetaminophen prior to infusion. Infusions were each given as two diluted infusions limited to 100 mL of reconstitution volume, with cumulative quantities equivalent to standard treatment regimen dosages. Drug was given over no longer than four hours per manufacturer's recommendations. A total of three cycles of three weekly infusions were completed. The patient had no anaphylaxis recurrence. Tebentafusp treatment was withheld after the third cycle due to disease progression.DiscussionFor patients with HLA-A*02:01 positive metastatic uveal melanoma with suspected IgE-mediated HSR to tebentafusp, desensitization can be completed safely. Given the patient's disease progression within two months of treatment, it is unknown whether desensitization impacts the drug's clinical benefit.

IntroductionPatients receiving long-term endocrine treatment (ET) for hormone receptor-positive breast cancer commonly use supportive-care and concomitant medicines, resulting in complex regimens with greater risks of drug-related problems (DRPs) and non-adherence. This study quantified DRPs per patient and assessed their management, potential drug-drug interactions, ET adherence, and within-patient quality-of-life (QoL) changes.MethodsThis prospective, single-centre, single-arm pre-post study included 95 outpatients receiving ET. A clinical pharmacist reviewed medication regimens, classifying DRPs and interventions with Pharmaceutical Care Network Europe V9.0. Assessments included Micromedex screening for potential interactions, the 8-item Morisky Medication Adherence Scale for adherence, and the European Organisation for Research and Treatment of Cancer QLQ-C30 and QLQ-BR23 for QoL at baseline and 2 months.ResultsOverall, 287 DRPs were identified in 88 patients (92.6%; 3.02 ± 1.77 per patient): 15 (5.2%) involved ET, 118 (41.1%) supportive-care medicines, and 154 (53.7%) other concomitant medicines. Of 688 interventions, 686 (99.7%) were accepted, while 142 DRPs (49.5%) were completely resolved. Potential interactions were detected in 54 patients (56.8%); 54/110 (49.1%) were major. Low ET adherence was identified in 50/93 patients (53.8%). Among 85 patients with paired QoL data, global health/QoL and functional scores increased significantly. Higher DRP counts correlated with poorer QoL, whereas higher adherence correlated with lower symptom burden.ConclusionsDRPs extended beyond ET to patients' complete medication regimens. Despite high intervention acceptance, complete resolution was less frequent. Controlled multicentre studies with longer follow-up are needed to evaluate the effects of clinical pharmacist-led care on DRP resolution, ET adherence, and QoL.

BackgroundCisplatin induced nephrotoxicity affects approximately 30% of treated patients and remains the primary dose limiting toxicity of this essential chemotherapeutic agent. In resource-limited settings, inconsistent implementation of prevention protocols may increase nephrotoxicity risk, yet prospective data from African populations remain scarce.MethodsWe conducted a prospective cohort study of 76 women with cervical or ovarian cancer receiving cisplatin based chemotherapy at Tikur Anbessa Specialized Hospital (TASH), Ethiopia. Comprehensive risk factor assessment included demographic, clinical, and treatment related variables. All patients received standardized prevention protocols including intravenous hydration (2.5-3.5 L normal saline per cycle), antiemetic prophylaxis, and serial renal function monitoring. The primary outcome was the incidence of cisplatin induced nephrotoxicity graded by creatinine elevation according to CTCAE v5.0 criteria. Secondary outcomes included risk factor associations and prevention strategy effectiveness.ResultsThe cohort comprised 45 cervical (59.2%) and 31 ovarian (40.8%) cancer patients with mean age 52.4 ± 11.8 years. All 76 enrolled patients completed the primary treatment monitoring period. Despite universal hydration, nephrotoxicity of any grade occurred in 76.3% (58/76), predominantly Grade 1 (56.6%, 43/76). Severe nephrotoxicity (Grade ≥3) occurred in only 5.3% (4/76), with no Grade 4 events. Independent risk factors for moderate to severe nephrotoxicity included baseline eGFR <75 mL/min/1.73m[2] (OR 4.72, 95% CI 1.89-11.78, p = 0.001), advanced age ≥60 years (OR 3.41, 95% CI 1.28-9.07, p = 0.014), and cumulative cisplatin dose >200 mg/m[2] (OR 2.93, 95% CI 1.14-7.52, p = 0.025). Magnesium supplementation was associated with reduced nephrotoxicity severity (p = 0.042). The mannitol forced diuresis subgroup showed lower 48-h creatinine elevation compared to hydration alone (0.18 ± 0.11 vs 0.31 ± 0.18 mg/dL, p = 0.038).ConclusionsIn this Ethiopian cohort, cisplatin induced nephrotoxicity was common when assessed by serial creatinine monitoring, but implementation of structured prevention protocols effectively limited progression to clinically significant renal impairment. Baseline renal function, age, and cumulative dose independently predicted nephrotoxicity risk. These findings support the feasibility of safe cisplatin administration in resource-limited settings through protocolized prevention strategies.

IntroductionExtravasation of vesicant chemotherapy is an oncological emergency that may result in severe tissue injury, functional impairment, and long-term morbidity. Management becomes particularly challenging in combination regimens containing agents with different vesicant properties and opposing treatment recommendations.Case ReportWe report a fatal case associated with administration of a combination chemotherapy regimen through difficult peripheral venous access. Mild symptoms during infusion of a non-vesicant agent led to suspected extravasation; consequently, antidotes were not administered. The patient was initially discharged without clinical signs of injury. However, subsequent presentation revealed severe local damage attributed to extravasation of vesicant agents within the regimen.Management & OutcomeClinical assessment suggested injury secondary to extravasation of vesicant agents previously administered within the regimen, most likely doxorubicin and/or vincristine. Despite hospital admission and multidisciplinary management involving haematology, dermatology, and plastic surgery teams, the lesion progressively deteriorated. The patient died from the resulting complications.DiscussionThis case highlights key challenges in combined chemotherapy regimens, where identification of the causative agent may be uncertain and management strategies differ substantially. It underscores the importance of appropriate vascular access in high-risk patients, early suspicion of vesicant involvement regardless of infusion sequence, and adherence to updated guidelines. Strengthening institutional protocols and decision-support tools is essential to prevent catastrophic outcomes.

ObjectiveTo evaluate the effect of a computerized physician order entry (CPOE)-based intervention (a new 'ONCE' ordering frequency combined with a system-generated confirmation pop-up) on STAT order burden and on delayed STAT orders in a tertiary cancer hospital.MethodsA Pre-Post study design conducted at Shaukat Khanum Memorial Cancer Hospital and Research Centre (SKMCH&RC) in Lahore, Pakistan, utilizing the Hospital Information System (HIS) for the analysis of STAT medication orders, as a quality improvement project. A pop-up prompt, generated by the system, was incorporated into the STAT medication ordering process. The primary goal of this integration was to decrease the number of STAT orders and the associated delays.ResultsThe intervention was associated with a 51.5% decrease in STAT order volume (33,334 to 16,162 orders), with the overall STAT burden falling from 25.4% to 12.2% of all medication orders (p < 0.001). Delayed STAT orders declined by 55.4% (15,033 to 6711), from 11.5% to 5.1% of all orders. The two areas with the highest baseline burden showed marked declines: the Preoperative Holding Bay from 52.1% to 29.6% and the Intensive Care Unit from 43.6% to 24.5%. By the final study month, STAT orders comprised 7.8% of all orders, with delayed STAT orders comprising 3.3%.ConclusionThe implementation of a new frequency of ONCE and system-generated pop-ups has proven to be an effective method for reducing both the volume and delays of STAT orders.

IntroductionThe estimated incidence of etoposide infusion-related reactions (IRRs) in the general population is 1-3%, with pediatric reports ranging from 1-27.1%, and adult data being limited. Inconsistent documentation of IRR onset and underreporting of mild reactions have contributed to gaps in the literature. Rechallenging practices following infusion interruption are not standardized. This study aimed to evaluate the incidence, onset, severity, risk factors, and rechallenge strategies for etoposide IRRs in adults.MethodsThis retrospective cohort study included adult patients who initiated intravenous etoposide at Horizon Health Network in New Brunswick, Canada, between January 1, 2023, and June 30, 2025. Descriptive statistics were used to characterize IRR incidence, onset, severity, and rechallenge strategies. Demographic and treatment characteristics were compared between patients with and without IRRs using chi-square, Fisher's exact, and Mann-Whitney U tests.ResultsAmong 199 identified patients, 29 experienced at least one etoposide IRR (14.6%), most commonly occurring during cycle 2 (51.7%), with grade 2 reactions (65.5%) predominating. No demographic or treatment-related factors were significantly associated with IRR occurrence. Rechallenge strategies primarily involved infusion rate reduction and addition of diphenhydramine, corticosteroids, and famotidine following first IRRs. Switching to etoposide phosphate was more generally reserved for second IRRs.ConclusionThe incidence of etoposide IRRs in adults was higher than previously reported. Reactions may occur beyond initial infusions and can recur. Although no clear risk factors were identified, rechallenge strategies were generally successful and allowed for continuation of therapy following infusion interruptions.

IntroductionGlucarpidase 50 units per kilogram (units/kg) intravenously is indicated for high-dose methotrexate (HDMTX) toxicity, however lower doses are often used.Case seriesThree patients with Acute Lymphoblastic Leukemia were administered HDMTX 5g/m[2] intravenously over 24 h, developed toxicity, and required glucarpidase. Retrospective data collection included methotrexate (MTX) and creatinine levels and toxicity management. An acute kidney injury developed for all patients with serum creatinine increasing from 79 micromol/L to 172 micromol/L for patient A, 76 micromol/L to 130 micromol/L for patient B, and 67 micromol/L to 117 micromol/L for patient C. Forty-two hour MTX levels returned as 11, 13, 8.6 micromol/L (target is <1 micromol/L) and serum creatinine peaked at 250, 164, and 125 micromol/L for patients A, B, and C, respectively.Management and outcomeCalcium folinate, fluids, sodium bicarbonate, and diuretics were administered as indicated. All patients received glucarpidase 2000 units within 56 h of HDMTX commencing. MTX levels took an average of 12 days to fall to <0.1 micromol/L. Regain of normal renal function post-glucarpidase took 25 and 8 days for patients A and C respectively; patient B was lost to follow up.DiscussionWith evidence of efficacious glucarpidase dosing lower than 50 units/kg, including in this case series (2000 units), combined with its pharmacokinetic properties, 1000 units should be considered for adult patients less than 200 kilograms with a supratherapeutic MTX level of 200 micromol/L or less, from 24 h or 36 h (depending on the protocol used) to 60 h post-HDMTX commencement. This necessitates one 1000 units vial, reducing cost and potentially improving access.

IntroductionSevere liver injury is uncommonly encountered in zanubrutinib and other bruton tyrosine kinase inhibitors. In previous reports of severe liver toxicity associated with bruton kinase inhibitors, the offending agents were often withdrawn although resumption of ibrutinib was ever reported.Case ReportWe shared our clinical experience of 2 cases of follicular lymphoma treated with obinutumumab and zanubrutinib. Severe liver injury, as shown by high levels of transaminase (ALT up to 1350 and 406 IU/L respectively) occurred within a week of drug exposure.Management and OutcomeZanubrutinib was withdrawn shortly then resumed with low dose (80 mg) after hepatic enzyme levels stablized. The dose was titrated up to full dose (320 mg) and lymphoma responded well (partial response in one and complete response in the other) to treatment.ConclusionThis report highlighted a rare but important complication of zanubrutinib. On the other hand, it also suggests zanubrutinb should not be excluded from subsequent treatment and can be re-introduced with caution.