Gastric cancer is the fifth most common cancer and the third leading cause of cancer-related death. The low-abundance of mutations on comprehensive molecular evaluation of primary tumors suggests that other mechanisms contribute to this disease. For example, epigenetic alterations including DNA methylation of promoter sites, short and long noncoding RNAs and histone modifications ultimately control gene expression. This presentation aims to elaborate on the role of epigenetics in the pathogenesis of gastric cancer and the potential identification of new targets for prevention and treatment of disease based exclusively on epigenetic alterations. 

Learning Objectives:

1. Review Gastric Cancer;
2. Understand Genetic and Epigenetic bases of gastric cancer; and
3. Discuss Translational epigenetic research in diagnosis and treatment on gastric cancer.

Concurrent Sessions 3
Clinical 3A:  Pediatrics/Adolescents/Young Adults Update

14:30-16:00

Description of Tools Pharmaceutical Care in Acute Lymphoblastic Leukemia (Pharmacogenomics) Hospital Pediatric Experience Chilean Program Associated with Antineoplastic Drugs (PINDA)
Jorge Morales Vallespín, Luis Calvo Mackenna Hospital, Santiago, Chile

Acute lymphoblastic leukemia (ALL) is the most common oncological disease in children, with the peak incidence occurring at 3 to 5 years of age. In Chile, diagnosis, treatment and monitoring of these patients is within the PINDA program, the Spanish “Programa Infantil de Drogas Antineoplásicas”, where these patients receive multidisciplinary care.

Treatment of patients with ALL is generally classified into different phases: induction, early intensification, consolidation, re-induction and maintenance, showing remission rates close to 90%. In these phases of the protocol, patients receive different types of antineoplastic drugs, highlighting the 6-mercaptopurine (6-MP) in oral therapy, being present in 3 of the 5 stages of treatment.

Although 6-MP plays a pivotal role in treatment, it is not without side effects, and these effects are much increased in patients with single nucleotide polymorphism in genes coding for 6-MP metabolizing enzymes such as TPMT and ITPA. Therefore, it is important to detectaction and incorporate pharmacotherapeutic monitoring in this group of patients.

Learning Objectives:

1. Introduce the PINDA program for the treatment of acute lymphoblastic leukemia in pediatrics in Chie;
2. Evaluate the clinical monitoring tools for patients with acute lymphoblastic leukemia in Chile;
3. Establish a connection between certain genotypes coding for the enzyme TPMT and adverse effects during therapy of acute lymphoblastic leukemia (RAM reports and prevalence in patients at follow-up);
4. Determine the most effective phamacotherapy based on genotype frequencie; and
5. Evaluate and adhere to treatment guidelines: Mercaptopurine dose changes according to polymorphism results and according to pharmaceutical care.

Update on Paediatric Bone Tumours
John Wiernikowski, McMaster Children’s Hospital, Hamilton, ON, Canada

Bone tumours in children are comprised primarily of Osteogenic Sarcoma and Ewings Sarcoma which is often subcategorized as Osseous, Extra-Osseous and Primitive neuroectodermal tumours. The annual incidence of these tumours are on the order of 4 and 3 cases per million respectively, but show considerable geographic variability.

Despite aggressive management with chemotherapy, surgery and (for Ewings sarcomas) radiation; 5 yr EFS rates range from 60-70% for children and adolescents with localized disease, and only 20-25% for those with metastatic disease at diagnosis. 

Recently, advances in molecular biology of these tumours has identified a host of new targets including Tyrosine Kinases, IGFR-1, m-TOR, EWS-FLI-1 and targetable pathways that offer the promise of better outcomes for this patient population. This talk will review and update the data on these new molecular targets and available clinical trial data.

Learning Objectives:

1. Be able to distinguish between Osteogenic and Ewing’s Sarcomas and appreciate the geographic variability in incidence of these entities;
2. Appreciate the various treatment modalities utilized in the treatment of bone tumours;
3. Understand newly identified molecular targets in these disease entities and drugs currently being evaluated in clinical trials; and
4. Appreciate approaches to global co-operation in clinical trial execution that are accelerating accrual of patients to these trials.

Fundamental 3B: USP 800 Implementation and Practical Considerations

14:30-16:00

USP 800 Implementation: Considerations Across Practice Settings
Rowena Schwartz, McKesson Specialty Health, Magnolia, TX, USA

The recent USP 800 guidelines have recently been published and are widely being evaluated around the world.  During this presentation we will discuss the guidelines, and the practicalities of implementing these recommendations in a variety of practice settings in the United States. 
 

USP 800 Implementation: Consider a Case of the National Cancer Center Hospital East, Japan
Shinya Suzuki, National Cancer Center Hospital East, Japanese Society of Pharmaceutical Oncology, Kashiwa, Japan

Recently, the first guideline for handling hazardous cancer agents, “JSCN/JSMO/JASPO Joint Guidelines for Safe Handling of Cancer Chemotherapy Drugs 2015” has been established in Japan. (*JSCN: Japanese Society of Cancer Nursing, JSMO: Japanese Society of Medical Oncology, JASPO: Japanese Society of Pharmaceutical Oncology) The JASPO played an important role in making the guideline, and the National Cancer Center Hospital East (NCCHE) is one of the leading institution that will conduct projects to prevent exposure of the hazardous medicines. When we made the guideline, we realized many real world discrepancies between ideal management and daily practice management within a hospital. At NCCHE, we encountered some problems when implementing the international guidelines, such as the USP 800, which is one of the core ideas to perform safe handling of hazardous medicine. In the session, I will share ideas and tips on how to implement the USP 800 for the non-US countries through our experience at the NCCHE in Japan.

Learning Objectives:

1. Recognize and share the problems with implementing the USP 800 in other countries;
2. Understand how to implement the USP 800 in other countries; and
3. Share the experience and ideas learned when we implement the USP 800.

Fundamental 3C: Fundamental: Education, Competency and Mentorship

14:30-16:00

Judith Smith, The University of Texas Health Science Center at Houston Medical School, Houston, TX, USA
Barry Goldspiel, National Institutes of Health Clinical Center, Bethesda, MD, USA

This session will discuss how the three topics of education, competency and mentorship are related. The first part of the didactic lecture will provide key elements and tools to be used for chemotherapy education and tools for the “peripheral brain” reminders. Examples and electronic copies (bring your own jump drive) will be provided for audience to take home and implement. This will transition how and why oncology pharmacy can take the lead in establishing chemotherapy competency programs for the multidisciplinary team.  Finally, the session will discuss role of mentorship throughout professional development across lifespan. Real-life scenarios will be provided to help role model successful mentorship and how it is key ingredient in professional development. 

Learning Objectives:

1. Compare and contrast education tools to assist in chemotherapy order process;
2. Explain how Oncology Pharmacy can lead efforts to establish multidisciplinary chemotherapy competency;
3. Develop an action plan for identifying a mentor; and
4. Describe different approaches for requesting mentorship from others.

Concurrent Sessions 4
Fundamental 4A: Oral Medication Adherence and Management in Oncology

16:30-18:00

Steve Stricker, Takeda Oncology, Florence, KY, USA
As the global focus of drug development shifts from injectable to oral routes of administration, the responsibility for successful completion of the prescribed treatment regimen shifts from the infusion center to the patient and their caregivers. This paradigm shift for cancer therapy introduces new challenges for health care providers responsible for the management of patients with cancer. In this presentation, we will discuss challenges and barriers to oral medication adherence; methods for improving oral medication adherence; and clinical pearls related to the education and management or oral oncolytics.

Learning Objectives:

1. Discuss the current status of approved and investigational oral oncolytics;
2. Identify challenges with the use of oral oncolytics and common causes of nonadherence;
3. Review opportunities and methods for pharmacists to improve adherence with oral oncolytics; and
4. Discuss clinical pearls related to education and management of oral oncolytics in clinical practice.​

Strategies to Improve Oral Medication Adherence in Oncology
Harbans Dhillon, University Malaya Medical Centre, Kuala Lumpur, Malaysia

Increasingly the delivery of chemotherapy has changed from an inpatient to an outpatient model and many oral therapies are managed in the patient’s home environment. Adherence rates impact dosing, adverse events and ultimately, overall survival. The World Health Organization has cited the issue of non-adherence with oral chemotherapy as the single most important yet modifiable factor that can compromise treatment outcomes.

In this presentation, several interventions to improve adherence to oral chemotherapy will be discussed. Maximizing adherence to oral chemotherapy agents can improve overall survival and life expectancy; improved safety and quality of life. Patients risk improper dosing and an increase in disease recurrence when there is non-adherence with medications. Correct dosing, education and symptom management are all critical to ensuring adherence. Other interventions incorporate education, early symptom identification and reminder prompts to improve adherence.

Learning Objectives:

1. Identify interventions to improve adherence to oral chemotherapy;
2. Identify risks to patients on non-adherence; and
3. Incorporating patient education and reminder prompts as part of counseling to improve adherence to oral chemotherapy.

Research 4B: Investigational Agents Update

16:30-18:00

R. Donald Harvey, Winship Cancer Institute of Emory University, Atlanta, GA, USA
Rowena Schwartz, McKesson Specialty Health, Magnolia, TX, USA

One of the most exciting aspects of cancer care is the rapid evolution of drug therapy.  In the last five years we have seen the development of new agents, many first in class, and subsequent new applications of those agents. This rapid evolution of new anticancer drugs should be coupled with the practical challenges of successfully implementing these therapies into cancer care beyond the clinical trial.  New mechanisms of actions may be associated with unique treatment related toxicities, which may require innovative approaches to care.  During this session we will focus on drugs and drug classes that are currently being evaluated in clinical trials and discuss the role of the oncology pharmacist in optimizing care with these agents.

Learning Objectives:

1. Identify potential applications for the investigational agents discussed during this session;
2. Describe proposed mechanism of action and toxicities associated with the drugs discussed; and
3. Provide healthcare team and patient and caregiver team education about drugs discussed.

Clinical 4C: Oncology Patients and Special Circumstances

16:30-18:00

Incidence of Drug-Induced Liver Injury in Patients Hospitalized at The Instituto Nacional de Enfermedades Neoplasicas Lima
Martha Estacio, Instituto Nacional de Enfermedades Neoplasicas Eduardo Caceres Graziani, Lima, Peru

The actual incidence of drugs that cause liver damage in clinical practice is poorly understood. The international incidence in hospitalized patients is 0.7% to 1.4%. Most are idiosyncratic or unexpected origin. The main mechanism is the production of reactive metabolites produced in Phase I metabolism. The final outcome varies from a delay in treatment, liver failure or death.

The diagnosis of hepatic adverse reactions in cancer patients remains a challenge due to the complexity of drug therapy, opportunistic infections, radiotherapy, pre-existing liver disease and genetic susceptibility.

Learning Objectives:

1. Identify the incidence of drug-induced liver injury in patients hospitalized at the Instituto Nacional de Enfermedades Neoplasicas Lima; and
2. Determine medications that cause liver damage.

Cancer in Pregnancy
Peter Gilbar, Toowoomba Hospital, Toowoomba, Australia     

Cancer in pregnancy occurs rarely with an estimated incidence of one in 1,000 pregnancies. The most common malignancies in gestation are breast and cervical cancers, lymphoma, leukemia and melanoma. Diagnosis is often delayed as symptoms and physical signs of malignancy may be masked by those of pregnancy. Clinicians are faced with the challenge of providing the mother with the best options for treatment while ensuring the safety of the unborn child.

The risks of systemic antineoplastic treatment (cytotoxic, endocrine, targeted agents and immunotherapy) administration during pregnancy depend on the drugs used and the gestational age of the fetus. During the period of organogenesis, chemotherapy administration carries an increased risk of fetal malformation and spontaneous abortion. The risk of malformations is significantly reduced in the second and third trimesters but chemotherapy can cause intrauterine growth retardation, pre-maturity and low birth weight. Administration of chemotherapy within 3 weeks of anticipated delivery is not recommended to avoid neonatal myelosuppression and potential complications like bleeding and sepsis. If chemotherapy is indicated, unless delivery can be accomplished within a few weeks of diagnosis, treatment should be instituted during pregnancy rather than waiting until after delivery.

Information on the effects of antineoplastic drugs given during pregnancy is limited and has largely been derived from case reports and small case series. Most existing data is from older drugs such as the anthracyclines, with little information available on newer agents including monoclonal antibodies or targeted therapies.  Breast cancer in pregnancy should be treated similarly to that in non-pregnant patients except that chemotherapy is delayed until the second trimester. Hematologic malignancies are also treated in the same way.

Learning Objectives:

1. Understand the process for diagnosis of cancer in pregnancy;
2. Recognize the risks associated with the use of systemic treatments in pregnancy;
3. Understand which antineoplastic agents and supportive therapies are safe for use during pregnancy; and
4. Appreciate the specific management of some of the more common malignancies (e.g. breast, lymphoma) seen in pregnancies.

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Tuesday, April 19

Plenary: Dermatologic Toxicities: The Superficial Side of Targeted Therapies         

09:00-10:00

Milan J. Anadkat, Washington University School of Medicine, St. Louis, MO, USA

Systemic therapies (cytotoxic/targeted agents, immune checkpoint inhibitors) have resulted in remarkable improvements in patient survival across all cancers. Despite this remarkable success, the majority of patients treated with these drugs will develop dermatologic adverse events, which lead to decreased quality of life and inconsistent antineoplastic therapy, both of which may affect clinical outcome. This will provide up-to-date information on dermatologic adverse event incidence, mechanisms, clinical presentation, and preventive/therapeutic interventions. All of which is essential for optimal dermatologic care of people living with cancer.

Learning Objectives:

1. Recognize impact on quality of life and clinical characteristics of dermatologic adverse events to therapies in cancer;
2. Describe the mechanisms involved in dermatologic adverse events to therapies in cancer; and
3. Discuss mechanistically-based interventions to improve quality of life and decrease toxicity in cancer patients.

Concurrent Sessions 5
Clinical 5A: Hematological Cancer Updates 

10:30-11:30

Hematological Cancer Update: Chronic Lymphocytic Leukemia (CLL)
Tara Leslie, Tom Baker Cancer Centre and University of Alberta, Calgary, AB, Canada

Chronic Lymphocytic Leukemia (CLL) is characterized by the progressive accumulation of functionally incompetent monoclonal lymphocytes.  Recently, additional treatment options have become available for our CLL patients including those with deletion 17p and those with relapsed or refractory disease.   

Learning Objectives:

1. Discuss update of recent publications and abstracts for novel agents in CLL; 
2. Discuss the role of ibrutinib and idelalisib in the management of CLL patients in current clinical practice; and
3. Discuss the unique side effect profiles of these agents and a review of patient monitoring recommendations.

Hematological Cancer Update: Lymphomas
Alexandre Chan, National University of Singapore, Singapore

Lymphomas are a heterogeneous group of malignancies that arise from malignant transformation of immune cells that reside predominantly in lymphoid tissues. Over the past few years, a number of clinical studies as well as novel treatment strategies have evolved the management of certain subtypes of lymphoma. In this session, the speaker will provide a succinct update on these findings.

Learning Objectives:

1. Discuss the role of lenalidomide in the management of Non-Hodgkin’s Lymphoma;
2. Discuss the novel therapies available for managing mantle cell lymphoma; and
3. Discuss the role of immunotherapy in treatment of lymphomas.

Fundamental 5B: Lean Thinking with the Toyota Production System

10:30-11:30

Shaun O'Connor, Box Hill Hospital (Eastern Health), Box Hill, VIC, Australia

The Toyota Production System (TPS), a collection of tools, strategies and philosophies has been used to improve efficiency and reduce waste in many varied industrial processes, including incrementally in health. Chemotherapy Day Units (CDUs) provide a ripe ground for process improvements aimed at improving the patient experience, with a complex network of staff and data interactions aimed at delivering efficient and safe care for each one of our patients.  St Vincent’s Health, Melbourne, supported by Toyota Australia undertook an 18 month long improvement project focusing on the CDU. This presentation will walk though some of the processes and techniques used in this process, highlighting opportunities and pitfalls.

Learning Objectives:

1. Gain a basic understanding of terminology and concepts used in TPS and Lean;
2. Understand the philosophy and process of a Jishuken improvement event; and
3. Understand how some basic elements of TPS can be applied in your workplace.

Clinical 5C: End of Life Care Discussion Session

10:30-11:30

Peter Gilbar, Toowoomba Hospital, Toowoomba, Australia

Palliative cancer patients in their last months of life are commonly prescribed potentially inappropriate medications. These medications may be for secondary prevention of co-morbid diseases, often have no short-term benefit and may cause potentially harmful effects. In the palliative phase of cancer management, the focus of care should be on the patient’s quality of life, including alleviating suffering from cancer-related symptoms and treating short-term, acute medical illnesses. “Deprescribing” can be defined as the process of withdrawal of an inappropriate medication supervised by health care professionals with the goal of managing polypharmacy and improving outcomes. Deprescribing can benefit patients by reducing the associated costs, potential adverse effects and other burdens of polypharmacy in the last months of life. Guidelines have recently been developed to assist in this process.

Delirium is the most common neuropsychiatric complication seen in patients with advanced cancer. The cause is generally multifactorial involving multiple medical conditions and adverse effects to medications. The management of delirium requires a team approach and involves a combination of non-pharmacologic and pharmacological interventions.

This session will involve a facilitator-led group discussion of issues that may complicate end of life care in cancer patients undergoing palliative treatment. The primary focus will be on deprescribing and the management of delerium but if time permits other neurological symptoms, such as terminal restlessness, may be discussed.

Learning Objectives

1. To understand the concept and benefits of deprescribing unnecessary medications at the end of life;
2. To recognise which medications and medication classes may be suitable for discontinuation in palliative patients and to formulate a strategy for deprescribing;
3. To appreciate the many potential causes of delirium seen in patients with cancer; and
4. To develop strategies for the management of delirium as part of a multi-disciplinary team involving both drug and non-drug approaches.

Concurrent Sessions 6

Clinical 6A: Supportive Care Updates

15:15-16:15

Milan J. Anadkat, Washington University School of Medicine, St. Louis, MO, USA

Supportive Care Update: Alopecia

Systemic therapies (cytotoxic/targeted agents) have resulted in remarkable improvements in patient survival across all cancers. Despite this remarkable success, the majority of patients treated with these drugs will develop alopecia and hair changes, which lead to decreased quality of life. This will provide up-to-date information on alopecia and hair change incidence, mechanisms, clinical presentation, and preventive/therapeutic interventions. All of which is essential for optimal care of people living with cancer.

Learning Objectives:

1. Recognize impact on quality of life and clinical characteristics of alopecia and hair changes to therapies in cancer;
2. Describe the mechanisms involved in alopecia and hair changes to therapies in cancer; and
3. Discuss mechanistically-based interventions to improve quality of life and decrease alopecia and hair changes in cancer patients.
   

Supportive Care Update: Antibiotic Prophylaxis for Infections
Claudio González, Unidad Oncología Hospital pediátrico Exequiel González Cortés, Santiago, Chile

Chemoprophylaxis is prevention of disease by administration of a drug. In the antibiotic prophylaxis an antimicrobial agent is given to an individual who is at risk of developing an infection because of exposure or an impairment of host defense. Patients with cancer are in a significant risk for infection due to their treatment with chemotherapy, radiation, or surgery. The antimicrobial prophylaxis has a role as preventive strategy in the setting of specific infections. Is very important to know the scientific reasons for indications, dosage and safety of this kind of drugs. In this session, the speaker will provide an update in antibiotic prophylaxis for Infections.

Learning Objectives:

1. Discuss the role of antibiotic prophylaxis for infections;
2. Review the pharmacokinetic/pharmacodynamic principles in this setting; and
3. Describe the safety of this preventive strategy.

Clinical 6B: Bone Marrow Transplant Update

15:15-16:15

Role of the Clinical Pharmacist in a Stem Cell Transplantation Ward
Tiene Bauters, Ghent University Hospital, Ghent, Belgium

The number of hematopoietic stem cell transplantations (HSCT) has expanded in the last decades and still continues to increase. To ensure safe and effective care in this vulnerable high-risk population, treatment should be undertaken by an experienced and fully dedicated multidisciplinary team.

HSCT pharmacists are well-positioned to take a lead role in patient assessment and development and implementation of guidelines for supportive care.

This presentation aims to give an overview on clinical pharmacy activities in the HSCT setting augmented with examples of routine management for immunosuppression or complications related to HSCT, including participation in ward rounds, analysis of drug-related problems, counseling on discharge medication.

In addition, the pharmacist’s role in the development and implementation of guidelines on acute and late effects or toxicities and involvement in quality assurance will be discussed.

Learning Objectives:

1. Recognize the role of the specialty pharmacist in a HSCT setting as a member of a multidisciplinary team; and
2. Define commonly observed complications after HSCT.

Bone Marrow Transplant Update
Pablo Ramirez, Catholic University, Santiago, Chile

Hematopoietic stem cell transplantation has become a standard curative procedure in a number of malignant and non-malignant hematological diseases. Since its beginnings, over a million transplants have been performed worldwide and over 50,000 transplants are performed every year around the world. Several advances including better HLA determination techniques, new kind of donors as haploidentical donors, cord blood expansion and ex vivo T cell manipulation, have increased the donor availability so now virtually every individual in need has a potential donor for transplant. Despite this, there are still some barriers to overcome the limitations of transplant associated specially with mortality due to infections, graft rejection, graft vs host disease (GVHD), drug toxicities and relapses. New developments including better antibiotics, new drugs to better control GVHD and new strategies to decrease disease relapse are under study.

Learning Objectives: