Abstract
Introduction
The International Society of Oncology Pharmacy Practitioners (ISOPP) has over 3500 members across 110 countries. ISOPP's strategic objectives are membership engagement, empowering the global oncology pharmacy community, facilitating professional development, and advocating for advancement. Aligning with these objectives, this research aimed to describe global oncology pharmacy service provision and knowledge requirements.
Methods
Fifty-three ISOPP global oncology pharmacy leaders from 45 countries were invited to complete a survey. Questions in the survey explored whether protected titles existed for oncology practitioners, the oncology pharmacy service levels that were being offered from the seven levels proposed, knowledge requirements for these levels, and access to education. Free text comments were analyzed for context or themes and described descriptively. Based on responses, the proposed service levels and required knowledge were reviewed to establish the ISOPP Oncology Pharmacy Service Levels.
Results
Responses from 35 countries were received. Thirty-five (100%) participants reported that pharmacist was a protected title, and 18 (51%) participants reported that pharmacy technician was protected. However, oncology pharmacist was a protected title in one (3%) country only, Singapore. Fourteen (40%) countries delivered all seven levels, and 35 (100%) countries delivered at least three levels. Some participants reported being unfamiliar with some of the survey terminology; this information was used to clarify the wording of the service levels and knowledge requirements.
Conclusion
This global review of oncology pharmacy services will aid professional development and advancement, by connecting countries with mentoring opportunities and resources, and establishing a benchmark for the future growth of services globally.
Keywords
Introduction
The International Society of Oncology Pharmacy Practitioners (ISOPP) represents oncology pharmacy practitioners across the world and has over 3500 members in more than 110 countries. The first International Symposium on Oncology Pharmacy Practice was held in 1988, and ISOPP was officially incorporated as an organization in 1996. ISOPP has four core strategic initiatives: engage the membership, empower the global oncology pharmacy community, facilitate professional development, and advocate for the advancement of oncology pharmacy (see Figure 1). 1 ISOPP hosts global oncology pharmacy leaders’ meetings which bring together representatives from the currently 45 represented countries to collaboratively work towards meeting its four strategic objectives.
Four core strategic initiatives of ISOPP.
The pharmacy services offered by oncology pharmacy practitioners around the world encompass a wide range of practices aimed at optimizing cancer treatment and improving patient outcomes. The disparity between oncology pharmacy services for different countries may be due to several factors such as access to education and training, availability of pharmacy workforce and access to medical records.2,3 For example, Adejumo and colleagues highlighted the unmet training needs of pharmacists in Nigeria, despite the pharmacists’ willingness to expand knowledge and upskill in patient care. 3 Education and training, particularly at the university level, was also identified by Dahmani and colleagues as a barrier to delivering oncology services in the community setting in Qatar. 4 Furthermore, results from a study which surveyed members of the European Society of Oncology Pharmacy Global in 2023, reported 20% of pharmacists had no access to patients’ medical records and identified this as a major limitation in performing clinical pharmacy activities. 2
While clinical oncology pharmacy is recognized as a specialized field in many countries 2 the scope of oncology pharmacy extends beyond the direct patient care activities such as patient education and symptom management.5,6 Additional services may include early detection and prevention guidance, the provision of systemic anticancer therapy (SACT), medication management, and service review.7–9 Such clinical oncology pharmacy services have been shown to play a critical role in enhancing pharmacotherapeutic effectiveness, reducing healthcare costs, improving medication safety, and increasing patients’ quality of life.2,9–12 In addition, a further advantage of clinical oncology pharmacy services is the reduction of burnout in other healthcare workers, leveraged by advanced scope oncology pharmacist roles such as prescribing. 12
Despite the growing recognition of oncology pharmacy as a key component of cancer care, there is, to our knowledge, no comprehensive research describing the full extent and scope of services provided by oncology pharmacy practitioners and the associated knowledge requirements, across multiple countries worldwide. This study aims to address that gap by defining the global scope of oncology pharmacy service provision using proposed service levels by ISOPP and identify the fundamental knowledge required for delivering these services. In this study, the definition of the word oncology includes all cancer service provision, and the definition of oncology pharmacy practitioners is limited to those working in organisations where patients access care.
Methods
This project was reviewed by the Medicines Use and Evaluation Committee, Princess Alexandra Hospital, as a quality assurance project exempt from Human Research Ethics Committee review (number CM0306202401).
Study design
This was a survey-based review of the current oncology service provision, and the associated knowledge required, to deliver this service in individual countries. The survey (see Supplementary File 1) consisted of 57 questions with survey questions designed by the study team, who are subject matter experts in oncology pharmacy. The survey was conducted at the global level and was open from 19th June 2024 until 21st September 2024.
Participant identification and recruitment
Participants were consenting pharmacists of the ISOPP global leaders’ meetings who understood the English language. The members of the ISOPP global leaders’ meetings are officially nominated to represent their country via the relevant national oncology pharmacy or national pharmacy organization or equivalent. All ISOPP global leaders’ forum members have knowledge of the oncology pharmacy services in their respective countries. Fifty-three global leaders from 45 countries across six continents (noting no oncology service in the seventh continent, Antarctica) were invited via email to read participant information and consent to complete a confidential online survey using the survey monkey platform. The survey was also included as an attachment in the email, so that if preferred, it could be completed and returned via email. The survey was supplied in English. Email addresses used to contact prospective participants were those provided by the ISOPP oncology pharmacy global leaders’ members in 2024.
Data collection
The survey included sections on participant demographics, questions regarding minimum qualifications for a pharmacist, pharmacy technician, and oncology pharmacist within the participant's country and whether these roles were protected titles. There were also questions regarding availability of structured education such as Master's and PhD programs.
In addition, questions regarding the existence of national organisations and intellectual property rights for educational programs were asked to assist the study team in verifying responses to other questions in the survey, if required. Furthermore, there were questions regarding the oncology pharmacy service levels and the nature of the service provided in the individual countries and knowledge requirements. Sections for free-text comments throughout the survey allowed participants to provide context or explanation to their responses.
Participants were de-identified in the published reporting of results. However, the names of participants were collected in the survey so that the study team could review the details of the participant completing the survey and ask any follow up questions or obtain clarification, if needed. This was also used as a quality control mechanism to best ensure participants were the current global leader or co-leaders for their country, and were therefore appropriate to respond to the survey on behalf of their country.
Data analysis
Each participant's response was individually reviewed by a minimum of two members from the study team. Responses to questions that invited comments, if applicable, were described descriptively. For any countries that had more than one participant complete the survey, the most detailed response was used. If there were any discrepancies or omissions of data, this was resolved by email correspondence between a member of the study team and the participants.
Based on the responses, changes to the Proposed Service Levels for Oncology Pharmacy Services in the survey (see Supplementary File 1) were made and a final ISOPP Oncology Pharmacy Service Levels (Table 1) was created. The data was then checked by all members of the research team to confirm changes to the tables. Each country's response was then reviewed against the new ISOPP Oncology Pharmacy Service Levels table to confirm if the service level was being offered in the individual country. The final service level allocation was presented to the participants virtually at the January 2025 global leaders meeting to allow for any discrepancies to be challenged. No discrepancies were identified by attendees. The Human Development Index (HDI) for each country was also considered against the oncology pharmacy service level results so that any potential relationships could be observed. The HDI is a summary measure of average achievement in three key dimensions of human development: a long and healthy life, being knowledgeable and having a decent standard of living. 13
ISOPP Oncology Pharmacy Service Levels.
Note: 1) Italicized text indicates update to the table post survey results. 2) All levels of oncology pharmacy services include an awareness of best practices for safe handling of SACT. In addition, all levels typically include participation in research initiatives and education of students/trainees based on areas of expertise and increasing experience.
Results
A total of 38 responses from global leaders were received from 35 unique countries, giving a response rate for countries of 35 out of 45 (78%), this is visually presented on a world map (see Figure 2). There were 3 countries that had two participants each complete the survey; for these responses, the most detailed response out of the two was used for each country, resulting in 35 responses included in total. The survey took between 30 min to 90 min for participants to complete.
World map of responding countries. Key: Purple shaded countries = Response by participant received.
Protected titles for oncology practitioners
Protected title was defined as ‘requires official registration with a regulatory body and/or a license’. All countries reported that pharmacist was a protected title, with minimum qualifications ranging from Bachelor of Pharmacy to Doctor of Pharmacy. Eighteen out of 35 (51%) countries reported that pharmacy technician was a protected title. Of these 18, the minimum qualifications ranged from completion of four years of secondary school to a Diploma. The participant from Belgium stated that there were plans for pharmacy technician to become a protected title in 2025, if further education by the pharmacy technician was completed.
Four out of 35 (11%) participants reported that oncology pharmacist was a protected title in their country. These were United States which offers Board-Certified Oncology Pharmacist (BCOP) Specialty Certification, United Arab Emirates which utilises BCOP from the United States, Singapore which has its own accreditation, and DR Congo. Despite DR Congo stating oncology pharmacist was a protected title, it was noted by the participant that there is currently no longer an institution in the country offering certification. Also, upon further analysis, it was revealed that only one country (Singapore) had registration for oncology pharmacists with a regulatory board (or similar) as per the study definition (see Table 2).
Protected titles for pharmacist, pharmacy technician and oncology pharmacist.
Key: ✓ = Protected title.
Education and national organisations
Availability of structured education was unsurprisingly variable between the countries (see Table 3). Twenty-nine out of 35 (83%) countries had access to postgraduate education (Master's or PhD degree). Fourteen out of 35 (40%) countries had access to General Pharmacy Practice Residency (PGY1). Nine out of 35 (26%) had access to Oncology Pharmacy Specialty Residency (PGY2), 9 out of 35 (26%) had access to Fellowship (research), and 14 out of 35 (40%) had access to and used Board Certification (BCOP). One country (Fiji) had listed no postgraduate education opportunities, and the participant from Australia listed for ‘other’ that Australia offered a two-year Pharmacist Registrar Training Program in oncology and haematology. Over half (51%) of the countries did not own (hold intellectual property rights to) and/or provide any educational programs.
Availability of structured education.
Note: Options for selection were: Post-graduate (Master's or PhD degree), General Pharmacy Practice Residency (PGY1), Oncology Pharmacy Specialty Residency (PGY2), Fellowship (research), Board Certification (BCOP), None, or Other.
Terminology and interpretation of survey questions regarding service levels and knowledge required
Responses indicated terminology used for the service levels varied between countries for some service levels. For example, one-third of participants stated the service level term ‘community pharmacy’ is not used in their country. Based on results, this description was then changed to also include ‘retail pharmacy/pharmacy outside of hospital setting/pharmacy outside of cancer specific setting’. In another example of different terminology use, about 45% of participants said operational (parenteral only) was not reflective of the terminology in their country. Based on feedback, ‘Technical/ Sterile compounding’ was also added to describe this service level. Furthermore, the participant from Romania stated pharmacy medical assistant was the term used rather than pharmacy technician, for applicable service levels.
It was clear from some responses, that the oncology pharmacy service levels and the oncology pharmacy knowledge tables in the survey were being interpreted as all activities had to be delivered to meet that level. The authors noted the table should have stated ‘examples of clinical practice’, to imply these are examples of what the service can be, rather than inclusive of all services listed. See Table 1 for the updated final ISOPP Oncology Pharmacy Service Levels. Any updates to the table based on responses are indicated in italicized text.
In the survey, safe handling was mentioned in three of the service levels, however, based on survey responses as well as discussion by the authors, it was agreed best practices for safe handling are required across all service levels. In addition, research and education were also added as a requirement across all levels (see note at bottom of Table 1 reflecting this change). Only two additions to the description for the knowledge required for service levels were suggested by the participants. These were ‘Good Manufacturing Practice, Quality Control, and ‘Quality Assurance’ to the service level ‘Operational (Parenteral only) /Technical/Sterile Compounding’; and ‘in-depth clinical knowledge and training’ for the service level ‘Advanced/Specialist’.
Pharmacy practitioner roles in oncology pharmacy service delivery
Participants included comments regarding the primary reasons why some staff were carrying out different service levels. For example, Kenya noted that pharmacy technicians were sometimes carrying out verification of SACT orders due to a lack of pharmacist resources. This was different to the United Kingdom, where pharmacy technicians are trained as part of an advanced scope of practice to verify SACT orders.
Service levels provision by country
The results for service level provision by country were ordered by highest to lowest HDI (see Table 4). For approximately the top half (18) countries with the highest HDI, all had a HDI of 0.875 or above and all offered the seven service levels described bar a few exceptions. These exceptions included Iceland who was offering all levels except strategic, Malta who offered just the first four service levels, and Poland and Qatar who offered all but oncology services in community pharmacy/retail pharmacy/pharmacy outside of the hospital setting/ pharmacy outside of a cancer specific setting. Regarding advanced service level provision, United States, United Kingdom and Qatar participants commented that their countries offer prescribing (either independent, collaborative practice agreements or partnered charting).
Service level provision as defined by ISOPP Oncology Pharmacy Service Levels sorted by Human Development Index (HDI).
In response to the question asking participants if they had any comments in general about this survey and work proposed, participants highlighted appreciation for the work being conducted, with gratitude expressed by six global leaders in written format, as well as verbally by even more global leaders during the quarterly meetings. Their feedback underscores the value and relevance of the research, reflecting its usefulness in advancing oncology pharmacy for their country. In addition, there were five reflections from participants remarking on the gap between service levels offered in their country compared to the seven possible levels presented and the need to advance services.
Discussion
ISOPP oncology pharmacy service levels
The findings from this study have contributed to the review and expansion of the initial definitions and terminology associated with the proposed oncology pharmacy service levels, culminating in the establishment of the ISOPP Oncology Pharmacy Service Levels. This refinement aims to foster a broader global understanding of the terminology used, ensuring clarity when these levels are reviewed by different countries. Furthermore, the study has facilitated the refinement of example definitions, enabling countries to self-assess and map their services to these proposed levels. This process of refining terminology will also enhance future surveys related to service levels. The ISOPP Oncology Pharmacy Service Levels will play a crucial role in helping countries advocate for the expansion of services and models of care, whether within healthcare organizations or at a national level, through strategic and operational plans. ISOPP will continue to assist in facilitating the advancement of oncology pharmacy practice globally as part of the society's key strategic initiatives. 14 In addition, it is recommended that future surveys include the new definitions for service levels and knowledge required to assist with accuracy of data. For example, in the community service definition, include pharmacy services outside of the hospital setting or outside of a non-hospital cancer pharmacy setting.
Differences between countries of ISOPP oncology pharmacy service levels being offered
As expected, significant variation in the provision of ISOPP Oncology Pharmacy Service Levels was observed across the countries represented in the survey. Analysis of the results, categorized by the HDI (Table 4), suggests that lower HDI is associated with a reduced provision of oncology pharmacy services at strategic or highly specialized levels. However, due to the absence of statistical analysis, this correlation remains speculative and may reflect the overall maturity of clinical pharmacy in these regions rather than a direct indication of the state of cancer services. Future studies should explore which of the HDI dimensions of human development (a long and healthy life, being knowledgeable, and having a decent standard of living) may be impacting advancement of service level provision in individual countries. This may provide insights into opportunities for ISOPP to advocate for advancement in these human development aspects. Notably, countries such as Iceland and Malta, despite their high HDI, lacked some advanced services, potentially due to factors such as smaller population sizes. In contrast, countries like Nigeria, Pakistan, Kenya, and Ghana with lower HDI rankings, offered a comprehensive range of services, possibly due to strong government support for the advancement of cancer services.15–18
It was surprising that Malaysia, Qatar and Poland did not provide the community pharmacy service level, despite providing all other ISOPP Oncology Pharmacy Service Levels. However, a 2022 study by Dahmani and colleagues, did provide insights into this finding specifically for Qatar. 4 Dahmani and colleagues explored community pharmacists’ readiness to manage the safe and effective use of oral SACT, and found an apparent inadequacy regarding the knowledge of SACT dosing, side effects, and potential interactions. 4 In addition, Dhamani and colleagues also found the most significant predictors of community pharmacists’ readiness were employment status, number of oral anticancer medicine prescriptions dispensed per month, and education on oral chemotherapy in undergraduate training. The latter underscores an opportunity for targeted education and training programs in oncology pharmacy services to enhance professional capabilities.
With 19 countries offering all seven levels of the ISOPP Oncology Pharmacy Service Levels, and the expert level having prescribing as a service example, further research should identify which countries have oncology pharmacists prescribing and describe any differences in the type of prescribing, e.g., partnered prescribing, prescribing under a collaborative practice agreement, or independent prescribing. Differences should include context, if any, and facilitators (e.g., physician buy-in) and barriers (e.g., prescribing not being legal in the individual country) to facilitate advancement of oncology pharmacy practice. Understanding these factors will therefore be crucial for advancing oncology pharmacy practice and informing future policy development in this area.
Recognition of education and certification
Across many countries, the availability of, and the need for, post-graduate education to improve practice was emphasised. This reflects a global desire for advanced education for pharmacists, with a strong focus on enhancing clinical, research, and managerial skills. In addition to education, certification was also recognised as being a valuable service provision. The access and use of BCOP certification, is highlighted in countries like Japan, Singapore, Canada, and Thailand, underscoring its international significance. The importance of standardized certification programs should be emphasized, as they ensure that pharmacists meet specific competencies, especially in high-risk and specialised fields like oncology. Consideration of an international oncology pharmacist certification process is recommended as a future area for collaboration between countries and professional bodies. This recommendation is due to the results showing that only one country, Singapore, had oncology pharmacist as a protected title, and that many countries do not have a certification process as a step to achieving a protected title.
International certification may also help to facilitate individual countries giving consideration to having a protected title for oncology pharmacists. There are many potential advantages of having a protected title, such as recognition, regulation, accountability, and legal protection, 19 and advocacy and policy influence. 20 To the authors’ knowledge, there is no international certification and protection of any specialist pharmacist titles in individual countries across the world. Oncology pharmacists could lead the way with an international certification, and it could extend to other specialities such as cardiology, kidney and transplant services, and intensive care.
Regarding ownership of and provision of education across the surveyed countries, there was a notable disparity. The role of local and international pharmacy bodies in shaping educational programs is crucial for standardizing global pharmacy practices. A recommendation for future research is how professional organizations could potentially be involved in shaping pharmacy education globally. A 2023 study by the European Society of Oncology Pharmacy (ESOP) Global that mapped clinical oncology pharmacy activities in four continents, also highlighted opportunities for oncology pharmacy education to advance clinical oncology pharmacy services. 2 This was similar to our findings from participants across five continents, who supported the notion that increasing knowledge is required and correlates with advanced service levels. A key vehicle to support pharmacists to learn from each other and increase knowledge is mentoring, 21 and ISOPP intends to support its members with mentor and mentee opportunities as a result of findings in this study in the future.
Limitations
A key limitation of the survey was that it was only available in English, which is the designated language for ISOPP. Translating the survey into other languages would introduce significant complexities in the analysis and could potentially lead to misinterpretation of the results. Future surveys could consider offering translations to increase inclusivity for countries where English is not the primary language, although careful consideration would be required regarding how the results are analyzed across different languages. Providing future surveys in English may also address the limitation of the absence of responses from South American countries, which were not represented in the survey results. It is hoped that future surveys will include responses from this continent, in addition to responses from a greater number of countries from already included continents, to provide a more enhanced global perspective.
It is also acknowledged that there is the assumption that the global leader participant responses are providing an accurate reflection of the state of the individual country. For example, for access and use of BCOP, there may be one or more oncology pharmacists certified in a particular country, but it was unknown by the survey participant, so they responded no to that option. Another example, is that the participant may not have been aware of post-graduate options in their country such as Master's and PhD programs, particularly for countries with many universities. Furthermore, as described in the results, some participants may have answered no to some questions regarding service levels if they did not provide all suggested areas, and while the authors did attempt to follow up, it is possible that there may be some service levels not stated as being offered but are available.
A further limitation was the inability to compare and contrast findings from this study to other similar studies, due to a lack of studies in this area. The 2023 study by the ESOP Global was the most similar research to date, however it had different aims of determining whether certain clinical pharmacy tasks were being performed (such as drug-drug interaction checking) and identifying barriers to providing clinical oncology pharmacy. The lack of existing literature on oncology pharmacy service levels and knowledge required highlights the gap in knowledge prior to this present study, and therefore the importance of this study.
Finally, for the oncology pharmacy practitioner protected title questions, there may have been some countries that have differences in protected titles among individual states in a particular country. For example, in the United States, pharmacy technician is a protected title in some states, however, the focus of these questions was at the whole of country level.
Conclusion
This is the first review of global oncology services and knowledge requirements across countries in five continents of the world and has facilitated the establishment of ISOPP Oncology Pharmacy Service Levels. The results will assist in advancing ISOPP's strategic objectives, particularly with respect to facilitating professional development and advocating for oncology pharmacy advancement, by connecting countries with mentoring opportunities, sharing of educational resources, and providing a benchmark and a description of possible oncology pharmacy services. It is recommended that a review in four to five years’ time be carried out to articulate advancements of global oncology pharmacy within this timeframe, and to also include data from countries not represented in the survey results. As the profession continues to grow, collaboration and knowledge sharing across borders will be essential in harmonizing global pharmacy practices.
Supplemental Material
sj-pdf-1-opp-10.1177_10781552251332199 - Supplemental material for Global oncology pharmacy service levels and knowledge requirements: A review by the International Society of Oncology Pharmacy Practitioners
Supplemental material, sj-pdf-1-opp-10.1177_10781552251332199 for Global oncology pharmacy service levels and knowledge requirements: A review by the International Society of Oncology Pharmacy Practitioners by Marissa Ryan, Evelyn Handel Zapata, Irene Weru and Annette Netty V Cracknell in Journal of Oncology Pharmacy Practice
Footnotes
Acknowledgements
The research team would like to thank study participants for their valuable responses and time.
Author contribution statement
Concept and design of study: NC, EH, MR, IW. Data collection, management and analysis: MR, NC, IW, EH. Drafting of manuscript: MR, EC, IW, EH. Review and approval of final version of manuscript: MR, NC, EH, IW.
Data availability statement
The de-identified data that support the findings of this study are available from the corresponding author upon reasonable request.
Ethical approval and informed consent statements
This project was reviewed by the Medicines Use and Evaluation Committee, Princess Alexandra Hospital, as a quality assurance project exempt from Human Research Ethics Committee review (number CM0306202401). Written informed consent was obtained from all study participants.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
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References
Supplementary Material
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