CPI: DPYD

Identifying workforce development and education needs to support the DPYD clinical pathway in the oncology setting

DPYD is a gene that codes for an enzyme called dihydropyrimidine dehydrogenase (known as DPD). This enzyme helps the body break down fluoropyrimidine-based chemotherapy drugs, such as capecitabine, 5-fluorouracil (5-FU) and tegafur. For some individuals variants in the DPYD gene can make them susceptible to severe adverse reactions to fluoropyrimidine-based chemotherapy, some of which can be life threatening.

Before initiation of 5-FU, capecitabine or tegafur treatment, all patients should be tested for partial or complete DPD deficiency. Information about the approved test for DPD deficiency is updated regularly within the National Genomic Test Directory.

This Clinical Pathway Initiative (CPI) project identifies the education and training needs of those delivering DPYD genomic testing in the oncology setting.

How to use this page

The pathway is broken down into key steps, numbered below. Each step has associated competencies, each listed within a blue box, that a healthcare professional should have to be able to deliver that step. Clicking a blue box will expand the competency to provide additional information, and associated learning.

You can use this pathway to plan service delivery, identify and address workforce training needs, or to assess and develop your own knowledge and skills.

Who developed this CPI project?

An initial draft of the DPYD CPI was developed by Pharmacy Operational Group for Genomics in 2022. The initial draft was shared with subject matter expert groups for review and pertinent recommendations were incorporated into a subsequent revision of the DPYD CPI. The revised DPYD CPI was presented to an expert ratification group for final review and approval.

Ratification group members

Helen Bethell, NHS North East and Yorkshire Genomic Medicine Service workforce development and education lead and genetic counsellor
Victoria Cuthill, St Mark’s Hospital hereditary GI cancer syndromes nurse consultant
Emma Groves, NHS North East and Yorkshire Genomic Medicine Service lead pharmacist
Jessica Keen, NHS North West Genomic Medicine Service Alliance lead pharmacist and The Christie NHS Foundation Trust specialist clinical pharmacist
Ed Miller, NHS England’s Genomics Education Programme education specialist
Prof Bill Newman, NHS North West Genomic Medicine Service Alliance clinical director and University of Manchester honorary consultant in genetic medicine and professor of translational genomic medicine
Prof Sir Munir Pirmohamed, David Weatherall chair of medicine, NHS chair of pharmacogenetics, Centre for Drug Safety Science and Wolfson Centre for Personalised Medicine director, Health Data Research UK North director and Royal Liverpool University Hospital consultant physician
Dr Paul Ross, Guy’s and St Thomas’ NHS Foundation Trust consultant medical oncologist
Nisha Shaunak, Guy’s and St Thomas’ NHS Foundation Trust associate chief pharmacist

Additional support and thanks

The DYPD Pharmacogenomics Transformation Steering Group
Macmillan Cancer Support: Genomics education working group
NHS England’s Genomics Education Programme: pharmacogenomics working group for GeNotes
NHS England: Pharmacy Workforce Group for Genomics
Oncology colleagues for their comments and feedback

Key

We have identified the type of competency in each of the drop-down boxes below:

G: General competency
P: Pathway-specific competency
St: Step-specific competency
K: Knowledge
S: Skills
A: Attitudes

STEP 1

Recognise that the patient requires fluoropyrimidine-based chemotherapy

Competencies

A. Explains fluoropyrimidine-based chemotherapy treatment including metabolism, side effects and appropriate patient management. (St, K)

Associated learning:

NHS England’s Genomics Education Programme: GeNotes: Dihydropyrimidine dehydrogenase (DPD) deficiency
NHS England’s Genomics Education Programme: GeNotes: Fluoropyrimidine-based chemotherapies

B. Can recall all local fluoropyrimidine based chemotherapy treatment protocols and pathways. (St, K)

Associated learning:

Please refer to local chemotherapy protocols and guidelines

Workforce groups

Oncology medical staff, oncology pharmacist, oncology pharmacy technician, systemic anti-cancer therapy (SACT)-trained nurse, oncology clinical nurse specialist, allied healthcare professionals working in oncology, and healthcare professionals (medical and non-medical) who are registered as competent to prescribe SACT

STEP 2

Advise the patient and/or caregiver on DPYD testing

Competencies

A. Employs communication skills to discuss pharmacogenomic concepts and the potential risk of adverse drug reactions associated with genetic variants in the DPYD gene at a level appropriate for the patient. (P, S)

Associated learning:

Cancer Research UK: DPD deficiency
North West Genomic Medicine Service Alliance: DPYD patient information leaflet

B. Can recall a wide range of avenues of patient support, including patient information leaflets, online information and other healthcare professionals, and is able to communicate these to the patient. (G, K, S)

Associated learning:

Cancer Research UK: DPD deficiency
North West Genomic Medicine Service Alliance: DPYD patient information leaflet

Workforce groups

Oncology medical staff, oncology pharmacist, oncology pharmacy technician, SACT-trained nurse, oncology clinical nurse specialist, allied healthcare professionals working in oncology, and healthcare professionals (medical and non-medical) who are registered as competent to prescribe SACT

STEP 3

Request DPYD testing and collect a sample

Competencies

A. Can complete local DPYD pharmacogenomic test request forms, following local procedures. (St, S)

Associated learning:

Please refer to local protocols and guidelines

B. Demonstrates the ability to follow local governance processes for sample collection and transportation to a regional Genomic Laboratory Hub. (St, S)

Associated learning:

Please refer to local protocols and guidelines

C. Can use the National Genomic Test Directory. (G, S)

Associated learning:

NHS England: National Genomic Test Directory
NHS England’s Genomics Education Programme: GeNotes: The National Genomic Test Directory

Workforce groups

Oncology medical staff, oncology pharmacist, SACT-trained nurse, oncology clinical nurse specialist, and healthcare professionals (medical and non-medical) who are registered as competent to prescribe SACT

STEP 4

Apply the DPYD test result to treatment review and decision making

Competencies

A. Can interpret a DPYD pharmacogenomic test report using evidence-based pharmacogenomic clinical guidelines. (St, K, S)

Associated learning:

The Clinical Pharmacogenetics Implementation Consortium: CPIC^® Guideline for Fluoropyrimidines and DPYD
UK Chemotherapy Board: Publications (see ‘Personalised Medicine Approach for Fluoropyrimidine-based Therapies’)
NHS England’s Genomics Education Programme: GeNotes: Dihydropyrimidine dehydrogenase (DPD) deficiency

B. Recognises differences in pharmacogenomic allele frequencies among ancestry groups. (G, K)

Associated learning:

Chan TH, Zhang JE and Pirmohamed M. ‘DPYD genetic polymorphisms in non-European patients with severe fluoropyrimidine-related toxicity: a systematic review’. British Journal of Cancer 2024: volume 131, pages 498–514. DOI: 10.1038/s41416-024-02754-z
The Clinical Pharmacogenetics Implementation Consortium: CPIC^® Guideline for Fluoropyrimidines and DPYD
Li B, Sangkuhl K, Whaley R and others. ‘Frequencies of pharmacogenomic alleles across biogeographic groups in a large-scale biobank’. The American Journal of Human Genetics 2023: volume 110, issue 10, pages 1,628–1,647. DOI: 10.1016/j.ajhg.2023.09.001

C. Demonstrates shared treatment decision making with the patient, incorporating multiple factors including renal function, hepatic function, patient comorbidities, the DPYD pharmacogenomic test result and others, to determine the appropriate fluoropyrimidine dose or alternative treatment. (P, S)

Associated learning:

UK Chemotherapy Board: Publications (see ‘Personalised Medicine Approach for Fluoropyrimidine-based Therapies’)

D. Recognises that absence of a toxicity-related variant does not preclude fluoropyrimidine based chemotherapy toxicity. (St, K)

Associated learning:

NHS England’s Genomics Education Programme: GeNotes: Dihydropyrimidine dehydrogenase (DPD) deficiency

E. Illustrates appropriate documentation/record of the DPYD pharmacogenomic test result in the patient’s healthcare record; for example, the electronic prescribing system and chemotherapy prescribing system. (P, S)

Associated learning:

Please refer to local protocols and guidelines

Workforce groups

STEP 5

Communicate the DPYD test result and the impact on treatment

Competencies

A. Can explain the patient’s DPYD test result and the implications of fluoropyrimidine-based chemotherapy treatment to the patient and/or caregiver. (P, S)

Associated learning:

Cancer Research UK: DPD deficiency
North West Genomic Medicine Service Alliance: DPYD patient information leaflet

B. Uses communication skills to discuss pharmacogenomic concepts and the potential risk of adverse drug reactions associated with genetic variants in the DPYD gene at a level appropriate for the patient. (P, S)

Associated learning:

Cancer Research UK: DPD deficiency
North West Genomic Medicine Service Alliance: DPYD patient information leaflet

C. Can recall a wide range of avenues of patient support, including patient information leaflets, online information and other healthcare professionals, and is able to communicate these to the patient. (G, K, S)

Associated learning:

Cancer Research UK: DPD deficiency
North West Genomic Medicine Service Alliance: DPYD patient information leaflet

Workforce groups

ALL STEPS

Common to all pathway steps

Competencies

A. Explains the fundamental principles of genomics. (G, K)

Associated learning:

NHS England’s Genomics Education Programme: Genomics 101: Genomics in Healthcare

B. Identifies where DPYD pharmacogenomic testing may be appropriate in a patient’s clinical pathway and recommend testing where appropriate. (G, K)

Associated learning:

Centre for Pharmacy Postgraduate Education (CPPE): Introduction to genomics in pharmacy (education specific to pharmacists and pharmacy technicians)
Centre for Pharmacy Postgraduate Education (CPPE): Genomics in pharmacy: an introduction to person-centred consultations (education specific to pharmacists and pharmacy technicians)
Gov.uk: Medicines and Healthcare products Regulatory Agency: 5-fluorouracil (intravenous), capecitabine, tegafur: DPD testing recommended before initiation to identify patients at increased risk of severe and fatal toxicity
NHS England’s Genomics Education Programme: GeNotes: Dihydropyrimidine dehydrogenase (DPD) deficiency
NHS England’s Genomics Education Programme: GeNotes: Introduction to pharmacogenomics
NHS England’s Genomics Education Programme: GeNotes: Presentation: Patient requiring fluoropyrimidine-based chemotherapy
University Hospital Southampton NHS Foundation Trust’s Medicines Learning Portal: Pharmacogenomics (open-access education targeted at pharmacy professionals)

C. Recognises the benefits and limitations of DPYD pharmacogenomic testing. (P, K)

Associated learning:

Centre for Pharmacy Postgraduate Education (CPPE): Genomics in pharmacy: an introduction to person-centred consultations (education specific to pharmacists and pharmacy technicians)
Centre for Pharmacy Postgraduate Education (CPPE): Introduction to genomics in pharmacy (education specific to pharmacists and pharmacy technicians)
Gov.uk: Medicines and Healthcare products Regulatory Agency: 5-fluorouracil (intravenous), capecitabine, tegafur: DPD testing recommended before initiation to identify patients at increased risk of severe and fatal toxicity
NHS England’s Genomics Education Programme: GeNotes: Introduction to pharmacogenomics
NHS England’s Genomics Education Programme: GeNotes: Presentation: Patient requiring fluoropyrimidine-based chemotherapy
NHS England’s Genomics Education Programme: GeNotes: Dihydropyrimidine dehydrogenase (DPD) deficiency
University Hospital Southampton NHS Foundation Trust’s Medicines Learning Portal: Pharmacogenomics (open-access education targeted at pharmacy professionals)

D. Recognises and acts within professional and/or role-specific boundaries and competencies, and understands when to seek multidisciplinary support or when to refer to relevant specialists for further advice. (G, A)

Associated learning:

Core training typically obtained as part of the professional skill set

E. Demonstrates how to access educational resources and clinical guidelines to support learning where relevant. (G, S)

Associated learning:

Core training typically obtained as part of the professional skill set

F. Applies the communication and counselling skills needed to engage and communicate effectively with patients, carers and other healthcare professionals. (G, S)

Associated learning:

Core training typically obtained as part of the professional skill set

G. Generates accurate, legible and appropriate clinical records. (G, S)

Associated learning:

Core training typically obtained as part of the professional skill set

Workforce groups

All roles and professions

CPI: DPYD

Identifying workforce development and education needs to support the DPYD clinical pathway in the oncology setting

Ratification group members

Key

STEP 1

Recognise that the patient requires fluoropyrimidine-based chemotherapy

Competencies

Associated learning:

Associated learning:

Workforce groups

STEP 2

Advise the patient and/or caregiver on DPYD testing

Competencies

Associated learning:

Associated learning:

Workforce groups

STEP 3

Request DPYD testing and collect a sample

Competencies

Associated learning:

Associated learning:

Associated learning:

Workforce groups

STEP 4

Apply the DPYD test result to treatment review and decision making

Competencies

Associated learning:

Associated learning:

Associated learning:

Associated learning:

Associated learning:

Workforce groups

STEP 5

Communicate the DPYD test result and the impact on treatment

Competencies

Associated learning:

Associated learning:

Associated learning:

Workforce groups

ALL STEPS

Common to all pathway steps

Competencies

Associated learning:

Associated learning:

Associated learning:

Associated learning:

Associated learning:

Associated learning:

Associated learning:

Workforce groups

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