Introduction: Malignant hematological neoplasms are characterized by substantial therapeutic complexity, prolonged treatment, and a considerable risk of drug-related problems. These characteristics create a clear rationale for the active involvement of hospital pharmacists in monitoring pharmacotherapy and providing clinical pharmacy services.
Aim: To analyze the dynamics and structure of mortality from malignant hematological neoplasms in Bulgaria during the period 2019–2025 and to discuss the implications of the observed national mortality pattern for the development of clinical pharmacy services and pharmaceutical care in clinical hematology.
Materials and Methods: A secondary analysis was conducted using official mortality data provided by the National Statistical Institute, stratified by cause of death, sex, and age group. Malignant hematological diseases were represented as an analytical aggregate of ICD-10 categories C81–C86, C88, C90, C91–C95, and C96. Annual mortality rates, sex-related differences, distribution by diagnostic group, and the relative contribution of hematological malignancies to overall cancer mortality were analyzed. The findings were interpreted in the context of published evidence on clinical pharmacy interventions in patients with hematological neoplasms. Categories D45–D47 were excluded because, under ICD-10, they are classified as neoplasms of uncertain or unknown behavior rather than malignant neoplasms.
Results: The overall mortality rate ranged from 10.3 to 13.2 per 100,000 population and reached 13.2/100,000 in 2025. Malignant hematological neoplasms accounted for 4.98% of overall cancer mortality in 2025. Leukemias remained the leading component, while mortality was consistently higher among men. Published evidence indicates that clinical pharmacy services have the potential to reduce drug-related problems, improve medication safety, and support adherence to therapy in this patient population.
Conclusion: The absence of a sustained decline in mortality, together with the increasing complexity of contemporary pharmacotherapy in clinical hematology, supports the development of specialized and structured clinical pharmacy services. As a member of the multidisciplinary team, the hospital pharmacist can contribute through medication review, assessment of drug interactions, safety monitoring, adherence support, patient counseling, and participation in multidisciplinary decision-making. Systematic documentation and evaluation of these activities would allow their contribution to the quality, safety, and continuity of pharmaceutical services and patient care to be assessed.
Maleki S, Alexander M, Fua T, Liu C, Rischin D, Lingaratnam S. A systematic review of the impact of outpatient clinical pharmacy services on medication-related outcomes in patients receiving anticancer therapies. J Oncol Pharm Pract. 2019;25(1):130-9. doi:10.1177/1078155218783814.
Tan BK, Chua SS, Chen LC, Chang KM, Balashanker S, Bee PC. Acceptability of pharmacist-led interventions to resolve drug-related problems in patients with chronic myeloid leukaemia. J Oncol Pharm Pract. 2021;27(7):1644-56. doi:10.1177/1078155220964539.
Curry MA, Chineke I, Redelico T, Terrell C, Bell W, Flood D, et al. Adherence to oral anticancer medications after implementation of an ambulatory adherence program at a large urban academic hospital. JCO Oncol Pract. 2020;16(4):e350-6. doi:10.1200/JOP.19.00167.
Paolella GA, Boyd AD, Wirth SM, Cuellar S, Venepalli NK, Crawford SY. Adherence to oral anticancer medications: evolving interprofessional roles and pharmacist workforce considerations. Pharmacy (Basel). 2018;6(1):23. doi:10.3390/pharmacy6010023.
Zhou D, Zhu X, Xiao Y. CAR-T cell combination therapies in hematologic malignancies. Exp Hematol Oncol. 2024;13:69. doi:10.1186/s40164-024-00536-0.
Okoro RN, Nduaguba SO. Community pharmacists on the frontline in the chronic disease management: the need for primary healthcare policy reforms in low and middle income countries. Explor Res Clin Soc Pharm. 2021;2:100011. doi:10.1016/j.rcsop.2021.100011.
Albayrak A, Özbalcı D. Determination of drug-related problems in the hematology service: a prospective interventional study. BMC Cancer. 2024;24:552. doi:10.1186/s12885-024-12291-w.
Farias TF, Aguiar KDS, Rotta I, Belletti KMDS, Carlotto J. Implementing a clinical pharmacy service in hematology. Einstein (Sao Paulo). 2016;14(3):384-90. doi:10.1590/S1679-45082016AO3667.
Escudero-Vilaplana V, Ribed A, Romero-Jimenez RM, Herranz-Alonso A, Sanjurjo-Saez M. Pharmacotherapy follow-up of key points in the safety of oral antineoplastic agents. Eur J Cancer Care (Engl). 2017;26(3):e12463. doi:10.1111/ecc.12463.
Valgus J, Jarr S, Schwartz R, Rice M, Bernard SA. Pharmacist-led, interdisciplinary model for delivery of supportive care in the ambulatory cancer clinic setting. J Oncol Pract. 2010;6(6):e1-4. doi:10.1200/JOP.2010.000033.
Sweiss K, Calip GS, Wirth S, Rondelli D, Patel P. Polypharmacy and potentially inappropriate medication use is highly prevalent in multiple myeloma patients and is improved by a collaborative physician-pharmacist clinic. J Oncol Pharm Pract. 2020;26(3):536-42. doi:10.1177/1078155219851550.
Zerbit J, Kroemer M, Fuchs B, Detroit M, Decroocq J, Vignon M, et al. Pharmaceutical cancer care for haematology patients on oral anticancer drugs: findings from an economic, clinical and organisational analysis. Eur J Cancer Care (Engl). 2022;31(6):e13753. doi:10.1111/ecc.13753.
Acheampong F, Anto BP. Perceived barriers to pharmacist engagement in adverse drug event prevention activities in Ghana using semi-structured interview. BMC Health Serv Res. 2015;15:361. doi:10.1186/s12913-015-1031-9.
Lopez-Martin C, Garrido Siles M, Alcaide-Garcia J, Faus Felipe V. Role of clinical pharmacists to prevent drug interactions in cancer outpatients: a single-centre experience. Int J Clin Pharm. 2014;36(6):1251-9. doi:10.1007/s11096-014-0029-4.
Battis B, Clifford L, Huq M, Pejoro E, Mambourg S. The impacts of a pharmacist-managed outpatient clinic and chemotherapy-directed electronic order sets for monitoring oral chemotherapy. J Oncol Pharm Pract. 2017;23(8):582-90. doi:10.1177/1078155216672314.
European Association of Hospital Pharmacists. The European Statements of Hospital Pharmacy. Eur J Hosp Pharm. 2014;21(5):256-8. doi:10.1136/ejhpharm-2014-000526.
Mohamed A, Salman B, Al Maskari R, Al-Farsi K, Yassin MA. Pharmacist-led interventions in hematological malignancies: a systematic review of clinical, process and economic outcomes. Front Pharmacol. 2026;17:1779201. doi:10.3389/fphar.2026.1779201.
World Health Organization. ICD-10 Version:2019 [Internet]. 2019 [cited 2026 Aug 13]. Available from: https://icd.who.int/browse10/2019/en#/II.
National Statistical Institute. Умирания по причини и смъртност по причини [Internet]. [cited 2026 Aug 13]. Available from: https://www.nsi.bg/statistical-data/234.
National Statistical Institute. Смъртност по причини по пол и възрастови групи, 2020-2025 година [Internet]. [cited 2026 Aug 13]. Available from: https://www.nsi.bg/infostat/1830.
National Statistical Institute. Смъртност по причини по пол и възрастови групи, 2005-2019 година [Internet]. [cited 2026 Aug 13]. Available from: https://www.nsi.bg/infostat/593.
Неева А, Григоров Е, Салчев П. Възможности и предизвикателства при внедряването на 11 ревизия на Международната класификация на болестите в България. Обща медицина. 2025;27(3):28-36.
World Health Organization. ICD-11 [Internet]. 2022 [cited 2026 Sep 7]. Available from: https://icd.who.int/en/.
Muluneh B, Schneider M, Faso A, Amerine L, Daniels R, Crisp B, et al. Improved adherence rates and clinical outcomes of an integrated, closed-loop, pharmacist-led oral chemotherapy management program. J Oncol Pract. 2018;14(6):e324-34. doi:10.1200/JOP.17.00039.
Xiang HW, Shen YY, Wang JX, Zhao Y, Yi BW, Zhao N. Impact of pharmacist-led interventions on oncology drug therapy outcomes: a systematic review and meta-analysis. Int J Pharm Pract. 2026;34(2):117-29. doi:10.1093/ijpp/riaf098.
Virani A, Schlei Z, Gleason C, Ackermann M, Wolfe B, Major S, et al. Impact of an oncology clinical pharmacist specialist in an outpatient multiple myeloma clinic. Clin Lymphoma Myeloma Leuk. 2020;20(9):e543-6. doi:10.1016/j.clml.2020.04.012.
Tibensky B, Hutton L, Wentzell J, LeBlanc M, Edwards S, McFarlane T. Clinical pharmacy services in ambulatory oncology: an environmental scan of the Canadian practice landscape. Can J Hosp Pharm. 2022;75(4):259-66. doi:10.4212/cjhp.3208.
Shawahna R. Development of key performance indicators to capture in measuring the impact of pharmacists in caring for patients with epilepsy in primary healthcare: a Delphi consensual study. Epilepsy Behav. 2019;98(Pt A):129-38. doi:10.1016/j.yebeh.2019.07.034.
Shah S, Dowell J, Greene S. Evaluation of clinical pharmacy services in a hematology/oncology outpatient setting. Ann Pharmacother. 2006;40(9):1527-33. doi:10.1345/aph.1H162.
Read H, Ladds S, Rhodes B, Brown D, Portlock J. The impact of a supplementary medication review and counselling service within the oncology outpatient setting. Br J Cancer. 2007;96(5):744-51. doi:10.1038/sj.bjc.6603634.
Zerbit J, Chevret S, Bernard S, Kroemer M, Ablard C, Harel S, et al. Improved time to treatment failure and survival in ibrutinib-treated malignancies with a pharmaceutical care program: an observational cohort study. Ann Hematol. 2020;99(7):1615-25. doi:10.1007/s00277-020-04045-y.
Wind LS, Knight TG, Auten JJ, Bates JS, Marucci L, Creedle CJ, et al. Evaluation and optimization of a clinical pharmacist driven transitions of care model for malignant hematology. J Oncol Pharm Pract. 2021;27(2):283-7. doi:10.1177/1078155220916516.
Zanetti MOB, Rodrigues JPV, Varallo FR, Cunha RLG, Simões BP, Pereira LRL. Impact of the insertion of the clinical pharmacist in the Allogeneic Hematopoietic Stem Cells Transplantation team. J Oncol Pharm Pract. 2023;29(2):375-85. doi:10.1177/10781552211073797.
Colombo LRP, Aguiar PM, Lima TM, Storpirtis S. The effects of pharmacist interventions on adult outpatients with cancer: a systematic review. J Clin Pharm Ther. 2017;42(4):414-24. doi:10.1111/jcpt.12562.
De Grégori J, Pistre P, Boutet M, Porcher L, Devaux M, Pernot C, et al. Clinical and economic impact of pharmacist interventions in an ambulatory hematology-oncology department. J Oncol Pharm Pract. 2020;26(5):1172-9. doi:10.1177/1078155220915763.
Davenport L, Tadros M, Sagheer TA, Roy S, Rubens M, Morales AR, et al. Clinical role of oncology pharmacy specialists in oral oncolytic management in the outpatient hematology clinic setting. J Hematol Oncol Pharm. 2023;13(5):264-9.
Krikorian S, Pories S, Tataronis G, Caughey T, Chervinsky K, Lotz M, et al. Adherence to oral chemotherapy: challenges and opportunities. J Oncol Pharm Pract. 2019;25(7):1590-8. doi:10.1177/1078155218800384.
Chun DS, Faso A, Muss HB, Sanoff HK, Valgus J, Lund JL. Oncology pharmacist-led medication reconciliation among cancer patients initiating chemotherapy. J Oncol Pharm Pract. 2020;26(5):1156-63. doi:10.1177/1078155219892066.
Heffner C, Dillaman M, Hill J. Pharmacist-driven medication reconciliation reduces oral oncolytic medication errors during transitions of care. Am J Health Syst Pharm. 2020;77(Suppl 4):S100-4. doi:10.1093/ajhp/zxaa168.
Debenito JM, Billups SJ, Tran TS, Price LC. Impact of a clinical pharmacy anemia management service on adherence to monitoring guidelines, clinical outcomes, and medication utilization. J Manag Care Spec Pharm. 2014;20(7):715-20. doi:10.18553/jmcp.2014.20.7.715.
Delpeuch A, Leveque D, Gourieux B, Herbrecht R. Impact of clinical pharmacy services in a hematology/oncology inpatient setting. Anticancer Res. 2015;35(1):457-60.
Fentie AM, Huluka SA, Gebremariam GT, Gebretekle GB, Abebe E, Fenta TG. Impact of pharmacist-led interventions on medication-related problems among patients treated for cancer: a systematic review and meta-analysis of randomized control trials. Res Social Adm Pharm. 2024;20(5):487-97. doi:10.1016/j.sapharm.2024.02.006.
Bulgarian Pharmaceutical Union. Правила за добра фармацевтична практика [Internet]. 2020 [cited 2026 Sep 6]. Available from: https://bphu.bg/upload/files/Pravila_Good%20Pharmacy%20Practice-VERSION%E2%80%932020.pdf.
Email this article (Login required) 
