Community Pharmacists Are Redefining Bispecific Antibody Care Beyond Academic Centers: Brooke Peters, PharmD, BCOP

Bispecific antibodies are rapidly reshaping the oncology treatment landscape, and community pharmacists are at the forefront of operationalizing these complex therapies outside of academic medical centers. At the recent Community Oncology Conference hosted by the Community Oncology Alliance, Brooke Peters, PharmD, BCOP, a clinical pharmacist at the American Oncology Network (AON), was a panelist for the session, “Strengthening the Community Pharmacist’s Involvement in Operational Workflows for BsAb Therapy,” offering practical insights on how community practices can successfully implement bispecific antibody programs.

As agents are increasingly studied in earlier lines of therapy and in combination regimens, the number of patients receiving bispecifics in community settings is expected to grow significantly. Peters discussed how pharmacists can lead the development of scalable workflows, toxicity management protocols, and formulary decision-making frameworks tailored to the unique resource constraints of community oncology. She spoke with The American Journal of Managed Care^® (AJMC^®) to explore the key clinical data driving these shifts and what community pharmacists need to know to stay ahead.

This interview has been lightly edited for clarity.

AJMC: From your perspective as a community oncology pharmacist, what has been the most clinically impactful data to emerge around bispecific antibodies, and how are they shifting expectations for patient outcomes outside of academic medical centers?

Peters: Data are emerging demonstrating that bispecific antibodies can be safely administered in the outpatient setting, without hospital observation. These data are particularly impactful for community oncology because they confirm that we can safely administer therapy for our patients in the community without requiring planned hospitalization. For community practices without a hospital affiliation, coordinating with a local hospital for the administration of and/or observation following step-up doses has been one of the greatest barriers to operationalization of bispecific antibodies. Although we are still responsible for ensuring patients have a hospital nearby equipped and trained to treat potential toxicities, we now have more confidence that we can manage the majority of toxicities at home or in the community clinic.

AJMC: How do you see these emerging approaches changing the way community oncology teams think about treatment sequencing, and what challenges does that create for pharmacists who need to stay ahead of those shifts?

Peters: Epcoritamab plus lenalidomide and rituximab is an FDA-approved combination for second-line and beyond treatment of follicular lymphoma. National Comprehensive Cancer Network guidance lists multiple bispecific combination regimens for both follicular lymphoma and diffuse large B-cell lymphoma as earlier-line options vs monotherapy. Bispecific monotherapy is also being studied in earlier-line settings. We expect to see more bispecifics utilized in earlier-line settings rather than reserved for third-line and beyond administration, based on meaningful efficacy improvements in clinical trials. This could result in an exponential increase in our volume of patients receiving bispecific antibodies, and therefore, pharmacists should be prepared to scale operations and can play an important role in ensuring that procedures/policies are scalable and broader staff are trained.

AJMC: What framework does AON use when evaluating whether a bispecific antibody is appropriate for formulary adoption across its network of community practices?

Peters: At AON, we consider first the clinical efficacy and safety of the drug. We look at the particular setting in which the drug is approved and consider alternatives. We ask, how do the efficacy and safety compare? If relatively equivalent from an efficacy/safety standpoint, is there a clinical or operational difference that would make this therapy better suited for a particular patient subgroup? This could include a different toxicity profile, different drug/disease interactions, less frequent dosing/shorter administration time, continuous vs definitive therapy, etc. Cost, reimbursement, and contract are also considered in formulary decisions.

AJMC: What operational workflow changes have you found most essential when implementing bispecific antibody therapy in the community setting, and where do you see pharmacists having the greatest opportunity to add value to the care team?

Peters: Pharmacists can, and should, contribute to policies and procedures for toxicity prevention and management with bispecific antibodies. This includes recognition and management of cytokine release syndrome (CRS) and immune effector cell–associated neurotoxicity syndrome and prophylactic medications for the prevention of CRS and infection. Pharmacist input in these protocols has become even more important as practices develop a fully outpatient approach without hospital observation. Community pharmacists, without the after-hours and weekend resources of an academic center, may need to be creative to develop appropriate monitoring plans for patients. To name a few strategies at AON, we have modified step-up schedules, crafted a specific office visit/registered nurse tele-evaluation schedule for each bispecific, created at-home monitoring logs for patients, and developed wristbands linking to toxicity management guidelines in case of an emergency department visit.

AJMC: What advice would you give to a community oncology pharmacist who is just beginning to build their institution’s approach to bispecific antibody therapy and wants to make a meaningful clinical and operational impact from day one?

Peters: Pharmacists should develop their institution’s approach according to their site’s available resources and provider comfort, but with the future in mind. Bispecifics are moving into outpatient with more and more data supporting safety with this approach, so new programs should aim to allow for this strategy. Bispecifics are also moving into earlier lines, and programs should be developed anticipating a growing patient volume, and therefore will require broad staff training and procedures that can accommodate large patient volume.