John L. Fox, MD: There is a lot of value in consulting with oncologists, including gynecologic oncologists, on how we manage drugs used to treat ovarian cancer. But to some extent, that depends on how we decide to provide access to those drugs. For example, if we decide to provide open access to those therapies, there’s not a lot of advantage in consulting with those physicians. On the other hand, if we’re trying to evaluate whether or not we should prefer one therapy over another, there are several things that we need to consider. First would be the efficacy, and we have pretty good data on the efficacy, but the toxicities of the therapies are a little more difficult to assess.
For example, in first-line ovarian cancer, physicians typically choose carboplatin over cisplatin because it has lower toxicity. They typically choose paclitaxel over docetaxel, simply because it has less myelosuppression. But paclitaxel also causes neuropathy, so that has to be weighed. Understanding the nuances from the physician's perspective is very important. Likewise, with the new PARP inhibitors, those have their toxicities, including nausea and vomiting, dysgeusia, and some myelosuppression. So, understanding the relative impact of those toxicities on drug choice is an important factor and one of the things we would want to talk to the oncologists about. But it’s also important for them, as they consider which therapies to cover, to talk about what the relative costs of those therapies are. If all things are equal, including the efficacy and the safety, they need to understand what the costs are to help inform their decisions as well.
In addition, some therapies are IV and some are oral, and different physicians have different preferences about which they think is going to be the most effective in a given patient. So, for us as a health plan, we’d like to consult the oncologists early during the process before we ever take things to the P&T (Pharmacy and Therapeutics) committee, so that we can get their insight on which factors are going to be most impactful in their decision making. Who do we use? It depends on the expertise that we have locally. We’re an integrated delivery system, so we tend to use the physicians who are available, but we’ll use anybody who we think has the expertise to help make us a better-informed decision than we would without their input.
The other reason to consult specialists is the changing reimbursement models. For example, the oncology care model from CMMI (Center for Medicare and Medicaid Innovation) puts physicians at greater risk for the total cost of care for patients. Currently, in that model, there’s just upside gainsharing if the providers reduce the costs. So, providers really need to critically evaluate not only the efficacy, the safety, and the associated toxicities, but also the cost of therapy.