Immunotherapy in the Oncology Care Model - Episode 8
Bruce Feinberg, DO: Rich, you’re in the world of melanoma, and basically, chemotherapy has disappeared from your world for the most part.
Richard D. Carvajal, MD: I use it very, very rarely.
Bruce Feinberg, DO: Right. You’ve got targeted therapy, you’ve got IO [immuno-oncology] therapy, and in some cases you have options to use both. You have a population of patients who are BRAF mutated, for which there is evidence for both types of therapy. Could you perceive a situation in which a practitioner in a community in the OCM [Oncology Care Model] might feel that they can’t just make a choice based on what they believe to be the better option, especially when the short-term data points are similar, but we have evidence that long-term data points may not be?
Richard D. Carvajal, MD: Yeah. I hope practitioners do not feel that pressure. I can say that, certainly at my institution and for the other kinds of folks in the academic melanoma space, there is constant debate as far as should you do targeted versus immunotherapy up front, given the lack of long-term data. But no one feels a financial pressure to pick 1 versus another, and rather we’re definitely selecting therapies that we think are best for the patient. In the community, that is something I can’t say. I don’t know if there are different financial pressures there, but I would hope that’s not the case.
Bruce Feinberg, DO: It’s got to be something that comes up at COA [Community Oncology Alliance] meetings.
Ted Okon, MBA: Absolutely. Recently, at our conference a couple weeks ago, we had a big review. In fact, Kavita led that, in terms of the OCM 1., and what we’re working on in the OCM 2.0. We actually had a group of practices in a closed-door meeting talking about some of these issues, in terms of the risk base of it. I have to tell you, I have not heard anybody say, “Oh, I’m pressured to use an inferior drug” versus—in this case we’re talking about an IO drug—chemotherapy versus an IO drug. I haven’t heard that at all. But what’s interesting is when you’re making the decision now of going at risk, and you realize that this model has a basic problem in terms of price prediction. I have example after example right here of problems in that area. Now you’re talking about a 2-sided risk. You’re talking about rolling the dice and putting your practice on the line. You just can’t do that, because you don’t want to be in a situation as a physician where you’ve got to make that decision—literally, based on your practice survival—that you have to use an inferior drug. So what do you do? You drop out, you don’t, you don’t go to 2-sided risk.
Richard D. Carvajal, MD: It’s really challenging, especially if we’re talking about combination immunotherapy where if we do that, you know half the patients will end up in the emergency department. A third of those are going to end up admitted for toxicity. So there are clearly added costs of doing some of these aggressive regimens. We certainly take into account, from a patient perspective, the toxicities and managing that, but from a financial perspective…
Bruce Feinberg, DO: Well, you’d hope that we could figure it out with IO. If we have to start dealing with gene therapy and cellular therapy, and we think IO is problematic—in terms of the cost profile and that long-term perspective—it gets insane when we start thinking about therapies that could be curative and represent decades of life extension, depending on the population in the study. So it’s pretty interesting.
Susan, I always struggle from the patient advocacy perspective how do you get shared decision making with the complexity of information of this nature?
Susan Ash-Lee, MSW, LCSW: That’s right. I’m glad you asked that, because there are 2 real positive opportunities with the OCM, and 1 is the transparency in explaining to folks early and often what their financial impact of care is going to be. Simultaneously, there’s a care plan that is to be really transparent: “What is my diagnosis? What does that even mean?” This puts things into real words, so that real human beings understand what we are talking about.
I think that when done right, from a patient advocate perspective, patients are more clear on what’s happening to them, which means that they ask better questions and engage much differently. If you do not understand what it means to be treatable but not curable, which is the language we use in oncology, you don’t even know follow-up questions. “What does that mean for me?” You may hear that question, and it might get answered very differently. If you don’t understand what the Medicare Part D drugs are going to mean for you and what that might mean when you’re on a fixed income, you may make very different decisions based on just understanding that financial impact.
The practices that have really transformed their culture are translating that clinical information into a language that patients can understand. They’re often doing that with the team members who are better at that. These are your translators on the team, the advance practice providers, the nurses and the social workers, and the specialized financial counselors who can understand the clinical and the financial piece and be able to track patients over time. They can also flag those folks when the cost of care is getting extraordinarily tough.
Bruce Feinberg, DO: I’m curious about the perspective from the patient advocacy community regarding direct-to-consumer marketing. Is it an asset that brings them information that they need? Or is it complicating things because it invades their provider-patient relationship by injecting another party into that conversation that’s not really at the table per se at the time? They’re there, and they’re the manufacturer or the innovator of the drug. How does the community weigh in on direct-to-consumer marketing?
Susan Ash-Lee, MSW, LCSW: As you know, we’re all watching TV, and we see those really thrilling drugs that are still allowing us to play tennis. And so yes, obviously the community has an impact.
Bruce Feinberg, DO: It’s like the allogenic, right? How does it go again with the violin?
Susan Ash-Lee, MSW, LCSW: I never played violin before, but now I can because of this drug.
Bruce Feinberg, DO: Right. I blew that one. That would have been so good.
Susan Ash-Lee, MSW, LCSW: Yeah.
Bruce Feinberg, DO: All right.
Susan Ash-Lee, MSW, LCSW: But we know that folks are online and consulting “Dr Google” every day. If you’re in the oncology world, you have to be prepared that folks are reading things, but that doesn’t mean that they’re reading the right thing or reading anything about them. I think that oncology practices and oncologists in particular should be prepared during those initial consults to be able to answer questions from WebMD and able to level set—here’s what you’re looking at, which might be different from all the people in your support group, on the discussion boards, or whatever else has come into your in-box.