Advances and Best Practices in the Utilization of Novel Agents in Metastatic Breast Cancer - Episode 7
Joyce O’Shaughnessy, MD: The issue of adherence is one that I just keep thinking about because we don’t have a way to track patients who leave our practice. If somebody doesn’t show up for their appointment, they get a phone call. They get rescheduled if they answer their phone. We make a few attempts, but then we lose track of them altogether. I would imagine that this would be something that could be improved, not necessarily completely overcome, of course, but improved with a team that can follow the patient and see what the issue is. If there was somebody who could take the time to ask them what’s really going on—maybe it is access to medications, financial issues, etcetera—they could try to help them with resources. That would be incredible.
Michael Reff, RPh, MBA: There is a lot of opportunity in adherence. Any time folks talk about oral oncolytics, adherence is right there. It’s almost the next thing that we want to talk about. One of the quality standards addresses adherence and trying to improve it from a medically integrated team perspective. We share best practices across the NCODA [National Community Oncology Dispensing Association] network on how to do that better or how to elevate our gains individually to help improve adherence, whether it’s financial toxicities and sourcing funds to keep patients on therapy or whether it’s how to enact a callback schedule so that we can document that.
And so, one of the best practices that we share may seem obvious, but again, we’re all very busy when we’re at our practice. That’s why it’s called “best sharing of best practices.” Somebody came up with an idea. It may not necessarily be rocket science, but it’s still a best practice. People become aware of it, and implement it, and see the benefits for the patients.
Some molecules and the CDK4/6 [cyclin-dependent kinases 4 and 6] inhibitors have unique adverse effect profiles. Instead of always having a callback on day 7—let’s say diarrhea will happen within a certain timeframe—maybe you move day 7 to day 4. Or if neutropenia happens on day 14, maybe you don’t do a call on day 7 and then monthly after. Maybe you do it on day 13, to remind them to come in and to make sure that they schedule their appointment. So those are some of the things that you don’t just script out. It’s always a callback on day 7 and then 30 days after.
You create these callback schedules and then document them with an EMR [electronic medical record] so that the prescribers and the whole team are aware of that, based on the molecule or oral oncolytic that was prescribed. And also, in some cases, we document notes on the patient. Maybe there are some language issues and you’re wondering if they are going to be adherent or not. Do they fully understand and grasp the concept? Or maybe there are some cognitive issues that you’re unsure of. Maybe there are some caregiver issues that you want to make sure are addressed. And so, you should adjust your callback schedules based on the individual patient and the oral oncolytic that they’re prescribed.
Joyce O’Shaughnessy, MD: I was just thinking about the insurer. Often, the patient will get a call from a nurse or an insurance company person whose job is to try to help the patient. They work to keep them away from serious toxicities, etcetera. But things get very scattered, or a bit decentralized. Do you know what I mean? Everybody means well, but it’s much more effective to have it all within the same practice, where communication is a great deal easier.
Michael Reff, RPh, MBA: Absolutely, and critical. It’s more critical.
Joyce O’Shaughnessy, MD: Yes. I think the EMR is the central thing that you’ve got to have available to really know what’s going on with the patient. It’s necessary to doing the job of keeping them out of trouble and on track to benefit. New drugs are coming in, etcetera. There are so many examples of this. We’re kind of at the tip of the iceberg here. What’s the future? It seems like this has been evolving pretty rapidly over the last few years. Do you think this is going to be the new way of doing business going forward here?
Michael Reff, RPh, MBA: As you’re probably well aware of, especially in the breast cancer space, there are more options available every day. There are more and more indications with already approved compounds or oral oncolytics. And then there are new therapies coming into the market all the time. Oral therapies continue to become more prevalent. In fact, there are studies that show a large percentage of the molecules within research or discovery are in the oral space. So there are a lot now, and there are more coming.
As an oncologist and practitioner within an oncology practice, embracing the oral space is critical. It’s absolutely important for better patient care, but all of the other benefits of having a team devoted toward the oral space is….
Joyce O’Shaughnessy, MD: Increasing.
Michael Reff, RPh, MBA: Yes.
Joyce O’Shaughnessy, MD: I was thinking about the new data that came out with alpelisib, which is the first of our hopefully-to-be-approved by the FDA options with an alpha-specific inhibitor of PI3 kinase. Around 40% of breast cancers have a PI3K mutation. Of course, it has its own set of toxicities. Importantly, it’ll increasingly be put into combination regimens. Or the CDK4/6 inhibitors with the mTOR inhibitor, everolimus, for example. So now you’ve got multiple oncolytics of different ratios and different toxicity profiles. It’s going to become increasingly great for managing cancers, but that much more critical in terms of drug-drug interactions, dosing, adverse effects, etcetera.
Michael Reff, RPh, MBA: Absolutely.