Jamile Shammo, MD, Ruben Mesa, MD, and Michael Reff, RPh, MBA, discuss having pharmacists on MPN care teams and the effect they have on patient compliance.
Bruce Feinberg, DO: Jamile, a lot of the points Michael was making have me thinking about the fact that there is an increasing trend toward including a pharmacist on care teams. I am curious if, in your program, you have a pharmacist on the care team or even potentially a pharmacist who is in the clinic environment, meets with the team on a regular basis, or works in the hospital with rounds. Is that the case?
Jamile M. Shammo, MD: Yes, we [at Rush University Medical Center] have a pharmacist on the hospital rounds, and we have 1 on the outpatient side. They meet with patients—let’s say on the outpatient side—they meet with them once the drug is approved, and they go over the adverse-effect profile and everything else. That would not tackle the issue of compliance, and that is the biggest problem. Even though you may educate the patient on how to take the drug and how important it is to be compliant, you will often find that to be the issue. You may often suspect it, but the problem is that the patient may sometimes not even admit to the fact that they have stopped taking their medication. In that sense, having a program that may sort out the reasons or the causes behind not taking the medication—the cost, the symptoms, or what have you—is extremely important. I have always said—and maybe this is my quote—is this: If we had the pill for noncompliance, that would be awesome, but maybe it would not work anyway.
Bruce Feinberg, DO: Ruben, is there a pharmacist on the team? Are compliance and adherence issues?
Ruben Mesa, MD: We [at The University of Texas San Antonio MD Anderson Cancer Center] definitely have an outpatient clinical pharmacist, exactly as Jamile stated, both for when the patient is getting a new medication but also seeing everything else that they are on and being a resource in that setting. With the number of medications that people are on with your standard physician—and I certainly include myself in that group—it is simply impossible to keep track of potential interactions between medications as they are evolving. The expertise that the pharmacist brings to the table is crucial.
The compliance issue is interesting in MPNs [myeloproliferative neoplasms] in particular with the advent of the JAK inhibitors. Jamile and I both have had practices where we have cared for a lot of patients with chronic myeloid leukemia where we had incredible efficacious therapies, but in general, they did not make people feel better. They were treating a terrible disease, and they put the disease in remission, but they had adverse effects. There were issues with compliance despite the fact that they were almost miraculous in terms of their level of efficacy.
In MPNs, we have therapies that are clearly active, and they definitely improve how patients feel. That positive benefit in terms of symptoms has increased compliance much more than almost anything else we could do, because if the patient did not take the medicine, they then felt worse.
Bruce Feinberg, DO: Let me pause you there. What are the symptoms that are getting better with treatment? Let’s rehash them.
Ruben Mesa, MD: Fatigue, night sweats, weight loss, bone pain, and itching. Those are some of the main ones, but missing doses of medication will potentially make any of those aggravated.
Bruce Feinberg, DO: We are not talking about baby aspirin making that change; we are talking about Hydrea [hydroxyurea] making that change, or is it not until we get to a JAK inhibitor that we get that benefit?
Ruben Mesa, MD: A JAK inhibitor has a dramatically more impactful effect than the others, but there can be areas of symptomatic improvement with the aspirin, particularly with erythromelalgia or painful skin manifestations that can sometimes be responsive to aspirin. There are symptoms related to high blood counts that benefit from either phlebotomy or Hydrea [hydroxyurea], so patients will sometimes text me to say, “I feel like I need a phlebotomy” because they are having headaches or migraine and difficulties concentrating. Most of the time, they are correct. The biofeedback even with thrombocytosis can sometimes be surprisingly active.
I care for many physicians who have ET [essential thrombocythemia] or PV [polycythemia vera], and they will tell me, “Before I had the disease, if patients told me that that they knew what their platelet counts were, I thought that they were making it up. Now that I have the disease, I realize that they were correct. I can tell that my platelets are up and that I need an adjustment for my medicine because I am having some visual changes. I am having some migraines, and if I read an article, I start to get a headache.” They can be quite well dialed in in terms of their symptoms.
Bruce Feinberg, DO: Jamile, I see you shaking your head exactly like that.
Jamile M. Shammo, MD: Just yesterday, I had a patient who had a whole slew of symptoms. She said, “I know that I am supposed to have a CBC [complete blood count] next week, but all the symptoms that I had before I had my phlebotomy came back.” I said, “There is only 1 way to know: Get your CBC.” Sure enough, she had a hematocrit level of 46.7%, to be exact. So I said, “Get your phlebotomy.” It is true for patients who are in tune with their bodies. I could not agree more: We have to listen to what the patients say.
Bruce Feinberg, DO: Michael did you have a comment?
Michael Reff, RPh, MBA: I was going to say that this is the importance of what we are talking about. That is right, and others have talked about educating the staff. When getting the staff as well as patients educated and then developing an adherence program particular to those products or those disease states, you could see how the random generic questions are not as helpful or robust as they could be for this disease state. Developing a buffet of questions around this particular disease state or product could help the medically integrated oncology team—in this case, to better care for their patients by asking more focused or thoughtful questions to the patients, whether they are in front of you on-site or virtually through telehealth. It can help the care team know how well the patient is being adherent to their medication.
Bruce Feinberg, DO: It is valuable. One of the things I think about is some of the unintended damage of things like meaningful use criteria. You have to ask 7 systems in order to be able to get payment for your visit where all the symptoms of the patient’s disease were in 1 system, and you needed to ask 10 questions about the 1 system, not 7 questions about 7 systems. What we are hearing about in terms of that quality is that, hopefully, there will be a movement from OCM [Oncology Care Model] to OCF [Oncology Care First], and there will be disease-specific and treatment-specific evaluations of patients and not these generic “check all the boxes” questions. I thought that was helpful.
That was a good conversation there about the need for specificity around this. It is not just for MPN, but MPN has an interesting constellation of symptoms that are unique, and they are not seen in other patients you would see in a typical hematology-oncology office.
Transcript edited for clarity.