A Review of the Treatment for Multiple Myeloma - Episode 27
John Fox, MD, MHA: I’m going to give you a scenario. There are 8 preferred regimens in the NCCN [National Comprehensive Cancer Network] for relapsed/refractory patients. Six of them are category 1. All but 1 of them are triple combination therapy.
There’s 1 that’s all oral—the ixazomib, lenalidomide, dexamethasone—and 1 that—daratumumab, bortezomib, plus the dexamethasone—is all IV [intravenous] or subQ [subcutaneous] injection. One of those, the all oral therapy, could cost a patient $3000 to $4000 a month when they’ve blown through their donut hole. Now they have a 5% catastrophic coverage, because oral drugs are covered under Medicare Part D. So they could have $3000 to $4,000 in out-of-pocket costs a month.
On the IV or subQ injection side, they could finish their out-of-pocket costs very quickly, especially in the Medicare Advantage plan, and have no cost because they’ve met their out-of-pocket maximum. Does that situation ever influence what your preferred regimen is in treating your patients who have relapsed/refractory disease?
Sundar Jagannath, MD: That’s a very good question. Usually the patients bring that forward, because we come up with a treatment option and you put a plan into place, but the patient doesn’t know, and the physician doesn’t know the out-of-pocket costs. They listen to you. You think you are creating a good program, and they go. Then afterward, you start getting phone calls back. You know?
John Fox, MD, MHA: Right. But do you even present those options?
Sundar Jagannath, MD: Or the patient comes, so then we change.
John Fox, MD, MHA: Yes. Do you present those options to patients and say, we’ve got all IV or subQ versus an all oral?
Sundar Jagannath, MD: We do present the option because, as I said, some patients—such as an older patient—cannot travel back and forth. Coming into Mount Sinai, even if they are in Queens, New York, for an 80-year-old person, they are dependent on somebody else also coming and things like that.
John Fox, MD, MHA: Right.
Sundar Jagannath, MD: They can’t just pick up an Uber service and come every time because that adds to the financial toxicity too. Some other patients have to have a family member, a son or a daughter has to take up responsibility. So you do discuss all oral regimens, IV regimens, and things like that.
John Fox, MD, MHA: But are you incorporating cost in those discussions? And if you’re not, should you?
Sundar Jagannath, MD: That’s a good question, because to be honest with you, I really do not know the financial toxicity that’s going to happen to that patient per se. We discuss the convenience, and the toxicity, and what they prefer. When they go back home and the others put on, then I get a phone call.
John Fox, MD, MHA: Then you get a phone call, right.
Sundar Jagannath, MD: Then immediately you respond to it. So yes, we do address it, because this is the real world and these are real patients, and I’m here to care for the patient, no matter what the circumstances are.
John Fox, MD, MHA: We’re blessed because we have a plethora of treatments now for the relapsed/refractory setting, but they have their clinical benefits and their clinical and financial toxicities. I think especially now because of those financial toxicities, because of these combination therapies given over many years, is it incumbent upon us to make sure that we ask those questions upfront rather than prescribing a therapy that the patient can’t take because of those? It’s a fair question, and I think in the OCM model, Oncology Care Model, physicians are required as part of their care plan to discuss those financial toxicities to help ensure that before we ever start therapy, that we know the patient can take it.
Ola Landgren, MD, PhD: These are great perspectives and I agree with that, but I think from a treatment perspective, being in a basic clinic, the patient is sick, and you need to make decisions. You have more patients waiting, and you have to do the best.
John Fox, MD, MHA: That doesn’t mean the physician has to do it. But are we doing the best thing for our patients if we’re not asking those questions?
Ola Landgren, MD, PhD: What I was about to say is that the physician should make the decision early on. Because if the physician makes the decision, even if other people jump in later, I think it’s too late. When the decision is made, or when the different options are presented, if you don’t have that information, everything appears equal when in reality, it may not be equal. I think this is a big problem in real time in the clinic.
John Fox, MD, MHA: Sure.
Ola Landgren, MD, PhD: The patient doesn’t know what his or her co-pay will be, and the doctor doesn’t know, and you strictly look at the data, you look at the different options, and then you make a decision on that. You maybe would have made another decision if you had the other piece, but it’s just not there.
John Fox, MD, MHA: We won’t come to a consensus on this, but I would say that if you didn’t have a critical piece of laboratory data in order to make a treatment decision, you’ll get that. I think in the future, we need to consider that as a critical piece of data in making a treatment recommendation to patients, if we want to ensure that they get the optimal outcome. We need to make sure that the patient doesn’t stop at 9 months because they can no longer afford the drug, and they’re afraid to tell you that they can’t afford it.
Sundar Jagannath, MD: My pushback to that is if I give blood, I get fixed lab data. But on the other side, I don’t have a Web page or a listing that says, “This is the patient,” since they’re all registered upfront. Right? So they’re taking the insurance. But I don’t have a computer program or an app that says, “This is a patient,” and you type in carfilzomib, pomalidomide, dexamethasone. This would be the patient’s cost….
John Fox, MD, MHA: It’s coming. Just like new drugs are coming, that would be available to you. So I think this is a whole new age in terms of not only the options that are available but trying to understand how to get the transparency for a patient.
Ola Landgren, MD, PhD: I think it sounds very good.
John Fox, MD, MHA: Transparency and cost.
Ola Landgren, MD, PhD: I think it’s the right way to do it.