Pharmacists Help Navigate Precision Lung Cancer Care: Stefanie Houseknecht, PharmD

At the Washington, DC, Institute for Value-Based Medicine® (IVBM) event, panelists discussed the operational and clinical considerations for integrating targeted therapies into lung cancer treatment plans.

Communication from patients and physician advocacy work together to overcome cost and symptom barriers patients may face, Stefanie Houseknecht, PharmD, a panelist at the IVBM and clinical pharmacy specialist at Johns Hopkins Hospital, explained in an interview with The American Journal of Managed Care^® (AJMC^®).

In this Q&A, Houseknecht unpacks the importance of patient education, how to reduce financial barriers, and how to streamline precision lung cancer care, including for non-small cell lung cancer.

This transcript was lightly edited for clarity.

AJMC: Many newer lung cancer therapies require patients to remain on treatment for months or even years. What have you learned about supporting long-term adherence and managing cumulative toxicities that may not become apparent early in treatment?

Houseknecht: This is a really important question because we can finally say—especially for certain molecular subsets of lung cancer—that we are helping patients live longer, to the point where they may eventually succumb to something other than their cancer.

For patients with ALK-positive and EGFR-positive disease, we want to help them not just live longer but live better. That means encouraging patients to actively communicate about the adverse effects affecting their day-to-day quality of life. It also means making sure that, with chronic toxicities such as metabolic changes and an increased risk of cardiovascular disease or type 2 diabetes, we're engaging their primary care providers and specialists. Cardiologists and endocrinologists play an important role in helping optimize those disease states as well.

We always want to make sure that, yes, we're keeping patients alive from their lung cancer, but we don't want them to succumb to something else. That's why we need to engage other members of the health care team while also making sure patients' voices are heard.

A grade 3 toxicity often gets a lot of attention, but it's really these chronic, low-grade toxicities—those grade 2 toxicities—that can have the greatest impact on a patient's quality of life and daily functioning. Without that 2-way communication between the patient and the care team, we don't know how to intervene and make things better.

It really comes down to talking with patients at every stage of care—not just when they're first diagnosed or when they're coming in for scans. We want them to feel comfortable reaching out to the care team whenever they need support, whether that's 1 year, 2 years, or even 5 years into treatment.

AJMC: From your experience managing patient access, where do you see the greatest disconnect between the availability of innovative lung cancer therapies and patients' ability to actually receive them?

Houseknecht: We're seeing a shift. Historically, our Medicare beneficiaries experienced the greatest financial toxicity, particularly with oral targeted therapies. Many patients were paying $800 to $900 per month out of pocket and were under tremendous stress trying to figure out how they were going to afford their medications.

With the Inflation Reduction Act and the Medicare Part D reforms, that's no longer as significant an issue for many Part D beneficiaries. Instead, I'm seeing a shift toward commercially insured patients with employer-sponsored insurance who are struggling to understand and navigate their pharmacy benefits. At the same time, employer-sponsored insurance simply isn't as comprehensive as it used to be.

Gone are the days when many working patients had a $25 copay for a high-cost medication. Now there are increasingly complex structures within pharmacy benefit managers, or PBMs, that shift more of the financial responsibility from employers to patients.

That's incredibly difficult because patients often don't understand how their benefits work. They're trying to navigate an already complicated insurance system while also coping with a cancer diagnosis. They finally understand why they're in therapy and why they need it, but now they're worried they can't afford to receive it.

This is where pharmacists and pharmacy technicians are uniquely positioned to help. We speak the language of insurance and pharmacy benefits, serving as a bridge between the clinical care team, PBMs, and insurance companies. We can help patients understand their benefits and identify available resources, whether that's manufacturer copay assistance programs, independent foundations, or charitable grants. Ultimately, our goal is to eliminate as much financial stress as possible so patients can focus on their treatment.

AJMC: Patient education has become increasingly individualized as treatment options expand. How have your educational conversations changed as patients are asked to understand complex biomarker results, oral therapies, and evolving treatment sequences?

Houseknecht: I think the first step in making sure patients are truly invested in their care and treatment plan is helping them understand why. Why was this therapy recommended for them instead of another treatment they may have seen advertised or heard about? It starts with helping patients understand personalized medicine and how the biomarkers found in their tumor make them a good—or not a good—candidate for a particular therapy.

Once patients understand the "why," they're much more invested in their treatment. We also want them to know what to expect in terms of efficacy. How is this drug going to improve their symptoms? How is it going to control their cancer? Just as importantly, what are the major adverse effects we want them to monitor for and report?

I think it helps to break information into smaller, more manageable sections so patients can better digest it. Education also isn't a one-time conversation. It's multiple education sessions and multiple points of contact across the care team. It's written information as well as verbal education, and it's engaging care partners whenever possible.

It always makes me a little nervous when a patient comes to the clinic by themselves. Every patient needs a support network. That doesn't necessarily have to be someone they live with, but having someone who can serve as another set of ears—someone who can take notes, listen to what the physician, pharmacist, or nurse is saying, and later help the patient process that information—can make a tremendous difference.

Education shouldn't be viewed as a single point in time. It's an ongoing process that continues throughout treatment and may span 1 year, 2 years, or even 5 years.

AJMC: If you could redesign one aspect of the current lung cancer care pathway to improve operational efficiency and patient access, where do you think pharmacy could have the greatest impact?

Houseknecht: I think 2 areas tend to slow us down. One involves some of these "me-too" immunotherapy and chemoimmunotherapy regimens, where we have multiple treatment options that are all very similar, and none is necessarily superior to another. From a formulary management, inventory, and health system perspective, selecting one primary pathway based on a thorough evaluation of the efficacy and safety data can help streamline care.

When providers, nurses, pharmacists, and everyone involved in caring for the patient become familiar with the same regimen, it creates greater consistency across the care team and improves operational efficiency.

The second area is reducing the administrative burden associated with insurance denials. Ensuring the appropriate clinical information is documented in the medical record before a treatment plan is submitted can significantly reduce the need for appeals later on.

Doing more of the work upfront ultimately pays dividends. It reduces downstream administrative work, decreases delays in treatment, and prevents unnecessary stress for patients who receive letters saying their medication wasn't approved or that they may be responsible for unexpected out-of-pocket costs.

This is another area where pharmacists and pharmacy technicians can make a meaningful impact. Their clinical expertise, combined with their understanding of insurance requirements and documentation, can help reduce that burden for both patients and the health care system.