Precision Therapies Are Advancing Fast, and Care Delivery Has to Catch Up

Oncology is advancing faster than the systems built to deliver it. At an Institute for Value-Based Medicine^® event in Denver, Colorado, pharmacists, oncologists, and health care leaders from academic and community practices gathered to confront that gap directly. Across 4 panel discussions, speakers traced a common thread: As biomarker testing, chimeric antigen receptor (CAR) T-cell and bispecific therapies, and antibody-drug conjugates (ADCs) reshape treatment for lung cancer, multiple myeloma, and breast cancer, care teams must evolve just as quickly.

Pharmacists are taking on larger roles in navigating toxicities and prior authorizations, and oncologists are rethinking sequencing and dosing strategies as evidence evolves in real time. Yet innovation alone isn’t enough. Persistent access barriers—rural distance, fragmented records, and financial toxicity—underscore that closing the gap between scientific progress and patient outcomes requires collaboration as much as new therapies.

Precision in Practice: Implementing Biomarker Testing in Lung Cancer

The first panel discussion, moderated by Urs Weber, MD, a thoracic oncologist at the University of Colorado Anschutz (Anschutz), addressed workflow barriers clinicians may encounter when managing tissue and plasma testing.

“It takes about 2 to 3 working weeks to get the report back,” said Rao Mushtaq, MD, FACP, medical oncologist and hematologist at National Jewish Health. “Excluding the time of running the testing, getting the tissue by the commercial labs can be a little bit challenging, so there is further delay.”

Although testing tumor tissue can be more accurate than blood-based testing, heavily relying on tissue for multiple rounds of testing can be challenging. Obtaining samples requires extensive measures, and once acquired, the number of tests is limited because they rely on a fixed sample size. In contrast, alternative blood-based testing may be less efficient, as cancer DNA is not always detectable in these tests, further creating delays in diagnosis and treatment.

“I think where the biggest gap in understanding [is] what is actually adequate biomarker testing,” Weber said in an interview with The American Journal of Managed Care^®.

Weber pivoted the conversation to address the role of multidisciplinary care teams, specifically the role of pharmacists. Benjamin Yoder, PharmD, BCOP, a clinical pharmacy specialist in thoracic oncology at Anschutz, provided unique insights into the various roles in collaborative oncology workflows.

Pharmacists help to navigate prior authorizations and payer communication to ensure continuity of care in addition to managing toxicities. Yoder explained that pharmacists’ expertise helps to streamline treatment decisions, given their experience with different driver mutations, targeted therapies, and the associated toxicities.

“It’s a good place for the pharmacist to also help navigate. [For example], retesting some of those situations where they’re having different breakthrough drivers,” he said. “We can help with that process and then make sure that we’re not increasing toxicity at the same time if there are overlaps in the drug interactions.”

Overall, the panelists addressed potential solutions to gaps in access that hinder continuity of care, including multidisciplinary care, expanding pharmacists’ roles, and streamlining workflows to best deliver care to patients and improve outcomes.

Scaling Innovation: Delivering Targeted Therapies, CAR T, and Bispecifics in Multiple Myeloma

Delivering targeted therapies requires precision medicine to coordinate ideal timing, especially when balancing CAR T-cell and bispecific therapies. Moderated by Peter A. Forsberg, MD, a hematologist-oncologist at Colorado Blood Cancer Institute (CBCI), the discussion began with panelists being asked to explain their decision process when formulating treatment plans and subsequent lines of therapy for patients.

“I think that I’m a little bit more pragmatic in thinking about what can the patient do when they come to the university [then] go back to the local oncologist and get right,” said Jorge Monge, MD, an assistant professor of medicine-hematology at Anschutz.

Tara K. Gregory, MD, president and director of the cellular therapy program at CBCI, commented on Monge’s point, noting that the line of therapy a patient is currently on or most recently received is a significant factor when deciding the next line of treatment. Yet, as the number of T-cell–engaging therapies increases, more data support positive outcomes and even remission in later lines of therapies when used.

“We need to stop playing with the other drugs. We can save those for later. But I agree with you; I think it’s about performance status and what a patient can tolerate,” Gregory said. “When you have a patient who’s on a bispecific, they’re going to a BCMA [B-cell maturation antigen] for long periods of time, and they’re on that drug and they relapse, they’re typically going to relapse without BCMA expressions.”

Forsberg then turned the conversation to address why bispecific potential for broader utilization requires proper infrastructure and workflows to effectively implement them into care plans.

“We’ve worked with all of our community partners to help them figure out their approach to bispecific start-ups that they do themselves, not just sending bispecific patients to us to do the start-up and then transitioning those back,” Forsberg said. “What does a community need to have in place to sort of do a bispecific pandemic?"

Gregory explained that inpatient care centers are limited by payer authorizations, especially because many patients referred for bispecifics are on Medicaid/Medicare, therefore pushing receipt of care onto outpatient centers. This care burden puts a significant strain on community clinician workflow, she said.

“Largely, we’re still seeing patients referred to us to ramp them up on the outpatient side,” Gregory said, describing instances where she’s gone above and beyond to ensure patients received proper dosing regardless of their location, to the point of making “free phone calls.”

Overall, the panelists emphasized why expanding access should focus on strengthening outpatient infrastructure, training community sites to safely manage cytokine release syndrome and neurotoxicity, and creatively navigating payer and logistical barriers so more patients can receive these transformative therapies.

Targeted Success: Operationalizing Therapies in Breast Cancer

Moderator Mabel Mardones, MD, a medical oncologist and hematologist at Rocky Mountain Cancer Centers (RMCC), started the conversation by addressing the most prominent advancement in breast cancer care in the past 5 years: the growth in ADCs. Mardones asked the panelists how they’ve implemented these therapies into their practice and shaped their clinical workflows and treatment strategies.

Panelist Stephani Giangiuli, PharmD, BCOP, a clinical pharmacist at the University of Colorado Health, referenced adjuvant CDK4/6 inhibitors, specifically noting that prior data support positive outcomes in lower doses for patients with fewer adverse events.

“Now we can explain to patients, especially when we’re [educating them], ‘Now you’ve got 3 years on this medication, or 2 more years on this medication.’ We can say, even if we have to drop a dose, ‘You don’t have to be miserable with these [adverse] effects,'" she said. “We can still make sure [patients are] tolerating it and get [them] through these next 2 to 3 years to get this additional reduction in your risk of recurrence.”

Adherence has also grown among ADC therapies as providers have operationalized dosing and patient follow-up during the first few months of treatment. Giangiuli and Enrique Soto Perez de Celis, MD, PhD, a breast medical oncologist at Anschutz, agreed that dosing in the first couple of months determines adherence throughout the duration of treatment, encouraging clinicians to be diligent with regular check-ins.

“One of the challenges for me of doing adjuvant CDK4/6 inhibitors [is] not so much the adherence but the burden related to getting labs, having to come to the clinic more often. With adjuvant endocrine therapy, you can see the patients every 3 [or] 4 months with very little monitoring involved, and this requires more,” de Celis said. “That being said, also the adherence. The main challenges are in the first couple of months. Once the patients get past those couple of months, it’s fairly easy to maintain them on a certain dose.”

Considering the toxicities associated with ADC therapies, Mardones shifted the conversation to address dosing escalation in the adjuvant setting, using abemaciclib (Verzenio; Eli Lilly and Company) as an example.

Giangiuli affirmed Mardones’ suggestion, explaining that a tapered start to slowly introduce adjuvant therapies benefits patients, especially older patients or those with comorbidities, as opposed to administering them all at once.

“Patients were allowed to start a CDK4/6 inhibitor after 12 to 18 months, right after their definitive surgery,” Mardones said. “It makes a lot of strategic sense to allow patients to understand their endocrine suppression symptoms first, manage those, and then introduce the CDKs thereafter.”

Mardones next focused on the phase 3 SERENA-6 trial (NCT04964934), which is assessing the efficacy of camizestrant in combination with palbociclib, ribociclib, or abemaciclib, a combination not currently approved by the FDA. The trial sparked interest among clinicians because it measures progression-free survival 2 (PFS2) molecularly. Mardones questioned whether this new end point should be used to guide treatment plans and strategies, although patients may appear radiographically stable.

“The SERENA-6 trial is an example of a trial that has, in my perspective, critical design issues,” de Celis said in response to Mardones’ question. “One is the outcomes, particularly the PFS2 outcome, which is not an outcome that actually correlates with overall survival.”

De Celis continued to describe the pros and cons to this shift in assessment and the logistical complications associated with future implementation, but he ultimately said he doesn’t think it should change how disease progression is currently assessed and managed in breast cancer care.

“For me, this is not ready for prime time. It is a concept-generating thing because it shows you that monitoring mutations more closely may—in the future, when we have better treatments—lead to improvements,” he said. “But in my opinion, this is just hypothesis generating and shouldn't change practice for the moment.”

Marie Wood, MD, professor of medicine at Anschutz, agreed with de Celis’ sentiment, reiterating that the therapy is not ready for prime time. She also explained how patient education and sometimes misinformation about the SERENA-6 trial PFS2 end point may discourage patients from their current therapies as they’re looking for the most efficacious treatment.

“Patients are gobbling this up because they want reassurance that their treatment is working, and they want to know as soon as it’s not working that they have a different option,” Wood said. “It's really tough as a patient, and the amount of time I spend trying to walk people back from that is often more time-consuming. Sometimes you say, ‘OK,’ but then when I think about the financial toxicity and…emotional burden, it really gives me pause.”

The discussion concluded with the panelists emphasizing the rapid advancements in therapies heavily influencing how adjuvant and metastatic care are managed, because clinicians rely on multidisciplinary care to navigate and balance operationalizing newer therapies, patient tolerability, and efficacy for the best possible outcomes.

Cancer Care in the Mountain West: Addressing Needs in a Rapidly Growing Region for Operational Success

The final panel discussion focused on cancer care management and gaps in access specifically in the Mountain West region. Moderator Glenn Balasky, executive director at RMCC, opened the discussion by addressing cancer care in the Mountain West. He urged clinicians and health care leaders to acknowledge geographical barriers—significant barriers to care—and navigate patient care to accommodate and expand care access for patients.

“I think sometimes we think about physical access, especially in rural communities and where we know that we maybe have community oncology settings closer, but I think that the distance often just amplifies existing needs that were already there,” said Dana Weber, MSN, RN, senior director of transformation and quality at McKesson. “That on top of a cancer diagnosis—the cancer diagnosis amplifies it, and the distance makes it louder.”

Another barrier rural health systems in this area face is financial, Balasky noted. These systems still need a source of income and often struggle to balance patient care in a rural setting, but persistent communication gaps also hinder access to value-based care and cross-specialty oncology collaboration, both of which are known to improve patient outcomes.

“What idealized partnership models can we talk about to bridge this issue of connection and overcome and make collaboration better?” Balasky asked panelists.

Anosheh Afghahi, MD, a senior medical director at Paradigm Health and a clinical assistant professor at University of Colorado Health, provided insights as an administrator and physician at a health institution.

“I think one of the issues that I run into sometimes is that our EHRs [electronic health records] are not connected. We’re getting more of that through Care Everywhere, and even across other states, we can see patient notes, hospitalizations, and things like that. The more connected we become, the easier it is for the patients to get the right care, for the providers to really have a sense of what’s going on with that patient. I love the idea of that network and really honing in on the EHR being one of the frameworks by which we can work together,” she said.

Communicating through EHRs and empowering patients to choose larger, resource-rich cancer care settings to receive care shouldn’t be tied to a single institution or provider, Afghahi emphasized.

“I also think that patients should be empowered to move. There shouldn’t be this concept of this patient belongs to this site or this patient belongs to this provider,” Afghahi said. “A lot of patients feel bad when they seek opinions or move from one provider to another, and I really feel like as a community, we should let go of that and empower patients to make choices that make sense for them.”

Weber further emphasized the importance of developing stronger relationships between health institutions and the individual specialists within oncology care teams, such as nurse navigators.

“Having a navigator really be able to be that primary point of contact for the patient, for the provider, and for the academic institution or the hospital has made a real difference in a lot of collaboration models,” Weber said.

Balasky acknowledged another barrier to care prevalent in the region: financial toxicity. High-deductible plans and Medicaid plans in both rural and urban areas continue to burden patient access, he noted, asking the panelists, “What financial infrastructure do you see that allows people to navigate, and what are the gaps that you’re seeing from patients to get access?”

Efforts to curb financial toxicity surrounding care include patient navigation programs, exemplified by Anschutz, Afghahi noted.

“We have oncology navigators who are working with patients to connect them with financial assistance and co-pay programs,” she said. “There are a lot of hidden costs that are not as easy to get to, even just co-pays for medications. I usually don’t have visibility for that unless the patient tells me, and sometimes they don’t feel comfortable sharing that with us. I think that beyond these more institutionalized programs that are hugely beneficial, there's a lot more that we could do.”

Weber also noted that standardization of screening and artificial intelligence (AI)-based tools can also help address hidden health care costs.

“Sometimes we’re seeing patients not even make it to their consult, and some of that could be related to financial toxicity or other practical concerns,” Weber said. “I think that we’ re trying to understand that, but really, standardizing early and often screenings and then closing the loop on the gaps, following up with that patient, making sure that they’re not falling off our radar, and really exhausting all of our resources—I think AI and some algorithm-based technologies are really helping in that space.”