Clinical Insights: December 2015

Tuesday, December 15, 2015

STATEMENT OF NEED

The overall goal is to update the healthcare professional’s knowledge of cancer detection and prevention and to understand current and new research regarding state-of-the-art care for those with or at risk for cancer.

TARGET AUDIENCE

Intended for advanced practice nurses, registered nurses, and other healthcare professionals who care for cancer patients.

OVERALL EDUCATIONAL OBJECTIVES

Upon completion, participants should be able to:

  • Describe new preventive options and treatments for cancer patients
  • Identify options for individualizing the treatment for cancer patients
  • Review new evidence to facilitate survivorship and supportive care for cancer patients

ACCREDITATION STATEMENT

Dannemiller is approved by the California Board of Registered Nursing, Provider Number 4229, for 1.0 contact hour. CBRN credit is not accepted by the Michigan and Utah State licensing boards.

DISCLOSURES

The planners and authors of this CE activity have disclosed no relevant financial relationships with any commercial companies pertaining to this activity.

METHOD OF PARTICIPATION

  1. Read the articles in this section in its entirety.
  2. Go to www.dannemiller.com/onn-nov-dec-2015
  3. Complete and submit the CE posttest and activity evaluation.
  4. Print your Certificate of Credit.

This activity is provided free of charge to participants.

Gastrointestinal Cancer

Agent Relieves Diarrhea in Carcinoid Syndrome

Silas Inman

Treatment with telotristat etiprate reduced the average number of daily bowel movements by up to 35% for patients with carcinoid syndrome, according to results from the phase III TELESTAR trial presented this fall at the 2015 European Cancer Congress (Abstract 37LBA).

Patients treated with oral telotristat etiprate at 250 mg experienced 1.71 fewer average daily bowel movements compared with a reduction of 0.87 in the placebo arm (P <.001). Those treated with the 500-mg dose experienced 2.11 fewer average daily bowel movements compared with baseline.

The phase III study enrolled 135 patients with metastatic neuroendocrine tumors and a documented history of inadequately controlled carcinoid syndrome (defined as ≥4 daily bowel movements). Patients were evenly randomized to receive oral telotristat etiprate 3 times per day at 250 mg, 500 mg, or placebo. Treatment with a somatostatin analog was maintained throughout the trial, with all patients receiving a minimum dose of octreotide of 30 mg every 4 weeks or a minimum dose of lanreotide 120 mg every 3 weeks upon entering the trial.

After 12 weeks of follow-up, average daily bowel movements were reduced by 29% and 35% with the 250-mg and 500-mg doses of telotristat etiprate, respectively. The 12-week decline in bowel movements was 17% with placebo. At least a 30% reduction in bowel movement frequency for ≥50% of the study was achieved for 44% of patients in the 250-mg arm and for 42% in the 500-mg group compared with 20% with placebo.

All-grade treatment-related adverse events (AEs) occurred in 82% of patients treated with the 250-mg dose of telotristat etiprate compared with 93% with the 500-mg dose and 87% with placebo. AEs led to treatment discontinuation for 7% of patients in each telotristat etiprate arm compared with 13% with placebo.

Patients treated with telotristat etiprate did not experience a statistically significant reduction in flushing and abdominal pain. Eight patients treated with the 500-mg dose of the therapy experienced depression versus 3 with placebo and 2 with the 250-mg dose. Mild-to-moderate nausea was experienced by 6 patients in the 250-mg arm versus 13 (500-mg dose) and 5 (placebo).

 

Nurse Perspective

 
Laura Metcalfe, MSN, RN, APN-C, AOCNS 
Laura Metcalfe, MSN, RN, APN-C, AOCNS
John Theurer Cancer Center Hackensack, NJ
 
Neuroendocrine tumors begin in the hormone-producing cells of the body’s neuroendocrine system, which is made up of cells that are a combination of hormone-producing endocrine cells and nerve cells. Neuroendocrine cells are found throughout the body in organs such as the lungs and gastrointestinal (GI) tract.

Carcinoid tumors are a specific type of neuroendocrine tumor. Carcinoid tumors most often develop in the GI tract, with the most common site being the small intestine. However, they can also occur in the rectum, lungs, appendix, colon, stomach, pancreas, and liver. Because carcinoid tumors develop from neuroendocrine cells, they can make high levels of neuropeptides and amines, which are hormone-like substances.

Neuroendocrine tumors can be classified as functional or nonfunctional. Functional tumors secrete hormones that can cause symptoms including flushing, asthma attacks, and diarrhea. Nonfunctional tumors do not secrete hormones. Fortunately, fewer than 10% of patients have functional tumors. However, the potent chemicals and hormones made by the functioning carcinoid tumors, through their effects on the cardiovascular, GI, pulmonary, and other systems of the body, cause carcinoid syndrome.

In many cases, the symptoms of carcinoid syndrome are worse than the symptoms from the growth of the tumor itself. For those patients experiencing the sometimes intractable diarrhea, their quality of life can be greatly impacted. They will describe being unable to leave the house for fear of needing a bathroom urgently and being unable to find one. Some have described the humiliation of having an “accident” when out in public.

Therefore, when reading the results of this study, showing a 29% to 35% reduction in average daily bowel movements (depending on dose), I can’t help but be impressed and encouraged. I would definitely like to see this drug approved as it appears to have the potential to greatly improve the quality of life of those patients affected by carcinoid syndrome– induced diarrhea. As an oncology nurse, I know that improving a patient’s quality of life is often the most important thing we can do for them and also often the most important thing to them.
 

Head and Neck Cancer

For HPV-Positive Oral Cancers, Less Toxic Treatments May Work

Lauren M. Green

While the prognosis remains good for individuals with HPV-positive oropharyngeal cancers, the incidence of these cancers continues to rise, and researchers are currently seeking less intense treatment options that are equally effective but not as toxic for patients.

Oncogenic HPV infection is now a recognized etiology in approximately half of oropharyngeal squamous cell cancers. HPV-positive cancers typically have better outcomes and a lower likelihood of second primary cancers than their HPV-negative counterparts.

On the other hand, the incidence of oropharyngeal cancers is growing—now surpassing cervical cancer—and the increase is expected to continue over the next 30 years, particularly for men currently aged ≤40 years.

“This is a major public health concern of our time,” said Missak Haigentz Jr, MD, presenting an update on treatments for head and neck cancers at the 33rd Annual Chemotherapy Foundation Symposium.

Effective therapies exist, often involving combinations of chemotherapy, radiotherapy, and surgery, but long-term effects of these complex treatment regimens can negatively impact quality of life for survivors. Multiple studies have corroborated a survival advantage in patients with HPV-associated disease, with 5-year survival of HPV-positive patients approaching 80%, noted Haigentz, an associate professor of Clinical Medicine at the Albert Einstein College of Medicine, Montefiore Medical Center.

Although current staging classifications do not account for HPV status, Haigentz said, HPV status is the most important prognostic factor, followed by smoking status.

It is well established that patients with head and neck cancers have severe, acute, and frequently long-term toxicities from curative therapy, with some resulting in chronic functional impairment. These toxicities include mucositis, dysphagia (including feeding tube dependence), xerostomia, dental complications, hypothyroidism, lymphedema, and fibrosis.

He suggested that HPV-associated cancers’ more favorable prognoses can set the stage for “treatment deintensification, where a gentler therapy may be sufficient to cure a patient,” underscoring that such an approach assumes treatment efficacy will be preserved. Alternatively, for poor-risk, HPV-negative patients, treatment intensification is needed.

Several strategies for treatment deintensification for HPV-positive oropharyngeal cancers are under clinical evaluation, for example, replacing concurrent cisplatin with cetuximab or reducing radiation doses.

A phase III trial under the auspices of the Radiation Therapy Oncology Group (RTOG 1016) is comparing high-dose cisplatin with cetuximab in patients with oropharyngeal cancer whose tumors are p16-positive. The primary endpoint of the study, which accrued nearly 1000 patients and closed in 2014, is 5-year overall survival. Haigentz said that outcomes over the next several years are eagerly awaited to shed light on the efficacy of replacing chemotherapy with the targeted agent.

Other ongoing international studies comparing chemotherapy with cetuximab have novel endpoints, including the DE-ESCALATE study in the United Kingdom where the endpoint is severe toxicity, and the TROG 12.01 study in Australia, where the primary outcome is symptom severity. Haigentz said that patient selection presents a unique opportunity to be able to impact quality of life and treatment morbidity in this patient population. “Rather than being stronger, perhaps we need to be smarter.”
 

Targeted Therapies Improve Outcomes in Thyroid Cancer

Tony Hagen

The kinase inhibitors sorafenib and lenvatinib have significantly altered the treatment paradigm for patients with advanced radioactive iodine (RAI)–refractory differentiated thyroid cancer (DTC) in both older and younger populations, with combination strategies hoping to further build upon this success, Marcia Brose, MD, told attendees at the 33rd Annual Chemotherapy Foundation Symposium.

Over 65,000 new cases of DTC are expected this year, along with over 2000 deaths, said Brose, director of the Thyroid Cancer Therapeutics Program at the University of Pennsylvania. In 5% to 15% of patients, the disease becomes RAI-refractory, with median survival estimated at 2.5 to 3.5 years. Prior to sorafenib becoming the first kinase inhibitor approved for RAI-refractory DTC in 2013, the chemotherapy doxorubicin was the standard, though it was found to be ineffective, Brose said. The pivotal phase III DECISION trial was the first successful analysis of a kinase inhibitor in this setting.

“Here we had patients with definite evidence of progression, as well as evidence of RAI-refractory [DTC] either because the disease did not take up radioactive iodine or because the disease took up radioactive iodine and grew anyway,” Brose said.

In the study, 417 patients were randomized in a 1:1 ratio to sorafenib or placebo, and crossover was allowed at the time of progression, with the primary endpoint of progression-free survival (PFS). The sorafenib cohort had a PFS of 10.8 months; PFS for the placebo group was 5.8 months.

The multikinase inhibitor lenvatinib joined sorafenib in 2015 as an approved therapy for patients with RAI-refractory DTC. This agent demonstrated value for patients with progression on prior sorafenib, Brose said. In the phase III SELECT study, patients were randomized in a 2:1 ratio to lenvatinib or placebo. A portion of these patients had received prior VEGF/ VEGFR-targeted therapy, providing hints at an optimal sequence for these therapies. In the full population, lenvatinib achieved an 18.3-month PFS versus 3.6 months for placebo.

“This is clearly a different population than the DECISION trial, with patients more rapidly progressing,” Brose said. “In the second line, we also had a very good PFS, at 15.1 months. Now, it’s been argued by some that because it’s active in the second line that lenvatinib can be used in the first or second line after sorafenib, whereas others argue lenvatinib is suitable for first-line treatment only,” Brose said.

“I think both are true, and I think it’s just very good for our patients that we now have 2 lines of therapy.” Further data from the SELECT trial indicated that patients over 65 years did well, achieving 16.7-month PFS versus 20.2 months for the younger group.
 

Hematology Malignancies

Novel Antibodies Arrive in ALL

Silas Inman

Monoclonal antibodies are poised to revolutionize the treatment of adult patients with relapsed acute lymphoblastic leukemia (ALL), specifically the CD3 and CD19 bispecific agent blinatumomab and the CD22-targeted antibody-drug conjugate inotuzumab ozogamicin, according to a presentation by Gail J. Roboz, MD, at the 33rd Annual Chemotherapy Foundation Symposium.

“In ALL we have spectacular success with older drugs. You can get a lot of adults into remission, but you can’t really keep them there. We’re still only at a 40% to 50% cure rate,” said Roboz, from the Weill Medical College of Cornell University and the New York-Presbyterian Hospital.

Within the past decade, the CD20 antibody rituximab (Rituxan) has been established as a standard of care for patients with ALL. Exploration of other novel antibodies with unique targets further builds upon this success.

The first agent Roboz described was blinatumomab, which is a monoclonal antibody that possesses antigen-recognition sites for CD3 and CD19. The combination of these sites into one therapy is thought to promote cytotoxic T lymphocyte and helper T lymphocyte activity against CD19-expressing B-lymphocytes. “This is a theme that you’re going to see increasingly, as we try to harness the novel technology and also the reintroduction of immunotherapy into acute leukemias, which have traditionally not been very successful,” said Roboz.

In December 2014, the FDA granted an accelerated approval to blinatumomab for patients with Philadelphia chromosome-negative relapsed/refractory B-precursor ALL, based on a phase II study, in which blinatumomab showed a complete response (CR) rate of 33%. The CR plus CR with incomplete hematologic recovery (CRh) rate was 43%. Of patients who achieved a CR/CRh, 82% tested minimal residual disease (MRD)–negative (≥.001% cells). Overall survival was longer in those who achieved MRD-negativity versus those who did not (11.5 vs 6.7 months).

Phase III studies continue to assess blinatumomab for patients with ALL. Studies also are attempting to move this agent into earlier lines of treatment. “This is FDA-approved. The Black Box warning does talk about cytokine release syndrome and neurotoxicity, which are rare, and there are tricks for how to use this. It’s always a good idea to talk to someone who has done it before,” Roboz advised.

The next antibody mentioned by Roboz was inotuzumab ozogamicin, which is composed of an anti-CD22 antibody covalently linked to the cytotoxic agent CalichDMH. In an open-label phase III trial, inotuzumab ozogamicin showed a CR or CR with incomplete platelet recovery rate of 80.7% versus 33.3% with chemotherapy for patients with relapsed/refractory ALL. Of these patients, 78.4% were MRD-negative (<0.01% cells).

“This agent was initially very promising, but the method of administration was concerning for veno-occlusive disease. It actually had subsequent data in a weekly administration that looked like the efficacy was the same but the safety was better,” Roboz noted. In the study, veno-occlusive disease occurred in 15 of 259 patients in the inotuzumab ozogamicin arm versus 1 in the chemotherapy arm. The majority of cases were seen after stem cell transplant (n = 10).

Positive findings from this study were presented at the European Hematology Association Congress in June. In October 2015, inotuzumab ozogamicin received a breakthrough therapy designation from the FDA for relapsed or refractory ALL. This designation is meant to expedite the review process.

“This agent is leading to very impressive CR rates, and we are awaiting the ability to use this, since the drug is able to induce MRD-negativity with a very high percentage,” Roboz said. “It’s not FDA approved yet, but it can be acquired through compassionate access through Pfizer [the drug’s developer] for eligible patients.”

 

Nurse Perspective

 
Phyllis McKiernan, MSN, APN, OCN 
Phyllis McKiernan, MSN, APN, OCN
Blood and Marrow Transplant Program
John Theurer Cancer Center Hackensack, NJ
 
Monoclonal antibody therapy has been successful in the treatment of various hematologic malignancies, and now 2 new agents have shown effectiveness in the treatment of acute lymphoblastic leukemia (ALL). While considered to be highly curable in very young patients, ALL in older patients does not have the same high cure rates. Blinatumomab and inotuzumab ozogamicin both have been shown to be effective in relapsed/refractory ALL, and most importantly, have improved rates of MRD negativity, which can increase overall survival.

Although monoclonal antibodies do not have the same side effect profile as traditional chemotherapy, the adverse effects can be severe and in some cases, life-threatening. For blinatumomab, cytokine release syndrome (CRS) and neurologic toxicity are rare but serious potential reactions. Dexamethasone is recommended as a premedication prior to the first dose of blinatumomab to decrease the pro-inflammatory response,1 and patients need to be educated to report fever, nausea, headache, seizure or any changes in neurologic status.

Hepatotoxicity, including veno-occlusive disease (VOD), is a serious potential effect of inotuzumab ozogamicin. Due to the high rates of response, more patients were able to proceed to transplantation, thus increasing risk for VOD. In early studies of inotuzumab ozogamicin, the drug was given monthly, but current studies are using a weekly schedule, which may have less hepatoxicity.

Staff education regarding the rare, but serious potential effects of monoclonal antibodies should be provided prior to administration of these novel agents. Consulting with a center that has experience with the drug may be helpful to gain insights on how to prevent or manage untoward effects.

With the approval of blinatumomab and the breakthrough therapy designation for inotuzumab ozogamicin, patients with relapsed refractory ALL will have therapy choices that can lead to better disease control and hopefully cure. As nurses, we need to stay abreast of the latest data and drug information to provide these therapies in a safe and effective manner.
1. Blincyto [prescribing information]. Thousand Oaks, CA: Amgen, Inc; 2014. http://pi.amgen. com/united_states/blincyto/blincyto_pi_hcp_english.pdf. Accessed November 18, 2015.

Brentuximab Vedotin Effective in Elderly Hodgkin Lymphoma

Kelly Johnson

New evidence suggests that there may be a safe and effective treatment option for older patients with Hodgkin lymphoma who are ineligible for chemotherapy.

In a phase II, open-label study, researchers administered the antibody-drug conjugate brentuximab vedotin (Adcetris) as frontline therapy to patients aged 60 years and older who were either unfit to receive chemotherapy or declined treatment because of the risks. The study showed that the overall response rate (ORR) was 92%, and 73% of those achieved complete remission. All of the patients achieved stable disease or better and had decreased tumor volume following treatment of brentuximab vedotin.

“In this population of older patients with Hodgkin lymphoma who were unfit for standard chemotherapy, we observed that brentuximab vedotin as a single agent produced a very high rate of response, including a very high rate of complete remission,” lead author Andres Forero-Torres, MD, of the University of Alabama at Birmingham, said in a statement. Brentuximab vedotin targets Hodgkin lymphoma cells and delivers a potent dose of chemotherapy without harming surrounding healthy cells. Previous studies have shown that the therapy has achieved remissions in patients with relapsed or treatment-resistant disease.

For the study, researchers administered 1.8 mg/kg of brentuximab vedotin intravenously to 26 patients every 3 weeks for up to 16 doses. Patients who benefitted from the treatment could continue past 16 doses until cancer progression, intolerable toxicity, or study closure.

The patients received a median of 8 cycles, with 4 completing 16 cycles, and 1 patient completing 23 doses. The median duration of objective response was 9.1 months and median progression-free survival was 10.5 months.

The treatment was well tolerated, with the most common adverse event being peripheral sensory neuropathy (78%). Fatigue and nausea were experienced by 44% of patients. Peripheral neuropathy occurred in 30% of patients, most of whom had risk factors of diabetes or hypothyroidism. Standard chemotherapy can be effective in achieving complete remission in younger patients with Hodgkin lymphoma; however, outcomes in older patients tend to be poor following chemotherapy due to treatment-related toxicity and comorbidities.

The authors concluded that this study shows brentuximab vedotin monotherapy has the potential to provide a safe and effective frontline treatment option for elderly patients unable or unwilling to receive conventional chemotherapy.

“While we observed promising responses, the next step is to evaluate this drug in combination with additional chemotherapy or immunotherapies that might allow us to prolong the response without relapse,” Forero-Torres said.
Forero-Torres A, Holkova B, Goldschmidt J, et al. Phase II study of frontline brentuximab vedotin monotherapy in Hodgkin lymphoma patients aged 60 years and older [published online before print September 16, 2015]. Blood.
 

Focusing on Personalized Care in Polycythemia Vera

Lauren M. Green

Patients and practitioners can expect more personalized options for the treatment of polycythemia vera (PV), including more refined criteria for diagnosing symptomatic patients and identifying those at highest risk, along with more therapies for treating a disease which carries a heavy symptom burden.

“Polycythemia vera is a disease that is evolving quite a bit—it really is not the ‘P vera’ of 1995, in which it was just a question of phlebotomy, aspirin, and hydroxyurea,” Ruben A. Mesa, MD, told attendees at the recent 33rd Annual Chemotherapy Foundation Symposium.

One important way in which knowledge of PV has advanced, said Mesa, is more rigorous diagnostic criteria. He noted that many patients will have obvious signs of PV but do not necessarily meet thresholds set by the World Health Organization (WHO) in its 2008 guidelines. WHO is expected to issue revised criteria in 2016, and among the changes, will be a lower hemoglobin threshold for unexplained erythrocytosis.

“The criteria are becoming more sensitive,” which is important, but even this doesn’t tell the whole story, Mesa noted, because patients with PV may experience serious symptoms, including vascular events, cytopenias, and splenomegaly, along with a risk of progression to myelofibro- sis or acute leukemia. “Our understanding of risk has evolved as well,” continued Mesa, who serves as deputy director of the Mayo Clinic Cancer Center in Phoenix, Arizona. Key factors in assessing progression risk include age, leukocytosis, and prior thrombotic events.

Current management of all PV patients includes maintaining hematocrit levels <45% in men and <42% in women, though some patients may benefit from a lower threshold based on their symptom burden and history, said Mesa. In addition, low-dose (≤100 mg) aspirin is recommended for those who are not allergic or intolerant, along with aggressive control of cardiovascular risk factors.

Mesa said the use of cytroreduction for treatment of PV is also evolving in important ways. Though hydroxyurea remains the default standard of care, limitations of this treatment have generated significant interest in new agents.

Phase III global programs are underway examining pegylated interferon alpha (PEG-IFN α) as frontline therapy in high-risk PV patients. The MD-RC 112 study (NCT01259856) will com- pare PEG-IFN-2a (PEGASYS) with hydroxyurea and aspirin in patients with essential thrombocythemia or PV and is currently recruiting participants. Another trial (NCT01949805) is comparing Peg-P-IFN-alpha-2b (AOP2014) with hydroxyurea in patients with high-risk PV. Mesa said that results for the latter were reported recently, and the agent produced durable respons- es (Am J Hematol. 2015;90(4):288-294).

Because JAK2 driver mutations are commonly associated with PV, JAK inhibitors represent an- other area of interest, among them, ruxolitinib. Mesa cited findings from the RESPONSE study showing that the oral JAK1/JAK2 inhibitor was superior to best alternative therapy in such areas as improving blood cell counts and reducing phlebotomy procedures in patients with difficult PV, a significant unmet need. Ruxolitinib demonstrated durable responses and eased symptom burden (N Engl J Med. 2015; 72[5]:426-435).

Oncology Practice

Patients Divided on Desire to Discuss Treatment Costs

Lauren M. Green

Despite growing interest in the financial burden of out-of-pocket cancer treatment costs, little is known about whether patients actually want to talk about costs with their oncology team. A survey of 300 insured patients is shedding some light on the subject, finding that although 48% indicated that they never wanted to discuss the topic, the remainder expressed some level of interest in such conversations. (Am J Manag Care. 2015;21(9):607-615).

The survey also found that when such patient– provider discussions took place, it had a positive impact on treatment costs. Patients with cancer face higher out-of-pocket expenses than individuals with other chronic illnesses, and studies have shown that worry over treatment costs negatively impacts patient quality of life, even for patients with health insurance.

For this study, a research team led by S. Yousef Zafar, MD, MHS, of the Duke Cancer Institute, sought to gauge patient preferences for cost discussions with their oncologists, specifically among patients who have insurance.

Adult patients with a solid tumor diagnosis were recruited from a comprehensive cancer center and 3 rural oncology clinics over an 8-month period, beginning in November 2012.

Response rates were high: of 349 patients approached to participate, 86% (N = 300) completed the baseline survey, and 246 completed an identical follow-up survey 3 months later.

The survey asked patients these questions and rated their responses on a 1-10 scale: (1) How much do you want to talk to your doctor about your cancer-related out-of-pocket costs (1 = not at all, 10 = a great deal), and (2) Do you want your cancer doctor to take your costs into account when he/she decides how to treat your cancer (1 = never, 10 = always take into account).

Forty-eight percent of participants selected not at all when asked if they wanted to discuss costs with their provider; of the 52% who expressed some interest, 15% indicated the middle value of 5, and 9% responded a great deal.

In reply to the second question, 49% responded they never wanted costs taken into account. Of the 51% of patients who did want them factored in to some degree, 62 (21%) answered “always,” and the remaining 30% were evenly split across values 2-9. Of the total cohort, 19% had talked with their oncologist about costs, whereas 76% (n = 227) did not think their physician knew how much patients were paying out of pocket for their care.

Among the 56 patients who said that they did discuss costs with their oncologists, 32 (57%) indicated treatment costs were lower due to
the following: referral to financial assistance services (53%), facilitating insurance approval of coverage (25%), changing to less expensive prescription medicines (19%), changing/decreasing the number of tests (13%), and reducing physician visits (6%).

When asked their reasons for avoiding cost discussions with their doctor, 53% of respondents reported having no difficulty affording care, and 34% indicated that they wanted the best possible care, regardless of cost. Nevertheless, more than half of the respondents reported spending some of their savings to pay for their cancer care, and 25% used credit.

The median respondent distress score was 3.62, with 1 representing the least distress and 10 the most. Overall, 16% of patients had scores of 8-10, representing high or overwhelming financial distress.

Future priorities for research the authors cited include finding reliable ways to identify those patients who want, or would most benefit from, a discussion of treatment costs, and validating interventions at the practice level to reduce out-of-pocket costs.

 

Nurse Perspective

 
David Leos, RN, MHA, OCN, CBCN  
David Leos, RN, MBA, OCN
Manager, Clinical Protocol Administration
Department of Plastic Surgery
The University of Texas
MD Anderson Cancer Center Houston, TX
 
Increasingly, we read articles or have conversations with patients about rapidly growing out-of-pocket costs of care. To have the Institute of Medicine enter the fray and make its recommendations underscores the importance and impact of this topic. Additionally, the NCCN recently announced its Evidence Blocks tool that helps level the communication playing field and allows both patients and their providers to consider variables, including affordability, as they evaluate treatment decisions.

All this comes at a time when defining and paying for value are concepts at the forefront of oncology practice. Unfortunately, discussions of approaches to address costs have often been skewed to conjure up thoughts of rationed care and compromised outcomes.

This study falls squarely in the midst of this controversy and provides the necessary exploration of the patients’ perspective. Not surprisingly, the most common reason for patients to want a discussion about costs with their provider was due to higher copays for prescription drugs. The growth in these costs is particularly acute in the setting of newly approved precision agents. According to a recent Advisory Board article, all 9 cancer agents approved in 2014 cost at least $120,000 per year.1 With this in mind, it was a bit surprising to read that “no difficulties affording care” was cited by a high percentage of patients who stated a preference for avoiding cost discussions.

Hence, it is easy to understand the urgency of gauging how patients feel about facing the financial burden associated with their care along with participating in their treatment decisions and how adding discussion of costs to the mix will affect the former two. Despite the wide variance in stated desire to have these discussions, it seems that there was little disagreement as to the eventual perceived helpfulness these had on the costs. Hopefully, this study serves as a proof-of-concept and will lead to the widespread availability of such discussions.
Bonnette J. When a pill costs $1000, how should providers cope? The Advisory Board Company website. Published September 15, 2015. http://bit.ly/1H9dBxR. Accessed November 18, 2015.


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