PANELISTS: JOYCE OSHAUGHNESSY, MD; MICHAEL REFF, RPH, MBA; SARA M. TOLANEY, MD, MPH; LINDSAY SHAW, NP; KATE JEFFERS, PHARMD
Tuesday, February 26, 2019
Kate Jeffers, PharmD: Adherence is one of the biggest issues with our oral medications, and it’s something that our organization has focused on and tried really hard to improve upon. But it’s definitely something that I think, in general, in oncology is a concern. We know that if the patient doesn’t take the drug, it doesn’t work. And so it’s really this education with patients of getting them to take that therapy. IVs are so different because the patient is there in front of you. You put an IV in their arm, and you know they got the drug. Whereas, with an oral, you’re sending them home and you’re telling them to take something that they may or may not take.
I will actually joke with my patients, when I’m doing their education visits, about adherence and say, “I can barely remember to take my multivitamin every day, so I understand what we’re asking you to do is probably going to be very hard.” Some patients that are on multiple medications, they’re like, “Oh, it’s another pill, not a big deal.” Other patients that are on a lot of medications are like, “How am I going to take 1 more pill?” And so, it’s interesting to see how patients approach the situation differently.
But I really try to stress with my patients that this is the treatment for your cancer, and I think that’s the key. Patients often will get home and they’ll start to have side effects, and they’ll say, “Well, if I take it every other day, I don’t have side effects,” which is great, except that it’s probably not working like it’s supposed to. And so we really need you to take it every day like you’re supposed to. And if you’re having side effects, you need to call us because we have ways that we can manage those side effects and make it better. It may be that we reduce the dose. It may be that we go to every other day. But we’re the ones that really need to help make that call and then be able to monitor the effects of that.
It’s always a discussion with patients, in terms of how to fit in that pill to their daily routine, whatever that may be. And thinking about our oral medications, some of them have to be taken with food or without food, 2 hours before a meal or 1 hour after a meal, or whatever it may be. And so I’ll spend time talking with my patients about, “How do we do this? How does this work for your schedule? If you’re not a breakfast person, then let’s not take it at breakfast. If you think you’re never going to remember to take it at dinner time, can we put it next to your bed so that you take it every night before you go to bed? How do we make this work into your lifestyle, so that you have the treatment and you’re able to get all of the benefits of the medication and have it impact your quality of life as least as we can?”
Running an oral oncology program, there are lots of different quality metrics that you can look at. And I think every organization looks at slightly different information. The specialty pharmacies also have kind of their own quality metrics that they’ll follow. In terms of a URAC accreditation, there are specific quality metrics that are required through that program as well. Things that we look at specifically with our program: First of all, we look at the staff compliance, which I know seems kind of silly but we want to make sure that our staff understand the importance of monitoring adherence, just like we want the patient to understand how important it is to take therapy. So we do monitor to make sure that every time a patient comes into clinic that they are being assessed for adherence and toxicity. Without the staff doing what they’re supposed to do, there’s no way that we can help the patients get the most out of their therapy if we’re not asking the questions. And so, we do monitor that.
From a quality perspective for patients, we also will monitor for side effects. We’ll monitor for the number of dose reductions that happen. We do, of course, monitor their lab values to help look at dose adjustments. Although difficult, we try to look at fill capture rates. So are they filling the prescription? If they only got a 30-day supply, are they filling it every 60 days? Because that tells you they’re probably not taking it like they’re supposed to. Sometimes the fill rates are hard because you have patients that aren’t filling at your pharmacy, and so getting that information from outside pharmacies is sometimes difficult; or looking at when they’re refilling the medication. So those kinds of patterns are all things that we look at.
But there are a number of institutions all across the country that look at different quality metrics. So I think one of the things, as we get more into this oral oncolytic paradigm, that we need to start thinking about is, what are the best practices in quality metrics? And how do we all start looking at the same thing or approximately the same thing so that we’re able to really keep track of our patients, making sure that they’re getting the best benefits out of therapy?
For final thoughts, I would say that with any oral medication, particularly with the CDK4/6 inhibitors, we know that these drugs have benefit—progression-free survival benefit, potentially overall survival benefit—especially when we’re talking about other agents as well. But patients don’t get those benefits if they don’t take their medication. And so, I think oral oncolytics have really kind of shifted the way that we have to think about cancer care in general, because the patient is not sitting there in front of you. You can’t put an IV in them. You really have to talk to the patient and find out if they’re taking the medication and if they’re not, why? Because it’s not just a, “You have to do this,” but you need to understand what their motivations are. Maybe it’s that the cost is too high. So how do we help get the cost down for that patient? What programs do we have options for? Or maybe it’s that they’re having delays in getting their prescription every month. How do we address that?
So really taking the time to talk to patients about their adherence, and then of course about their toxicity. If they’re having side effects, what are those side effects and how can we manage them? So I think oral oncolytics have created this fantastic new opportunity for patients and for the field of oncology, but it also comes with new challenges of how do we really continue to monitor our patients and make sure that they’re getting the best care possible?