Kevin Cast

Treatment advances have made many cancers a chronic disease rather than a terminal disease. Here is how one dedicated team works to coordinate care and work with patients.

Cancer requires a coordinated and specialized clinical approach to patient care, given the complexity of the disease, variety of treatments, management of treatment side effects, and associated lifestyle issues. For oncology patients to receive a focused level of care from pharmacists who are specially trained to support the specific requirements associated with the unique characteristics of oncology medications is paramount to achieving optimized outcomes—clinically and emotionally.

Great changes have been made in the treatment of cancer, and the pipeline is filled with promising targeted therapies. And while the 5-year survival rate has improved to 68%,  an estimated 1.6 million new cancer cases were diagnosed in the United States in 2012 and more than 570,000 people were expected to die from the disease. In addition, an aging population is expected to increase the number of new cancer cases diagnosed annually. According to a study published in the 

, cancer cases in the United States are expected to increase 45% to 2.3 million by 2030.

As a direct result, advances in cancer detection, new therapies, and improvements in adherence tools have not curbed rapidly escalating cancer treatment costs, which total $263.8 billion in the United States, including $102.8 billion from direct medical costs with the remainder in lost productivity through illness and premature death. According to the Express Scripts 

, cancer drug utilization increased only 3.4% compared with 2011, while unit cost increased 22.3% for a total drug trend growth rate of 25.8%. Much of that growth can be attributed to newer, more expensive therapies being used to treat patients.

Treatment advances have made many cancers a chronic disease rather than a terminal disease. Therefore, having patient-centric pharmacy oversight supplementing the patient’s medical provider care is an even greater factor in helping to improve patient outcomes. At Accredo Health Group, the nation’s largest specialty pharmacy, there is a dedicated Therapeutic Resource Center (TRC) for oncology, where teams consisting of specialist pharmacists, pharmacy technicians, nurses, reimbursement specialists, patient service representatives, and other experienced support personnel provide unique insight and consistent interaction regarding the specific indications, drugs, and emotional issues the patient may be facing.

Due to the various forms of cancer that exist, the TRC is further divided into sub-teams that specialize in providing drug-specific support (ie, breast, genitourinary/prostate, malignant and benign hematologic conditions, and special needs populations, such as pediatric patients). This patient-centric approach to the treatment of cancer—most  commonly utilizing oral medication&mdash;allows for extra specialization based on evidence-based protocols and continuity of care for individual patients by the pharmacist team.

Specialization and coordination of care means nothing without oversight. Comprehensive support for oncology patients is crucial, especially those new to therapy and ordering their specialty prescription drug(s) for the first time. Understanding how to take the medication and the often severe side effects it may cause is essential to maintaining compliance and getting the full benefit of the drug. Careful monitoring throughout the course of therapy and proactive outreach to physicians and patients helps to ensure that a renewal or refill of the prescription regimen remains on schedule.

Considering the seriousness of a disease like cancer, one would think that compliance with a patient’s medication regimen would not be an issue. Unfortunately, cancer patients have a higher nonadherence rate compared with people being treated for diabetes, high blood pressure, or high cholesterol. According to the Express Scripts 

, 37% of patients are nonadherent to their oncology medications, which is higher than the 29% nonadherence rate to high blood cholesterol medications.

A number of factors account for this high nonadherence rate, including severe side effects and complex medication regimens. Comprehensive support services incorporating side effect management is extremely important in helping a cancer patient remain compliant to receive the optimal benefit from their therapy. By proactively performing outreach to physicians and patients throughout the course of therapy, renewing or refilling a prescription is far more likely to occur.

At the oncology TRC, side effect management occurs with every patient touch point. All oncology personnel are trained to listen for cues related to specific symptoms. If a cue is triggered, the representative transfers the patient to the appropriate clinician who provides the necessary counseling related to the side effect. Side effect management occurs during ongoing scheduling of drug shipments with the patient, patient interactions with the reimbursement team, and patient calls with nurses. If a patient is experiencing side effects or any clinical issue that can impact therapy adherence, a specialist pharmacist will contact the physician regarding the prescription. Critical clinical information is shared with the physician who can then determine whether a dose titration or other intervention is necessary.

But often it is not just 1 medication that triggers an issue or leads to noncompliance. A comprehensive review of a cancer patient’s total drug burden, including medications for comorbid conditions and OTC products, is essential and should be a standard part of any specialty pharmacy program. By understanding a patient’s comorbidities and nonspecialty medications, adverse events such as drug—drug interactions, allergic reaction to medications, and therapy duplication can be avoided. In addition, rules that can address maximum daily dose, cyclic excessive dosing, drug–age conflicts, and drug–pregnancy issues can be put in place.

Despite the millions of cases, each patient—and his or her respective cancer&mdash;is unique, and this demands highly personalized care. This starts with the diagnosis of cancer and its treatment, both of which have been revolutionized by advances in genetics. Efficacy of treatment depends on the patient’s genetic profile or mutations within the cancer itself. Gene tests can lead to a much more targeted approach to care and less waste.

However, in a national survey of physicians conducted with the American Medical Association in 2010, Express Scripts found that only 26% (about 1 in 4) of physicians have had any type of education in the field known as pharmacogenomics (PGx), and only 10% of physicians currently believe they have the necessary information and training to put pharmacogenomics testing to use.

Collaborating with clinical experts within the specialty pharmacy can ensure that genetic tests are performed appropriately and that physicians understand how to interpret and apply the test results. An example would be ensuring test results for HER2 and KRAS are integrated into the therapeutic decision making when treating breast cancer with Tykerb, or colorectal cancer with Erbitux, respectively. Through personalized medicine, the use of the right drugs only in the right patients can minimize wastage and support better clinical outcomes.

Even with the wealth of studies available to support a treatment plan, cancer patients are ultimately treated 1 at a time. People tolerate therapy differently, and cancer responds widely to the different types of treatment. Benefit programs need to balance the use of evidence-based medicine with patient needs, since the condition is complex.

Managing treatment options is challenging. It needs to take into consideration patient characteristics (other illnesses, general state of health) and tumor characteristics (type of cancer; early vs advanced; molecular characteristics). Oncologists need to use a mix of therapies that integrate different modalities, including surgery, medication, and radiation.

At the most fundamental level, filling and taking medications as prescribed is imperative for cancer patients. Taking medications incorrectly can become life threatening. Taking too much medication or interrupting therapy can contribute to long-term complications, emergency hospitalizations, and other undesirable results—possibly even death. From a coordination of care standpoint, pharmacists should know about all medications that are in a treatment program to warn doctors of any duplicate therapies or harmful drug interactions.

Specialist pharmacists, like those in our TRCs, can identify potential effects of drug interactions and make recommendations to patients or their physicians for other medications to alleviate related symptoms.

Considering treatment without regard for nutrition in a cancer patient is incomplete care. Human resource managers also need to consider this in benefit design. Without good nutrition, cancer treatment and the money spent on it could go for naught. Nutritional needs change during cancer treatment and recovery, especially for patients receiving chemotherapy because it impacts digestion, absorption, and the body’s use of food. Nutritional status of patients also affects surgery outcomes. For example, mortality rates were 50% in elderly patients with head and neck cancer who were malnourished, compared with 11% among the well nourished.

Health benefit providers do not want patient care compromised, but they also want to ensure they are paying for effective treatment by implementing clinically sound rules governing care, as well as establishing economic and clinically sound rules for diagnostics.

Cancer therapy needs to be thorough but also efficient, given the high cost of the medications. With treatments that can exceed $10,000 a month, it’s imperative that waste be avoided. That can entail encouraging patients to buy their medications from a specialty pharmacy, where coordinated care and support services will help provide better outcomes and overall lower health care costs.

Accredo is developing the Clinical Day Supply program based on results of a pilot program that addresses the high drop-off rate among patients receiving oral oncology agents. The pilot program focused on therapies with probable side effects. In this study, patients received an initial dose of therapy for half the number of days prescribed. For example, for a 30-day prescription, patients received a 14-day fill. On the eighth day, a nurse called the patient to perform a clinical assessment and any needed counseling to determine how the patient was tolerating the medication and his or her adherence to the drug. If the nurse determined that the patient was not tolerating the therapy, the second half of the prescription was not shipped, and the patient’s physician was contacted.

Structuring a health plan to have coinsurance rather than a flat copay, or implementing coverage rules to encourage the drugs to be covered by the pharmacy benefit, rather than the medical benefit, will also help reduce waste.

The evolution of oncology has transformed the lifestyles of many cancer patients, allowing them to engage in activities that were out of the question when the treatments were less targeted and much more debilitating. A job provides a sense of satisfaction to cancer patients and the nature of treatment can allow some to continue working.

Accommodations need to be made for employees to continue with treatment, such as providing schedule adjustments and time to leave for doctors’ appointments and recuperate from difficult treatments. In some cases, it’s not easy for cancer patients to get to doctors’ offices or hospitals. Circumstances like this can require high-touch care with nurses visiting the patient at home to provide treatment and specialist pharmacists available for professional consultation and patient counseling.

Cancer care needs to be managed from diagnosis through the duration of treatment. The cost of treating cancer makes it an important part of addressing health benefits. There needs to be some flexibility in addressing the circumstances of patients. Clinicians need to be fully informed about the treatment programs to coordinate care. Pharmacists, especially those who specialize in oncology, are in an ideal position to help with the coordination of care since they are frequently engaged with patients and have expertise in treatments and managing the side effects.

Monalisa Mohanty, DPh, MBA, is the director of specialty clinical marketing at Express Scripts.

Kevin Cast is the vice president of strategy and contracting at UBC: An Express Scripts Company. He is a member of the 

Kevin Cast

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