Matthew Farber

Cancer care continues to evolve in innovative ways, from novel treatments to new technologies designed to help patients manage their therapy and associated adverse effects. All aspects of the care team will play a role in deploying and activating these technologies with their patients. Certainly, physicians, nurses, and social workers will be at the front lines of these developments. In addition, due to the increase in oral cancer therapies reaching the market over the past 5 years, the role of the pharmacist will be crucial in integrating these technologies into patient care. 

Technological advancements empower patients to manage their own health. Tools such as smart pills and pill bottles, wearable technology, and cloud-based communications are essential to engage patients and also ensure safety and adherence to medications. It is important for specialty pharmacists to be aware of and know how to best leverage these advancements.

In November 2017, the US Food and Drug Administration approved the technology to insert a microchip into a pill to track when patients have taken their medications. However, the availability of this technology has been slow as companies test its use in individual drugs. Despite this ongoing testing, the use of smart pill bottles has increased.

The smart bottle differs from the traditional bottle in numerous ways, such as monitoring when the cap is opened, weighing the bottle’s contents, and alerting patients when it is time to take their medication. A common theme with all these options is the ability to track and report adherence data back to patients, providers, and caregivers. Specialty pharmacies are considering multiple factors as they decide whether to adopt and offer this technology to their patients.

Cost and training are among the biggest considerations. Pharmacies must decide whether they want to invest in training pharmacists on how the bottles work, how to troubleshoot if a patient is having an issue, and how to incorporate this tool into their existing arsenal of resources to help patients stay on therapy. These factors add to the hard costs of smart bottles, which cost considerably more than traditional ones. However, most pharmaceutical companies are footing the bill to avoid passing on the increased cost to the patient or the dispensing pharmacy. Finally, as pharmacists consider the required time and costs, many may also be evaluating patient adoption. Some patients may be reluctant to share their personal information or be monitored, and some may be unwilling to undergo the education required to get comfortable with using the new technology.

Pharmacies that offer these options to their patients could see significant adherence benefits and will gain access to data to prove that these technologies can increase overall adherence. This is important as specialty pharmacies become increasingly accountable for patient outcomes, which are inherently tied to adherence.

Insulin pumps, pedometers, and wearable fitness trackers have been in use for years in health care. Most of these wearable technologies measure only a specific aspect of health care, such as number of steps taken. However, in recent years, the offerings have expanded to include such things as heart rate and electrocardiogram monitors.

Wearables not only track steps but also encourage standing or exercising and monitor consumption of food or water. This is important for cancer care, as studies have demonstrated the positive impact that exercise and diet can have on cancer treatment. For example, the National Institutes of Health states that dietary changes can help reduce the symptoms of cancer and cancer treatment.

As pharmacists play a larger role in cancer care, it is important to understand how patients are using these technologies to make decisions regarding their lifestyle, diet, exercise, and even treatment. Wearables give pharmacists an additional tool to help treat their patients. Some pharmacies complement these devices with their own services to assist in holistic cancer care. An entire section of the Walgreens website is dedicated to helping patients with cancer manage common adverse effects related to treatment by making changes to their diet (walgreens.com/topic/pharmacy/specialty-pharma- cy/side-effect-help.jsp).

As these devices are more broadly adopted, questions arise about what will be done with all the data being collected and who will have access to them. Some app designers and insurers would like to use this information to promote overall heath, including adherence to medications. A February 2019 

 article reports that an employer in Texas has begun a program with United Health that allows supervisors access to certain employee information in order to promote better and healthier choices.

 Given the consolidation in the pharmacy space, it could be easy to imagine a future in which those same data are shared openly with pharmacy teams to help improve outcomes in patients.

Until recently, patients with cancer could be seen carrying large binders containing all their research and health information related to their care. This was not very portable or convenient to share with various care team members. Information regarding treatments and other aspects of the patient's condition was hard to find among the pages and pages of information enclosed in these heavy binders. This began to change with the introduction of cloud technology. As the use of the internet and cloud technology grew among health care organizations, patients became more empowered with quicker and more convenient access to their own health care information. However, privacy concerns and usability have been major hurdles to increased adoption of these technologies. In addition, patients may not know what to do with this information or how exactly to use it to improve their health.

Newer technologies are working to leverage the increased portability of the cloud to make health information more sharable while protecting patients’ privacy. New cloud-based platforms allow patients to download their health information to an app on their phone. When patients want to share that information with a heath care provider, they can show a QR code that can be scanned to grant access to their health records.

Other companies are partnering to use the cloud to develop new health care delivery models and transform the cus- tomer retail experience. Walgreens and Microsoft recently partnered to migrate data centers to the cloud and adopt a cloud-native and artificial intelligence—first mind-set. Combining the expertise of both companies with cloud-based technology will enable new and seamless health networks that integrate the digital–physical experience; deliver new care management solutions; and better connect patients, providers, pharmaceutical manufacturers, and payers to deliver a more cost-effective, personalized, and integrated health care experience.

Cloud-based services offer many potential benefits. Pharmacists, in particular, can take advantage of this technology to help advise their patients on medication management and drug interactions. One challenge that pharmacists could face involves the possibility that patients may fill prescriptions at multiple pharmacies and must be relied on to accurately report their medications and dosages. A technological solution that would allow pharmacists to leverage the data, thus eliminating the human error factor of reporting, could lead to better advice for patients and better overall outcomes. The interoperability of this technology likely still needs additional work before widespread usage, but advances in this space seeming to happen every few months.

Cancer care remains a highly complex endeavor in which patients are best served when they are actively engaged with their entire care team, from physicians and nurses to navigators and pharmacists. Advances in technology will assist all members of the team to better help patients stay on their therapies and manage adverse effects. However, some of the technology is still in its infancy, and it will take some time and buy-in from pharmacies to see a sustained and measurable impact on patient care. All pharmacies are experimenting to determine how best to incorporate these advances. As outcomes studies reveal new insights, pharmacies will begin to understand which technologies have the largest impact on patients.

1. Nutrition in cancer care (PDQ)—patient version. National Cancer Institute website. cancer.gov/about-cancer/treatment/side-effects/appetite-loss/nutrition-pdq. Updated March 16, 2018. Accessed March 3, 2019.

2. Rowland C. With fitness trackers in the workplace, bosses can monitor your every step — and possibly more. 

 February 16, 2019. washingtonpost.com/business/economy/with-fitness-trackers-in-the-workplace-bosses-can-monitor-your-every-step--and-possibly-more/2019/02/15/75ee0848-2a45-11e9-b011-d8500644dc98_story.html?noredirect=on&utm_term=.d31c0bb1a335. Accessed March 3, 2019. 

Articles

Technological advancements empower patients to manage their own health.

The Intersection of Technology and Cancer Care: The Opportunity and Implications for Specialty Pharmacy

The cancer care landscape is continuously evolving. In the past decade, more than 25% of oncology drugs in the development pipeline were oral antineoplastic agents, and this percentage is expected to grow.

Additionally, new molecular entities and new drug indications that have been approved include dual therapy regimens, some of which involve at least 1 oral antineoplastic agent. Oral cancer treatment options and multiple drug regimens provide new opportunities in cancer care with improved overall survival rates.

These opportunities lead to a shift in care from the in-patient setting to the out-patient setting, and patients are increasingly responsible for higher out-of-pocket costs as they self-manage their therapy. This paradigm shift has resulted in various challenges for the health care team, while they work to successfully care for the cancer patient.

These challenges include, but are not limited to, medication adherence and financial toxicity. Patients often assume that oral anticancer treatments have less toxicity than infused chemotherapy. This misperception can frequently lead to ineffective management of side effects, which may result in more office or emergency department visits, thus increasing overall health care costs.

Additionally, many patients do not fully understand the importance of taking their medication as prescribed. For example, missing an occasional dose is not viewed as something that could ultimately decrease progression-free survival or prevent a patient from entering remission.

This assumption makes managing patients and their medications even more difficult for those patients taking long-term antineoplastic agents to treat their cancer. Poor adherence may be the primary reason that certain cancer patients have an inability to obtain an adequate molecular response, as seen in a 2010 study by Marin et al.

For example, variability was noted in patients with chronic myeloid leukemia (CML), and the level of molecular response achieved with imatinib (Gleevec) therapy suggesting variability exists in the patient’s therapy adherence. A strong correlation between adherence rates of ≤ 90% or > 90% and the 6-year probability of obtaining&ensp;» a major or complete molecular response was noted in 87 patients with CML administered imatinib. Similarly, a cohort study examining tamoxifen adherence and its relationship to mortality in women with breast cancer suggests that women who were <80% adherent had a 10% increased risk of death.

It is important to note that the rate of adherence year over year is likely to decrease. For example, a cohort of early-stage breast cancer patients starting adjuvant tamoxifen showed overall mean adherence rate percentages decrease over time.

Medication counseling in patients on long-term maintenance therapy with antineoplastics should be continuous and does not end after the patient’s first time to fill. A rising challenge among patients on an oral anticancer regimen includes managing financial toxicity. Financial toxicity can be defined as “the objective financial consequences of cancer, as well as the subjective financial concerns that come along with expensive health care.”

The average annual cost of cancer treatment prior to 2000 was $10,000. Now, with recently approved anticancer agents, this amount has increased to $100,000 or more.

 These average annual costs continue to rise with the evolution of combination therapy, in both office-administered and patient self-administered treatment regimens.

Combination therapy of nivolumab (Opdivo) and ipilimumab (Yervoy) was originally approved for patients with BRAF V600 wild-type unresectable or metastatic melanoma. In 2016, the combination received expanded FDA-approval in patients regardless of BRAF mutational status. This indication was granted accelerated approval based on progression-free survival. This treatment regimen is administered as an infusion in the physician’s office.

Collectively, the annual price tag of a melanoma treatment regimen including nivolumab and ipilimumab would cost $256,000. If purchased individually, the 2 drugs carry a list price of approximately $300,000.

Fortunately, patients typically are not responsible for the full cost of treatment. However, with these higher costs, the patient’s out-of-pocket expense will likely increase. Furthermore, payers may require an increase in documentation to justify coverage, which increases the administrative burden for the health care team.

New combination anticancer regimens are not limited to office-administered medications. In 2015, an oral self-administered treatment regimen including ixazomib (Ninlaro), lenalidomide (Revlimid) and dexamethasone was approved for the treatment of multiple myeloma in patients who have received at least 1 prior therapy.

These new regimens are exciting for treatment advances, but come with a high price tag that may affect how effectively they are used. Anticancer combination treatment options may involve both office-administration and patient self-administration.

“Multiagent therapy with newer proteasome inhibitors such as ixazomib or carfilzomib (Kyprolis), and with monoclonal antibodies such as daratumumab (Darzalex) added to lenalidomide, can boost the monthly drug costs to $30,000 to $40,000,” wrote the authors of a July 2016 article in 

Depending on a patient’s insurance coverage, their financial responsibility may range well above 10% to 20% of the drug costs. These examples indicate how financial toxicity has become a major concern for the patient, as well as the health care team, when treating cancer patients.

The high cost of the medications in these treatment regimens raise concerns about adherence. These regimens are cyclic and depend upon multiple agents administered at specific days during the cycle. Careful collaboration across the entire health care team is vital.

The current anticancer treatment options are increasing survival rates, as more patients are living longer with cancer. These trends reflect the chronicity of cancer, and in some cases, indicate that patients are requiring anticancer medications for a longer duration.

While patients are on therapies longer, challenges with financial toxicity and adherence increase, as well. The specialty pharmacy will continue to play an increasing role in the collaboration of care for a cancer patient.

Regardless of whether a patient is new to therapy or picking up his or her refill, the specialty pharmacy often includes the last health care team member to speak with a patient prior to the start of their therapy. It is during these interactions that the specialty pharmacy can access a patient’s adherence behavior and identify factors that may affect it.

When the primary barrier to adherence includes cost of therapy, the specialty pharmacy can assist in securing funding that supports treatment costs. Furthermore, the specialty pharmacy is positioned to connect patients with additional resources that may help with the indirect costs that are often associated with anticancer treatment.

For example, additional financial support may include travel and/or housing grants. According to the Family Reach Foundation annual report, more than 50% of the grants they awarded were for housing (mortgage and rent) assistance to patients with cancer.

Not only can financial toxicity create tremendous stress for the cancer patient—in extreme cases requiring bankruptcy&mdash;it may be tied to poor patient outcomes and even increased mortality.

 It is difficult to discern whether financial toxicity directly correlates to diminished patient outcomes because of distress or if it contributes to poorer adherence, thus resulting in negative patient outcomes.

In either case, the role of the specialty pharmacy is vital in addressing this concern. As the landscape of cancer treatment continues to evolve and side effects associated with treatment are discussed with the cancer patient, the concept of financial toxicity must also be addressed and monitored, along with its impact on medication adherence. The impact of these changes in the cancer care space reaches beyond the specialty pharmacy.

Collaboration of care across the entire health care team is of the upmost importance to the success of anticancer treatment. It is during this paradigm shift that the specialty pharmacy must be consistently incorporated as a critical member of the health care team. By working together, not only will cancer patients have the best choice for treatment, but they will be able to better afford costs associated with their treatment without financial distress.&ensp;

Jennifer Powers, PharmD, is Walgreens senior manager, Oncology Disease State

Matthew Farber, MA, is Walgreens senior director, Oncology Disease State

Oral cancer treatments provide new opportunities for improved overall survival rates, but patients are increasingly responsible for higher out-of-pocket costs as they self-manage their therapy.

Management of Long-Term Cancer Care Costs 

The care of cancer patients has always been a team effort: from the medical and radiation oncologists, to the nurses and navigators, to the social workers and financial counselors.

The best care is delivered when patients can count on each member of this team to work to treat the whole patient, not just their disease. With the onslaught of new oral therapies in cancer care, there is an emerging new key member of the team: the pharmacist, or more specifically, the specialty pharmacist. According to the Hematology Oncology Pharmacy Association, there are more than 800 drugs currently in development to treat cancer, and roughly 40% of these are oral agents.

With this change in how and where care is delivered come significant changes in how patients interact with their caregivers and how they pay for their therapies. The difference in how oral therapies are covered, usually on the pharmacy benefit versus the drug benefit of insurance plans, is well documented in other articles, case studies, and patient testimonials.

Rather than dive again into those topics, let’s focus instead on the patient care team and the role of the pharmacist. In discussing the new collaboration between the Leukemia and Lymphoma Society (LLS) and Walgreens, Lou DeGennaro, PhD, LLS president and CEO, explains that with the high number of oral therapies, specialty pharmacies are now on the frontline of cancer treatment.

This is due to the increasing role these pharmacists play, be it onsite at a dispensing pharmacy, nearby at a local community specialty pharmacy, or miles away from the patient at a mail order pharmacy. In fact, it is increasingly the case that a pharmacist, either over the phone, in person, or via a mobile streaming conversation, will have the last conversation with a patient prior to the initiation of their oral therapies.

This offers a tremendous opportunity to help ensure the success of a patient’s treatment regimen. That is why specialty pharmacies need to adapt in order to fill this vital role. Many smaller practices and hospitals may not have the resources or staffing to handle the needs of cancer patients in today’s insurance and cost environment, replete as it is with insurance verification, prior authorization facilitation, patient assistance procurement, etc.

In fact, even if cancer programs do have the staff to handle these responsibilities, many can still be overwhelmed by the administrative burdens put on practitioners by insurance mandates. If specialty pharmacies can position themselves as a solution to filling these vital roles, they can more easily integrate themselves into the normal process of treating the patient.

In continuing the message from Dr. DeGennaro, being on the frontline of cancer care also means ensuring that patients stay on their therapy. Here, too, the pharmacist is the solution. As more therapies shift to being orally administered, it is more difficult to monitor adherence and compliance.

All specialty pharmacies have adherence protocols; however, many may be passive in nature, only checking on patients if refills are not filled. A more proactive approach can be much more successful, allowing pharmacists to stay ahead of adverse events and better manage side effects common to oral therapies. By managing these events, pharmacists may also be able to better triage patient care, lowering the risk of unnecessary emergency department (ED) visits, admissions, and the attendant high costs.

Walgreens recently conducted a study into this vital role of the pharmacy and found that patients eligible for pharmacy interventions experience 3% greater medication adherence and nearly 2% less hospitalizations.

The study also found that, on a per-patient basis, those in the Walgreens intervention group incurred lower total health care costs, including pharmacy, outpatient, and ED expenditures, over a 6-month period.

“This data quantifies the role our community pharmacy platform plays in achieving better population health outcomes,” said study author Michael Taitel, PhD, Walgreens senior director of health analytics, research, and reporting. “These findings clearly illustrate that the combination of pharmacist counseling, medication therapy management, refill reminders, and telephonic and digital pharmacy interventions, tailored to patients’ needs, drive better adherence. Further, this improvement in adherence results in fewer hospitalizations and emergency department visits, ultimately benefitting payers by lowering the overall cost of care.”

Finally, the role of the pharmacist extends beyond helping the patient to access, afford, and stay on their medication. The pharmacist, especially in a disease state such as cancer, has to truly treat the whole patient, from diagnosis through survivorship. This includes helping the patient with their medication, but it can also help them manage their side effects and successfully transition into survivorship care.

After a patient completes their therapy, and hopefully goes into remission, their needs will likely remain high. Therefore, given the important role of monitoring drug interactions, the pharmacy can, and should, remain an integral part of the patient care team.

This may be easier to do for a national pharmacy chain that can follow patients, no matter where they may be in their treatment or where they may live, given that they have the ability to connect a patient’s cancer care with other comorbidities for which they may be taking medications. Treatment for cancer takes a whole team, including physicians, nurses, social workers, nutritionists, genetic counselors, and financial advocates.

Pharmacists—long a player on that team, even when the therapies were mostly injectables&mdash;now see a future where orally-administered drugs make them potential most valuable players. With nearly half of all drugs in development destined to be administered orally, the role of the pharmacist keeps growing. Given the ability of specialty pharmacies to help patients get, afford, and stay on their medications, all while treating the whole patient, this is a role the pharmacist should wholeheartedly embrace. 

http://news.walgreens.com/press-releases/general-news/study-shows-that-walgreens-pharmacy-interventions-lead-to-improved-adherence-and-lower-healthcare-costs-for-commercial-patient-populations.htm

http://www.prnewswire.com/news-releases/walgreens-and-the-leukemia--lymphoma-society-create-new-approach-to-support-cancer-patients-in-their-communities-300237350.html

 is senior director, Oncology Disease State, Walgreen Co.

With the high number of oral therapies hitting the market, specialty pharmacies are now on the frontline of cancer treatment.