CLL: The Logistical Process of Using Oral Oncolytics


After reviewing the status of oral oncolytics across disease states, the panel considers the specific logistical processes involved in chronic lymphocytic leukemia.


Troy Trygstad, PharmD, MBA, PhD: Where are we at with these oral oncolytics generally? So you said they have changed practice in the treatment plan, not just the drug regimen but also how you administer it, continuity of care, how you follow the patient, where they go, and how flexibility leads to quality of life. But these additional supports are needed. Are we talking about a couple of drugs here and a couple of drugs there in the oncological space, or is it bursting and changing all of oncology practice?

Michael Reff, RPh, MBA: I’ll start. Right now, there are probably 80, 85, maybe a few more oral oncolytics. I would say the majority of them have been approved in the past 5 to 7 years. And it’s not just new entities or chemical entities that are being approved but compounds like ibrutinib that have had multiple indication approvals. So the same molecule or the same presentation now has multiple indicates within, certainly in this case, hematological treatment.

Troy Trygstad, PharmD, MBA, PhD: So not necessarily just niche products, but the delta of innovation is large on these. So it’s not 8000 products but really 40 categories. It sounds like the incremental new approval opens up a range of options for a range of conditions.

Michael Reff, RPh, MBA: Absolutely, yes.

Troy Trygstad, PharmD, MBA, PhD: Well, that’s transformational.

Michael Reff, RPh, MBA: Yes.

Troy Trygstad, PharmD, MBA, PhD: And that’s within the pipeline as well? We’re going to see more and more oral oncolytics?

Michael Reff, RPh, MBA: Yes, absolutely. There are a lot of studies in the literature that talk about the fact that we’ve had a lot of new approvals and new indications within existing commercial products. But our pharmacology partners are discovering there’s more within these targeted therapies, and there’s a lion’s share. Forty percent or so are going to be in the oral space.

Troy Trygstad, PharmD, MBA, PhD: It sounds like you all are going to be pretty busy.

Michael Reff, RPh, MBA: Yes.

Troy Trygstad, PharmD, MBA, PhD: So I’m imagining, now that I go to this practice, I’m a patient again, I’m diagnosed, and we walk through the options. I say, “Oral oncolytics for me,” because I travel the world. What does that process look like now for the procurement? Am I getting it in the mail? Am I coming to your practice on a regular basis? Am I getting a week’s supply, a month’s supply, or a 90-day supply? How is that different from what we think about when we think about pharmacy practice and dispensing?

Michael Reff, RPh, MBA: I’ll just start and ask our experts to build on this. The advent of the increase in oral therapies has really transformed the oncology service community in a sense that IV [intravenous] therapies have been used flawlessly for decades, and now you have this advent of oral therapies. And yes, they’re equally toxic, equally efficacious, equally expensive. But the operational side and the business side are totally different. And oncology clinics have had some challenges in adopting the fact that there are a lot of oral agents that are there and, as we mentioned, more that are coming. And so one way that practices have adopted to this change in therapies is through process-flow mapping and dedicating a team, folks who are with us today, that is solely focused on oral therapies. So again, for decades it’s always been IVs. Now 20%, 30%, 40% of prescriptions that come out of an oncology practice are oral, not just strictly IV.

Troy Trygstad, PharmD, MBA, PhD: You said something important there too around the patient’s perception. Do you run into any times in your practice when you come across a phenomenon in which a patient says, “Well if I’m getting a needle put in me, and I’m in the office, that must mean it’s more serious and potentially I need to pay attention to it more. But if I get a pill, it’s just a pill. I buy pills over the counter”? What does the patient education look like? “No, no, this is very effective, but we have to watch after it, just as if you were in the office.” Do you run across that? What does that feel like in your practice? What does that patient conversation look like?

Kirollos Hanna, PharmD, BCPS, BCOP: So that’s where, as Mike said, the process in oral oncology is significantly different. So generally, when a clinician and a patient have met and they’ve come up with a plan to start the patient on an oral oncolytic, clinical pharmacists have really been playing a large role in treating these patients. So education is really a big key factor up front, providing patients education that they are receiving chemotherapy or even targeted therapy. These medications, when they’re at home, have specific handling precautions that must be taken, or specific laboratory monitoring that we must do cycle to cycle, or EKG [electrocardiogram] requirements, etc. So the educational piece here is really critical because these patients are going home with a drug and not coming in and having that needle stuck in their arm.

The pharmacist and the care teams have really played a big role here. We have financial advocates who help with assistance. There has really been a role, a multidisciplinary approach, for the provider, the pharmacy, and the coordinators to really give the patients that optimal treatment.

Christina Patterson, PA-C: I think that’s key: the education. The patients need education specific to the oral therapy that they’re going on. Not just on how to handle it, but the importance of it, what it’s going to do, and that it will just be a prescription for a cycle to cycle or month to month. You’re not getting a 90-day fill and going on your way. You have to have the labs in between. You have to have an office visit to manage or to monitor for toxicity.

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