Cost Considerations for Treatment Involving a PARP Inhibitor


Dr Haumschild navigates financial considerations associated with treatment of ovarian cancer.

Ryan Haumschild, PharmD, MS, MBA: [PARP inhibitors are in] a competitive space, no doubt about it. There continues to be innovation in this area, which is a huge benefit for patients with ovarian cancer, especially those who relied a lot on surgery or traditional chemotherapy. PARP inhibitors have created a unique pathway forward, but there are differentiators. We start to look between these in the clinical trials. How many patients were enrolled? What was the study design? In the same regard, are there any complementary therapies being used in combination to improve the end points, such as progression-free survival, overall response rates, and overall survival?

We also want to see which patients were treated in the clinical trial from the perspective of diversity, equity, and inclusion. Were African Americans well represented in the clinical trial if that’s the patient type you’re treating? What does that look like? At the end of the day, what genomic expressors were treated? Are they HRD [homologous recombination deficiency] positive? Are they patients with BRCA? What are some emerging genomic tests that we need to look at or mutations that we can target? At the end of the day, what types of arms were available? Was it an all-comers arm? Was it looking at germline mutation in BRCA? Was it looking at other treatment modalities, in terms of first-line [therapy] vs maintenance? That’s what started to separate them.

Lastly, we’re starting to see indication expansions outside ovarian cancer. We’re starting to see it come into prostate cancer and hopefully breast cancer, and you’re going to see the utilization and the mechanism of action of PARPs become beneficial in many more solid tumors. That’s what is making it so exciting, in addition to the PARP combination therapies that are being studied.

Utilizing clinical pathways is important, and building them out is important. But if people aren’t utilizing them, what benefit are they bringing to the patient? One of the best ways to create good compliance around clinical pathways is to make sure your order sets and your EMR [electronic medical record] match those that you’ve outlined. If the order sets aren’t available, then you’re not going to see people going that way unless there’s a medical exception and there’s scientific evidence that prompts it. Also, with clinical pathways, you want to make sure that they’re easy for providers to use. If they have a clinical pathway they can recognize—what’s the tumor type? What line of therapy?—and it’s easy for them to pull this up with a few clicks, then that increases your compliance with clinical pathways.

There are some EMR vendors and ways being used to look at how you identify clinical pathways in order set noncompliance. There are a lot of tools being launched by big electronic medical record vendors that allow you to see protocol deviations. It’s OK to have some deviations; it’s all about patient-specific care. But you want to trend it over time. If you’ve made decisions through the shared decision-making methodology, you have best practices built out, and some providers don’t follow that consistently, then you want to look into it. Why aren’t they following it? Do they know something that our team doesn’t know? How do we bring that information forward and share it with everybody? [How do we] update our order sets and pathways? Maybe they practice differently because there’s a lack of understanding. That gives a great opportunity for a medical director or someone to come along with that provider, understand their treatment selection, and educate them about the best practices order set that we developed through shared decision-making. The incentive is quality practice—not necessarily dollars, but making sure they have an expectation to practice quality medicine and quality oncology. When you establish that as the precedent, you can use that as the baseline as you head into conversations where you see significant deviations from that best practice.

Transcript edited for clarity.

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