Inlexzo Underscores Growing Need for Urology, Oncology Pharmacy Integration

In an interview with Pharmacy Times, Scott Soefje, PharmD, MBA, BCOP, FCCP, FHOPA, director of pharmacy cancer care and an associate professor of pharmacy at Mayo Clinic College of Medicine and Science in Rochester, Minnesota, discussed how Inlexzo and increasingly complex urologic cancer therapies are driving closer coordination between urology and oncology pharmacy.

Pharmacy Times: When a patient starts on Inlexzo, who actually calls oncology pharmacy—the urologist, a nurse, someone else—and when does that call happen?

Scott Soefje, PharmD, MBA, BCOP, FCCP, FHOPA: For us, the treatment plan gets entered, and when the nurse releases the treatment plan, it goes into the pharmacy preparation queue. We prepare everything and send it down.

One of the things we're trying to do is determine whether there are drugs we can prepare in advance. A lot of times, we'll reach out to urology and ask, “What are the chances of this patient actually coming in tomorrow?” If they're confident the patient will be treated, we'll go ahead and prepare it in advance. If they say, “We need to hold off. We need to make sure their labs look good or that they're not having any problems,” then we won't.

For us, it's more about treatment plans than phone calls. We try to reduce phone calls as much as possible these days. It might be a Teams message or some other electronic communication, but usually the nurse lets us know that the patient is ready for treatment.

Pharmacy Times: What does oncology pharmacy actually need to know from urology to do their job well here—and are they getting it right now?

Soefje: We try to build the treatment and therapy plans with everything we need. If there are specific labs, follow-ups, or other requirements, we try to have all of that included.

Where things can begin to fall down a little bit is if the patient has held a dose or treatment has been delayed. With a drug like this, where you don't dose reduce but may delay reinsertion, those changes aren't always communicated to us as well as they could be.

In our treatment plans, we use what are called cycle comments, and we ask providers to document any dose modifications, holds, or other information that pharmacy and nursing need to know. Our pharmacists are also reading progress notes, but the reason we use cycle comments is that if the physician dictates the progress note, it isn't always available right away. Particularly when the patient is being seen and treated on the same day, the progress note may not yet be available.

The cycle comments are there immediately and carry forward from cycle to cycle, so if we do something during cycle 1, we can see what happened when we get to cycle 2.

For the most part, I haven't heard of major problems with us sending bladder instillations down to urology. Occasionally, the treatment plan gets released because the patient has checked in, but they haven't finished evaluating the patient. Then they may notice blood in the urine or another issue and cancel the treatment.

If we're really on the ball that day, we may have already prepared the drug or started preparing it. Then we have to determine whether there's another patient who can use it or whether we're going to end up wasting it, which we hate doing because it's very expensive.

Pharmacy Times: Is there a standing meeting or touchpoint between the 2 teams, or does it happen ad hoc when something comes up?

Soefje: It's ad hoc. Our interaction with urology at Mayo Clinic is a little interesting because some of the drugs come from our operating room pharmacy. If they're doing the procedure in one of the OR procedure rooms, it comes from the OR pharmacy. If they're doing it in the urology clinic procedure room, it comes from the oncology pharmacy.

There has to be coordination around where those drugs are coming from. What we finally decided to do was make it drug specific. If a drug is primarily given in the OR, but for a particular patient they're going to administer it in urology, it still comes from our OR pharmacy.

That creates a little bit of a communication issue. Urology has to know where the drug is coming from and, if there's an issue, who they need to communicate with.

I'd like to get to the point where, when we build our new pharmacy out, we assume responsibility for all of the drugs going through the urology infusion center, while the OR pharmacy handles those being administered in the OR.

Pharmacy Times: What's the most common thing that falls through the cracks when urology and oncology pharmacy aren't talking enough?

Soefje: A lot of it is that the patient is there and, for whatever reason, the order didn't get released correctly. Then we end up hearing from them saying, “Hey, this patient's been here an hour and we haven't seen the drug. What's going on?”

The other issue is that when our oncology infusion center gets really busy and we have an overload of patients, sometimes things get delayed for urology, and they don't always understand why that's happening.

There has to be communication back and forth: “Hey, we're delayed today. Let the patient know it's going to take a little longer than normal because we're backed up.”

It's one of the reasons we're expanding our infusion center. We've recently reached more than 100% capacity on some days, and that has a ripple effect on all of the other places we work with, including urology. There just has to be that communication back and forth.

Other than that, we haven't had a lot of problems. Having an integrated electronic health record really helps with communication. We can build the treatment plans so that they contain the information we need.

Again, though, we've had occasions where we've prepared the drug and sent it down, and then the patient ends up not being treated for whatever reason. The drug comes back, and then it's potentially wasted.

Pharmacy Times: Zooming out—as more urologic therapies start to resemble oncology drugs in complexity and toxicity, do you see urology and oncology pharmacy becoming more integrated as a matter of course, or does that depend heavily on the institution?

Soefje: I think it depends heavily on the institution, but I do believe there's going to be more integration. It depends on how well urology and medical oncology work together and whether, once patients reach a certain point in their disease progression, urology sends them to the medical oncology team.

We had a long discussion with Inlexzo about who should be doing this. Should it be medical oncology, or should it be urology? The reason we stayed with urology is because urology has a procedure room and medical oncology does not. Urology also does most of the bladder instillations, whether they're chemotherapy or not, whereas medical oncology does not.

I could see other institutions doing it the other way around, where they send all of the chemotherapy bladder instillations to medical oncology. I think it's going to be a coordination issue.

I also think you're going to see more of this beyond urology. There are other drugs coming down the pike where pulmonology, nephrology, or other specialties may become involved with drugs that have traditionally been considered cancer drugs.

Now, all of a sudden, we're sending them to other places. I think there's going to be more and more conversation about this on a drug-by-drug basis.

Pharmacy Times: Is there a bigger cultural or training gap here? Do pharmacists coming up now get exposed to urologic oncology the way they do other tumor types, or is this still a blind spot in how the field thinks about specialization?

Soefje: I think particularly with our PGY-2 oncology residents, when we talk about genitourinary tumors, we have discussion sessions about bladder instillations and things like that. But they may not actually see those patients in the clinic until the disease has progressed and become metastatic and the patient ends up going to medical oncology. So I would say there is a little bit of a blind spot.

The other issue—and we've had this conversation around resident training—is that the amount a PGY-2 oncology resident has to learn these days is more than can be done in a year. There's just more than they can do in a year.

Are we reaching the point where we're going to have to split hematology and oncology into 2 different residencies? If that's the case, does the medical oncology resident need to make sure they're getting exposure to urology patients as well?

Or do we see some institutions begin specializing their residents, where maybe they have 1 or 2 rotations in hematology and everything else is medical oncology, or vice versa?

I think we're almost going to have to do that, particularly in larger academic centers where we have specialty-based clinics. We're getting to the point where it wouldn't surprise me if someday we have a prostate-specific clinic or a bladder cancer-specific clinic, because the treatment is becoming more and more specialized over time.

Pharmacy Times: Any additional thoughts for pharmacists?

Soefje: I think oncology pharmacy leaders—the heads of infusion centers, managers, and others—have to pay attention to what's being approved because you never know where something is going to end up being used.

Is it going to be in your infusion center? Is it going to be in a procedure room somewhere else? If it's in a procedure room, who's going to provide it?

More and more, we're getting patients without cancer being treated in cancer facilities because the drugs being used are beginning to overlap. I think these situations are going to become increasingly challenging over time.

To be a leader in oncology pharmacy, you're going to be touching a lot of different areas, and I think that's something people are just going to have to pay attention to.