Second-Line Maintenance Challenges for PARP Inhibitors in Ovarian Cancer


Bhavesh Shah, RPh, BCOP; and Thomasina Morris, RPh, MHA, BCOP, delve into the challenges faced with using PARP inhibitors as second-line maintenance therapy for the treatment of ovarian cancer.

Bhavesh Shah, RPh, BCOP: We talked about a lot of toxicity management, dose customization, having holistic support for these patients from a pharmacist perspective, and having electronic medical record where you can have a lot of these regimens and supportive care, a regimens program into your system. Have you seen any access issues? How have you been involved in making sure patients have access?

Thomasina Morris, RPh, MHA, BCOP: Knowing the cost of the PARP inhibitors, which is not something we discussed, we know they’re very expensive per month for patients to be able to obtain them. AstraZeneca, GlaxoSmithKline, and Clovis, have all come together knowing that this is an opportunity for them to step up and try to do the best they can for the patients. Clovis has a voucher program where you can get 30 days free based on just any prescription, it does not matter if they have insurance or not. AstraZeneca has AZ&Me, where noninsured patients can have access to, and they can look and see what kind of foundations are available that patients can have access to. Even if they do have commercial insurance or there’s a delay in authorization, they can still get about 15 days for free. When we look at the different opportunities, GlaxoSmithKline does the same thing. They give maybe $26,000 to patients per calendar to spend on their medication. It might cover their copays versus covering the whole cost of the drug.

We find that most of the insurances do cover the PARP inhibitors. They’re not designating whether they’re BRCA or HR [homologous recombination]-deficient; they don’t look at that. I think their ovarian cancer diagnosis for us is what they look at. They’re also in breast and prostate and pancreatic like you said. The insurance companies are now a little bit on board now than they were in 2014-2016. They’re seeing more opportunity to fill these prescriptions for PARP inhibitors. What we do see is about a 1-2 week lag most of the time before these patients can start, and that’s why the quick start or the voucher program works great. That time allows those patients to be on treatment. Even if it’s for 15 days, you can still assess, determine labs, determine toxicity, and make a benefit for those patients to continue.

At the end of the day, I think right now there are so many medications that are so expensive; as long as there’s opportunities to get these patients on the medications, that’s what we do in our clinic. We will facilitate those opportunities by calling the insurance company, by calling the drug company, by filling out the forms and faxing them over and having the doctor sign until they’re blue in the face, so we can get these medications for these patients. Yes, for part of our medical records we do have it set up that you can send a prescription to any pharmacy electronically. We have at Moffitt Cancer Center specialty pharmacy. They’re the mainstay of getting these authorizations done, finalized, and getting the medication dispensed. If we come across an issue and it says you must send it to your specialty pharmacy, then the Moffitt specialty pharmacy will then send it to whatever specialty pharmacy, whether it’s Biogenics, whether it’s CVS specialty, etc., for them to fill the prescription.

We try not to let the ball drop; that’s the biggest thing. Between the pharmacists and the nurses, we are calling the patient within a week and saying, “Hey, have you gotten your prescription?” or “Hey, have you started your prescription?” Like you said, having your primary care pharmacist kind of know what to manage when it comes to hypertension or rash and things like that. Our clinics are looking to make sure they’re getting started. Then, once they start, we bring them in and do a reassessment.

Bhavesh Shah, RPh, BCOP: Essentially, you’re saying that you need a Thomasina model.

Thomasina Morris, RPh, MHA, BCOP: Sure.

Bhavesh Shah, RPh, BCOP: If you want adherence to be perfect. Like you said, there is so much involved in access, especially initially for a patient. This is where we see this drop off in adherence. If we don’t have this type of model where somebody is making sure that prior authorization is done, the financials are taken care of, and then that education happens for the patient and then the supportive care. We know physicians are so busy with a lot of the day-to-day practices. I think having this integrated model of a pharmacist managing all the patients on oral therapy really essentially drives better adherence. Essentially, we want to see the real-world evidence showing the same thing that we see in a clinical trial for a patient to have.

Before we conclude, are there any final thoughts from you, Thomasina?

Thomasina Morris, RPh, MHA, BCOP: You know, Bhavesh, it’s just exciting from my standpoint. I work with ovarian [cancer], plus I work with other cancers, and to see the opportunity of an option for patients to be able to get a benefit. If it’s 3 months or if it’s 6 months—it’s a benefit. These patients, most of them in our ovarian setting, are looking for something more. They’re moms, they’re daughters, they’re sisters; just like breast cancer. At the end of the day, when we see these patients respond and do well, we know we’ve done the right thing.

We want to be able to see overall survival in combination treatment. We want, like you said, the tumor agnostic for pembrolizumab [Keytruda]. We use pembrolizumab in any tumor type right now that’s a PD-L1 designation greater than 1%. That’s great, and we want to be able to target chemotherapy. If we’re looking at molecular structure of DNA, then we can give anticancer treatment which becomes individualized treatment.

I will say maybe about 12-13 years ago, one of the medical gynecological oncologists was here. Avastin [bevacizumab] had just gotten approved, and he came up and said, “Can I get a vial of Avastin?” I said, “Do you have a credit card because I’d like to put the charge on your credit card,” and he said, “Sure.” He was doing a news segment to show how a VEGF [vascular endothelial growth factor] [inhibitor], such as bevacizumab, was now doing to change the world for ovarian cancer patients because it was just targeting the VEGF. That was it; it wasn’t affecting hematological toxicities, nausea and vomiting like chemotherapy, it was just the VEGF. I think back on that all the time saying that was targeted medicine for ovarian cancer, and I’m excited because I think that’s where we’re going.

Bhavesh Shah, RPh, BCOP: It is exciting to be part of it and see the evolving treatments for ovarian cancer. I want to thank you, Thomasina, for sharing all the best practices and the years of experience that you’ve had, and just the knowledge of managing your patients. Also, I would like to thank our viewing audience. We hope you found the Directions in Oncology Pharmacy® Insights discussion to be rich and informative.

Thomasina Morris, RPh, MHA, BCOP: Thank you, Bhavesh. I appreciate it, and I’m humbled to be part of it.

This transcript has been edited for clarity.

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