Peter Salgo, MD: Hello, and thank you for joining this Specialty Pharmacy Times® Practice Pearls® titled, “Best Practices for Dispensing Multiple Myeloma Medications.” With a plethora of FDA-approved regimens for the treatment of multiple myeloma, a personalized approach is the key to obtaining deeper and more durable responses for both newly diagnosed disease and in the relapsed setting. Some of the newer agents are oral medications adding to the patient’s quality of life. With the multiple steps involved, with obtaining prior authorization, with a limited number of pharmacies allowed to fill these specific agents, it’s important to identify the challenges and to discover best practice processes to get the medications into the patient’s hands quickly to ensure therapy is not impacted.
I’m Dr. Peter Salgo. I’m a professor of medicine and anesthesiology at Columbia University College of Physicians and Surgeons and an associate director of surgical intensive care at NewYork-Presbyterian Hospital.
Joining me for this panel discussion are: Cheryl Allen, vice president of industry relations at Diplomat.
And, Dr. Noa Brian, attending physician and medical oncologist at the Myeloma Division of the John Theurer Cancer Center in Hackensack, New Jersey.
Thank you both so much for joining us.
We’re going to be talking about multiple myeloma. Why don’t we set the table a little bit? How big a problem is it? How many people have it? What are we talking about?
Noa Biran, MD: So multiple myeloma is the second most common hematologic malignancy, second to non-Hodgkin lymphoma, which is actually about 100 different cancers. So, really, it’s the most common hematologic malignancy. It’s actually of a rare disease. There’s only about a 100,000 folks in the United States with it.
Peter Salgo, MD: Is that right?
Noa Biran, MD: And 30,000 or so newly diagnosed cases per year.
Peter Salgo, MD: You know from the way it’s discussed in medical school, and the number of cases that I’ve seen at Columbia, which is a tertiary coronary care center, you’d expect it to be a lot more common than that, but it’s not. So why are we having this conversation?
Cheryl Allen, BPharm, MBA: I think, you know, the impact on the healthcare system, you know we talked a little bit about the cost. We know that just oncology in general, about $133 billion globally; the US, we’re about $50 billion of that. It’s estimated that by 2020 the global spend will be $200 billion, and then the US will be responsible for about $100 billion.
When you’re, we’re talking billions here. You’re either talking government money; I mean the kind of money that you see in the newspapers for CEOs of tech startups. Do we know how many of these billions are related to myeloma as opposed to other cancers, or we don’t know that?
Noa Biran, MD: So the therapies for myeloma are so rapidly changing. Just in 2015 we had 5 new drugs approved, and the market is becoming saturated and from what I understand, the cost of myeloma therapies is the second highest of all cancers, despite the fact.
Peter Salgo, MD: Despite the fact that it’s rare.
Noa Biran, MD: Despite the fact that it is one of the rarest cancers.
Peter Salgo, MD: Why? Is it that the drugs are expensive or you need a lot of them, what?
Cheryl Allen, BPharm, MBA: The drugs are very expensive. So to your point, you know, the recent oral oncolytics that come to market, the cost of those is about $150,000 per patient annually. So when we talk about global spend and oncology being in the billions, it’s the top 35 drugs across the space that’s driving that, that spend.
Peter Salgo, MD: All right. And of the money we’re spending on multiple myeloma, what percent do you think is spent on the therapeutics on the pharmaceuticals, as opposed to the rest of the therapy?
Noa Biran, MD: I think that to answer that question you have to understand the disease, and multiple myeloma is a chronic disease. Patients now, it used to be that life expectancy was 3 to 5 years. Now, patients are living for decades, for the most part, standard risk patient.
So therapy is chronic. And these patients are on treatment for the almost entirety of their life—from diagnosis until death. There are areas of time, periods of times, where they’re not on therapies but they’re on triplet regimens, you know; for up-front induction therapy they get a triplet therapy from anywhere from 2 to 8 months. Then they may or may not get a transplant. Then they may or may not receive maintenance therapy, which is an oral oncolytic, and then once their disease relapses, they are on line after line of triplet therapy.
Peter Salgo, MD: So every time you opened your mouth I heard, caching, caching, caching. It’s expensive.
Noa Biran, MD: It is.
Peter Salgo, MD: You know, it’s be careful what you wish for.
Noa Biran, MD: Yup.
Peter Salgo, MD: Because, yes, we’re going to extend people out. It’s true for many diseases. But the cost of doing that is real. How much of that cost now is oral oncolytics as opposed to IV [intravenous]? Do we know?
Cheryl Allen, BPharm, MBA: I think what we’re seeing, you know not really quoting anything, but we’re seeing an erosion of the dollars, the topline dollars, in the infused oncolytic space, because we’re seeing some generic and biosimilar erosion, and we’re expecting more of that to come as the biosimilars come to market. Now true, we’ve had a lot of legal action in this space so that some of the biosimilars aren’t getting to market, and even the list price isn’t what we would have had expected them to be, but ultimately, you know, we’ll see the cost come down.
Peter Salgo, MD: But what I’m trying to parse out here is we have the IVs, and we have the oral oncolytics, the oral oncolytics I’m assuming are newer, tend to be on patent, tend to be more expensive. What percent of the total burden of the pharmaceutical cost can we, can we get an estimate on this? Is the oral, the oral limb?
Noa Biran, MD: I think it’s more than 80%.
Peter Salgo, MD: So, I think that’s what you were referring to also.
Cheryl Allen, BPharm, MBA: Yes.
Peter Salgo, MD: The IVs are already out there.
Cheryl Allen, BPharm, MBA: The cost driver is definitely in the branded oral oncolytic space.