Successful Integration of Oral Oncolytics — [PODCAST] EP 96

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The successful integration of oral oncolytics into practice depends on collaboration of the multidisciplinary cancer care team to guide patients through treatment with optimal medical, financial, and psychosocial support. CANCER BUZZ spoke to Dr. Mazyar Shadman, MD, MPH, Associate Professor of Clinical Research at Fred Hutch in Seattle, WA. Hear as our expert describes process improvement strategies to successfully integrate oral oncolytics into practice, and highlights how patient goals can be included in treatment planning.

Guest:

Mazyar Shadman, MD, MPH
Associate Professor – Clinical Research Division - Fred Hutch
Associate Professor – Medical Oncology Division - University of Washington
Attending Physician – Seattle Cancer Care Alliance
Seattle, WA

“There are three major factors that we have to consider in picking the right treatment, disease factor (or specific molecular change), patient factor (patient preferences), and social supports.” –Mazyar Shadman, MD, MPH

Resources:

• Blog: Integrating Oral Oncolytics into Chronic Lymphocytic Leukemia Practice
• Integrating Oral Oncolytics into Chronic Lymphocytic Leukemia (CLL) Practice
• The Role of Pharmacy to Help Manage Patients with Cancer on Oral Oncolytics

Transcript

Mazyar Shadman, MD, MPH: I really emphasize on the importance of communicating between each other, like physicians from different settings. This is a teamwork. We have amazing colleagues in the community. As somebody who works in academia, we learn a lot from them and we are always available to help.

CANCER BUZZ:  That was Dr. Shadman. He'll be back later in the show. Today, successful integration of oral oncolytics to treat patients with chronic lymphocytic leukemia—or CLL.

Welcome back to CANCER BUZZ. I'm your host, Summer Johnson. In the past few years, treatments for CLL have shifted to oral chemotherapies leading to better outcomes and greater convenience for patients. But these oral therapies bring with them complexities such as side effects, adherence, and cost. Many things cancer centers need to consider to successfully integrate these therapies into practice. Our guest today uses a collaborative approach to these treatments. Dr. Mazyar Shadman is a Medical Oncologist and Hematologist at the Seattle Cancer Care Alliance in Seattle and teaches at the University of Washington.

Mazyar Shadman, MD, MPH: Yeah, with the introduction of novel therapeutic agents for CLL, we have really seen a major shift and a true revolution in how we treat CLL. We have moved away from chemo immunotherapy, which used to be standard of care. Those were type of therapies that patients had to come to the clinic and receive chemotherapy drugs combined with some monoclonal antibodies. And those cycles of chemotherapy would be repeated number of times, usually six times.

And they had to deal with the chemotherapy type side effects for weeks and risk of infection, not being able to work, really disrupting the family and need for caregiver and frequent visits to the clinic. So truly for four to six months, depending on the type of treatment they were receiving, these patients had to be really disconnected from their normal life and work. And the side effects actually continued after finishing therapy. A lot of those treatments really came with long-term side effects like infections, risk of immunosuppression, and some of them even years later, would come with a risk of other cancers.

CANCER BUZZ: Sometimes patients struggle to afford treatment or get therapies approved by insurance. How has integrating oral oncolytics financially impacted the patients that you see in your practice?

Mazyar Shadman, MD, MPH: In my practice, at least for using drugs that are approved by the FDA, we rarely have problem from the insurance companies to get the drugs approved. And if you think about, you know, even financial toxicity, think about a treatment that's not interfering with somebody's work. And for a patient who, for example, 10 years ago was receiving FCR, a combination chemotherapy that would really make them, you know, for at least a period of therapy really sick and unable to work.

Now you can have somebody in an oral therapy, you can work full time and this is really an amazing change. If you think about it from the cost benefit standpoint and the days that patients kind of are enabled to really attend their workplace or spend time with their family, they're also significant improvement by using the novel drugs.

CANCER BUZZ: Can you share any best practices about process improvement strategies for successful integration of oral oncolytics?

Mazyar Shadman, MD, MPH: I think there are three major factors that we have to consider when we talk about picking the right treatment and when we have that conversation with the patient. There is definitely disease factor as a major variable that you know, really plays a role in finding the right treatment. So if I have a patient with a specific molecular changes, then I make my recommendation about the class of drug. And then there is a patient factor, you know, really patient preferences in settings that we don't have a preferred choice. I give you an example.

So if I have a patient who doesn't have high risk disease, to be more specific, they don't have evidence of deletion  17p or p53 mutation and there's currently no data or clinical trial to suggest that a BTK inhibitor versus venetoclax  based therapy would be pre preferred. So we really present both scenarios and it's interesting how patients’ factors and by that it has to do with comorbidities, what medical conditions they have and also their social support, .the type of job that they have can actually play a role in what they decide to go with. For example, if a patient has a history of cardiac disease or some other comorbidities, major bleeding, if you have that initial conversation and make the right choice for them, that will impact their adherence to the drug, the number of visits they make to the clinic later on. And basically their ability to continue treatment at the full dose without interruption and without those reductions. So considering disease factors, patients factor and really support factors are extremely important.

Not only in picking the right treatment at the time that they need treatment, but also increasing the likelihood that patients continue the treatment the way they should be continuing. We don't want to start a treatment and not being able to deliver it the way we should. And I think those three factors should be kept in mind and discuss the role with the patients before starting any treatment.

CANCER BUZZ: How do you identify and implement patient goals in treatment planning?

Mazyar Shadman, MD, MPH: So the teamwork in our clinical setting, we have clinical nurses who are well educated and experienced using these drugs. It's important to be familiar with the side effects, with the labs that we do before and after each dose and during that ramp up period. And basically the communication that they make with the patient and just through the ramp up at even later. So really that education that starts with our clinical pharmacists talking to the patient about the side effects after, for example, physician conversation after a physician has the conversation with the patient, the clinical pharmacist follows that.

And we make sure that patients to only understand the commitment that they're making before starting treatment. We don't want any surprises when we are ready and we have the drug available and patient is not well aware of the responsibility for starting treatment. So education, making sure that patients are familiar with the commitment, having a team that's prepared and is ready to implement that plan. So starting a ramp up program requires a lot of work. Nurses that follow the patient in the morning and the afternoon, you want to make sure that you have an infusion center that's prepared to add on someone last minute for maybe hydration.

So if you're not a setting that's used to high volume kind of patient care for drugs like this, I think pausing for a minute or two and think about the resources that you have to provide the treatment that you're planning to give.

CANCER BUZZ: What are some examples of best practices and clinical decision-making tools that are in place for oral oncolytics in CLL that help optimize clinical treatment flow and education?

Mazyar Shadman, MD, MPH: So we have many clinical decision tools, but from the disease standpoint, like to define or to categorize the risk of CLL and their number of them, I would say still the most important variable would be the molecular or cytogenetic information. So that tool sometimes helps us to decide, you know, one class of drug may be superior to others. Then we have clinical decision tools to assess and categorize the comorbidity  level of patients and decide how unfit a patient would be for a type of treatment.

You know, we are fortunate that with the novel drugs, that fitness factor, it's becoming less and less important because these novel drugs are feasible to be used in pretty much most of the kind of comorbidity settings unlike chemotherapy. But still here, the difference is that we are focusing on a specific side effects and comorbidities. So instead of using general scoring systems that we used to have with chemotherapy, we're now more focused on a specific adverse events of each drug and make sure that we pick the patients that are not particularly high risk for those side effects.

So it's really focusing on a specific side effects of each drug. But the clinical decision tools that are specific to each side effect are still helpful with treatment. You know, if you have a patient with atrial fibrillation and a BTK inhibitor, you use the clinical tools that you have for AFib with help of your cardiologist to decide if you need to start anticoagulation or not. So really like the treatment decisions that are becoming more and more personalized, I think that the decision tools are also personalized and customized for both patient and the treatment we are using.

CANCER BUZZ: Why are you so passionate about this and what do you see in the future?

Mazyar Shadman, MD, MPH: So I used to say, and I still say that this is an exciting time to be in this field of kind of CLL and lymphoid malignancies in general for a physician and for an investigator for those of us who have experienced giving as a physician, that intensive chemotherapy, seeing the side effects, even now 10 years later, I unfortunately sometimes see patients who come with really serious side effects from the chemotherapy that they had years ago. And now also seeing the changes that we have observed in the past 5, 6, 7 years.

And not only moving from chemotherapy to first oral targeted drugs that patients would take indefinitely. Now we are moving to using non chemotherapy treatments that are also time limited and it's only getting better. Our drugs are getting better, they're better tolerated, they're more active, and we are combining them together. Does it mean that we are done? No, there are patients who still unfortunately need further treatment options and that's really what we're trying to do. So I would say that for CLL specifically, there are two major unmet needs.

Number one, for patients who are standard risk, we have to come up with a treatment that's really short and well tolerated and cures patients. We can't cure CLL still. So that's our goal. So that's something very important that most of us in the field are really hoping to see. And the second unmet need is that you do have those patients who unfortunately despite this great drugs have a disease that you know is smarter than our treatment. So we have a lot of work to do, coming up with new drugs, with new mechanism of action and combining different treatment modalities.

So still a lot of work to do, but a lot of things to be proud of. And really it gives you a better feeling when you see your patient that comes to see you after three or four years of being on these treatments and you really don't have any many things to talk about in terms of CLL and you kind of talk about other topics. So that's really the goal eventually, and that's what keeps me basically active and excited about this area.

CANCER BUZZ: What kind of change do you think is needed to successfully integrate oral oncolytics into more practices?

Mazyar Shadman, MD, MPH: I really emphasize and importance of communicating between each other, like physicians from different settings. This is a teamwork. We have amazing colleagues in the community. As somebody who works in academia, we learn a lot from them and we are always available to help. And we are very confident when these patients go back to their primary oncologist and continue these treatments. So I, I would love to have that communication open and stronger. And also within our own clinical teams, this is an ongoing process and learning about the weaknesses and learning from patients and from each other and to make this system more efficient and in the meantime, trying to make the drugs easier to deliver logistically. And that helps both patients and the healthcare providers.

CANCER BUZZ: You can head to the show notes if you'd like to learn more about integrating oral oncolytics and to practice or other treatment planning guides by ACCC. Stay tuned the rest of this week as CANCER BUZZ is live at ACCC'S 39th National Oncology Conference. The theme of the conference this year is ‘Deconstructing Innovation’. And here on CANCER BUZZ you'll get up close with the speakers on the topics and presentations right from the conference. Keep an eye on your podcast feed for those episodes. Until next time, for the entire CANCER BUZZ team, this is Summer Johnson.

CANCER BUZZ is a resource of the Association of Community Cancer Centers (ACCC).