The Journey of an Oral Oncolytic

February 2019 Vol 10, No 2
Left to right: Rowena Schwartz, PharmD, BCOP; Kristina Rua, BSN, RN, ONN-CG; and Clara Lambert, BBA, OPN-CG.
For patients with cancer, developing an individualized treatment plan requires a multidisciplinary team approach, and as the use of oral oncolytics increases, so does the need for effective communication between all oncology providers involved in patient care.

At the AONN+ 9th Annual Navigation & Survivorship Conference, Kristina Rua, BSN, RN, ONN-CG; Rowena Schwartz, PharmD, BCOP; and Clara Lambert, BBA, OPN-CG, discussed their respective roles as a gynecologic oncology nurse navigator, oncology pharmacist, and oncology financial navigator and shared how they each contribute to patient navigation and management when it comes to this unique type of cancer treatment.

Generating the Prescription

According to Ms Rua, the role of the nurse navigator in this area can sometimes be covered by patient or lay navigators, or even social workers. “When a prescription for an oral oncolytic is generated, the first thing that needs to happen is education,” she said. “Patients need to be aware of what kind of treatment plan they’re getting into.” Education will increase their chances for adherence, symptom management, and reporting of side effects.

Initially, comorbidities should be considered. Does the patient have issues swallowing? Are they able to take an oral oncolytic? Social support should also be evaluated because some patients have dementia or Alzheimer’s disease and cannot remember to take medication; do they have a support network to help? Encourage patients to advocate for themselves, but remember that all providers—pharmacists, physicians, nurses, and navigators—should work together during this process to advocate for patients, she said.

Before generating a prescription, determine if the plan is appropriate in terms of financial resources, advised Dr Schwartz. “Also, consider the patient’s longitudinal ability to pay for treatment. Insurance changes, life changes, and their ability to pay may change,” she said. “That really should be considered if we’re initiating therapy and generating a treatment plan.”

Optimize the initiation of therapy with the care team in terms of timing of care and disease evaluation, and ensure adequate follow-up to assess the patient’s tolerability to the drug. “Because we’re going from intravenous to oral therapy, a lot of the care is dependent upon the patient in terms of identifying and coordinating self-management of toxicity,” she noted.

Educate the patient on the drug, and coordinate that education so patients don’t leave confused. “It’s impor­tant to determine who will be the best person on the team to provide education,” she added.

Following Up Throughout the Continuum

According to Ms Rua, nurse navigators play a crucial role in helping to overcome the barriers patients might face in filling their prescription. Those barriers might be socioeconomic (insurance), psychosocial (mental status, social support), treatment-related (complexity of regimen, pill burden, duration of treatment), or personal (ability to take medications, comorbidities, adherence, patient learning).

Once the patient receives the medication, he or she should be reminded again about proper administration and symptom management. “Re-educate,” she said. “Let them know what happens if they miss a dose. They need to be able to keep track.” These are still cancer treatments; patients need necessary follow-up and should be followed through the care continuum, she added.

Drug-drug interactions are monitored at the initiation of therapy by specialty pharmacists and providers, but throughout care, people may have changes in their medication. This is often not communicated between the patient’s community pharmacy and their specialty pharmacy. “The number 1 thing I tell patients when they go on a drug that comes from a specialty source is to tell their community pharmacy that they’re taking this drug so every new drug can be checked against it,” said Dr Schwartz.

Many unfunded patients also use multiple pharmacies, Ms Rua added. This can increase the risk for inadequate communication and adverse drug-drug interactions.

Know when the patient received and started the drug, and enter that information into the medical record, Dr Schwartz advised. This will help to inform decisions on scans, follow-up for side effects, and further appointments. Finally, coincide refill tracking with disease evaluation. “There’s nothing worse than someone getting a month of drug that’s $10,000 and then their scans show progression,” she added. “That coordination is helpful to both the pharmacist and the patient.”

Overcoming Financial Barriers

When a prescription is written for an oral oncolytic, a patient’s insurance company will require that it be filled at their own specialty pharmacy. Copays can be significant, and copay issues can arise from a lack of funding or from copay accumulators (a problem primarily seen with employer-based insurance). While copay assistance from pharmaceutical companies is helpful for commercially insured patients, financial navigators can assist patients with government-funded insurance in looking elsewhere for assistance (ie, through open foundation funds or applying for free drug from a pharmaceutical company).

“Know your patients, their diagnosis, and their insurance type,” said Ms Lambert. “Some of the programs are calendar year, and for some you need to put in a request every 120 days. It’s important to know the program and make sure it’s active.”

Financial navigators should track patient demographics, program information (including program name, enrollment date, retroactive date, expiration date, first or second grant), and financial information (including total grant, used grant, and remaining grant). “This can be a trigger to you to apply for a second grant or look for other resources,” she said. “If the patient doesn’t have enough left to fill, you should be proactively looking for a solution to that rather than waiting for the patient to call you.”

“My dream since oral oncolytics came out 15 years ago is to give a small amount to make sure patients can tolerate it before we give them $10,000 worth of medication,” added Dr Schwartz. “In some places you can do that, and in some you can’t. The approach to this is to understand what your resources are for each agent, each insurer, and each disease, and what you can do in terms of optimizing the fill for the patient as well as for their finances.”

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Last modified: February 11, 2019

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