“The promise of immunotherapy that was seen 100 years ago is now a reality,” said ICLIO Advisory Committee Chair Lee Schwartzberg, MD, FACP, in his remarks kicking off the first Institute for Clinical Immuno-Oncology Conference. “Where we are today, particularly with checkpoint inhibitors, is just the tip of the iceberg. … We are starting a new era with combination immunotherapy. … The challenge is how we will afford these new treatments.”
The conference, which took place October 2, 2015 in Philadelphia, reflected the reality that adoption of immunotherapy in the community setting comes with challenges, and that strategies for successful implementation are already emerging. Read on for some key conference takeaways.
Immunotherapy is a completely different therapy
From the clinical perspective, there is the need to understand differences in patients’ responses to immuno-oncology (I-O) therapy; to understand how to manage toxicities; and to educate all members of the multidisciplinary care team, the broader provider community, and patients and caregivers.
In a panel on Immuno-Oncology Applications, Sigrun Hallmeyer, MD, Oncology Specialists, SC, described her experience implementing immunotherapy in the community setting. “This is really a completely different therapy,” she said. “What happens to patients in terms of side effects is unpredictable. … You can have 20 patients with no side effects and the 21st patient will have every side effect.”
Despite the challenge of understanding toxicities, Hallmeyer said, “What we are seeing in our community practice mirrors what is happening in clinical trials in terms of efficacy and side effects. … This is no longer a niche therapy for one or two tumor types.”
“We need to think in broad terms about educating other providers about immunotherapy toxicities,” said panelist Lee Schwartzberg, MD, The West Clinic, PC. He added that immunotherapy and toxicity profiles should be discussed in providers’ multidisciplinary conferences and during tumor boards.
Panelist Gordana Vlahovic, MD, MHS, Duke University Medical Center, has been proactive in teaching residents at her program about toxicity profiles. The promise of these therapies is fueling demand, she said: “My practice has referrals from 45 states. Immunotherapy is something that people usually ask for.”
Dr. Hallmeyer agreed. “My patients are educated and well informed,” she said. “They’ve known about these drugs. There was huge anticipation from the patient perspective and also from physicians.”
Panelists agreed that advances in immunotherapy are accelerating more rapidly than the healthcare system’s ability to integrate them, particularly in terms of coverage and reimbursement. It can take months for new drugs to be assigned J codes. In the meantime, payers may put a “hold” on drug claims, essentially putting the claim in limbo — neither denied or approved. Without a denial, patients cannot apply to patient assistance programs for help.
These are costly therapies, and “insurance and payment for these agents is a huge issue,” said Dr. Hallmeyer.
Immunotherapy from the payer perspective
Any discussion of new cancer therapies today must include cost and issues of financial toxicity — for the health system as a whole, for cancer programs and practices, and for patients. “It’s impossible not to be enthusiastic about the topic of today’s discussion,” said Michael Kolodziej, MD, Aetna, “but that doesn’t mean it’s easy.” From the payers’ perspective, immunotherapy presents a problem that requires collaborative effort — the critical need to understand the patient population that responds to I-O. “We need to get the right treatment to the right patient at the right time, and we need you [providers] to help us figure it out,” he said.
Over the next two years, a number of immunotherapy drugs are likely to be approved for new indications, increasing the financial challenges, said panelist Michael Seiden, MD, PhD, McKesson Specialty Health.
Immunotherapy comes with unique administrative challenges
Three core administrative challenges in I-O implementation were spotlighted by Niesha Griffith, MS, RPh, FASHP, The Arthur G. James Cancer Hospital, The Ohio State University, in a panel discussion on tackling I-O integration challenges:
- Managing the deluge of immunotherapy information for patients and staff
- Ensuring appropriate triage of patients
- Managing reimbursement and patient financial support
Reinforcing the need for provider and staff education on immunotherapy, Griffith cited the critical issue of patients needing emergent care: “Everyone in the practice needs to understand that immunotherapy patients need to be treated differently when they go to the emergency department.”
“Education about I-O toxicities is critical,” commented panelist Steven D’Amato, BSPharm, BCOP, New England Cancer Specialists. “It’s especially important in order to avoid emergency department admissions and unintended downstream costs.”
In tackling the reimbursement and financial issues related to I-O therapies, Griffith said, “I can’t say enough about the importance of financial advocate support.” A key to success at her program has been adding dedicated reimbursement specialists to the pharmacy department.
Using patient assistance programs for immunotherapy agents is essential, she said. And to do this effectively, reimbursement specialists and the clinical team must work together. Administrative staff needs information from and communication with the clinical team to help patients access these therapies. “Financial advocates need to know everything about these new agents,” Griffith added.
While physicians are excited by these new therapies, in private practice it’s essential to have processes and efficiencies in place — especially on the back-end — to ensure reimbursement for I-O therapies, said panelist Spencer Green, MS, MBA (HA), Bozeman Deaconess Cancer Center. “Smaller cancer programs need access to experts to help think through the challenges of implementing new immunotherapy agents,” he said.
I-O care coordination requires consistent, strong communication before, during, between, and after treatments
Attendees got a bird’s-eye view from the front lines of I-O implementation from panelists Catherine Schott, RN, BSN, CCRC, Wheaton Franciscan Healthcare; Jennifer Diehl, RN, Moffitt Cancer Center; and Gary Cohen, MD, Greater Baltimore Medical Center. Ms. Schott offered three essentials for care coordination of I-O patients:
- Begin care coordination early
- Encourage early reporting of adverse events
- Encourage compliance and long-term follow-up visits
Providers and staff — including office staff answering phone lines — need to be well educated about potential adverse events, said Schott. Educating patients and their families is equally important. She emphasized three key steps in care coordination of patients on I-O therapy:
- Conducting ongoing patient and caregiver education
- Providing wallet cards or symptom logs for patients
- Encouraging accurate reporting of adverse events
Schott stressed the importance of good communication during, between, and after treatment. “It’s important to know there may be late-occurring side effects,” she said. “As more patients are treated with immunotherapy agents, we need to be vigilant about late-occurring side effects.”
“For immunotherapy patients, it’s important to know who to call 24/7,” said panelist Jennifer Diehl. “Other providers may not be familiar with I-O agents, side effects, and treatments.”
Provider-to-provider communication is essential, said Dr. Cohen. Treating patients with these new immunotherapy agents is very different from “our experience in treating cancer patients with traditional chemotherapy or other modalities,” he noted. Assessment of patients is very different. With immunotherapy, progressive disease may not always be due to metastasis. Toxicities are different. “With immunotherapy we have to teach our radiation oncologists, our endocrinologists, about how immunotherapy agents work,” Dr. Cohen said.
Immuno-oncology indications are rapidly evolving
The conference’s closing session featured Timothy Kuzel, MD, FACP, Northwestern University, discussing evolving I-O indications in renal cell carcinoma and melanoma; and Renato G. Martins, MD, MPH, Seattle Cancer Care Alliance, presenting on evolving immunotherapy indications for lung cancer. “We believe very strongly that molecular profiling is a key component of improvement of care in non-small cell lung cancer,” said Dr. Martins.
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