Improving Adherence to Oral Therapy for Cancer: The Role of the HCP

Transcription

1 Improving Adherence to Oral Therapy for Cancer: May 3, 2016 Held in conjunction with the AOSW Annual Conference Tampa, Florida CLL: Update on Treatment and Side Effects Management Welcome and Introductions Lauren Berger, MPH Senior Director The Leukemia & Lymphoma Society Professional Education & Engagement Rye Brook, NY 1

2 Faculty Cara Kondaki, LCSW, CBPN-IC, OSW-C Department of Oncology Cleveland Clinic Florida Weston, FL Lisa Nodzon, PhD, ARNP, AOCNP Department of Malignant Hematology Moffitt Cancer Center Tampa, FL Jennifer Powers, PharmD Senior Manager, Oncology Disease State Walgreen Co. Deerfield, IL Disclosures Lisa Nodzon, PhD, ARNP, AOCNP is on the Speakers Bureau for Ariad, Gilead, Novartis, and Pfizer. She is also a Consultant for Ariad & Gilead. Jennifer Powers, PharmD does not have any relevant financial relationships with any commercial interests to disclose. Cara Kondaki, LCSW, CBPN-IC, OSW-C does not have any relevant financial relationships with any commercial interests to disclose. 2

3 Oral Adherence for Optimal CML Management Lisa Nodzon, PhD, ARNP, AOCNP Department of Malignant Hematology Moffitt Cancer Center Tampa, FL Decline in Deaths Related to Ph+ CML Since the Utilization of TKIs 1. American Cancer Society (ACS). Cancer Facts & Figures 2001.Atlanta, GA: ACS, Inc., ACS. Cancer Facts & Figures Atlanta, GA: ACS, Inc., ACS. Cancer Facts and Figures Atlanta, GA: ACS, Inc., ACS. Cancer Facts and Figures Atlanta, GA: ACS, Inc., ACS. Cancer Facts & Figures Atlanta, GA: ACS, Inc., ACS. Cancer Facts and Figures Atlanta, GA: ACS, Inc., ACS. Cancer Facts and Figures Atlanta, GA: ACS, Inc., ACS. Cancer Facts & Figures Atlanta, GA: ACS, Inc., ACS. Cancer Facts & Figures Atlanta, GA: ACS, Inc., ACS. Cancer Facts and Figures Atlanta, GA: ACS, Inc., ACS. Cancer Facts & Figures Atlanta, GA: ACS, Inc., Kantarjian H et al. Blood. 2012;119(9):

4 Probability of MMR Probability of CMR 7/1/2016 Poor Overall Survival for CML Patients that Progress to Blast Crisis Despite TKI Therapy Even with Imatinib Treatment Median OS in Blast Crisis ~9 mos. BC, blast crisis; OS, overall survival; TKI, tyrosine kinase inhibitor. Hehlmann R. Blood. 2012;25(4): Reproduced with permission of AMERICAN SOCIETY OF HEMATOLOGY in the format - republish in presentation/slides via Copyright Clearance Center. Long-term Adherence to Imatinib is Critical for Achieving Molecular Response Adherence to Imatinib monitored for 3 mos in 87 consecutive CML patients with CCyR using microelectronic monitoring devices 1.0 MMR Adherence > 90% (n = 64) Adherence 90% (n = 23) 1.0 CMR Adherence > 90% (n = 64) Adherence 90% (n = 23) 0.8 P < P = Mos Since Start of Imatinib Therapy Mos Since Start of Imatinib Therapy Marin D, et al. J Clin Oncol. 2010;28:

5 % Days With Correct Number of Bottle Openings 7/1/2016 Adherence Rates and Dosing Frequency Several meta-analyses have suggested that less frequent dosing was associated with greater adherence 1-4 * Adapted from Saini, et al. 1 In the bar graph above, study populations comprised adult patients with chronic diseases taking oral medications for various disease conditions: hypertension, dyslipidemia, type 2 diabetes mellitus, asthma, seizure disorder, congestive heart failure, migraine headaches, and stable angina. * In one of the four meta-analyses, Claxton et al (2001) compared compliance rates and dosing frequency and discovered no significant differences between once-daily and twice-daily dosing. 4 Statistically significant (P<0.05) between once daily and other doses specified. 1. Saini SD, et al. Am J Manag Care. 2009;15(6):e22-e Iskedjian M, et al. Clin Ther. 2002;24(2): Parienti JJ, et al. Clin Infect Dis. 2009;48(4): Claxton AJ, et al. Clin Ther. 2001;23(8): Specific Factors Affecting Patient Adherence With Oral Oncology Therapies Disease Treatment Chronic conditions Severity of symptoms Complexity of regimen Asymptomatic disease Number of daily doses Duration of therapy Lack of immediate benefit Actual/perceived side effects Impact on lifestyle Patient Knowledge of disease/treatment Perceived benefit of treatment Fear of side effects Psychological impairment Motivation Socioeconomic Healthcare System Low health literacy Lack of family/social support Access to pharmacy/facilities Medication cost Lack of healthcare insurance Poor HCP-patient relationship Poor HCP communication skills Lack of positive reinforcement Lack of knowledge on adherence HCP=healthcare practitioner. Moore S. J Adv Pract Oncol. 2010;1:

6 Predictors of Poor Adherence Patient s lack of insight into the illness Poor providerpatient relationship Presence of barriers to care or medications Missed appointments Complexity of treatment Cost of medication, copayment, or both Major Predictors of Poor Adherence Patient s lack of belief in benefit of treatment Side effects of medication Inadequate follow- up or discharge planning Treatment of asymptomatic disease Presence of cognitive impairment Presence of psychological problems, particularly depression Financial Toxicity and Adherence Barriers Jennifer Powers, PharmD Senior Manager, Oncology Disease State Walgreen Co. Deerfield, IL 6

7 Navigation Through Insurance is Complex Insurance Challenges Commercially insured Medicare / Medicaid Requires multiple prior authorizations Continued follow-up Appeals & off-label use Defining Financial Toxicity Objective Direct costs associated with treatment Subjective Financial concerns resulting from high treatment costs De Souza J, The ASCO Post. 2015, 6 7

8 Financial Toxicity has Multiple Impacts to Patient Outcomes Qualityof- life Treatment compliance Survival Financial Toxicity A Correlation Between Bankruptcy in the Cancer Patient and Mortality Data suggests cancer patients are 2.5 times more likely to become bankrupt than people without cancer The adjusted hazard ratio for mortality in cancer patients who become bankrupt is 1.79 (95% CL { }; P<.001) Associations persisted even after excluding patients with distant-stage disease at diagnosis Bansal A, Ramsey SD, Feorenko Cr, et al. Journal of Clinical Oncology. 2015;34: ASCO Abstract

9 Financial Toxicity in Insured Patients with Multiple Myeloma 100 Multiple Myeloma Patients At least minor financial burden 71 Borrowed money to pay for medication 21 Utilized savings to pay for treatment 46 Applied for financial assistance 36 Higher than expected costs for tx 59 Huntington S, et al. The Lancet Haematology. 2015;2 Discussing Financial Toxicity with Cancer Patients The time is now, especially with oral cancer treatments routinely over $10K per month Consider financial toxicity s impact on patients health-related quality of life and not simply on costs associated with treatment Patients must be given the tools and resources to discuss the side effects of financial toxicity as they would other side effects related to cancer treatment Ubel PA, Abemethy AP, Zafar SY. New England Journal of Medicine. 2013;369:

10 Psychosocial Factors Affecting Adherence to Oral Cancer Therapies Cara Kondaki, LCSW, CBPN-IC, OSW-C Department of Oncology Cleveland Clinic Florida Weston, FL Psychosocial Factors Affecting Adherence to Oral Cancer Therapies Cost-co-pays, not on formulary, lack of insurance Taking multiple medications Multiple chronic conditions 10

11 Psychosocial Factors Affecting Adherence to Oral Cancer Therapies Education and Literacy Cultural Differences Belief Systems Side effects and Quality of Life Issues Because patients with cancer self-administer oral chemotherapy, they typically do not receive the same amount of teaching and monitoring as patients receiving IV chemotherapy. Patient education is vital to promote patient safety, optimal dosing, and adherence to the treatment plan. Hartigan, K. Clinical Journal of Oncology Nursing. Nov/Dec 2003 Supplement, Vol. 7 Issue 6, p Psychosocial Factors Affecting Adherence to Oral Cancer Therapies Depression and anxiety Substance abuse/smoking Lack of access to mental health support Support system or lack of 11

12 Strategies that May Be Effective for Long-term Adherence National Comprehensive Cancer Network (NCCN ): Strategies to Improve Adherence Careful explanation of the importance of adherence 1 Direct questioning of patients during office visits 1 Follow-up appointments to review side effects 2 Adequate and appropriate side effect management 2 Cochrane literature review of over 69 RCTs suggests strategies that may be effective 3 Reinforcement Manual telephone follow-up Counseling More Frequent Interaction with the Patient Reminders Financial Toxicity Selfmonitoring RCT=randomized controlled trials. Crisis Intervention Psychological therapy 1. NCCN Clinical Practice Guidelines in Oncology : Breast Cancer V NCCN Clinical Practice Guidelines in Oncology : Chronic Myelogenous Leukemia V Haynes RB, et al. Cochrane Database Syst Rev. 2008;(2):CD Myeloma Oral Adherence Information & Resources: 12

13 The Leukemia & Lymphoma Society (LLS) offers: Patient education programs: Patient videos: Free education materials: The Leukemia & Lymphoma Society (LLS) offers: Information Resource Center: Speak with an Information Specialist who can assist patients and HCPs through cancer treatment, including clinical trial searches, and financial and social challenges. TOLL-FREE PHONE: (800) Live, Online Chats moderated by oncology SWs provide forum for patients to share experiences: What to ask: Lists of questions for patients to ask the healthcare team. Share question guides with your patients: LLS Online Social Network for HCPs and patients to seek answers and share information: CommunityView.LLS.org 13

14 The Leukemia & Lymphoma Society (LLS) offers: Continuing education programs and videos - offer free continuing education credit: Question & Answer Session 14