Second-line maintenance challenges for PARP inhibitors in ovarian cancer


Bhavesh Shah, RPh, BCOP: We talked about a lot of toxicity management, dose customization, holistic support for these patients from a pharmacist’s point of view, and having an electronic medical record where you can have a lot of these diets and supportive care, a diet program in your system. Have you noticed any access problems? How were you involved in making sure patients have access?

Thomasina Morris, RPh, MHA, BCOP: Knowing the cost of PARP inhibitors, which we haven’t discussed, we know they cost patients a lot per month to be able to get them. AstraZeneca, GlaxoSmithKline and Clovis all came together knowing this was an opportunity for them to step up and try to do their best for patients. Clovis has a voucher program where you can get 30 days free on the basis of any prescription, regardless of whether they have insurance or not. AstraZeneca has AZ & Me, where uninsured patients can access, and they can look and see what kind of foundations patients can access. Even if they have trade insurance or there is a delay in authorization, they can still get about 15 days for free. When we look at the different opportunities, GlaxoSmithKline does the same. They give patients maybe $ 26,000 per schedule to spend on their drugs. This could cover their co-pay instead of covering the full cost of the drug.

We find that most insurance covers PARP inhibitors. They do not designate if they are BRCA or HR [homologous recombination]-deficient; they don’t watch it. I think their ovarian cancer diagnosis for us is what they’re looking at. They are also found in the breast, prostate, and pancreas, as you said. Insurance companies are now a bit on board now than they were in 2014-16. They see more opportunities to fill these prescriptions for PARP inhibitors. What we are seeing is a lag of about 1 to 2 weeks most of the time before these patients can start, and that is why the quick start program or the vouchers program works very well. This time allows these patients to be on treatment. Even if it’s for 15 days, you can still assess, determine labs, determine toxicity, and keep those patients going.

At the end of the day, I think right now there are so many drugs that are so expensive; As long as it is possible to make these patients take these drugs, that is what we do in our clinic. We will facilitate these possibilities by calling the insurance company, calling the pharmaceutical company, filling out the forms and faxing them and having the doctor sign until they are blue, so that we can get these drugs for you. these patients. Yes, for part of our medical records we have configured it so that you can send a prescription to any pharmacy electronically. We have at the Moffitt Cancer Center Specialty Pharmacy. They are the cornerstone of obtaining and finalizing these authorizations and dispensing medicines. If we run into a problem and it says you need to send it to your specialty pharmacy, then Moffitt Specialty Pharmacy will send it to any specialty pharmacy, be it Biogenics, CVS, etc. ., for them to fill the prescription. .

We try not to drop the ball; this is the most important thing. Between the pharmacists and the nurses, we call the patient during the week and say, “Hey, did you get your prescription? Or “Hey, have you started your prescription?” Like you said, ask your primary care pharmacist about what to deal with if you have high blood pressure or a rash and things like that. Our clinics are looking to make sure they get started. Then once they start, we bring them in and do a reassessment.

Bhavesh Shah, RPh, BCOP: Basically you say you need a Thomasina model.

Thomasina Morris, RPh, MHA, BCOP: Sure.

Bhavesh Shah, RPh, BCOP: If you want the grip to be perfect. As you said, there is so much at stake in access, especially early on for a patient. This is where we see this decline in membership. If we don’t have that kind of a model where someone makes sure that the prior authorization is given, the finances are taken care of, and then that education is done for the patient and then the supportive care. We know that physicians are so busy with so many daily practices. I think having this built-in model of a pharmacist managing all oral therapy patients really essentially leads to better adherence. Basically we want to see real world evidence showing the same thing that we see in a clinical trial for a patient.

Before concluding, do you have any final thoughts, Thomasina?

Thomasina Morris, RPh, MHA, BCOP: You know, Bhavesh, it’s just exciting from my point of view. I work with the ovary [cancer], besides I work with other cancers, and to see the opportunity of an option so that the patients can obtain an advantage. If it’s 3 months or if it’s 6 months, that’s an advantage. These patients, mostly in our ovarian environment, are looking for something more. They are mothers, they are daughters, they are sisters; just like breast cancer. At the end of the day, when we see these patients reacting and doing well, we know we’ve done the right thing.

We want to be able to see overall survival in the combination therapy. We want, as you said, the tumor agnostic for pembrolizumab [Keytruda]. We currently use pembrolizumab in any type of tumor with a PD-L1 designation greater than 1%. That’s great, and we want to be able to target chemotherapy. If we look at the molecular structure of DNA, then we can come up with cancer treatment that becomes individualized treatment.

I might say maybe about 12 or 13 years ago one of the medical gynecologist oncologists was here. Avastin [bevacizumab] had just been approved, and he came over and said, “Can I get a vial of Avastin?” I said, “Do you have a credit card because I would like to charge your credit card” and he said, “Of course.” He was doing a report to show how a VEGF [vascular endothelial growth factor] [inhibitor], like bevacizumab, was now making a world change for ovarian cancer patients because it only targeted VEGF. That was it; it didn’t affect blood toxicities, nausea and vomiting like chemotherapy, it was just VEGF. I think about it all the time saying it was a targeted drug for ovarian cancer, and I’m excited because I think that’s where we’re going.

Bhavesh Shah, RPh, BCOP: It’s exciting to be a part of it and to see the evolution of treatments for ovarian cancer. I want to thank you, Thomasina, for sharing all the best practices and years of experience you have gained, as well as knowledge of managing your patients. Also, I want to thank our audience. We hope you have found the Directions in Oncology Pharmacy® Insights the discussion should be rich and informative.

Thomasina Morris, RPh, MHA, BCOP: Thanks, Bhavesh. I appreciate it and I am honored to be a part of it.

This transcript has been edited for clarity.

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