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Ragavan MV, Swartz S, Clark M, Chino F. Pharmacy Assistance Programs for Oral Anticancer Drugs: A Narrative Review. JCO Oncol Pract 2024; 20:472-482. [PMID: 38241597 DOI: 10.1200/op.23.00295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 09/20/2023] [Accepted: 11/28/2023] [Indexed: 01/21/2024] Open
Abstract
Oral anticancer medications (OAMs) are high priced with a significant cost-sharing burden to patients, which can lead to catastrophic financial, psychosocial, and clinical repercussions. Cost-conscious prescribing and inclusion of low-cost alternatives can help mitigate this burden, but cost transparency at the point of prescribing remains a major barrier to doing so. Pharmacy assistance programs, including co-payment cards and patient assistance programs administered by manufacturers and foundation-based grants, remain an essential resource for patients facing prohibitive co-payments for OAMs. However, access to these programs is fraught with complexities, including lack of trained financial navigators, limited transparency on eligibility criteria, onerous documentation burdens, and limits in available funding. Despite these drawbacks and the potential for such programs to incentivize manufacturers to keep list prices high, assistance programs have been demonstrated to improve financial well-being for patients with cancer. The increasing development of integrated specialty pharmacies with dedicated, trained pharmacy staff can help improve and standardize access to such programs, but these services are disproportionately available to patients seen at tertiary care centers. Multistakeholder interventions are needed to mitigate the burden of cost sharing for OAMs, including increased clinician knowledge of financial resources and novel assistance mechanisms, investment of institutions in trained financial navigation services and centralized platforms to identify assistance programs, and policies to cap out-of-pocket spending and improve transparency of rates charged by pharmacy benefit managers to a health plan.
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Affiliation(s)
- Meera V Ragavan
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Scott Swartz
- School of Medicine, University of California, San Francisco, San Francisco, CA
| | - Mackenzie Clark
- Department of Clinical Pharmacy, University of California, San Francisco, San Francisco, CA
| | - Fumiko Chino
- Affordability Working Group, Memorial Sloan Kettering Cancer Center, New York, NY
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Belcher SM, Mackler E, Muluneh B, Ginex PK, Anderson MK, Bettencourt E, DasGupta RK, Elliott J, Hall E, Karlin M, Kostoff D, Marshall VK, Millisor VE, Molnar M, Schneider SM, Tipton J, Yackzan S, LeFebvre KB, Sivakumaran K, Waseem H, Morgan RL. ONS Guidelines™ to Support Patient Adherence to Oral Anticancer Medications. Oncol Nurs Forum 2022; 49:279-295. [PMID: 35788731 PMCID: PMC9303042 DOI: 10.1188/22.onf.279-295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
PURPOSE This evidence-based guideline intends to support patients, clinicians, and others regarding interventions and processes to support patient adherence to oral anticancer medications (OAMs). METHODOLOGIC APPROACH A panel of healthcare professionals and patient representatives developed a clinical practice guideline to support patients taking OAMs. GRADE (Grading of Recommendations Assessment, Development, and Evaluation) methodology and criteria for trustworthy guidelines were followed. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool. A quantitative or narrative synthesis of the evidence was completed. Certainty of the evidence was assessed using GRADE. FINDINGS The panel agreed on recommendations and suggested an adherence risk assessment, education addressing adherence, ongoing assessment, proactive follow-up, coaching, and motivational interviewing in addition to usual care. The panel suggested the implementation of a structured OAM program. IMPLICATIONS FOR NURSING As cancer treatment shifts from clinic to home settings, interventions and programs to support patients on OAMs are needed.
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Affiliation(s)
- Sarah M. Belcher
- School of Nursing and in the Palliative Research Center at the University of Pittsburgh in Pennsylvania
| | - Emily Mackler
- Michigan Institute for Care Management and Transformation and the Michigan Oncology Quality Consortium in Ann Arbor
| | - Benyam Muluneh
- Eshelman School of Pharmacy at the University of North Carolina in Durham
| | - Pamela K. Ginex
- School of Nursing at Stony Brook University with a joint appointment in the Division of Population Science at the Stony Brook Cancer Center, both in New York, and was, at the time of writing, the senior manager of evidence-based practice and inquiry at the Oncology Nursing Society in Pittsburgh, PA
| | | | | | | | | | - Erica Hall
- Oncology Consultants, P.A., in Houston, TX
| | | | | | | | | | - Maegan Molnar
- Waco Therapy and Holistic Wellness Services in Texas and a cancer policy and advocacy team member at the National Coalition for Cancer Survivorship in Silver Spring, MD
| | | | | | - Susan Yackzan
- Cancer Service Line at Baptist Health System in Lexington, KY
| | | | | | | | - Rebecca L. Morgan
- Evidence Foundation and an assistant professor in the Department of Health Research Methods, Evidence and Impact at McMaster University
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Marineau A, St-Pierre C, Lessard-Hurtubise R, David MÈ, Adam JP, Chabot I. Cyclin-dependent kinase 4/6 inhibitor treatment use in women treated for advanced breast cancer: Integrating ASCO/NCODA patient-centered standards in a community pharmacy. J Oncol Pharm Pract 2022:10781552221102884. [PMID: 35642282 DOI: 10.1177/10781552221102884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Outpatients treated with oral anti-cancer drugs, including selective cyclin-dependent kinase 4/6 inhibitors (CDK4/6i), may benefit from a pharmacy practice setting adapted to support proper oral anti-cancer drug monitoring. This real-world study aimed to characterize patient-centered pharmacy practice aligned with American Society of Clinical Oncology (ASCO)/National Community Oncology Dispensing Association (NCODA) standards and to describe its impact on CDK4/6i treatment use. METHODS This retrospective study included women with confirmed hormone receptor-positive/human epidermal growth factor 2 negative locally advanced or metastatic breast cancer treated with either palbociclib, abemaciclib or ribociclib combined with letrozole or fulvestrant. Pharmacists collected patient characteristics, clinical activities, and treatment patterns using data from the pharmacy chart. CDK4/6i treatment adherence rates were estimated based on medication claims data. Time-to-treatment discontinuation, a proxy for time-to-event, was assessed using the Kaplan-Meier estimate. RESULTS Of the 195 patients assessed for eligibility, 65 were included in this study. The median observation duration was 13.6 months. An average of seven pharmaceutical care activities (range 2.8-21.7) per patient was documented for each treatment cycle. The mean proportion of days covered was 89.6%. The median time-to-treatment discontinuation was estimated at 44.2 months in patients treated with CDK4/6i + letrozole and 17.0 months in patients treated with CDK4/6i + fulvestrant. The average relative dose intensity was 85%, and the benefits of treatment were maintained regardless of the relative dose intensity levels. CONCLUSION A structured patient-centered pharmacy practice model integrating the ASCO/NCODA patient-centered standards and ongoing communication with patients and healthcare providers ensure timely refills, close monitoring, and allows patients to achieve high adherence and persistence rates comparable to those reported in clinical trials.
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Affiliation(s)
| | | | | | | | - Jean-Philippe Adam
- Department of Pharmacy, Centre hospitalier de l'Université de Montréal, Montréal, Canada.,CHUM Research Center, CHUM, Montréal, Canada
| | - Isabelle Chabot
- Faculty of Pharmacy, Université de Montréal, Montréal, Canada
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Husinka L, Koerner PH, Miller RT, Trombatt W. Review of cyclin-dependent kinase 4/6 inhibitors in the treatment of advanced or metastatic breast cancer. J Drug Assess 2020; 10:27-34. [PMID: 33414982 PMCID: PMC7751387 DOI: 10.1080/21556660.2020.1857103] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Objective The purpose of this study is to review CDK 4/6 inhibitors used to treat metastatic breast cancer for patient safety, cost and utilization. By evaluating patient outcomes and payer influence, this study will provide critical information to aid prescribers in therapeutic decisions. Methods This retrospective cohort study included patients from a national specialty pharmacy with a diagnosis of breast cancer and received either palbociclib, abemaciclib, or ribociclib for treatment. Patients were stratified into four subgroups based on their total oncolytic regimen at the time of their first eligible study medication dispense. Pharmacy claims data were reviewed to determine cost and therapy adherence. Results The mean proportion of days covered was highest in patients on combination therapy with a hormone agent, 81.0%. While secondary insurances largely affected final patient out-of-pocket costs, final copays were significantly lower than the average wholesale price (AWP) of each CDK 4/6 inhibitor. When analyzing patient reported side effects, over 60% of the study population did not experience an adverse drug event (ADE) during the study time period. Ribociclib had the fewest number of reported side effects with abemaciclib patients reporting the most. Although reported ADE profiles were similar across all three study medications, difference in frequency should be evaluated when considering medication choice with specific comorbidities. Conclusion CDK 4/6 inhibitors have demonstrated safety and tolerability in HR-positive/HER2-negative breast cancer patients. Real world safety data and out-of-pocket patient costs in addition patient specific comorbidities should be considered when developing a treatment plan that includes a CDK 4/6 inhibitor selection.
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Affiliation(s)
- Lakyn Husinka
- AllianceRx Walgreens Prime, Pittsburgh, PA, USA.,Duquesne University School of Pharmacy, Pittsburgh, PA, USA
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Kymes SM, Sullivan C, Jackson K, Raj SR. Real-world droxidopa or midodrine treatment persistence in patients with neurogenic orthostatic hypotension or orthostatic hypotension. Auton Neurosci 2020; 225:102659. [PMID: 32200263 DOI: 10.1016/j.autneu.2020.102659] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 01/23/2020] [Accepted: 02/27/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Neurogenic orthostatic hypotension (nOH) is a subtype of orthostatic hypotension (OH) observed in the presence of neuropathy and is associated with increased risk of falling, impaired function, and poor quality of life. Droxidopa and midodrine are approved in the United States to treat symptomatic nOH and OH in adults, respectively. In this study, we compared the treatment persistence of droxidopa and midodrine. METHODS A retrospective analysis of patients prescribed either droxidopa or midodrine was conducted using the Symphony Health Solutions database (Symphony Health Solutions, Phoenix, AZ, USA). Inclusion criteria were (1) a pharmacy insurance claim in at least 16 consecutive quarters from mid-2014 to 2018 and (2) an active prescription for droxidopa or midodrine of ≥30 days' duration during that period. Treatment persistence was defined as the time to the first break in drug coverage of ≥45 days and was capped at 365 days. RESULTS Data from 2305 patients who received droxidopa and 117,243 patients who received midodrine were included in this analysis. Median (95% CI) treatment persistence was significantly longer in the droxidopa cohort versus the midodrine cohort (303 [274-325] vs 172 [169-176] days; P < 0.001). After adjustment for confounding factors, patients using droxidopa monotherapy (i.e., without any concomitant midodrine and/or fludrocortisone use) were 16% more likely to be persistent at any time point than patients using midodrine (P < 0.001). CONCLUSIONS In this real-world data analysis, patients using droxidopa without concomitant medications for OH were more likely to remain on treatment than patients on midodrine.
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Affiliation(s)
| | | | | | - Satish R Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada; Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
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Parente M, Pignata I, Gnavi R, Spadea T, Di Martino M, Baratta F, Brusa P. Assessment of Non-Adherence to Oral Metformin and Atorvastatin Therapies: A Cross-Sectional Survey in Piedmont (Italy). Patient Prefer Adherence 2020; 14:261-266. [PMID: 32103910 PMCID: PMC7028384 DOI: 10.2147/ppa.s226206] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 11/16/2019] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION It is not possible to recover from chronic diseases; however, a healthy lifestyle and correct adherence to therapy can avoid complications and co-morbidities. The aim of this study was the cross-sectional evaluation, by means of a questionnaire, of real-world data on the prevalence of non-adherence to metformin and atorvastatin oral therapies in a sample of patients that attend community pharmacies in the Piedmont Region. The secondary aim was to evaluate the presence of correlations between non-adherence and a number of variables detected by the questionnaire. MATERIALS AND METHODS Data were gathered from face-to-face interviews in six community pharmacies in Piedmont. The questionnaire was divided into two sections: the first included the Morisky, Green and Levine Medication Adherence Questionnaire (MAQ) (to assess therapy adherence); the second included questions on gender, age, level of education and the pharmacy in which the questionnaire was administered. Comparisons between proportions and mean values were performed using the χ2 test. Modified Poisson regression with robust standard errors was used for multivariate analysis. The level of significance was fixed at 0.05, CI at 95%. RESULTS The sample analysed was composed of 408 subjects (receiving either metformin or atorvastatin). According to MAQ, 62 patients were non-adherent (15% of the total cohort). Crude and multivariate analysis did not show any statistically significant correlation between gender, age, level of education and non-adherence. It emerged that there was a correlation between non-adherence and being a customer of two of the pharmacies involved [PR = 3.31 (p=0.028) and PR = 3.11 (p=0.027)]. CONCLUSIONS Community pharmacies can be an appropriate setting to identify non-adherent patients. Therefore, healthcare professionals could realize an integrated and structured intervention to improve adherence. However, MAQ could underestimate the number of non-adherent patients. Further studies to test the association between non-adherence prevalence and being the customer of a specific pharmacy should be performed.
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Affiliation(s)
- Marco Parente
- Department of Drug Science and Technology, University of Turin, Turin, Italy
| | - Irene Pignata
- Department of Drug Science and Technology, University of Turin, Turin, Italy
| | | | | | - Mirko Di Martino
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Francesca Baratta
- Department of Drug Science and Technology, University of Turin, Turin, Italy
| | - Paola Brusa
- Department of Drug Science and Technology, University of Turin, Turin, Italy
- Correspondence: Paola Brusa Department of Drug Science and Technology, University of Turin, Via Pietro Giuria 9, Turin10125, ItalyTel +39 011 670 66 65 Email
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