Development of oral oncolytic nonadherence estimator (ORACLE): A pretreatment nonadherence risk assessment for oral oncolytics

INTRODUCTION

To date, there is no adherence estimator to identify risk of nonadherence prior to initiating oral oncolytics.

METHODS

A workgroup was assembled through the National Community Oncology Dispensing Association and tasked with creating a tool to meet this need. Tool constructs were defined after a review of the literature identifying top barriers to adherence. A second literature search was conducted to identify questions targeting specific barriers from validated adherence questionnaires. Once a finalized draft was complete, the risk assessment tool was built into an electronic survey where a risk category can be automatically calculated for the patient.

RESULTS

The six most impactful factors affecting compliance to oral oncolytics were identified as patient's confidence, health literacy, perception of treatment, quality of life, social support, and complexity of chemotherapy regimen. A six-item questionnaire was created with five patient-directed questions and one clinician-directed question. Examples and descriptions were provided for clinicians to consider when categorizing complexity of a regimen. The tool was designed for responses to each question to be indexed into categories through a 10-point system. Results will be stratified into low, moderate, or high risk for nonadherence.

CONCLUSION

The creation of a tool to predict nonadherence prior to starting therapy is an unmet need for patients initiating oral oncolytics. The aim of this tool is to meet those needs and better guide clinicians to provide patients with strategies to better manage nonadherence. Next steps include tool validation and piloting in clinical practice.

Implementation of preemptive DNA sequence-based pharmacogenomics testing across a large academic medical center: The Mayo-Baylor RIGHT 10K Study

PURPOSE

The Mayo-Baylor RIGHT 10K Study enabled preemptive, sequence-based pharmacogenomics (PGx)-driven drug prescribing practices in routine clinical care within a large cohort. We also generated the tools and resources necessary for clinical PGx implementation and identified challenges that need to be overcome. Furthermore, we measured the frequency of both common genetic variation for which clinical guidelines already exist and rare variation that could be detected by DNA sequencing, rather than genotyping.

METHODS

Targeted oligonucleotide-capture sequencing of 77 pharmacogenes was performed using DNA from 10,077 consented Mayo Clinic Biobank volunteers. The resulting predicted drug response-related phenotypes for 13 genes, including CYP2D6 and HLA, affecting 21 drug-gene pairs, were deposited preemptively in the Mayo electronic health record.

RESULTS

For the 13 pharmacogenes of interest, the genomes of 79% of participants carried clinically actionable variants in 3 or more genes, and DNA sequencing identified an average of 3.3 additional conservatively predicted deleterious variants that would not have been evident using genotyping.

CONCLUSION

Implementation of preemptive rather than reactive and sequence-based rather than genotype-based PGx prescribing revealed nearly universal patient applicability and required integrated institution-wide resources to fully realize individualized drug therapy and to show more efficient use of health care resources.

Abstract PS7-49: Assessment of patient out-of-pocket cost for palbociclib therapy in advanced breast cancer

Assessment of patient out-of-pocket cost for palbociclib therapy in advanced breast cancerBackground:Palbociclib has demonstrated improved outcomes in patients with advanced hormone receptor positive (HR+)/human epidermal growth factor 2 (HER2) negative breast cancer when used in combination with endocrine therapy 1,2. The current average wholesale price of therapy with this medication class exceeds $190,000 per year (at full dose). Financial toxicity is a major concern in the oncology population and can decrease patient quality of life and may result in non-adherence 3,4. Our objective was to describe the out-of-pocket cost burden for patients treated with palbociclib.

Methods:A retrospective review of patients newly initiated on palbociclib therapy between May 5, 2018 and May 30, 2019 was completed at our institution. Patients were included if they were 18 years of age and older, newly starting palbociclib for advanced or metastatic HR+/HER2- breast cancer, had US-based insurance, and received palbociclib from our internal specialty pharmacy. Cost information was collected utilizing dispensing reports and additional patient-specific information was obtained from the EHR. Descriptive statistics were performed on the collected data.

Results:A total of 44 patients were included in the cost analysis. Primary sources of coverage for these patients included commercial insurance (n=13), Medicare (n=25), and state/federal insurance (n=6). We first assessed costs with primary insurance coverage alone. The sum of all the initial cycle out-of-pocket copays after primary insurance totaled $49,108. The median individual copay was $291, the range was $0 to $2,943, and 9 of the 44 patients had no copay after the primary insurance was applied.

The impact of assistance programs, which include independent grant funding, copay cards, vouchers, and secondary Medicaid plans, was significant. After applying primary insurance and aid from assistance programs, the sum of all initial cycle out-of-pocket copays reduced from $49,108 to $3,172. After assistance, 33 of the 44 patients had an initial copay cost of $0. Over 90% of the out-of-pocket total was from two patients (one each with a copay of $2,467 and $497). Ultimately, Mayo Clinic Specialty Pharmacy helped patients avoid $45,851 in first cycle out-of-pocket copays, of which $41,079 and $4,772 were for Medicare and commercially-insured patients, respectively.

Copay cost by type of insurance was assessed. All patients with commercial insurance (n=13) had no actual copay for the first cycle. Medicare patients (n=25) are not eligible for copay cards and had larger pre-assistance copays compared to commercial patients (median $2,454 vs. $45). Vouchers or grants were utilized by 16 out of 25 Medicare covered patients. State/Federal insurance included 2 Tricare and 4 Medicaid patients. While ineligible for copay card assistance, the copays for these patients were low, ranging from $0-$28.

Standard Medicare D plans do not have an out of pocket maximum for the year. The catastrophic phase requires an ongoing copay of 5% of the total claim cost, resulting in approximately a $600 per month copay for the remainder of the calendar year during the study period. When combined with the first cycle cost of approximately $2500, the yearly out-of-pocket cost for a patient with a standard Medicare D plan is roughly $10,000.

Conclusion:Patients initiating therapy with palbociclib are commonly faced with high out-of-pocket costs. The availability, eligibility, and use of financial assistance programs are imperative in decreasing the financial toxicity. Specialty pharmacies play an important role in obtaining financial assistance which leads to decreased out-of-pocket expenses for patients.

Citation Format: Allison P Golbach, Matthew D Smith, Jodi L Taraba, Karthik V Giridhar. Assessment of patient out-of-pocket cost for palbociclib therapy in advanced breast cancer [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS7-49.

Invited review: Compost-bedded pack barns for dairy cows

Compost-bedded pack barns (CBP) are receiving increasing attention as a housing system for dairy cows that has potential to improve animal welfare. This article reviews current scientific knowledge about CBP with the aim of providing a comprehensive tool for producers and researchers using this housing system. In CBP, cows are provided with an open bedded pack area rather than the individual stalls and concrete alleys found in freestall systems. The bedded pack, a mixture of organic bedding and cattle excreta, is cultivated frequently (1-3 times per day) to incorporate fresh manure and air into the pack, thus promoting an aerobic composting process. To function well, CBP generally require a large area per cow. Optimal animal densities over the bedded area range from 7.4 to more than 15 m²/cow depending on several factors, including climate, bedding, pack management, and cow characteristics. Studies have indicated that CBP, compared with conventional systems such as freestall barns, have the potential to improve the welfare of dairy cows. In particular, the main reported benefits include improved comfort during resting, better foot and leg health, and more natural animal behavior. Research has also indicated that adequate udder health can be achieved in CBP. However, because the bedded pack has been shown to contain high bacterial concentrations, proper management is essential to maintain adequate cow cleanliness and reduce the risk of mastitis. Controlling pack moisture is consistently indicated as the most important issue with CBP. Especially under cold and humid weather conditions, large amounts of bedding may be necessary to keep the pack adequately dry and comfortable for the cows. Nevertheless, the improvements in cow health may offset the higher costs of bedding.

The effect of dietary crude protein on growth, ammonia concentration, and litter composition in broilers

An experiment was conducted to determine the effect of diets with reduced CP and supplemental amino acids on broiler performance, N excretion, litter characteristics, and equilibrium NH3 gas concentration. Results suggest that reducing CP (and lysine) below 241 g/kg (13.7 g/kg lysine) in the diets fed during the first 3 wk may slightly increase feed:gain and therefore may not be advisable. During the period 22 to 43 d of age there were no significant differences in weight gain and BW at 6 wk of age when reducing CP from 215 g/kg (11.5 g/kg lysine) to 196 g/kg (11.3 g/kg lysine), but feed intake and feed:gain ratio increased. However, reducing CP did cause equilibrium NH3 gas concentration and litter N to decline by 31 and 16.5%, respectively. Both of these advantages will improve air quality within the housing facility and possibly reduce heating costs during winter associated with higher ventilation rates required to reduce elevated NH3 gas concentrations.

The effect of dietary protein and phosphorus on ammonia concentration and litter composition in broilers

An experiment was conducted to determine whether broiler litter concentration of N and P and equilibrium NH3 gas concentration can be reduced by reducing dietary CP and P levels and supplementing with amino acids and phytase, respectively, without adversely affecting bird performance. Equilibrium NH3 gas concentration above the litter was measured. The experiment was divided into a starter period (1 to 21 d) and grower period (22 to 42 d), each having two different CP and P levels in a 2 x 2 factorial arrangement. The CP treatments consisted of a control with a mean CP of 204 and 202 g/kg for starter and grower periods, respectively, and a low CP diet with means of 188 and 183 g/kg, respectively, but with similar amino acid levels as the control. The P treatments comprised starter and grower control diets containing means of 6.7 and 6.3 g/kg P, respectively, and low P treatment means of 5.8 and 5.4 g/kg P supplemented with 1.0 g/kg phytase. Reducing starter diet CP by 16 g/kg reduced weight gain by 3.5% and, hence, body weight at 21 d of age, but did not affect feed intake or feed efficiency. Reducing P did not affect feed intake and weight gain, but improved feed efficiency by 2.0%. Responses in feed intake and efficiency to CP depended on the level of dietary P. For the grower period there were no significant differences in feed intake, weight gain, and feed efficiency, nor in body weight at 42 d of age, after correcting for 21-d body weight, between CP and P treatments. There were significant (P < 0.001) reductions in litter N and P concentrations, but not equilibrium NH3 gas concentration, moisture content, or pH, for low CP and P diets. Mean equilibrium NH3 gas concentration was 63 ppm. Litter N concentration was reduced 16.3% with the low CP diets, and litter P by 23.2% in low P treatments. The results suggest that dietary manipulation shows merit for reducing litter N and P concentrations while maintaining acceptable production performance from broilers.