Evolving Oncology Pathways, CLL Treatment Advances, and the Role of Multidisciplinary Care Teams

Shaffee Bacchus, PharmD, discusses the evolution of oncology pathways, advancements in chronic lymphocytic leukemia (CLL) treatment, and the importance of multidisciplinary care teams in addressing comorbidities and enhancing patient quality of life.

Transcript:

Dr Shaffee Bacchus: My name is Shaffee Bacchus. I'm the Oncology Access Lead for Value and Access at AbbVie, and I'm here at the Clinical Pathways Congress because we believe that pathways are a critical access channel for oncology. We need to be aware of how pathways are evolving to ensure that we have continual access of oncology products to our patients. To tell you a little bit about myself, I'm trained as a pharmacist, and I'm very fortunate to have always had opportunities to be a patient advocate for my early career. I started in nephrology, where I did outcomes research, essentially trying to understand medication-related problems in complex patients with kidney disease. Then I spent some time with a GPO connected to Premier, and that exposed me to the supply chain of medications and how they traverse the healthcare landscape. After a few years of that, I joined Janssen where I got my first introduction to hematology-oncology, and for the last 3 or 4 years I've been at AbbVie in the oncology space, primarily in the hematology space here.

What are some of the most common treatments for patients with chronic lymphocytic leukemia (CLL)?

Dr Bacchus: Chronic lymphocytic leukemia (CLL), as you know, is a complex disease state. Initially we had chemo-immunotherapies, which were a broad-based approach to CLL treatment using agents within the alkylating agents and so forth. However, over the last 10 years we've had targeted therapies like BTK inhibitors and Bcl-2 inhibitors, and these drugs are incredibly effective, prolonging the 5-year survival for patients up to as much as 88%. We also see that there could be combination therapies of BTKI and Bcl-2 inhibitors, and we have CAR T therapies on the horizon.

Given the advanced age of patients with CLL and their complex medical needs, how can a holistic approach to care address comorbidities, concomitant medications and socioeconomic conditions to optimize outcomes?

Dr Bacchus: That's a great question because the average age of diagnosis for CLL is 70 years of age and usually occurs in white males. By that time, these patients have developed different comorbidities. Usually they have underlying cardiovascular comorbidities, diabetes, they might have kidney disease, they might even have other cancers. Both diabetes and kidney disease are independent risk factors for cardiovascular disease as well. In addition, they're treating multiple other comorbidities, so taking multiple medications multiple times a day. That in itself is challenging for these patients. What we need to do is ensure that there's a very strong multidisciplinary team that could provide the type of support that these patients need throughout their care. Survival is improved, so you have to have a system that can provide that care over a long period of time. We have 10-year data showing that patients do well in overall survival. What we need in terms of this care team are oncologists. Of course, you may need cardio-oncologists, pharmacists, nurse navigators, and you do want to engage the patient's caregivers as well.

The last thing I'll say is that shared decision-making is very important because you want to elevate that patient voice and understand their experience. If a patient is going to live that long on a therapy, that is great, but you want to make sure that they have the quality of life that they need to have as well. You really do want to listen to them. In fact, there are many programs here and even by the FDA that are elevating the patient voice into the early research process.

What specific attributes of therapeutic options are crucial for the long-term management of patients with CLL?

Dr Bacchus: That's also an amazing question, and it really goes into what we talked about before, around 5-year survival being at 88%, and quite honestly, since the introduction of targeted therapies, there's this adage that says patients don't die from CLL but with CLL. You really want to incorporate the CLL treatment into the patient medication regimen. You want to do that as simply as possible. The best way, or one of the best ways, is to decrease the pill burden or reduce the pill burden as much as possible. Therapies that are once daily are going to be easier to use and they will most likely promote adherence. If patients take the drugs, you're going to maintain the outcomes as well.

Additionally, we've learned that 1 in 6 adults has some difficulty swallowing. In fact, a study looked at the general population and found that for swallowing difficulties or dysphagia, there was a 5% prevalence. When you look at patients with CLL, there was a 6% prevalence. And when you look at patients with Waldenström macroglobulinemia, there was a 7% prevalence. But in fact, when you look at dysphagia, you can think about it as difficulty swallowing solids or soft foods or liquids. I'm sure that you probably know of somebody that has intermittent difficulty swallowing. A good way to mitigate these challenges is to develop the kind of formulations that would be needed to address dysphagia, and one of those would be an oral suspension. Oral suspensions are great because they address some of those issues around swallowing, but if you need to do a dose modification, it's also easier to decrease the dose, because essentially you're decreasing the number of milliliters that the patient is taking and you retain the integrity of the remaining drug, thereby reducing waste. That's important because cancer therapies are quite expensive.

How do the attributes you mentioned contribute to improved patient outcomes?

Dr Bacchus: One of the key issues in oncology is that adverse events (AEs) are par for the course. They are going to occur at some point in a patient's therapy. It’s really important to understand how AEs present across the therapy, be able to have some sense of predictability of what those AEs are going to be, and then have a very strong AE mitigation strategy or process or dosing guidelines. Those dosing guidelines should also be well-researched, scientifically proven, and physicians should be able to easily implement those changes. Those changes result in the type of resolution of AEs that is needed with these patients.