Chemo-Free Regimen in Later-Line Settings

Expert oncologists and pharmacists discuss the significant of chemotherapy-free regimens in later-line settings, and the role of specialty pharmacists to direct individuals toward the appropriate treatment plan.

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Maurie Markman, MD: One of the obvious conclusions from these conversations is we actually have regimens now that basically don't include chemotherapy. Is there a thought on, what does that mean for our patients? Toxicity? We've been giving chemotherapy since alkylating agents in the 1950s.

Michael Birrer, MD, PhD: Before my time.

Maurie Markman, MD: Now we have actual regimens that are highly effective that are not cytotoxic. Comment on what that means, good or bad, or...?

R. Wendel Naumann, MD: A couple of things. Just because something is oral doesn't mean it's less toxic than something IV [intravenous], as you pointed out, or compliance is an issue, cost is an issue. The biggest problem we have is the fundamental treatment up front is moving so fast, it's almost impossible to design a second-line trial that has any meaning. Because as soon as we do, the upfront treatment may change and nullify the results of that trial.

Michael Birrer, MD, PhD: I would completely agree with that. I do think SOLO-3 is kind of an interesting trial. I remember I was at Harvard Medical School at the time. We opened it, but there was a huge controversy. SOLO-3 was platinum-sensitive recurrent patients. On one arm they got single-agent chemotherapy, not platinum. And on the other arm they got olaparib. And there was a huge controversy because everyone thought you can’t do that for patients.

That’s part of the reason it didn’t accrue well and got closed early, but it’s an interesting study because the response rates on the olaparib arm were astonishingly high, at least suggesting that in the right patient population, a nonchemotherapy regimen could give you very high response rates. I can envision the time, I’ll throw this out here just to get everybody excited but also agitated. Could you take germline mutated patients upfront and treat them with olaparib, BEV [bevacizumab], and Taxol and leave the platinum out? I said it first.

Annette Hood, PharmD, BCACP: I think one thing that’s beneficial about having these oral therapies, it’s a better quality of life for patients. They don’t have to keep coming back and forth to the clinic. Obviously compliance is something that we do have to worry about, but coming to the clinic creates a lot of anxiety for patients. They might have anticipatory nausea, so this is beneficial because they can get treated at home, and they don’t have to keep coming back and forth to the clinic.

Maurie Markman, MD: A question comes to my mind now. With all of these options we’re talking about, the role of the pharmacist also helping the patient, directly talking to the patient and their family, is there a critical role for that kind of conversation, in your opinion?

Annette Hood, PharmD, BCACP: Definitely. I think that the patients get a lot of information thrown at them when they have their first chemotherapy session. So I really find my role, I like to go in and talk to the patients and their families maybe on cycle 2, after they’ve gone through 1 cycle, they’ve had a chance to, if they have to use their nausea medication, sometimes they have questions that they don’t think to ask before they start. So I help make adjustments to the nausea regimen. A lot of times patients come in and they want to take herbal therapies or things like that, so I do spend a lot of time talking to the patients about that as well and what’s appropriate, what’s not appropriate.