Expert: Treating Patients As Individuals Is Essential to Minimizing Disparities in Oncology

In an interview with Pharmacy Times as part of the American Society of Clinical Oncology (ASCO) 2022 Annual Meeting, Jan Beumer, PharmD, PhD, DABT, discussed equity in renal formula considerations. Expanded glomerular filtration rate (GFR) testing in the United States could be one step toward minimizing disparities in renal formulas, Beumer said.

If the technology for glomerular filtration rate testing is available, why are these tests not widely available in the United States?

Jan Beumer, PharmD, PhD, DABT: So, in Britain, for example, they use radioactive chromium EDTA, and so they're a little bit more comfortable with just using something radioactive. I think in America, there's a bit of, like, the cootie factor. They go “Oh, radioactive!” and there's real regulatory issues with that, and so that's fine. But there are non-radioactive alternatives like iohexol, which is a compound that we're using in one of our research trials that the nephrology field has used extensively. It's just a contrast agent that is used every day in cancer patients everywhere. And so, why is it not more widespread? Well, because institutions will need to invest and physicians will need to be willing to order it. It’s just the attention span is not there to get the basics, right? And that is something that is a recurring theme. I'm getting a little older and more cynical. For all the innovations, sometimes we fail to just get the basics right. And that's not just on the research side, it's actually at the institutional level. How do you implement things? How do you deliver the best care that's equitable for everyone? And not just race, but you know, sex is important in this formula. Not everyone is the same. And so, I would say, yes, there's a racial aspect of equity, but I would say everyone deserves equity, and the current medical establishment is just not doing a good job at it in certain ways. And these are not expensive things, right? If this is a decision that is made on a sort of system-wide level, these are not expensive tests. I mean, there's no patent stuff involved, it's just, you know, a compound that is already used as a contrast agent, it's relatively cheap, it's $10 or something. And then, you know, once you create the volume to have these things measured in oncology patients, sort of regularly or, you know, when needed, the volume will take care of the of the measurement as well. It's not rocket science. Like you said, we have the technology, we're just you know, following the next shiny object.

What is pharmacists’ role in utilizing these formulas and considering the equity issues you’ve discussed?

Jan Beumer, PharmD, PhD, DABT: So, I have to give the disqualifier that I'm a pharmacist, I’m licensed even back in the Netherlands, but I don't practice here. But I have these discussions often with our investigational drug pharmacist. So, he'll sometimes call me up and say, you know, we've got this patient, really obese, usually at the extremes of the demographics. With the average patient, you know averagely what to do. But when you get these outliers—like I said, everyone deserves equity, and then it gets tricky. And then which formula you use can really make a big difference. And so, you know, if you get someone who's obese, then you say, well, their mass is not as much muscle as the formula will assume it is. And so, we need to work with lean body mass. And so, every organization has their sort of workarounds to deal with these sorts of extremes. And so, some organizations say, I won't consider any creatinine value that's below 0.7, because that looks like a ridiculously healthy kidney and we just don't believe it. And so, we're just going to use 0.7 for any value below that. And other people say, well, we're going to use lean body mass or altered or adjusted ideal body weight, and there's all these different workarounds. And knowing that these estimates are exactly that really wide margin. Again, if only we could measure it, and then you'd know where you are with this specific patient. It’s personalized medicine, equity down to the individual level, not the group level, right? Thinking about groups, I know it's heuristics, right? It's sort of like, it's a shortcut. It works somewhat. But at the end of the day, when you're in front of a patient, you want the best treatment for that individual patient at that moment. You don't want to treat that person like the group they belong to So that would be my take.

Is there anything you want to add?

Jan Beumer, PharmD, PhD, DABT: This is a touchy subject, and I think rightfully so, right? In this country and other countries, there is a history of discrimination. And so, if we can get rid of these race factors, I think that would be good because of the history, but also because it is this catch-all. Like, we're just going to account for that, even though we really don't really understand what's going on. And so, it will be good to get rid of the race factor. But until we have properly functioning alternatives, where the consequences for the individual patient are not less drug or no drug, we just have to work on getting properly functioning alternatives in place. Because it sounds great, but there are going to be consequences down on the individual level. And at the end of the day, like I said, you have a responsibility for an individual patient. So, you want to get the best treatment for that patient and that means the best estimate for that individual. Whatever group they belong to.