Navigating Medication Therapy Management in mBC Treatment

Ryan Haumschild, PharmD, MS, MBA: When we’re looking at these patients, a lot of times pharmacists—we talked about through clever practice agreements—are the ones who are selecting therapy or they’re the ones who are managing therapy. Or they’re the ones sometimes doing the dose reductions independently to make sure that patients stay successful in therapy. A lot of that deals with medication therapy management [MTM], not only from the original prescriptive decision around what treatment, but the ongoing management of that patient. We’ve heard a lot about MTM in the past. Dr Kettle, can you provide even further clarification? How can medication therapy management be utilized when we’re working with patients with advanced metastatic breast cancer [mBC]?

Jacob K. Kettle, PharmD, BCOP: This has really been an emerging area for many years. Like I said previously, oncology has changed a lot in the 15 years I’ve been doing this. What fits so well in the metastatic breast cancer space, particularly now when we’re talking about aromatase inhibitors and CDK4/6 [cyclin-dependent kinase 4 and 6] inhibitors being combined, patients are going to be on this combination for 18 months to 2, 3-plus years—potentially even longer than that. That’s a lot of opportunity where patients are going to be on this treatment. That’s very different [from] in previous use of oral oncolytics, when we started experimenting and using these drugs a little bit where patients weren’t on them so long, with the exception of imatinib and drugs for CML [chronic myeloid leukemia]; that would be the lone exception. But now we see patients on these drugs for very long periods of time. The longer someone’s on a drug, the more opportunities there are for intervention and more of a need for that routine medication therapy management. Again, if a patient would be on a drug for, you know, 2 to 3 months at best, there’s not a lot of opportunity for an intervention.… A small improvement in optimization doesn’t really shift things. Now, if we talk about the clinical trial patient who has 18 months median progression-free survival, if we up our game and increase those intervention points, manage toxicities, keep patients on therapy longer, the benefit of that effort really compounds because the starting point is so much higher. It’s critical. A key piece is frequent monitoring, early intervention, lots of education. It’s very easy to think, 1 good education session and that’s all you need to worry about, but these are ongoing assessments that need to be evaluated. The other piece too is the emotional piece. You know, most of us don’t live with a daily reminder…we’re all mortal, but most of us don’t live with a daily reminder. When you have metastatic breast cancer and take a pill multiple times a day and sometimes multiple medications, that’s a constant reminder that you have this lingering terminal illness in the background. That alone has a significant emotional toll. It really goes beyond just the adverse effect management, dose adjustment, making sure we’ve got good adherence in those things. There’s really an emotional support component. I think it’s really key. That’s why pharmacists play such a critical role building relationships early and maintaining them throughout the course of care.

Ryan Haumschild, PharmD, MS, MBA: Pharmacists are so uniquely positioned to provide that ongoing monitoring. You really summarized it well.

Heather Moore, CPP, PharmD, BCOP: If I can just add something to that, because I feel we are pharmacists and we just talk about medications, but we’ve not talked about drug interactions throughout this entire time. That is something that is essential, especially going back to medication management and more so thinking about the chronic use of these drugs and think about the supportive side of things. With so many of our agents, thinking in terms of like Paxlovid [nirmatrelvir/ritonavir] with COVID-19. I’m thinking about pain management, palliative care therapies, antidepressants, and thinking about all the supportive care therapies that we’re using and patients who are continuing to live their lives on these drugs. We do have to be mindful of drug interactions, specifically thinking about CDK4/6 inhibitors. All of them are CYP3 [cytochrome P450], [CYP4] substrates. Ribo [ribociclib] in itself has a few more interactions and it’s also a CYP3A4 [cytochrome P450 3A4] inhibitor. But I just think it’s essential to be mindful of all these things as patients continue on their journey. But as they’re having other medications, we’re checking that. My clinic’s pretty good that when patients are started on something else…I tell them when we educate, if anyone starts you on anything new and it is not us, please let us know because we always have to assess to make sure that it is appropriate [and] there aren’t interactions there and that we’re not setting ourselves up for disaster. That’s just something that I would add to that piece.

Jacob K. Kettle, PharmD, BCOP: What a great point. I’ve been a pharmacist for a lot of years, and that didn’t even come [to the] top of [my] mind. But you nailed it. Because, again, they’re on these drugs. The patient’s other comorbidities are going to change during that time they’re on therapy. Heart medications, all those things will come and go. Absolutely, you have to have a touchpoint, an awareness of that whole picture. Really glad you added that color.

Transcript is AI generated and edited for clarity and readability.