Oncology Stewardship Can Take Multiple Forms in Practice

Implementing oncology stewardship in health-systems can come in several forms, including dose rounding and banding, biosimilars, and various sites of care, according to a session at the 2022 American Society of Health-System Pharmacists Midyear Clinical Meeting.

Financial challenges are a constant and growing issue in health care, with increasing costs of hospitalization, diagnostic and therapeutic procedures, equipment, and labor. Cancer care is at the higher end of the health care cost spectrum, making up a large percentage of expenditures, according to presenter Donald Moore, PharmD, BCPS, BCOP, DPLA, FCCP.

Importantly, the rising costs of cancer care are not only an issue for health systems but pose serious problems for patients who struggle with financial toxicity. Moore noted that this toxicity is associated with worse clinical outcomes, such as more advanced stage of presentation, and therefore, growing costs of care, increased morbidity, and higher mortality rates.

To manage these costs and improve patient care and outcomes, Moore said there is a growing sense of stewardship outside of the context of antimicrobial stewardship programs. In the oncology space, Moore said stewardship can be defined as “measures to use and preserve resources for the benefits of health care organizations to effectively, efficiently, and holistically address the needs of patients with cancer.” An alternative definition is a “set of coordinated strategies to improve the use of antineoplastic agents with the goal of enhancing patient outcomes while reducing financial toxicity.”

Three key opportunities for oncology stewardship are dose rounding, implementation of biosimilars, and management of sites of care.

Moore said dose rounding is exactly what it sounds like—rounding doses to the nearest vial size when the difference is less than an established percentage. This practice has several benefits: minimizing drug waste, ensuring accuracy during preparation, and reducing health care expenditure.

The Hematology/Oncology Pharmacy Association (HOPA) has published a position statement with 3 key recommendations for dose rounding. First, the statement recommends that monoclonal antibodies (MABs) and biologic agents can be dose-rounded to the nearest vial size within 10% of the prescribed dose. Second, for MABs with a cytotoxic constituent, the statement suggests that dose rounding should be applied to a cytotoxic agent. Finally, the statement recommends that traditional cytotoxic agents be considered independently for dose rounding within 10% of the prescribed dose.

Moore also discussed dose banding, which can be automated using electronic health records that automatically update the dose.

“I think when we think about barriers to oncology stewardship and initiating some of these processes, whatever we can do to initiate electronic medical records and what it can do for you,” Moore said. “…and whatever you can do to have your front-line pharmacist be involved.”

Next, panelist Kate Taucher, PharmD, MBA, BCOP, FASHP, FAPO, discussed the implementation of biosimilars and how it can help oncology stewardship. Biosimilar approvals are accelerating, with 39 now FDA-approved and 3 interchangeable products. However, Taucher said a 2018 survey of oncology clinicians found very low levels of knowledge about biosimilars. Specifically, 74% could satisfactorily define a biosimilar, 40% incorrectly considered a biosimilar to be the same as a generic, and 30% said they were “not likely” or “never” would use a biosimilar in practice.

“Now it’s really interesting…if the FDA considered the products interchangeable, 94% of respondents would use that product interchangeably in their practice,” Taucher added.

When implementing biosimilars in a health-system, Taucher said there are formulary, operational, and payer considerations. Pharmacy and therapeutic committees should consider analytical or scientific equivalence data rather than clinical data alone, as well as indications for biosimilar versus originator products, interchangeability versus therapeutic interchange, and new biosimilar agent approvals.

Additionally, committees should define their approach to biosimilars to make future reviews as straightforward as possible.

“Defining that approach early on is the key to making this a smooth process as more products come to market,” Taucher said.

Operational considerations are also important, including reliability of supply, physical space capacity for storage, technical support for converting order sets, and a comprehensive rollout and communication plan to ensure that all stakeholders are informed.

Finally, presenter Jason Bergsbaken, PharmD, MBA, BCOP, reviewed site of care options. There are many potential sites of care for oncology, including inpatient, outpatient, home infusion, and specialty pharmacy.

“We’ve seen more and more transitions to outpatient care, but inpatient care continues to have a role,” Bergsbaken said.

Site of care matters for oncology stewardship because of its impact on patient safety and outcomes, as well as cost and reimbursement. Regimen frequency and timing, supportive care and monitoring needs, and patient satisfaction are all key aspects of patient safety and outcomes that are strongly impacted by site of care. Additionally, resource utilization, reimbursement models, and payer influencers have significant impacts on cost and reimbursement.

“Again, back to our core stewardship principle, from a resource utilization standpoint we’re trying to do all this work with the lowest possible resources,” Bergsbaken said. “We know that inpatient site of care is known to have the highest level of resources, so if we can transfer out of that setting, that would make a lot of sense.”

In all of these various considerations, the panelists agreed that pharmacists have a crucial role to play. In both dose rounding and biosimilar implementation, pharmacists can work to educate clinicians and other stakeholders on the benefits and best practices, and pharmacists are crucial team members in transitioning patients between sites of care, according to the panel.

REFERENCE

Bergsbaken J, Moore DC, Taucher KD. Note Just for Antimicrobials: Integrating Oncology Stewardship into Practice. Presented at: ASHP 2022 Midyear Clinical Meeting. December 4, 2022.