Optimizing Success for Community Physicians

Expert pharmacists provide community physicians with recommendations for optimizing success on treatment for patients with chronic lymphocytic leukemia (CLL).

Alison Duffy, PharmD, BCOP: What are your recommendations, Dr Steeves, for physicians in the community to optimize the success of these treatments?

Cody Steeves, PharmD, BCOP: I think the simplest answer to this is following the literature. We've said it many times, we need this literature to mature. This is a long-term, chronic illness. When we see a patient with CLL [chronic lymphocytic leukemia] walk in our doors, we expect them to have years, maybe even decades, of survival, not just trying to control the disease for a few months and see what happens.

The data will tell us more as we move along with that. I think about long-term MRD [minimum residual disease] response rates, what they may mean, the efficacy of long-term drug-free intervals, and as we mentioned, the rechallenging versus switching to a new agent, what that's going to look like, we're going to have to have data on that. For CLL, the nature of the disease, it probably will come back. To think that we will cure the disease in most patients is pretty unlikely; these chronic diseases generally aren’t eliminated.

So we need to figure out what we're going to do with these patients, if and likely when the disease does return, and how many months or years that's going to take. Additionally, I would urge physicians to use all their resources, whether it's in-house pharmacists in the clinic, nursing staff, PAs [physician assistants] NPs [nurse practitioners], pharmacists in the specialty and community settings, use all the resources at their disposal, to provide education to the patients.

As a pharmacist in the specialty setting, nothing makes us happier than when a patient answers the phone and they say, “I already had a teaching session at the doctor's office, but why don't I hear it one more time from you?” These are the patients I have the most confidence are going to be the most adherent to therapy, and again, will do the best long term on the therapy because of that adherence, because they crave the education and because they're seeking it out.

But it's because it started in the doctor's office with, “These are the resources we're going to give you to help you with this therapy.” Even if the adverse effects are pretty tolerable in those cases, it's still a complicated regimen usually, and there are a lot of issues that go along with it. What about you? Same question: how to optimize therapy for the doctors and how should they move forward?

Alison Duffy, PharmD, BCOP: I agree with everything you said. From an education perspective, something that can be really helpful is recapping, like you said, on education, using those open-ended questions that we learned about in school that sometimes get missed in the shuffle that can be enlightening to help physicians understand what some of the challenges are for patients. It might be assumed that patients are taking the drug and understand it, and maybe patients are too nervous to ask questions.

That can be helpful, to use open-ended teach-back questions initially, but also at follow-up, to make sure the patient really comprehended and retained it, because there's so much information. I agree with what you said in terms of the evolving literature, and also using different colleagues for help; I think that's also a great point.

Before we conclude today, I'd like to get any final thoughts that you have, Dr Steeves.

Cody Steeves, PharmD, BCOP: I'd like to thank you, Dr Duffy, and thank you to Pharmacy Times® for allowing us to have this discussion today.

I urge all pharmacists working in CLL or any disease to continue to follow the literature, keep track of the NCCN [National Comprehensive Cancer Center] guidelines which are updated all the time. Any time you click on them there's a new update or a new category, or something like that, of the disease. As literature homes in, and the question, I learned this back in my rotations in my education, we always ask ourselves, “How will this change my practice?”

Because I can tell you the percentages, A versus B had this percentage versus this percentage, but we have to weigh all the factors. Did it increase toxicity? How is it going to change what I do and what I recommend, and what I think is most appropriate for the best course for our patients? We do have the luxury of multiple agents in this disease, which is a very good thing, but it creates the problem of deciding and dealing with which is the best for each patient.

Medicine, we've all heard stated, can be as much or more of an art than a science, sometimes. It's being creative and deciding which is the best option for every patient. But thank you, again, for helping with this, and thank you, everybody, for watching the discussion today.

Alison Duffy, PharmD, BCOP: I agree with your thoughts. I would also add, don't be afraid as pharmacists to clarify questions.

Oncology can be daunting, for sure, so know that these therapies are not going anywhere. Some of the resources that we pointed out already on the HOPA [Hematology/Oncology Pharmacy Association] website, HOPArx.org, and oralchemoedsheets.com, are great resources for education. Honestly, it takes so many different pharmacists within the team, but other health care practitioners as well, to make sure that things don't get missed.

Know that you're important in the whole treatment algorithm and treatment landscape for patients, and you should feel empowered to feel like you can help. I also think it's important to reflect and think about what are our strengths as pharmacists, because you're probably assuming correctly that we can always help with some of the things we mentioned today in terms of access and adherence and interaction.

So go with your gut, and know that that is helpful, and more eyes on the patient is always a good thing.

I wanted to thank you as well, Dr Steeves, and to our viewing audience today, we hope you found this Directions in Oncology Pharmacy™ insights discussion to be rich and informative. We hope you have a great day.