Pharmacists’ Involvement in Treatment Decisions for NSCLC Has Increased and Evolved

The use of targeted therapies and immune biomarker testing at an earlier stage could significantly improve outcomes in non–small cell lung cancer (NSCLC), according to a panel of experts at a Pharmacy Times Clinical Forum event.

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“I think it is really important to take a step back about why lung cancer is important to talk about [and] why we’re talking about NSCLC in particular,” said moderator Chris Elder, PharmD, BCOP, associate director of Pharmacy Clinical Services at Florida Cancer Specialists & Research Institute in West Palm Beach. “Lung cancer is the leading cause of cancer-related mortality in the United States. When we talk about lung cancer, [we know] it’s an important disease state, yet lung cancer awareness [activity] falls [short] every year after Breast Cancer Awareness Month.”

However, significant research has been done to assess driving mutations and biomarkers in NSCLC, Elder explained. In addition to smoking, other risk factors include occupational factors, radiation expo-sure, family history, and personal history of other cancers and diseases. Earlier testing and evaluation of prognostic markers remain crucial as well, although the focus of the event’s discussion was around immune biomarkers, PD-L1 expression, and immunotherapies.

Some panelists noted that there have been chal-lenges with biomarker or next-generation sequencing testing at their institutions, particularly in terms of communication among providers, commercial labs, and pharmacy teams. Panelist Amber Cipriani, PharmD, BCOP, CPP, a precision medicine pharmacy coordinator at University of North Carolina Medical Center in Chapel Hill, explained that despite having significant resources, her facility still encounters barriers to getting the necessary biopsies and tests scheduled.

“One thing that actually surprised me was not just [problems associated with] ordering the actual test, but what it takes to actually get to that step,” Cipriani said. “[Because of this,] at some of these sites, they’re having trouble getting patients scheduled for biopsies. Patients come in with tumors, and it takes 4 weeks before they can get a biopsy.”

Because of some of the challenges for patients with NSCLC when pursuing cancer care, pharmacists can often wear multiple hats to help address their treatment needs. The panelists agreed that the ways pharmacists engage and interact with patients can vary based on institutional processes and treatment protocols. For example, Bryan Fitzgerald, PharmD, BCOP, an oncology clinical pharmacy specialist at University of Rochester Medical Center in New York, said he works primarily with oral oncolytic agents and typically gets involved when patients are initiating therapy with an EGFR inhibitor.

The panelists also noted that as therapeutic options for NSCLC become more complex, the pharmacist’s role and involvement in treatment decisions has increased and evolved.

“Now with all the noncomparative data and the different ways that we’re splitting the hairs of who will and will not respond to these immunotherapies, I’m more involved, at least in the treatment decision perspective,” explained Kevin Chen, PharmD, MS, BCOP, CPP, clinical pharmacist specialist at University of North Carolina Medical Center. “From the oral oncolytic [perspective], I certainly am involved now that there’s more controversy in—let’s say—selecting the best KRAS or MEK inhibitor. But [when] it comes to ALK or EGFR, there’s not necessarily as much involvement needed from me.”

Patients are also becoming more involved in treatment decisions, although some panelists noted associated challenges around health literacy. To address health literacy, cancer support centers at various institutions can provide short educational videos that clarify, in layman’s terms, different disease states or treatment terms, such as the differences between genomics and genetics. This can help patients interested in engaging with their own care and treatment process do so from a more knowledgeable starting point.

Panelists then discussed the significant unmet needs and challenges in terms of treatment access and adherence for this patient population. Specifically, financial toxicity for patients with NSCLC is considerable, as well as health care access issues pertaining to testing and other requirements. The complex nature of these treatments and multitude of experts needed also present logistical challenges.

“The discontinuity of care between different stages, and especially for a non–small cell lung cancer, [is a challenge],” explained Samantha Shi, PharmD, BCOP, clinical pharmacy manager at the University of Southern California Norris Comprehensive Cancer Center in Los Angeles. “You may go from a radiation oncologist to the medical oncologist, the surgeon, and then to chemotherapies and to management—and then switching to oral [therapies] when your biomarkers are coming back. And even within the same health system, you have the disconnect between different teams and [associated] communication challenges.”

Having a multidisciplinary approach is crucial in NSCLC, according to the panelists. In addition to oncologists and pharmacists, the panelists explained that social workers, genetic counselors, financial assistance experts, and palliative care experts are all crucial members of a patient’s care team. However, of critical importance are pharmacy technicians, who take on a lot of the work required for coordinating and facilitating patients’ treatment processes.

“Pharmacy technicians [are] the unsung heroes of the pharmacy world,” Elder said. “They take on the brunt of the workload, and they probably work the hardest in the pharmacy department and get paid the least.”

Panelists next discussed the common agents used in NSCLC and noted that surgical approaches should always be the first consideration because they provide the best chance for a cure in earlier stages. For patients who are not candidates for surgery, however, Elder said a plethora of targeted therapies, biomarker-driven therapies, and immunotherapies are now available.

“It’s very interesting that we’re now moving immunotherapy up, and we’ve seen targeted therapy move up with osimertinib [Tagrisso; AstraZeneca],” Elder said. “Now as we start getting into nivolumab [Opdivo; Bristol Myers Squibb] in the neoadjuvant setting, how are treatment choices being made between neoadjuvant versus adjuvant?”

Panelists explained that tocilizumab (Actemra; Genentech) and pembrolizumab (Keytruda; Merck) are both available in the adjuvant setting, with supportive data from the IMpower010 trial (NCT02486718) and KEYNOTE-091 trial (NCT02504372), respectively. Although pharmacists may not always be involved in these treatment decisions, a few panelists noted that they have taken part in discussions recently that favored neoadjuvant therapies; however, further data from the ongoing KEYNOTE-671 trial (NCT03425643) with pembrolizumab in resectable stage II, IIIA, or IIIB NSCLC may impact that in the future.

The panelists also noted that a critical need remains to expand access and address health inequities for patients with NSCLC, and further data are needed to understand how best to address the challenges patients face.

“I think we have a lot of inequities in terms of patients participating [in clinical trials], and I think if we’re able to really change that paradigm, it’s going to be easier for patients to access care,” explained Maya Leiva, PharmD, BCOP, APh, lead advanced practice pharmacist at Bass Comprehensive Cancer Center in Walnut Creek, California. “We’re going to get data more quickly as well. So I think that’s a major barrier to care that we’re still dealing with.”