Pharmacy Involvement Can Improve Patient Outcomes When Treating Leukemia

Jenna Ciervo, PharmD, BCOP, a leukemia clinical pharmacy specialist with Memorial Sloan Kettering Cancer Center, New York, discusses the role of the oncology pharmacist in managing chronic lymphocytic leukemia (CLL) with Pharmacy Times. Ciervo breaks down how to identify treatment options, the importance of accounting for co-morbidities, how to help patients overcome barriers to care, education and counseling, and more.

PT Staff: What is your role as a pharmacist in managing chronic lymphocytic leukemia (CLL)?

Jenna Ciervo, PharmD, BCOP: So, as one of the leukemia pharmacists, we have 4 different pharmacists that all kind of cover the leukemia services; we rotate between the inpatient and outpatient settings. So on a monthly basis, we will go on the inpatient round on the team, and then on the other months we'll be in the clinic helping providers with new visits and things like that.

So for CLL, we work with all of the CLL providers (whether it be inpatient or outpatient), but I think the majority of the treatments are in the outpatient setting. So that's where we really shine, with our help there. So mainly in the clinics, we'll see all of the new patients that come in with CLL that are either seeking second opinions or looking to establish care, and then we'll help with drug education, therapy selection, and assisting providers with any information they need regarding treatments.

Investigators enrolled a total of 523 patients with CLL. Image Credit: © jarun011 - stock.adobe.com

PT Staff: What is your involvement level on the patient care team for patients with CLL, and does that involvement vary depending on any factors in particular?

Jenna Ciervo, PharmD, BCOP: We are pretty involved with our CLL patients, and as I said, we'll see all the new visits, and then we'll meet with the providers and talk through their disease states, then deciding whether they even need treatment or not. And then once we determine that, we really go into selecting the best therapies for the patients. And then once that's selected, we'll review their medication lists, go through potential drug interactions, and comorbidities to make sure that the therapy is appropriate. Once that's all done, we'll help with providing education to the patients. If there's any issues with denials or appeals that needs to be done, we will also assist with those. We help with all aspects of it, even coming down to like drug acquisition.

PT Staff: What is the process for identifying the best treatment for an individual patient with CLL?

Jenna Ciervo, PharmD, BCOP: I feel like, especially since this is like a diagnosis of elderly patients, people can have a ton of comorbidities and a ton of medications, so it's really just starting out by like looking at (I would say) their comorbidities first; that will help narrow down between which treatments we want to look at. And also obviously the disease characteristics of what their CLL like, there are different types of cytogenetics and mutation status, so that comes into consideration too.

For example, if people have cardiac comorbidities, maybe we'll want to stay away from the bruton’s tyrosine kinase (BTK) inhibitors because we know they tend to have more cardiac side effects versus a venetoclax-based regimen. So we'll kind of take a look into that and then dive into the drug interaction standpoint. That can be sometimes challenging, especially with a lot of different cardiac medications as well. I think something that's important and comes into mind is patient preference. So we do have therapies that are time-limited and patients can potentially get, such as our venetoclax-based with an anti-CD20. So those can be time-definitive therapies, versus something like a BTK inhibitor, which is more of a long-term, lifetime-long medication.

Patient preference is something that comes into play if they don't have any reason why they couldn't get either of the therapies. Then [there is] access to care as well, because our venetoclax-based regimens tend to require more monitoring upfront. So it requires people to sometimes have to be admitted for initiation of treatment for up to 5 weeks, whereas the BTK inhibitors don't require admission for initiation. So access to care is going to be something that comes into play. And then the last part of that is going to be the drug interaction standpoint as well.

PT Staff: What are some of the ways that pharmacists, care teams, and treatment centers can help patients overcome hurdles like access to treatment (i.e., access to venetoclax therapy regimen?)

Jenna Ciervo, PharmD, BCOP: So we have a lot of support for our patients [and] I feel like it's actually a little bit easier than you would think. The admissions are usually just 2 days every week for 5 week for something like the venetoclax ramp-up. So if we need to help coordinate transport and things like that, we have services and teams that are really great at doing that.

And we also have regional sites. So, for example, if patients met criteria where they didn't actually require a hospital admission but they needed like monitoring in a clinic, we do have regional sites around New Jersey and in Westchester, New York, in Long Island, New York, that can be a little bit more accessible for patients. So if they do meet the criteria for outpatient initiation, they can do that there in the clinic setting and not even have to come into the city for admission to the hospital.

PT Staff: What impact does your counseling have on treatment decisions for patients with CLL?

Jenna Ciervo, PharmD, BCOP: Adherence and compliance is just important for all medications. So that's 1 of the number one biggest things that we will counsel on. How to take the medication appropriately is going to be another thing; so if [it] requires food, or if it has to be taken at a certain time of day. We'll definitely go through all of that stuff. And then I think the side effects portion of it is probably the most impactful for patients because, especially if they're going to be on a lifelong medication, they want to know “What's going to happen to me if I take this for the rest of my life?”

It helps that we provide education to help ease patients anxiety and [help them to] understand that, if anything comes up, we're here (the pharmacists), we're here and ready to deal with it. But just encouraging them that overall [that] these medications are really well tolerated and, again, we're always here as a resource in case something comes up if they have questions on.

PT Staff: Are there supplementary interventions or treatments that can prevent adverse events?

Jenna Ciervo, PharmD, BCOP: There are some supportive measures, but a lot of the BTK inhibitors can cause increased risk of bleeding, so recommend things like a soft bristle toothbrush to avoid anything too abrasive on the gums can prevent bleeding. But supplement-wise, typically no supplements.

Actually, [they] are problematic in our eyes for the most part because a lot of patients with CLL do a lot of research and there's some information about some things that can potentially help with their CLL, [but it can] actually potentially have drug interaction. For the most part we don't recommend supplements unless a patient is deficient in something. So like vitamin D, B12, things that we can kind of check in their labs. So supplementation typically not.

But really just a lot of the other supportive measures: healthy diet, monitoring blood pressure, staying on top of vaccinations is super important for our CLL patients. So we do a large majority of recommending those and encouraging patients to stay up-to-date on their vaccinations.

PT Staff: What is the value of the oncology pharmacist on the patient care team for patients with CLL, and how might the absence of an oncology pharmacist effect treatment?

Jenna Ciervo, PharmD, BCOP: I think in general, pharmacy involvement on any team has been shown to improve outcomes and provides better outcomes for patients—[it] can help to optimize care. So I think with our involvement with the CLL patients, it really helps to provide a blanket for less anxiety for patients because they feel more educated, they feel like they are empowered, know how to take their medications or when to reach out and what to reach out about.

And then on the other side of that is being a resource for providers. I think it's super impactful, our involvement, and it's amazing being able to work with our providers here and be involved in clinical trials as well— seeing what things are going to look like in the future. So I think we have such a big involvement, especially with like odd side effects that might come up and unique situations where we might need to do something quicker. An escalated venetoclax ramp-up has occurred a few times for patients that are admitted, so we provide a lot of support and education for our providers in those difficult and challenging situations. I think our impact is amazing and great.