“Driving the Future of Cancer care,” an evening presented by the Institute for Value-Based medicine and The American Journal of Managed Care took place in Boston on July 17.
It brought together experts from Beth Israel Deaconess Medical Center, Boston Medical Center, Dana-Farber Cancer Institute, Lahey Health, Lowell General Hospital, Massachusetts General Hospital, and Tufts Medical Center.
Advances in precision oncology have transformed cancer care and reshaped treatment paradigms. During an evening of dialog on value-based oncology at the Boston regional Institute for Value-Based Medicine, key intersecting themes in this space emerged: the critical role of biomarker-driven therapies, the challenges of implementing innovative treatments, and the necessity of multidisciplinary collaboration to optimize patient outcomes. the evening highlighted the delicate balance between innovation and implementation and emphasized the importance of collaborative care models in optimizing oncology’s evolving landscape.
Discussions focused on lung cancer and how the shift from chemotherapy to personalized approaches has improved outcomes, despite persistent barriers that include tissue acquisition and insurance coverage for next-generation sequencing (NGS).Experts said there is debate over how long patients should receive immunotherapy and how to rechallenge patients with therapy. Similarly, in hematologic malignancies, bispecific antibodies and chimeric antigen receptor (CAR) T-cell therapies demonstrate remarkable efficacy but pose logistical and toxicity management challenges. Breast cancer has seen progress, too, with antibody-drug conjugates (ADCs), which show superiority over traditional regimens in HER2-positive and HER2-low disease, but adjuvant CDK4/6 inhibitors face adherence and reimbursement hurdles, especially in community practices.
Central to these advancements is the expanding role of pharmacy in value-based care, particularly in managing complex therapies like CAR T and bispecifics. Pharmacists contribute to toxicity management, care transitions, and real-world data utilization, yet site-of-care restrictions and payer mandates complicate delivery.
Lung Cancer Care Requires Biomarker Analyses
Over the past 2 decades,there has been meaningful advancement in lung cancer care,with treatment shifting from platinum-based chemotherapy to precision medicine and immunotherapy. “Today, we will not move ahead with any treatment for non-small cell lung cancer (NSCLC) without biomarker analysis,” stated Karl D’Silva, MD, a medical oncologist with Lahey Health, whose practice is now approximately 30% thoracic medicine. He was joined by Umit Tapan, MD, thoracic oncologist, Boston Medical Center; and Julia Rotow, MD, clinical director, Lowe Center for Thoracic Oncology, Dana-Farber Cancer Institute, who moderated the discussion, “Value-Driven Precision: Advancing Equitable Access to Targeted and Immuno-Oncology Therapies in Lung Cancer.”
Key advancements include the identification of EGFR and its role in lung cancer development1 and how ALK mutations can direct treatment choice and response,2 followed by immunotherapy approvals,with nivolumab (Opdivo; Bristol Myers Squibb) being the first in 2015,3 which have extended survival from 6 to 9 months to 3 to 5 years for many patients,Tapan explained.
However, significant implementation challenges remain, including delays in accessing tissue; slow turnaround times, particularly for second-opinion referrals and identifying candidates for targeted therapies or immunotherapy;
Navigating Treatment Hurdles and Emerging Therapies in Hematologic Malignancies and Breast cancer
Recent discussions highlighted the complexities of delivering cutting-edge cancer care, emphasizing the critical need for strong academic-community partnerships and addressing unmet needs in both hematologic malignancies and breast cancer.
Bridging the Gap in Hematologic Malignancies
A panel explored the challenges of referring patients from community settings to academic centers, particularly those with relapsed diffuse large B-cell lymphoma (DLBCL). Hurdles include insurance approvals,travel logistics,and differing dialogue systems. The panelists stressed the importance of robust academic-community collaborations to ensure continued patient monitoring and care.
The discussion also centered on the evolving landscape of CAR T-cell therapy versus bispecific antibodies. CAR T therapy offers high response rates and potential durability, ofen requiring a single dose after treatment failure, but demands significant infrastructure. Bispecifics, while having lower response rates and requiring continuous delivery, provide off-the-shelf access and can be considered earlier in treatment lines – even after just one prior line with ciltacabtagene autoleucel (Carvykti) or two with idecabtagene vicleucel (Abecma).
Addressing Unmet Needs in Breast Cancer
Experts from Dana-Farber and Lowell General Hospital/Tufts convened to discuss advancements and challenges in breast cancer care, emphasizing the need to translate clinical progress into personalized and equitable treatment.
The growing role of antibody-drug conjugates (ADCs), particularly trastuzumab deruxtecan (T-dxd), in HER2-positive and HER2-low metastatic breast cancer was a key focus, citing positive results from the DESTINY-Breast09 and DESTINY-Breast06 trials. While T-DXd shows promise in earlier treatment lines, questions remain regarding optimal patient selection, toxicity management, and cost-effectiveness, prompting consideration of more affordable alternatives like capecitabine for certain patients.
Expanding Access to Complex Therapies: The Role of Pharmacy
pharmacy is stepping up to address the growing need for accessible and well-managed complex therapies like CAR T-cell therapy and gene therapy. These treatments, while incredibly promising, present unique challenges in terms of administration, monitoring, and cost. Pharmacists are proving vital in overcoming these hurdles and ensuring patients receive the best possible care.
One major focus is decentralizing care. Traditionally,these therapies were confined to large academic medical centers. Now, hospitals like Beth Israel Deaconess Medical Center (BIDMC) are actively working to expand treatment to community settings. This shift isn’t simple; it requires careful planning and robust support systems.
“Its about more than just sending a drug to a different location,” explains Brendan McEwen, PharmD, MBA, Chief Pharmacy Officer at BIDMC. “It’s about ensuring consistent quality and safety across all care sites.” Pharmacists are instrumental in developing guidelines,providing training,and establishing clear protocols for managing potential toxicities.
A key component of successful decentralization is seamless facts sharing. Providers need rapid access to crucial resources. McEwen emphasizes the importance of embedding valuable resources into electronic medical records so that any provider can make informed decisions.
“It’s great for a provider to put something in their notes, but when you have to dig after 6 months or so for supportive care resources,” he posed, “how do you have enduring resources that are really retrievable to every single member of the care team?”
At BIDMC, Shamaileh shared how pharmacy has helped establish criteria for delivering CAR T outside the hospital, taking especially careful consideration with things like proximity to care, housing during treatment, and comorbidities-anything that may predispose these patients to a higher risk of complications. They’re even preparing emergency departments for potential complications to safely decentralize care.
“It’s just a lot of making sure that everybody on board knows about the toxicity management and feels agreeable with something that’s so nuanced,” she explained.
By expanding therapies to community sites, pharmacy teams also enable broader access, which eases capacity burdens and brings care closer to home. pharmacy develops guidelines and training to ensure consistency, McEwen noted.Though, payer-imposed site-of-care mandates are creating new challenges. Instead of letting providers decide where care occurs, payers often dictate administration sites, and he noted that inadequate infrastructure for outpatient infusion makes this especially hard, not only on the treatment front but regarding revenue, too.
“I woudl say we’re losing out on at least tens of millions of dollars of revenue of just all of those drugs that we’re no longer being able to buy and bill for,” he said, citing the burdens of white bagging and outside pharmacy requirements.