Not surprisingly, costs and reimbursement issues are the #1 challenge associated with checkpoint inhibitors
The most common type of immunotherapy are checkpoint inhibitors, which disrupt tumor cells' ability to evade the immune system. Since FDA approved Keytruda and Opdivo in 2015, use of checkpoint inhibitors has skyrocketed. In our 2017 Trending Now in Cancer Care survey, 96% of respondents reported that providers in their program prescribe checkpoint inhibitors. But adopting these new therapies is not easy. Unsurprisingly, due to their high price tags, in our 2018 Trending Now in Cancer Care survey, "cost/insurance reimbursement" was by far the most common challenge reported by survey respondents. Challenges with access to drugs was a distant second.
Big opportunity for programs to better support patients receiving immunotherapies
In the 2018 survey, we also asked respondents about how they manage adverse events associated with checkpoint inhibitors. This is critical because these patients may experience severe toxicities, which often look very different from the traditional side effects associated with chemotherapy.
Three-quarters of respondents reported that at least some of their non-oncologist clinicians had received specific training on managing these side effects, with oncology nurses (70%) and pharmacists (46%) most commonly receiving training. However, less than half of cancer program respondents had incorporated any additional services or tools to directly support patients experiencing side effects. Among cancer programs that had, tailored patient education or classes and immunotherapy patient ID cards were most common.
As you might expect from research-driven organizations, academic medical centers (AMCs) and PPS-exempt cancer hospitals (n=15) were more likely than the overall sample to have incorporated services or tools to help immunotherapy patients manage adverse events, with 60% of them doing so. For this cohort, patient ID cards (33%) beat out patient education or classes (27%) as the most commonly provided resource.
To provide additional support for providers and patients receiving immunotherapy, progressive cancer programs have developed clinics with specialists equipped to deal with the unique side effects of immunotherapy and other innovations, such as targeted therapies. For example, Avera Cancer Institute created the Precision Oncology Clinic as a consultative service to co-manage these patients with the treating physician. The clinic helps providers at every step of care—from selecting the appropriate genomic tests to managing patients on targeted therapies. The team coordinates with treating providers to answer questions and help with symptom management.
Read our research brief, "Innovations in Medical Oncology," for more details on this clinic and other tactics to support oncologists and patients using personalized therapies.
All providers—not just those at academic programs—becoming familiar with CAR T
CAR T-cell therapy, which reprograms the patient's own T cells to target and kill cancer cells, has been in the headlines recently—for both its efficacy in certain populations and eye-popping cost. FDA just approved the first two CAR T-cell therapies back in 2017. However, there are fewer than 200 organizations in the United States authorized to offer CAR T by the drug manufacturers.
We asked cancer programs how familiar their providers are with CAR T. Half of respondents told us their providers are somewhat familiar. The other half was evenly split in reporting that their providers are very familiar and not too or not at all familiar with the new therapy.
Unsurprisingly, given the years of research and excitement behind CAR T, respondents from AMCs and PPS-exempt cancer hospitals (n=19) were more likely to report their providers are very familiar with CAR T-cell therapy (63%). None of these respondents reported that their providers are not at all familiar with CAR T.
CAR T programs concentrated among AMCs and PPS-exempt cancer hospitals
Compared to the national sample, AMCs and PPS-exempt cancer hospitals were also more likely to report that they had established or planned to establish a CAR T-cell therapy program at their institution (48% vs. 94%). More than half of AMCs had already established a CAR T program, while 41% were currently developing one or had plans to develop one in the next two years. In contrast, only 16% of the national sample had established a CAR T program and 32% were currently developing or planning to develop a program. Almost half of the national sample had no plans to develop a CAR T program.
A main challenge to offering CAR T is reimbursement. Despite a couple moves by CMS this summer, reimbursement for the procedure still falls well short of the total cost of the therapy (not including the cost of hospitalization, labor, or supplies). The other challenge is having enough patients to support the resource investment. Today, CAR T is limited to relatively rare diagnoses. But with more than 50 trials in solid tumors across the United States, everyone in the field is waiting to see if a broader patient population can benefit from this exciting innovation.
More than one-third of respondents reported that their providers are not comfortable managing side effects of CAR T
Like with checkpoint inhibitors, there are serious risks associated with CAR T. Across 2016, one clinical trial was stopped twice due to five patient deaths resulting from severe side effects and toxicities. We asked cancer programs how comfortable their providers are managing adverse events and side effects related to CAR T-cell therapy. Notably, almost half of respondents were unsure. Of those that were sure, 39% reported that their providers are not at all or not too comfortable managing adverse events associated with CAR T. Less than one-quarter reported that their providers are very comfortable managing these side effects.
Yet again, respondents from AMCs and PPS-exempt cancer hospitals were more likely to report that their providers are very comfortable managing these adverse events.
However, it's critical that all providers are educated about managing adverse events related to CAR T. While AMCs and PPS-exempt cancer hospitals providing the procedure will likely be responsible for managing acute adverse events, other cancer programs may encounter patients suffering from delayed side effects after they return to their community cancer program—especially as CAR T becomes available to more patients.