Stepwise Approach Helps Ease the Integration of BiTEs Into Community Cancer Centers

Courtney Van Houzen, PharmD

Before opening the door to an entire class of novel agents, community centers should familiarize themselves with an individual agent from that class, according to Courtney Van Houzen, PharmD, who noted that currently approved bispecific T-cell engagers (BiTEs) each require their own Risk Evaluation and Mitigation Strategies [REMS] program. Van Houzen added that by maintaining open channels of communication with academic treatment centers providers in the community can help improve the accessibility of treatment, ensuring each patient has the best chance of cure.

“Staying on top of FDA drug approvals [is useful], as bispecifics have been coming out quickly; with clinical trials now using them in combination with other therapies, especially in multiple myeloma, that’ll be important to stay on top of as a community center,” Van Houzen explained.

In an interview with OncLive^®, Van Houzen, a PGY-2 oncology pharmacy resident at Cowell Family Cancer Center, Munson Healthcare, in Traverse City, Michigan, discussed how to navigate the implementation of BiTE programs in community settings; expanded on the importance of education, communication, and collaboration among various groups within the community; and highlighted the need for more accessible treatment options and BiTE programs in community settings.

OncLive: What prevents the optimal use of BiTEs in the community setting? What can be done to ensure that these agents are administered properly?

Van Houzen: The biggest [challenges] would be navigating interprofessional care for patients and [understanding] how to safely use these products from initiation to subsequent treatment. Each of the bispecifics has specific regulations and they do not, unfortunately, all follow the same REMS program. Therefore, I implore community centers to start with one bispecific. If they decide to branch out and use a different drug for a different indication, those REMS programs all change. Certain products have inpatient hospitalization requirements, whereas others don’t and they have different timing. Ensuring that we’re treating patients appropriately is important.

Working with other provider groups in a community hospital who may be caring for these patients is also important, [as is] educating emergency department staff on short- and long-term toxicities. Many patients [receiving] BCMA-targeting bispecifics have infectious complications as they proceed through therapy. It would not be unheard of for any of those patients to end up in the emergency room [ER] with pneumonia, a urinary tract infection, or time zero sepsis; those are all common toxicities of these products. Working with ER and hospital staff [lets them] know they can reach out to oncology for further recommendations for treatment if they see a specific agent on their [patient’s] medications list.

Not all provider groups are going to be on the same page, so navigating communication is huge in the community setting. Discussing other barriers like financial or educational barriers and ensuring that nursing, pharmacy, and physician staff are all comfortable from a clinical perspective while administering these products and doing so safely [is vital].

Has the introduction of BiTE programs in the community setting increased patient accessibility to these therapies?

I’ve recently spoken with 2 patients on the use of bispecifics in the community setting. One [patient] initiated [treatment] at the University of Michigan, but he said that making the decision was not easy on him or his family. He shared that whenever he went [to the University of Michigan] he always had to have a family member drive down with him. These [treatments require] weekly injections, so driving over 3 hours to Ann Arbor, Michigan, from [his home] for a 5-minute subcutaneous injection every week is a lot to ask of patients.

Being able to offer [the treatment] and offer it safely at community centers leads to accessibility, because [asking] a patient [to make] the decision upfront of whether they will be able to [commit to treatment] for an indefinite period is a huge ask of a patient and their family. [This patient] was able to make that decision easier by knowing that he would eventually have the option to come back to us for subsequent treatment. There are probably a lot of patients who feel like this [treatment] could not be an option unless they’re able to return to a community center or have the entire treatment [administered] at a community center. Unfortunately, travel and finances limit a lot of patients in rural areas.

What other advice would you give other centers that are looking to implement these programs based on your experience?

Oncology is unique in that we have a lot of new, FDA-approved drugs constantly, probably more than most other areas of medicine. Dedicating a team [to the care of these patients], whether it’s pharmacy or whomever [is important]. We have our quality and safety team, and a couple of our providers meet every few weeks to discuss all the new FDA-approved medications.

If we’re not already using [certain drugs] at our center, we ask ourselves whether they’re something we should consider adding. We like this because the physicians can tell us from a clinical perspective if that is something they would want to prescribe and utilize. If they have a patient who’s eligible for [the agent] off the top of their heads, then we can go from there, and bring it up to our oncology section where we have all our providers present.

We [will be able to] ask ourselves when we can use this [drug]. Trying to be proactive will make life easier and we will be able to be more intentional about incorporating these products at centers, knowing who to reach out to. However, the writing is on the wall. If you’re at a community center that feels like this is a feasible thing to do, I would implore you to ask questions and find centers that are doing this already; try to get some advice. It is not the easiest thing to do, but we deserve to all try and give our patients the best options they can have in the community setting.

What kind of support can academic cancer centers offer their colleagues in the community to ensure the successful implementation of these programs?

We have a nice working relationship with a couple of big centers in Michigan, namely Corewell Health and the University of Michigan. We reached out to pharmacy teams at both [centers] to look at their order sets and see how they designed power plans or automated order sets for physicians. We asked how patients did, how nursing staff did, what errors they saw, what issues they saw, and what the biggest things we should be looking for at a community site were. [This is helpful] because they have the benefit of [administering] a lot of bispecific therapy and can give clinical advice on what they have and haven’t seen and what is or isn’t reflected in clinical trials.

I would implore community centers to ask and reach out, because [both institutions we spoke with] were wonderful, as they understand that these patients struggle [with travel]. I don’t ever think it’s a greed situation––everyone wants the best for these patients. If that means getting treated in Traverse City vs Ann Arbor, whatever is best for the patient is what we want.

[These institutions] have been wonderful about sharing information, so I think it’s easiest if the community center reaches out to them, especially if they already have a contact, or can reach out to whom they think is best. A lot of our providers in the area know other providers at other sites, so that could always be a route of communication as well.