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VBCC - May 2016, Vol 7, No 4 - In the Literature

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Oncology Benchmarks Annual Report Shows New Patient Visits, Drug Spending Are Rising

The oncology National Practice Benchmark (NPB) annual report provides important information regarding oncology providers’ productivity, costs, practice revenues, and profits. Key findings from the 2015 report show that new patient visits and average drug spending are on the rise (Balch C, et al. J Oncol Pract. 2016;12:e437-e475). Benchmarking can suggest opportunities to improve oncology practices.

More than 1700 medical oncologists, radiation oncologists, and practice administrators from more than 200 community practices and cancer centers across the country were invited to participate in the 2014 NPB online survey. Overall, data covered 2014 or the most recently completed 12-month fiscal period, and reflect 42 cancer practices in 23 states. This represents 587.8 full-time equivalent (FTE) hematology/oncology physicians and 755.5 physicians in all specialties.

Physician productivity can be analyzed using different measures. An important predictor of financial health is the number of new patients served by the practice. A new patient visiting the practice is defined as a patient who has not been seen by a clinician in the exact specialty at the practice in the past 3 years.

Based on the new oncology NPB report, the number of new patient visits in a 12-month period per 1 hematology/oncology physician was 358, representing an increase from the 325 reported last year per 1 physician. One new metric measured in this year’s report was hospital visits as a percentage of total patient visits for 34 oncology practices, based on 569.6 FTE hematology/oncology physicians.

Healthcare expenditures is a crucial benchmark that garners attention among stakeholders. The new report shows that the average drug spending per 1 hematology/oncology provider this year was $3.6 million compared with last year’s adjusted average of $3.1 million.

Of note, total infusions per 1 chemotherapy administration staff saw a slight decline compared with last year. The researchers note that the view of initial chemotherapy administrations as a productivity measure may need to be amended in future NPB reports to reflect the increasing number of oral chemotherapy drugs. Oral drugs require patient education, which is usually done by a staff member.

Furthermore, with the rise in oral cancer drugs, in-house and specialty pharmacy dispensing is an increasingly important topic for oncology practices. The majority of oral prescriptions are currently filled in nonaffiliated, mail-­order or specialty pharmacies; the survey results show that between 24% and 40% of practices rated their experience with clinical support services provided by specialty or mail-order pharmacies as “poor.” Commenting on this finding, the researchers noted, “It is disappointing to see significantly few excellent or good ratings, especially considering the categories being graded for performance included patient drug education, adherence oversight, timely refills, adverse effects, and adverse event management.”

The researchers concluded the report by saying, “As science stretches into the 21st century, it will be important to add new metrics to the NPB to raise awareness of new opportunities (and challenges) in operating a fiscally responsible practice so that patients have a refuge for treatment and healing.”

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Personalizing Therapy for Patients with Multiple Myeloma

Multiple myeloma, 2 experts say, is no different from other cancers that have wide variations in their genetic and mutation profiles. Furthermore, many subsets of patients with multiple myeloma exist, with different biologic drivers and patient-specific characteristics that impact therapeutic efficacy. Understanding the patient’s genetic and functional status can therefore help in tailoring patient-specific treatment regimens, according to 2 multiple myeloma experts. In a new review article, they discuss the role of functional status and genetics to help guide therapeutic decisions for patients with multiple myeloma and improve patient outcomes (Lonial S, Nooka AK. J Oncol Pract. 2016;12:287-292).

Dr Lonial and Dr Nooka note that the genetic landscape of this disease is complicated, involving from 5 to 20 different genotypes. “However,” they add, “as clinicians, we all know that there are in fact patients who can do quite well for extended periods, with median survival times in excess of 10 years, and, perhaps, 10% to 15% of patients are cured.” Therefore, assessing each patient carefully for functional and genetic status may help improve outcomes.

Functional assessment in a patient with multiple myeloma is an important early driver, because it determines the intensity of therapy. Traditionally, functional status was used to determine if a patient should undergo autologous stem-cell transplant (SCT) as part of the initial therapy. The authors argue that this may not be necessary, because evidence shows that patients aged ≥70 years can undergo transplant as long as they receive a lower dose of melphalan chemotherapy during the transplant process.

A patient’s frailty may be more important when deciding on an initial treatment regimen that includes either an intensive triplet therapy or less intensive with only doublet therapy. For patients fit enough for a transplant, the authors recommend initial triplet therapy with lenalidomide (Revlimid), bortezomib (Velcade), and the corticosteroid dexamethasone, followed by transplant. By contrast, for older patients who are frail, they note that evidence from recent clinical trials suggests that a 2-drug regimen is better tolerated in this patient population and has equivalent outcomes to triplet therapy.

Genomic profile can also be used to tailor therapy to the individual patient with multiple myeloma. Evolving molecular diagnostic tests, such as targeted gene sequencing, RNA sequencing, or copy number arrays, can facilitate a more accurate stratification of patients.

In transplant-eligible newly diagnosed patients with multiple myeloma, Dr Lonial and Dr Nooka recommend intensive induction triplet therapy with lenalidomide, bortezomib, and dexamethasone, and continued triplet maintenance therapy for patients with high-risk disease at diagnosis; for standard-risk patients, they recommend lenalidomide-only maintenance therapy.

Patients with newly diagnosed disease who are too frail to undergo an SCT and have standard-risk disease, can receive doublet therapy with lenalidomide and dexamethasone or with bortezomib and dexamethasone. However, newly diagnosed patients with high-risk disease should receive a modified dose of lenalidomide, bortezomib, and dexamethasone triplet therapy.

“The use of an optimal induction regimen followed by high-dose therapy does not limit the ability to tailor therapy to patients,” the experts note. “Once the initial induction and consolidation (with a transplant) are complete, there are likely to be opportunities to tailor therapy in the maintenance phase on the basis of genetics.”

As for future directions on how to tailor treatments for multiple myeloma, they conclude, “The current literature suggests that the use of biology-driven treatments, taking into account functional status and genetics, is likely the first and most important step. The incorporation of these agents with biology-based approaches will likely yield the best and most effective treatments as we continue to learn how best to target the many mutations found in patients with myeloma.”

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Last modified: June 3, 2016
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