Multidisciplinary Care in Breast Cancer

Lindsay Shaw, NP: I think there are a number of people involved in managing these patients. The pharmacist is a very important member of our team because they will help us find out where the medicine needs to come from based on the patient’s insurance, which is a huge worry for patients, and our team is great at helping them figure that out very quickly.

We also have nurses who answer our phone calls. So lots of our phone calls are about adverse effects, and the nurses are the first line of defense in calling people back, and they’re knowledgeable about the adverse effects of these drugs. Most of it can be handled over the phone, and the patient doesn’t even need to come in, and we can talk to our staff and help them and educate them over the phone. So…the pharmacists are, for us, extremely helpful.

Sara M. Tolaney, MD, MPH: I think our group has realized, just as Lindsay suggested, that it is really a team effort from the very first day you write a prescription, when you need to maybe get prior authorization, to then also finding out whether it needs to go to specialty pharmacy versus…, for example, our institutional pharmacy. And for those things, we have people set up in place to do that on the back end, which is particularly helpful. For example, our program nurses can assist with the prior authorization process, the pharmacist can assist in figuring out where the drug is going to be coming from, and then that gets communicated back to the patient so they know when to expect arrival of their drug and when they can start therapy. And that’s also important on our end because we need to then time when we’re doing the first blood count check, which is supposed to be about 2 weeks after they’ve initiated therapy. But if it took them a week to even get the drug, then you’ve got to account for that extra time when you schedule their follow-up visit. So it does take a little bit of organization—when you first write a prescription, getting them the drug, and then doing their follow-up checks.

And we also have a pharmacist who makes a phone call to them a week after they’ve started, which is really helpful because that…helps us better understand…how they’ve been doing while taking the drug and whether they had questions about how they’re supposed to take it, and then to assess whether there are any adverse effects that have started within that first week of taking the drugs.

Lindsay Shaw, NP: And I think there needs to be more of an effort with communication with these drugs because we’re not necessarily seeing these people once a week. So it’s really helpful when you lay eyes on someone and talk to them yourself. So communicating with the nurses and with the pharmacy is added work on our end, but it helps the patient not have to come in as much.

Sara M. Tolaney, MD, MPH: You know, I think having a team that helps with the prior authorization process is really key because we’ve also learned that sometimes there’s a co-payment, and even if they get prior authorization, the pharmacists are also able to tell us what the patient’s co-payment is and whether there are any co-payment assistance plans that they’re eligible for, and I can help take care of that, again, all with the effort of trying to get the patient the drug. And now also a lot of these pharmaceutical companies have plans in place where they get them their first month of drug for free, which can sometimes help, as well, when they’re going through all of this and to get the drug approved or deal with co-payment assistant plans and to not cause delays.

And I do think, again, having that in place has helped us. It was a challenge at first. I think the other challenge that I think our team has helped with is when we change the dose of a drug, sometimes that then triggers yet another prior authorization, which can cause a delay to the patient getting drug. And again, that’s set up on the back end between our pharmacist and program nurses to deal with…so that the patient can get the drug as soon as possible.

I think both Lindsay and I work very well together as a team. Lindsay is a nurse practitioner, so she or I will see patients at each of the visits, and I think the key really has been communication. And so usually there’s a discussion up front that usually I would have had with the patient to initiate a drug to decide what is the treatment plan, what drugs are we going to be administering. And then either Lindsay or I will be seeing the patient along the way, to monitor blood counts and make recommendations if we need dose modification.

I think maybe the difference in the roles comes in with changes of therapy. It’s usually me who’s going to see a patient for restaging scans to make decisions to continue or change treatment. Lindsay is really in charge of pretty much everything else. She’s really making decisions about monitoring adverse effects, dose modification. And so, again, we really do it together.