The Power of an Immuno-oncology Collaborative Care Team

The advantages of care collaboration are not restricted to immuno-oncology (IO), or for that matter cancer. However, when novel treatments like the immune checkpoint inhibitors encounter clinical success, a team-based approach can ensure improved patient outcomes.

At the Institute for Clinical Immuno-Oncology National Conference, organized by the Association of Community Cancer Centers in Philadelphia on September 30, 2016, a panel of care providers presented institutional experiences with IO and how a collaborative care approach helped the process. Panelists included Gary Cohen, MD, medical director, Sandra & Malcolm Berman Cancer Institute, Greater Baltimore Medical Center; Carole Miller, MD, medical director, Saint Agnes Cancer Institute; and Shawn Regis, PhD, patient navigator, Lahey Clinic.

Cohen, the first panelist to speak, said that while surgery, radiation, and antineoplastic agents are 3 common interventions in cancer, IO is emerging as the fourth modality. Systemic treatments in cancer patients include hormonal treatments, chemotherapy, biologicals, targeted agents and IOs.

“Checkpoint inhibitors are a new addition to the long-standing armamentarium of immune treatments in cancer,” Cohen said. He listed cytokines, myeloid growth factors, tumor-infiltrating lymphocytes, chimeric antigen receptor T cells, vaccines, and viral oncolytics as some of the other immune-based treatments in cancer.

He pointed out, however, that institutional costs associated with the new breed of checkpoint inhibitors has seen a significant jump. A pharmacy audit at his cancer center showed that the drug cost associated with the use of ipilimumab and nivolumab was “14% of the total cost in June 2016—$71,345 of a total drug and supply cost of $527,972.” If as part of payment models this cost is not completely reimbursed, who will pay for the difference? Would the burden fall on the patient’s plate?

According to Cohen, several important criteria must be considered to decide if a patient can be provided IO treatment, including the patient’s performance status, their monetary status (can they afford treatment), and medical comorbidities that can restrict use of IO agents.

Cohen is a firm believer that caring for a patient on IO should be a team effort and should include the oncologist, family/caregiver, nursing staff, pharmacist, financial advisor, and the business manager. “The care team should also include other consultants including experts in gastroenterology, dermatology, pulmonary care, neurology, and radiology. Consultants need to be educated on all the toxicities associated with these agents,” he said.

Budget impact

Miller’s talk emphasized the financial impact of IO on the healthcare system. She pointed out that Maryland is an all-payer state. In 2014, the state received approval for a demonstration waiver from the Center for Medicare & Medicaid Innovation to open a unique hospital-based reimbursement model, which was based on a global budget revenue model (GBR model). This model emphasizes coordinated care, so providers need to be better aligned and should avoid unnecessary testing and hospitalization to reduce costs.

“A major flaw with the GBR model is that it does not account for new technologies and drugs and is based on a 2013 revenue cap on volumes. So alternative settings of care may be needed for new drugs such as IOs,” Miller told the audience.

In her opinion, an IO dream team should include physician champions, clinical coordinators (nurse practitioners), oncology pharmacists, and social workers. At their hospital, patients meet with financial counselors and social workers who ensure extensive patient education on IO.

Regis highlighted the important role that of a patient navigator in the complex process of oncology care. He listed the following patient concerns:

• Physical: fatigue, pain limiting medications
• Financial: treatment cost, health insurance, employment changes
• Psychosocial: stress guilt depression
• Logistical: getting to the site of care

The physical concerns can be managed by healthcare providers such as the patient’s primary care provider, oncologist, and other specialties like cardiologist and nutritionist. The social worker, a psychologist, and the patient’s family and friends can attend to the psychosocial concerns. For financial concerns, patients should be directed to financial resources such as insurance, government programs, nonprofit hospitals, copay programs, and patient assistance programs.

Then there are the logistical challenges that need to be met such as appointment scheduling, travel coordination, and communicating the results across the team of care providers.

“A navigator’s role is to help coordinate all of the above and filter it down to the patient,” Regis said. “A navigator’s job starts right at the time of diagnosis to make patients aware of available services, answer questions, coordinate appointments and follow-up, communicate with the entire team, and move the patient effectively through the entire treatment.”