Two Ways Health Systems Are Moving Toward Greater Oncology Stewardship

Most health care professionals are familiar with the concept of antibiotic stewardship, but the idea of oncology stewardship is relatively new.

The trend is being driven by the increasing complexity and rising costs of oncology care and resulting patient financial toxicity, said Donald C. Moore, PharmD, BCPS, BCOP, DPLA, FCCP, who discussed the concept at a session during the American Society of Health-System Pharmacists (ASHP) 2022 Midyear Clinical Meeting & Exposition.

The session, called "Not Just for Antimicrobials: Integrating Oncology Stewardship Into Practice," focused on 2 ways that that health care systems are practicing oncology stewardship in their pharmacy services. The methods—dose rounding and dose banding—seem to be gaining ground by more systems, albeit to varying degrees.

Moore, clinical oncology pharmacy manager, Levine Cancer Institute, Atrium Health, in North Carolina, was joined during the session by Kate D. Taucher, PharmD, MBA, BCOP, FASHP, FAPO, system manager, Oncology & Infusion Pharmacy Services at UCHealth in Colorado, and Jason Bergsbaken, PharmD, MBA, BCOP, pharmacy coordinator, Regional Oncology Services at UW Health in Wisconsin.

There are several reasons why the concept is becoming more prevalent, said Moore. One is the ever-rising cost of oncology drugs.

Last month, Reuters reported that annual price of a newly-launched cancer drug in the United States averaged $283,000 last year, up 53% increase from 2017. In 2019, out-of-pocket cancer care costs paid by US patients amounted to about $16.2 billion, Moore said.

Financial toxicity is not just a burden on a patient’s financial well-being; it is also linked with worse clinical outcomes, including a more advanced stage of presentation, which carries increased costs of care, increased morbidity, and higher mortality.

Why Oncology Stewardship Is Gaining Ground

There are a number of reasons as to why the idea of stewardship—which started with antibiotics and is now expanding to other clinical areas—is important to oncology, Moore said.

“I think first and foremost, is we want to be able to improve the quality of care. I think that improving patient access to care is also incredibly important as well,” he said.

Improving patient safety and minimizing cost are 2 other reasons driving stewardship activities, which, he noted, are likely already being practiced by many institutions, even if they are not categorizing them under the “stewardship” label. Those activities may include optimization of 340B program opportunities; formulary management, restriction, and standardization; using biosimilars or generic/therapeutic equivalents; minimizing the administration of high-cost medications in inpatient settings; and dose rounding or banding to the nearest vial size.

Most of the discussion centered on dose rounding, which is only applicable for therapies supplied in preservative-free, single-use vials, and is supported by a positive position statement from the Hematology/Oncology Pharmacy Association and backed by the National Comprehensive Cancer Network, he said.

The first recommendation is that biologics can be dose rounded to the nearest vial size within 10% of the prescribed dose. The second recommendation is that for biologics with a cytotoxic constituent or antibody drug conjugate, the dose rounding is applied to the cytotoxic agent.

“Dose rounding is exactly what it sounds like,” Moore said. “It is rounding the dose to the nearest vital size when the difference is less than an established percentage, which can be very important. This can help to minimize waste and ensure accuracy during drug preparation, as well as reduce health care expenditures.”

The rationale for dose rounding stems from looking at the experience of how biologics, which have a wide therapeutic range without raising safety concerns, performed in clinical trials, he said. Depending on the size of the institution, hundreds of thousands of dollars could be saved, Moore said.

Cytotoxic chemotherapy drugs, which have a narrow therapeutic range, can be rounded by 10% of the dose, Moore said, citing the rationale from the National Cancer Institute (NCI).

“If it’s good enough for the NCI, it’s probably good enough for me as well,” he said.

Not every patient is appropriate for this, he noted. Their clinical factors may not allow for it; they may need dose reductions due to toxicity; they may be in a clinical trial; or the dosage may have been pharmacokinetically determined.

To implement dose rounding, dose banding, where the calculations are done automatically within the electronic health record, both makes it easier for staff and removes human error from having to make calculations manually, Moore said.

Moore asked his panelists how these issues are handled at their institutions.

Taucher said UCHealth elected not to change cytotoxic therapies, and for monoclonal antibodies, it started a pilot program by phasing in 28 drugs, and not all at once. Two drugs were added each month once the program began.

“We do not do it across the board,” she said.

UW Health adjusts 10% for biologics and 5% for cytotoxics across the board, and it selects therapies based on the cost and vial size, Bergsbaken said. The institution is also very supportive of banding, both from a safety standpoint of removing human error and also for pharmacist workflow.

At Levine, Moore said, there are 10% adjustments across both types of therapies, but the institute doesn’t band, although it is hoping to do that soon.