Cancer Treatment for Everyone

Oral Versus IV Oncolytics

January 10, 2018

Peter L. Salgo, MD: I’m going to ask a question. Here, we have oral drugs. How do these oral oncolytics compare to the parenteral drugs–the only drugs, really, when I was growing up in medicine–in terms of use and in terms of access?

Carl T. Henningson, MD: The drugs that we traditionally used in oncology were intravenous drugs, and those drugs tend to have more side effects. There’s also more administrative costs with those drugs. What’s developed more recently is the use of oral oncolytics, which is obviously more convenient for patients because they are in and out of the office less frequently. Generally, they tend to have fewer side effects. But it also brings up the issue of cost. Traditionally, the IV chemotherapies were covered under most insurances, whereas the orals were part of Medicare Part D, in many cases. That was a limitation to the use of those drugs because patients just couldn’t afford the co-pays.

Peter L. Salgo, MD: We’re going to cover that a little bit later, but in terms of patients and acceptance, it occurs to me that if I’m a patient with a tumor with some sort of hypermitotic issue, and you can pick the tumor you like, it’s a big difference for me if I can go home and take a pill, or if I have to go to an office, get hooked up to an IV, get an infusion for a day, and take a day off of work. The oral oncolytics, seen as a class, seem to be much better for patients.

Noa Biran, MD: Yes. Cancer has become a chronic disease. Patients are on treatment for pretty much, for many cancers but not all, their whole life. Would you prefer to come in twice a week to get an injection, or sit for half an hour or even 90 minutes in an infusion chair wasting your life? Or, would you prefer to take a pill and come in once a month for a checkup, or once every other month? I think it’s a clear answer as a patient. What you would prefer to do?

Steven L. D’Amato, RPh, BSPharm: Absolutely, but adherence is a major factor when looking at oral agents. If you look at the studies that have been done to date, adherence doesn’t have a great track record, even when we’re talking about diseases like cancer. So, I think oral adherence is one of the big barriers that we need to conquer in that route. From a clinician’s perspective, they know when the patient goes in the chair and when intravenous therapy is given. They know the patients have seen the therapy. They’re done. They’re going to come back for another cycle, or another day of therapy. They know the patients on board with the drug. Whereas, with the oral oncolytics, we’re really relying on the patient to make sure that they take those drugs appropriately.

Peter L. Salgo, MD: When I was in medical school, they gave placebos to medical students. They said, “Take 1 pill a day for a year.” They didn’t tell them anything more than that. At the end, they collected the residual pills. Approximately a third of those pills were untaken. That’s with motivated medical students.

Noa Biran, MD: Yes.

Peter L. Salgo, MD: They weren’t curing anything. Here, we’ve got cancer. “It’s important that you do this, and you do it right.”

Noa Biran, MD: Right. And even taking it wrong can be harmful. You have to find ways, and you have to educate your patient. Everybody has their own way, but we always make a calendar, for every single patient, because oral oncolytics are part of every regimen that we give in multiple myeloma. So, you have to make a calendar. You have to write down every day that they need to take the pill. They put it on their refrigerator. That’s how they remember to take it. Most of the time, it works. Sometimes, that doesn’t even work.

Arturo Loaiza-Bonilla, MD, MSEd, FACP: Right. Every single new drug that’s coming is going to be linked to a specific companion diagnostic, a specific target. We’re doing personalized medicine, now, for most of our patients. Of course, as the patient feels better and their treatment is actually working, then you get used to it and say, “Maybe I don’t need to do this anymore. Maybe they can skip this day.” So, I think it’s important to have that communication and education available for all patients.

Peter L. Salgo, MD: “I checked my blood pressure and it’s normal, so now I can stop my hypertensive agent.”

Arturo Loaiza-Bonilla, MD, MSEd, FACP: Exactly. That is the rationale, right? So that’s how we do it. 

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