In the third article of this series, Paul E. Dato, MD, provides comprehensive insights on the multidisciplinary care of patients with metastatic castration-resistant prostate cancer.
Urology Times®: What care team members are involved with patients diagnosed with metastatic castration-resistant prostate cancer?
Paul E. Dato, MD: The multidisciplinary team involves multiple members in the community setting. More typically, it will have a urologist or advanced practice provider [APP], such as a PA or a nurse practitioner, who would be evaluating the patient through their hormonal therapy and then as the development of metastatic [castration-resistant prostate cancer] progresses. The diagnosis will be principally evaluated by them. Depending on group dynamics and the makeup of the group, there may be a medical oncologist involved or a radiation oncologist [who] could potentially be making that diagnosis as well.
The direct management would be more commonly through the urologist, APP, or medical oncologist, [whereas] a radiation oncologist may be providing additional therapeutics. But the principal therapeutics—the quarterback of the team, if you will—will probably be the urologist, APP, or medical oncologist. In addition to those providers, we have [several] other staff workers [who] could also be involved in the patient care—perhaps not in the direct diagnosis but certainly in support. For example, these would be a pharmacist or pharmacy technician. If there’s in-office dispensing associated with the group, we would also have nurse navigators who could be a medical assistant, a [licensed vocational nurse, or] a [registered nurse]. In my group, we have chronic care managers who work as navigators, and they’re able to provide that additional benefit to the patients as true navigators to their entire disease process.
Urology Times: How do you use shared decision-making with your patients and their caregivers?
Paul E. Dato, MD: It’s vital that a shared decision-making process occurs with patients. We utilize—principally and initially—the direct patient-to-provider consultative process [for] the explanation of the disease state. As a result of that, the available treatment options are provided. We utilize protocol-based and guideline-based information that we give to our patients. We principally utilize [National Comprehensive Cancer Network], but there are certainly other national guidelines, such as the [American Urological Association], that can provide that kind of information.
We feel it’s very important that patients are educated [about] their condition, the implications of their diagnosis, and what [the] available options [are]. This is very incumbent upon the providers—either the urologist, medical oncologist, or APP—to maintain a high level of interest and expertise [regarding] this…rapidly evolving and emerging science. Providing up-to-date information is very important. We also provide literature that comes from the pharmaceutical companies because they provide very good, patient-centered information to assist…. After the office visit, [patients are] able to then continue to read and educate themselves. We also will direct them to community-based support groups. We have several in the San Diego area, where I practice, that provide some very timely and helpful information for the patient to help make the best decisions for themselves on that basis of it.
The role of all the team members in that multidisciplinary team is based on their areas of expertise. We utilize APPs and have them work in our office, so they will make the decisions themselves, but also in collaboration with me or the other urologists in the office as needed. They’re very expertly trained [and] remain up to date with the information, so we feel very satisfied that all team members can provide the best information for the patients.
Other members of the team [are] providing a lot of valuable background [and] follow-up information, [such as] psychosocial information, insurance barriers, or challenges. Our pharmacy tech will provide detailed drug-drug interaction data that may not be immediately apparent to the prescribing physician or APP. The coalition of the benefits, co-pay analyses, and applications for financial support are all vital to make sure patients get on the right therapy. Then we have the ongoing support through our nurse navigators to guide the patient through the whole process.
Urology Times: Walk us through how medications are prescribed at your institution.
Paul E. Dato, MD: In our institution, we utilize both in-office dispensing [and] specialty pharmacies. That decision is driven by the particular insurance plan the patient has. There are also availability [options, such as] free drug and specialty pharmacy foundation. When a decision is made regarding a particular medication that is triggered either verbally or through the electronic health record order, our pharmacy tech or navigators will then initiate a manufacturer benefits investigation. That will involve an eligibility check and a claims submission, which will determine [whether] a prior authorization is required.
If a [prior authorization] is required, then we utilize services such as CoverMyMeds to make further determination regarding co-pay. Depending on the co-pay, [we utilize] resources such as manufacturer assistance, foundation assistance, or Medicare Extra Help…. Our claim will first be submitted to see [whether] we can put that through our in-office dispensing. If it is rejected for our own clinic, then we will submit to the specialty pharmacy within the network of the patient’s insurance plan.
Urology Times: How do you ensure your patients get the desired version of a medication?
Paul E. Dato, MD: Ensuring patients get the desired medication is always a challenge. It’s impossible to keep up with all the vagaries of the insurance drug coverage, especially in Southern California. We’re very dependent on our staff to be able to assist. Unfortunately, I usually have to have an alternative medication in mind once I have developed a treatment plan if my first choice is denied. I also then develop an actual document, a DHR, arguments to utilize if I need to do a peer-to-peer [for] the appeal of a denial.
There are certainly sometimes step edits that are available, trying a covered or formulary medication on the plan first, then if it is intolerable or there [are] other issues, we can then go to the original choice that I have for the patient. My staff are incredibly helpful to try to find every avenue available so we can get the medication of choice for them. But ultimately, it still comes down to what medication is covered and what the co-pays are.
Urology Times: Do you see challenges with commercial coverage for micronized abiraterone?
Paul E. Dato, MD: There are challenges for commercial coverage for micronized abiraterone. That commercial piece is truly still a struggle. It’s difficult to have a branded medication in a generic market. Different insurance plans across the country work differently. They work differently in the same geographic area. What coverage means to a patient is not the same as coverage to an insurance plan. There are multiple tiers, and most patients don’t have a good understanding of the entire process.
The staff is a vital piece to sort through all this information, work through the myriad of layers, and to provide education to the patient regarding the process and what appears to be a delay from the patient’s perspective. So, it is first education. It’s going down all these different pathways that the staff are able to do to try to overcome those challenges and find avenues [where] the patient may still be able to receive that initial choice of medication that we’ve made for them. But [they] also educate me as a provider [regarding] what other avenues and pathways we need to pursue to try [to] get that patient’s medication. That would include [an] appeal and to do that peer-to-peer…for them. Finding that coverage, finding financial resources for patients [where] co-pays are high for them, identifying potential step edits…and then setting up peer-to-peer conversations for me is where the staff really shine.
Urology Times: What do you wish your colleagues knew about micronized abiraterone?
Paul E. Dato, MD: Micronized abiraterone has some definite benefits and advantages because of its micronized formulation. It translates to a lower dose, which can also then translate out to better tolerability. The key factor [is that] the bioavailability is the same at the lower dose as compared [with] the higher dose of generic abiraterone or other formulations of it. Therefore, that means the patient then can remain on the medication [and] receive the benefits of the medication without having to make other changes. As long as the patient can remain on medication, the better the response is going to be to their [treatment].
The formulation also provides flexibility in dosing [because] it’s independent of diet, so we don’t need to worry about the patient worrying about what they’ve eaten. If they have eaten, they can take micronized abiraterone with food. It’s easier on the stomach. I think that leads to better [adherence]. It’s not only for the patient themselves—and we have older individuals who may be living on their own, so we don’t have to worry about that aspect of it—but [it’s] also for the caregivers. If they’re looking after them, they [don’t] have to worry. Did they take the medication? Did they take it on an empty stomach? We’ve eliminated those variabilities, [which] leads to better [adherence] for the patient.