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The Impact of Telehealth on Treatment Selection in Advanced Prostate Cancer


Shared insight on the current state of telehealth and how its use affects treatment selection and followup for patients with advanced prostate cancer.


Paul R. Sieber, MD: Different question.... Changing gears a little bit, and I don’t know if this applies to everybody. It probably applies most to Chris, so I’ll pick on him first. Chris, what do you think about telehealth? Is that a big part of your practice, and is that making you do anything differently in that regard? Because I know telehealth is a modest number of business for us, but I think for you, you’ve got people traveling the farthest. Are people travel some distance because we’re the only show in my county, and I have a pretty big county, but you’ve got counties that people are coming from. So, I’ll let you run with telehealth and whether it affects your dispensing processes.

Christopher M. Pieczonka, MD: Simple answer is yes. We have taken on, for example, a 1-person practice, a 2-provider practice a couple hours north of us, literally on the Canadian border, so we’re seeing referrals that would have come into our system that never would have before. So we do have an outpost that injections can be done, dispensation can be done, but the day-to-day nuts and bolts of monitoring the patient’s care, we do a fair bit of...video visits. My understanding is that Medicare is going to allow that to happen until 2024. So, even though the public health emergency ended, that’s still legislatively allowed until all of next year. There’s speculation in New York State, because we have a pretty significant rural community outside New York City, that there’ll be some injunctive relief for New York State residents. So, it’s an important part of our practice.

I can tell you that what was...a curveball for us and certainly not beneficial was we had been traditionally...able to ship prescriptions from a central site through the mail for our patients. Even though we’re not a pharmacy, we can have a physician’s dispensary...the same thing at the end of the day. But that really changed things around quite a bit recently. And so, patients [who] were on relugolix from our pharmacy, some of them would essentially not be able to get the prescriptions from us because we couldn’t mail them anymore. And so, that has changed our business model around to make the injectable medicine...particularly 6-month medicines...much more attractive because we don’t want to lose the potential ability to provide good quality care for medicines that we think work but pay the bills a little bit. So, when we send prescriptions to the specialty pharmacies, no one wins besides the big specialty pharmacies.

Paul R. Sieber, MD: So, do you stock on the injectables? Do you take the stock on shorter-duration injectables, like 3 and 4 months, or you’re pretty much just stocking on 6 months?

Christopher M. Pieczonka, MD: I think that we’ve really tried to tighten down and get out of the business of doing things that we used to before, which is completely off topic, but I’ll give you an example. We were getting all these recent requests for prior authorizations for sildenafil and for tadalafil for our [patients with erectile dysfunction] who have Medicare, and we took a step back and said, Why? You can get these things for a couple dollars, a prescription. So, I use that as an example because we’ve looked at also the injectables for these people, particularly, we have what are called snowbirds, so there are some people who come here and they go to Florida for the winter, and then they come back. And then they have to time it the right way and all these other things. And we essentially got out of the business of anything besides the handful of … when you really need to for patients who are acutely symptomatic, and then everything else is 6 months, just everything else. So, we got out of the whole business of the 3 and the 4 months, and then people say they want this, and they want that, and we just said: This is the way that is. It’s 6 months and 6 months only.

Paul R. Sieber, MD: Aaron, what are you doing along those lines? Well, first with telehealth, and then, secondly, with the duration, but how about telehealth? We’ll start with that one first.

Aaron Berger, MD: Telehealth, we’re not as geographically spread out as...Upstate New York, but we still do have a fair number of patients coming from a distance from Northwest Indiana and various other rural areas and...even farther outside Chicago. So, still, we do a pretty good amount of telehealth, and obviously some of these [patients with] prostate cancer, they have other medical issues that sometimes it’s difficult for them to get in the car, into the office, and in the office. So, just for management purposes, doing a telehealth visit just to review their symptoms, make sure they’re feeling [OK], taking their bone agents, making sure they’re on their medications, reviewing labs. That just makes it much easier for the patients, their caregivers, all that stuff, especially those [who] are driving from long distances, but hopefully it’ll continue.…

Some of the studies say patients like coming to the office. I keep reading those articles that patients like coming in, but there’s certainly those [who] prefer to stay home and do a telehealth. So...certainly for us, and especially for the advanced practice providers [APP], I think it’s a really good option to do quick, straightforward follow-ups for something like ADT [androgen-deprivation therapy] management for some of these patients. But...[as for the] second part of that question, as far as what we’re stocking, I have...2 colleagues [who] continue to like using 3-month injections. I don’t really get it. I think the argument is they want the patients to come back, make sure they’re doing OK, make sure they’re getting their labs done, but I don’t have any problem personally seeing patients...who are on 6-month injections. For … patients, they’ll still come in every 3 months to just get labs done and have a checkup. So, I don’t see that being an issue. So, we may very well move, like Chris has done, to say, “You know what, we’re getting 6-month injections, and that’s it.”

Because, again, there are lots of products, as you mentioned earlier, we have pared down the options. So, there [are] really 3 injectables plus the oral that we’re using. A couple of other products we don’t really use at all, but I think just getting down to the 6 months makes ordering and everything easier for everybody. So, there’s no confusion about what they’re getting and the timing, because there [have] been a couple of instances where patients will come in and you think they’re there for an injection...or they think they’re coming in. It’s like, wait a second, you got a 6-month shot. They’re like, “Oh, I was getting the 3-month shot.” So obviously, you don’t want to make a mistake and give an injection that’s not due because then you’re going to eat that cost. So, having everyone getting 6 months...is just going to make it easier moving forward.

Paul R. Sieber, MD: Richard, you’re last. You probably have the most constraint about what you could do, since your insurers are telling you what to do. So, I’ll start with…what you’re giving.

Richard David, MD, FACS: Well, the other issue for us, Paul, is if we’re dispensing medication, we have to physically hand the bottle of pills from the physician or the APP directly to the patient. So, that means the patient’s still coming into the office, typically monthly. So, for them, it’s not that big of a deal for us to just say, “Well, you’ll be seen and get your blood drawn today, or you’ll be seen and you’ll get your shot today. But I did also want to really agree with what some of the other guys said, that I think one of the other issues is us sticking to 6-month injections...leads to fewer mistakes. Fewer missed doses and fewer early doses and all those things. So, I think the 6-month does bring us some advantages, and we still see the patient back at 3 months.

Transcript is AI-generated and edited for clarity and readability.

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