Optimizing NSCLC Care Through Extended Dosing and Alternative Formulations

Key Takeaways

• Extended dosing intervals and subcutaneous immunotherapies in non-small cell lung cancer (NSCLC) improve patient convenience, adherence, and satisfaction while preserving efficacy and safety.
• These strategies significantly reduce infusion chair time, allowing oncology practices to increase capacity and better accommodate complex treatments.
• Clinical pharmacists play a critical role in implementing these changes by monitoring regulatory updates, updating electronic medical records (EMRs) and Beacon plans, and collaborating closely with providers, fellows, and industry partners.

Please introduce yourself by stating your name, title, and any relevant experience you’d like to share.

Corrine Stahura, PharmD, BCOP: Hi, everyone. My name is Corrine Stahura. I am currently a thoracic clinical pharmacy specialist at Penn Medicine and the University of Pennsylvania. I'm excited to be here today.

What dosing and administration trends are you seeing in NSCLC right now—particularly around less frequent dosing and the movement toward subcutaneous or alternative formulations—and what’s driving these changes?

Stahura: Modern-day non-small cell lung cancer therapies, particularly immunotherapies and targeted agents, are really moving towards extended dosing intervals when supported by pharmacokinetic data.

For example, oftentimes we'll start with 4 cycles of chemotherapy plus immunotherapy, typically given every 3 weeks. Then we'll transition to immunotherapy, plus or minus chemotherapy maintenance. It's much more convenient for the patient, of course, to come into our infusion center with these extended intervals every 6 weeks, for example, with pembrolizumab, as compared to the normal dosing, which is every 3 weeks.

There are pharmacokinetic data that state that these longer intervals are equally efficacious and have a similar toxicity profile. From a clinical standpoint and a chair-time standpoint, which we'll probably get into a little bit later, as well as from a patient satisfaction standpoint, it does make sense to extend the interval.

There are also many medications within non-small cell lung cancer that are being administered subcutaneously. Within immunotherapy, we have atezolizumab, nivolumab, and pembrolizumab. Most recently, we have amivantamab. They just came out with their subcutaneous product, which we were waiting for.

These products are starting to become preferred because they don't need an IV line, the administration times are shorter, and the patient is able to get in and out of the infusion center quicker. From an administrative standpoint, these doses save on chair time, and we're able to accommodate more patients.

Particularly, with amivantamab, we also see that the subcutaneous formulation and route of administration have a lower risk of infusion-related reactions. We're talking only 16% with the subcutaneous formulation versus 67% with IV formulation. It also saves time that nurses have to spend monitoring patients and managing these reactions.

This has been also demonstrated in other subcutaneous formulations outside of non-small cell lung cancer, such as daratumumab, which is used in multiple myeloma. This is not new, but we're very excited to have it now in the non-small cell lung cancer world.

How do changes in dosing frequency and administration route affect patient access, adherence, and persistence, especially for patients facing transportation, time, or financial barriers?

Stahura: I did refer to this a little bit in the first question, but changes in frequency of clinic visits significantly affects patients' treatment experiences. This is particularly pertinent for patients who face barriers to receiving treatment, whether it be transportation, parking, trying to find childcare, or having to miss work; all of these things, unfortunately, cost money. Less frequent visits altogether can really cut down on patient costs.

Additionally, we see that patients have better adherence to their therapies when they're given less frequently because there's less opportunity for other life events to get in the way.

The one challenge I will state with these less frequent visits for our providers and myself is that we are not monitoring and seeing the patient to evaluate them as frequently. We overcome this at our clinic because patients are provided with our office phone number, where we always have someone on call 24/7, even during our nonwork hours.

They also have the ability to always message us through the chart with any tolerability or toxicity concerns. We really do encourage our patients to reach out to us. Another challenge, of course, can unfortunately be insurance companies. Usually, when we change the dose or even just the route of administration from IV to subcutaneous, even if it's equivalent and we give it every 3 weeks, for example, it often requires a new prior authorization, which can, unfortunately, take time and delay care.

From an operational standpoint, how are extended dosing intervals or alternative administration options impacting chair time, scheduling flexibility, and overall practice efficiency in oncology settings?

Stahura: Extended dosing intervals have really freed up a significant amount of chair time by eliminating entire infusion visits; for example, with pembrolizumab, giving every 6 weeks compared to every 3 weeks. That's a whole extra visit; we're cutting down on half the time. It not only adds extra chairs but also frees up time for infusion chairs for patients needing more complex care, for example, a platinum desensitization, which can last all day long. We're able to fit more patients in sooner.

The subcutaneous injections for immunotherapies also saved us a good amount of time. A lot of these infusions are given over only 1 to 7 minutes. Pembrolizumab is given over 1 to 2 minutes, nivolumab is given over 3 to 5 minutes, and atezolizumab is given over 7 minutes, while their IV counterparts are given over 30 minutes.

We're saving a significant amount of time. They don't need IV access, which also takes time. The chair times are significantly cut down. We have not yet operationalized subcutaneous amivantamab, as it just came out, but this would be administered over 5 minutes compared to 1 to 5 hours, depending on the dose of amivantamab, where you're at in therapy, and also if you have previously reacted.

This will be saving us a significant amount of chair time and the time that the nursing staff has to closely monitor patients for infusion reactions and, of course, treating those infusion reactions. As I stated previously, they happen quite often.

When new dosing regimens or labeling updates are introduced, how do pharmacists, payers, and population health teams evaluate and integrate these changes into EMRs, formularies, and utilization management strategies?

Stahura: When changes in the package insert and labeling are introduced, updating the Beacon plans and the EMR most frequently falls on the clinical pharmacy specialist within each disease state to update this. That is mostly me within the thoracic world, and my counterpart.

The most important part of our job in keeping all of these up to date is staying up to date in terms of new drugs coming out and package inserts changing. We do this in a few different ways. I have signed myself up for emails from the US Food and Drug Administration (FDA) oncology drug updates, which provide me with any new FDA-approved drugs and alert me for the need to have them be presented at the pharmacy and therapeutics committee (P&T). We typically bring the new drugs to P&T first, and then we're able to build new Beacon plans and update the EMR.

My counterpart and I also have great relationships with our providers, so we'll periodically check in with them and see if there are any new regimens. They're always very quick to inform us if they have anything new that they want to use in clinic so that we're able to make these Beacon builds for them.

Additionally, after big meetings like the American Society of Clinical Oncology (ASCO), in the thoracic group, our fellows always provide updates and give a presentation about any interesting new trials that could become standard of care through the National Comprehensive Cancer Network (NCCN).

My counterpart and I also do occasionally meet with Medical Science Liaisons (MSLs) from various different drug manufacturers to answer any clinical questions that we may have about various drugs. Whenever we meet with them, we always emphasize that we want to be informed about any new drugs that are coming down the pipeline and any changes in the package insert, whether it be fluids, observation times, dosage, strength changes, pre-medications, etc. Most of them are actually pretty good at reaching out to us when these changes do occur, so that we're able to always update these in the Beacon plans as well.

Lastly, I do precept pharmacy residents, where we work up patients and do a ton of topic discussions together. During these topic discussions, we always re-review the NCCN guidelines. They do a great job at keeping me up to date. I've even had residents correct me on a couple of changes that have occurred since the last time I had previously reviewed the NCCN guidelines, as we know how quickly the lung cancer guidelines change. They keep me very up to date as well.