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Chronic Myelogenous Leukemia: achieving a 76% major molecular response rate at 24 months by pharmacist-driven oral oncology program.

Chronic myelogenous leukemia (CML) is a disease where the bone marrow makes too many white blood cells. According to the American Cancer Society, the median age of patients is 67 years and most patients can have a normal life expectancy if they take their medications properly and have appropriate clinical management.

Major molecular response (number of leukemia cells in your blood) is a surrogate marker for overall survival (see Figure 1). If patients achieve MMR at 24 months, their lives can be prolonged for an extended period of time. However, multiple published papers demonstrate that patients are only taking their medications 60-70% of the time, leading to lower survival and higher total cost of care (days in the hospital, emergency room visits, other prescriptions, etc.).  

Overall survival for patients in MMR at 24 months vs. those never in MMR
Figure 1. Overall survival for patients in MMR at 24 months vs. those never in MMR. Source: http://www.bloodjournal.org

 

In 2013, based on published literature from a phase 3 randomized controlled trial in CML, where 100% of patients were taking their medications, less than 50% of patients achieved a major molecular response at 24 months.

Knowing that adherence can be a barrier across all patients and wanting to achieve as better outcomes for our patients, Boston Medical Center’s specialty pharmacy began a pharmacist driven oral adherence management program for each patient that included intense education, structured follow-up with clinical support, assessment of medication adherence and appropriate financial support.   

Through a specialty workflow developed internally with the electronic medical record, all prescriptions for CML patients were exclusively handled by an oncology trained pharmacy specialist.

  • Clinical – pharmacists would help evaluate each prescription for clinical appropriateness based on patient risk factors, comorbidities, drug-drug interactions and frequent assessment and follow up for adverse events. 
  • Education – once medication was ordered, the specialty pharmacist set up an in-person meeting with the patient to discuss the medication, how to take it, address questions and concerns, and review other medications the patient was taking.  They also planned a next phone or in-person touch point, any lab follow up and the pharmacist provide the patient a calendar, in their native language with a schedule of when to take their medication. 
  • First appointment with provider or pharmacist - patients received a call from the same pharmacist, or had an in-person appointment, one or two weeks after the first meeting. This time was used to ensure that the medication was being taken as prescribed as well as ask about new or persistent side effects and answer questions and address concerns.
  • Medication adherence – after the first four weeks, monthly check-ins between the pharmacist and patient ensured patients were receiving their medication, and taking it. During these check-ins, patients could alert pharmacists to any issues with insurance, co-payments, refills, side effects, or receiving the medication, and pharmacists could intervene and support the patient.  Further, if the patient felt the need, they could reach out to the pharmacist directly between meetings through 24-hour on-call service.  
  • Interactions, side effects and toxicity management – the pharmacist not only checked in regularly with the patient about side effects of their CML medication, but also took over management of non-specialty medication prescriptions. This allowed the pharmacist to monitor potential drug interactions, ensure adherence with other medications too, and improve time to access for any medications that needed to be initiated for side effect management.  
  • Social workers – if necessary, pharmacists connected patients to social workers for support with emotional and issues related to social determinants of health. 
  • Interpreter services – for patients for whom English was not their first language, in-person or telephonic interpretation allowed the pharmacist and patient to have effective, two-way communication.
  • Food insecurities – patients can receive a prescription for food and they can go to the hospital food pantry and get food for their entire family 
  • Financial support/drug access – for patients with high co-pays a drug access patient assistance program coordinator would meet with the patient and help enroll patients into appropriate (co-pay programs, foundations or charities) to overcome any financial barriers.   

At the end of five years, patients who participated in this specialty pharmacy model with oncology trained pharmacists achieved a 76% molecular response rate in CML patients at 24 months.