Impacting Patient Outcomes with Personalized CLL Care

Dr. Caudle: 
Welcome to Project Oncology on ReachMD. I'm your host, Dr. Jennifer Caudle, and joining me to share their viewpoints on providing personalized care for patients with chronic lymphocytic leukemia, or CLL, are Dr. John Allan and Ms. Amy Goodrich. Dr. Allan is an Associate Professor of Clinical Medicine in the Division of Hematology and Medical Oncology at Weill Cornell Medicine in New York City. Dr. Allan, thank you so much for being here today.

Dr. Allan:
Thank you so much. It's a pleasure.

Dr. Caudle: 
Well, we're happy that you're here. And Ms. Goodrich is a Nurse Practitioner at Johns Hopkins Hospital and a Research Associate at Johns Hopkins University School of Medicine in Baltimore, Maryland. Ms. Goodrich, it's great to have you with us as well.

Ms. Goodrich:
Thank you. Great to be here.

Dr. Caudle: 
Well, we're delighted that you're both here. So to start us off, from a clinician's perspective, Dr. Allan, how do you work with your team to provide patient-centric care?

Dr. Allan:
Yeah, so it's obviously in the CLL space that I operate in with a lot of different therapeutic approaches that don't really have clear evidence to suggest one approach over another for any specific type of patient, really becomes important to have this personalized type of medicine. And really that comes down to employing shared decision-making models and utilizing the various layers of the patient care team to provide that high-level, personalized care. And that comes in various forms, working with our physician assistants, myself, the patient, their caregivers, our pharmacists, our social workers, and really trying to utilize all of these various entities within the healthcare system to identify barriers and patient preferences, and trying to understand what approach is going to be the best for that patient.

Dr. Caudle:
And as a quick follow-up to that, Dr. Allan, what challenges could prevent optimal personalized care?

Dr. Allan:
Yeah, so obviously we treat patients with CLL who, by definition, are older in nature. And so we deal with many issues that arise in an older patient population. Socioeconomic issues I practice in a large academic urban center, and so being able to transit back and forth from their home to the center can be costly. It can be problematic in terms of just logistics and timing, and with many steps and stairwells and things along those lines. And these factors can start to come into play, and potentially impair care and actually dictate which type of treatment approach you might be able to use for the patient. And so we think about all these things, and we try to identify them through this shared decision-making process, utilizing our social work resources and our copay assistant programs and trying to understand any issues with insurance and that so they can actually get the top level care and the best therapeutic approaches for their disease state.

Dr. Caudle:
Turning to you now to get your perspective, Amy, what gaps in patient care need to be addressed when working with a team?

Ms. Goodrich:
Right. So Dr. Allan hit some of them. Certainly, transportation is an issue when we talk about CLL therapy. Some are oral drugs that have very few and infrequent visits versus our Venetoclax with obinutuzumab or other infusional-related therapies where there are lots of back-and-forth visits, can a patient really—can they do this? Can they get to our centers? Social support is a big issue that can cause gaps in care for patients. Just the whole access to care as well, their health literacy. We're relying on these people to take an oral drug and to be adherent. And then, Dr. Allan also talked about cost in terms of travel, but there are copay issues with a lot of our therapies as well.

And the other thing that we have to make sure are for adherence purposes, making sure patients understand what they can be doing at home to alleviate side effects. But then, who do they call? Where do they call? Why do they call? When do they call? And just making sure that they know that we're here for them as well. One of the best things about treating patients with CLL is that these are typically very repeated discussions that you are having. You have visit after visit after visit to talk out the options and the requirements and sort of work through some of these barriers that may come up for patients

Dr. Caudle: 
For those of you who are just tuning in, you're listening to Project Oncology on ReachMD. I'm your host, Dr. Jennifer Caudle, and I'm speaking with Dr. John Allan and nurse practitioner, Ms. Amy Goodrich, about caring for patients with CLL.

So now that we've discussed some barriers in CLL care, let's look at some potential ways to overcome them. Coming back to you, Amy, what approaches would you recommend to help the care team have better coordination and communication?

Ms. Goodrich:
Sure. So within our care teams, Dr. Allan did talk about all the folks we have. We've got our oncologists, we've got our advanced practice folks, whether it's PAs or nurse practitioners, we have pharmacists, we have nurses, we have our financial specialists, we have social workers. We have a host of folks who interact with these patients. I find that having a consistent team really helps. Or if you don't have a consistent team, that folks’ role within the team is consistent. So if you have a number of pharmacists, say, that they're doing all of the same things that their practices are not wildly different, so that we all know what everyone else is doing.

I mean, in terms of communication on my team, we have weekly meetings, reviewing the patients, where they are, what's happening. I'm checking to make sure patients are having labs done. Our pharmacists are following up with patients, our nurses are making sure that folks are okay as well. And really, this does require a multidisciplinary team, and the more solid and well-organized you can be so that everyone understands what everyone else is doing is critical here to support these patients through this therapy.

Dr. Caudle:
Thank you for that. And with those strategies in mind, Dr. Allan, can you share an example of when you applied those and other strategies to collaborate with your team and care for a CLL patient?

Dr. Allan:
Yeah. I mean, I think as Amy had stated before, this is almost done on a daily basis between myself, our patients, our advanced practitioners, etc. And so I mean, just in my last clinic there was a patient who's nearing therapy, needing treatment indications. And as Amy had stated before, you start to plant the seed of these various approaches, these continuous therapy approaches, these fixed duration approaches, clinical trial approaches, start to introduce the concepts of what these classes of drugs are lead them to resources that are great for them to start to educate themselves on some of these topics. And then, relying on the communication back and forth over these various interactions.

And then there was another patient just recently that is requiring treatment. And so the follow-up with the pharmacist, we fortunately, have an internal pharmacy, specialty pharmacy, and so it's very simple for us to write the script, to send the email, to talk about the patient that you're going to be receiving a phone call from this member of the team. And they really come to rely on our pharmacist. And I found that that's invaluable to making sure that they're taking the medication, they understand drug interactions, they follow up with side effects. And many times, the pharmacists are being told side effects that I'm not being notified about, or the patient's not calling in, but it's because the pharmacy has that follow-up call. And so it just provides this well-rounded full-circle service to the patient to where they feel empowered to speak up, to reach out, and to have their voices heard, and some direction in their care.

Dr. Caudle:
And before we end today, Amy, what impact could personalized care have on CLL patients and their outcomes?

Ms. Goodrich:
It has a very big impact. When I think about personalized care in CLL, the cornerstone of that is really that shared decision-making that Dr. Allan was talking about, and really a patient-centric approach. And we know that when patients are involved and they are involved with their decision-making, adherence is better, their engagement is better, we have more trust with our patients. And the whole point is to improve outcomes, to have patients on these drugs as long as we can to get the maximum benefit from these drugs. So that personalized care is really integral to the success of any therapy for our patients.

Dr. Caudle:
Excellent. And with those impacts in mind, I'd like to thank my guests, Dr. John Allan and Nurse Practitioner Ms. Amy Goodrich, for joining me to discuss their experiences in managing patients with CLL. Dr. Allan and Ms. Goodrich, it was great having you both on the program.

Ms. Goodrich:
Thanks so much.

Dr. Allan:
Thank you.

Dr. Caudle:
For ReachMD, I'm your host, Dr Jennifer Caudle. And to access this and other episodes in our series, visit Project Oncology on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening.