FDA Approves In-home Breast Cancer Treatment

[radiation]

FDA Approves In-home Breast Cancer Treatment

www.medscape.com

Couple of thoughts about this.
- Is this the med onc equivalent of the rad onc supervision rule? As precision oncology moves away from cytotoxic agents, we will be getting more systemic therapies that are either pills or subq injections like this. What happens to reimbursement from infusion centers if their volumes go down?
- Will this make it easier for rad oncs to prescribe systemic agents in the future? Some already do for ADT. If cetuximab becomes subq, its not a huge leap to think about a rad onc prescribing at some point

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[scarbrtj]

FDA Approves In-home Breast Cancer Treatment

www.medscape.com

Couple of thoughts about this.
- Is this the med onc equivalent of the rad onc supervision rule? As precision oncology moves away from cytotoxic agents, we will be getting more systemic therapies that are either pills or subq injections like this. What happens to reimbursement from infusion centers if their volumes go down?
- Will this make it easier for rad oncs to prescribe systemic agents in the future? Some already do for ADT. If cetuximab becomes subq, its not a huge leap to think about a rad onc prescribing at some point

In theory the mere prescribing per se is not the hurdle right? E.g., any rad onc in America may totally and wholly and legally write a script for 5FU Xeloda, have the patient get that filled at the pharmacy (or oft times it's just mailed), and the patient takes it at home. (That one drug itself definitely affected infusion center volume, albeit mildly.) The hurdle is: if you prescribe it, you own the side effects. You own the backlash at the hospital from the med oncs or hospitalists who will round on your patient you had to admit once you inevitably get that DPD deficiency reaction. None of the non-cytotoxics are 100% severe side effect symptom-free either. If oral (or at-home injectable) antineoplastic agents were 100% safe, I'm sure there would already be a trend toward rad oncs prescribing. The neuro oncs prescribe Tmz...

 

[Gfunk6]

Also this has significant consequences for infusion (J-codes) for Med Onc.

It would be interesting to learn more details about the HCP who administers this and how long they have to stick around for a potential "reaction."

 

[radiation]

In theory the mere prescribing per se is not the hurdle right? E.g., any rad onc in America may totally and wholly and legally write a script for 5FU Xeloda, have the patient get that filled at the pharmacy (or oft times it's just mailed), and the patient takes it at home. (That one drug itself definitely affected infusion center volume, albeit mildly.) The hurdle is: if you prescribe it, you own the side effects. You own the backlash at the hospital from the med oncs or hospitalists who will round on your patient you had to admit once you inevitably get that DPD deficiency reaction. None of the non-cytotoxics are 100% severe side effect symptom-free either. If oral (or at-home injectable) antineoplastic agents were 100% safe, I'm sure there would already be a trend toward rad oncs prescribing. The neuro oncs prescribe Tmz...

Agree, but some of these new targeted agents are extremely well tolerated. Whats the moat (besides the political one) around something like Larotrectinib, which has not published a single grade 4 tox and has 10% grade 3 tox. I don't know if having to admit for an adverse event from a systemic therapy is that much different than admitting a head and neck patient for confluent mucositis and nutritional support.

I'm not saying we would jump into TPF or anything, but we could pick our spots. Kind of like that neuro onc who will prescribe TMZ, but punt seizure management to his epilepsy colleagues.

 

[ramsesthenice]

Agree, but some of these new targeted agents are extremely well tolerated. Whats the moat (besides the political one) around something like Larotrectinib, which has not published a single grade 4 tox and has 10% grade 3 tox. I don't know if having to admit for an adverse event from a systemic therapy is that much different than admitting a head and neck patient for confluent mucositis and nutritional support.

I'm not saying we would jump into TPF or anything, but we could pick our spots. Kind of like that neuro onc who will prescribe TMZ, but punt seizure management to his epilepsy colleagues.

The biggest (non-clinical) issue is doing this in a way that avoids a turf war. If your referring docs feel like you are cutting them out, they wont' stay your referring docs for long. Not saying there is no solution. Only that this is an area in which we need to proceed with caution.

 

[Palex80]

I thought that had been approved for quite some time now... Xeloda, anyone?


Just kidding...

The same has already happened several times in medical oncology.
Do you recall the endless rows of patients receiving biphosphonates iv (over at least one hour) - like Zometa?
All gone now with Denosumab.

Rituximab is also available as s.c. injection, gone are the days of all the follicular (and other low grade lymphoma) patients coming in for infusions of antibodies...

 

[scarbrtj]

 

[Gfunk6]

In all honesty the "it's all about patient safety" argument is used continually in medicine whenever a cheaper alternative is proposed:

1. CRNAs performing anesthesiology independently of MDs
2. No supervision required for hospital based radiation facilities
3. NPs being able to practice independently of PCPs

And the list goes on and on and on

 

[radiation]

In all honesty the "it's all about patient safety" argument is used continually in medicine whenever a cheaper alternative is proposed:

1. CRNAs performing anesthesiology independently of MDs
2. No supervision required for hospital based radiation facilities
3. NPs being able to practice independently of PCPs

And the list goes on and on and on

...hypofractionation? *crickets chirping*

 

[scarbrtj]

...hypofractionation? *crickets chirping*

The most hypofractionated, lowest dose RT treatment (1.5 Gy/1 fx) I’ve seen in modern times brought out editorials from many an academic bigwig about how unsafe THAT was. So you’re not wrong.

 

[Gfunk6]

Here is ASCO's official policy statement on administering in-home IV chemotherapy.

Should we expect a miniaturized linac that you can order from Amazon in the near future?

 

[taserlaser]

Here is ASCO's official policy statement on administering in-home IV chemotherapy.

Should we expect a miniaturized linac that you can order from Amazon in the near future?

Hey there could be a surplus of ROs - they could offer tailored ‘at home’ treatment delivery!

I’ve always maintained a linac on a cruise ship would be great. In the era of covid though - not so much sadly

 

[medgator]

Hey there could be a surplus of ROs - they could offer tailored ‘at home’ treatment delivery!

I’ve always maintained a linac on a cruise ship would be great. In the era of covid though - not so much sadly

Always thought about the same thing, esp for prostate/breast... Few weeks in the Mediterranean while you get it taken care of

 

[scarbrtj]

Should we expect a miniaturized linac that you can order from Amazon in the near future?

John Adler once told me Cyberknife became feasible due to linac compactification that was a result of the military researching a linac that could be carried in a backpack by a soldier on the battlefield. Don't know how true it was but definitely a "cool story bro."

 

[Chartreuse Wombat]

Now that SBRT cool for prostate and breast. Build a bunker in Aruba and treat while on holiday...kinda like HIFU in the Bahamas