UNC Health Medical Center
Chapel Hill, NC
Precision oncology approaches that integrate molecular biomarkers into treatment selection may result in dramatic improvements in survival and quality of life for patients with cancer.1 Despite this promise, significant barriers to broad implementation exist.2 The lack of access to precision oncology expertise may result in the use of costly therapeutics that have minimal therapeutic benefit yet appreciable side effects, or a missed opportunity to provide an optimal therapy based on individual tumor biomarkers.3
The UNC Precision Oncology Program (POP) aims to assist clinicians in the effective use of molecular testing technologies and to provide expertise on emerging targeted therapies and biologics, which require careful deliberation to ensure appropriate use.
The UNC POP began as a traditional multidisciplinary molecular tumor board that met weekly to discuss cases referred to the service by treating physicians. We adapted this model to support increased demand for consults by placing a clinical pharmacist at the hub of case review and response. We utilized an e-consult model to facilitate consultative services across a health system that spans the state of North Carolina, thus positioning the pharmacist to centrally connect laboratory vendors, pathologists, and patient-facing clinicians. The use of the e-consult model also allows for documentation to support off-label uses of medications, thus streamlining the medication access process. Additionally, we recognized a consult-based model may not meet the needs of our community sites, and therefore established a collaborative partnership with a system community cancer site to provide targeted assistance with genetic testing workflow optimization. We expanded our services at this site to both aid in appropriate test selection and to provide reflexive review of genetic testing results ordered. This service was unique from our MTB e-consults as the POP pharmacist independently reviewed ALL tumor genetic testing completed at the site without the need for referral.
As of May 2024, POP had received 200 consults originating from each of the six major cancer centers in the health care system. Biomarker directed therapy options were recommended in 133 cases, with 50/133 patients (37.6%) having started treatment. We identified biomarker directed clinical trials in 103 (52%) consult cases. Although test interpretation was specifically requested in only 18/200 cases, we recommended additional molecular testing in 52/200 (26%) of cases reviewed, demonstrating significant opportunities to ensure testing was utilized appropriately. Furthermore, we identified 28 cases (14%) where a referral to Clinical Genetics was warranted for germline testing. After expansion of our services to a partner site outside the academic hub, we provided reflexive review of 100 patients cases between February 2023 and April 2024. We recommended on-label biomarker directed therapy in 18/100 cases (18%) and recommended consideration for POP e-consult for off-label therapy in 22/100 cases (22%).
Our model advances pharmacy practice by recognizing the pharmacist as a central precision medicine expert. Our experience has led to the creation of novel interdisciplinary collaborations, the integration of pharmacists in a peer-to-peer e-consult model, and more equitable access to precision oncology expertise across a diverse health system.
References:
- Shin SH, Bode AM, Dong Z. Addressing the challenges of applying precision oncology. NPJ Precis Oncol. 2017;1(1):28. Published 2017 Sep 4. doi:10.1038/s41698-017-0032-z
- Schilsky RL, Longo DL. Closing the Gap in Cancer Genomic Testing. N Engl J Med. 2022 Dec 8;387(23):2107-2110. doi: 10.1056/NEJMp2210638. Epub 2022 Dec 3. PMID: 36472952.
- Hamilton JG, Banerjee SC, Carlsson SV, et al. Clinician perspectives on communication and implementation challenges in precision oncology. Per Med. 2021;18(6):559-572. doi:10.2217/pme-2021-0048
Back Row, Left to Right: Daniel J. Crona, Jaime Richardson, John Valgus
Front Row, Left to Right: Amber Cipriani, Elizabeth Tinoco
Not Pictured: Crystal Dula, Maurice Alexander