Abstract
BACKGROUND: Emerging therapeutic classes continue to answer the call for novel therapies for multiple myeloma (MM), particularly for patients with relapsing/refractory MM (RRMM) after doublet or triplet therapy. Bispecific antibodies (BsAbs) are at the forefront of leading the expansion of the treatment landscape yet are not without their challenges in the community setting. To resolve real-world barriers to guideline- and evidence-based care, ensure appropriate treatment decision-making, and align patient-provider goals for care in the community setting we designed a 4-phase implementation-science (IS) initiative with educational interventions.
METHODS: The initiative was submitted and approved by a centralized institutional review board. Phase 1 included baseline data analyses, phase 2 included a data-informed tethered educational initiative, phase 3 is a plan-do-study-act follow-up, and phase 4 includes dissemination of findings. Approved materials were used in collaboration with Premier to identify 3 appropriate community cancer centers to engage in the initiative with a minimum of 25 active patients with RRMM. The 3 centers completed chart extractions (EHR) following the protocol's inclusion criteria, provider and patient surveys, constituting the baseline data in phase 1 of the initiative. The data was presented to each center by an MM expert and benchmarked against current evidence. Guidance was provided to each center to develop action plans designed to address specific areas of need to improve patient care with BsAbs. The baseline data collected in phase 1 in addition to the action plans for the 3 centers will be presented.
RESULTS: Across the three sites, EHR data (n=73), provider surveys (n=37), and patient surveys (n=21) were collected. Only 51% of community providers very frequently/always performed prognostic scoring; however, there was discrepancy in which system was most utilized as provider surveys show 85% prefer the R-ISS while EHR-reported use of ISS (47%) and R-ISS (53%). Of note, R2-ISS was not considered for use. Provider responses were consistent with EHR data on molecular and cytogenetic testing with testing occurring >50% of the time prior to initiating therapy. Of all 73 charts, 41% showed high-risk cytogenetics, 26% displayed complex/very high-risk cytogenetics, and only 6% (n=4) of charts did not have evidence of cytogenetic testing being ordered. Bispecific antibody use was seen as early as third-line therapy and while 59% of providers showed a preference for BsAb treatment after 3 prior therapies and 95% reported experience with BsAbs, only 16% of patient charts showed a patient on BsAb therapy. Of the three approved therapies at the time of EHR data collection, only two were used across all three sites. Patients (n=21) reported having very little or no awareness of BsAbs or CAR T as novel therapies. Differences in the most difficult-to-manage AE emerged with providers revealing infections and CRS/ICANS, patients revealing bone disease and gastrointestinal (GI) AEs, and chart data with highest reporting for GI AEs and fatigue. Guideline-concordant supportive care was evident in evaluated charts with highest adherence for renal dysfunction, venous thromboembolism, anemia, and bone disease. Providers revealed proactive infection management coupled with multidisciplinary team engagement resulting in lower frequency of dose modifications. Despite low patient knowledge of novel therapies and a lack of awareness of their current therapy, patients identified treatment with novel therapies as their top treatment goal. Educational needs, barriers to care, and areas in which they need additional assistance were identified directly by patients and shared with their providers.
CONCLUSIONS: This IS initiative in its first two phases has been successful in uncovering the critical challenges in the integration of bispecific antibodies in community cancer centers. The comparison of provider survey responses and EHR data revealed discrepancies attributed to aspirational vs realistic practice. Action plan domains centered around internal AE protocol development, team education, patient education, alignment on prognostic scoring systems, evaluation on care models, patient navigation services, and EHR documentation integrity. The IS initiative provided a blueprint for key operational, logistical, and practice considerations when considering and integrating bispecific antibodies.
