Daniel Joyce: It's a pleasure to be here, Zach. Thanks for asking me.
Zachary Klaassen: Always good chatting with you. So we've seen over the last decade a real just explosion of opportunity for treatments in advanced prostate cancer. Many options now. We used to have ADT alone, ADT and docetaxel, and have all these oncolytics that have really sort of transformed quality and quantity of life for these patients. But as expected, these are expensive treatments. And I know you've done a lot of work in this space in terms of cost and cost-effectiveness. What are some of these barriers for these patients and access to medication administrative issues? I know it's a loaded question. We could spend a lot of time on this, but maybe just for a high level set.
Daniel Joyce: I mean, there's a lot there. The really kind of crazy thing about advanced prostate cancer is that you've got, yes, multiple different treatment options, but in many cases, very few comparative head-to-head data on those treatments. Also, different modalities of treatments. So you have radioligand therapy, you have oral drugs, you have IV drugs. And that matters when you talk about cost because each of those are reimbursed a little bit differently and the insurance plans manage those differently. And so there's a lot of coordination that happens also, I think, to get patients drugs, coordinations between all those people who are involved in administering the drugs, but also in the kind of financial wheels of each institution and how they're obtaining that drug, how they're getting that drug to the patient, how they're getting reimbursed for that drug, how they're getting access to things like Pluvicto. Not everybody has that ability available to them. There's nuances in costs in how different institutions get access to those kinds of things. So it is super, super complex.
I think the interesting thing is when you have multiple different treatments across modalities that are in some cases equivalent from an oncologic standpoint, and we're really just kind of choosing apples to apples. It is mind-boggling to me that a lot of the time we as clinicians, that decision isn't made by looking at all of the toxicities of treatment. We do consider a lot of the clinical trial-reported toxicities when we prescribe these treatments, but the cost toxicity, the financial toxicity, is something I think we as clinicians could do a better job of acknowledging. And I think you see that when you start to see how prostate cancer patients do once they're on treatment and when you look at their financial side of things. So we ages ago now looked at how patients cope with the costs of their advanced prostate cancer care. And what's interesting is that in a lot of other cancers, what you see is higher-cost treatments, patients become bad patients. They become non-adherent, non-compliant with their treatment regimens, just because they can't afford it. They're not bad patients. It's just they literally can't find the money to pay for their drugs.
What we found was that prostate cancer patients were a little bit different. And I think it's because a lot of these oral drugs that people were getting put on, they're really high-cost buy-ins. So when you start looking at our patients staying adherent, I think they put so much of their wealth into the getting on treatment upfront that there's a lot higher stakes to come off of treatment for them because they've already invested so much. What we're not capturing in that data are all the patients who could not get on treatment in the first place because they didn't have that upfront cost available to get on treatment and stay on treatment.
Zachary Klaassen: No, that's fantastic. I think there's so much in terms of prior authorizations, out-of-pocket costs, as you mentioned. It's interesting, there's some trials going on looking at treatment breaks, treatment discontinuations, and that's for toxicity really. And you think about they've had a great response and for two years, let's say they're on a doublet therapy. What happens if we take them off that? Just thinking about this now, I had this conversation yesterday, from a financial standpoint, that could also help the patient as well. I mean, there's a lot to unpack in terms of how we go forward with some of these new trials, how we interpret that data. Dan, in your research, there's clearly differences between academics and community practices. What are some of those and how do you lay that out for our listeners?
Daniel Joyce: I don't know is the answer. The reason is because, when you talk about a community practice versus an academic practice, there's a wide variety of what that community practice looks like. I think a lot of us that are in academics want to think like, oh, disparities aren't as big of a deal in academics because we have all these bells and whistles at our disposal. But that's not always the case. I mean, we know there are disparities in the academic center. We know getting patients on the drugs we want them on is a challenge even in academic settings. And a lot of that, as you alluded to, is prior authorization. We know that prior authorization delays care. That remains a major obstacle. The formularies of a lot of these insurance companies inhibit what you can put on and when and how much that's going to cost the patient.
Different community practices sometimes, based on how they've set up their kind of financial process of access to a lot of these drugs, they may in some settings actually have more access for patients, including clinical trials, than what an academic center might. So I think there's probably trade-offs in each, which is why I don't know the answer because I think it's region-specific. I think it's type-of-practice-specific even within that community setting. But certainly I don't think any of us are immune to it, I guess is the moral of the story, is that I think all of us, no matter what kind of practice we're running, we all face these cost challenges and challenges of keeping patients on their treatments due to the financial toxicity of these drugs.
Zachary Klaassen: Yeah, absolutely. I think that's totally fair. It's so many variables involved with that. So you're at sort of the fingertip of this stuff in terms of has there been or is there going to be legislative or insurance changes that are coming that may or may not help us with some of these drug costs?
Daniel Joyce: Yes. They're here, actually, and we've already seen the benefit of them. So the vast majority of these patients are on Medicare. The Inflation Reduction Act did a lot for these patients, especially with oral drugs capping at $2,000 max out of pocket. There's a recent study in JAMA Network that basically showed it did what it was supposed to do. These drugs were super expensive and then it dropped down to that $2,000 max once it kicked in. The problem with it is that, one, $2,000 is still a lot of money. And when patients get hit with that bill, they're hit immediately. So if they get prescribed that drug in January, boom, $2,000 they got to get out of their pocket right now to get that drug. For most patients, they don't have $2,000 sitting around.
So what they've done is there's now a Medicare Prescription Payment Plan that most people don't actually know about and is super huge and helpful for patients. And all clinicians need to know about it, I think. What it does is it just smooths out that cost over the remaining calendar year, so instead of $2,000 upfront, they're paying a hundred-some-odd dollars every month, which is a lot more manageable for patients. Obviously the total cost is the same, but you're not getting charged insurance for delaying your payments or anything like you would on a car. It just makes those monthly payments a lot easier to get on drug then.
The caveat to it is that it is voluntary and you have to enroll in it and you have to know about it to enroll in it. So there's, with all of this, an administrative burden on the patient to kind of get their financial status in line and getting access to these things requires effort and a lot of work on somebody's behalf. And I think we as clinicians could do a better job of getting patients knowledge of that. And also financial navigators, things built into our system that can help direct patients to that and get them the resources they need to go through that process and get enrolled.
The Inflation Reduction Act also has price negotiation built into it and we're starting to see that. Right now the government does not price negotiate any prostate cancer drugs, but hopefully that will be on the horizon and help lower these costs even more. There's kind of a long history of trying to get pre-authorization better for patients through legislation. I have yet to see any widespread sort of changes, but things like automatic authorization for any drug included in NCCN guidelines, something like that, has been discussed, has been toyed with, especially on the state level. I think we shouldn't ignore prior authorization. I think it is a big deal and I think it's something that our political figures need to keep looking at. There's obviously a lot of pressure on a lot of sides, financially invested people that make that a tough ask, but I think it's possible and will probably come in the future.
Zachary Klaassen: No, that's super helpful, Dan. Thank you. My last question is just some practical tips. I mean, there's so much going on. It's region-specific. It could be bladder. It could be advanced prostate. We're focusing on advanced prostate today. But any practical tips for keeping these patients on treatment, helping with these financial toxicity issues?
Daniel Joyce: Yeah. I should preface by saying that I actually don't treat advanced prostate cancer patients. I'm more of a localized cancer specialist. But I do, because of my research, interact with a lot of our clinicians who manage these patients. And what I've come to find is that a lot of them, almost all of them, have a pharmacist in the office with them basically who is helping with this whole process. There's a lot of interaction between the people that dispense the drug and the provider who prescribes it immediately after the decision's made. I think that's crucial. I think from a physician side of things, you really need to understand financially where the patient's coming from. And we don't want to do that. It takes time. But it's, I think, easy to assess in a very short period of time actually.
One of the things we're trying to do is give patients out-of-pocket estimates for all their treatment options before we make a decision in the office. And that works actually as a really good screening tool for patients because if you show them a price tag on any of these drugs, it doesn't take much for them to say, "I can't afford that." Which is the perfect screening to say, "Okay, we need to figure out how to get this ... Is it an access program that we can get you involved in? Or is there a way to break up the payments so you can get it done?" I think knowing that early on is probably the best way.
And then keeping tabs on it, because we know it changes too. We've seen financial toxicity fluctuate over time. Just because your patient's in a good situation upfront doesn't mean that a year from now, two years from now, and in prostate cancer, that really matters because these are prolonged disease courses now where patients are going through multiple drug options, so I think keeping in tune with that, keeping the finger on the pulse of their financial wellbeing, is important throughout their cancer care.
Zachary Klaassen: Awesome. We touched on a lot today, Dan. Any take-home messages? Anything we haven't hit on for our listeners?
Daniel Joyce: The only thing I'd say is that we as clinicians don't like to talk about cost because we're not trained on talking about cost. We don't understand insurance, honestly. We don't understand the way money moves through the system. And I would just lobby for physicians to stop letting that be okay and to take ownership of it. We are, at the end of the day, I think, the gatekeepers of these drugs. And because of that, it's on us if we cause a toxicity financially to our patients.
And so every time I talk about cost, I try to instill in people a passion for it, for trying to figure out what high-value care is for their patient and including costs in that discussion. It's not just a toxicity in the traditional sense versus oncologic benefit discussion, which is how it happens in our clinics, I think, most of the time. It's possible. It takes a little extra research and work and care and investment in it, but I do think it's possible for us as clinicians to listen to our patients because they're telling us they want to talk about cost and helping them out with that.
Zachary Klaassen: Yeah. Well said, Dan. Really enjoyed it. Learned a lot, and I know our listeners will as well. Thanks for joining us on UroToday.
Daniel Joyce: Thank you, Zach. It's a pleasure.