Hi ,

Welcome back to the Oncology Insights Newsletter which fosters your continuous growth in oncology pharmacy practice

Last time you learned about the 16 things that are obvious to me now but weren't always, the story of post-transplant cyclophosphamide, and a reminder that you get what you ask for

This week you'll learn about my spicy take 🌶️ on commercial drug reps, who gets febrile neutropenia prophylaxis, and how the universe is conspiring against your progress

Have a great week!

Kelley

🧠 IPS (Insight, Pearl, Sundry)

Insight

🌶️ Spicy take alert 🌶️

Isn’t the role of a commercial drug rep obsolete these days?

Back when information was hard to come by (in those archaic days before the internet), drug manufacturers needed a way to communicate with prescribers about their drugs - the studies conducted, approved indications, basic drug information so they didn’t have to pull out the giant PDR book 😅

That role is antiquated now. We have information at our fingertips - everything the reps are allowed to talk about (on label) is what anyone with internet access can find almost immediately.

They are an expense that contribute to the crazy high cost of drugs

There are nuances between a rep for a drug and one for a device - I’m talking about the drug specific ones here

I attend a lot of conferences and talk with the commercial people in attendance and am often asked the same question: “how can I get in to talk to the pharmacist?”

The answer? Have something of value to offer. Which in most cases, they don’t have 🤷‍♀️

I asked my ELO Collaborative community their take and heard:

🥪 They like getting free lunch

Yes, this still happens and isn’t a good reason to keep them around - they only pass this expense on to all of us through drug prices

💊 Samples are helpful

It has been estimated that samples provided to offices in one year are valued at $16 billion 🤯, so free samples are not actually free...and almost all companies now have medication access teams to help facilitate getting patients medications (although definitely a lot of room for improvement there)

‼️ Why do they need a nurse educator AND a drug rep?

Great question - if given a choice, the nurse has a medical background that matters in an area as complex as oncology

📘 They help me stay up to date on new drugs

This is definitely a challenge in the rapidly changing world of oncology, but should we be trusting someone that isn’t a clinician and whose job is to sell a specific drug to keep us updated? They only know what they are told to know about the disease/drug they cover.

If a pharmacist or another clinician needs information about the drug that isn’t publicly available, and most of the information they need falls into that category because anyone can Google the basics, that’s exactly what the role of MSL (medical science liaison) is for

MSLs are firewalled from the commercial side of the company and they often have a robust clinical background (as we know because our experienced BCOPs are moving into these roles in unprecedented numbers)

Sure, everyone likes free food, but we don’t need it (and many organizations/states don’t allow it any more)

This was a historical need that we have evolved from, like we have from these also:

🎦 We watch movies online so no longer need Blockbuster

🎵 We listen to music digitally and no longer need our Sony Walkman

🛰️ We get directions through our phones and no longer need our Garmin GPS unit

📺 We can watch our favorite shows at any time and no longer need Tivo to record them

📱 We want touchscreens on our phones and no longer need the keyboard on the Blackberry

What value do commercial reps bring to the healthcare system? Because right now it seems like they only bring cost and a tax write off for the company.

Pearl

Febrile neutropenia (FN) is a potentially life-threatening complication of cancer treatment and is one of many oncologic emergencies to watch for (and ideally prevent) in our patients

FN is exactly what its name implies - it is a fever during a period of neutropenia

The textbook definition of fever in this context is 101F+ or 100.4F for at least 1 hour, but in practice, we don’t wait an hour to retake a temperature so 100.4 is usually the trigger

The definition of neutropenia is an ANC of <500 cells/mm3 or an expected decrease to that level in the next 48 hours

Don’t worry, you don’t actually need a crystal ball 🔮

This is where drug-specific knowledge comes in. By knowing the nadir of a particular drug (nadir = the low point), we can anticipate when the ANC will fall below 500. For most myelosuppressive drugs, this is between 7 and 12 days (there are outliers, like lomustine at 4-6 weeks)

FN is a bit of an odd condition. We know that infection risk increases when ANC decreases, and fever is often the first sign of infection. This is why FN is an oncologic emergency; we need to nip infections in the bud fast during neutropenia because the body’s reserve to fight is low.

Interestingly, we don’t find evidence of an infection in about half of patients with FN 😳 and we’re not really sure why. Maybe there is an infection and we can’t detect it or maybe fever was the result of something else. Regardless, we don’t want to risk having an untreated infection so these patients are given antibiotics asap.

Because of the risk and costs associated with an episode of FN, we want to prevent it. We do that with prophylactic GCSF (growth colony stimulating factors) which stimulate the production of neutrophils and reduce the duration and severity of neutropenia.

And also because of costs and risk of side effects, we don’t give GCSF to everyone that walks through the door - so who gets it?

The threshold of when to give prophylactic GCSF is based on pharmacoeconomic models that account for cost of hospitalization, drug use, and the impact of chemotherapy dose reductions and subsequent impact on patient outcomes. The data that drives this is older and didn’t account for a changing pricing landscape (such as biosimilars), but it’s what we have to work with.

It has been suggested, and has been standard practice, that regimens that cause FN in >20% of patients are high risk and warrant prophylaxis; this incidence data comes from published studies. Remember 20% risk as the magic number.

Those regimens in the intermediate category cause FN in 10-20% of patients and is less clear cut. Most patients getting these treatments will not receive primary prophylaxis unless they have at least one of these are other factors that can increase their risk of FN:

• Prior chemotherapy or radiation therapy: Prior treatment can beat up the bone marrow leaving it it in less than ideal condition to be pumping out new, healthy cells
• Tumor in the bone marrow: Similar to prior chemo - having malignant cells in the bone marrow impact its ability to do its job.
• Persistent neutropenia: Either from inadequate recovery from treatment or due to the disease.
• Recent surgery and/or open wounds: Both increase infection risk and will be compounded by neutropenia.
• Liver (bilirubin >2) or kidney dysfunction (CrCl <50): We need healthy organs to metabolize our toxic drugs and if they are too slow, myelosuppression is going to be prolonged.
• Age >65 years receiving full-dose chemotherapy: Older adults just don’t tolerate treatment as well as younger patients and they are more likely to have liver/kidney dysfunction and poor bone marrow reserves.

Patients who have experienced FN previously, will receive secondary prophylaxis regardless of the category of the treatment regimen - they have already demonstrated their personal risk is higher than the standard and warrant prevention

Payers love to push back against the use of, and payment for, GCSF so equip yourself with the data to understand when it should be used. If a particular regimen is not listed in the Hematopoietic Growth Factors NCCN guidelines (under supportive care guidelines), it does not mean it doesn’t have a risk. They can’t list every regimen, especially in the intermediate table, so you might have to go digging for data that demonstrates the incidence of FN in patients that received it.

Sundry

You are being tested

Have you noticed that after making a significant decision (often following very careful deliberation) it seems like the universe conspires to block your path forward? A relentless series of obstacles suddenly emerges, challenging your commitment.

This is your brain's strategic test - it’s assessing how committed you are to this decision 👀

⌛ Need dedicated work time? Unexpected emergencies suddenly demand your attention.

🎯 Seeking deep focus? Social media's siren call becomes irresistibly strong.

🎨 Trying to tap creative energy? Blank page syndrome strikes, transforming once-fluid creativity into a walk through molasses in winter.

The brain does not like expending energy - it craves efficiency

When you pursue a goal requiring substantial mental effort, your brain becomes a vigilant gatekeeper. It deliberately introduces barriers to assess your resolve.

These obstacles are not random - they're calculated challenges designed to determine how serious you are about your chosen path

Why? Because halting forward progress requires less mental work than the persistent commitment to pursue it.

The real question is: How determined are you?

Will you surrender when you hit resistance, or will you push through, or embrace your decision with conviction?

The choice is yours

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