Neha Mangini, Pharm.D, the only pharmacist at Johns Hopkins who specializes in treating breast cancer patients, explains her integral role on the care team. Mangini serves as an important resource for prescribing physicians and patients alike.
What role do pharmacists play in caring for patients with breast cancer?In the last five years, there have been several new oral medicines approved for breast cancer that target specific characteristics of cancer cells. These oral therapies offer the convenience of more time at home and fewer visits to the oncologist’s office or to the infusion center. However, they do place greater responsibility on the patient and the caregivers to know how to properly take the medicine, track the on-days and off-days of a cycle, and what side effects are common and how to manage them and which ones require a phone call to the medical team. There is also a lot of care coordination, as these medications are often mailed from specialty pharmacies to the patient’s home. I help educate patients on how to take these medicines and safely handle and store them at home. I try to empower patients on ways to prevent common side effects. Behind the scenes, I’m making sure the medicine is dosed properly based on their kidney and liver function, identifying if there are any serious drug-drug interactions, getting prior authorization approved by the insurance and helping order the appropriate labs for monitoring. When patients first start on a new medicine, I provide teaching in person or over the phone. I also call them within a week of starting to make sure they’ve received the medicine and that they’ve gotten off to a good start. After that, I check in at least once a month so that they have the support they need.
I also serve as a resource to the physicians, nurse practitioners and nurses on the cancer care team by helping answer drug information questions—for example, how to dose chemotherapy for a patient on dialysis or what chemotherapy and supportive care medicines are safe during pregnancy.
What special challenges do these patients have from a pharmaceutical perspective?
I’ve noticed that many patients with cancer take complementary medicines, herbal supplements or vitamins. I look through the available data to make sure everything they take is safe and won’t conflict with their prescribed cancer medicines. I make sure their supplements do not have phytoestrogens— plant based estrogens—as they can encourage some types of breast cancer to grow. Sometimes patients may stop taking medicines because of side effects without letting their cancer care team know. I work with patients to make sure they remember to take their cancer medicine every day.
In what other ways do you help patients manage their disease?
The new oral targeted therapies can be extremely expensive, up to $10,000 per month without insurance. Many of my patients are insured through Medicare, which has a coverage gap, also known as the “doughnut hole,” where they have to pay $5,000 out-of-pocket every year. Patients without Medicare can also have high copayments. I work closely with our patient assistance program specialists to utilize all available financial resources to help our patients afford their cancer medicines. These include one-time free trial vouchers, copay cards, nonprofit grants, and free medicine programs from the manufacturer. In 2018, we helped 248 breast cancer patients by obtaining 91 copay cards, 73 nonprofit grants, and 84 free medicine approvals from the manufacturer.
What advances do you see on the horizon for breast cancer pharmaceuticals?
One of the most exciting developments for cancer in general is the use of immunotherapies, medicines that harness the immune system to fight disease. Some seem promising for certain types of breast cancer, such as triple negative breast cancer. I am also excited to see clinical trials of oral targeted therapies that are currently FDA approved for advanced breast cancer being studied for earlier stages. The goal is keeping cancers from coming back so that people will live longer with cancer and so that more cancers will be cured.