Improving Referral for Geographic Atrophy

Eleonora Lad, MD, PhD: Can you talk to us about referral dynamics? How will we reach out to the community and be able to serve more patients with GA [geographic atrophy] and have them referred to you?

David R. Lally, MD: It’s going to be very important for the retina community and the ophthalmology community to reach out to referring providers to educate them on a few things. No. 1, there’s still an old mantra among a lot of general ophthalmologists and optometrists that geographic atrophy is a slow disease. Why is that the mantra? Nancy, you can probably speak better to the mantra based on your experience, but my understanding is that before we had anti-VEGF therapies, neovascular AMD [age-related macular degeneration] was scary to everyone. That was the 1 where patients lost vision very fast. Because 1 was fast, the other had to be slow. We’ve learned with lots of natural history studies over the years that both can affect vision fast, not slow. Time matters for these patients, so we want them to know that this disease progresses fast, and that for the first time we have therapies that we can intervene and affect the rate for that patient’s vision loss. What do you think, Nancy?

Nancy M. Holekamp, MD, FASRS: I agree. We have fast and slow just as we have wet and dry. It’s a very binary system, and it’s confusing to patients that you can have wet and dry [AMD] at the same time. It’s fun to think about how these terms that we use evolved over time. I’m very fortunate because I live in an area that has a very high medical and health literacy. I’m surrounded by high-quality optometrists and general ophthalmologists, and they all routinely do OCT [optical coherence tomography] scans in their offices. They’re very good at referring patients with wet AMD based on the OCT. They can see fluid and prompt a referral. I’m a more concerned about the referring doctors being able to accurately diagnose geographic atrophy; it could get missed. Although we may be moving toward OCT for clinical trials, it’s a little more sophisticated to identify the geographic atrophy and the OCT. Nora, maybe you agree with me?

Eleonora Lad, MD, PhD: It’s not easy. The early lesions are difficult to pick up when they’re small, and they might be critically located where time is of essence. We have some educational needs. This is worth discussing. This will be a new drug, so we have a different patient population and degrees of speed of referral that are necessary. We’ll probably have to educate about the mechanism of action: we can’t administer the drug through intravitreal delivery, as we do for wet AMD, but we can manage adverse events. What educational tool, Jay, do we need for these programs to be implemented in clinical care?

Jayanth Sridhar, MD: I love Nancy’s point about imaging. You’re right: OCT is ubiquitous. Even though it’s harder to diagnose GA with an OCT than it is with a fundus autofluorescence, maybe we need to start teaching referring doctors what to look for in OCT: transmission artifacts, involution of drusen, infrared imaging. That could be easy because there are smart, motivated people taking care of these patients and seeing them as frontline providers. They can get them to us when they need treatment. That’s a very low-hanging fruit. The natural history of GA is also great point, in terms of making sure people understand that.

The final thing is the understanding about area under the curve and quality of life. We’re all talking about how the 1-year data showed this lesion progression, but each patient is living that year. If you’re maintaining their vision or reducing the progression, it’s not just that their lesion progression was reduced by X percentage of the year. That whole year, their quality of life might have been better. Other fields have been good about talking about quality-of-life improvement over time. When you’re hearing about a 5-year survival rate in oncology, it’s about that extra time. That time is valuable. That conversation needs to be introduced here as well.

If you look at natural history data over 10 or 15 years, once we start using these drugs for a long period of time, hopefully there will still going to be a drop-off over time given what we know. It’s going to be, “What was that patient’s quality of life? What did they do during that year? Did they see their kids? Could they read? Could they function?” These were not captured in the trial data. This is important for people to understand because someone who looks at the data but doesn’t understand the nuances, might say, “Well, 20% isn’t a big deal. I’ll send that patient to see Dr Holekamp in 6 months.”

Nancy Holekamp, MD, FASRS: I love your idea about a 5-year survival rate for the fovea because we can identify the foveal center, we know where the GA location is, and we can personalize that to every patient. Hopefully we can create a virtual reality of their projected 5-year foveal survival and what that would be lengthened to with treatment, even if the treatment slows the progression of disease and alters that slope by only 20% or 25%.

David R. Lally, MD: One thing I’ll add is that we retina specialists need to make the referring doctor feel comfortable referring their patient to us. There are some marketing data that I learned about yesterday in which 1 of the biotechnology companies went to an optometrist’s practice and asked, “What’s the No. 1 reason you hesitate to refer a patient with suspected GA to your local retina specialist?” Not all patients with geographic atrophy are coming to us, and optometrists say the No. 1 reason is that they weren’t sure if it was the right diagnosis. They didn’t feel comfortable referring to a retina specialist in that situation if it was going to be the incorrect diagnosis. The attitude we should be taking is to tell optometrists to send us everything so we don’t miss patients in our community who may qualify for these therapies. Make them feel welcome to send us anything. It’s OK if it’s not geographic atrophy. We don’t want to miss anybody in the community who could have had access to these therapies.

Jayanth Sridhar, MD: Do something all of us do: communicate back when that patient comes in. Give that feedback and say, “Thank you for sending that patient.” Even if it isn’t the right diagnosis or they’re not a candidate, I’m still glad that they got to see me. We can establish a plan that they follow.

Transcript edited for clarity