Bringing the Oncology Care Model into Focus

By Leah Ralph, Manager, Provider Economics and Public Policy, ACCC

imagesAs ACCC members are well aware, on February 12, the CMS Innovation Center (CMMI) released its much-anticipated Oncology Care Model (OCM) as part of the broader effort to lower healthcare costs and tie reimbursement to quality and value. ACCC has been conducting an in-depth analysis, and, overall, the OCM generally resembles the discussion draft we saw in August; while the model contains many positive elements, other areas still need clarification.

At its core, the OCM looks similar to a patient-centered oncology medical home or accountable care organization (ACO), with a target expenditure and shared savings component that encompasses the total cost of patient care during a particular period of treatment. The model is a voluntary, five-year program slated to begin in spring 2016. Physician group practices, hospital-based practices (except for PPS-exempt hospitals), and solo practitioners that furnish cancer chemotherapy are eligible to participate. Payments will be based on a six-month episode of chemotherapy treatment that is triggered by the administration of a pre-set list of chemotherapy drugs, and will take into account all Part A, Part B, and some Part D expenditures for that patient during the episode. In addition to a FFS payment, providers will receive a care coordination payment to improve quality of care ($160 per patient, per month during the episode) and a performance-based payment to incentivize lower costs that will be based on the difference between a risk-adjusted target price and actual expenditures during the episode. The payment arrangement is one-sided risk, with the option of converting to two-sided risk in the third year.

Importantly, the OCM is a multi-payer model in which commercial payers and state Medicaid agencies are encouraged to participate. Aligning financial incentives by engaging multiple payers will leverage the opportunity to transform oncology care across a broader population. During the selection process, CMMI will favor practices that participate with other payers in addition to Medicare. In addition, practices will have to meet certain quality metrics and undergo practice transformation requirements, including: effective use of electronic health records; 24-hour access to practitioners who can consult the patient’s medical record in real time; comprehensive patient care plans; patient navigators; and continuous quality improvement.

While we were pleased to see much of ACCC’s feedback incorporated in the final version, our dialogue with CMS is ongoing. Our members continue to have questions about the benchmarking methodology, specifics on the quality metrics and practice transformation requirements, eligibility to participate in the model, and more. ACCC will continue to seek answers to these questions, and will offer CMS feedback based on member input.

If your practice is interested in participating, or considering participation, we encourage you to submit a non-binding letter of intent to CMS by the deadline of April 23, 2015. We anticipate CMS will continue to provide additional guidance until the application deadline, which is June 18, 2015.

Join us at ACCC’s Annual Meeting CANCERSCAPE on March 17 and hear directly from Ron Kline, MD, Medical Officer with the Center for Medicare and Medicaid Innovation—an author of the Oncology Care Model, as he shares an insider’s perspective on New Payment and Delivery Models in Medicare.

Transformation ⇒ From Volume to Value

Centers_for_Medicare_and_Medicaid_Services_logoBy Leah Ralph, Manager, Provider Economics and Public Policy, ACCC

This week the CMS Innovation Center announced the launch of the Oncology Care Model—the agency’s newest payment and service delivery model, described as a multi-payer, oncology practitioner-focused model designed to improve the quality of cancer care while lowering cost.

According to the CMS announcement, key facets of the model include:

  • Episode-based payment that targets chemotherapy and related care during a six-month period following the start of chemotherapy treatment.
  • Multi-payer design with Medicare fee-for-service and other payers working in tandem to promote care redesign for oncology patients.
  • Requiring physician practices to engage in practice transformation to improve quality and coordination of care.

This is the latest signal that the shift from volume-based reimbursement to payment for value and quality is gaining momentum. The interest in moving healthcare payment away from a system that incentivizes quantity has been reflected in every major healthcare law in recent years—from the Medicare Modernization Act (MMA) in 2003 to the Affordable Care Act (ACA) in 2010.

In fact, the ACA created the $10 billion Center for Medicare and Medicaid Innovation (CMMI) with the sole aim of developing and testing innovative ways to pay providers. And on Feb. 12 the Innovation Center provided its first model for oncology care.

The launch of this model is not unexpected given that in January 2015, for the first time in Medicare’s history, the Department of Health and Human Services (HHS) announced explicit goals for tying Medicare payments to alternative payment models and value-based payments. According to the HHS timeline, 30 percent of all fee-for-service (FFS) Medicare payments will be tied to alternative payment models by 2016—including, but not limited to, Accountable Care Organizations (ACOs), medical homes, and bundled payments for episodes of care. By 2018, 50 percent of payments will be tied to these models. CMS also set a goal of tying 85 percent of traditional Medicare payments to quality or value by 2016 and 90 percent by 2018 through such programs as the Hospital Value Based Purchasing or Hospital Readmissions Reduction programs.

Ambitious Goals

The initial benchmark of 2016 sets a laudable, but ambitious, goal. Certainly the announcement signals the Obama Administration is making this issue a priority, and we can expect to see an accelerated push to transition Medicare payments and, in turn, private payers.

This shift is a huge undertaking that will not only affect payments, but fundamentally change incentives for how providers deliver care. Implementation will take time, and will require the right balance of forward momentum and important safeguards to ensure that patients continue to receive the most appropriate, quality care. As HHS moves full steam ahead, the provider community must speak up and urge policymakers to:

  • continue to work to find consensus on appropriate quality measures,
  • establish a sound, fair methodology for calculating financial benchmarks and risk adjustment, and
  • allow providers the time, resources, and flexibility they need to implement these new payment models.

The just-announced Oncology Care Model (OCM) will test the bundling of payments for chemotherapy administration. But with other models, such as the Medicare Shared Savings Program (Medicare ACOs) that are primary care focused, it’s still unclear how oncologists will be included or even participate. Caring for cancer patients is complex and often expensive, leaving inherent challenges in how to account for cancer care in alternative models. How will high-cost drugs and innovative therapies be treated in the construct of an ACO? Will high-cost cancer patients be included in the financial benchmark? What is oncology’s role in shared risk and savings? ACCC and other organizations are continuing to work with CMS to answer these questions.

Call to Action

ACCC encourages the provider community to remain informed and active participants in the policy-making dialogue to ensure that we do, in fact, achieve meaningful, realistic payment reform. One of the best ways to get engaged is meeting with your legislators at ACCC’s upcoming Capitol Hill Day on March 16. The next day, at ACCC’s Annual Meeting, CANCERSCAPE on March 17, we’ll be hearing from Ron Kline, MD, Medical Officer with the Center for Medicare and Medicaid Innovation – an author of the Oncology Care Model. Now is the time to come to Washington D.C. – get your questions answered and voices heard at a pivotal moment for oncology care. Join us!


8 Strategies to Help Gastric Cancer Patients Cope with Nutrition Problems During Treatment

Posted in ACCC News, Cancer Care, Education by ACCCBuzz on February 2, 2015

ACCC’s Improving Care in Gastric/GE Junction Cancer project seeks to better the quality of care for gastric and GE cancer patients treated at community cancer programs. This guest post by Colleen Gill, MS, RD, CSO, is the final blog in a series on gastric and GE junction cancers. Colleen Gill is outpatient dietitian at the University of Colorado Cancer Center, and she serves on the Advisory Committee for ACCC’s Improving Care in Gastric/GE Junction Cancer initiative.

Gastric-GE JunctionBy Colleen Gill, MS, RD, CSO

More than 70 percent of patients with gastric cancer develop malnutrition, depleting muscle mass, slowing healing, and limiting the immune system.

The growth of any tumor within the stomach will limit intake and create problems with the digestion of food. Unfortunately, diagnosis of gastric cancer may be delayed due to symptoms—such as feeling extremely full after small amounts of food and abdominal pain or heartburn—that may be attributed to more common causes. As a result, malnutrition in gastric cancer patients can begin early. Nausea and vomiting are inevitable when there is tumor blocking either the gastro-esophageal junction or gastric outlet. Fatigue can result from iron deficiency anemia due to problems with iron absorption.

Patients with gastric cancer may undergo a combination of chemotherapy and radiation prior to surgery, and may be given adjuvant therapy after surgery as well. Treatment side effects may include inflammation, pain, nausea, and vomiting which can further affect a patient’s ability to eat and maintain weight.

Here are 8 strategies that may help the patient eat better, avoid excess loss of weight and muscle, and stay on treatment:

  • Schedule 5 – 6 times to eat each day. Because stomach capacity is reduced due to tumor and/or surgery, patients can try eating smaller amounts of food at intervals during the day. Scheduling a cell phone reminder to eat can be helpful. Without some type of reminder to eat every two and one-half to three hours, patients can easily miss these opportunities, and limited stomach capacity makes it impossible to make up their calorie intake at a later meal.
  • Choose softer foods. The stomach usually breaks down solid foods into smaller pieces through muscular contractions and acid secretion, but both functions may be limited by the cancer. Consider foods that are pre-processed, like shredded meats, and canned or cooked fruits and vegetables. Take advantage of foods that are already in soft “pureed” texture, like fish, refried beans, most dairy products, eggs, mashed potatoes, winter squash.
  • Make it slick. Moist foods, or those with gravies and sauces, spread taste through the mouth, increasing palatability. These foods also slide down more easily.
  • Make it easy. There are many prepared foods that will work for you, so tour the aisles of the grocery store with your goals in mind. Frozen/prepared pasta dishes, mini-quiches, and microwavable mashed potatoes, soups and breakfast dishes are available. Friends and family often offer their help which can be coordinated through websites like or Include liquid calories. They slip through narrow openings and are less likely to distend the walls of the stomach. Options include milk-like oral supplements, which are usually lactose free if that is a concern. Choose the “plus” versions for an extra 100 calories and higher protein levels. If milk is tolerated, many enjoy Carnation Instant Breakfast powder, stirred in, adding 130 calories. Scandishakes will add 440 calories and are well liked. Clear liquid drinks include Boost Breeze and Ensure Active, which some people also enjoy mixed with carbonated clear sodas. In the grocery store’s produce area, you’ll find fruit-based drinks such as those from Odwalla, Naked Juice, and Bolthouse that include versions with protein. All of these can be used as a base for smoothies, which should always include some source of protein.
  • Create a list. Coming up with ideas for what to eat on the spur of the moment can be stressful. Create a “go to” list of options for your refrigerator (or wallet). This can help you avoid falling back on the same things over and over, which can lead to “burning out” on particular foods. Including the “extras” that add calories on your list. These can help ensure that each bite counts. For example, add cheese when you warm up refried beans or scramble an egg, or add walnuts or peanut butter to oatmeal. Jot down ideas for days when you struggle, so you can always “go to” something from the list. Use the list when making shopping lists, so that foods are available to you when you want them.
  • Adjust your list by tolerance. Never cross something off your list until it has failed you more than twice. However, if you notice that higher fat or high fiber foods cause food to “sit” on the stomach for long periods of time, you may try lowering the content of fat/fiber in the food you eat and see if that is helpful. Journaling can help you see patterns.
  • Keep food safe. Many patients with gastric cancer will be on acid suppressive therapies or have less secretion of acid as the result of their cancer. Without acid in the stomach, you have less protection from bacterial contamination in food. Be careful to take precautions to keep food safe: avoid letting food sit at room temperature (keep it cold or hot), wash your hands frequently, and avoid cross contamination by keeping surfaces clean and using separate cutting boards for raw meats and foods that won’t be cooked. Be cautious with self-service salad bars and high-risk foods. Use leftovers within 48 hours.
  • Talk to your team about anything that is getting in the way of eating. They will have some solutions if you are having problems with nausea/vomiting, constipation, dehydration, sleeping, or anything else that is limiting your ability to eat. They can guide you about over the counter and prescription medications that may help, or schedule you for IV fluids or other procedures to deal with the problems. Waiting never resolves anything!

Read other blogs in this series here. Learn more about ACCC’s Improving Care in Gastric/GE Junction Cancer project here.

Optimal Treatment for Gastric Cancer—Two Multimodality Approaches

Posted in ACCC News, Cancer Care by ACCCBuzz on January 27, 2015

Gastric-GE JunctionACCC’s Improving Care in Gastric/GE Junction Cancers project seeks to better the quality of care for gastric and GE cancer patients treated at community cancer programs. This guest post on Optimal Treatment for Gastric Cancer — Two Multimodality Approaches is the fourth in a five-part blog series focused on gastric and GE junction cancers.

by Gurleen Dhami, MD; Veena Shankaran MD; Brant K. Oelschlager, MD; and Shilpen Patel, MD, FACRO

In 2013, there were approximately 21,600 cases of gastric cancers in the U.S. with 10,990 deaths. The incidence, however, is much higher worldwide, being the third most common cancer in the world and second leading cause of cancer-related death. Surgery has been the primary modality of treatment for early-stage gastric cancers. However, many gastric cancers are diagnosed at an advanced stage, leading investigators to find the optimal modality of treatment in this setting.

Two multimodality treatment approaches have been investigated in randomized clinical trials, both of which have been shown to improve survival beyond surgery alone. Perioperative chemotherapy (MAGIC trial) and postoperative chemoradiation therapy (INT 0116) have not been directly compared to each other. The findings and limitations of both key studies are discussed below.


The landmark international phase III randomized MAGIC trial evaluated the role of perioperative chemotherapy in patients with resectable gastric cancers as well as GE junction tumors. The hope was for perioperative chemotherapy to improve the likelihood of a curative resection and to downstage the tumor at time of surgery. Five hundred and three patients with resectable gastric adenocarcinoma, GE junction, and lower esophageal cancers were randomized at the time of diagnosis to undergo either perioperative chemotherapy, entailing both pre- and post-operative chemotherapy, versus no additional treatment after surgery. Nearly three-quarters of the cases were gastric cancers. The chemotherapy arm consisted of three cycles of ECF (epirubicin, cisplatin, and 5-FU) before and after surgery. In terms of the surgical resection, the extent of lymph node dissection was determined by the surgeon. With a median follow-up of 4 years, only 42% of participants randomized to the chemotherapy arm actually completed the entire course. Despite this completion rate, patients who received perioperative chemotherapy had a statistically significant improvement in 5-year overall survival, 36% in the chemotherapy arm versus 23% in the surgery alone arm (p = 0.009). Progression-free survival also was improved in patients who underwent perioperative chemotherapy (HR 0.66, p<0.001). Additionally, perioperative chemotherapy decreased the tumor size, 3 versus 5 cm median maximal diameter at time of surgery (p<0.001), as well as increased proportion of stage T1 and T2 tumors at time of surgery (p=0.002). Postoperative complications were similar in both groups. The results of this study established that perioperative chemotherapy had superior survival outcomes in addition to shrinking the tumor at time of surgery. A major limitation of this study was the limited extent of lymph node dissection, with only 38% of patients undergoing a D2 resection. Resections were curative in 69% of the perioperative chemotherapy arm and 66% of the surgery alone arm. This stems from the design of the study as patients were randomized at time of diagnosis and prior to any treatment. Thus, approximately one-fourth of the patients actually had non-curative surgery. Another limitation of this trial was that laparoscopy to rule out occult metastasis was not required prior to randomization. Thus, disease burden could have been underestimated prior to enrollment.

INT 0116

Another hallmark study, the Macdonald trial (INT 0116), evaluated the role of postoperative treatment after a R0 resection in stage IB-IV adenocarcinoma of the stomach and GE junction tumors. Five hundred and fifty-six patients were randomized to two arms after surgery: chemoradiation therapy sandwiched with chemotherapy versus no further treatment. The treatment arm consisted of one cycle of chemotherapy (5-FU and leucovorin), followed by combined treatment of radiation to 45 Gy in 25 fractions with concurrent 5-FU and leucovorin which was then lastly followed by by two more cycles of 5 FU and leucovorin. With a median follow-up of 5 years, slightly longer than the MAGIC trial, there was a statistically significant survival advantage with postoperative treatment. Median survival increased from 27 months to 36 months with postoperative treatment (p=0.005). Three-year RFS increased from 21% in the observation arm to 48% in the adjuvant treatment arm (p=0.001). A major limitation of this study is the low rate of D2 resection with only 10% of patients having a D2 resection and with approximately half of patients with a D0 resection. Treatment toxicity was also another concern of this study with over 40% of patients in the chemoradiotherapy arm experiencing grade 3 toxic effects and approximately one-third having grade 4 toxicity. Approximately one-third did not complete treatment due to toxicity. While postoperative chemoradiotherapy has been shown to have high toxicity rates in clinical trials, this toxicity has decreased with modern methods of administering radiotherapy. A 10-year update showed that there was a persistent benefit to adjuvant chemoradiation in terms of overall survival and RFS.

Making a direct comparison between these two trials is difficult as the treatment regimen and timing differed. Both trials highlight the survival benefit of additional treatment for resected gastric cancers. Patients who received perioperative treatment in the MAGIC trial did having down-staging of their tumor with preoperative portion of treatment whereas the patients in the MacDonald trial treatment arm only received postoperative treatment. In order to be eligible for INT 0116, patients had to complete a R0 resection, as opposed to the MAGIC trial in which approximately one-quarter of patients had non-curative surgery. Worth noting is in the MAGIC study, the trial was limited by hetereogenous staging, including limited use of ultrasound for staging and the variable quality of surgery and pathology. In addition, two-year survivals in the Intergroup trial was 58% versus 48% in the MAGIC trial.

These studies do highlight the importance of a multidisciplinary approach for gastric cancers. Hopefully, future trials will be able to delineate the patient timing of adjuvant treatment for gastric cancers. Many in the oncology community are awaiting the Dutch CRITICS trial which will analyze the survival benefits of perioperative chemotherapy versus neoadjuvant chemotherapy plus adjuvant chemoradiotherapy.

The authors are all affiliated with the University of Washington and the Seattle Cancer Care Alliance.



National Comprehensive Cancer Network.  Gastric Cancer. Available at: Last accessed February 27, 2014.

Cunningham D, Allum WH, Stenning SP, et al. Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer. N Engl J Med. 2006 Jul 6;355(1):11-20.

Sasson AR. Localized gastric cancer: chemoradiation is not always needed. Gastrointest Cancer Res. 2009 Mar;3(2 Suppl):S22-5.

Macdonald JS, Smalley SR, Benedetti J, Hundahl SA, et al. Chemoradiotherapy after surgery compared with surgery alone for adenocarcinoma of the stomach or gastroesophageal junction. N Engl J Med. 2001 Sep 6;345(10):725-30.

Smalley SR, Benedetti JK, Haller DG, et al. Updated analysis of SWOG-directed intergroup study 0116: a phase III trial of adjuvant radiochemotherapy versus observation after curative gastric cancer resection. J Clin Oncol. 2012 Jul 1;30(19):2327-33.





A Conversation on Caring for Patients with Gastric or GE Junction Cancer

Posted in ACCC News, Cancer Care by ACCCBuzz on January 22, 2015

Gastric-GE JunctionACCC’s Improving Care in Gastric/GE Junction Cancers project seeks to better the quality of care for gastric and GE cancer patients treated at community cancer programs. Recently, ACCCBuzz asked Gregg Shepard, MD, a community-based medical oncologist, who is serving on the project’s Advisory Committee to provide some perspective on caring for patients with gastric cancer in the community setting.

ACCCBuzz: Could you give an example of a gastric cancer patient treated in your community recently?

Dr. Shepard: I’ll give three examples. Patient A (patient names and some details have been changed to protect privacy), age 50, had been developing burning abdominal discomfort gradually over a two-year period. Endoscopy showed a non-ulcerated intestinal type carcinoma of the body of the stomach limited to the mucosa. Radiographic staging did not reveal any evidence of metastatic disease. Endoscopic ultrasound did not reveal any local lymphadenopathy. Patient A underwent endoscopic mucosal resection by an expert local community gastroenterologist.

Patient B had gastroesophageal (GE) reflux and dyspepsia (indigestion) symptoms for many years and, at age 66, had also developed difficulty swallowing. He did not have much pain. He had a 50 pack-year history of smoking cigarettes but did not drink significant amounts of alcohol. By endoscopy and clinical staging he was found to have stage IIIA gastroesophageal (GE) junction adenocarcinoma with HER2 amplification by FISH analysis. He was enrolled to a clinical trial and treated with combination chemotherapy, lapatinib, and radiation followed by a transhiatal esophagectomy. About six months later, Patient B developed retroperitoneal and abdominal lymphadenopathy consistent with recurrent metastatic disease. He started treatment as part of a clinical trial with immunotherapy and a targeted agent, and he has done well with near complete response.

Patient C, age 32, developed diffuse cramping abdominal pain and distention about two years after delivering a healthy baby. Imaging studies showed a large pelvic tumor. Surgical exploration with debulking of this tumor revealed signet ring type carcinoma with deposits involving the uterus, ovaries, and mesentery. Endoscopy revealed a diffuse infiltrative signet ring carcinoma involving the body of the stomach with HER2 amplification by FISH and an activating EGFR mutation detected by PCR. She was treated with combination chemotherapy with trastuzumab but this was poorly tolerated. She developed recurrent severe pain with intestinal obstruction from carcinomatosis requiring parenteral nutrition.

ACCCBuzz: Do we know who is likely to get gastric or esophageal cancer? In other words what is the epidemiology of these cancers and how is it changing?

Dr. Shepard: In the U.S. today, gastric cancer is indeed relatively rare compared to some other cancers such as breast, lung, and colon cancer. Over the last few years in the U.S. about 22,000 individuals were diagnosed with gastric cancer annually.

On the other hand, historically gastric cancer has been one of the most common and deadly forms of cancer worldwide. It was one of the first types of cancer documented in ancient Egyptian writings. Until the 1980s, it was the leading cause of death from cancer worldwide. In recent decades, stomach cancer has declined significantly in the Western developed countries; however, other parts of the world have seen only slight decreases in the disease. In fact, today in eastern Asia, eastern Europe, and South America, gastric cancer remains more common as a percentage of all cancers diagnosed. There are differences in terms of the typical population of patients affected by gastric cancer as well as risk factors, histology, and disease behavior between these countries and the U.S. and other Western developed countries. This becomes an important factor when evaluating published literature and treatment regimens.

In the U.S., risk factors for gastric cancer are non-white race, male sex, and older age, and these individuals typically have the intestinal type of gastric cancer affecting the distal stomach, which predominantly forms focal mass lesions without severe gastritis and atrophy. The decline of gastric cancer incidence in the U.S. has largely been due to the decline in this intestinal type of stomach cancer, while proximal cardia or GE junction adenocarcinoma has dramatically increased in younger adults. This type is associated with Barrett’s esophagus and with tobacco and alcohol use. There has also been a slight decline in the diffuse form of gastric cancer which diffusely involves the stomach with gastritis and atrophy, may have a signet ring cell appearance, has a worse prognosis, and can affect men and women of any age, including young adults. It is clear that there are several different subtypes of gastric cancer, which can be a disease that affects any age, sex, or region.

ACCCBuzz: What is a particular challenge of treating patients with gastric cancer in community centers?

Dr. Shepard: Most of the challenges arise from the fact that best practice for gastric cancer usually requires multidisciplinary cooperation. The most cited New England Journal of Medicine article about gastric cancer is the 2006 article by Cunningham et al., which showed increased survival for patients treated in a multidisciplinary fashion with perioperative chemotherapy and surgical resection, a treatment approach recommended in a majority of important publications and national guidelines. This can be difficult to achieve in real-time for patients in communities with limited numbers of providers or resources. Even in larger community cancer centers with physicians in multiple specialties, ancillary services such as nutritional support may be constrained due to limited resources and poor reimbursement—which can make it difficult for patients to access these supportive services.

ACCCBuzz: What are some new and important advances in gastric cancer treatment?

Dr. Shepard: One of the most significant findings in the last decade is the recognition that some gastric cancer is characterized by over-expression of the oncogene protein HER2. Tests for HER2 status have been well established for breast cancer. While the same methods may be used to test HER2 status for gastric cancer, the level of expression is typically lower and there is heterogeneity of expression between tumor cells in an individual patient. This has important treatment implications for patients with advanced disease. Providers should use appropriate criteria when classifying HER2 status. A Phase III randomized trial with about 600 patients published in 2010 showed modestly improved response and survival with trastuzumab and chemotherapy treatment compared to chemotherapy alone for advanced or metastatic gastric cancer. Research is ongoing about the use of similar targeted therapy in early stage disease as part of multidisciplinary treatment. We are still learning about the prognostic implications of HER2 expression in gastric cancer, which continues to have a poor prognosis overall when compared to other cancers of similar stage.

ACCCBuzz: How can the care of patients with gastric cancer be improved?

Dr. Shepard: In my opinion, community cancer center providers must become expert in the care of patients with symptomatic metastatic disease. These patients may have limited life expectancy and a high symptom burden and are often, therefore, unlikely or unable to seek care at a highly specialized tertiary center.

Ancient physicians recognized the importance of the stomach as a center of mortal well-being. They understood, as we do today, that even small alterations of gastric function can have a profound impact on our mental and physical health. Certainly we must provide the right guidance about palliative chemotherapy and other systemic therapies. In addition, we must improve our ability to provide palliation and improve quality of life. Inexplicably, many palliative interventions have been evaluated using survival or similar surrogates as outcome measures without knowing if these measures are clinically meaningful. Clinical research in terminally ill patients nearing end of life is fraught with ethical and practical complications but can be completed in a scientifically sound fashion. A recent publication by Badgwell et al. in the Journal of Palliative Medicine investigated patient-reported outcome measures of quality of life in patients with gastric obstruction, while a recent publication by Mariani et al. describes a randomized, double blind, placebo controlled trial of lanreotide microparticles to treat bowel obstruction symptoms. More needs to be learned in this area.


To read about “Effective Practices in Gastric Cancer Programs” and access additional resources on ACCC’s Improving Quality Care in Gastric/GE Junction Cancer project page, click here. Next in the ACCCBuzz blog series on gastric and GE junction cancers: Optimal Treatment for Gastric Cancer—Two Multimodality Approaches.

Dreaming BIG to Cure Stomach Cancer

Posted in ACCC News, Across the Nation, Advocacy, Cancer Care, Education by ACCCBuzz on January 15, 2015

ACCC’s Improving Care in Gastric/GE Junction Cancers project seeks to better the quality of care for gastric and GE junction cancer patients treated at community cancer programs. This is the second post in an ACCCBuzz blog series focused on issues related to gastric and GE junction cancers.

By Guest Blogger Debbie Zelman, President and Founder, Debbie’s Dream Foundation: Curing Stomach Cancer

Debbie Zelman head shot 2014-NEWStomach (gastric) cancer is a silent killer with symptoms that are non-specific, or non-existent. Stomach cancer screenings are not available in the United States, so 80% of patients are diagnosed late at stage IV, and only 4% of stage IV gastric cancer patients live for five years after diagnosis. More than 22,000 Americans will be diagnosed this year, and rates are rising among adults aged 25-39, which is of great concern.

I know this because I was diagnosed with stage IV stomach cancer in April 2008, when I was 40 years old. I was the mother of three young children, married to a physician, and a practicing attorney with my own firm. I was healthy, didn’t smoke or drink, exercised, took vitamins, and didn’t have a family history. I had NO risk factors for stomach cancer. I thought I was doing everything right, and then I was told that I had a few weeks to live.

My first thoughts were of my children. I was scared to die and that my three-year-old daughter wouldn’t remember me, and my 10-year-old twins would go through their teen years without a mother. I immediately decided that I was NOT going to let that happen, so I began the fight of my life. I underwent very harsh chemotherapy treatments, lost my hair, got neuropathy, almost lost several nails, spent years in bed, hospitals, and doctors’ offices, and had many painful days.

However, I refused to be another statistic. Soon after I started chemotherapy, a friend connected me to another stage IV stomach cancer patient, who became a huge resource for me. I had so many questions about the cancer journey that only he could answer. The doctors, nurses and other healthcare professionals were not as knowledgeable about the stomach cancer experience as another patient with the same diagnosis as mine.

I was shocked to discover there weren’t many resources for stomach cancer, and that a new stomach cancer drug had not been developed in 30 years. How was that possible?

I realized there was a lot of work to be done to raise awareness, so I began to raise funds for stomach cancer research, and educated patients, families, and caregivers. This was the beginning of Debbie’s Dream Foundation: Curing Stomach Cancer (DDF), which was founded in April 2009 to increase awareness, funding, advocacy, and education.

As the first organization in the United States to fight stomach cancer, we have helped hundreds of patients, families and caregivers in 26 states and 12 countries. We set up the Patient Resource Education Program (PREP) so stomach cancer survivors and caregivers can be matched as mentors to other patients and caregivers with similar cancer stage, biomarker, age, gender, and region.

We host free educational symposia and webinars about stomach cancer treatment, surgery, radiation, side effect management, clinical trials, nutrition, and more, which are available on our website. Our next symposium is on April 18, 2015, and we have webinars each month. We’ve held two Capitol Hill Advocacy Days and have successfully increased federal research funding for gastric cancer by millions of dollars. Our upcoming Advocacy Day is on March 4-6, 2015. We’ve funded three Young Fellowship Awards, totaling $150,000, as these researchers will lay the foundation for future discoveries for stomach cancer treatments.

Debbie’s Dream Foundation: Curing Stomach Cancer is pleased to partner with the Association of Community Cancer Centers on its Improving Care in Gastric/GE Junction Cancers education initiative, which offers tools and resources for community cancer programs across the country.

There are plenty of opportunities to get involved in the fight against stomach cancer. Debbie’s Dream Foundation makes it easy. To learn more about Debbie’s Dream Foundation, our events, and how you can get involved, visit us at

Please dream BIG with me to make the cure for stomach cancer a reality. Together we can do anything!


To read about “Effective Practices in Gastric Cancer Programs” and access additional resources on ACCC’s Improving Care in Gastric/GE Junction Cancer project page, click here. Next in the series, perpsectives on caring for patients with gastric and GE junction cancer from a community-based provider.

Improving Care in Gastric and GE Junction Cancers

Posted in ACCC News, Cancer Care by ACCCBuzz on January 8, 2015

By Becky DeKay, MBA

resources-Gastric-Effective-Practices-150x202ACCC’s Improving Quality Care in Gastric/GE Junction Cancers project seeks to better the quality of care for gastric and GE junction cancer patients treated at community cancer programs.

The detection, diagnosis, and treatment of gastric and gastroesophageal junction (GEJ) cancers involves many different specialties within the multidisciplinary cancer care team—outreach and screening, nutrition, surgery, medical oncology, radiology, pathology, nursing, social work, integrative medicine, and administration.

For this project, ACCC developed a publication on Effective Practices in Gastric Cancer Programs that summarizes findings from a needs assessment survey of ACCC membership and highlights approaches to caring for patients with gastric cancer at three ACCC-member programs that are serving as Community Resource Centers for this project:

  • Curtis & Elizabeth Anderson Cancer Institute at Memorial University Medical Center, Savannah, Georgia
  • Stanford Cancer Center, Stanford, California
  • University of Colorado Hospital, University of Colorado Cancer Center, Aurora, Colorado.

Over the next few weeks, ACCCBuzz will offer a blog series focused on gastric and GE junction cancer that will present perspectives from a community-based provider caring for patients with gastric and GE junction cancer, the views of a patient advocate, practical tips for working with patients on nutritional issues related to chemotherapy and radiation therapy treatments, and a look at two recent studies addressing the issue of optimal treatment for patients with gastric and GE junction cancers.

Providers are invited to visit ACCC’s Improving Quality Care in Gastric/GE Junction Cancer project at for additional resources.

Learn about ACCC’s Community Resource Centers for the following less-common cancers: acute promyelocytic leukemia, chronic myeloid leukemia, multiple myeloma, myelofibrosis, pancreatic cancer.

Becky DeKay, MBA, is President of the Association of Community Cancer Centers (ACCC).

Ringing in the New Year

Posted in ACCC News, Advocacy, Cancer Care, Healthcare Reform, In and Around Washington, DC by ACCCBuzz on December 19, 2014

US Capitolby Leah Ralph, Manager, Provider Economics and Public Policy, ACCC

The last few months have brought big changes to Washington, D.C. We will ring in the New Year with both chambers of Congress under GOP control, which means the parties are reorganizing and, importantly, the legislative agenda is shifting. While it’s still anyone’s guess whether new leadership will mean less political infighting in 2015, issues like trade, energy, and tax reform are early contenders for potential areas of compromise next year.

The ACA (Affordable Care Act) will also make the top of the political agenda: starting in January, you can count on Republicans to look for every opportunity to take the legs out from under President Obama’s signature achievement. Although full repeal is unlikely, as it would face an all-but-guaranteed presidential veto, expect the new majority to focus their efforts on introducing a series of stand-alone bills targeting the most unpopular provisions of the law.

Predicting the fate of non-ACA healthcare legislation is a tougher call. On the one hand, healthcare fatigue still looms large among legislators, making issues like a long-term fix to the Sustainable Growth Rate (SGR), oral parity, and sequestration more of an uphill climb. On the other hand, new leadership, a renewed vow to work across the aisle, and public dissatisfaction with the status quo are bringing new energy to Congress.

Will 2015 Bring a Permanent SGR Fix?

In 2014 we saw what was arguably the best opportunity in years to finally fix the fundamentally flawed SGR formula. Congress came to agreement on a bipartisan bill that had a relatively low price tag, but in the end could not reach consensus on how to pay for the fix. As a result, the bill never came to a vote and will need to be reintroduced in the new Congress. Still the fact that Congress achieved consensus on policy is a promising sign for 2015. We have now weathered seventeen (17!) “doc fix” patches that, if added together, cost far more than the comprehensive approach lawmakers are considering today. This year’s ACCC Capitol Hill Day is scheduled for March 16, so we will be visiting with our legislators just weeks before the current “doc fix” expires on March 31.

Will We See Federal Oral Parity Legislation?

Passing a national oral parity law continues to be a top priority for ACCC membership. On the state level, oral parity efforts are gaining momentum. To date, 34 states and D.C. have enacted oral parity laws, and several other states are ramping up their grassroots efforts for 2015. Given that an estimated 25 to 35 percent of all oncology therapies in the pipeline will available only in pill form, the need for comprehensive, federal oral parity legislation is increasingly critical to patient access. While state-level legislation remains important, lawmakers need to understand that federal legislation would ensure consistency in oral parity laws across the country and would include plans that fall outside the purview of state regulation.

Will We See Any Relief from the Sequester?

Last year, legislation to exempt cancer drugs from the Medicare sequester gained more than 100 cosponsors. ACCC will be advocating for this legislation to be reintroduced in 2015.

As you can see, 2015 is the year to make your voice heard! Join us for Capitol Hill Day on March 16, and stay for the ACCC 41st Annual Meeting, CANCERSCAPE, which will follow March 17–18 in Crystal City, Va. Read our agenda and register today!

If you have additional questions, or would like to get involved with ACCC advocacy, please contact me at



With the Midterm Elections Behind Us, What Lies Ahead for Healthcare in 2015?

Posted in ACCC News, Advocacy, Healthcare Reform, In and Around Washington, DC by ACCCBuzz on November 25, 2014

Working-Federal-Government-FeaturedBy Leah Ralph, Manager, Provider Economics and Public Policy, ACCC

With election results still rolling in, one thing is clear: the 2014 midterm elections dealt an unequivocal win to Republicans, helping them pick up more than the six seats needed to gain the majority in the Senate, bringing both chambers of Congress under GOP control. While this will mean big changes in leadership and the legislative agenda for the remainder of President Obama’s term, it may have fewer implications for healthcare than many anticipated. Here’s why.

The Affordable Care Act (ACA)

One of President Obama’s signature achievements, the ACA faces little chance of repeal in the remainder of the President’s term. Depending on the election results in Louisiana – the last undecided Senate race – in early December, Senate Republicans will hold 53 or 54 seats, falling well short of the 60 vote super-majority needed to get most things passed in today’s Senate. Even more important, Senate Republicans do not have the two-thirds majority to overcome a presidential veto. This means that even if incoming Senate Majority Leader Mitch McConnell rounds up the votes needed to pass repeal, he will not have enough votes to overcome the President’s all-but-guaranteed veto. In the end, even if Republicans control Congress, we can expect that the ACA will remain largely intact.

So does this mean the entire law is safe? Not exactly. Republicans are already outlining a different strategy, in which they will target individual ACA provisions for repeal or significant modifications. The list includes the 2.3% medical device tax; the employer mandate to provide qualified, affordable coverage; and the ACA definition of a full-time employee as 30 hour/week. We can expect the Senate to take votes to roll back these provisions in the next Congress.

The real fate of the ACA may lie with the Supreme Court. Earlier this year, conflicting rulings came from the Appeals Courts on the legality of providing subsidies to those accessing coverage through the federally-run health insurance exchanges, as the law appears to stipulate that subsidies may only be provided to those in state-based exchanges. The Supreme Court recently announced it would take up the case, and is expected to issue a ruling in June 2015. With the federal marketplace serving 34 states and expected to enroll nearly 11.8 million people in 2016 – an estimated 7.3 million of whom would receive federal subsidies – the Court’s decision could have enormous implications for the success of the law.

Sustainable Growth Rate (SGR)

Last year we saw the best opportunity to permanently repeal the SGR. A bipartisan bill had broad support, and the price tag was (comparatively) low at $138 billion – but Congress could not come together to determine how to pay for it. Instead, Congress passed another short-term patch that will expire in March 2015, which prevented roughly a 24% cut in Medicare physician reimbursement rates for 12 months. In keeping with previous fixes, Congress cut healthcare expenditures to pay for the extension. The Congressional Budget Office (CBO), Congress’ official budgetary scorekeeper, recently re-estimated the cost of the bipartisan legislation at $144 billion over 10 years. This is still considered a bargain by most policymakers, and although we can be hopeful the new Congress will consider the legislation, do not be surprised if another short-term patch is what we’re stuck with; despite an “on sale” SGR fix, offsets continue to be a critical stumbling block.


For more than 18 months providers have faced sequester-mandated cuts to Medicare payments, and more than 10 years remain of the 2% Medicare claims reduction. This year, H.R. 1416, a bill that halts the cuts on reimbursement for cancer drugs, garnered some support, but not enough to pass in either chamber of Congress. Many advocacy organizations will push to have the bill reintroduced next year, but H.R. 1416 will remain difficult to pass as part of any stand-alone healthcare bill. The best chance for a solution will be to attach some kind of fix to a larger bill, such as SGR reform.

A number of other issues may come up in the 114th Congress, including oral parity and prompt pay discounts, but would likely be included in larger healthcare-related vehicles. Stay tuned.

The Association of Community Cancer Centers will host a Capitol Hill day for its members on March 16, 2015. We encourage all of our members to attend this annual event and educate elected officials on these important issues. For more information, please click here.


Making the Case for Oncology Financial Navigation

Posted in ACCC News, Cancer Care, Healthcare Reform by ACCCBuzz on November 14, 2014

Dan-Sherman-150x170By Dan Sherman, MA, LPC, Guest Blogger

Yes, it’s that time of year again. Open enrollment for health insurance plans spans the range of employer-based policies, ACA policies, and the host of Medicare options available to Medicare beneficiaries. For many this is a dreaded period of time; they are forced to make important decisions about their finances and health coverage without having a core understanding of insurance terminology and how these policies will affect their access to care. For many there is little understanding of how the basic terms “deductible,” “max out of pocket,” “co-pays,” and “co-insurance” may affect the financial well-being of the enrollee. Nor do many understand the differences between HMO, PPO, POS, HSA, or PFFS, and how these differences may play a major role in the financial well-being and access to care for the oncology patient. Unfortunately, for far too many patients confusion leads to decision paralysis; they end up making no choice at all, or keeping the plan they have even though it may not be in their best interest. A time that should be viewed as an opportunity ends up being a time of dread and frustration, resulting in less than optimal coverage for care the patient desperately needs.

Changing the Paradigm

We, who are in the business of assisting oncology patients, also need to be in the business of changing this scenario from a time of dread and angst to a time of opportunity and hope. However, in order to accomplish this, many in the oncology community need to take ownership of the fact that we have aided in the mass confusion that our patients experience when it comes to understanding their health insurance policy. How often do we respond to a confused patient with the well thought out answer, “You will need to call your insurance company with that question”? How often do well-intentioned staff encourage patients to go through the cumbersome process of applying for Medicaid even though they do not qualify for this benefit in the first place? Have you tried to make sense of an itemized bill? It’s time that we in the medical field acknowledge that we are often just as confused about the health insurance policies as our patients.

Facing the Problem

Acknowledging this problem is the first step toward solving the problem of financial toxicity. So, let’s face it! Navigating the financial ramifications of cancer care is complex! If it were simple, we would be seeing much less financial toxicity in the oncology setting. Patients and providers alike are getting lost in a maze of health insurance policies, enrollment guidelines, and assistance programs, all requiring different information for successful enrollment. The rules governing Medicare Part D, with the initial coverage, coverage gap, catastrophic coverage levels, co-pay assistance guidelines, and steps to qualify for extra assistance programs, are overwhelming for most individuals. Up to 35 percent of new oncology products are oral medications covered by Part D, with 11 out of 12 of these medications costing more than $100,000 a year. It is essential that we understand the core benefits of patients’ insurance policies and help these patients apply for programs that are the most appropriate and readily available to meet their specific needs. All too often I have seen patients refuse oral treatment recommendations due to cost; only to find out that if these patients had received comprehensive financial navigation, they would have had access to these medications without significant cost-sharing responsibilities.

Then there is the complexity of choosing Medicare plans. Have you tried to explain the coverage differences between Medicare Advantage, Medigap, employer-based plans, and Medicaid? The fact is that Medicare beneficiaries who choose from a list of 30 to 60 different coverage options, many with significant cost-sharing responsibilities, need advice from someone with significant experience with these options, particularly in terms of how those policies cover cancer treatments. The oncology community is seeing similar trends with the health insurance exchanges under the Affordable Care Act (ACA). Patients are overwhelmed and confused about the enrollment process and the choices of coverage policies available to them.

Helping Patients Navigate the Maze

When patients are left on their own to wade through the 50+ Medicare options; the extra help program for Part D; co-pay assistance programs; premium assistance programs; ACA enrollment guidelines; the choices of bronze, silver, gold, or platinum plans; and available out-of-pocket subsidies, they will likely experience financial toxicity as they journey through cancer treatment. One of the main tools I use when providing financial navigation services to oncology patients is taking advantage of open enrollment and educating the patient on better options available to them in the context of their medical condition. Our patients need not only high-quality medical care provided in a compassionate environment, they need expert financial navigation services to help reduce the very real side effect of financial toxicity.

I contend that we need to see open enrollment as an opportunity for education and a way to decrease financial toxicity. So, let’s change the mindset of open enrollment from a time of dread to a time of opportunity so our patients suffer less, and providers get paid for the services they provide.

An important resource in this effort is ACCC’s Financial Advocacy Network, which provides tools, resources, and education for oncology team members involved in helping patients with issues related to the costs of cancer diagnosis and treatment.

Dan Sherman, MA, LPC, is a clinical financial consultant for Mercy Health Saint Mary’s, The Lacks Cancer Center, Grand Rapids, MI. He is also founder and president of The Navectis Group, a consulting company that assists oncology providers in implementation of financial navigation programs. Mr. Sherman serves on the Advisory Committee for ACCC’s Financial Advocacy Network.


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