CANCERSCAPE Session to Demystify Site-Neutral Payment Policy

By Amanda Patton, ACCC Communications

In recent months MedPAC, the Centers for Medicare & Medicaid Services (CMS), Congress, and the GAO have ramped up attention on the impact of consolidation and integration, shifts in sites of service, and how unequal payment rates across settings of care are affecting Medicare costs.

Adding to the controversy (and confusion) around site-neutral payment as a solution to reducing the Medicare “spend” is the recently passed Bipartisan Budget Act of 2015 at Section 603, “Treatment of Off-Campus Outpatient Departments of a Provider.”

Although the issues surrounding site neutral payment policy are complex, “Section 603 is pretty straight forward,” says Ronald Barkley, MS, JD, of the CCBD Group. “It’s the downstream unintended consequences that cancer programs need to understand.” In a session at the upcoming ACCC Annual National meeting in Washington, D.C., March 2-4, Barkley will demystify site neutral payment policies, lay out pros and cons, and provide a realistic assessment of the potential impact of Section 603. Attendees will leave with a 360-degree understanding of the issues and a “knowledge base to work from” going forward, Barkley said.

Site-neutral payment policies have the potential to affect revenue and budgeting, strategic planning, pro forma development, and 340B Drug Program participation. Thus, a thorough understanding of Section 603 is critical for today’s cancer program leadership.

Time is of the essence, according to Barkley. “There is a window of opportunity to take your message to CMS before [the agency] translates the [Section 603] legislation into regulation.”

Attend the ACCC 42nd Annual Meeting, CANCERSCAPE, from March 2—4, 2016, in Washington, D.C., and gain strategic insight into key drivers of change impacting our evolving oncology care delivery system in sessions focused on Policy, Value, and Quality. Learn more here.  Want to discuss this issue with your elected representatives on Capitol Hill? See what’s planned for ACCC Capitol Hill Day on March 2.

 

Why ICD-10 Codes Must Tell Your Patient’s Story

By Amanda Patton, ACCC Communications

We’re four months post ICD-10 implementation and some are comparing the transition to Y2K—a lot of sound and fury over what ultimately turned out to be a relatively calm transition.

If you think it’s all smooth sailing from here on out, think again. “ICD-10 is nothing like Y2K,” says Cindy Parman, CPC, CPC-H, RCC, Principal, Coding Strategies, Inc. “Moving to ICD-10 is more like having a baby. Once the baby’s arrived the work begins.”

In a session on Friday, March 4 at the ACCC 42nd Annual Meeting, CANCERSCAPE, Parman will be sharing tips for cancer programs to take stock of their ICD-10 transition.

Post implementation, what ICD-10 pain points is Parman seeing in oncology programs?

· Coding errors.  These may be coder mistakes or they may stem from insufficient documentation in the medical record—for example, physicians not providing enough information.
· Productivity.  Working with ICD-10 is taking coders longer because there is more information to sift through and coders may have to go back to physicians with questions.
· Reimbursement issues.  Insurance payers are taking an opportunity to tighten up qualifications for reimbursement. Some ICD-9 codes may have been reimbursed in the past, where the corresponding ICD-10 code will not result in payment. Even smooth transitions to ICD-10 don’t necessarily mean that cancer programs are coding correctly, Parman warns.

“It’s important for cancer programs to understand that ICD-10 is a patient classification system,” says Parman. Used appropriately, the code set will generate the data that tells the patient’s story and ensure that providers are getting credit for all of the care that is being provided. But when codes are missed that story is incomplete.

New payment models will be driven by ICD-10 codes, and capturing all the care provided for patients is critical, Parman says. “The data that cancer programs are collecting today will be used by the Centers for Medicare & Medicaid Services (CMS) to develop future alternative payment models (APMs). If the codes used do not reflect the full scope of services provided, cancer programs won’t be able to go back later and say ‘we left these codes off.’ ”

During her meeting session, Parman will discuss the potential for mining ICD-10 data to measure quality, safety and efficiency, among other indicators. But, she points out, “You can’t mine data you don’t have.”

Join us at the ACCC 42nd Annual Meeting, CANCERSCAPE, from March 2—4, 2016, in Washington, D.C., and gain strategic insight into three key drivers of change impacting our evolving oncology care delivery system: policy, value, and quality. Full session and speaker information available here.

Required Reading: “Advancing Immuno-Oncology in the Community Setting”

By Lee Schwartzberg, MD, FACP
Chair, Institute for Clinical Immuno-Oncology, Advisory Committee

Along with their copies copy of the January/February Oncology Issues, ACCC members will receive “Advancing Immuno-Oncology in the Community Setting,” the inaugural white paper from the Institute for Clinical Immuno-Oncology (ICLIO), an institute of the Association of Community Cancer Centers (ACCC).

As members of the oncology community well know, the last five years have brought us thrilling advances in immunotherapy. We’ve seen the introduction of checkpoint inhibitors and vaccines that are unleashing the power of an individual’s immune system to fight cancer. In the past few months, we’ve witnessed a surge of new FDA indications for immunotherapy agents in a number of disease sites, including melanoma, lung cancer, and renal cell carcinoma.

Immuno-oncology is now emerging as the fourth pillar of cancer treatment. It is a new field, bringing new promise and new challenges for patients, providers, and payers.

As Chair of the ICLIO Advisory Committee, I urge you to take a few minutes to explore the ICLIO white paper. Whatever your role in cancer care delivery, you’ll benefit from learning about the resources ICLIO offers today and those planned for tomorrow. Here are three reasons to learn about ICLIO:

1. The immunotherapy momentum continues to build. There is a robust pipeline of new immunotherapies in development, as well as emerging combination therapies. Staying up-to-date on advances in this new field is imperative—for your cancer program and your patients.
2. Empowered, informed patients and their families will be asking about (and for) these new immunotherapy options.
3. The challenges of integrating new therapies occur on many fronts—clinical, administrative, programmatic—and across disciplines. ICLIO brings a multidisciplinary approach to addressing these challenges with practical resources that help build a bridge from bench to bedside so that eligible patients in the community can access these new therapies and receive care in an evidence-based way.

For more, explore ICLIO resources online at accc-iclio.org and learn about future ICLIO initiatives. Take advantage of our upcoming ICLIO webinars in January:

Immunotherapies for the Treatment of Metastatic Renal Cell Carcinoma (mRCC)
January 15, 2016
12 pm, ET

Navigating Patient Assistance Programs for Immunotherapy Treatment
January 21, 2106
12 pm, ET

Coordination of Care for Immunotherapy Patient
January 27, 2016
12:30 pm, ET

Learn more and register for the webinars here. Join our community centered on transformative care!

National Oncology Conference—Keep the Conversation Going

Featured speaker Peter Bach, MD, MAPP, delivers the opening presentation of the ACCC National Oncology Conference.

By Amanda Patton, ACCC, Communications

From the opening presentation by featured speaker Peter Bach, MD, MAPP, to the final sessions focused on cancer survivors and the workplace and providing survivorship services on a shoestring budget—last week’s ACCC National Oncology Conference covered challenges large and small facing cancer programs and practices across the country.

Macro challenges—occurring at the health system and population health level—are well known to the oncology community. Among these are the high cost of cancer drugs and new therapies, the transformative shift in payment from volume to value, workforce shortages, reimbursement constraints, and the many issues tied to ever-increasing demands for data collection and reporting.

Micro challenges—occurring at the service line and individual provider and patient level—range from adapting delivery infrastructures to meet the evolving treatment landscape, to determining  metrics to track and how to best to communicate these to leadership, to ensuring patient access to supportive care services that remain unreimbursed, to fostering a holistic, patient-centric culture of care.

Common themes across conference sessions and conversations: Collaboration, integration, evidence-based medicine, and value.  Five key takeaways from the conference:

Cancer programs and providers must collaborate outside the box and across the care continuum.
Attendees heard first-hand from programs that are already making this work—from implementing virtual tumor boards, to engaging primary care physicians in survivorship care, to collaborating across disciplines to provide cancer prehabilitation services, and more.

There are formal & informal operational pathways to create integrated delivery networks with stakeholders for quality patient care.
Panelists in the Advancing Quality Care session agreed: to achieve a truly integrated delivery network transparency and trust between all partners is needed.

Oncology programs are increasingly turning to dynamic dashboards to demonstrate value to payers and patients.
Solutions and tools may exist outside the oncology service line. Reach out to the data analytics team or business intelligence team within your organization. Take advantage of or adapt existing resources and tools.

From personalized medicine to immuno-oncology, cancer treatment is undergoing a transformative shift.
For both providers and the patients they serve, the value proposition presented by genomic medicine is that it allows clinicians to make better therapeutic decisions.

Patients are key stakeholders in healthcare integration efforts.
“Successful integration will depend on aligned patient-centered care, patient-focused care, and patient engagement,” said ACCC President Elect Jennie Crews, MD, in the panel discussion on Advancing Quality Care.  Panelists touched on the findings included in a new ACCC white paper released at the National Oncology Conference that outlines forward-looking essential steps to ensure quality patient care in the increasingly integrated healthcare environment.

ACCC encourages members to keep the conversation going by sharing your key conference takeaways in our members-only online community ACCCExchange.

Save the date and join us in Washington, D.C., March 2-4 for the ACCC Annual Meeting: CancerScape 2016.

National Oncology Conference: Framing Issues & Finding Answers

ACCC President Steven D’Amato, BSPharm, BCOP, welcomes attendees to National Oncology Conference

by Amanda Patton, ACCC, Communications

Featured speaker Peter Bach, MD, MAPP, addressed a packed room in the opening session of the ACCC National Oncology Conference on Oct. 22, in Portland, Oregon.  Dr. Bach is Director, Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center.

Dr. Bach’s remarks centered on four prime issues challenging oncology today: the cost of cancer drugs, the need for oncology to do a better job on comparative outcomes research, the 340B drug pricing program, and the importance of incorporating end-of-life care into cancer program services.

Finding a rational way to address drug costs matters on both the macro level [in terms of the impact of healthcare costs nationally] and on the micro level at point of care when “drugs are being left at the pharmacy counter because patients can’t afford the copay,” he said.

 

Conference sessions throughout the day focused on challenges and innovative solutions that can have powerful micro- and macro-level impacts on cancer programs and providers, and the patients they serve: From “how to” sessions on benchmarking salaries, applying lean principles for staffing, establishing a virtual tumor board, distress screening, and preparing for alternative payment models, and more, to a big picture session on Advancing Quality—from Oncology Medical Homes to Integrated Delivery.  One cross-cutting takeaway message: work across disciplines and siloes—think about how to collaborate outside the box and across the care continuum.

Stay tuned for more conference highlights. Follow conference on Twitter at #ACCCNOC.

Institute for Clinical Immuno-Oncology (ICLIO) Conference Spotlights Challenges & Strategies

By Amanda Patton, ACCC Communications

“The promise of immunotherapy that was seen 100 years ago is now a reality,” said ICLIO Advisory Committee Chair Lee Schwartzberg, MD, FACP, in remarks kicking off the first Institute for Clinical Immuno-Oncology Conference on Oct. 2, in Philadelphia. “Where we are today, particularly with checkpoint inhibitors, is just the tip of the iceberg. . . . We are starting a new era with combination immunotherapy. . . . The challenge is how we will afford these new treatments.”

Conference sessions reflected the reality that adoption of immunotherapy in the community setting comes with challenges, and that strategies for successful implementation are already emerging. Read on for some key conference takeaways.

Immunotherapy is a completely different therapy.

From the clinical perspective, there is the need to understand differences in patients’ responses to immuno-oncology (I-O) therapy, to understand how to manage toxicities, and to educate all members of the multidisciplinary care team, the broader provider community, and patients and caregivers.

In a panel on Immuno-Oncology Applications, Sigrun Hallmeyer, MD, Oncology Specialists, SC, described her experience with implementing immunotherapy in the community setting. “This is really a completely different therapy,” she said. “What happens to patients in terms of side effects is unpredictable. . . . You can have twenty patients with no side effects and the twenty-first patient will have every side effect.”

Despite the challenge of understanding toxicities, Hallmeyer said, “What we are seeing in our community practice mirrors what is happening in clinical trials in terms of efficacy and side effects. . . . This is no longer a niche therapy for one or two tumor types.”

“We need to think in broad terms about educating other providers about immunotherapy toxicities,” said panelist Lee Schwartzberg, MD, The West Clinic, PC. Immunotherapy and toxicity profiles should be discussed in providers’ multidisciplinary conferences and during tumor boards, he said.

Panelist Gordana Vlahovic, MD, MHS, Duke University Medical Center, has been proactive in teaching residents at her program about toxicity profiles. The promise of these therapies is fueling demand, she said. “My practice has referrals from 45 states. Immunotherapy is something that people usually ask for.”

Dr. Hallmeyer agreed. “My patients are educated and well informed. They’ve known about these drugs. There was huge anticipation from the patient perspective and also from physicians.”

Advances in immunotherapy are accelerating more rapidly than the healthcare system’s ability to integrate them, particularly in terms of coverage and reimbursement, panelists agreed. It can take months for new drugs to be assigned J codes. In the meantime, payers may put a “hold” on drug claims, essentially putting the claim in limbo—neither denied or approved. Without a denial, patients cannot apply to patient assistance programs for help.

These are costly therapies, and “insurance and payment for these agents is a huge issue,” said Dr. Hallmeyer. Listen to a podcast of the Immuno-Oncology Applications session here.

Immunotherapy from the payer perspective.

Any discussion of new cancer therapies today must include cost and issues of financial toxicity—for the health system as a whole, for cancer programs and practices, and for patients. “It’s impossible not to be enthusiastic about the topic of today’s discussion,” said Michael Kolodziej, MD, Aetna, “but that doesn’t mean it’s easy.” From the payers’ perspective immunotherapy presents a problem that requires collaborative effort—the critical need to understand the patient population that responds to I-O. “We need to get the right treatment to the right patient at the right time, and we need you [providers] to help us figure it out,” he said.

Over the next two years, a number of immunotherapy drugs are likely to be approved for new indications, increasing the financial challenges, said panelist Michael Seiden, MD, PhD, McKesson Specialty Health. Listen to a podcast of the Payer Directions session here.

Immunotherapy comes with unique administrative challenges.

Three core administrative challenges in I-O implementation were spotlighted by Niesha Griffith, MS, RPh, FASHP, The Arthur G. James Cancer Hospital, The Ohio State University, in a panel discussion on tackling I-O integration challenges:

• Managing the deluge of immunotherapy information for patients and staff
• Ensuring appropriate triage of patients
• Managing reimbursement and patient financial support

Reinforcing the need for provider and staff education on immunotherapy, Griffith cited the critical issue of patients needing emergent care. “Everyone in the practice needs to understand that immunotherapy patients need to be treated differently when they go to the emergency department.”

“Education about I-O toxicities is critical,” commented panelist Steven D’Amato, BSPharm, BCOP, New England Cancer Specialists. “It’s especially important in order to avoid emergency department admissions and unintended downstream costs.”

In tackling the reimbursement and financial issues related to I-O therapies, Griffith said, “I can’t say enough about the importance of financial advocate support.” A key to success at her program has been adding dedicated reimbursement specialists to the pharmacy department.

Using patient assistance programs for immunotherapy agents is essential, she said. And to do this effectively, reimbursement specialists and the clinical team must work together. Administrative staff needs information from and communication with the clinical team to help patients access these therapies. “Financial advocates need to know everything about these new agents,” Griffith said.

While physicians are excited by these new therapies, in private practice it’s essential to have processes and efficiencies in place, especially on the back-end, to ensure reimbursement for I-O therapies, said panelist Spencer Green, MS, MBA (HA), Bozeman Deaconess Cancer Center. “Smaller cancer programs need access to experts to help think through the challenges of implementing new immunotherapy agents,” he said. Listen to a podcast of this session here.

I-O care coordination requires consistent, strong communication before, during, between, and after treatments.

Attendees got a bird’s-eye view from the frontlines of I-O implementation from panelists Catherine Schott, RN, BSN, CCRC, Wheaton Franciscan Healthcare; Jennifer Diehl, RN, Moffitt Cancer Center; and Gary Cohen, MD, Greater Baltimore Medical Center. Ms. Schott offered three essentials for care coordination of I-O patients:

• Begin care coordination early
• Encourage early reporting of adverse events
• Encourage compliance and long-term follow-up visits

Providers and staff—including office staff answering phone lines—need to be well educated about potential adverse events, said Ms. Schott. Educating patients and their families is equally important. She emphasized three key steps in care coordination of patients on I-O therapy:

• Conducting ongoing patient and caregiver education
• Providing wallet cards or symptoms logs for patients
• Encouraging accurate reporting of adverse events.

Schott stressed the importance of good communication during, between, and after treatment. “It’s important to know there may be late occurring side effects,” she said. “As more patients are treated with immunotherapy agents, we need to be vigilant about late occurring side effects.”

“For immunotherapy patients, it’s important to know who to call 24/7,” said panelist Jennifer Diehl. “Other providers may not be familiar with I-O agents, side effects, and treatments.”

Provider-to-provider communication is essential, said Dr. Cohen. Treating patients with these new immunotherapy agents is very different from “our experience in treating cancer patients with traditional chemotherapy or other modalities,” he said.  Assessment of patients is very different. With immunotherapy progressive disease may not always be due to metastasis. Toxicities are different. “With immunotherapy we have to teach our radiation oncologists, our endocrinologists about how immunotherapy agents work.”

Immuno-oncology indications are rapidly evolving.

The conference’s closing session featured Timothy Kuzel, MD, FACP, Northwestern University, discussing evolving I-O indications in renal cell carcinoma and melanoma, and Renato G. Martins, MD, MPH, Seattle Cancer Care Alliance, presenting on evolving immunotherapy indications for lung cancer. “We believe very strongly that molecular profiling is a key component of improvement of care in non-small cell lung cancer,” said Dr. Martins. Listen to a podcast of Dr. Martins’ presentation here.

Learn more from the ICLIO Conference: Access session podcasts and view presentations here.

The Institute for Clinical Immuno-Oncology is a hub of I-O information and resources for the entire multidisciplinary cancer care team—both clinical and non-clinical program staff. Access webinars, articles, and join the ICLIO community: Transform care today!

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The Association of Community Cancer Centers (ACCC) established the Institute for Clinical Immuno-Oncology (ICLIO) to empower multidisciplinary cancer care teams to advance application of immuno-oncology by providing comprehensive I-O resources.

Key Takeaways from NCCN Summit on Value, Access, & Cost of Cancer Care

By Maureen Leddy, JD, Manager, Policy and Strategic Alliances, ACCC

On September 11, 2015, the National Comprehensive Cancer Network (NCCN) convened healthcare experts for a policy summit on “Value, Access, and Cost of Cancer Care.” ACCC policy staff was in attendance, along with a host of provider and patient organizations. The summit explored methods to achieve optimum cancer patient care while considering rising care costs, and NCCN’s work groups on Value, Access and Cost also reported their findings. Some key takeaways follow.

Views on Value

The discussion on value centered on appropriate measures for value from the patient, provider, and payer perspectives. Panelists generally agreed that a broader view of healthcare is necessary to assess value. This includes consideration of the continuum of care, rather than just a specific episode of care. The full cost burden of cancer care on patients must also be addressed, and may include employment, caregiver, and housing and transportation issues.

Access Issues

Panelists explored access issues, focusing on the growing demand for cancer care services and its impact on access. Health exchange plans were identified as a source of disparate care, in that enrollees choose plans based on cost and then, upon cancer diagnosis, are faced with inadequate provider networks and prescription drug coverage. The discussion also touched on recent legislation driving providers to value-based reimbursement, and projected impacts on patient access to academic cancer centers. For the employer-insured population, one panelist commented on a shift to contracts with specific hospitals for second opinion and potential treatment of specific malignancies.

Cost Control

Among potential methods for curbing costs, panelists cited caution in use of high-cost diagnostics, treatments and therapies; avoidance of hospitalizations and emergency room use; and increased emphasis on palliative and end-of-life care. The panel noted that savings in provider care costs are possible, particularly through increased care planning and patient navigator uptake.

In discussing the cost of anti-cancer therapies, panelists pointed out that oncology is unique in that there is currently maximum use of generics with little opportunity for shifting to lower-cost prescription drugs until the further introduction of biosimilars. While drug costs make up just 15% of cancer care costs, they represent the fastest rising cost in cancer care. The panel acknowledged the challenges to containing prescription drug costs, and noted that some pharmacy benefit managers (PBMs) are looking to employ an indication-based formula for drug pricing, reimbursing for drugs by value and differentiating claims by condition. In the context of biologics, greater approval and high usage rates of biosimilars will be important to cost containment in the coming years.

The policy team at ACCC will continue to engage in this discussion of rising cancer costs and challenges in patient access to care.

Continue the Conversation

Join ACCC in Portland, Oregon, Oct. 21-23, at the 32nd National Oncology Conference and continue the conversation in sessions that will explore issues of value, cost, and patient access to care including:

Patient Access and the Cost of Cancer Care Across Specialties
Peter B. Bach, MD, MAPP, Center for Health Policy and Outcomes,
Memorial Sloan Kettering Cancer Center

What Will It Take? Must-Haves for Alternative Payment Models
Erich Mounce, MSHA, The West Clinic, PC

Palliative Care Models: Solutions for Programs of All Sizes
Moderator: Michael Kolodziej, MD, FACP, Aetna; Amy J. Berman, BS, RN, The John A. Hartford Foundation;
Sibel Blau, MD, Northwest Medical Specialties; and Brad Smith, Aspire Health

The full conference agenda and registration information is available here.

 

Preparing Ourselves for a New Frontier

By Steven L. D’Amato, BSPharm, BCOP, President, ACCC

The current pillars of cancer treatment incorporate radiation, surgery, and chemotherapy, with the goal of targeting the tumor and inducing complete or partial responses. Immuno-oncology (I-O) is a rapidly developing area of science and treatment that focuses on harnessing the ability of the patient’s own immune system to fight cancer. While great strides have been made in the fight against cancer, improved survival remains a challenge for some advanced malignancies. Surveillance, Epidemiology, and End Results (SEER) program data from 2014 show the five-year survival for lung, colorectal, kidney and renal pelvis, and melanoma to be 3.9, 12.5, 12.3 and 16 percent respectively. Specifically, malignant melanoma, renal cancer, and prostate cancer are potentially immunogenic, which makes them good candidates for immunotherapeutic approaches. Currently, more than 900 I-O clinical trials are in various phases of development.

A Long Road

The history of immunotherapy dates all the way back to 1796 when Edward Jenner used cowpox to induce immunity to smallpox. In 1890, Coley demonstrated that bacterial products (Coley toxins) had benefits for inoperable cancers, which led to the application of Bacillus Calmette-Guerin (BCG) in the 1960s. More than two decades later interferon-alpha was approved as hairy cell leukemia cancer immunotherapy, followed closely by interleukin-2 which was approved for the treatment of renal cell carcinoma and melanoma. Then came the birth of the monoclonal antibodies bevacizumab and cetuximab in 2004, followed by panitumumab in 2006. The first cellular immunotherapy (sipuleucel-T) was approved for prostate cancer in 2010. Ipilimumab (anti-CTLA-4) was approved for advanced melanoma in 2011. This year saw the first programmed cell death protein 1 (PD-1) monoclonal antibody inhibitors (nivolumab and pembrolizumab) approved.

These two new PD-1 inhibitors are currently indicated for the treatment of advanced melanoma (nivolumab, pembrolizumab) and squamous non-small cell lung cancer (nivolumab). These agents also have activity in a variety of other disease states and are currently being evaluated in numerous clinical trials. In addition to the development of anti-PD-1 agents, agents are being developed that target the PD-1 receptor and its ligands (PD-L1/2). I-O therapies have the potential to be used as monotherapy or as a part of combination regimens. Combinations of complementary I-O therapies with chemotherapy, radiotherapy, and targeted therapy have the potential to enhance antitumor effects. One can imagine the complexities of incorporating these new agents into the treatment of various diseases as more agents are developed and approved for use.

The anti-PD-1/PD-L1 agents are relatively well tolerated. However, there are many drug-related adverse events with potential immune-related causes, such as pneumonitis, vitiligo (a skin condition where skin loses its pigmentation), colitis, hepatitis, hypophysitis (inflammation of the pituitary gland due to autoimmunity), and thyroiditis. Because most tumor-associated antigens are also expressed in normal cells, the potential exists for toxicity against healthy tissues. Adverse events can be serious and potentially lethal, demanding vigilance throughout and after treatment. When combined with other forms of cancer treatment, I-O therapies can lead to numerous toxicities that must be identified early and managed appropriately. Another caveat with I-O is the monitoring of response with these new agents. Therapies that affect the immune system may not induce a measurable effect on tumor growth immediately. After initiating I-O therapy, immune activation and T-cell proliferation can start within days to weeks, but measurable antitumor effects may not be realized until weeks to months after initial treatment; the potential effects on survival may not be seen until several months after initial administration.

A New Frontier

This new frontier of medicine requires specialized education so that we can understand the immune system, its relationship to different tumor types, how these new agents interact with the immune system, and how to identify and manage immune-related events. To meet this critical need, ACCC formed the Institute for Clinical Immuno-Oncology (ICLIO), which launched in June 2015. ICLIO translates the latest I-O scientific research and findings for the multidisciplinary cancer care team, making the information accessible and—most importantly—breaking it into digestible action items that can be easily implemented in the community setting. ICLIO has brought the new frontier of immuno-oncology to your door. The next step is up to you. Visit accc-iclio.org today for information about clinical optimization, coverage and reimbursement, management best practices, patient access and advocacy, and training and development.

On Oct. 2, the ICLIO National Conference in Philadelphia, Pa., will bring together multi-disciplinary oncology team members to discuss the “how to’s” for putting immunotherapy into practice. I hope you’ll join me for this exceptional event.

Steven L. D’Amato, BSPharm, BCOP, is President of the Association of Community Cancer Centers, 2015-2016. He is Executive Director of New England Cancer Specialists.

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

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.

By 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 mealtrain.com or lotsofhelpinghands.com. 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!

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

Dreaming BIG to Cure Stomach Cancer

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

Stomach (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 www.debbiesdream.org.

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

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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.