Discussing Personalized Medicine at #ACCC2014
ACCC’s recent 31st National Oncology Conference featured 45-minute “think tanks,” supported by a grant from Genentech, on four hot topics in oncology. This is the third in a four-part ACCCBuzz blog series recapping these discussions from Think Tank facilitator, Joseph Kim, MD, MPH, of MCM Education.
By Joseph Kim, MD, MPH, Guest Blogger
The era of genomic personalized medicine is finally upon us and oncology professionals working in the community setting are delivering personalized care to cancer patients. At the 2014 ACCC National Oncology Conference, a Think Tank discussion focused on current trends and the future direction of personalized medicine.
Personalized medicine in the field of oncology can be defined as “the use of molecular diagnostics and genome analysis to select targeted therapies designed to treat cancer.” Some may refer to this as precision medicine and others may insist that the phrase “genomic” should be included to indicate that the level of personalization that is being offered today is based on the results of genomic sequencing data and identified mutation markers.
Targeting Treatments with Precision
Predictive biomarkers are being used to identify cancer patients who may respond to certain targeted therapies or to identify patients who may be resistant to other therapies. This allows oncologists to focus their treatment strategies by using drugs that have been approved by the FDA based on results from molecular biomarkers or companion diagnostic studies. This laser-focused approach to cancer care has led some to refer to this practice of medicine as “precision medicine” instead of personalized medicine. Since 2005, the FDA has been providing guidance in the area of personalized medicine for researchers, clinicians, and industry.
The Role of Biopsy
Of course, to perform highly specialized molecular testing on cancer biopsy samples, pathology labs must have access to adequate tissue. Think Tank participants agreed that this continues to remain a challenge in the community setting because so many physicians performing diagnostic biopsies are still only obtaining enough tissue to establish a diagnosis and are not obtaining extra tissue for molecular mutation testing. To further complicate matters, health insurance companies are not always providing reimbursement for certain mutation tests, so some hospitals are not performing critical tests that may be the gateway for personalized targeted care.
Ongoing Research
A growing number of academic research centers are establishing “Cancer Centers of Genomic Personalized Medicine” that are staffed with experts trained in tumor genetics, translational science, and bioinformatics. Think Tank participants noted that cancer centers in the community may not have staff who are trained in this highly specialized areas, but they are forming collaborations with research centers so that they can coordinate care for their patients and also identify those who may be appropriate candidates for clinical trials studying experimental therapies or combination approaches that target multiple genetic mutations.
Big Data Analytics
Some academic research centers are exploring the use of supercomputers like IBM Watson to analyze a wealth of information and identify a personalized approach to treating cancer. An example is the Memorial Sloan Kettering-IBM Watson Collaboration where oncologists are working with Watson to go through massive quantities of clinical data and published research to form actionable clinical practice for specific cancers. The New York Genome Center (NYGC) IBM Watson collaboration is looking at ways to leverage genomic research as a tool to help oncologists accelerate how they may more effectively deliver personalized care to patients with brain tumors and other complex diseases.
Conclusion
Personalized genomic medicine is here to stay and will dramatically alter the treatment strategies in cancer patients who have identifiable mutation markers that can be targeted with specific therapies. As cancer centers in the community develop treatment pathways based on biomarker and genetic mutation test results, they will be more effective in delivering care that is both evidence-based and potentially less toxic to patients.
Stay tuned for Think Tank #4 Discussing Molecular Tumor Boards at #ACCC2014.
Discussing Healthcare Reform at #ACCC2014
ACCC’s recent 31st National Oncology Conference featured 45-minute “think tanks,” supported by a grant from Genentech, on four hot topics in oncology. This is the second in a four-part ACCCBuzz blog series recapping these discussions from Think Tank facilitator, Joseph Kim, MD, MPH, of MCM Education.
By Joseph Kim, MD, MPH, Guest Blogger
At the recent 2014 ACCC National Oncology Conference, a Think Tank focused on the healthcare marketplace was held to discuss how recent changes have impacted oncology care. Since the Affordable Care Act (ACA) was signed into law on March 23, 2010, the evolving market forces have driven community cancer centers, hospitals, and oncology providers to focus more on affordability, access, quality, and accountability. The ACA has made it possible for millions of Americans to purchase health insurance through new employer requirements, the Health Insurance Marketplace, and the expansion of public programs like Medicaid.
- In 2014, it is estimated that up to 32 million people will receive health insurance coverage through the ACA.
- More than 8 million have selected a marketplace plan since enrollment began in October 1, 2013.
- Adults lacking health insurance was 18% in the third quarter of 2013 and dropped to 13.4% in May of 2014.
Growing Need for Patient Navigation
The oncology community continues to face tremendous pressures and challenges as new patients enter the system. Many first-time insurance purchasers need assistance navigating the process of signing up for healthcare coverage and they remain confused about newly encountered terms like deductible, co-pay, co-insurance, and out-of-pocket maximum. As cancer patients evaluate treatment options and the total cost for treatment, some will enroll in patient assistance programs while others will lean heavily on family members for financial support. Although some cancer programs are staffed adequately to educate and counsel patients through this process, others are struggling to fill these critical positions as they anticipate a rapid influx of new patients. ACCC has developed a set of resources around cancer patient navigation and patient assistance programs, as well as the Financial Advocacy Network with resources for both clinicians and administrators.
Pharmaceutical patient assistance programs continue to be a valuable resource for cancer patients who are being treated by expensive new therapies. Medicare lists most of the programs by drug name.
The Patient Access Network Foundation (or PAN Foundation) is another helpful resource that also provides information about co-pay assistance programs.
New Patients Remain Functionally Uninsured
Although Medicaid expansion is one of the key ways that uninsured patients will gain health coverage through the ACA, not every state is participating. Currently, 28 states (including Washington, D.C.) are implementing Medicaid expansion, 2 states are in open debate, and 21 states are not expanding. As a result of the Medicaid expansion, approximately 10.5 million new patients will receive health insurance coverage. However, many of these patients will remain “functionally” uninsured because they will lack access to providers who are willing to accept new Medicaid patients. (Less than half of physicians are accepting new Medicaid patients.) Think Tank participants also emphasized the growing importance of care coordination in oncology since more patients are living longer with a cancer diagnosis and are requiring care by other specialists such as cardiologists or psychiatrists.
Value in Oncology
Think Tank participants agreed that the growing focus around the “value” of healthcare can be difficult to measure in the area of oncology. The measurement of subjective clinical endpoints can be challenging when cancer patients are dealing with severe nausea or vomiting, fatigue, rashes, or pain. Cancer programs and oncology clinicians are also noting the growing importance of focusing on patient satisfaction scores, since these metrics are directly impacting reimbursement.
Conclusion
Think Tank participants also acknowledged that other complex and intertwined issues related to healthcare reform are directly impacting cancer providers and patients. There are ongoing discussions about the 340B Drug Pricing Program, the consolidation and acquisition of oncology practices, and of creative ways for achieving patient-centered care in oncology.
Stay tuned for Think Tank #3 Discussing Personalized Medicine at #ACCC2014.
Discussing Lung Cancer Screening at #ACCC2014
The recent ACCC 31st National Oncology Conference featured 45-minute “Think Tanks,” supported by a grant from Genentech. The discussions focused on four hot topics in oncology: Lung Cancer Screening; the Healthcare Marketplace; Personalized Medicine; and Molecular Tumor Boards. This is the first in a four-part ACCCBuzz blog series recapping these discussions from Think Tank facilitator, Joseph Kim, MD, MPH, of MCM Education.
By Joseph Kim, MD, MPH, guest blogger
A small group Think Tank convened at the 2014 ACCC National Oncology Conference focused on key questions around lung cancer screening and how cancer programs are developing lung cancer screening programs. A question on everyone’s mind: Will low-dose CT (LDCT) scans for lung cancer screening be covered by Medicare?
The U.S. Preventive Services Task Force (USPSTF) lung cancer screening guidelines target asymptomatic adults aged 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit smoking within the past 15 years. The USPSTF is basing its recommendations on multiple studies including the NLST (National Lung Screening Trial) where 90% of the population was younger than 70 years, while MEDCAC (Medicare Evidence Development & Coverage Advisory Committee) is focusing on patients over the age of 65. The oncology community awaits MEDCAC’s final recommendation coming soon.
Think Tank participants acknowledged that an effective lung cancer screening program can be very cost effective. After all, lung cancer is the leading cause of cancer-related mortality in the U.S., with 159,000 deaths annually. Today, most patients are diagnosed with advanced disease, but effective screening would allow patients to get diagnosed and treated earlier in their disease. When LDCT was used for lung cancer screening, 55% to 85% of detected cancers were found at stage I.
Ensuring Appropriate Follow-Up
Are cancer programs in the community ready to handle the volume of new lung cancer patients? According to expert estimates, almost 9 million adults would be eligible for lung cancer screening. Although many hospitals may be prepared to handle the volume of performing LDCT scans and having radiologists interpret those studies, they are not adequately prepared to run and maintain a lung nodule clinic that will provide ongoing follow-up to patients who have a non-negative screening test. Some programs are implementing interdisciplinary teams, comprised of pulmonologists, surgeons, radiologists, oncologists, and nurses, who are working collectively to develop effective follow-up programs for patients who have a lung nodule. To ensure appropriate follow-up, these lung nodule clinics will need to maintain a strong level of communication with the patient’s primary care provider (PCP), but this may be especially challenging when patients who undergo a screening LDCT scan do not have an established PCP.
Smoking Cessation Remains Key
Think Tank participants also noted that some patients who undergo LDCT or who get diagnosed with lung cancer may not want to quit smoking. Therefore, cancer programs are making every effort to integrate robust smoking cessation interventions into the lung screening program so that every patient who is a smoker receives thorough counseling about the importance of smoking cessation.
Lung Cancer Navigators
To prepare for the increase of new lung cancer patients, many cancer programs in the community are investing in training or hiring new lung cancer navigators who can provide appropriate follow-up and care for patients.
Conclusion
Regardless of CMS’ coverage decision on LDCT for lung cancer screening, cancer programs in the community are developing and launching lung cancer screening programs because they believe that the evidence supports the value of having such programs in place. Think Tank participants agree that community hospitals recognize the key challenges they will face and are proactively planning ways of navigating around those barriers and obstacles. The Lung Cancer Alliance offers a wealth of resources and information about lung cancer screening.
Stay tuned for Think Tank #2 Discussing Healthcare Reform at #ACCC2014.
Two Tracks, One Destination: Quality Care
by Amanda Patton, ACCC Communications
Last week hundreds of cancer care providers gathered in San Diego for the 31st ACCC National Oncology Conference. Over two days, attendees joined in a range of dynamic sessions focused around two track themes: YOUR PATIENTS and YOUR PROGRAM.
A unifying message underlying this year’s conference sessions: Regardless of care setting, oncology care providers are facing the same challenges—new payment models, declining reimbursement, increasing competition, quality demands, rapidly evolving technology, and growing emphasis on patient engagement. To achieve the triple aim of improved quality, reduced cost, and enhanced services, providers will need to work together, collaboratively, across settings and service lines.
For those of you unable to be with us in San Diego, here are some key takeaways from each track.
Takeaways from YOUR PATIENTS TRACK:
- Truly patient-centered care requires conversations. For example, when a distress tool triggers a referral to financial assistance: Is the patient having trouble paying rent? Is the patient unable to pay for medications? Is the patient uninsured? Providers need to have conversations with patients to identify and meet these complex needs.
- Patients and families want to be active participants in treatment decision-making. And, they want a say in how our programs provide services, whether this means ensuring access to financial counselors, developing a patient transportation program, or creating a healing garden for reflection during treatments.
- All cancer programs have a responsibility to conduct community outreach—and we are doing this in a number of innovative ways, leveraging our community resources to reach at-risk and under-served populations.
- Proactive patient education provided before the start of treatment can help improve care and patient adherence to treatment recommendations.
- Patient engagement is key to patient-centered care. This requires on-going conversations between patients and their care providers. Patient portals are an emerging tool with potential to improve engagement and, under Meaningful Use, cancer programs will be required to use them.
- Cancer programs need to find ways to make communication easier for patients—whether it’s through an innovative symptom management clinic, patient advisory councils, patient portals, or other venues.
Takeaways from YOUR PROGRAM TRACK:
- The market place is in a state of flux—hospitals acquiring physician practices; practices coming together to strengthen their bargaining power with payers, while remaining autonomous. No matter what the practice setting, physicians and hospitals will need to work together to meet the growing needs of our cancer patients.
- Patient-centered care is not only a requirement for accreditation; it is the right thing to do for our patients!
- The oncology community is exploring a number of new care models. For example, Oncology Medical Home Models that put the patient front and center. This model is accessible to practices of all sizes. Requirements: being innovative and willing to change—tools are available to help.
- The most successful cancer programs have access to and actively mine data to identify areas for improvement and marketplace differentiators.
- With the growing demand for services and a shrinking workforce, the oncology community will need to explore ways to partner with primary care providers to meet the needs of cancer patients.
Stay tuned for additional session highlights from the ACCC 31st National Oncology Conference.
Ready for Some Good News?
By ACCC Communications
Prepare to be inspired.
Richard Rossi, the keynote speaker at ACCC’s 31st National Oncology Conference in San Diego, Calif., October 8-10, 2014, will introduce meeting attendees to some of the country’s most gifted teenage researchers who are already changing the future of cancer care.
“With all negative news in healthcare, with all the stress and challenges as a cancer care professional, this will be a wonderful opportunity to hear how young people have fundamentally changed the future of medical care by their interventions,” said Rossi. He co-founded the National Academy of Future Physicians and Medical Scientists, an educational enrichment organization that honors, inspires, and motivates the nation’s most promising future physicians.
“Jack Andracka. He’s 17, but when he was 14 and sitting in his science class, he imagined a way to diagnose pancreatic cancer in stage I,” said Rossi.
According to Jack’s Wikipedia entry, the idea for his pancreatic cancer test came to him while he was in high-school biology class, drawing on the class lesson about antibodies and an article on analytical methods using carbon nanotubes he was surreptitiously reading in class at the time. Afterward, he followed up with more research using Google Search on nanotubes and cancer biochemistry, aided by free online scientific journals.
“At age 15 he contacted 200 professors asking for lab space to test his thesis. One hundred and ninety-nine turned him down,” said Rossi. Finally, he received a positive reply from Anirban Maitra, Professor of Pathology, Oncology, and Chemical and Biomolecular Engineering at Johns Hopkins School of Medicine.
The result of his project was a new dipstick-type diagnostic test for pancreatic cancer using a novel paper sensor, similar to that of the test strip for diabetes. This strip tests for the level of mesothelin, a soluble cancer biomarker, to determine whether a patient has early-stage pancreatic cancer. The test is over 90 percent accurate in detecting the presence of mesothelin.
“Jack is not an anomaly,” said Rossi. “The good news is that there are a whole bunch of young people making a huge difference in cancer research.”
And cancer research is not the only area of oncology that’s engaging tomorrow’s leaders.
Some ACCC-member cancer programs are finding innovative ways to connect with the next generation of oncology professionals–from mentoring future oncology nurses to offering internship opportunities to tapping into the energy and enthusiasm of young volunteers in the community.
Stay tuned to ACCCBuzz for highlight’s from Rossi’s keynote talk, “The Good News About the Future of Medicine,” next Friday, October 10, 2014.
Rossi currently serves as president and executive director of the National Academy of Future Physicians and Medical Scientists. Its mission is to identify, encourage, and mentor students who wish to devote their lives to the service of humanity as physicians, medical scientists, technologists, engineers and mathematicians.
It’s not too late to attend the ACCC National Oncology Conference, learn more here.
A Survivorship Roadmap Linked to EMRs
By Don Jewler, Guest Blogger
In a perfect world each patient who has recently completed cancer-directed therapy should receive a survivorship care plan that clearly summarizes his or her treatment and provides direction on what to expect in the next several weeks, months, and years of their life to come. That survivorship plan should be available in print form as well as easily accessible electronically on a patient web portal.
Oncology Specialists, SC, in Park Ridge, Ill., did exactly that. What’s more, they developed their survivorship care plan with the idea of incorporating many of the information points that are already collected within the patient’s electronic medical record (EMR) that essentially self-populates into the plan. The plan provides a treatment summary, including side effects, as well as health maintenance issues and the impact of cancer diagnosis on the well-being of family members.
Oncology Specialists, SC, will be honored with a 2014 ACCC Innovator Award for its EMR-driven approach to survivorship care plans.
“The impetus for development of the survivorship plan was a mandated change in the Commission on Cancer standards,” said Mary Beth Mardjetko, RN, MN, administrative director.
Standard 3.3 (a 2012 standard that must be phased in for 2015) states that the cancer committee must develop and implement “a process to disseminate a comprehensive care summary and follow-up plan to patients with cancer who are completing cancer treatment.”
Initially, after reading Commission on Cancer (CoC) requirements, Mardjetko and others in the oncology practice were worried. With limited resources and time, how could they put together a survivorship plan for all their patients?
“We saw 40-page survivorship plans. We knew these would not be realistic in our practice. So, a small group consisting of a physician, three nurses, and myself looked at the CoC requirements,” said Mardjetko. “We decided to use the template function of the EMR and build a generic survivorship plan that would be individualized for each patient using information that would pull directly into the note. We developed a four- to six-page survivorship plan with the CoC standards as the guide.”
Those standard elements include a treatment summary, drug names, doses, side effects, and names of all physicians and supportive care personnel involved. A treatment plan for years one to five is provided, as well as long-term outlook and recommendations, such as genetic testing for first-degree relatives.
Since nurses and physicians constantly update the EMR, the survivorship plan is dynamic and versatile. It can easily be sent to the primary care physician or other physicians involved in that patient’s care.
“The most wonderful part was how grateful patients were for learning what was to come next—what they could expect now and in the future,” said Mardjetko. “Physicians and nurses found the experience wonderful, too, as they went over the survivorship plan with patients and provided closure at the end of treatment.”
The next step is for Oncology Specialists, SC, to work out a survivorship plan for patients who are metastatic or on oral therapies.
“This is still a work in progress,” said Mardjetko.
Want to learn more? Join us at ACCC’s upcoming 31st National Oncology Conference in San Diego, October 8-10. Sigrun Hallmeyer, MD, medical director, Cancer Survivorship Program, Oncology Specialists, SC, Advocate Lutheran General Hospital, will provide more details. And check out a video about the survivorship plan here.
ACCC members will recognize the byline of guest blogger, Don Jewler, former ACCC Communications Director. We coaxed Don out of retirement to contribute to ACCCBuzz.
Optimism in the New Clinical Trials Landscape, Says ACCC 2014 Award Winner
by Don Jewler, Guest Blogger
Nicholas J. Petrelli, MD, FACS
In case you didn’t notice, the cancer clinical trials infrastructure across the country is changing.
In August 2014 the National Cancer Institute (NCI) awarded 53 new five-year grants to researchers across the country to conduct multi-site cancer clinical trials and cancer care delivery research studies in their communities. The grants were awarded under the NCI Community Oncology Research Program (NCORP), a national network of investigators, cancer care providers, academic institutions, and other organizations that provide care to diverse populations in community-based healthcare practices across the United States. The program funding is $93 million a year for five years.
“I’m cautiously optimistic,” said Nicholas J. Petrelli, MD, FACS, who will be presented with ACCC’s 2014 Clinical Research Award at the upcoming 31st National Oncology Conference, in San Diego Calif., October 8-10, 2014. “With developments in genomics and in the infrastructure of NCORP, perhaps we can make a dent in overall survival in many of the solid tumors, beyond two- and three- and four-month survival, especially in the top five cancers we see in this country.”
Dr. Petrelli is also optimistic in the area of cancer prevention. “We spend so much effort and so much money on advanced disease and even early-state disease that we are long-overdue for a paradigm shift towards prevention. Perhaps as we enter into the world of proteomics and genomics, we will be able to do a better job at preventing the top cancers. I’m hoping that NCORP will move us forward on this front.”
Thirty-four NCORP Community Sites and 12 Minority/Underserved Community Sites will implement the latest, most scientifically advanced clinical research designed and led by NCORP. These clinical trials will bring added opportunity to test new technologies and strategies to fight cancer. They will also enable research on how cancer care is delivered in today’s changing healthcare environment, all with an eye toward improving outcomes and reducing disparities of care.
NCORP replaces two previous NCI community-based clinical research programs: the NCI Community Clinical Oncology Program (CCOP, made up of the Community Clinical Oncology Programs, Minority-Based Clinical Oncology Programs, and Research Bases) and the NCI Community Cancer Centers Program (NCCCP). The new program builds on the strengths of the previous programs and aims to better address the most pressing issues affecting the conduct and delivery of cancer care in communities across the nation.
With the 34 NCORP Community Sites and a realignment of the cooperative groups, Dr. Petrelli hopes to see a rise in the annual 4 percent national accrual average of adults on clinical trials.
A major sticking point remains: adequate funding.
“We’re running on a quarter tank of gas with NCORP, and that’s not going to get us too far,” said Dr. Petrelli. “There’s got to be a change in funding at the federal level in order for the program to be successful; otherwise, we are spinning our wheels.” What’s more, he noted, we will have to find a way for hospitals not funded by NCORP to continue their infrastructure of clinical trials.
Dr. Petrelli expressed hope that resources will improve as NCORP’s infrastructure begins to grow.
As for the opportunities ahead for clinical cancer research, Dr. Petrelli singled out his top two. “First, we need to evaluate the costs of what we are doing,” he said. “We need to evaluate patients as they go through treatment—how often they get imaged or blood drawn, for example. We need to take a hard look and be very practical in the management of costs. Second, genomics, which will allow us to move faster with regard to overall survival,” as genomic data helps us improve cancer prevention, early detection, diagnosis, and treatment.
Dr. Petrelli is the Bank of America endowed medical director of Christiana Care’s Helen F. Graham Cancer Center & Research Institute in Newark, Delaware. The institution earned a five-year grant from NCORP to bring leading-edge cancer screenings, prevention, control, treatment, and imaging research trials to more people in the places closest to where they live.
Hear more from oncology thought-leaders at the ACCC National Oncology Conference, Oct. 8-10, 2014, in San Diego. Learn more here.
ACCC members will recognize the byline of guest blogger, Don Jewler, former ACCC Communications Director. We coaxed Don out of retirement to contribute to ACCCBuzz.
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