Last year we got a better glimpse of what managed care will look like in the future. Although there still are many unknowns, especially in light of this being an election year that will bring a new administration, it’s already very clear how the transition to value is affecting oncology practices.

For example, this trend continues to create a lot of anxiety for community oncologists. Many are concerned about payment changes, the loss of longstanding referral relationships as primary care physicians and other specialists align with specific networks, and whether oncologists can maintain practice autonomy. Given what we know today, practices should be sure to address the following items this year:

1. Be aware of and involved in what’s coming. 

Most oncologists chose their profession because they love caring for patients and find joy in conducting research to find new and better treatment options. Negotiating with payers and keeping abreast of payment changes are some of the “necessary evils” that many prefer to hand off to practice administrators. However, with so much at stake during this transition to managed care, oncologists must make it a priority to be aware of and involved in what’s coming.

While the future of payment methods for oncology care is still murky, there’s no doubt that our industry is rapidly shifting away from fee for service (FFS) to value-based care. There continues to be a lot of discussion about what constitutes value, and many organizations from payers to associations and physician networks are working to develop definitions and guidelines.

Payers now expect physicians to make treatment recommendations that are in the best all-around interest of the patient. That means choosing evidencebased therapies that deliver the best outcomes and being economically responsible. These have been the foundation of evidence-based pathways since they were first introduced by The US Oncology Network 10 years ago.

Value Pathways powered by NCCNTM are based on the National Comprehensive Cancer Network’s Clinical Practice Guidelines in Oncology® and The US Oncology Network’s Level I Pathways. They are up-to-date, peerreviewed, evidence-based practice algorithms for cancer treatment, and are designed to maximize survival, minimize toxicity, and provide cost-saving opportunities. They are brought to the point of care by Clear Value Plusâ„ , a regimen support tool that can interface with most electronic medical records (EMRs) and provides financial transparency and real-time reporting.

Oncologists should also keep a watchful eye on what The Centers for Medicare & Medicaid Services (CMS) is doing. Because a majority of cancer patients are 65 years or older and covered by Medicare, many practices receive 40% to 50% of their payment from Medicare.

CMS plans to launch its Oncology Care Model (OCM) on July 1. This episodebased payment model will manage chemotherapy treatment and the spectrum of care provided to beneficiaries receiving chemotherapy. Practices chosen to participate in the five-year pilot will receive financial support for transforming their practices, including monthly care management payments for participating Medicare FFS beneficiaries as well as retrospective performance-based payments. This compensation will be in addition to the services the physician provides and bills to Medicare.

Practices in this pilot are expected to rely on the most current medical evidence and share decision-making with patients about whether they should receive chemotherapy. The performance-based incentives are based on comprehensively and appropriately addressing the complex care needs of the beneficiary population receiving chemotherapy as well as furnishing services that specifically improve the patient experience or health outcomes.

Another organization with skin in the game is ASCO, as indicated by their development of a “value framework.” This framework compares one new agent in cancer treatment with the prevailing standard of care for a specific clinical cancer indication using data from a prospective randomized trial. Rather than scoring different drugs against each other, the value framework examines the clinical benefit and toxicity of an agent in order to generate a “net health benefit” score that is juxtaposed against the cost of treatment. It is designed to help evaluate the value of different cancer treatment options and facilitate discussion between physicians and patients when it comes to making decisions about cancer care.

2. Think holistically about your patients. 

Unplanned hospitalizations are very expensive, and physicians are being held accountable for their patients’ overall care. This elevates the need to be more aware of the treatment patients are receiving outside the oncology office.

Practices that have not already established a solid framework for providing holistic care must take steps to do so this year. Many oncology practices are finding success with patient navigators who help ensure that patients adhere to treatments by proactively monitoring their health and progress between appointments. Others are offering extended office hours to better handle patient questions and concerns.

Patient portals are also being used to heighten engagement with patients by providing them with easy access to their personal health records and educational resources. Portals help patients to better understand their care and treatment plans while improving communication with the practice.

Many of these tools and ancillary services are crucial for meeting the guidelines being established for value-based care and payment. Practices should evaluate the appropriateness of each in order to achieve better care and outcomes.

With value-based payment becoming a reality, physicians need proven tools and processes to support evidence-based medicine—from treatment guidelines and pathways to reporting solutions that provide insight into practice trends. These tools are essential to thriving in a value-based payment system that recognizes and rewards physicians for providing cost-effective, high-quality patient care.

Many practices have already implemented the ancillary services discussed above and were early adopters of oncology-specific EHRs and other technologies that enable them to capture, monitor, and report data. In fact, some practices are collecting so much data, they are not sure what to do with all of it.

One of the most important things physicians can do to show payers that they are meeting their criteria for delivering high-quality care at a lower cost is to know the rules. Now, more than ever, oncologists must be vigilant in understanding the various contracts they have with each of their payers so they know which metrics are most important to each payer and are able to provide each with the right information in a timely manner.

Oncologists should also be on the lookout for new technologies. For example, it is going to be increasingly important to be able to provide comprehensive information to payers that combines the information from the oncology practice with data from other providers. Practice solutions that connect providers and allow sharing of information will be the catalyst for providing the required information to payers.

Cancer is one of the most important and complex healthcare challenges of our time. We have a lot of work to do as our industry works through changes aimed at improving outcomes and lowering costs. While the evolution toward managed care can create unrest among oncologists, it also creates many opportunities to shape the future of how care is delivered to patients in our communities.

Diana Verrilli is vice president and general manager of Managed Care, Quality & Provider Solutions for McKesson Specialty Health. Dr Marcus Neubauer is medical director of Oncology Services for McKesson Specialty Health & The US Oncology Network.

Articles

Although there still are many unknowns,
especially in light of this being an election year that will bring a new
administration, itâ€™s already very clear how the transition to value is
affecting oncology practices.

Top 3 Must Do's to Prepare for Managed Care in 2016

, we take you to Hawaii and Alaska to peel back the curtains on how oncologists in remote corners of the United States have innovated to keep their businesses vibrant and effective.

In the fiftieth state, for example, oncology is all about building relationships with fellow medical practitioners in the community. Our practice profile this month puts a spotlight on OnCare of Hawaii, which relies heavily on its physician network for referrals and does almost no advertising. Physicians in these idyllic islands know the importance of keeping good relations.

In a separate cover story, we take a look at the business of oncology in Alaska, where many patients must travel great distances for treatment, sometimes by plane and snowmobile. In this state, oncologists have innovated by using telemedicine to communicate remotely with patients, primary care physicians, and nurses. This helps to compensate for the shortage of doctors and the tremendous distances separating the sparse Alaskan population. In telemedicine, a healthcare worker is physically present with the patient while the oncologist participates via monitor.

It may sound unlikely to some, but tele-oncology may be coming to many locations in the lower 48 in the near future, for various reasons.

In the mid-1990s, the University of Kansas Medical Center (KUMC) replaced its timeconsuming and expensive “fly-in” oncology service with a distance treatment experiment that quickly proved its worth. Tele-oncology has improved access to specialty services and has been well received by patients, and its use endures at KUMC to this day, officials there have stated.

Now, payers and The Centers for Medicare & Medicaid Services (CMS) are incorporating incentives for use of telemedicine into their payment plans, on the theory that it cannot fail to save money and improve efficiencies not only between patient and oncologist, but among all health team members whose decisions affect patient outcomes and the cost of care.

A recent CMS study of 2014 data found that only 27% of Accountable Care Organizations (ACOs) in the Medicare Shared Savings Program achieved enough savings and quality improvements to qualify for financial incentives, and only 20% of these ACOs employed telemedicine services. With CMS trying to funnel 30 percent of Medicare payments through alternative payment models this year, and 50 percent by the end of 2018, use of telemedicine is poised to soar, according to a report by the healthcare consultants Foley & Lardner. Indeed, the telemedicine market on a global scale measured $14.3 billion in 2014 and is forecast to hit $36.2 billion in 2020, Foley & Lardner said.

Just as old-time journalists used to phone in their stories, oncologists may soon be phoning in their next patients. It may not be the ideal patient-doctor experience; on the other hand, technology once again is extending the reach and power of modern medicine. Read all about it in this month’s issue of 

In this monthâ€™s issue of Oncology Business Management, we take you to Hawaii and Alaska
to peel back the curtains on how oncologists in remote corners of the United States have
innovated to keep their businesses vibrant and effective.

"Press '1' to Speak to Your Next Patient"

Many oncologists have doubtless thought, just as they were about to board the plane and fly back to their snowy homes after a Hawaiian vacation, “This place is paradise. I wish I could move my practice here someday.”

Jonathan K. Cho, MD, understands the temptation, but he urges such people to be careful what they wish for.

“Hawaii is a very difficult place to be a doctor,” explained Cho, who practices with Oncare Hawaii. “Blue Cross Blue Shield dominates the private insurance market so completely that it can virtually set its own reimbursement rates, and the reimbursements paid by Medicare are also low because the government lumps Hawaii in with all Pacific Islands and claims it’s a low-cost market. As a result, doctors make considerably less here than they do on the mainland, and that disparity is increased by what is actually a very high cost of living.”

The practice that’s currently known as Oncare Hawaii opened its doors in the 1980s. It operated from a single office in Honolulu until, in 1997, it was bought out by a Georgia-based firm called Oncare that essentially cornered the market for both medical and radiation oncology in Hawaii. The parent company went out of business, but the business it left behind is still the largest player in Oahu’s community-based medical oncology market. It is also the only one with the economies of scale to provide infusion chemotherapy treatments.

The main competition comes from hospitals, such as Queen’s Medical Center, Kuakini Medical Center, and the Straub Clinic & Hospital. Kaiser Permanente also controls about 20% of the market, but it doesn’t really compete with other providers because its members must use its facilities. The same could be said of the US Department of Veterans Affairs facilities that care for the state’s many active and retired military families.

Oahu measures only 597 square miles, less than twice the size of New York City, but Oncare Hawaii operates seven separate offices to minimize the time patients spend traversing the island’s mountains and crawling through its often congested streets.

	Relationship Building Is Critical to Survival

The practice has made a point of locating its satellite offices in medical office buildings attached to different hospitals. Oncare physicians maintain privileges at those hospitals — some of them even have a contract to provide services for Queen’s &mdash; and they all maintain relationships with the doctors who work in and around each facility.

“Hawaii is a small market. Everyone knows everyone here, at least through a friend of a friend. Long-term business success hinges upon the ability to build relationships and, for us, the key relationships are those we build with referring doctors,” said Leslie Chinen, Oncare’s chief financial officer since 2011, who noted that all of the group’s doctors had been born and raised on the island. “The insularity here virtually eliminates our need to market ourselves. We don’t advertise. All of our patient referrals are from other physicians.”

The size of the market also places some limits on the services that Oncare Hawaii can provide. Less than a million people live on Oahu, and the total population of Hawaii is just over 1.4 million. Those figures are far too small to allow oncologists to specialize in anything but the most common tumor types. They’re also too small to give surgeons much practice with rare procedures or to let the hospitals justify the purchase of specialty equipment stocked by mainland cancer centers. As a result, some Hawaiian cancer patients need to seek treatment on the mainland.

In addition to being relatively small, Hawaii’s population differs dramatically from that of any other state in the union. Nearly 40% of the people there are Asian (mostly Japanese). Europeans are the next most common group (24.7%), followed by people of two or more races (23.6%, more than triple the percentage in any other American state) and Pacific Islanders (10.0%, including people of Native Hawaiian ancestry).

This mix has little effect on the incidence of major cancers, such as breast cancer and lung cancer, which all reflect national norms, but Hawaii’s large Asian population suffers from significantly elevated rates of liver cancer, thyroid cancer and biliary cancers — mostly because it also suffers from unusually high rates of hepatitis B and C. (Hawaii’s climate is also unique among American states, but it does not boost the number of patients at Oncare Hawaii: melanoma incidence rates are actually below the national average.)

At present, Oncare Hawaii does not have the equipment or the personnel to provide radiation regimens, but Cho and his partners are exploring ways to add radiation as a means of attracting more patients and providing more complete service to current patients. The practice has already added in-house facilities for performing common tests and dispensing pharmaceuticals. According to Chinen, both additions have produced financial benefits, while the pharmacy service has produced medical benefits in the form of helpful patient information.

	Trial Participation Makes for More Robust Offerings

“The financial benefits are pretty straightforward. We can perform both services efficiently, so they have been valuable new revenue streams for us at a time when reimbursement rates have either stayed flat or gone down,” Chinen said. “The medical benefits of the pharmacy stem from the extra information we get about patient behavior. When patients fill prescriptions elsewhere, we have no way to know if they’re filling them as frequently as they should. When they fill them with us, the dates give us a pretty good idea about which patients are taking their medications correctly, and they give us a chance to improve adherence among patients who use our pharmacy.”

Another relatively recent initiative that has succeeded for Oncare Hawaii has been participation in more clinical trials, which allows the practice to offer patients more (and often better) treatment options. Many of those trials originate at the University of Hawaii, which has a cancer center at its medical school that performs research but avoids most clinical practice. The other trials mostly originate with drug companies that want to test experimental medications. Oncare Hawaii now assigns a staff member to track new trial proposals and sign up for trials that might benefit the practice’s patients.

Oncare’s efforts to participate in more clinical trials echo similar moves by other successful independents around the country. The similarities do not end there. Oncare Hawaii has embraced a number of basic strategies that have helped many oncology groups remain independent. For example, the practice works continuously to increase productivity, reduce waste and use its size to secure the best rates from suppliers.

Chinen believes, however, that Oncare Hawaii is unusual in the autonomy it affords to its doctors. Each physician sets his or her own hours, recruits most of his or her own patients, and then becomes the only Oncare physician to see those patients.

“The idea is to combine the best of both worlds,” Chinen said. “On a day-to-day basis, our physicians practice almost as though they were totally independent, but their participation in the group obviously gives them access to more facilities and resources and support staff than any solo practitioner could ever have. The only time they really act collectively is at the meetings they hold at least once a month, when they discuss things that affect the practice as a whole, review each other’s clinical performance, and otherwise support each other.”

The strategy has worked so far, but Cho believes that he and his partners must keep evolving if they want to keep pace with changes that threaten to make a tough market even tougher.

“We expect all the other hospitals to follow the lead from Queen’s and develop their own chemotherapy and radiation departments. Queen’s has done pretty well, so they all think they can make cancer care into a profit center. We also expect Blue Cross Blue Shield and the federal government to keep putting downward pressure on reimbursements, even as the cost of living continues to rise,” said Cho, who noted that a large hidden cost of living in Hawaii is the need that most professionals feel to school their children privately rather than rely on much-maligned public schools.

“If we’re to survive as an independent practice over the long term, we cannot get complacent. We need to consider every option for improving our position, and we’re considering many options right now. Should we bring in an accelerator? What are mainland practices doing that might make sense for us? Should we partner with a primary care group and other types of specialists to create a much bigger organization with more bargaining power? These are things we have to talk about.” 

Oncare Hawaii is unusual in the autonomy it affords to its doctors. Each physician sets his or her own hours, recruits most of his or her own patients, and then becomes the only Oncare physician to see those patients. 

Hawaiian Oncologists Surf Lower Pay, Fewer Resources

		Huntsman Cancer Institute at the University of Utah

		Clinical staging of prostate cancer by digital rectal examination and/or computed tomography scan findings is limited by the incomplete ability to accurately assess disease distribution, volume, and presence of adverse staging findings such as extra-capsular extension (ECE) or seminal vesicle invasion (SVI), which are far more often detected on final surgical pathology. Prostate magnetic resonance imaging (MRI) offers a significant advance in the availability of potential valuable clinical data prior to making a treatment decision.

		The challenges in incorporating MRI findings into treatment decision making algorithms include: one, sometimes disparate reports of the sensitivity and specificity of MRI findings for predicting the true extent of disease as reported by surgical pathology; two, understanding the subtleties of MRI versus pathological findings as they relate to prognosis (should MRI find gross but not microscopic ECE or SVI, perhaps MRI findings could represent the more severe cases of these pathological predictors); three, defining the role of MRI in the pre-treatment decision making model; and four, proving that gains in decision making provided by MRI do in fact improve outcomes and are cost-effective.

		Answers to each of these questions are needed prior to the routine inclusion of MRI in to the evaluation and decision making algorithm for all patients with prostate cancer. Surgical pathology investigations continue to better define the answers to the first two challenges. Here, the authors present one of the first efforts to address the far more complicated third and fourth question, and begin an investigation that hopefully will be continued and clarified over the next decade.

	To evaluate the role of magnetic resonance imaging (MRI) in the clinical staging of prostate cancer in the definitive and salvage settings, and to identify changes in treatment recommendations.

	Between November 2008 and November 2011, 114 patients referred for radiotherapy (RT) consultation underwent a prostate-protocol MRI of the prostate and pelvis. Charts were retrospectively reviewed for demographic and clinical information.

	Eighty-six patients were evaluated for definitive treatment, 26 for salvage treatment, and 2 for RT planning in the adjuvant setting. Of the definitive subjects, MRI was performed after RT consultation in 68 patients and before consultation in 18 patients. For patients who underwent an MRI after consultation, MRI led to a change in treatment recommendation for 6 of 68 (9%) patients. Androgen deprivation therapy was added or extended in 3, prophylactic nodal RT was added to 3, and definitive nodal RT was added to 1. Active surveillance was no longer recommended in two persons, and brachytherapy alone was no longer an option in two persons. Of the 86 definitive treatment patients, nodal metastases were identified in 6 (7%). For the 26 salvage patients, imaging did not lead to any changes in planned treatment. MRI evaluation can influence clinical decision making for both physician and patient, but how those decisions change outcome is still unresolved.

	In most cases when treatment recommendations were modified based on MRI findings, therapy was escalated to correspond with clinical upstaging. It remains to be seen if this translates into improved disease control, and it is possible that the “Will Rogers phenomenon” (when moving an element from one set to another raises the average values of both) will result from incorporating the high-resolution MRI information into clinical decision making.

Historically, magnetic resonance imaging (MRI) has not been routinely used for the diagnosis and staging of prostate cancer (PC). Accurate staging is important because there is wide variability in recommended treatment options and expected outcomes for patients with low-risk, intermediate-risk, and high-risk PC.

 Although useful for risk stratification, prostate-specific antigen (PSA) measurements can be unreliable correlates of tumor stage and disease burden.

 In addition, while digital rectal examination (DRE) can detect high-risk features such as extracapsular extension (ECE), DRE has been shown to have a low sensitivity.

 MRI has several possible roles in the management of PC, and its utility is being investigated in numerous single-institution studies. MRI findings have been correlated to pathologic features after radical prostatectomy.

MRI is being evaluated as a tool for selecting patients who are appropriate active surveillance (AS) candidates, 

 despite some evidence that it may not be useful at predicting adverse pathologic features,

 or for predicting risk of recurrence based on high-risk features.

 A better understanding of tumor extent and location within the gland may lead to improvements in therapeutic decision making and in surgical and radiotherapy (RT) treatment planning. Use of prostate MRI could also lead to delivery of more aggressive therapies because of the detection of adverse features that would otherwise remain occult. We reviewed the use of prostate MRI to characterize its effect on the clinical stage and subsequent treatment recommendations for patients referred for RT consultation.

After Institutional Review Board approval was obtained, all patients who were evaluated in the radiation oncology department and underwent a prostate protocol MRI between November 2008 and November 2011 were identified. In total, 114 patients met these criteria. Charts were reviewed for age at diagnosis, PSA level, date of biopsy, Gleason score, and pathologic or DRE-based T-stage. The clinical American Joint Committee on Cancer (AJCC 7th edition) Tumour, Node, Metastases (TNM) stage and the National Comprehensive Cancer Network (NCCN) risk groups were documented. Prostate protocol MRI reports were reviewed, and an MRI stage was assigned by the authors based on the extent of disease identified on imaging. Treatment recommendations, per dictated reports, were given at the time of initial RT consultation and again after MRI information was obtained. In situations where the MRI was obtained before the RT consultation, only one set of recommendations was made.

MR imaging studies were performed on a whole body 3 Tesla Siemens Magnetom TrioTim or Verio (Siemens Medical Solutions, Erlangen, Germany) with an 8-channel pelvic phased-array coil and spine coil. Routine techniques and sequences were used, including small field of view (FOV) T2-weighted turbo spin-echo sequences in the axial, sagittal, and coronal directions, covering the prostate and seminal vesicles (SVs). Scanning parameters were TR range/TE range, 3000—3300/101-121; slice thickness 3-4 mm; an echo train length of 17-19 and 1-2 averages.

Each plane took 5 to 6 minutes to acquire with a FOV of 160 x 160 mm. A 256 x 256 pixel matrix was used. An axial T1 small FOV series was performed to detect postbiopsy hemorrhage. Whole-pelvis imaging T1 and T2 with fat saturation was performed to look for lymph node (LN) and osseous involvement. Axial whole-pelvis diffusion-weighted imaging was performed with b values of 0 and 1000. All studies were evaluated by one of five abdominal fellowship- trained radiologists with two to 15 years of experience. Imaging was evaluated as part of usual clinical care on a PACS image viewer (iSite, Philips Healthcare, Andover, MA)

, with full access to any previous imaging and medical records, including PSA level and biopsy results. No additional review was performed for this study.

Clinical interpretation was focused on providing information for local staging, including an assessment of the prostate capsule, SVs, and pelvic nodes. Criteria used to classify local disease included a focal T2 hypointense mass in the peripheral zone without corresponding T1 hyperintense signal, to suggest postbiopsy hemorrhage. ECE included evaluation on the T2-weighted images for direct extension into the periprostatic fat or an interruption of the T2 dark band that surrounds the prostate, or broad contact of the low-signal intensity focus of disease with the capsule (≥10 mm).

Eighty-six patients were evaluated for definitive treatment, 26 for salvage treatment, and 2 patients were evaluated for treatment planning in the adjuvant setting. Patient and tumor characteristics are described in Table 1. For the 86 patients with newly diagnosed PC, AJCC TNM stages before and after MRI acquisition are displayed in Table 2. The most common clinical stage was T1cN0M0 (50%). MRI revealed that 17 (19.8%) had findings concerning for ECE, and 13 (15.1%) had SV invasion (SVI). Of the patients with ECE diagnosed on MRI, the clinical stage was formerly T1c in 7 cases, T2a in 3, T2b in 4, T2c in 1, and T3a in 2. Of the patients with SVI on MRI, the clinical stage was formerly T1c in 4 cases, T2a in 1, T2b in 1, T2c in 3, T3a in 2, and T3b in 2. In 29 cases (34%), MRI findings agreed with the clinical examination findings. In 54 (63%) patients, MRI findings suggested more advanced disease than DRE, and in 3 (3%) cases the MRI findings were less concerning than DRE. Of the 54 who were clinically upstaged, 33 (61%) had clinical T1c disease prior to MRI. Of these, 14 had imaging findings reported as involving both lobes of the prostate gland, 7 had findings concerning for ECE, and 4 had SVI on MRI. Of the 3 who were downstaged, in two cases of clinical T2a disease, the tumor could not be detected on MRI, and in one case of clinical T3a disease, ECE could not be identified on MRI. MRI reported newly found nodal metastases in 6 (7%) patients, and pelvic LNs were “concerning” in an additional two. Distant metastases (DM) were not identified in any patient. MRI was performed after RT consultation in 68 patients and before consultation in 18 patients.

For patients who underwent an MRI after consultation, MRI led to a change in treatment recommendation for 6 of 68 (8.8%) (Table 3). Two patients were initially considered for brachytherapy monotherapy but after MRI they underwent surgery or combined modality treatment with external beam radiation therapy (EBRT) and androgen deprivation therapy (ADT). Two patients were considered for AS, but after MRI underwent definitive treatment. In four patients, EBRT to the prostate and SVs was recommended at the time of diagnosis, but after MRI, the field was extended to include the pelvic LNs. In three cases, ADT was not considered at diagnosis but was recommended after consideration of MRI findings. For the 26 patients evaluated in the salvage setting, the mean time from definitive surgical treatment to MRI was 4.4 years (range 0.5 to 21 years). Retained SVs were identified in seven (26.9%) patients. For the 28 patients evaluated in the salvage and adjuvant settings, no nodal or DM were identified, and imaging did not lead to changes in planned treatment.

MRI use for prostate cancer staging, decision making, and treatment planning is supported by most payers and treatment guidelines,1 and has both proponents and opponents. The mantra of “Don’t order a test unless you will action the result” is a refrain most medical students learn early in their training. This study was undertaken specifically to evaluate how the diagnostic MRI altered clinical decision making, despite the absence of level 1 evidence that proves or disproves its merit in changing oncologic outcomes. There are no universally adopted guidelines to inform the clinician on how MRI results should affect patient care. At our institution, in the definitive treatment setting it is our bias that MRI findings of SVI, grossly evident extracapsular extension, lymphadenopathy, or very-high-volume disease should be considered a very-high-risk feature. In these cases, it is our bias that patients should have pelvic lymph nodal radiation, dose-escalation with brachytherapy if possible, as well as ADT as part of their definitive treatment. With the exception of lymphadenopathy, CT scans perform poorly at discriminating these particular features. Conversely, in low-risk and favorable intermediate-risk patients, we consider very-lowvolume or no evidence of disease on MRI to be a favorable prognostic feature that may support the use of monotherapies or AS when taken in context with other clinical parameters. Reports of “capsular abutment concerning for extracapsular extension” are generally considered nonactionable.

Irrespective of how these findings affect the choice of therapy delivered, these authors feel that properly performed MRI sequences can greatly assist in the contour definition of the prostate and surrounding anatomy for both radiation oncologist and surgeon to assist in high-quality treatment planning. In this series of patients, most were found to have more advanced disease on MRI than what DRE implied. Bilateral gland involvement, ECE, and SVI were identified on MRI more often than DRE detected rates of T2c, T3a, and T3b disease. This is consistent with published reports, such as that by Fuchsjager et al,12 who evaluated 224 patients who underwent an endorectal MRI before EBRT for PC. On MRI, bilateral gland involvement, ECE, and SVI were identified in 24.6%, 40.2%, and 7.1%, respectively, compared to 0%, 7.6%, and 5.4% with DRE-based T2c, T3a, and T3b disease, respectively. Numerous studies have demonstrated a correlation between these MRI findings and biochemical failure after RP or EBRT.10,12,13 A study of 977 men demonstrated that PSA failure was predicted by preoperative PSA, MRI T-stage, percentage of positive prostate biopsies, Gleason score, and 1992 AJCC clinical stage in men undergoing RP.10 Riaz et al13 reported on 279 men with intermediate-high risk PC who underwent an endorectal MRI prior to combination EBRT and brachytherapy. ECE on MRI and Gleason score were the only independent predictors of recurrence. Fuchsjager et al found that pretreatment PSA and ECE on MRI were significant predictors of PSA relapse.12 ECE and SVI on MRI predict for poor outcome, and it is therefore appropriate that these features should be considered when treatment recommendations are made.

Use of pelvic MRI for identifying LN involvement is more controversial than the role of MRI in diagnosing locally advanced disease. A meta-analysis of series evaluating the diagnostic accuracy of MRI in diagnosing LN metastases revealed that the sensitivity and specificity of MRI were 0.39 and 0.83, respectively, compared to 0.42 and 0.82, respectively, for CT imaging.

 MRI is limited in detecting LN metastases because the imaging criteria in routine practice depend on a size threshold of ≥10 mm in short axis for elongated nodes or ≥8 mm in short axis for rounded nodes suggesting malignancy. Nodes with malignant deposits often measure less than these thresholds, accounting for the low sensitivity of conventional MRI in malignant LN detection.

While many studies have analyzed the prognostic significance of the high-risk features detected on MRI, it is more challenging to understand how frequently and significantly this information changes treatment recommendations. In our series of 86 patients with newly diagnosed PC, MRI findings had an impact on treatment decision making in six (8.8%) definitively treated patients. Usually, this resulted in an escalation of therapy to address a higher clinical T-stage than what was previously thought. Whether or not this results in a change in outcome remains to be seen. At best, the practice of changing the treatment recommendation based on the imaging findings may lead to more cures; at worst, these men may suffer additional treatment-related morbidity and cost with no therapeutic gain. Improvements in diagnostic imaging techniques will lead to improved resolution of tumor burden on MRI than can be appreciated on most physical examinations. Hence, it is possible that the “Will Roger’s phenomenon,” which describes the apparent improvement in average outcomes in two cohorts when moving elements of one into another, will be seen by incorporating the high-resolution information that MRI affords. That is, if patients previously thought to be low-risk were now reclassified into the highrisk category with DRE occult disease, both the low- and high-risk groups may demonstrate improved outcome over historical controls. A similar phenomenon was noted when Gleason pattern interpretation shifted over time.

 Therefore, the outcomes of patients diagnosed and treated using MRI information cannot be readily compared to historic controls. One barrier to incorporating MRI findings with clinical stage is the current challenge in diagnosing ECE on MRI. A change in stage from T1/T2 to T3 disease can lead to an increase in RT field size (prostate/SVs vs pelvic field), a change in duration of ADT (none vs months to years), and omission of alternative treatment options such as brachytherapy monotherapy or AS. The detection and interpretation of ECE can be challenging. The diagnostic criteria for ECE include concrete findings such as periprosatic fat infiltration with or without direct extension into the neurovascular bundle, and softer features, including areas of capsular bulging, obliteration of the rectoprostatic angle, and capsular contact of tumor extending ≥10 mm.5,17 A recent study of 151 patients in Korea,

which compared local staging and detection of ECE at 3.0 T with and without endorectal coils, found a sensitivity of 33.3% versus 31.3%, specificity of 96.6% versus 97.5%, and accuracy of 63.% versus 61.4%, respectively. In no case was the difference statistically significant. The high specificity argues that the prostate MRI protocol is very accurate for detecting disease when it is present, which may account for the change in management decisions that is attributed to the MRI. Recent studies have demonstrated that sensitivity of MRI in local staging improves in poorly differentiated PC.

 This again suggests that the MRI is useful in detecting patients who are at risk of clinical understaging, without increasing the likelihood of overtreatment.

Contrary to patients with newly diagnosed PC, in our limited series of patients evaluated for adjuvant or salvage RT, MRI did not add clinical information that altered our treatment approach. There were no cases of LN involvement or DM, no marginal local recurrences, and the instances of retained SVs seen would have likely been detected on planning CT simulation. In a recent publication by Liauw, endorectal MRI identified a radiographic local recurrence in 21 of 88 (24%) men with clinically undetectable, post-RP biochemical recurrence with a mean pretreatment PSA of 0.30 ng/mL.

Retained SVs were identified in 14% and LN involvement in 5%. Other institutions have demonstrated that MRI allows for detection of locally recurrent disease in most cases. In a series by Sella et al,

 soft tissue local recurrences as identified on MRI were considered confirmed if a positive biopsy was obtained and if the PSA decreased after RT or if the mass progressed on follow-up imaging. However, in the Sella et al series, the indication for MR imaging was not given, and it is possible that imaging was obtained to confirm the presence of a mass or nodule identified on physical examination. In addition, the authors did not state if a retained SV in the setting of an elevated PSA was considered a local recurrence. The discrepancy between these series and ours could lie in the study methodology. In the work published by Sella et al and Liauw et al, MRI images were retrospectively reviewed for study purposes. This has the potential to bias the reading radiologists and lead to a greater documentation of locally recurrent disease. In our study, MRI results were obtained retrospectively from the initial radiologist’s diagnostic report, and therefore the local recurrence detection rate more accurately represents average rates in practice. Limitations of this study include its retrospective nature. Identification of high-risk features on MRI could lead to delivery of more aggressive treatment, yet this may not have been explicitly stated in the dictated notes. In this case, we may be underestimating the effect of MRI on treatment decision making. Change in treatment recommendations based on MRI findings is a subjective measure; however, it is important to recognize the possible impact of MRI on cancer staging and consider how this may affect treatment outcomes. Use of MRI to detect PC in the definitive and salvage settings is significantly different, and each of these topics warrants review. Additionally, the clinical routine prostate MRI protocol at our institution is performed at 3.0 T without an endorectal coil. The literature has been inconclusive as to whether 1.5 T imaging with an endorectal coil is clearly superior to 3.0 T without an endorectal coil when a multiparametric approach is used.

This study demonstrates how advanced imaging in PC detection can influence treatment planning and delivery. In most cases, when treatment recommendations were modified based on MRI findings, therapy was escalated to correspond with clinical upstaging. It remains to be seen if this translates into improved disease control. It is possible that the “Will Rogers phenomenon” will result from incorporating the high-resolution MRI information into clinical decision making.

University of Utah, Department of Radiation Oncology, (JT, BT, KK, DS) University of Utah, Department of Radiology (MH) University of Utah, Department of Surgery, Division of Urology (WL) Address correspondence to: Jonathan Tward, University of Utah, Department of Radiation Oncology, 1950 Circle of Hope, Room 1570, Salt Lake City, UT 84112. Tel: 801-581-2396 Fax: 801-585-2666 Email: jonathan.tward@hci.utah.edu

Address correspondence to: Jonathan Tward, University of Utah, Department of Radiation Oncology, 1950 Circle of Hope, Room 1570, Salt Lake City, UT 84112. Tel: 801-581-2396 Fax: 801-585-2666 Email: jonathan.tward@hci.utah.edu

Conflicts of Interest: Jonathan D. Tward consulted for Myriad Genetics, provided expert testimony for Garlington, Lohn & Robinson, and received an HCI Directors translational research initiative grant. Dennis C. Shrieve provided expert testimony for a law firm and receives book royalties from Lippincott. Marta E. Heilbrun has a grant from RSNA/ NIBIB and receives book royalties from Amirsys publishing. For the remaining authors, no conflicts of interest were declared.

			Mohler JL, Armstrong AJ, Bahnson RR, et al. Prostate Cancer, Version 1.2016. 

			Thompson IM, Ankerst DP, Chi C, et al. Operating characteristics of prostate- specific antigen in men with an initial PSA level of 3.0 ng/ml or lower. 

			Schroder FH, van der Maas P, Beemsterboer P, et al. Evaluation of the digital rectal examination as a screening test for prostate cancer. Rotterdam section of the European Randomized Study of Screening for Prostate Cancer. 

			Obek C, Louis P, Civantos F, Soloway MS. Comparison of digital rectal examination and biopsy results with the radical prostatectomy specimen.

 1999;161(2):494-498; discussion 498-499.

			Turkbey B, Albert PS, Kurdziel K, Choyke PL. Imaging localized prostate cancer: current approaches and new developments. 

 2009;192(6):1471-1480. doi: 10.2214/AJR.09.2527.

			Renard-Penna R, Roupret M, Comperat E, et al. Accuracy of high resolution (1.5 tesla) pelvic phased array magnetic resonance imaging (MRI) in staging prostate cancer in candidates for radical prostatectomy: results from a prospective study.

. 2013;31(4):448-454. doi: 10.1016/j.urolonc. 2011.02.017.

			Puech P, Potiron E, Lemaitre L, et al. Dynamic contrast-enhanced-magnetic resonance imaging evaluation of intraprostatic prostate cancer: correlation with radical prostatectomy specimens. 

. 2009;74(5):1094-1099. doi: 10.1016/j.urology.2009.04.102.

			Schoots IG, Petrides N, Giganti F, et al. Magnetic resonance imaging in active surveillance of prostate cancer: a systematic review. 

 2015;67(4):627- 636. doi: 10.1016/j.eururo.2014.10.050.

			Guzzo TJ, Resnick MJ, Canter DJ, et al. Endorectal T2-weighted MRI does not differentiate between favorable and adverse pathologic features in men with prostate cancer who would qualify for active surveillance. 

 2012;30(3):301-305. doi: 10.1016/j.urolonc.2010.08.023.

			D’Amico AV, Whittington R, Malkowicz SB, et al. Combination of the preoperative PSA level, biopsy gleason score, percentage of positive biopsies, and MRI T-stage to predict early PSA failure in men with clinically localized prostate cancer. 

			Joseph T, McKenna DA, Westphalen AC, et al. Pretreatment endorectal magnetic resonance imaging and magnetic resonance spectroscopic imaging features of prostate cancer as predictors of response to external beam radiotherapy. 

 2009;73(3):665-671. doi: 10.1016/j. ijrobp.2008.04.056.

			Fuchsjager MH, Pucar D, Zelefsky MJ, et al. Predicting post-external beam radiation therapy PSA relapse of prostate cancer using pretreatment MRI. I

. 2010;78(3):743-750. doi: 10.1016/j. ijrobp.2009.08.040.

			Riaz N, Afaq A, Akin O, et al. Pretreatment endorectal coil magnetic resonance imaging findings predict biochemical tumor control in prostate cancer patients treated with combination brachytherapy and external-beam radiotherapy. 

. 2012;84(3):707-711. doi: 10.1016/j. ijrobp.2012.01.009.

			McKenna DA, Coakley FV, Westphalen AC, et al. Prostate cancer: role of pretreatment MR in predicting outcome after external-beam radiation therapy-- initial experience. Radiology. 2008;247(1):141-146. doi: 10.1148/radiol. 2471061982.

			Hovels AM, Heesakkers RA, Adang EM, et al. The diagnostic accuracy of CT and MRI in the staging of pelvic lymph nodes in patients with prostate cancer: a meta-analysis. 

 2008;63(4):387-395. doi: 10.1016/j. crad.2007.05.022.

			Harisinghani MG, Barentsz J, Hahn PF, et al. Noninvasive detection of clinically occult lymph-node metastases in prostate cancer. N Engl J Med. 2003;348(25):2491-2499.

			Albertsen PC, Hanley JA, Barrows GH, et al. Prostate cancer and the Will Rogers phenomenon. 

			Kim BS, Kim T-H, Kwon TG, Yoo ES. Comparison of pelvic phased-array versus endorectal coil magnetic resonance imaging at 3 Tesla for local staging of prostate cancer. 

. 2012;53(3):550-556. doi: 10.3349/ ymj.2012.53.3.550.

			Vargas HA, Akin O, Shukla-Dave A, et al. Performance characteristics of MR imaging in the evaluation of clinically low-risk prostate cancer: a prospective study. 

. 2012;265(2):478-487. doi: 10.1148/radiol.12120041.

			Liauw SL, Pitroda SP, Eggener SE, et al. Evaluation of the prostate bed for local recurrence after radical prostatectomy using endorectal magnetic resonance imaging. 

. 2013;85(2):378-384. doi: 10.1016/j. ijrobp.2012.05.015.

			Sella T, Schwartz LH, Swindle PW, et al. Suspected local recurrence after radical prostatectomy: endorectal coil MR imaging. 

			Barentsz JO, Richenberg J, Clements R, et al. ESUR prostate MR guidelines 2012.

 2012;22(4):746-757. doi: 10.1007/s00330-011-2377-y.

Researchers evaluate the role of magnetic resonance imaging in the clinical staging of prostate cancer in the definitive and salvage settings, and to identify changes in treatment recommendations.

The Effect of Prostate MRI on Cancer Staging and Radiotherapy Treatment Recommendations

There’s a place for Vice President Joe Biden to stay in North Carolina if he would like to come and witness some of the problems the National Cancer Moonshot is going to encounter before its lofty goal of doubling the pace of clinical discovery is achieved. John Powderly, MD, of the Carolina BioOncology Institute, would welcome Biden to stay in his second floor guest bedroom, if only for the chance to show him how tough it is to get coverage for clinical trial patients.

“Joe Biden can come see how, on a daily basis, insurance companies deny patients routine care, how much the federal regulations have made it impossible to do day-to-day routine patient care, and how much money I have lost and the debt I have incurred in fighting insurance companies to just do the right thing,” Powderly said.

Powderly’s clinic specializes in early phase trials for immunotherapy and personalized medicine. He says a number of well-intentioned government actions designed to guarantee coverage of routine costs of care associated with trial participation have been compromised by concessions to the payer industry, Powderly said.

Physicians who have been active in clinical trials programs were divided in their opinions of how well the Moonshot initiative would succeed, and whether it would benefit independent oncology practices. Powderly and Luke Nordquist, MD, of the Urology Cancer Center and GU Research Network in Omaha, said that private industry-sponsored research is likely to be the more successful source of innovation in cancer research and treatment. Industry payments amply cover trial costs—to the point of supporting other practice activities&mdash;and process efficiency is far greater than can be achieved through government supported research efforts, such as are carried out through the Cooperative Group System, they said.

On the other hand, Stephen Grubbs, MD, a longtime practicing oncologist and clinical trials researcher who participated in talks with Biden and his White House staff on developing the Moonshot, said that curing cancer is a major bipartisan goal and Biden’s involvement could unlock government-led discovery and result in many exciting advances. “This family tragedy of losing his son has really motivated him to do the right thing and advance where we are with cancer,” said Grubbs, who also serves as vice president of Clinical Affairs for ASCO.

“I think he’s sincere about this. As an oncologist, what I heard from him that I found encouraging, was that he wants to move research and advances at a faster pace and get more done quickly. He’s also looking at how we can improve cancer care delivery—how do we get the discoveries into the hands of physicians who are taking care of patients all over the US, even in remote areas. Those are the two take-home messages from him that I thought were very important.” He added that the Moonshot could be a turning point signifying increasing government funding for research.

Under the Moonshot, public and private partnerships will be developed to streamline research and the government’s vast computing and medical resources could be tapped to give a solid boost to compiling and understanding the large volumes of medical data already collected and still accumulating, much of which may contain clues to meaningful advances in cancer treatment, such as ASCO hopes to achieve through its CancerLinQ initiative, Grubbs said. “We think there are abilities to partner with the Departments of Defense and Veteran’s Affairs. We’re hoping there’s more help with electronic health records and interoperability,” he said.

Powderly contends that the $755 million in funds promised for the Moonshot in the FY2017 budget will not achieve much. He expects very little of this money, if any, to trickle down to the independent oncology practice level. Government compensation for trial participation was scant to begin with, he said.

Nordquist also is doubtful about the impact the money will have. He expressed the view that government spending is often diluted by the siloed character of research institutions and the tendency for grant money to serve institutional goals, rather than pure research interests. “These grants usually provide academic careers for people, because they’ll apply for a grant, and that funding solidifies their job at the university, and then they have to support their staff and their lab techs, etc. That’s a very necessary form of investigation, but it’s a very slow process for doing cancer research because everybody’s working in their siloes. Very rarely do they work in some sort of network where people are learning from what the others are doing. It’s more, how do we keep funding these people’s careers through that money?” he said.

Many independent oncologists would like to participate in publicly funded trials, but the financial support is too slim, Nordquist said. Affected by declining compensation for IV chemotherapy and other activities, investigative practices like Nordquist’s would be in peril without the financial support that comes from privately funded research, he said. In addition, doing clinical trials requires a large staff, which Nordquist said is another reason why adequate funding is vital.

“The cooperative group studies are a dying thing because they keep cutting the funding for it,” he said. “You don’t make any revenue on that as an independent practitioner. In fact you kind of do it altruistically, because you have to supply all of the time, effort, and resources to do those studies. It’s important research; and that’s mainly why it’s done in academic centers, because they have all the extra staff.”

Accepting private money doesn’t come with the stigma that it used to, and new opportunities have arisen that now represent lifeblood for independent oncology centers, Nordquist said. “Private industry only used to want to do work with academic centers. Now I get several calls a week to open studies. In the past that was looked down upon as kind of getting into bed with pharma, but more and more—even large academic centers&mdash;are seeing the importance of this. Memorial Sloan Kettering has even developed its own research LLC, basically as a way of doing more efficient cancer research.”

Nordquist is involved in developing networks of practices of various sizes that can supply the large patient base and resources necessary to make privately funded trials a success. Comprehensive private funding is not just supporting research centers like his, he said. “Last year alone, we saved over $3 million dollars for Medicare and insurance companies just by the studies that we did here. So, it’s really a win for the patient getting a free drug; and it’s a win for society where the drugs are now being paid for by the drug companies; and it’s a win for me, because, 1) I can say that I have these studies that others may not have and, 2) they’re paying me, and that’s helped offset the loss in revenue from cuts in IV therapy.”

Powderly’s experience has been similar: “The only way that I am able to survive is because we are 90% supported by clinical research from biopharmaceutical companies. What really pays for my accrual and my overhead and the research, is investors.”

Additionally, Powderly and Nordquist said delays and administrative burdens connected with public trials amount to disincentives for community oncologists to participate in federal trials. “Even the Medicare compliance is so overwhelming that clinicians would give up before they would participate in a clinical trial,” Powderly said. “In fact, there’s data now that less than 3% of physicians are principal investigators on trials.” That’s a shame, he said, because it used to be a matter of pride for community oncology practices to participate in federal trials.

In addition, the predominantly older drugs examined in federally sponsored research represent a problem for the oncologist whose patients are demanding newer drugs because of their growing awareness of the strength of personalized medicine, Powderly added. “The current model is cooperative groups. They don’t develop and invent new drugs, they just look at combinations of old drugs, and there is an important role for that, but the pipeline of new drugs that industry is developing is gi-normous, and there’s no good infrastructure to get all of those new drugs to the community practices efficiently.”

Grubbs said that ASCO and the White House are aligned in their desire to solve that problem. “We are working on trying to get clinical trial availability to as many physicians as possible for all of the targeted molecules that are coming out, that need to be tried in all of these new genomic variations that we see in cancer, so that you don’t have to go to any single cancer center and there’s a limit [on enrollment]; so I think that’s another area where there’s going to be some important help in that,” he said.

To pick up the pace of cancer innovation, Powderly said, the White House should plug the coverage holes that make it difficult to enroll patients and that threaten to send more clinical trials work overseas. During his time in office, former President Clinton ordered Medicare to cover routine costs of care for trial patients, but the rise of Medicare Advantage plans in which payers manage Medicare payments has undermined the scope of that directive. “How sad is that?” Powderly asked.

In 2001, North Carolina joined with more than 20 other states in passing laws requiring coverage of routine costs; however, payers have declined to place trial-active physicians in-network. “Joe Biden would not be covered by his insurer for a trial at our clinic today if he had cancer, because his insurance company has declared me off-network for the sole reason that I participate in clinical trials,” Powderly said.

And an amendment to the Affordable Care Act, was meant to guarantee payment for routine costs of care starting in 2014, but that was diluted by a grandfather clause that exempted preexisting plans, Powderly noted.

Such things give him and Nordquist cause to think that the Moonshot may be more of a Fourth-of-July rocket than a trip to the moon. Grubbs said he is inspired to believe that the Moonshot can succeed, based on the sincerity he has detected in the vice president’s message and based on what the Delaware doctor believes is a plan with true substance.

“To have successful advances in cancer, it requires government and private funding. There are trials that need to be done that will never be done in the private sector—quality of care trials, surgical trials, and things like that, and that’s the importance of public funding. New drugs, new pharmaceuticals&mdash;certainly, the private side can build those trials themselves; but you really need a combination of both of those to make the advances go forward, so I think more money in the public sector will push along the type of trials that need to be funded in the public arena,” he said.

Physicians who have been active in clinical trials programs were divided in their opinions of how well the Moonshot initiative would succeed, and whether it would benefit independent oncology practices. 

Community Practices Say Moonshot May Sputter

Obtaining quality cancer care in Alaska is often difficult and expensive owing to the sparse highway network and the scattered nature of the state’s population of 736,000 people, who are spread out over more than a half-million square miles. For oncology practices, the use of local primary care providers to aid oncologists and recent advances in telemedicine have helped to overcome these barriers and increase the availability of cost-effective, evidence-based medicine.

For radiation and chemotherapy treatment spanning several weeks to months, patients may have to travel to one of the major population centers, such as Anchorage or Juneau, and live out of a hotel room throughout that time. Coupled with the medical expenses and the long-term leave from their job, the extended hotel stay puts an economic and emotional toll on patients and their families.

“Patients are in an unfamiliar environment and are going through one of the most difficult times of their lives,” said Eugene Huang, MD, medical director of the Southeast Radiation Oncology Center in Juneau. “The logistics are quite humbling.” Twenty-three of Alaska’s 27 boroughs and census areas are medically underserved areas/populations or governor-designated medically underserved populations, and they account for about 59 percent of the state’s residents.

In addition, about 75 percent of communities in the state do not have road access to a community with a major hospital, meaning that many people need to travel by airplane, boat, or ferry to get treatment. Huang stated that some women with breast cancer will choose to undergo a mastectomy because it is less time-consuming and expensive than traveling to an urban center for radiation therapy, even if a less-invasive option is more appropriate.

Most medical and radiation oncologists are located in Anchorage, according to Matthew Olnes, MD, medical director of Hematology and Medical Oncology at Alaska Native Medical Center (ANMC), which treats a majority of the state’s far-flung native population, members of whom travel via complicated routes to reach centers of care. “A very typical pathway for them is to take a snow machine to get to the closest village that has an airstrip, then get on a propeller plane and fly to the largest regional city that has a jet, then get on the jet to fly to Anchorage,” said Olnes. “It’s literally a 12-hour trip for them, and they’re doing it every couple weeks for long-term treatment. It really wears them down.”

For the handful of independent oncology practices in Alaska, the patient base is more urban-suburban; however, a large proportion of those patients still must travel for treatment, making accommodations and rapid, well-coordinated care a priority for oncologists and other healthcare specialists who are a part of the effort.

Juneau is the third largest city in Alaska, with an estimated 32,406 residents in 2014;

 yet there is no road access from Juneau to the rest of the state. Before Huang opened his clinic in 2013, the closest radiation center was in Anchorage and required travel by plane or ferry. His $7 million center is located near the Bartlett Regional Hospital, which has an infusion center for patients undergoing chemotherapy.

 “Before we came to Juneau, patients would often omit doing their treatment because, logistically, it was too hard to travel or afford,” said Huang.

Because most of Alaska’s oncologists are in Anchorage and Fairbanks, primary care providers often perform tasks that, outside of Alaska, are typically done by oncologists. Larry Daugherty, MD, director of Radiation Oncology at the Alaska Cancer Treatment Center in Anchorage, described a situation in which a local primary care provider was tasked with administering prostate-specific antigen tests after radiation treatment for one of Daugherty’s patients who lived in Valdez (a town approximately 300 miles east of Anchorage).

Medical oncologists based in larger cities, such as Anchorage or Seattle, in Washington, also travel to small Alaskan communities once or twice per month and prescribe chemotherapy, which internists or trained nurses administer under an oncologist’s supervision. Between chemotherapy treatments, the primary care providers also manage side effects, such as chemotherapy-induced nausea, and monitor blood counts. “Primary care physicians are excellent up here,” said Huang. “They don’t always have specialists on hand, so their scope of practice is much broader than it might be in the lower 48 states.”

For patients who live far from his Juneau location, Huang regularly relies on primary care doctors and nurse practitioners to provide follow-up care after his patients have completed radiation treatment. He also speaks with patients by phone to ensure that they know how to care for themselves after radiation treatment. “It is my responsibility that when a patient is done with their treatment here, that they have all the necessary education and follow-up care,” said Huang.

	Telemedicine for Follow-Up Care and Multidisciplinary Conferences

Oncology specialists in Alaska have a more diverse scope of practice than those in the lower 48. Whereas Daugherty’s previous experience as a radiation oncologist at the Mayo Clinic in Rochester, Minnesota, focused on gastrointestinal cancers, in Anchorage his practice has expanded to include any type of cancer. “In Alaska, I’ve gone back to ‘bread-and-butter’ oncology,” said Daugherty. “I see and treat the whole spectrum of cancers that need radiation.” Daugherty also tends to see a greater proportion of late-stage cancers in his Anchorage practice than he did at his previous practice at the Mayo Clinic, possibly due to patients in Alaska having less access to regular healthcare services and cancer screenings, he said.

Although Olnes and Daugherty stated that staffing is adequate in their respective Anchorage-based locations, adequate healthcare staffing is problematic for many rural areas. Olnes stated that the six regional hospitals in the state have high turnover and staff shortages largely due to difficulty recruiting qualified individuals to work in these remote locations. If the only nurse trained to administer chemotherapy leaves and the hospital cannot find a replacement, the infusion center is forced to shut down and patients are forced to travel elsewhere for treatment. The Alaska Health Workforce Coalition published a Healthcare Workforce Plan in 2010 in a statewide effort to improve recruitment and retention of healthcare staff in rural areas.

 According to the Alaska Physician Supply Task Force, the need to care for an increasingly older population means that maintaining a sufficient workforce and providing adequate services, such as cancer screening, is a priority.

 The population of Alaska is aging rapidly, with a 54% increase in the number of people older than 65 years from 2000 to 2010.

The Alaska Federal Health Care Access Network (AFHCAN) was developed in 1998 to improve access to specialized healthcare in rural Alaska using telehealth technologies.

 Data from 2013 show that AFHCAN connects approximately 180 Alaska Native community village clinics, 25 subregional clinics, 4 multiphysician health centers, 6 regional hospitals, and the ANMC in Anchorage, primarily for primary care-related concerns in the native population.

Oncologists at ANMC began incorporating video teleconferencing in 2012 to provide supportive care for former patients who have run out of treatment options or choose not to continue with treatment. Currently, patients who are receiving active treatment may use video conferencing in place of interim visits that do not require extensive physical examination. Olnes also indicated that some patients with prostate cancer have relied on telemedicine if they can be treated with hormonal therapies that are available in their community. Overall, telemedicine is important for reducing costs for patient and their health insurers and reduces stress on the patients and their families by saving them from unnecessary travel. “The biggest priority has been patient satisfaction, because they appreciate not having to come into Anchorage,” said Olnes.

However, Olnes stated that many patients who use telemedicine for follow-up appointments miss the one-on-one interaction with the physician, nurses, and office staff. Olnes stated that after a private video conference with a patient he often invites nurses and other staff members to exchange pleasantries with the patient via the teleconferencing system. “Patients get to know the nurses and support staff [during their treatment period in Anchorage] and they miss that experience,” said Olnes. “We also give them the option to come into the office in person.”

	Future Goals for Cancer Care in Alaska: A Patient-Centered Approach

Video teleconferencing also benefits remote-based primary care providers who manage patients with cancer. Olnes stated that physicians and providers from multiple cancer care centers in Anchorage conduct weekly multidisciplinary conferences to view and discuss cases and develop an evidence-based treatment plan for patients. Primary care providers in rural areas can join the conference from a remote computer to see their patients’ tests, hear the discussion, and ask questions.

Overall, unique geographical features and lack of road access to health care in Alaska have required increased reliance on primary care providers and greater use of telemedicine in rural areas to maintain adequate quality of care for patients with cancer. According to Daugherty, a key goal for providers in Alaska in the near future includes ensuring availability of modern treatments to all individuals in need and simplifying the process of obtaining cancer treatment. Huang opened his clinic to meet the demand for radiation oncology in Juneau and the surrounding areas, thereby easing patient travel burdens and allowing them to work and stay near their family and friends.

Daugherty stated that the comprehensive approach to the Alaska Cancer Treatment Center, which includes a medical oncologist, radiation oncologist, surgeons, primary care providers, a nutritionist, and a naturopathic oncologist, also helps to overcome barriers by enabling patients to complete all visits in one or two days. He also stated that the incorporation of traditional and alternative medicine has had an unexpected benefit in improving patients’ openness to receiving treatment. “Many patients in Alaska are interested in holistic and alternative approaches, said Daugherty. “To have a naturopathic oncologist on staff who can help mingle that with traditional medicine helps patients understand that natural approaches may be helpful as an adjunct but that they can’t be cured with herbal remedies alone.” According to Daugherty, the Alaska Cancer Treatment Center has a multispecialty cancer treatment team much like the larger, more renowned Mayo Clinic, and he stated that patients do not have to go to the lower 48 states to get high-quality cancer care.

Overall, working in Alaska has been fulfilling for both Huang and Daugherty because they feel that their work has a direct effect on patients and their community. “I get the warmest, sincerest thanks from our patients,” said Huang. “[Working in Juneau] was a great chance to work as I might have imagined in medical school—by having a visible impact on a community.”

			United States Census Bureau State & County QuickFacts. Alaska. www.census.gov/quickfacts/table/PST045215/00,02. Accessed February 14, 2016.

			University of Alaska Anchorage. About Alaska. Updated October 26, 2011. www.uaa.alaska.edu/acrh-ahec/frontier/alaska.cfm. Accessed February 14, 2016.

			US Census Bureau: QuickFacts Juneau City and Borough. www.census.gov/quickfacts/table/PST045215/00,0236400. Accessed February 15, 2016.

			Cancer treatment center opens doors [news release]. Juneau Empire. Published December 13, 2013. juneauempire.com/local/2013-12-13/cancer-treatment-center-opens-doors%23.UvO9BZ3naM8#.Uv0iDkJdW88. Accessed February 15, 2016.

			Alaska Health Care Workforce Coalition. Healthcare workforce plan 2010. www.uaa.alaska.edu/hpd/upload/Healthcare_Workforce_Plan.pdf. Accessed February 14, 2016.

			Alaska Physician Supply Task Force. Securing an adequate number of physicians for Alaska’s needs. Published August 2006. www.alaska.edu/health/downloads/PSTFweb.pdf. Accessed February 15, 2016.

			US Census Bureau. 2010 Census shows 65 and older population growing faster than total US population [press release]. Published November 30, 2011. www.census.gov/newsroom/releases/archives/2010_census/cb11-cn192.html. Accessed February 15, 2016.

			Agency for Healthcare Research and Quality. Telehealth improves access and quality of care for Alaska natives. AHRQ Innovations Exchange. Published May 22, 2013. innovations.ahrq.gov/perspectives/telehealth-improves-access-and-quality-care-alaska-natives. Accessed February 14, 2016.

			AFHCAN Telehealth Solutions. About us. www.afhcan.org/about.aspx. Accessed February 14, 2016.

Obtaining quality cancer care in Alaska is often difficult and expensive
owing to the sparse highway network and the scattered nature of the
stateâ€™s population of 736,000 people, who are spread out over more than
a half-million square miles.

March 2016 | Oncology Business News®

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March 2016 | Oncology Business News®

Top 3 Must Do's to Prepare for Managed Care in 2016

"Press '1' to Speak to Your Next Patient"

Hawaiian Oncologists Surf Lower Pay, Fewer Resources

The Effect of Prostate MRI on Cancer Staging and Radiotherapy Treatment Recommendations

Community Practices Say Moonshot May Sputter

Alaskan Oncology Practices Operate by Remote

"Press '1' to Speak to Your Next Patient"