A proof-of-principle prototype for CancerLinQ™ was demonstrated at the 2013 ASCO Annual Meeting. This “learning health system” prototype was first unveiled on March 27 at an ASCO-hosted panel discussion on big data in cancer care at the National Press Club in Washington, DC. At the ASCO Annual Meeting, attendees were able to view a demonstration of the CancerLinQ prototype in the exhibit hall as well as attend an educational session on the product, which ASCO calls the first demonstration of the feasibility of a health information technology-based learning health system. When the full build of CancerLinQ is available, it is expected to collect and analyze cancer care data from millions of patient visits and, using expert guidelines and other information, generate “real-time, personalized guidance and quality feedback for physicians.” Motivation for CancerLinQ was provided in part by an Institute of Medicine report that defined learning health systems as critical to the future of the nation’s healthcare system, and oncology as wellsuited for rapid health learning system development.

ASCO President Sandra M. Swain, MD, said, “We are motivated by the stunning fact that 97% of today’s cancer care does nothing to advance our collective knowledge of the disease or its treatment because only 3% of adult cancer patients participate in clinical trials. The learning health system is intended to bridge this gap.” Swain pointed out that the information on that 97% of patients not participating in trials is in paper files and electronic records that currently don’t talk to each other well, if at all. “CancerLinQ will transform cancer care by unlocking that wealth of information and enabling every patient to be a cancer knowledge donor,” she says. The CancerLinQ prototype shows that such a learning health system is feasible and is providing lessons about the challenges of building a full-scale system. The full-scale system is planned to have the core functions of real-time data collection, clinical decision support, data mining and visualization, and quality feedback.

The prototype was built in about 5 months using de-identified (anonymous) data from over 150,000 patients with breast cancer that was supplied by 26 practices in the US. The demonstration at ASCO included data from 100,809 patients that were available at the time the demonstration was prepared. Building the prototype required the collaboration of the oncology and information technology (IT) communities and included efforts to improve data standards in oncology, which is described below. Technology and legal analyses are also part of the development effort.

Since the first demonstration in March, three working groups were established to help take the lessons learned from the prototype and implement them in the development of the full system; these groups are working on clinical decision support, data quality, data governance, and natural language processing governance. Clifford A. Hudis, MD, president-elect of ASCO compared the prototype demonstration he gave at a press briefing to the Wright brothers’ first flight—although they demonstrated that man could fly, no one bought a ticket from them. Likewise, the prototype of CancerLinQ is not necessarily the exact shape and form of the final product. However, the prototype, which uses several open-source IT applications and at least one proprietary application, has demonstrated that the core functions of the health learning system are feasible. These core functions include the following:

		Real-time data collection of any type of data related to cancer care in any format, including laboratory test results and handwritten notes. The prototype didn’t use all types of data, but the full system will learn over time what different types of data mean.

		Clinical decision support that provides guidance on the care of a patient; in the prototype, guidance for a patient with breast cancer is linked to the ASCO Breast Care Guidelines; in the full version of CancerLinQ, treatment experiences for other similar patients will be accessible.

		Data mining and visualization in the prototype allowed queries of a database on patients with breast cancer; this could be used to identify trends and associations.

		Quality feedback would be immediate in real-time, comparing the physician user’s performance with that of 10 Quality Oncology Practice Initiative (QOPI) measures.

Ultimately, Hudis said, CancerLinQ will be able to establish correlations that could inform care and establish hypotheses for prospective clinical research. Physicians set up the system once, and every time an electronic health record (EHR) is used, each patient automatically becomes a data donor. The data set could confirm one study and eliminate the need for additional studies, and also help avoid doing some studies that might be fruitless. Robert Hauser, Pharm D, PhD, senior director of Quality at ASCO, emphasized that CancerLinQ will not replace clinical trials, but will be hypothesis generating.

Although CancerLinQ is designed to be “data agnostic,” and will not have to wait for new data standards for implementation, ASCO has been developing interoperability standards for cancer care data to improve data sharing among healthcare providers, researchers, and patients. The first standard, the 

Breast Cancer Treatment Plan and Summary Standard and Implementation Guide

, was announced at the 2013 Annual Meeting. The draft breast cancer standard was approved by open ballot through Health Level Seven International (HL7), an accredited Standards Developing Organization, and should be ready for implementation later this year. The major elements include diagnosis, patient health and comorbidity, surgical history and pathology, goals of therapy, chemotherapy regimen and dosage, duration of treatment and number of cycles, and major chemotherapy side effects.

There are many issues that remain to be resolved. Currently, CancerLinQ uses ASCO quality measures determined from ASCO Clinical Practice Guidelines, and although these guidelines do not cover the entire oncology territory, Josh Mann, associate director, Oncology Technology Solutions, Quality and Guidelines, ASCO, noted that there are no arrangements with other content providers at this time. The full CancerLinQ system will have to deidentify data, but when full genomic sequencing becomes available, theoretically it could be used to identify patients. Hudis expected that by the time the full system is up and running, this problem will have been solved. Hauser noted that those data used to measure quality already fall under HIPAA and can be part of the system. A state-by-state legal analysis is in progress, and some state laws regarding healthcare data disagree with federal regulations, so CancerLinQ likely may roll out targeting some states first where the legal situation is clearest. ASCO is also looking at international data laws and how cancer is managed worldwide.

Who will have access to CancerLinQ also remains a question. Mann said that the current thinking is that CancerLinQ will be free to ASCO members. Because EHRs and CancerLinQ will be implemented at the practice level, if one provider in a group practice is a member of ASCO but the other members aren’t, it isn’t clear how this will be managed. Physicians will be able to log in and access their own data for their own practice’s purposes. Other access is likely to be restricted. CancerLinQ developers are still defining data governance, and will have an as-yet-to-be-defined process in place to review data access requests. This may involve a panel of experts like that used to review a grant proposal. Researchers would have to apply to ASCO; ASCO could either do its study for them or give them access to data. Pharmaceutical companies would also have to prepare a research proposal for access to any data. Patients will have some tools available to them, (eg, to stay in touch with their healthcare team, report symptoms, and access treatment information).

Funding is also an issue. The prototype was funded by several million dollars from ASCO, primarily from the Conquer Cancer Foundation, and by donations from pharmaceutical companies, the Susan G. Komen Foundation, and private donors. Additional funding is needed to go forward, affecting how rapidly CancerLinQ develops.

Hauser said the CancerLinQ developers are hoping by 2014 to have something mainly geared at quality reporting that would use QOPI quality measures.Currently, practices in the US have access twice a year to compare their performance to these standards. QOPI is free to every ASCO member but requires manual chart extraction and manual entering into QOPI. The next goal for CancerLinQ is to have a version 1.0 live pilot within about 18 months that would encompass all tumor types and be available for a few dozen practices. Hauser expects that the version 1.0 CancerLinQ will be automatic in real-time, and generate reports as a QOPI “replacement” algorithm.

George W. Sledge, Jr, MD, Stanford University, who chaired the educational session on CancerLinQ, suggested the system might one day play a role in CME, automated recertification, exploring drug toxicity, and linking patients to clinical trials.

Mann said that over 400 demonstrations of the CancerLinQ prototype were given at the exhibit booth, and that at one point there was a line of 20 people waiting to see the demonstration. He said the reaction was extremely positive, and that the international practitioners seemed to be even more eager than those in the US to see the product developed. Mann hopes that the questions that come up in the next development phase will resolve rapidly. ASCO plans to publish its lessons learned—it has identified more than 60 so far&mdash;over the coming year, and will use them to inform its development of the full CancerLinQ system.

Articles

This "learning health system" prototype was first unveiled on March 27 at an ASCO-hosted panel discussion on big data in cancer care at the National Press Club in Washington, DC. 

CancerLinQ Proof-of-Principle Prototype

Traditionally, payers have been increasingly more proactive in their management of drug expenditures in cancers with the highest prevalence and with the more costly therapeutics—for example, nonsmall cell lung cancer (NSCLC), breast cancer, and colorectal cancer (CRC), according to Kantar Health’s survey of managed care directors. In a follow-up question to these payers, respondents cited the number of available treatment options as the top reason for targeting a specific cancer. This would account for the presence of kidney and prostate cancers on the list of targeted disease states since there has been an increase in the number of available treatments, where previously, few options had been available (Figure 1).

	Perhaps adding to this list of increased payer management to a disease state, where up to a few years ago limited treatment options were available, may be the emerging competition to the established standards of care in melanoma. As more treatment opportunities for metastatic melanoma become available, it increases opportunities for payers to manage utilization; it may also provide manufacturers with opportunities to define the value of their respective drugs through clinical and price differentiation.

	Melanoma has been a hot topic at the annual American Society of Clinical Oncology (ASCO) meetings since 2010, when the pivotal data for the novel immunotherapy Yervoy (ipilimumab; Bristol-Myers Squibb [BMS]), a CTLA-4 antibody, was presented, and subsequently, led to its FDA approval in 2011. This approval was followed shortly after with another FDA approval for metastatic melanoma in 2011: the BRAF inhibitor, Zelboraf (vemurafenib; Plexxikon/Genentech-Roche/Daiichi-Sankyo).

	Remarkably, only three days before this year’s ASCO meeting, GlaxoSmithKline (GSK) made headlines with the tandem FDA approval of its two drugs to treat metastatic melanoma: Tafinlar (dabrafenib), a BRAF inhibitor, and Mekinist (trametinib), a MEK inhibitor.

			Figure 1. Cancer Types Specifically Targeted for Utilization Management

Percentage of managed care organizations (n=16) with oncology as its highest utilization management programs.

: Kantar Health; Managed Care Organization Survey, August 2012. “Which of the following cancer types are specifically targeted for utilization management in your organization? Select all that apply.”

	Furthermore, this year’s ASCO meeting also presented further progress in the metastatic melanoma immunotherapy space with intriguing phase I data from a series of antibodies targeting PD-1. BMS presented phase I data on its investigational drug nivolumab, and Merck presented phase I data on its PD-1 antibody, lambrolizumab. Not to be left out of the mix, Roche presented phase I data on its PD-L1 antibody, MPDL3208A; and Amgen presented phase III data on its intratumoral immunotherapy, talimogene laherparepvec (T-VEC).

		Near-Term Management of Oral Therapies in BRAF-Mutated Melanoma

	With the imminent entrance of Tafinlar and Mekinist, GSK is redefining value. Both drugs were approved with a companion diagnostic called the THxID BRAF test (bioMerieux). The diagnostic will detect V600E and V600K mutations in the 

 gene. Tafinlar labeling indicates that, like Zelboraf, it is only approved for use in patients with the V600E mutation (approximately 80% of all 

 mutations). On the other hand, Mekinist is approved for use in patients with both of the 

 mutations. This difference in labeling between the two drugs represents an opportunity for sophisticated payers to differentially manage utilization.

	Price is an obvious difference between Tafinlar and Zelboraf, for which payers could implement step therapy, as both drugs are relatively similar in terms of efficacy. In the United States, the wholesale acquisition cost of Tafinlar will reportedly be $7600 a month, which essentially undercuts Zelboraf’s approximate cost of $10,000 a month. The lower price is likely related to being later to market with no obvious efficacy advantages and having different toxicity profiles.

	Arguably, Zelboraf has a lower risk for severe adverse events requiring dose interruption or reduction compared with Tafinlar. This could have contributed to the manufacturer launching at a lower price than Zelboraf. However, GSK has submitted applications to the FDA and the EU for use of Mekinist and Tafinlar in combination with each other, and is awaiting decisions from regulatory authorities. Currently, the use of Mekinist and Tafinlar in combination is not approved.

	Currently, Mekinist (priced at $8700/month) has a specific limitation in its label to not be used after treatment with a BRAF V600E inhibitor. This may be enforced by payers despite the combination regimen showing an improvement in progression-free survival (PFS) compared with Tafinlar alone. For the combination or single-use Mekinist to be widely accepted into practice or by payers, the National Comprehensive Cancer Network (NCCN) Guidelines and NCCN Compendium, which guide payer reimbursement, will come into play.

	In the meantime, GSK has initiated two phase III trials (NCT01584648/COMBI-AD and NCT01597908/ COMBI-v) to confirm the results that the combination therapy is superior to Tafinlar alone or Zelboraf alone. In all likelihood, the combination will move forward into clinical practice. The question is whether it will take an NCCN category 2A (generally reimbursed by payers) or 2B recommendation in the next update of the NCCN Guidelines. It is unclear whether Tafinlar and Mekinist will have an NCCN recommendation for combination use (or even to allow use of Mekinist after progression with a BRAF inhibitor) before launch in early Q3.

	Essentially, the combination regimen would bump the cost of therapy to over $16,000 a month, with an average duration of therapy of one year. This would represent a new price point in oncology, likely spurring greater interest in payer utilization management (

	Roche has also initiated a phase III trial (NCT01689519) combining Zelboraf with its experimental MEK inhibitor, GDC-0973, in the same manner as GSK’s combination.

			Figure 2. Reasons for Management Priority

Percentage of MCOs Among Those With Cancer Types That Are Specifically Targeted for UM (n=15)

Percentage of managed care organizations with utilization management programs specifically targeting oncology.

: Kantar Health; Managed Care Organization Survey, August 2012. “What are the reasons specific cancer(s) are management priority? Select all that apply.”

		Reshaping Value Propositions in Melanoma With Immunotherapy

	Melanoma tumors use various molecules, such as PD-1, PD-L1, and CTLA-4 to mask itself from the human immune system. The antibody Yervoy binds to CTLA-4 to potentially allow the immune system to attack the tumor cell. Yervoy was a breakthrough drug, and thus was able to be launched at a substantial price with a fixed regimen of four injections costing approximately $120,000. While the drug increases median survival, the most critical aspects of its activity are not response rate or median overall survival (mOS), but long-term disease stabilizations that lead to unprecedented longterm survival of approximately 30% at 2 years and 20% at 3 and 4 years. However, severe immune-related gastrointestinal (GI) adverse events may lead to costly hospitalizations due to diarrhea or GI perforations.

	Yervoy has only a few years to enjoy being the standard immunotherapy. PD-1 and PD-L1 antibodies first made a splash at ASCO 2012, but longer-term follow-up data strongly suggest Yervoy will be replaced or serve as a combination agent. Furthest along in development is BMS’s nivolumab. In a large phase I dose-finding study, nivolumab’s overall response rate (ORR) was 31% across all dosages, but reached 41% with a 2-year survival of 43% in patients who received the planned dosage for the phase III program. A separate phase I study of nivolumab suggested that it is active in both Yervoy-naïve and Yervoy-pretreated patients. BMS has initiated two phase III trials (NCT01721746/Check- Mate-037 and NCT01721772/CheckMate-066 in Yervoy- pretreated and Yervoy-naïve patients, respectively) comparing nivolumab to chemotherapy to confirm the outstanding activity observed for nivolumab in the phase I trial.

	In a cross-trial comparison, the phase I results discussed compare very favorably with Yervoy’s activity from its phase III results (11% ORR and 2-year survival of 24%). Additionally, nivolumab appears to have a better safety profile than Yervoy, particularly when comparing immune-related GI events.

	However, the greatest excitement for BMS would be the combination of Yervoy and nivolumab. In a clinical trial, the combination yielded a 54% ORR with all responders achieving an 80% reduction in tumor volume. These near-complete responses strongly suggest that inhibiting PD-1 and CTLA-4 could be the next standard of care for metastatic melanoma, though the combination resulted in a high rate of serious adverse events, primarily those associated with Yervoy.

	BMS has started a three-arm phase III trial (NCT01844505/Check- Mate-067) comparing each single agent (Yervoy and nivolumab) with the combination. With the superior value proposition of single-agent nivolumab, it would likely have yielded a premium price compared with Yervoy. However, the exciting combination data mean the company will have interesting launch choices, including whether to launch nivolumab with only single-agent data or the combination data from the CheckMate-067 trial.

	If the combination data are superior, the company will have to strongly consider the overall cost of therapy and potentially develop a creative patient assistance program. One key issue with the combination is that Yervoy is only dosed with four induction administrations, but nivolumab will be dosed continually until progression, potentially for longer than one year.

	In other studies in advanced melanoma presented at ASCO, Merck’s lambrolizumab and Roche’s MPDL3280A, which not have yet reached phase III, showed impressive response rates in phase I trials. At several dosages, lambrolizumab produced a response rate of 38%; however, at the highest dosage (10 mg/kg) the ORR was 52%, including a 10% complete response rate. As with nivolumab, response to lambrolizumab was independent of prior Yervoy treatment. Roche’s MPDL3280A produced a response rate of 29% at several dosages, similar to lambrolizumab and nivolumab.

	Lastly, promising data for the intratumoral injection, T-VEC from Amgen, showed an improvement in longterm disease control of advanced melanoma. A trend toward improvement in long-term survival in the pivotal phase III trial (NCT00769704/OPTiM) showed 2-year and 3-year OS had statistical significance at 50% and 41% for T-VEC compared with 41% and 28% for the control arm. Amgen is awaiting mature survival data before filing with the FDA, perhaps by the end of the year.

	The current number of available treatments for BRAFmutated melanoma, the emerging availabilities of immunotherapies, and their likely associated costs, suggest that strong payer management in advanced melanoma may be utilized in the near future. For a disease that has garnered little attention previously, the emergence of therapies will give payers impetus to manage drug therapy for advanced melanoma.

	A key clinical argument remains whether the emergence of the immunotherapies has physicians thinking that they will be used before BRAF inhibitors, given the long-term survival these convey in converse to current thinking. Payers and health authorities could mandate a BRAF or MEK inhibitor over Yervoy given the biomarker significance, yet resistance against the BRAF and MEK inhibitors is inevitable, suggesting that patients with 

-mutated melanoma have a definite ceiling in survival without either using an immunotherapy. Unlike the BRAF and MEK inhibitors, Yervoy does not have a biomarker. If a biomarker can be validated for PD-1 and PD-L1 antibodies, their value proposition would be more substantial, perhaps providing a larger reason to price the drugs highly.

	Melanoma treatment is likely heading toward combinations, whether it’s a BRAF/MEK combination, a BRAF inhibitor plus an immunotherapy or dual immunotherapies. These agents will increasingly affect drug expenditures for patients and payers. Manufacturers may need to become more creative with patient assistance programs as combination therapies push regimen prices beyond $15,000 a month. The resulting patient out-of-pocket costs for those with a high coinsurance that ranges from 20% to 33%, for example, could be pushed beyond affordability (Figure 3), particularly with the chronic nature of treatment (the emergent immunotherapies and the BRAF and MEK inhibitors).

			Source: Kantar Health; Managed Care Organization Survey, August 2012. “Do/Did you face any financial challenges with paying for your cancer treatment plan? Did anyone at your oncologist’s office suggest applying for financial assistance? Did you discuss the affordability of your treatment with your oncologist or anyone in the practice?”

	Gordon Gochenauer is the Director of Commercial Planning at Kantar Health, a global healthcare advisory firm and trusted advisor to the world’s largest pharmaceutical, biotech, and medical device and diagnostic companies.

Traditionally, payers have been increasingly more proactive in their management of drug expenditures in cancers with the highest prevalence and with the more costly therapeutics.

Advances in Metastatic Melanoma Bring Price Competition, Redefinition of Value, and Likely Increased Payer Utilization Management

Governor Steve Beshear did not sugarcoat the data on May 9, 2013, when he said Kentucky would take an offer it couldn’t refuse.

With his state ranked worst in the nation in smoking and cancer deaths, and not far behind in heart disease, Beshear was “tired of being at the bottom.”

 It was time for strong medicine—in the form of $608 million in new healthcare spending, which will come January 1, 2014, when Beshear accepts federal help to put 308,000 new people on Medicaid.

 Another 800,000 Kentucky residents are already in the program.

The decision followed Beshear’s 2012 call for Kentucky to create its own exchange to sell health insurance under the 2010 Affordable Care Act (ACA). In theory, all 640,000 uninsured Kentuckians should be able to gain health coverage.3 Cutting Kentucky’s cancer rates is a tall order, and Beshear is candid about the link between that grim history and his state’s economic conditions. Taking the Medicaid money, in his view, was the only choice that made sense.

“Kentucky is one of the least healthy states in the nation. In 2012, Kentucky’s overall health ranking was 44th. Kentucky is at or near the very bottom of many national health rankings,” said Governor Beshear. “A multitude of state and national reports have shown the positive impacts on health status that occur when an individual becomes insured. They are more likely to get preventive care and seek out medical treatment when they need it. They miss fewer days of work and school. And they live longer and more productive lives.

“By the time we reach 2020, I believe we will have seen such a measurable impact on prevention of disease, management of chronic health problems, and overall health of our workforce that to withdraw or shrink from Medicaid expansion would be unthinkable.”

Beshear, a prostate cancer survivor, feels he is on solid footing, morally and practically. The expansion affects single persons with incomes of up to $15,856 per year or a family of 4 with an income of up to $32,499;

 many of these are “working poor.” The infusion of healthcare spending will create 17,000 jobs and $15.6 billion in economic activity,1 and hopefully reduce absenteeism, and improve job performance to make Kentucky workers more attractive to industry.

Over time, Beshear believes, healthier children will miss fewer days at school, and the commonwealth will see economic benefits from a healthier population.

 All of this will require confronting Kentucky’s historic links to coal and tobacco, and resulting rates of cancer, especially lung cancer.

“While my primary concern is for the improved health outcomes that will be possible for many of our citizens through the expansion of Medicaid, my decision was not solely based on the obvious health benefits that extending insurance coverage will provide to the people of Kentucky. It was also based on the far-reaching economic benefits of expanding Medicaid,” Beshear said.

“If a company was willing to invest $15.6 billion in Kentucky in the next 7 years, creating nearly 17,000 jobs and significantly reducing the uninsured population, while greatly improving the health of our citizens, we would not hesitate to welcome them into our state. Medicaid expansion is no different.”

Kentucky health officials must overcome political and logistical hurdles, not to mention cultural ones. A fee-for-service delivery system, saddled by ignorance, poverty, and occasionally the belief that “God’s will” would determine the outcome, had to be replaced by one that relied on regular screenings and outreach. Healthcare advocates and observers said the record of failure meant that when the state’s poor interacted with the medical system, there were few expectations.

“Folks are not accustomed to getting healthcare and having healthcare work,” said Susan Zepeda, PhD, president of the Foundation for a Healthy Kentucky. “They may have family members who were diagnosed so late that the diagnosis was a death sentence.”

But critics of Kentucky’s approach say the state has rushed too quickly into managed care, in a quest to upend delivery systems that caused some low-income or rural residents to wait too long to seek treatment.

 In the breathtaking sprint to move 70% of the state’s 800,000 Medicaid recipients into managed care organizations (MCOs) for the first time, Kentucky Medicaid Commissioner Larry Kissner admits there were many bumps.

Over the long haul, however, Kissner insists the accountability of managed care under health reform will make a difference: In the first year, he said, officials are reaching more than 80% of Medicaid patients for regular screenings; once that baseline is established, officials will be able to track progress in measurements like blood sugar over time. Better still will be when more consistent healthcare shows up in higher test scores among school-age children, or lower smoking rates in the next generation of adults.

From academia to government, those who know Kentucky’s system hope to finally bridge a gap that has long existed: In a commonwealth with world-class healthcare at universities in Louisville and Lexington, there are aching needs among some of the most isolated, impoverished poor in the nation.

On paper, Kentucky envisions a system of federally funded health centers and managed care networks, providing regular screenings like colonoscopies and mammograms. Telephone calls would remind cancer patients when to come in for care, and will provide follow-up that the old system never could.

It remains to be seen whether cancer care delivery under Kentucky’s new model can serve a rural population. Steven W. Wyatt, DMD, MPH a veteran of the Centers for Disease Control and Prevention (CDC) who returned to his native state to become dean of the College of Public Health at the University of Kentucky, said getting more rural people enrolled in Medicaid is only the first step.

“Just because you remove the cost barrier doesn’t mean you are going to increase the access,” Wyatt said. “It’s all about other things that surround the payment of services.” Things like transportation, or missing work, or not having anyone to watch a child or grandchild, or just the fear factor of coming to a modern campus like the Markey Cancer Center in Lexington. “Navigating a university setting can be intimidating,” he said.

Zepeda concurred. Although Kentucky has a “more robust” network of federally funded health centers than existed even 5 years ago, she said, expanding Medicaid rolls and subsidized insurance mean “there will be capacity issues, particularly in rural areas of the state.”

With open enrollment under the ACA set to begin October 1, 2013, the pace of change remains swift. On May 9, Governor Beshear declared the Medicaid expansion “the single-most important decision in our lifetime for improving the health of Kentuckians,” and invoked his right to change Medicaid eligibility by regulation, not by statute as occurs in most states. Until 2017, when the expansion will require state matching funds, there is little the legislature can do.

Within days, Kentucky had launched a website (www.kynect.ky.gov) to help residents understand healthcare reform and to shop for coverage. A series of forums with the state’s Medicaid providers followed, allowing them to get information and to vent about the rapid conversion to managed care.

Kentucky’s healthcare efforts appeared in the national press almost daily in July. On some days the news was positive, like when the National Governors’ Association (NGA) included Kentucky in a demonstration project to reduce the number of “super-utilizers” in its emergency departments.

 offered a brutal assessment of the Medicaid program’s transition to managed care, with critics stating that its only aim was to fill a $1.3 billion budget hole.

July 12 offered the biggest news of all: After years of effort, the University of Kentucky’s Markey Cancer Center received a National Cancer Institute (NCI) designation, giving Markey eligibility to compete for millions in additional funding and the best faculty in the world. In their announcement, Markey officials said that Kentucky residents would gain access to better chemotherapy agents and to clinical trials.

University of Kentucky President Eli Capilouto, in making the announcement, said the designation strengthens Markey’s potential “to roll back this scourge in Kentucky.”

Kentucky’s fight against lung cancer starts with this fact: According to the Department of Public Health, 28.4% of the commonwealth’s adults smoke.

 It’s not easy to curb tobacco use when generations of farmers have grown it, and when tax coffers have relied on its sale (

“Our disease burden is heavily driven by lung cancer,” said Wyatt. While there are some other anatomical cancers with elevated rates relative to the rest of the country, such as breast and colon cancer, Wyatt said nothing comes close to lung cancer. “Take out lung cancer, and we look closer to the rest of the country.”

State-by-state mortality rates bear out Wyatt’s observation. SEER data, published by the NCI and the CDC, show lung cancer death rates in Kentucky of 71.7 per 100,000 residents among whites and 76.7 per 100,000 among African Americans for 2006 to 2010; corresponding rates for the United States were 48.1 among whites and 50.7 among African Americans.

 While rates for some other cancers exceed US rates, nothing comes close to lung cancer (

		Source: U.S. Census, NCI, Kentucky Cancer Registry, Kentucky DPH.

It’s not hard to understand why: At 87,641 acres, Kentucky devotes more land to growing tobacco than any other state except North Carolina, according to the US Department of Agriculture.

 But over the past decade, tobacco’s hold on the state’s economy has slipped. In the mid-1990s, University of Kentucky economist Will Snell estimated sales of Kentucky tobacco at $900 million; by 2009, a combination of fewer farms and lower prices had cut that figure to $390 million.

People around the nation were quitting, driven by greater knowledge, higher state taxes, indoor smoking bans, or a combination of the 3. And bans weren’t just happening elsewhere: On July 1, 2003, the college town of Lexington was the first in Kentucky to pass a smoking ordinance, which was upheld by the Kentucky Supreme Court the following year.14 As of July 1, 38 Kentucky towns or counties had indoor bans of varying degrees.

 In February 2013, a statewide indoor ban passed a Kentucky House committee for the second year in a row, although its prospects in the Senate were unclear. Governor Beshear has publicly endorsed the indoor ban.

Sarah Walsh, Foundation for Healthy Kentucky program director, said polling data from early 2013 show that for the first time, more than half of adults in Kentucky of both parties support an indoor smoking ban. This is important politically, because it reduces fears of elected officials that they would be challenged in a primary for supporting a smoking ban. Overall, the poll, which was funded by the Foundation and conducted by the Institute for Policy Research at the University of Cincinnati, found that 59% of adult Kentuckians support an indoor smoking ban. These findings confirmed a University of Kentucky study that found support for smoke-free laws in rural areas.

Commissioner Kissner said that healthcare reform, and the expansion of Medicaid in particular, will allow Kentucky to reach a whole new population with programs to help people quit smoking. This will follow a near doubling of the program from 2011 to 2012, when Governor Beshear expanded it. Participation nearly doubled from 3431 to 7015, and expenditures rose from $234,517 to $527,289.

Before 2011, Kissner said, Medicaid only funded programs for pregnant women. Now, “we pay for everyone.”

He knows, however, that progress among adults will be slow. Tucked into the most recent CDC figures, hope comes from data showing the share of teenagers aged 12-17 who took their first cigarette fell dramatically between 2002 and 2009, taking Kentucky out of the worst ranking into 10th.

When Kissner became Commissioner in July 2012, Kentucky’s march to managed care was at full throttle. Faced with a need to trim $1.3 billion from its Medicaid budget, Kentucky had announced in April 2011 that it would move beyond a managed care pilot in Louisville and enroll 560,000 Medicaid recipients into MCOs—which had to be publicly noticed, bid and awarded&mdash;between April and November 2011.

 That schedule avoided more dire consequences like cutting reimbursements 35% or pushing recipients off the rolls.

By March 2013, providers were complaining, and one MCO, Kentucky Spirit, wanted out. Providers wrote op-eds and petitioned the legislature about slow payments, contract cancellations, inadequate networks, or patient referrals to far-off providers. In Eastern Kentucky, which is especially rural and poor, patients complained of inadequate mental healthcare. 

 story profiled a family denied payment for a child’s nutrition supplement that had been covered under the old system.

In an interview, Kissner acknowledged the complaints

; he had just completed eight regional forums with other health officials, where providers offered feedback ahead of the Medicaid expansion. “The biggest complaint was the speed” with which the changeover occurred, he said. Providers accustomed to just dealing with “Medicaid” suddenly could be dealing with any one of three vendors, and each had a slightly different authorization system.

Kissner insists that in time, the “three-legged stool” of better care coordination, education, and preventive care will be positive for patients, both for catching cancer early and for treating it. Health experts concurred that Kentucky’s high cancer mortality rate has been driven by the number of tumors caught late when there is little that can be done. That’s where managed care can do a better job of making sure patients get preventive screenings to catch cancer early, Kissner said. And once treatment starts, he believes MCOs are better equipped than the old system, through telephone calls or other means, to remind patients to stick with treatment.

“The managed care companies do a much better job of care coordination than we did with fee-forservice,” Kissner said.

		Created by statecancerprofiles.cancer.gov on 07/22/2013 2:12 pm.

		Regression lines calculaed using the Joinpoint Regression Program

		Source: Death data provided by the National Vital Statistics System public use data file. Death rates calculated by the National Cancer Institute using SEER*State. Death rates (deaths per 100,000 population per year) are age-adjusted to the 2000 US standard population (19 age groups:(<1, 1-4,5-9...,80-84,85+). Population counts for the denominators are based on Census populations as modified by NCI. The US populations included with the data release have been adjusted for the population shifts due to hurricanes Katrina and Rita for 62 counties and parishes in Alabama, Mississippi, Louisiana, and Texas. The 1969-2011 US Population Data File is used with morality data.

Ultimately, the test once healthcare reform arrives is whether health officials can change the way the population thinks. But they know it won’t be easy.

“There’s a fatalism,” in some parts, Kissner said. “A thinking that says, ‘Everyone in my family dies of cancer.’ …Hopefully managed care can help address that.”

By keeping people insured, either through expanded Medicaid rolls or greater use of subsidized insurance, the hope is that fewer people will come on and off insurance. If they get insured and stay there, and their children stay there, chances are greater the family will get into the habit of seeking medical care regularly, not just when a crisis arises.

Wyatt knows it will take time. Even though he grew up in Kentucky, he said it’s easy to forget how challenging it can be to make changes in rural areas. Working with churches can help, getting to know local opinion leaders can help. For the HPV vaccine, he said, it’s not enough to convince parents; sometimes healthcare workers must convince grandparents.

“Removing the geographic barrier is very, very hard,” Wyatt said.

			Kliff S. Cancer clinics are turning away thousands of Medicare patients: blame the sequester. 

			Gov. Beshear expands health coverage to over 300,000 Kentuckians. May 9, 2013. Governor Steve Beshear’s communications office. Commonwealth of Kentucky. http://migration.kentucky.gov/Newsroom/ governor/20130509medicaid.htm. Accessed July 21, 2013.

			Cabinet for Health and Family Services. Cabinet solicits information regarding Medicaid managed care initiatives. January 5, 2011. Commonwealth of Kentucky. http://chfs.ky.gov/ news/DMS+Managed+Care.htm Accessed July 23, 2013.

			Gov. Beshear issues executive order creating Kentucky health benefit exchange. July 17, 2012. Governor Steve Beshear’s communication’s office. Commonwealth of Kentucky. http:// migration.kentucky.gov/Newsroom/governor/20120717health exchangeadvisoryboard.htm. Accessed July 22, 2013.

			May L. Kentucky Gov. Beshear decides to expand Medicaid in Kentucky to boost ‘abysmal health outcomes.’ May 9, 2013. WCPO Digital. www.kypost.com/dpps/shared/citing-abysmalhealth- outcomes-beshear-decides-to-expand-medicaid-inkentucky_ 8480448#ixzz2ZzKQsMtM. Accessed July 23, 2013.

			Bergal J. Kentucky’s rush into Medicaid managed care: a cautionary tale for other states. July 14, 2013. 

. www.kaiserhealthnews.org/ Stories/2013/July/14/kentucky-medicad-managed-care.aspx. Accessed July 14, 2013.

			Brammer J. Judge denies Beshear’s request to dismiss lawsuit against Medicaid expansion. July 1, 2013. Kentucky.com. www. kentucky.com/2013/07/01/2700008/judge-denies-beshearsrequest. html. Accessed July 24, 2013.

			Kentucky Press News Service. Kentucky chosen for project to reduce health costs while improving care. Kentucky.com. July 18, 2013. www.kentucky.com/2013/07/18/2719630/kentucky-chosen-forproject- to.html. Accessed July 24, 2013.

			Ungar L. Program offers aid to ER ‘super-utilizers’ to cut costs. Louisville Courier-Journal/USA Today. April 13, 2013. www.usatoday.com/story/news/ nation/2013/04/13/program-helps-frequent-er-patients/2080855/. Accessed July 18, 2013.

			Perry A. Markey earns prestigious National Cancer Institute Designation. Markey Cancer Center, July 12, 2013. University of Kentucky. www. ukhealthcare.uky.edu/markey/news/07122013-NCI-designation-pressrelease/. Accessed July 15, 2013.

			Prevalence of adult smokers, 2012. Survey Data provided by Irene Centers, Department of Public Health. Commonwealth of Kentucky. July 23, 2013.

			Howlader N, Noone AM, Krapcho M, et al (eds). SEER Cancer Statistics Review, 1975-2010, National Cancer Institute. Bethesda, MD, http:// seer.cancer.gov/csr/1975_2010/, based on November 2012 SEER data submission, posted to the SEER website, April 2013.

			Campaign for Tobacco-Free Kids. Report on 2007 Census of USDA Tobacco Census. www.tobaccofreekids.org/research/factsheets/pdf/0125.pdf. Accessed July 23, 2013.

			O’Farrell P. Kentucky and tobacco: It’s complicated. Cincinnati.com. January 30, 2011. http://news.cincinnati.com/article/20110130/ EDIT03/101300357/Kentucky-Tobacco-s-Complicated. Accessed July 22, 2013.

			Hahn E. Making Kentucky a smoke-free state. Letters to the editor, 

. July 24, 2013. www.courier-journal.com/article/20130724/ OPINION02/307240036/1016/opinion/Letter-Making-Kentucky-a-smokefree- state. Accessed July 24, 2013.

			Musgrave B. Proposed statewide smoking ban clears Kentucky legislative panel. 

. February 7, 2013. www.kentucky. com/2013/02/07/2507141/statewide-smoking-ban-clears-kentucky.html. Accessed July 24, 2013.

			Statewide smoke-free law gains support in Kentucky. Foundation for a Healthy Kentucky. January 7, 2013. www.healthy-ky.org/news-events/newsroom/ statewide-smoke-free-law-gains-support-kentucky. Accessed July 24, 2013.

			Rayens MK, Hahn E, Langley R, Zhang M. Public support for smoke-free laws in rural communities. 

			Smoking Cessation Drug Utilization Expenditures, 2008-2012, Kentucky Department of Public Health, bar graph provided by Irene Centers. Accessed July 23, 2013.

			Centers for Disease Control and Prevention. Smoking and Tobacco Use. State Reports, Kentucky. www.cdc.gov/tobacco/data_statistics/state_data/state_ highlights/2012/states/kentucky/index.htm. Accessed July 19, 2013.

Governor Steve Beshear did not sugarcoat the data on May 9, 2013, when he said Kentucky would take an offer it couldn't refuse. With his state ranked worst in the nation in smoking and cancer deaths, and not far behind in heart disease, Beshear was "tired of being at the bottom."

Leveraging Health Reform to Combat a History of Cancer

Increasing financial and administrative pressures—exacerbated by the federal sequester and continued rollout of the Affordable Care Act (ACA)&mdash;have created instability and uncertainty for oncology practices nationwide. To better understand how oncology practices are adapting to these environmental stressors, the American Society of Clinical Oncology (ASCO) launched the National Census of Oncology Practices to collect practicelevel data on the organizational, staffing, and service changes of oncology practices across the United States.

For an expert interpretation of the census data and its impact on independent oncology practices, we discussed the current state of oncology practice with Anupama Kurup Acheson, MD, medical oncologist at Providence Cancer Center Oncology and Hematology Care Clinic and 2013-2014 Chair of the ASCO Clinical Practice Committee.

Acheson’s expert analysis covers practice trends, cost pressures, sequestration, healthcare reform, consolidation, genetic testing, new care delivery models, payment reform, accelerated drug approvals, clinical trials, and quality and value measures.

What are the principal cost pressures affecting independent oncology practices?

Reimbursement for patient care from Medicare poses a major challenge, especially as the medications and technologies we use are bigticket items (

). The system has not been able to keep up with the upward cost curve. Also, with doctors facing the constant specter of severe cuts, the sustainable growth rate (SGR) formula represents an enormous impediment to successful healthcare delivery and payment reforms that can improve the quality of patient care while lowering growth in costs. The system is flawed and in need of a major overhaul, and it’s never been more important for oncologists to play a role in shaping the future of the payer system while also ensuring we are able to deliver high-quality, high-value care.

Another trend is that newer drugs typically cost a lot. Some specialty drugs, which are especially complex, also require management, particularly of toxicity. Different pharmacies offer varying levels of support, and so it’s very much part of our job to assist our patients while also helping them work out insurance coverage. This involves a major effort on the part of our office staff to accommodate payers, who request information in different ways; it’s not consistent.

Practices are also bearing the burden of the cost of some of these drugs. Chemotherapy drugs comprise the largest single expense for community oncology practices. These costs include purchasing the drugs, special storage and inventory costs, safe handling, and specialized staff to mix and administer the drugs as well as to monitor the patient during treatment.

The federal sequester has also had a significant impact on the bottom line. In a recent ASCO survey on the effects of sequestration, of the more than 500 practices that responded, 80% said they’d been impacted in some way. Fifty percent said they could not continue to care for Medicare patients without supplemental insurance, and about half said they were redirecting 10% to 50% of their patients to hospitals for chemotherapy. Around 14% said they were no longer taking Medicare patients.

What impact is the ACA having on independent oncology practices?

Under the ACA, physicians must participate in the Physician Quality Reporting System (PQRS) by 2015. The good news is that the Centers for Medicaid & Medicare Services (CMS) has released criteria for the approval of existing, qualified registries as a reporting device under the PQRS. ASCO is working with CMS to ensure that our Quality Oncology Practice Initiative (QOPI) would meet these requirements. A major issue the law did not address is the SGR formula. This reimbursement formula is really flawed, especially in light of expected increases in costs and the aging of the population. Physicians would like to get away from the SGR, as it creates intense instability within oncology and the larger practice environment. We are aware that we will be seeing more patients under ACA, but we’re still waiting to see when and how the law will have an impact on practices.

What are recent trends in services that independent practices are providing, and what market or regulatory forces are driving these?

Last year, ASCO launched its first national oncology census to better understand these trends and found that just over 40% of practices were providing chemotherapy onsite, almost 30% were offering social services, and 23% nutritional counseling (

). A quarter of practices had lab services onsite, and 26% were involved in clinical trials. The 2013 census is now open and we will be looking to its results for trend analysis.

One aspect of practice we want to track is the increasing use of advanced practice providers (APPs), specifically nurse practitioners and physician assistants. In an ASCO study released in the fall of 2011, we learned that non-physician practitioners were seeing patients at office visits independently of physicians, although a physician was on hand. Notably, 98% of patients polled in one survey recognized that the provider they saw was not a physician, and the average satisfaction score (92.5%) indicated that they were extremely satisfied with their care from a team that involved physicians and APPs. Practices in which the APPs worked with all physicians were nearly 20% more productive than practices where APPs worked with select physicians. A 2007 ASCO workforce study also found that practices involving APPs have higher visit rates than those that do not.

Broadly, what we’ve all known is that beyond delivering chemotherapy, services such as counseling, nutritional guidance, and social services are all highlights of quality oncology care. Independent practitioners provide them in a range of ways—some smaller practices use outside providers, including hospital services, while larger practices have them onsite. But everyone feels these are essential. We need to stay tuned, however, to see what effects the sequester will have on these services.

What sort of consolidation are you seeing among practices? How are independent practices managing to go it alone and what are the implications for services provided?

In the past two or three years we’ve been seeing a lot more consolidation as doctors transition out of community practice (

). One of the prime drivers of the recent census was to get a better handle on this trend, and from last year’s survey (

) we saw considerable movement. We’re seeing a lot of mergers, especially in metropolitan areas. Larger practices reported plans to purchase smaller ones, while smaller ones said they were more likely to close. Again, the sequester is having an impact.

In order to survive in this environment, solo practices are paying close attention to information provided to them by community oncology consortiums on how practices across the country are coping. They are able to manage some costs by joining together; group-purchasing for drugs is an example. In terms of providing multidisciplinary care, independent practices recognize the value of interacting with specialty providers given the complexity of disease, and while this takes more time, they see it as a necessity.

What sort of momentum is there behind new care delivery models such as patientcentered medical homes and accountable care organizations?

Over the past few years, there has been a lot of talk about developing new models and growing calls for more pilot testing, with the understanding that these new models would require a wholesale change in how we practice medicine. In cancer care, however, it’s important to keep in mind that a one-size-fits-all approach will not work. ASCO would look for a menu of options: different types of models that will support the level of care we need to provide.

In the near-term, we’re looking for more pilot testing of clinical pathways to guide evidence-based care and patient-centered medical homes. However, we recognize that these models may make sense in some parts of the country and not in others. These pilots, which require a significant commitment of time and resources on the part of practices, are still in the early stages. But we are very encouraged. Going forward, we need to make sure the menu is developed thoughtfully and that we put in place a transition period so that we can fully assess how they are working. In general, oncologists must continue to tie the work they do to what’s important to patients. We need to be more careful about utilization of tests and services, making sure that whatever we order is meaningful. A lot of positives will come out of this.

What’s happening on the payment reform front?

As the Medicare population grows, reimbursements for services are not keeping up with cost increases and we are bearing a large part of the added cost. So we are very encouraged at ASCO to see an appetite in Congress to reform unworkable aspects of the current payment system, including the SGR model and the fee-for-service system, which requires a wholesale change. Importantly, more elected representatives are reaching out to us for feedback, asking for our ideas about alternatives to SGR, for example. And we are putting pen to paper.

ASCO’s Payment Reform working group is examining proposals for different payment models. We’ve developed a set of principles, which we believe should underpin any new payment system. We believe any new payment system should be tied to quality improvement, be physician-led, not add to the deficit, and provide a transition period to allow for additional testing.

The House Energy and Commerce Committee has asked ASCO to provide feedback on its draft legislation. We’ve been supportive of the legislative proposals that encourage all specialty physicians to participate in a quality assessment and clinical improvement program.

Patient outcomes, with quality as the underlying goal, must drive these changes. To ensure value, physicians must make sure that the services we provide are clinically meaningful. The challenge is that there is so much variance among patients that care must be tailored accordingly. Also, these new models must work in relation to private payers; care has to be consistent across the patient population. But we do find that private insurers are interested in clinical pathways.

What is the impact on practices of new drug approval processes, including the FDA’s accelerated approval pathways? Are there increased responsibilities and risks as a result of these changes?

It’s very encouraging that the FDA is using regulatory flexibility to speed up the approval process for breakthrough therapies for life-threatening diseases. ASCO supports this and has worked closely, for example, with the agency’s Office of Hematology and Oncology Products to host workshops to advance surrogate endpoints for use in specific cancer types to enable use of the accelerated approval mechanism.

In each case, how quickly these drugs are approved depends on the data and how easy it is to collect. The FDA has demonstrated the ability to approve agents on the basis of trials that involve a relatively small number of participants. This translates to earlier access to the agents, but this does place the responsibility on us as clinicians to closely monitor patients for unexpected side effects and on organizations like ASCO to advise our members that they may have to change treatment plans if there are adverse effects or drugs are not working.

We also need to keep a close eye on information from clinical trials, understanding that use of agents in this setting is experimental, even if the agent is already approved for a different indication. Particularly in the case of agents approved via the accelerated approval mechanism, the approval is granted on the basis of a surrogate endpoint that is reasonably likely to predict clinical benefit. We need to stay in touch with confirmatory studies and data from these trials to understand whether the agent meets the clinical benefit expectation.

Are independent oncologists enrolling their patients in clinical trials? What are the practice implications?

Independent oncologists are interested in enrolling their patients in clinical trials, and just over a quarter of practices say they are involved in them. But there are significant additional costs associated with conducting clinical trials, and the National Cancer Institute (NCI) doesn’t adequately reimburse for trials conducted through the Cooperative Group system.

Changes the NCI and Cooperative Groups are implementing are helping to streamline the system and standardize the process, but the costs of conducting NCI-funded trials are not adequately compensated. This means practices lose money.

In ASCO’s survey on the sequester, a quarter of practices polled said they had stopped participating in them because of funding costs (

). Patients who are enrolled in trials need to be closely monitored, and nurses and other staff must take the time to counsel them. In addition, clinical trial participation involves staff with specialized expertise, increased data collection, facilities to store records and investigational agents, and time and space to accommodate auditors.

On another note, ASCO is in the process of developing recommendations that will help design trials with more clinically meaningful outcomes. We are hoping that trial sponsors will use these recommendations to prioritize development of trials with outcomes that hold greater clinical benefit. In addition, another ASCO group is examining eligibility criteria with the goal of limiting exclusionary criteria that prevent patients from qualifying for trials. If eligibility is so stringent, it makes screening incredibly challenging and raises questions about how widely applicable a given treatment is down the road.

How are oncologists improving the quality and value of the care they provide, and how are they measuring their performance?

The QOPI is the first national program in oncology. It covers the spectrum of practice/diagnosis, treatment, and assessment—and a range of services, including psychological counseling and end-of-life care. QOPI includes 160 quality measures, including 26 core measures. There are 17 standards alone for safely administering chemotherapy. It’s a rigorous process, but it gives practices that participate detailed reports on how they’re performing compared to national averages. And it’s an excellent way to manage quality care and a valuable learning tool. To date, 850 practices are registered with QOPI and 180 have gone through the process and received certification.

On the quality front, ASCO has just launched a prototype health information computer network called CancerLinQ that will collect and analyze individualized patient data from millions of visits and provide practitioners clinical guidance for real-time personalized care. For example, by inputting tumor characteristics, the provider would receive recommendations on what personalized therapies to pursue based on expert guidelines. This is a new way to get doctors information they can use in real time. They can also explore the database, which includes data on patient characteristics, treatments, and outcomes from a variety of sources to identify real-world trends. The system will also provide feedback on the services performed based on QOPI quality measures.

What is the impact of genetic testing on both oncology practice and care?

Tests such as companion diagnostics, biomarker tests, and next-generation sequencing allow us to provide more personalized care. These tests hold incredible promise to help us deliver molecularly targeted agents to the appropriate patient population, particularly with next-gen sequencing tests; however, they are not always available to community-based oncologists, and also may not be eligible for insurance coverage.

We also need to be mindful of clinical utility. Some tests and use of molecularly targeted agents are of questionable applicability. It’s important to be clear about tests and procedures that provide meaningful clinical information to direct choice of treatment.

We are in an era of rapidly expanding knowledge of the molecular basis of cancer, and it is important that we are clear about the difference between research, emerging data, and evidence-based care, so that we accurately present risk and benefit information to patients. As part of the American Board of Internal Medicine’s “Choosing Wisely” campaign, ASCO developed a “Top 5” list of procedures and tests whose use should be questioned. More generally, everyone looks to genetic testing for simple answers, but they are not always available. Just because we know A, B, C, and even D about a patient, there may be other factors driving their cancer, including environmental inputs. Going forward, this is another area where 

 should shed some light as we are able to aggregate data quickly on treatment outcomes in the larger population of cancer patients.

		Figure. ASCO National Oncology Census Data

		Source: American Society of Clinical Oncology. National Oncology Census. 2012. Available at: www.asco.org/practice-research/ national-oncology-census.

Increasing financial and administrative pressures-exacerbated by the federal sequester and continued rollout of the Affordable Care Act-have created instability and uncertainty for oncology practices nationwide.

September 2013 | Oncology Business News®

CancerLinQ Proof-of-Principle Prototype

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Leveraging Health Reform to Combat a History of Cancer

The State of Oncology Practice: A Discussion With Anupama Kurup Acheson, MD