Five years ago, Capital BlueCross, a health insurer in Pennsylvania, asked community oncology practices in its network what kind of reimbursement model they would like to try as they worked to stay financially viable and independent. After rejecting the idea of a clinical pathways program, the practices expressed interest in specialty medical homes, particularly the patient-centered model pioneered by John Sprandio, MD, in the Philadelphia area.

Sprandio spent years standardizing care, streamlining workflows, and improving the electronic medical record (EMR) system at his oncology practice, resulting in fewer hospitalizations and substantial cost savings. Starting in 2015, the insurance company asked Sprandio and his consulting firm, Oncology Management Services (OMS), to bring his model to 4 of its network practices.

In July, Capital BlueCross received the first batch of practice-performance data, covering the second half of 2016. Thanks to reductions in emergency department visits and hospital admissions, the financial results were “really positive,” said Denise Harr, MD, senior medical director of Capital BlueCross. Patients’ total medical costs over 6 months were down 5.2% compared with a previous baseline period, and pharmacy costs dropped 13.9%. Even with incentive payments that practices received along the way, the effort has already achieved savings, Harr said. Measures of care quality did not improve as much, but both the insurer and the practices expect to see more positive results in the first half of 2017. “I’m hearing the practices say that this increased support they’ve received from John Sprandio and his team really helped them to feel like they’re impacting our patients’ lives in a different way and a better way,” Harr said. “They’re doing something different, and it’s measurable.”

Two of the 4 practices are in CMS’ Oncology Care Model (OCM), which was influenced by Sprandio’s work and resembles his model in many ways. Under his team’s guidance, the practices created or expanded phone triage systems to better manage patients’ symptoms, improved processes and technology for collecting and analyzing data, and made other changes required by the OCM. “We are very thankful for the experience of being in the Capital BlueCross pilot, because we really feel it prepared us to be successful in the OCM,” said Azlynn Swartz, MHA, BSN, RN, OCN, executive director of Andrews and Patel Hematology/ Oncology in Camp Hill, Pennsylvania. “They really worked with us to make the changes we needed to make. Other practices, I think, are struggling. They’re where we were 2 years ago.”

The pilot kicked off in July 2015, with the practices filling out questionnaires to guide Sprandio’s recommendations, Harr said. His team held webinars, visited sites to observe workflows, developed individualized blueprints, established timetables, and suggested technology improvements. To help fund infrastructure upgrades and hiring, Capital BlueCross reimbursed the practices for meeting a series of participation milestones over the program’s first year.

In one part of the transformation process, the practices developed symptom-management maps to guide nurses’ phone conversations with patients experiencing adverse effects from drugs. Swartz said OMS provided a template for decision-making paths, which a clinical group at Andrews and Patel modified based on their beliefs about the best responses. This standardization leads to individualized management of patient issues, avoiding automatic emergency department visits and unnecessary interruption of busy physicians, she said.

“What we’re working on now is using that phone call as a launching point for continued proactive telephone calls to the patient to say, ‘We talked about this yesterday. How are you today?’” Swartz said. “We’ve come up with a way to utilize the EMR to form a queue that a nurse will look at each day and make outbound calls based on people who have had recent symptoms.”

The practice staff is also focusing on improving the often-complicated task of tracking different aspects of patient care to make sure no steps are missed. For example, Andrews and Patel wanted to track whether it had received radiology reports doctors had ordered. The EMR did not easily allow that, so the practice built in a button that would attach a radiology test to a patient’s chart, Swartz said. Now a report can be run to show all the tests received— provided staffers didn’t forget to click the button.

“We’re tracking what percentage [of the tests] are back in the time frame that we think makes sense, and then we have a benchmark: what percent do we want to be at? Here’s our goal, and can we do better the next month?” she said. “We’re running reports like that for many things that we’re doing, and that’s taking a lot of time, but it helps us to see where our gaps in care are. I do think it’s actually helping us be better.”

Such processes are laborious in large part because the EMR cannot perform them automatically. Swartz said the OMS consultants were disappointed in the limitations and said they had underestimated the importance of a customized EMR, such as the IRIS system Sprandio developed for his practice over many years. Sprandio said the obstacles he encountered at the Harrisburg-area providers resemble those he has wrestled with at other practices that are building oncology medical homes.

“The challenges were purely related to the deficiencies in their EMR product. All the practices that we’ve worked with have realized efficiencies. The degree of physician efficiencies was only limited by the IT systems that they were saddled with,” he said. “We ended up making the best of an equally bad situation with whatever EMR vendor that they had.”

In July 2016, Capital BlueCross launched the performance portion of the pilot. It began paying monthly care-management fees for each patient and using claims data to compare the practices’ total cost of care trend with that of nonparticipating providers. This summer, using results from the second half of last year, the payer adjusted each practice’s fee schedule to incorporate performance-based incentives, Harr said. Adjustments will be made every 6 months based on the latest batch of available data.

Swartz said Andrews and Patel has noticeably bulked up its staff and invested in more software and services. In addition to the incentives from Capital BlueCross, the practice receives Monthly Enhanced Oncology Services payments from CMS as part of the OCM. Those combined funds cover the ongoing costs of participating in the programs, but just barely, she said.

Swartz also said that, while her practice greatly appreciates the practice improvements and OCM preparation provided by Capital BlueCross, the pilot program does nothing to ease the administrative burden of managing prior authorizations and drug denials imposed by payers doing whatever they can to cut spending. She looks forward to a day when payers reward OCM practices with easier and more technologically advanced claims management, but she has so far seen no sign of such reforms, she said.

There is hope, however, of more sophisticated information management within some practices in the near future. Sprandio said McKesson Specialty Health and the US Oncology Network licensed OMS’s technology last year, and he’s working with the staff with the goal of introducing IRIS into their extensive practice network. “We would like nothing more than to be a part of a larger organization and scale this up, and really impact the lives of a lot of patients,” he said.

Sprandio is also connected to McKesson through the Vantage Cancer Care Network, an independent practice association in southeastern Pennsylvania that promotes value-based care by facilitating oncology medical homes and arranging risk contracts with payers. He serves as medical director of Vantage, which is owned by McKesson, and is on the executive committee of Tandigm Health, which pays primary care doctors to closely manage patients’ care with the goal of cutting costs. Vantage has a contract with Tandigm, which is owned by Independence Blue Cross and Davita Healthcare Partners.

The oncology medical home concept that Sprandio has been working to propagate, along with similar efforts around the country, will face a major test next year when the 192 OCM practices must decide whether to join the 2-sided risk version of the model. Few have expressed interest in taking that step, because the model will assess heavy financial penalties on providers that fail to meet cost-saving targets, possibly forcing them out of business.

According to Swartz, oncology administrators still don’t understand exactly how CMS will calculate performance scores and whether the data-collection process is robust enough to accurately portray everything a practice does. She’s also concerned about the feasibility of cutting costs year after year, as the OCM appears to require. “I’ll be surprised if we choose 2-sided risk,” she said. “It’s just scary.”

One of the very few oncologists who are bullish on participating in the 2-sided OCM is Sprandio. He acknowledged the concerns about how CMS will perform calculations but said the agency staff is working on those issues. “We’re positioned to strongly consider this and potentially do it, if in the final analysis it makes sense. I’m OK with taking risk as long as it’s an educated risk and there’s an understanding of the components,” he said. “CMS certainly anticipates there are going to be some practices participating. I’m anticipating we’ll be one of them.”

Articles

Five years ago, Capital BlueCross asked community oncology practices in its network what kind of reimbursement model they would like to try as they worked to stay financially viable and independent.

Savings Improve Faster Than Care Quality in New Medical Home Pilot

Chimeric antigen receptor (CAR) T-cell therapy may soon hit the market, and numerous cancer care centers are poised to offer this for what may be the first FDA-approved indication: relapsed/refractory B-cell acute lymphoblastic leukemia. The promise of CAR T cells along with the potentially severe adverse events (AEs) have been well documented. One of those AEs may be financial toxicity. Consider a potential price tag as high as $700,000! Advocates argue that the ability to give the gift of a cancer-free life to a child or young adult may well be worth the money.

Ensuring access for patients on Medicaid is no easy matter. Consider the challenges faced by cancer centers that helped to develop a lung cancer model of care just launched by the Association for Community Cancer Centers (ACCC). In Maine, an entrenched attitude among residents that "I’m going to die of something anyway" made it difficult to get patients to follow through with recommendations for care. In Florida, patients often were lost to follow-up efforts because of the lack of reliable contact information. In Louisiana, oncologists found that a bottleneck to access occurred with primary care physicians who failed to make referrals.

The innovative solutions from this group of practices helped to form a template for the Optimal Care Coordination Model from the ACCC, which is now entering beta testing, according to Randall Oyer, MD, co-principal investigator and co-chair of the project advisory committee.

Improving practice operations is a strong theme in this month’s issue of 

. Two years ago, John Sprandio, MD, of Consultants in Medical Oncology and Hematology of Philadelphia, was asked by Capital BlueCross to help establish a patient-centered medical home model in 4 member practices. This year, the first batch of performance data emerged, showing strong reductions in emergency department (ED) visits and hospital admissions. Also, Capital BlueCross paid physicians incentives for the achievements but still managed to save money. Measures of care quality did not improve as much as hoped, but Capital and the participating practices are counting on the next round of data to show progress there, as well.

Arizona Oncology, in the lower half of the state, is an independent group of practices that had the opportunity to build a completely modern facility from the ground up. They usually rent their offices, which limits their ability to have things the way they want, but this time they worked with the architects directly to design the shell of their building and arrange for all other details, as well. The result: a facility with high-volume services near the entrance to minimize walking for patients and sta members. They put more nurse stations in the infusion center, also to improve efficiency, and installed a modern radiation center that does not require the heavy shielding typical of older designs, thus enabling them to position this area closer to the center of operations and further reduce walking time. They even installed cooling waterfalls to create a refreshing sense of peace, something patients likely will appreciate as Arizona’s temperatures continue to soar.

Chimeric antigen receptor T-cell therapy may soon hit the market, and numerous cancer care centers are poised to offer this for what may be the first FDA-approved indication: relapsed/refractory B-cell acute lymphoblastic leukemia.

Why Oncology Can Be a Tough Sell in Maine

Outpatient branded drug sales in the 340B Drug Pricing Program now amount to almost 8% of the total market, well up from 5.4% in 2012, according to a whitepaper from the Berkeley Research Group.

The new figure highlights the dramatic growth of 340B and fuels concerns about the abuse that government officials believe is rampant in the program.

Outpatient branded drug sales under 340B will reach $29.6 billion this year, up from $12.8 billion in 2012, according to the whitepaper. Total outpatient branded drug sales are projected to reach $379 billion, up from $238.6 billion.

340B began 25 years ago with noble intentions to improve drug access for poor, uninsured, and otherwise vulnerable patients by offering savings that hospitals could apply to patient care. However, that intent has been corrupted, say critics, who contend that many of the participating hospitals, clinics, and pharmacies take advantage of the program by pocketing the difference between the discounted price they pay for drugs and the full price they charge patients.

The Community Oncology Alliance (COA) calls the program a good idea gone bad. “We’re seeing patient impact,” said Ted Okon, the executive director of COA, adding that ineligibility to participate in 340B puts many community oncologists at a severe competitive disadvantage. “Unfortunately, [the hospitals] look at 340B as more of a business, as opposed to what it should be about—the patients.”

A July congressional hearing on oversight of the 340B program

 included a review of audits performed by the Health Resources and Services Administration (HRSA), the body tasked to oversee participating hospitals and clinics. Due to the lack of regulatory authority over 340B, HRSA is limited in its ability to prevent misuse.

“You have to wonder why a program that has gotten as big as it has, as quickly as it has, doesn’t have more oversight and infrastructure. Certainly that would be part of a long-term sustainability solution. Is it a panacea? It is not, but it is absolutely part of the solution,” said Stephanie Silverman, spokeswoman for the Alliance for Integrity and Reform of 340B (AIR340B), a group aimed at getting the program back on its original track, which includes public health, advocacy, and industry innovation.

In the hearing, elected representatives agreed that faithfulness to the program’s initial purpose must be protected but that greater transparency is needed.

Some have argued that 340B contributes to price inflation because drug manufacturers are trying to compensate for the discounts they have to offer the large number of participants in the program. “Among our many concerns is that the 340B program, because it is not carefully aligned with the interests of patients, and because its oversight is not as aggressive as it could be, is currently driving market prices that are hurting the interests of many patients and, in the case of community physician practices, also a number of physicians,” Silverman said.

With HRSA currently unable to effectively oversee the program by, for example, making hospitals disclose where their savings are allocated, other changes must be made to prevent the hospitals from taking advantage, reform advocates say.

On July 13, CMS issued a proposal for 2018 that would change the payment formula for some of the Medicare Part B drugs that hospitals purchase through 340B. “CMS is committed to transforming the Medicare program and updating our policies to provide high-quality and affordable patient-centered care. These changes require innovative strategies, and we look forward to receiving stakeholder comment and incorporating new ideas in our final rule this fall,” Seema Verma, CMS administrator, said in a statement. “Additionally, the proposed rule takes a critical step toward fulfilling President Trump’s promise to lower the cost of drugs, particularly for Medicare beneficiaries.”

COA applauded the proposal, saying that it would result in significant cost savings for senior patients, Medicare, and all taxpayers. Under the policy, hospitals would be paid the average drug sales price (ASP) minus 22.5%, instead of the current ASP plus 6% that they are paid for most Medicare Part B outpatient drugs, which include two-thirds of oncology drugs, Okon explained. The CMS proposal is “a start to take some of the excesses out of this program, which are just exorbitant,” he said.

Okon also called for Congress to pass legislation to ensure greater transparency of where funds go and more clearly define which patients are eligible for the discounted drugs. Silverman also suggested that Congress address eligibility criteria for institutions to make sure that intended populations benefit from the program.

A few representatives at the hearing were not in approval of the CMS proposal. Representative Diana DeGette (D, Colorado) was troubled by the aspect of reduced payments for Medicare Part B drugs to 340B-participating hospitals. “Unfortunately, I don’t think this hearing nor the rule proposed by CMS addresses the broad problem of high drug prices,” DeGette said.

Efforts will continue to address program abuses. “There’s a belief that 340B is a financial bubble and that it is now costing everybody more, hurting everybody more, because the hospitals have no accountability,” Okon said.

Vandervelde A, Blalock Measuring the relative size of the 340B program: 2012-2017. July 13, 2017. thinkbrg.com/media/publication/928_vandervelde_measuring340Bsizejuly-2017_web_final.pdf. 

The Energy and Commerce Committee. Examining HRSA’s oversight of the 340B Drug Pricing Program. July 18, 2017. E&C website. energycommerce.house.gov/hearings-andvotes/hearings/examining-hrsa-s-oversight-340b-drug-pricing-program. Published July 18, 2017. Accessed August 2, 2017.

Outpatient branded drug sales in the 340B Drug Pricing Program now amount to almost 8% of the total market, well up from 5.4% in 2012.

Proposed Changes to 340B May Curb Hospital Abuses

It is not far-fetched to believe that, one day soon, automated systems will be able to obtain payer approval for therapies without any human involvement, says Debra Patt, MD, a member of the The US Oncology Network breast cancer research committee. “I think that’s coming and will be incredibly useful to patient care.”

It’s something that payers want as well as oncologists. The bottom line is that payers want improved resource management, and it is not their intention to deny claims and preauthorization requests simply for the sake of saving money, Patt says. “Payers aren’t trying to put inappropriate barriers between patients and the care that they need. Those delays are the only way they know how to make sure that utilization is appropriate. If we find a way to make sure that utilization is appropriate by getting payers the data faster, that serves everyone, and so I think there’s a willingness to participate in those kinds of collaborative solutions.”

Patt, who practices in Austin, Texas, recently discussed some of the limitations and advances in electronic health reporting with Oncology Business Management™. Much of the initiative these days is focused on drawing information from electronic health records (EHRs) without human involvement. This relies on the data being in a structured format that computer systems can recognize and make sense of. The advances in developing and implementing these systems have been uneven.

Patt says that The US Oncology Network has been vigilant about using technical teams to design systems that allow for critical clinical data to be carefully structured in the EHR so that it is accessible to retrieval programs. But that isn’t the case everywhere. Many oncology practices don’t have the luxury of large technical support teams to develop this software. Companies like Flatiron that mine oncology information for clues to better treatment must employ human chart reviewers to pore through clinical information that is unstructured, she notes.

“We need to have consistency in the structured data we are using. In my practice, the doctor interacts with the health information systems systematically, but given our robust number of structured data elements, it’s a unique scenario,” Patt said. Even so, one of the problems encountered is that physicians have individual styles of reporting data, which can confuse even the strongest forms of artificial intelligence (AI).

Patt gave an example of how she and another doctor from her own practice might differ in the way they explain things to a hypothetical patient. “I might say to a woman, ‘You have stage II breast cancer, but you’re 80 and you’ve had a heart attack, so although chemotherapy might reduce your risk of recurrence, it might increase your risk of a heart attack and other morbid occurrences, and so I would not recommend chemotherapy.’” Conversely, a practitioner known for his Texas-style metaphorical way of speaking might tell the same patient the same thing, but in a way that no computer could recognize as identical to the opinion voiced by Patt. “He might say, ‘Mrs Smith, your breast cancer is not good, and we could give you chemotherapy, but that dog is not going to hunt.’ There’s no language processing system in the world that would see those 2 reports as the same, but because we oncologists have so much variability today in how we report various elements that influence our treatment and treatment choices, right now that remains a large barrier.” The only solution is to standardize systems and data reporting styles to cause that barrier to diminish, Patt said.

Being able to tap clinical systems for data is vital to the success of using real-world evidence (RWE) for oncology solutions. The potential inherent in RWE is exciting because there are questions about treatment efficacy that can be answered only by examination of clinical feedback on large populations of patients who have been treated. “Ultimately, when we feel comfortable with that data, I think it should be used to support FDA approval, because once we feel really comfortable with the information that we’re getting, we should make the most of that data and learn from all patients and not just the 35 that we may enroll in a particular clinical trial,” Patt said.

Efforts have been under way for a long time to peel away the barriers to putting RWE to good use. Kaiser Permanente and Emcore have been very active in this sphere. “Within The US Oncology Network, too, we’ve been publishing and using our data on RWE for a long time,” Patt said.

Part of the revolution in using RWE involves AI playing more and more of a role in the clinic, now even going into the examination room with the same oncologist would not have been able to research and interpret independently. This type of support is available currently in the form of tools such as Watson for Oncology, which has had hiccups in its development and acceptance, but has gained a following nonetheless among clinicians who see it as able to provide a computerized second opinion. “There’s a role for AI to assimilate all of the external information important to cancer decision making,” Patt says.

But the AI tool is only as good as its access to relevant data, she notes. “You have to make sure that there is good communication between your data systems--that you have a good bridge--and that you have a clinician who understands informatics and information systems, so that those systems are going to be implemented in ways that are clinically useful.” IBM is not the only company working on this problem. Syapse and Orien are among many that are working to funnel clinical data through automated processing systems to inform oncologists and enhance clinical outcomes.

Whenever the physician’s toolkit includes a computer screen, the debate over whether that screen time is going to be useful or burdensome is renewed. Once again, it’s important for computer systems to be well integrated, streamlined, and capable of providing useful guidance. Practices across the country have systems with varying degrees of sophistication. And where less sophistication means less computer capability, humans have to step in and do the work themselves.

The increasing complexity of oncology means that clinical-decision support systems are becoming essential, but most oncologists don’t yet have them, Patt says. The advantage of having these is that they can do the work of eliminating duplication in filling out forms and data fields on-screen for multiple different programs. Although working on-screen can seem like an added chore, once the computer has the data it needs, it can take over time-consuming tasks elsewhere in the process of managing patient care, Patt notes. “Once I’ve filled out that information, it also populates all of our other data systems, which will provide information to the payers that fund care, and getting the information to them allows us to get approval for chemotherapy faster. I don’t have to fill out the same information 7 times, because the systems are integrated.”

In fact, much of what she needs to do to document patient visits and treatment paths can be completed while she is in the examination room with the patient. “One patient I saw recently had stage I breast cancer. I put all of her information into the computer while I was in the room with her. It took just a few minutes. And then I wrote for her therapy while I was in the room because I was using a decision support system. After that, the system nudged me with guideline prompts for her treatment. As a society, we need to have systems that are integrated with our process flow so they don’t diminish our ability to care for patients.”

For this to happen, there has to be cooperation between the people who design the systems and those who use them. “Efficiency can come only when you have people to serve as the Rosetta Stone between these engineers who build these systems and the clinicians who actually use them. Within our US Oncology network, we’ve managed that by having a team of clinicians who advise on our health record endeavor. I spend a lot of time doing that, to try to make sure that these systems are optimized, that they’re efficient and maximize physicians’ time for patient care.”

There’s another payoff, too. All of these efforts help to reduce levels of frustration in the clinic. “There’s no tolerance for putting in the extra time. If you don’t have an efficient system, you have unhappy doctors,” said Patt.

It is not far-fetched to believe that, one day soon, automated systems will be able to obtain payer approval for therapies without any human involvement.

Artificial Intelligence Is Still a Long Way From Understanding the Subtlety of a Texas Metaphor

The hallmark of an antigen-specific response is when T cells recognize and attack an invading pathogen. This same phenomenon occurs in some but not all cancers. The process of neoplasia, which is the development of abnormal cell genomes, results in production and expression of neoantigens that elicit a similar T-cell—mediated response. Once activated against specific antigens, T cells will consume cells that express the antigen until all are eliminated or the T-cell response is turned off via checkpoints.

As the lead story in our upcoming September issue of Oncology Business Management will discuss, a new industry is forming based on our ability to block such checkpoints and enable the antigen-specific T cells to remain active; finish off malignant cells; and, potentially, cure the patient. However, not all tumors express antigens for which a complementary T-cell receptor may conveniently exist to initiate an antigen-specific immune response. Sometimes there are just too many tumor cells for in vivo T-cell generation to succeed. To overcome these limitations, scientists began to manipulate T cells through gene therapy in the early 1980s, leading to the development of functional chimeric antigen receptor T (CAR T) cells in 1989.

To have a specific antigen receptor expressed on the surface of a T cell, genetic engineers created DNA constructs that coded for monoclonal antibodies and inserted them into T-cell DNA using retroviral carriers. Once translated into the DNA, the monoclonal antibody expressed a receptor on the T-cell surface with specificity to the antigen expressed by a target malignant cell. Clinical trials have shown CAR T cells to be highly effective in eliminating cancer cells in some patients and seemingly curing those whose malignancy had failed all prior therapies, including bone marrow transplant. There are drawbacks to this therapy. Severe and life-threatening toxicities have occurred because the CAR T cells released cytokines that caused extensive tissue damage; in some cases, the CAR T cells recognized antigens on vital organs such as the heart and attacked, resulting in the death of the patient. However, there is no doubt that for select patients, CAR T cells will be the only real hope for cure of an otherwise incurable disease.

One can only imagine how complex and expensive it will be to mass-produce these cells for clinical use. So, despite all the excitement and anticipation, there is a growing anxiety among payers and providers: “What will CAR T cells cost?” Early estimates are in the hundreds of thousands of dollars. Soon, the warning bell will ring, and everyone will demand explanations for why these modified cells cost so much. Will this be another example of a high-flying technology that is overused and won’t add value to healthcare? I think not, but we must be cautious. The expense and complexity of this therapy demand that it work most of the time and replace another costly procedure—bone marrow transplantation. It is comforting to know that manufacturers of these products are considering value-based reimbursements, requiring payment only if the therapy eradicates all detectable cancer cells. In addition, this product must eliminate the need for other products and services so that revenues and expenses stay in balance. In prior days, if you could not afford a car, you walked. Here, you may not be able to not afford a CAR T cell if your life depends on it, so we must find a place for CAR T cells in our healthcare budgets.

Despite all the excitement and anticipation, there is a growing anxiety among payers and providers regarding the cost of CAR T cells.

What If You Cannot Afford CAR T-Cells?

You would expect patients with suspected lung cancer to be eager to receive care, but that isn’t always the case. MaineGeneral Health, of Augusta, Maine, has had to combat an “I’m going to die from something anyway” attitude that makes patients unlikely to follow up with care recommendations and referrals.

This was one of the problems tackled at MaineGeneral’s Harold Alfond Center for Cancer Care, a development site for a program to improve treatment for Medicaid patients with lung cancer, who are at higher risk of poor outcomes. The Optimal Care Coordination Model (OCCM), sponsored by Bristol-Myers Squibb Foundation and developed by the Association of Community Cancer Centers (ACCC), was established in recognition of the fact that tobacco use is nearly twice as high among Medicaid patients as among the national population—29% of patients covered by Medicaid smoke, and tobacco use is the leading cause of lung cancer.

During the first year of the 3-year project, which concluded in December 2016, studies were made of cancer centers at 5 locations across the United States to identify challenges and success in caring for patients with lung cancer, and these findings were incorporated into planning for the OCCM test model for improved care. Those centers were Florida Hospital Memorial Medical Center; Mary Bird Perkins-Our Lady of the Lake Cancer Center in Baton Rouge, Louisiana; MaineGeneral Health-Harold Alfond Center for Cancer Care; Genesis Cancer Care Center in Zanesville, Ohio; and the Sidney Kimmel Cancer Center-Methodist Hospital at Thomas Jefferson University in Philadelphia. At all sites, program staff, physicians, referring providers, and even lung cancer patients who received Medicaid benefits took part in focus group interviews.

During the second phase of the project, which continues through the end of September 2017, the test version of the OCCM is being drafted. The OCCM builds upon National Cancer Institute Community Cancer Centers Program multidisciplinary care assessment tool and addresses patient access to care, care coordination, treatment team integration, survivorship care, tobacco cessation, physician engagement, and quality measurement and improvement.

Strength of Innovation Defined by Magnitude of Problem

For the 1-year final phase, which begins in October 2017, seven ACCC member programs, including 2 cancer centers that participated as development sites, were chosen to test the OCCM by implementing quality improvement projects. “The purpose of the study is to put together coordination programs with more timely access and better outcomes for people who may be underserved by the general medical processes and may have additional medical problems or comorbidities that may require time, attention, and coordination in addition to lung cancer treatment,” said Randall A. Oyer, MD, oncology director of the Ann B. Barshinger Cancer Institute in Lancaster, Pennsylvania. Along with Christopher Lathan, MD, a medical oncologist in the Lowe Center for Thoracic Oncology at the Dana Farber Cancer Institute in Boston, Oyer serves as both the project co-principal investigator and co-chair of the project advisory committee.

Some intensely challenging problems and innovative solutions were documented as part of the first, investigational phase of the project. At MaineGeneral, the difficulty of getting patients to show up for treatment was compounded by their lack of resources and their tendency to shun treatment. Many suspected cases of lung cancer were picked up only when patients turn up at emergency departments (EDs), which they rely on for primary care. Primary care physicians (PCPs) also tended not to appreciate the value of low-dose computed tomography scans and neglected to have pathology done when sending abnormal images, requiring fresh scans and biopsies at the cancer center.

To combat these problems, MaineGeneral arranged for PCP training both in and out of network to ensure compliance with prescreening protocol and established community-based education sessions to promote the importance of lung cancer screening. Geographic areas with known high tobacco use and high radon exposure were targeted for more focused efforts to identify candidates for screening. The Harold Alfond Center has encountered and solved many other problems related to lung cancer care. Similar barriers to access have been managed successfully at Mary Bird Perkins in Baton Rouge, which made this cancer program worthy of study in developing the OCCM. Patients tended to skip regular checkups and enter the system only after visiting EDs. To make matters worse, Medicaid requires a PCP referral for screening and diagnostic tests. Patients were not getting appropriate referrals through the healthcare system owing to the lack of a clinical pathway for lung cancer.

The solutions enacted at the Louisiana practice included developing a prompt in the electronic medical record so that PCPs would recognize candidates for screening. Further, PCPs were given educational materials on how to talk with patients regarding the risks and benefits of screening. A facility was designated as a “center of excellence” for lung cancer screening, and funds were earmarked to help at-risk populations.

Still, patient tracking issues persisted, Medicaid coverage restrictions posed additional complications, and scheduling and other program access challenges arose from patients’ lack of contact information or transportation.

Mary Bird Perkins standardized care for Medicaid patients; improved coordination of appointments; and encouraged more effective collaboration among surgeons, pulmonologists, and other physicians. Also, patient follow-up improved with the help of “post-op” teams and nurses.

At Florida Hospital Cancer Institute (FHCI) in Volusia County, in the state’s northeast section, one of the challenges was to develop an outreach program that created earlier screening opportunities for patients at high risk of lung cancer. Volusia County has a much higher rate of chronic adult smokers than the rest of Florida: 23% versus 17%. Tremendous delays in care were reported for the Medicaid population, partly because these patients are assigned a lower priority for PCP visits, and low numbers of PCPs and specialists in the area accept Medicaid. PCPs also cap the number of Medicaid patients they see. Most lung cancer patients with Medicaid coverage are stage III to IV by the time they get to the institute, FHCI reported. Owing to contract issues, FHCI had difficulty getting referrals from pulmonologists; instead, patients were sent to academic centers farther away.

Helping to Overcome the Medicaid Disadvantage

The solutions that made FHCI a choice for study in developing the OCCM included closer coordination between PCPs and imaging navigators and radiation oncologists. Other steps forward involved prioritizing thoracic malignancies for surgical care; improving communication between inpatient and outpatient teams; and implementing a lung nodule clinic, as well as a clinical care pathway for lung navigators.

It was clear to the OCCM project contributors that lung cancer is difficult for patients to manage without exceptional support and that Medicaid patients, who have fewer resources, tend to be at a particular disadvantage. “It takes a sophisticated person to be able to navigate the system,” Oyer said. Patients with lung cancer often lack the necessary insurance, education, and financial resources to get by. “Smoking is heavy, and there may be additional health disparities that may affect somebody’s ability to get into the system,” he said. “Sometimes the community hospitals that the patients have access to don’t have well-developed multidisciplinary programs.”

It’s essential to think of these patients as individuals with lung cancer rather than depersonalize them as a population that must be handled en masse, Oyer said. This involves carefully weighing their diverse psychosocial needs, financial needs, and comorbidities, for example. He believes that this evolution in thinking occurred at the development sites that helped sculpt the first outlines of the OCCM.

Improving or starting patient navigator programs has been a foundation of the OCCM, Oyer said. Another cornerstone principle: recognizing the importance of multidisciplinary care team coordination to deliver timely care. “You need to have a diagnostic radiologist, pathologists, medical oncologists, radiation oncologists, and surgeons,” he said.

Oyer stressed the diversity of challenges and resources at each of the development sites and noted that there is no one-size-fits-all approach. Achieving some goals may require more effort and investment for some institutions than for others. “You can’t do the same thing in every program. You have to adapt your methods and organization structure,” he said. “A hospital in New Jersey that has strong financial counselors and social workers can build on them. The hospital may be downtown, and people can get to it easily. On the other hand, in a rural area, people may have to travel a great distance to the hospital, so something you’ll need to coordinate is transportation.”

Having set the criteria for participation and standards for care, the OCCM Advisory Committee will convene in coming months to learn more about the testing sites’ progress with implementing their quality improvement projects. “We’ll ask the hard questions,” Oyer said. “What are the barriers? How did you solve them? How quickly are you getting your patients in, and what support do you need to provide?” Progress with patient and physician engagement also will be reviewed.

No one center is expected to ace every point. In fact, the purpose of the reviews will be to learn from each center’s experiences and share that knowledge with others, Oyer said.

The major questions will revolve around how these cancer centers succeeded in identifying and treating patients with lung cancer who normally skirt the healthcare system or fall through the cracks, Oyer said: “How did you get that patient scheduled for a CT scan, get a lung biopsy done, and get them plugged in to multidisciplinary lung cancer care? How did you turn that person into an engaged patient who had follow-up with your care team? What lessons did you learn that somebody else would have to spend 6 months learning?”

It’s impossible to know many of those answers at the beginning, and it’s only through the experience of one center that others can approach a model like the OCCM and start off on the right foot, without the learning curve, Oyer said. But in a year’s time, newcomers can follow a road map for success based on a lot of accumulated experience—“pretty much smooth sailing in what could have been the wild, wild West,” he said.

The ACCC has long recognized the principle of mass-producing success based on an individual cancer center’s achievement, Oyer said. But equally important is enrolling already successful practice participants in the model, because those are the ones that are likely to break new ground. “The way the ACCC works is, they find people who’ve done some components of what they want to accomplish,” he said. “They find experts and test the findings, and then they come up with something you can do back at home. They’ve done that with molecular testing; they’ve done it for exercise in cancer, for navigation programs, and for lung cancer screening.”

The Association of Community Cancer Centers has long recognized the principle of mass-producing success based on an individual cancer center's achievement.

ACCC Seeks to Build a Better Lung Cancer Model

Despite improved outcomes with new treatment and, especially, targeted therapies, patients with cancer continue to be afflicted by distressing symptoms and serious toxicities, which affect daily functioning and quality of life. Symptom burden is notable during therapy and can persist long after treatment. The patient and family experience is dominated by coping with symptom distress, including fatigue, gastrointestinal disturbances, and pain.

At the beginning of treatment, clinicians can provide patients with a variety of prescriptions for symptom prevention and treatment, as well as written educational materials on symptom management. When symptoms are not well controlled, patients must reach out to clinicians for additional help. Yet, there is evidence that patients do not always call, and symptom burden remains significant. Follow-up visits are constrained by limited available time. To make matters worse, clinicians are known to underestimate symptoms experienced by patients with cancer. Poorly controlled symptoms can result in emergency department (ED) visits, unplanned hospitalizations, delays in treatment, and lack of adherence to an effective treatment course.

Quality cancer care requires a focus not only on the tumor but also on the illness experience for patients and their families. The patient’s perspective on what constitutes value is central to improving quality. Studies have shown that cancer symptom monitoring and self-care support significantly improve survival

 However, patient experience, including symptom presence and severity, has not been tracked or documented in electronic health records (EHRs) as systematically as serum lab values and tumor markers have.

Adding patient-reported outcomes (PROs) to routine clinical care is certainly possible by using contemporary EHRs with patient portals, which benefit patients by providing access to information about appointments, test results, and prescriptions. Incorporating PROs, as well, requires significant planning, logistics, and adjustment in care delivery practices. Low vendor and institutional priorities for integration of PRO data into EHR systems, lack of payment for implementing and monitoring PROs, and lack of effective processes for integration into the clinical care workflow all present barriers to consistent tracking.

Prompting patients to report symptom distress between and prior to face-to-face visits can improve the quality of life, save lives, and reduce costly ED visits. Having the PROs available before walking into the exam room enables the clinician to focus on the assessment and avoid a game of 20 questions, during which many patients will deny existing issues. A variety of validated cancer-symptom questionnaires are available.

 The choice will depend on the setting and treatments, as well as the need to avoid burdening patients with too many questions or, conversely, failing to cover the important issues sufficiently. Practices may want to tailor online questionnaires to specific treatment regimens. How frequently patients are asked to report symptoms must be considered. If the PROs will be used only for care while a patient is on therapy, then an assessment within 24 hours prior to each clinic visit, plus the receipt of weekly patient-generated reports from home between visits, will help catch serious issues. However, if PROs will also be used for analyses of aggregate data, then a uniform, date-specific approach may be warranted (eg, pretreatment, monthly for the first year).

That monitoring could be achieved with a common technology: the patient portal component of an EHR. There are at least 5 requisites for implementation success: Patients must enroll to use the portal, the interface must be usable by patients of all literacy levels, clinicians should state the expectation that patients will use the portal to enhance communication, clinician response must be consistent and reliable, and a champion for implementation must oversee access and response metrics. The long-term results can certainly be beneficial, given careful planning and implementation.

Basch E, Deal AM, Dueck AC, et al. Overall survival results of a trial assessing patient-reported outcomes for symptom monitoring during routine cancer treatment. 

 2017;318:197-198. doi: 10.1001/jama.2017.7156.

Fann JR, Hong F, Halpenny B, Blonquist TM, Berry DL. Psychosocial outcomes of an electronic self-report assessment and self-care intervention for patients with cancer: a randomized controlled trial. 

Berry DL, Hong F, Halpenny B, et al. Electronic self-report assessment for cancer and self-care support: results of a multicenter randomized trial. 

 2014;32:199-205. doi: 10.1200/JCO.2013.48.6662.

Basch E. Patient-reported outcomes—harnessing patients’ voices to improve clinical care. 

2017;376:105-108. doi: 10.1056/NEJMp1611252.

Jensen RE, Moinpour CM, Potosky AL, et al. Responsiveness of 8 patient-reported outcomes measurement information system (PROMIS) measures in a large, community-based cancer study cohort.

 2017;123:327-35. doi: 10.1002/cncr.30354.

Despite improved outcomes with new treatment and targeted therapies, patients with cancer continue to be afflicted by distressing symptoms and serious toxicities, which affect daily functioning and quality of life.

PROs Save Money, Lives, and Improve QoL

Typical examination room doors separate slightly from the doorframe as they open and allow passersby to see into the rooms. It’s hardly ideal for a half-dressed patient inside. That’s why the new Arizona Oncology building at Arizona State University Research Park, southeast of Phoenix, has door-length hinges that eliminate gaps and protect patients from exposure.

It’s a small detail, but it illustrates how much architects can tailor new buildings to oncology’s specific needs and why Arizona Oncology, as it tries to succeed in an unusually competitive market, built its newest facility from the ground up rather than renting generic offices.

The greater Phoenix area is home to at least a half dozen other private practices, several large hospital chains, and satellite branches of the Mayo Clinic and MD Anderson Cancer Center. Each of these competitors is constantly working to expand its treatment options, improve the patient experience, and increase market share.

The freedom to build and expand can work against the best interests of practices. “Unlike some other states, Arizona does not require medical practices to demonstrate need for new services,” said Snehal Bhoola, MD, a practice partner who specializes in gynecologic oncology. “Private practices and corporations can build new facilities, buy new equipment, and otherwise expand as they see fit. It does not create the most stable and secure of business climates for healthcare providers, but it’s probably a good thing overall because it keeps us striving to get better and innovate.

“There are, obviously, a huge number of factors that decide which practices will succeed. We believe that all-inclusive facilities are a major differentiating factor and that this new location will be a major competitive advantage for us in the region it serves,” he said.

The 22,000-square-foot building has 19 exam rooms, 35 infusion chairs, a compounding pharmacy that is compliant with pending US Pharmacopeia <800> standards, and a retail pharmacy. Its diagnostic-imaging nuclear medicine department houses a positron emission tomography—computed tomography scan. Its 2 concrete radiology treatment vaults contain an external-beam treatment linear accelerator and internal radiation therapy with high-dose radiation brachytherapy equipment. Its staff includes 3 medical oncologists, 2 gynecologic oncologists, and 1 radiation oncologist, as well as genetic counselors, dedicated research nurses, financial counselors, nurse navigators, pharmacists, and nurses specializing in every cancer treatment modality.

Among Arizona Oncology’s competitors, only Mayo and MD Anderson can boast of so many treatment options under a single roof, and Bhoola contends that good design makes the new facility better for most patients than anything those renowned organizations can offer.

For example, patients park in a small lot, a short distance from the entrance, rather than in a huge garage that would require a long walk. The facility itself, while large by the standards of private oncology, still does not approach the dimensions of most hospitals. The radiation vaults are a few steps from the infusion chairs instead of being down in a distant basement.

Avoiding those extra steps is important to patients who are often significantly weakened by cancer and chemotherapy. Workers appreciate the convenience as well. Time spent walking affects productivity, which is why the architects who designed Arizona Oncology’s new facility modified their plans again and again to minimize steps for patients and staff alike.

“Essentially, we calculated all the places that every person inside the building would typically need to go and compared the efficiency of various layouts, with the emphasis on saving steps for patients,” said lead architect David B. Howell, the principal at David B. Howell Architecture & Design, of Tucson, Arizona.

Typical medical office design has cancer patients moving back and forth from a single large waiting area to examination rooms, infusion chairs, and other treatment zones. In the new Arizona Oncology building, each division—medical, gynecologic and radiation&mdash;has its own corridor, and the treatment rooms are organized such that the rooms patients are most likely to visit are closest to the entrance. To spare patients from unnecessary walking, there are mini-waiting areas between each of the major service areas.

“The emphasis on efficiency carried over into the individual rooms as well,” Howell said. “Many large treatment centers put a single nursing station to one side of their main infusion rooms. The new center has several nursing stations, so each nurse is closer to patients. Shave a few seconds off each walk and multiply that by the hundreds of trips that a nurse makes in a typical day, and you’ve given nurses significantly more time to help patients.”

Arizona Oncology now has 80 physicians practicing at 3 dozen locations in the lower half of the state, from Flagstaff to Nogales. It is thus a very large private practice, but its size is a recent development. As late as 2008, the practice had just 6 medical oncologists.

The decision to expand came in response to the increasing cost and complexity of cancer care and the increasing competition, much of it from large and well-funded organizations. MD Anderson teamed up with Banner Health to open a cancer treatment center in the Phoenix suburb of Gilbert. The Mayo Clinic has made huge investments on cancer care in Phoenix, including the construction of a $180 million proton beam facility, which opened last year.

Arizona Oncology was already part of the US Oncology network, which helps its members with nonmedical tasks ranging from purchasing to marketing, administration, and business planning. The practice partners, therefore, sat down with the business experts from US Oncology and devised a response to the changing market conditions, a response that entailed transforming the small medical oncology practice into a large and comprehensive cancer care organization that operated across the state.

Arizona Oncology’s growth has come from hiring new physicians and merging with existing practices. The increased scale brought many benefits. The practice could pitch itself to referring doctors as the right place to send their patients with cancer. It could afford to advertise itself via television and radio and billboards in one of the nation’s largest media markets. It even had the size to begin moving some of its offices from generic rental space to custom-designed facilities.

The new treatment center near Arizona State University is the first that Arizona Oncology both owns and built for itself, but 3 more of its offices were designed and built specifically for its operations and are in rented space.

“Determining where to put the treatment centers and how large to make them is more of an art than a science,” said Jeff Siupik, director of Arizona Oncology’s radiation services and practice development. “On the one hand, you want lots of well-distributed offices so you’re close to everyone. On the other hand, you want those offices to be large enough to offer a comprehensive treatment list.… We’re very happy with the balance struck by the new treatment center. It offers everything a specialty hospital can short of proton beam therapy, but it packs everything into a human-sized facility that’s convenient to a large patient population.”

As one of the practices that participates in CMS’ Oncology Care Model, Arizona Oncology has expanded its operating hours, started opening on Saturdays, and taken other steps designed to reduce long-term costs by giving patients the sort of easy access designed to address health issues early in development.

The practice has been talking to the local private payers about moving from strict fee-for-service reimbursement to fee-for-outcome payment, which would allow the practice to choose and design patient-centered services that would keep patients out of hospital beds and emergency departments. It would also allow the practice to share in the savings from reduced hospital use.

Those discussions have yet to result in any changes to Arizona Oncology’s compensation model, but periodic discussions are taking place with UnitedHealthcare, Blue Cross Blue Shield, and Aetna. Indeed, Bhoola and his partners believe that some flavor of fee-for-outcome is the future, and the only question is when pilot programs will produce enough data on best practices to trigger a significant shift.

Architects can tailor new buildings to oncology’s specific needs and Arizona Oncology built its newest facility from the ground up rather than renting generic offices.

Arizona Oncology Center Uses State of the Art Facility to Gain Market Share

Not enough is known about older populations of patients with cancer. They tend to be frailer, they have comorbidities, and they may be on multiple medications. Yet when it comes to treating them for cancer, it’s often the case that the only available data are based on trials of younger patients in far healthier condition.

All of that is about to change, says Grace Lu-Yao, MD, a pioneer in the use of big data to gain clearer understanding of how patients with cancer are affected by treatments. Lu-Yao, for example, worked with the Prostate Patient Outcomes Research Team on a large-scale study to document the treatment patterns of prostate cancer and to understand the value of conservative management for low-risk prostate cancer. The finding, first published in the 

Journal of the American Medical Association

 was so revolutionary at the time that it was initially resisted by the cancer community, which had difficulty accepting that quality-adjusted life years saved following conservative management of prostate cancer could be roughly equivalent to surgery or radiation therapy.

Clinical data-sharing partnerships established this summer by CancerLinQ, the FDA, and the National Cancer Institute (NCI) may bring more discoveries like this. Under these agreements, vast amounts of patient data—essentially real-world evidence (RWE)&mdash;will be shared among these institutions and the many cancer treatment centers operating across the United States. What happens in the community clinic, for example, will be relayed to the FDA to help inform drug policy decisions; and what is gathered and stored in the NCI’s Surveillance, Epidemiology, and End Results program will be available to far-flung clinics that need to know how a certain drug will affect geriatric populations&mdash;something that only recorded data gathered from multiple cancer centers may show.

“The difficulty we have is that most evidence, the gold standard, comes from clinical trials,” said Lu-Yao, associate director for Population Science at the Sidney Kimmel Cancer Center at Jefferson University in Philadelphia. “Yet clinical trials a lot of the time really are quite stringent. Their criteria are such that about half of elderly patients will not be eligible for clinical trials. Therefore, the result from clinical trials may not be applicable to these so-called vulnerable or frail populations.”

Lu-Yao, a widely respected epidemiologist, said that population science is made for this new wave of RWE. Many of the studies she has done have been based on analyses of large data pools, and her insights into prostate cancer treatment exemplify how investigation of existing information can be as useful as active trials that involve tests of drug efficacy. In other words, much information already exists. It just needs to be crunched and interpreted and put to good use.

More data are exactly what is needed to improve geriatric oncology, agrees Hyman Muss, MD, who directs the Geriatric Oncology Program at the University of North Carolina (UNC) Lineberger Comprehensive Cancer Center. Checkpoint inhibitors are so new that not enough is known about how they should be used in older populations. “Very few older patients have been on these studies, so we really don’t know how they fair with these treatments, especially when it comes to fatigue and functional change. I suspect there are not going to be dramatic differences in nausea and vomiting and other adverse events, but to take an older patient who is barely making it in the community [because of existing health problems] and add profound fatigue or some muscle weakness is going to really change that patient's life, and we know very little about it,” Muss said.

The shortcomings of clinical trials can be remedied in various ways by the broad sweep inherent in big data analysis, Lu-Yao explained. Rare adverse events that would not be spotted in smaller patient samples will be recognized and cataloged in the larger analysis. This can remove more of the uncertainty from the treatment process.

Lu-Yao has a special interest in developing risk-assessment tools that incorporate aggregated patient data and clarify the potential problems from a given medication. At Kimmel, she and others are building the first race-specific prediction model for prostate cancer. This would incorporate biomarkers, comorbidity status, and all clinical prognostic factors so that physicians can tell patients how likely they are to have disease progression or die from competing causes. The tool would enable doctors to judge whether aggressive treatment is a good option for a patient.

The Population Science center at Kimmel was created to enable integrated, multidisciplinary teams to make cancer-related discoveries and translate those findings to the clinical setting, with special emphasis on addressing the health needs of Philadelphia region. The diversity of this area makes understanding race-specific health issues paramount. In the greater Philadelphia area, the mortality rate for prostate cancer among African American men is twice that of white males. Currently, Kimmel is doing an intervention study in the poorest neighborhoods with the highest cancer burden to learn how education and changes in lifestyle can reduce the burden of cancer, Lu-Yao said.

Studies of dietary intervention and other forms of holistic care are fundamental to those investigations, she said. The Population Science team is conducting the first in-field human trial in breast cancer and prostate cancer patients to determine the value of caloric restriction as a therapeutic intervention. “In animal studies, we found that caloric restriction could delay metastases substantially, to a point almost comparable with radiotherapy, and it can improve treatment response of radiotherapy and chemotherapy. These results are really impressive,” Lu-Yao said.

She believes that if a clinical trial can demonstrate that caloric restriction is effective in delaying cancer metastasis, the implications in how cancer is managed would be huge. “We all know even the very expensive novel cancer therapies develop resistance, even in a few months, and dietary intervention is relatively safe by comparison, and it’s much more cost-efficient and less likely to have drug-resistance issues.”

The holistic approach to care also is endorsed by Muss, who is working with collaborators from the Duke Cancer Center, MD Anderson, and UNC to understand how exercise may slow or impede the process of rapid aging that occurs in patients who undergo chemotherapy. “Our treatment ages people, and what we’re trying to do is look at how simple interventions like exercise—a walking exercise&mdash;affects molecular changes reflective of aging and cell senescence. We’re monitoring people with Fitbits, we’re using a simple walking program, and we’re measuring their molecular markers of aging. It’s really a lot of fun, and when they’re done with treatment, we’re trying to enroll these older patients in special rehab programs that can keep them as functional as possible with a strategy that is very scalable,” Muss said.

In July 2017, Kimmel launched the Neu Center for Supportive Medicine and Cancer Survivorship, which will examine how quality of life, resource utilization, and cancer outcomes are improved by psychosocial support services. “We have applied ourselves to provide holistic care, not just to treat cancer but to treat the whole person,” Lu-Yao said.

Although her team’s findings in low-risk prostate cancer and conservative management took years to achieve acceptance from the broader cancer community, Lu-Yao said it is important to ensure that findings are corroborated. After nearly 2 decades, Lu-Yao and her team are now enjoying official confirmation of their research findings and the impact on the management of prostate cancer patients around the world. In 2010, the National Comprehensive Cancer Network adopted active surveillance as one of the viable options for patients with low-risk prostate cancer; and last year, the American Society of Clinical Oncology included active surveillance as an option for patients with low-risk prostate cancer.

1. Lu-Yao GL, McLerran D, Wasson J, Wennberg JE. An assessment of radical prostatectomy. Time trends, geographic variation, and outcomes. 

When it comes to treating older populations for cancer, it’s often the case that the only available data are based on trials of younger patients in far healthier condition.

September 2017 | Oncology Business News®