1. Nalley, Catlin

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NEW YORK CITY-The rate of treatment discoveries and innovations continues to gain momentum in oncology, but do all patients have access to state-of-the-art care?

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Many individuals who receive a cancer diagnosis do not live close to academic hospitals or NCI-designated facilities. When extensive travel is not an option, what can oncologists do to ensure all of their patients have access to the best treatment options?


Recognizing this need, in 2006, the Tahoe Forest Health System, in Truckee, Calif., located in a remote resort town of 15,000 with no prior oncology services, sought to create a cancer program. That's where Laurence J. Heifetz, MD, FACP, Clinical Professor of Medicine, UC Davis School of Medicine, and Medical Director of the now established Gene Upshaw Memorial Tahoe Forest Cancer Center, Truckee, Calif., comes in. Tapped to lead this initiative, Heifetz, who had a full career at Cedars-Sinai, a 900-bed, 2,000-physician medical center outside of Beverly Hills, Calif., was up to the challenge.


"Small rural hospitals in the U.S. have had challenging issues developing sustainable oncology programs," he said during a presentation at the Chemotherapy Foundation Symposium, held Nov. 8-10.


Building the Infrastructure

Everyone with a diagnosis of cancer has universal fears: death, pain, and disability. Other patient fears include the fear of getting disorganized care, becoming a burden on family and caregivers, and receiving "yesterday's therapy." While these concerns exist in the urban setting, they are amplified in rural areas, Heifetz noted.


As Heifetz and his team developed the cancer program, they sought to alleviate these fears and established a set of guiding principles:


* provide universal access to care;


* address enhanced rural fears;


* reach out to thought leaders;


* use technology to lessen the sense of isolation in a rural area; and


* engage local businesses and community leaders.



The Pareto principle, or the 80/20 rule, which says most results are due to a small set of causes, is also biologic, noted Heifetz, and this rule was applied in the development of the new cancer program. There are 20 major cancer sites, but four of them (20%) comprise 80 percent of all of our patients (colorectal, prostate, lung, and breast)," he explained. "Since we were a brand-new program, we chose to focus on these four disease types, which helped to develop the infrastructure for other cancers."


Virtual Tumor Board

Not long after the Gene Upshaw Memorial Tahoe Forest Cancer Center was opened with one medical oncologist and one nurse practitioner, the team met with clinicians at UC Davis Comprehensive Cancer Center in Sacramento, Calif., who were in the process of developing a cancer network that aimed to serve smaller communities. Heifetz's cancer center joined as a founding member.


To strengthen their partnership and provide more resources to their patients, the Virtual Tumor Board was created. Following the 80/20 rule, the team holds a disease-specific tumor board each day: gastrointestinal cases are reviewed on Monday; genitourinary on Tuesday; thoracic on Wednesday; and breast on Thursday.


The conference room includes a teleconferencing center that allows all participants to see one another and MRIs, pathology slides, presentations, etc.


How important are academic partnerships? To emphasize the stakes, Heifetz shared an example during his presentation. "It is important to remember that 80 percent of patients are being taken care of by community oncologists, not large cancer centers," he noted. "In 1974, Lawrence Einhorn, MD, started his trial of testicular cancer with cisplatin."


At that time, the 18-month survival for advanced disease was 38 percent, according to Heifetz. "In 1976, the first abstract was released and the paper was published 2 years later; 18-month survival was now 80 percent," he said. "There was a 4-year knowledge lag. If oncologists within 200 miles of Indiana University had been able to participate in a virtual tumor board at that time, they would have known about this trial.


"Their patients could have had access and may have lived instead of died during that 4-year interval," Heifetz emphasized. "It is extraordinarily important to have an academic partner if you are in community practice."


The Sierra Crest Initiative

Heifetz and his team did not limit the opportunities for community engagement to their partnership with UC Davis.


"We are located in the mountains, but we have patients coming to us from even farther away," he noted. "How do we harness telehealth for them?"


With this goal in mind, the team became more comfortable in front of the camera and honed their use of telecommunication tools. Remote telemedicine clinics staffed with a nurse practitioner were developed at the local hospitals. Patients continued to receive chemotherapy and radiation in Truckee, but follow-up and interim visits took place at the local facilities via telemedicine.


"Just as your internet signal degrades over distance so does knowledge; therefore, it stands to reason that this synaptic knowledge network will diminish that loss," Heifetz said. "This simple concept can be rolled out to the rest of the UC Davis Cancer Care Network, and then let's roll it out to the rest of the 69 NCI-designated cancer centers in the country. Why shouldn't we imagine that we can do this?"


This collaborative approach offers an array of benefits to all parties involved from the large cancer center to the community hospital to the patients they serve.


For UC Davis, they have seen an increased clinical trial accrual, according to Heifetz. "They became our preferred referral site, and it has never been easier to refer a patient," he noted. "I can see a patient with lung cancer on Thursday, present to the Virtual Tumor Board on Wednesday, and get him to see the UC Davis thoracic team the next week who will already know who he is.


"We have gone from 100 percent out-migration from our primary catchment area to 52 percent in-migration from outside our catchment area."


Heifetz concluded his presentation with a few key takeaways. "Appreciate the 80/20 rule; develop a virtual disease-specific, case-based conference with regional thought leaders to keep up with the exponential knowledge base growth; and use technology to improve doctor/doctor relationships and your doctor/patient communications.


"And lastly, utilize technology to enable effective outreach to remote patients and build your systems to address those patients' fears."


Catlin Nalley is associate editor.