1. Eastman, Peggy

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The 2020 Annual Meeting & Cancer Center Business Summit of the Association of Community Cancer Centers (ACCC) in Washington, D.C., highlighted trends showing how the field of oncology is currently in transition from hands-on care to more "distributed care" such as telehealth.

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An overarching theme at the meeting was the need to embrace the integration of innovative technologies such as telehealth into cancer care delivery while maintaining the highest standards of quality. At a time of oncology workforce shortages, cancer care that takes advantage of virtual technologies can increase the breadth of oncologists' expertise, help to solve unequal workforce distribution, ease the burdens of an increasing patient load, provide professional education, and decrease disparities in access to care, said keynote speaker Susan Dentzer, Senior Policy Fellow at the Duke-Margolis Center for Health Policy.


"The status quo is not an option," said Dentzer of the traditional cancer care delivery infrastructure. She predicted that innovative technology applications in oncology will grow, but she noted that using such technologies in cancer care has lagged.


"We have Star Wars medicine but we are delivering it on a Flintstones platform," she said. Indeed, during live polling at the 2019 ACCC National Oncology Conference, nearly half (44%) of those polled said their cancer care program did not currently use telehealth, as reported in the ACCC's 2019 Trending Now in Cancer Care Survey. Of those programs that do provide telehealth, the top four telehealth services are tumor boards (45%), genetic counseling (32%), molecular tumor boards (24%), and second opinions (16%).


Although their use has lagged, studies show that telehealth and "distributed care" programs have a high satisfaction level with cancer patients, said Dentzer. "Patients prefer to be at home."


She cited Huntsman at Home, a program of the University of Utah's Huntsman Cancer Institute. This program allows cancer patients to leave the hospital sooner or avoid going in at all. Health care providers visit patients in their homes to help them manage and control symptoms such as nausea, vomiting, or dehydration. The program, which encompasses palliative care, includes physicians and advanced practice registered nurses, and may also bring in community specialists such as pharmacists and social workers.


Examples of oncology telehealth programs for patients at home currently operating in the United States include symptom management via an interactive telephone-based voice response system, remotely monitoring the effectiveness of chemotherapy, and remote hospice support for patients and their caregivers. The smartphone has become a major vehicle for telehealth care delivery, noted Dentzer. She cited project L.A.U.N.C.H. (Linking & Amplifying User-Centered Networks through Connected Health), a broadband cancer collaboration between the Federal Communications Commission and the National Cancer Institute. L.A.U.N.C.H. is a broadband-enabled, connected telehealth program focused on improving cancer symptom management in the rural Appalachian mountains of eastern Kentucky. "We're seeing broad platforms for patient support," noted Dentzer.


A radiation oncologist in the audience at the ACCC meeting told Dentzer that he much preferred to see his patients in person face to face; she replied that in the future technology-enabled telehealth will not replace clinic visits but become part of a balanced combination of in-person and virtual consultations.


While telehealth can expand oncology services, major barriers continue to impede its evolution. On the 2019 ACCC trends survey of cancer programs, 74 percent of those counted in live polling listed reimbursement as a major barrier; 58 percent named regulatory requirements; and 58 percent listed operational changes required, such as staffing or technology. Dentzer agreed that these barriers can be considerable. Specifically, she said barriers may include privacy and security, licensing, existing payment models, lack of broadband access in rural areas, and the need for workforce retraining on how to use telehealth technology.


Despite these barriers, the ACCC 2019 trends survey showed that in the next 2 years a number of cancer programs planned to provide telehealth services. These include genetic counseling (35%); symptom management consults (28%); oral chemotherapy adherence and support (28%); symptom monitoring, for example through an app (28%); psychosocial counseling (24%); nutrition counseling (22%); financial navigation (21%); survivorship visits (21%); and tumor boards (21%).


"Acceptance is growing for teleoncology," said Linda D. Bosserman, MD, FACP, FASCO, Assistant Clinical Professor at the City of Hope, in a telehealth session at the 2020 ACCC meeting. Bosserman cited the "Amazon spillover effect," which means that young people, especially, want their medical care delivered at Amazon's high level of performance. They are used to ordering what they want and have a high level of expectation of getting it wherever they are. "They are mobile and they want expertise."


Bosserman said examples of teleoncology at the City of Hope include remote teaching throughout the world on cancer genomics, clinical cancer genomics education and training, and remote second opinions. "Our genomics program led things in telehealth," she noted, advising cancer program administrators planning to implement telehealth applications to "set practical and clear goals for what you want to achieve."


But Bosserman, like Dentzer, said major barriers have to be overcome for teleoncology to reach its full potential. She said reimbursement is a "big barrier" in telehealth, as is proper billing and coding. Agreeing was Emily H. Wein, who is of counsel at Foley & Lardner, LLP. She said both Medicare and Medicaid have complex telehealth rules and regulations, and noted that the Centers for Medicare & Medicaid Services (CMS) is trying to address telehealth regulatory issues. But, she said licensing is a state requirement, so where the patient is located generally dictates what licensing requirements are needed for reimbursement.


Advanced Practice Providers

In addition to new technologies such as telehealth, the ACCC meeting featured presentations on the growing use of advanced practice providers (APPs) in cancer programs. On the 2019 ACCC trends survey, 40 percent of respondents said they planned to add APPs to their staffs in the next 12 months.


"The use of APPs has streamlined and improved patient care at our practice," said Jiajoyce R. Conway, DNP, CRNP, AOCNP, of Cancer Care Associates of York. She noted that APPs "wear many hats" and help ensure consistency in decision-making, coordination of care transitions, and avoidance of gaps and fragmentation in patient care. Chanh Huynh, MD, an oncologist in the York private practice, said APPs ensure hands-on surveillance of patients and make sure the dispensary is functioning well.


Noting that the practice has been participating in the Oncology Care Model (OCM), Huynh said APPs help ensure depression screening, pain assessment and interventions, advance care planning, and survivorship services are integrated into the practice's care workflow. He said the practice has gone from two APPs to four and plans to increase that number to six. "We want more," he said.


Conway noted that APPs can be especially helpful in oversight of palliative care programs and high-risk cancer patients. She said that at the York practice hospice and home health services are initiated in a timely fashion via patient stratification, which helps to prevent emergency department visits and hospitalizations. The York practice also has an APP managed oral oncolytic program, and addresses medication adherence and compliance as part of a team-based approach, said Christian Patterson, PA-C.


Team-Based Services

A panel discussion at the ACCC meeting stressed the importance of team-based supportive services such as patient navigation, nutrition counseling, financial navigation, and survivorship care to enhance overall patient care. ACCC Immediate Past President Ali McBride, PharmD, MS, BCOP, Clinical Coordinator of Hematology/Oncology at the University of Arizona Cancer Center's Department of Pharmacy, stressed the need for adequate reimbursement for these supportive services during his presidential term.


Community cancer centers do plan to add more supportive care services to their programs, according to the 2019 ACCC trends survey. During the next year, sizeable numbers of respondents said they planned to add palliative care consults (60%), survivorship visits and/or clinics (65%), navigation (50%), genetic counseling (47%), oral chemotherapy adherence and support (43%), and financial advocacy (43%).


New ACCC President (2020-2021) Randall A. Oyer, MD, Medical Director of Oncology at Penn Medicine Lancaster General Health, stressed that, while oncologists often hesitate to initiate discussions on the topic of palliative care, they need to overcome their hesitation.


"Patients and families crave the opportunity to make more informed decisions," noted Oyer, a practicing medical oncologist at the Ann B. Barshinger Cancer Institute. In addition to extensive work on ACCC initiatives, he has served as a member of the CMS Ambulatory Payment Classification Panel and the American Society of Clinical Oncology Clinical Practice Committee.


Community Clinical Trials

Each ACCC president chooses a theme, and Oyer said he has chosen "community oncology can close the gap in cancer research." He noted that over the past year ACCC "has heard from its members that there are gaps in community research." He cited the 2019 ACCC trends survey, on which respondents said the top three challenges to offering cancer patients clinical trials are staff resources and training (53%), program infrastructure (50%), and a lack of patient understanding of the clinical trials process (46%).


"We have a serious imbalance in our clinical trials work," said Oyer. "Our patients are in the community, yet the trials are at academic medical centers. And I believe that ACCC is uniquely situated to close this gap."


He plans to create a multidisciplinary task force to identify staff/program/patient education resources to accelerate implementation of clinical trials in ACCC member practices and programs; bring together experts at the 2020 ACCC Institute for the Future of Oncology forum to share best practices and learn more about the challenges and barriers to clinical trials adoption; and develop a series of articles, blogs and podcasts on effective practices in clinical trials accrual and management.


Peggy Eastman is a contributing writer.