1. Eastman, Peggy

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The Association of Community Cancer Centers (ACCC) held its 48th Annual Meeting and Cancer Center Business Summit in person and virtually in Washington, DC, to explore strategies to achieve excellence in 21st century cancer care. The meeting came shortly after President Joe Biden announced that he is relaunching the Cancer Moonshot with the aim of reducing U.S. cancer deaths by 50 percent over the next 25 years. The ACCC stated that "the President's recommitment to the Cancer Moonshot holds great promise to increase cancer survivorship and reduce barriers to equitable cancer care, and we stand ready to aid in these noble efforts."

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To accomplish the goals of the Moonshot, the ACCC urges the Biden administration to support and strengthen the cancer workforce, which was inadequate to treat an aging population even before the pandemic, and support legislation to increase diversity in clinical trials and reduce racial, ethnic, geographic, and socioeconomic barriers to participation. The ACCC also urges the President to make cancer screening a priority, noting that currently Medicare covers early detection tests for only five cancer types. More than 70 percent of cancer deaths are caused by cancer types with no Medicare-covered screening options.


The ACCC's new president, radiation oncologist David R. Penberthy, MD, MBA, announced his presidential theme: "Leveraging technology to transform cancer care delivery and the patient experience." The theme has four key objectives: 1) equitably leverage data and digital health tools to identify ways to reduce health disparities; 2) identify strategies to use technology to help mitigate workforce shortages and improve efficiency of care; 3) advocate for equitable access to technology innovations and adequate reimbursement for their application in cancer care delivery; and 4) convene technology-driven change makers to share solutions and envision the future state of oncology driven by the patient experience.


"As oncology providers, we are exceptional at engaging with patients, and an opportunity exists to use technology like AI-driven practice support tools and patient wearable devices to free up our time so we are better able to focus on critical issues," said Penberthy, who is Medical Director of Radiation Oncology at Bon Secours Southside Regional Medical Center (SRMC).


Those critical issues include shared medical decision-making, improving care to underserved and marginalized patients, increasing clinical trial participation, and delivering person-centered care, said Penberthy, who has served as Cancer Committee Chairman at SRMC.


In a keynote address at the annual meeting called "(Over)-Paying for Cancer Care," Cary Gross, MD, highlighted the "cancer cost trifecta" facing the U.S., which he said is unsustainable. The trifecta is due to more cancers being diagnosed, in part due to the "silver tsunami" (population aging); higher use of cancer-related care; and more expensive testing and treatment options now available, said Gross, Professor of Medicine and Epidemiology at the Yale School of Medicine and Public Health and Director of the Cancer Outcomes Public Policy and Effectiveness Research Center at Yale University. "This is now a national crisis," he stated, noting that the financial toxicity of cancer costs is a leading factor in bankruptcies, and that those patients who do go bankrupt are more likely to die.


Gross said the country's current cancer research approach-which overemphasizes cure-is skewed and needs to focus much more on cancer prevention. He emphasized these solutions to address the cancer cost trifecta: increasing funds for tobacco control efforts; supporting evidence-based prevention strategies such as HPV vaccination to prevent cervical cancer and colorectal cancer screening; using payment reform to support high-value cancer care; spending less on aggressive end-of-life care when there is no chance for a cure; and expediting generic and biomarker drug development. Citing prevention successes in cardiovascular disease, Gross said, "We're not learning from what our cardiovascular colleagues are trying to tell us."


In a session on big data, James Hamrick, MD, MPH, Vice President for Clinical Oncology at Flatiron Health, emphasized the need for good stewardship of data to ensure its quality. He said what really matters is that the physician has the relevant data and information available when he or she needs them to make decisions and provide the best therapy to individual patients.


"We can use data to make our doctors smarter," he said. But, "as a general oncologist, it can be quite overwhelming" to confront today's data overload. Hamrick said there are ongoing problems in use of big data, including lack of interoperability and wide variability in data quality. "We still have systems that don't talk to each other," he noted.


During sessions on the business of oncology practice, Phil Watts, JD, a founding member of OneOncology and its General Counsel, said that today most oncologists (70%) are aligned with hospitals and/or academic centers. He said that, while there has been an explosion of new diagnostic and treatment options along with an increasing supply of cancer patients, the supply of oncologists has remained relatively static-so there is pressure on oncologists to be as efficient as possible. He predicted that alignment and consolidation will continue in community oncology, so there will be fewer and fewer purely independent practices.


Watts said that a key issue for practicing oncologists who decide to enter into an affiliation with another entity is how to maintain their independence and provide their patients with the highest quality care while navigating an increasingly complex health care system. Tension between the hospital setting and the community setting is a recurring theme in oncology, noted Michael Kolodziej, MD, FACP, Vice President and Chief Innovation Officer at ADVI Health.


During the pandemic, health care deals and acquisitions did not slow down, noted Adria E. Warren, JD, a partner and health care lawyer with Foley & Lardner. "Hospital transactions are still happening," she noted, along with increasing emphasis on value-based care and pricing transparency.


Lee Blansett, Principal with Proximity Health, said that, while the trend of hospitals buying practices has continued, "We do believe that this is tailing off." He noted that oncology is entering a new era he called "consolidation 2.0," in which corporate entities-vertical conglomerates-employ physicians directly. This is a trend that is primarily focused on primary care physicians, but Blansett predicted that corporate entities will adopt this strategy with oncology as well because "these folks always go where the money is."


Blansett said he can envision "consolidation 2.1," a next phase of health care delivery in which a corporate entity has a virtual front door (a Web-based patient interface enabled by artificial intelligence), narrow preferred provider networks, and an infrastructure in which a physician gives patients payer-prescribed care based on evidence-based guidelines and pathways.


One care delivery model that may emerge is a collaborative approach on the part of primary care providers which extends to all specialties, including oncology. In this model, primary care providers and specialists work closely together, and oncologists feed their work to the primary care practice.


Regardless of the oncology care delivery model, a patient-centered focus will continue to be a stronger and stronger factor, said Paul Martino, co-founder and Chief Growth Officer of VillageMD. "The world is changing...I think all providers have to step up their game." He also said patients themselves are going to be the drivers of this strong patient-centered focus.


In a session on cancer survivorship, speakers discussed the challenges of coming up with a model of care delivery that works best for the growing number of survivors. For these individuals, should primary care be embedded in oncology or should oncology be embedded in primary care?


Many cancer survivors don't know what comes next and experience uncoordinated care and undersurveillance, said Lauren P. Waller, PhD, MPH, Associate Professor of Internal Medicine and Epidemiology at the University of Michigan and Co-Leader of the Cancer Control and Population Sciences Program at Rogel Cancer Center. She said models of survivorship care include specialty-led (oncologists), team-based model, primary care provider-led model, nurse-led model, and multidisciplinary survivorship clinics. Patient preference is important, with Black, Latino, and low-income women tending to prefer an oncologist-led model.


"The models seem to be comparable in terms of quality of life," Waller said. The big elephant in the room is how the models are paid for, she noted, saying that many cancer survivors have co-morbid conditions which make following their care more challenging. She said non-specialist, nurse-led, and team-based models tend to be lower in cost. She also believes survivorship models are hampered by a lack of clarity around provider roles, limited primary care provider involvement in cancer care, and knowledge gaps. For example, how can primary care providers keep up to date with published articles on the best survivorship care when most depend on oncologists to do that?


Kimberly Peairs, MD, described a current survivorship program in which cancer care is an integral part of primary care. "We felt that cancer care should be embedded in primary care," said Peairs, Associate Professor of Medicine at Johns Hopkins School of Medicine in the Department of Medicine (Division of General Internal Medicine) and the Sidney Kimmel Comprehensive Cancer Center.


In this program, primary care providers partner with the oncology center, noted Peairs, a clinician educator who was the founder of the Johns Hopkins Primary Care for Cancer Program. The decision to refer a survivor is left to the oncologist, and the referral is built into the electronic medical record (EMR). She noted that survivor referral patterns cover all stages of cancer, although there has been a preponderance of breast cancer patients in their 60s. In addition, there was a strong institutional buy-in for the program, which was essential.


"We don't live in a silo...No one felt threatened that we would take all their cancer patients from them; there are plenty to go around," she said. The survivor's shared EMR provides continuity of care between primary care and oncology. In this Hopkins program, primary care providers address a number of survivors' needs and concerns, including their fear of recurrence, fatigue, and co-morbidities, Peairs explained.


Peggy Eastman is a contributing writer.