The National Comprehensive Cancer Network (NCCN) held its annual national conference virtually, with a special patient-centric emphasis this year. Robert W. Carlson, MD, the NCCN CEO, noted that three plenary sessions were devoted to the cancer patient's experience.
Carlson said that NCCN's core mission-to help people with cancer lead better lives-"means having frank discussions about implicit and explicit biases in care, and taking on social determinants of health." He added that this year's discussions were happening in the shadow of the COVID-19 pandemic, "which has exposed systemic problems and radically changed care delivery."
During a session on improving access to cancer care, speakers stressed that cancer centers are finding new ways of making it easier and more convenient for patients to get the care they need.
Using the analogy of banking-which has moved from a stage of banker's hours and teller lines to ATMs and electronic transfers-Lawrence N. Shulman, MD, said medicine is still stuck in a stage that does not meet patients' needs for convenience. To change that, he and his colleagues established a multidisciplinary team to look at all the complex issues of care delivery, said Shulman, who is Deputy Director for Clinical Services at the Abramson Cancer Center and Director of the Center for Global Cancer Medicine at Penn.
Shulman described the establishment of Penn Medicine's Cancer Care @ Home program, which aims to decrease the amount of time patients spend traveling to and from doctors' appointments and give them the convenience and comfort of care in their own homes.
Initially, patients were referred for home administration of 13 carefully selected cancer drugs during 2020. "It was very rapidly operationalized," Shulman noted. Critical considerations included safety (should the initial infusion be given on site?), the length and complexity of treatment, the stability of the medicines, and nurse staffing and nurse training. Nurses administering the medicines at homes needed to be highly educated, with advanced experience in oncology, critical care, and infusion-related protocols.
An e-triage tool to identify immunotherapy toxicity in advance of being treated at home was very helpful, said Shulman, noting that the program "has high patient satisfaction," but that the financial aspects can be daunting. These include site of care restrictions and differential costs. For example, he said out-of-pocket expenses for some Medicare patients were prohibitive. Shulman also noted that "it is harder to order labs and treatments to follow patients and understand their course fully." Electronic health record integration is "a huge challenge."
Despite the challenges, Shulman emphasized that a carefully designed home care program can be done well through time and effort. "This is something we should be doing for patients; this is patient-centered care." He stressed that the program is a hybrid model, and never should everything be done for all cancer patients at home. Currently, according to program data, nearly 3,000 Penn Medicine patients receive cancer care in the comfort of their own homes annually.
"I absolutely would encourage cancer centers that are not doing this to do it," said Diane K. Hammon, MHA, Vice President and Chief Strategy Officer at Moffitt Cancer Center. She described her personal experience helping her father-a 12-year bladder cancer survivor-manage his care to maintain a high quality of life in his own community during his last days.
Diagnosed with MDS and given a poor prognosis with no curative option, her father did not want to spend his days traveling to specialty centers for care-either 1 hour or 2 1/2 hours away. Hammon described helping him devise a treatment plan with shared care by a local oncologist and virtual doctors' visits, which gave him high-quality end-of-life care for his last 9 months.
Short of being cared for in their own homes, cancer patients can also receive high-quality care from major cancer centers which have satellite sites nearer to where the patients live, speakers noted. For example, the Mass General Cancer Center Network has sites that prove the value of an integrated network, said Elizabeth A. Souza, MHA, Senior Administrative Director of Outpatient Operations at Massachusetts General Cancer Center for the Boston campus and Massachusetts General/North Shore Cancer Center in Danvers.
Souza noted that there has been a transition of cancer patients from the Boston campus to care at network sites nearer to where patients live. "Building a cancer center network is a multi-year strategic initiative," she said, noting that it is important that all sites in the network meet the same high standards for network participation.
Research trials can also be brought to cancer patients at satellite centers, improving patient access and increasing accrual, said Anne Chiang, MD, PhD, Associate Professor, Chief Integration Officer, and Deputy Chief Medical Officer at Smilow Cancer Network. She described the 15 Smilow cancer centers in Connecticut and Rhode Island, noting that from the beginning the vision was to bring clinical research to patients closer to home. Chiang said the system is based on disease teams, which develop robust relationships, noting that the highest accruing sites have larger portfolios of clinical trials.
Technology can play a key role in improving the cancer patient experience by increasing access to specialists and reducing delays in care, speakers noted. In a session on the future of telemedicine in oncology, they stressed the value of telemedicine in caring for cancer patients-which was aptly demonstrated during the pandemic.
Going forward, as much as 46 percent of oncology visits could be telemedicine appointments, predicted Amye J. Tevaarwerk, MD, a medical oncologist in practice at the Mayo Clinic Cancer Center in Rochester, MN. Moving forward, she said there is a need for additional telemedicine training for providers and patients, outcomes data on use of telemedicine, clarity on privacy and confidentiality, and focus on reimbursement and regulatory issues.
The COVID-19 pandemic led to a public health emergency declaration which expanded flexibilities via waiver in the use of telemedicine, said Robin Zon, MD, FACP, FASCO, an Indiana medical oncology specialist and President of Michiana Hematology Oncology. She noted that the position of the American Society of Clinical Oncology (ASCO) is that the Centers for Medicare & Medicaid Services (CMS) should maintain these expanded flexibilities after the expiration of the Public Health Emergency declaration.
Zon said ongoing concerns about telemedicine include avoiding a digital divide which perpetuates health inequities by penalizing patients with lower education and incomes, especially those of color; establishing audio-only and video parity for telemedicine visits; and addressing out-of-state medical licensure restrictions. She urged conference attendees using telemedicine to check their medical liability policies, which should provide comprehensive coverage for telemedicine in all states where the providers practice.
"COVID-19 changed everything," said Lucy R. Langer, MD, MSHS, a medical oncology specialist with UnitedHealthcare. "Telemedicine is an important element of virtual cancer care," noting that "telehealth visits appear to be stabilizing at levels well above those pre-pandemic."
She said telemedicine is especially useful for symptom management, palliative care, second opinions, pre-treatment data review, discussions with family members who live in multiple locations, long-term follow-up, and genetic counseling. She noted that many patients are now more comfortable with digital applications in all areas of their lives, including health care, because they routinely ordered food and consumer goods online during the pandemic.
Langer said many payers plan to continue paying for telemedicine beyond the pandemic, and noted that payment parity (in-person vs. telemedicine visits) varies from state to state. As for bridging the digital divide, she cited the Lifeline Program of the Federal Communications Commission, which has provided discounted telephone services for qualified low-income U.S. consumers since 1985, and the program was expanded in 2016 to include broadband. Langer noted her vision for the future of telemedicine in oncology includes virtual centers of excellence, which could serve as resources of telemedicine expertise, information, guidance, and education.
During a session on health equity, speakers urged NCCN conference attendees to continue to work to eliminate health disparities in cancer care for People of Color and members of the LGBTQ community. Disparities continue to persist across the cancer care continuum, they said.
"We have to be intentional about health equity," said Shonta Chambers, MSW, Executive Vice President for Health Equity Initiatives and Community Engagement at the Patient Advocate Foundation. She described how the foundation developed a social vulnerability index tool to use with U.S. counties to design and provide a co-pay assistance program for needy patients in certain underserved counties. Chambers said that "social needs navigation" can be just as important as medical navigation in helping vulnerable patients.
"Cancer doesn't discriminate, but the care we receive absolutely does discriminate," said Liz Margolies, LCSW, founder of the LGBT Cancer Network and Co-Chair of the NYC Lesbian Cancer Support Consortium. "Don't assume anything" when it comes to LGBTQ patients, she urged oncologists, noting to really listen to LGBTQ patients, earn their trust, and show openness in their office atmosphere (such as welcoming brochures and signage).
Alyssa Schatz, MSW, NCCN's Senior Director of Policy and Advocacy, gave an update on the Elevating Cancer Equity initiative, a partnership of NCCN, the American Cancer Society Cancer Action Network, and the National Minority Quality Forum. As previously reported by Oncology Times, this plan has produced an equity report card with four domains for oncology professionals to assess their level of equity in providing cancer care. The report card also contains a total of 16 policy recommendations to improve health equity and reduce disparities in cancer care.
Schatz said NCCN plans to partner with five of its member institutions on a pilot project to evaluate the equity report card's feasibility of use in delivering high-quality cancer care to all patients regardless of their race, gender, education, or socioeconomic status.
The wide-ranging NCCN annual conference featured more than 30 educational sessions focusing on state-of-the-art practice algorithms for care across multiple cancer types; updates to NCCN Clinical Practice Guidelines in Oncology; new and emerging therapies; and best practices in oncology, including those for genetic risk assessment and counseling.
Peggy Eastman is a contributing writer.