The Association of Community Cancer Centers (ACCC) highlighted cutting-edge technology at its 49th Annual Meeting and Cancer Center Business Summit, held in Washington, D.C. Newly elected ACCC President, Olalekan Ajayi, PharmD, MBA, stressed that in an era of rapid advances, it is essential to train and support oncology professionals who are qualified to implement these advances in clinical practice.
"We need to develop our workforce to complement the technologies that are coming to cancer care," said Ajayi, Chief Operating Officer of Highlands Oncology Group, PA, in Fayetteville, AR. "We not only have to understand the technology, but we must invest in a new generation of leaders who are going to help drive the application of technology in cancer care. Technology is only as good as the people who use it."
Ajayi said he has chosen as his ACCC Presidential theme "(Re)Building the Oncology Workforce to Deliver Next Generation Cancer Care." During the next year, ACCC will convene thought leaders and key multidisciplinary stakeholders to foster and mentor key oncology leaders.
Emerging Technologies
A number of presentations and workshops during the 3-day meeting underlined the need for oncology professionals who are skilled in understanding and applying new and emerging technologies in their clinical practices. During an interactive workshop on precision medicine, speakers noted that today less than 50 percent of cancer patients receive next-generation sequencing (NGS), and attendees discussed significant barriers and challenges to implementing NGS testing in clinical practice.
While precision medicine is becoming the standard of care, in reality, there are many complexities and a number of obstacles in implementing precision medicine, said Sigrun Hallmeyer, MD, Director of the Cancer Institute and Cancer Survivorship Center at Advocate Lutheran General Hospital and Lutheran General Cancer Institute. There are many genomic tests on the market, she noted, and the oncologist must decide which is the test of choice-"the right patient for the appropriate test"-which genes to test for, where to get the outcomes data needed, which testing laboratory to use, and how to decide which genes are actionable.
Hallmeyer also cited the difficulties of the test ordering process, which can take hours of uncompensated time. She detailed a multi-step process that includes complex requisition forms, specimen acquisition, patient consent, physician signature, financial aid, and coverage options. "Should this be the job of the oncologist or the pathologist?" she asked.
In addition, Hallmeyer said there are reimbursement problems with payers, some of whom consider NGS testing experimental. There is pressure to start a newly diagnosed patient on a treatment, and some physicians may do this while waiting for NGS results, she noted.
Hallmeyer said the key is to have a point of contact (POC) administrative precision medicine navigator who can channel all molecular testing. This navigator follows up on all testing and makes sure the results are sent back to the physician.
Asked by Oncology Times who funds the POC precision medicine navigator, Hallmeyer said her cancer center pays for the person's services, which are not reimbursed by an outside source. But ultimately, she noted this administrative expense pays for itself by getting the right treatment to the right patient, ensuring the highest-quality care. Oncologists are overwhelmed and short-staffed and the POC precision medicine navigator allows her time "to be the doctor I want to be."
The electronic health record (EHR) itself can be a barrier in precision medicine, said Leigha Senter-Jamieson, MS, CGC, Licensed Genetic Counselor and Associate Professor of Internal Medicine at the Arthur G. James Cancer Hospital and Richard J. Solove Research Institute at The Ohio State University. She noted that most EHRs do not store genetic/genomic data in discreet fields, and these are scanned into the EHR with no standard labeling convention.
Another barrier Senter-Jamieson mentioned is laboratory differences in variant interpretation and reporting, which complicates decisions about how the results apply to patient care. There are many opportunities for quality assurance to improve precision medicine, she stressed, including standardized reporting of the results of NGS tests in the EHR. She also noted the importance of patient engagement, since many cancer patients are worried about how their genomic data will be used.
During a session on the role of oncology and primary care in multi-cancer early detection (MCED), speakers stressed that this emerging technology, also referred to as liquid biopsy, has much potential for cancer care. Currently, only four cancers have standard screening tests: lung, breast, colorectal, and cervical, noted industry experts. Since about two-thirds of cancer deaths occur in patients for whom there is no screening test, an accurate, validated, blood-based MCED test that can detect cancer signals from a wide variety of organ sites would be a boon in clinical practice.
However, such tests must be implemented carefully, since the downside is that patients who have MCED testing might forgo established screening tests. In addition, MCED tests could exacerbate health care disparities if they are not available to all patients, they could increase patient anxiety and they could lead to overdiagnosis and overtreatment (and high costs) if there are false positives.
As previously reported by Oncology Times, a bill proposed in Congress in 2021-the Medicare Multi-Cancer Early Detection Screening Act-would provide Medicare coverage and payment for MCED tests that screen across many cancer types and have been approved by the FDA.
"I think we should be wary," said Christopher V. Chambers, MD, Professor and Director of Clinical Trials in the Department of Family & Community Medicine at Thomas Jefferson University. "Are primary care physicians really ready to incorporate MCED tests into routine cancer screening?" he wondered aloud.
"We see ourselves as stewards of health care dollars," he said, and MCED tests are expensive. Chambers voiced concerns that MCED testing might inadvertently exacerbate cancer care disparities. "Equity in medicine should be an absolute essential to anything we do in medicine as we move forward," he said.
Survey Results
In this ACCC summit session, the results of a recent ACCC membership survey on MCED testing were shared with participants. The survey conducted between June 2022 and August 2022 included 108 health care providers representing diverse multidisciplinary roles from institutions in 34 states. In addition, focus groups were held with 27 providers in October and November 2022 to take a deeper dive into providers' attitudes and beliefs.
The survey results showed that the current use of MCED testing in clinical practice is limited, and only a handful of ACCC members said their practice was participating in a MCED clinical trial. Some 63 percent of respondents agreed or strongly agreed that MCED testing will improve outcomes for patients diagnosed with cancer, while 57 percent said that MCED testing would fit within existing processes used in patient care. Some 51 percent agreed or strongly agreed that this testing will improve existing disparities in cancer screening and 65 percent expressed concerns about access to follow-up diagnostics and treatment after MCED testing.
While ACCC survey respondents said this technology has the potential to decrease existing disparities in cancer care, they discussed the need to prevent the widening of disparities if access to MCED testing is provided only to those with higher incomes and more resources.
Survey respondents expressed the need for a coordinated plan throughout the MCED testing process; they voiced concerns about the management of false-positives, unnecessary procedures, overdiagnosis, and lead time bias.
In addition, they called for more evidence on clinical utility and MCED testing effects on patient outcomes and recommended public health policy interventions to fully support an MCED rollout, including FDA approval and Medicare coverage. They said testing should be rolled out with clear clinical guidelines to avoid confusion in the interpretation of test results and the follow-up diagnostic process.
One ACCC survey respondent, an oncology administrator at a health system offering MCED testing through a clinical trial, said, "We just caught positive cancer. We do not know how early it was caught, but I am really glad we found it because it is proof of principle that there is something here."
Another ACCC survey respondent, a cancer center program administrator, said, "Multi-cancer early testing needs a reimbursement structure to allow it to occur without being a cost burden to programs. Such reimbursement must attempt to include funding for covering the complexities of getting this new technology into the hands of cancer programs-with the need for deep education, working with false-positives and follow-up, navigation, etc."
In October 2021, the National Cancer Institute (NCI) sponsored a workshop to receive feedback from research experts on how MCED testing trials should be designed, including the following issues: What should be the primary endpoints? What should the process be for evaluating multiple MCED tests at the same time? What should be the diagnostic workup for those with positive results on MCED testing?
NCI is now using feedback from that workshop to guide the design of randomized clinical trials of MCED tests, according to Philip Castle, PhD, MPH, Director of NCI's Division of Cancer Prevention.
Peggy Eastman is a contributing writer.