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COA Meeting Day #1 - Best Of The Day

While attending the annual Community Oncology Alliance (COA) meeting in Orlando I’ve been absorbing content, networking at the breaks, and interviewing faculty. All of it has lead to a lot of new insights that I thought I’d try and summarize here. Note that I’m really only hitting some highlights, and there is nothing like being part of a meeting to really digest all the presentations, especially talking to presenters to put everything presented into context.

The Emperor of all Maladies: A Biography of Cancer

Siddhartha Mukherjee, MD, PhD

The keynote speaker at the meeting was Siddhartha Mukherjee, MD, PhD, the Pulitzer Prize winning Author of The Emperor of All Maladies: A Biography of Cancer. Dr. Mukherjee. Assuming you’re a stakeholder in the cancer industry, it is a book you have to read. Hard for me to do justice here, but Dr. Mukherjee does a terrific job of laying out the history of cancer, all the way back to mummies in fact, through to recent history and today’s understanding of the molecular basis of the disease, and finally looks forward into the future of the disease.

Dr. Mukherjee began his talk with a surprise for the audience, announcing that for past couple of years he has been working with Ken Burns  on a documentary based on his book. He shared the trailer with us, the first time it has been seen in a public forum.

Now onto the meeting - I’ll try and share a few of the things I learned and found interesting.

Molecular Profiling and Circulating Tumor Cells: Challenges as Declining Reimbursement and Clinical Policies Collide

John Powderly, MD, President, Carolina BioOncology Institute

The clinical track began with John Powderly, MD, President, Carolina BioOncology Institute presenting his experience with Circulating Tumor Cells (CTCs) and clinical trials at the Carolina BioOncology Institute. The CBI is heavily involved in research, including >40 early phase trials opened since 2005. They have studied products such as ipilimumab, panitumumab, PD1, aflibercept, and so on. Importantly, Dr. Powderly discussed the importance of companion diagnostics, and in particular their experience working with CTCs.

Companion diagnostics, and their use in clinical trials, are benficial because they match the drug to the patients most likely to benefit, can provide a better clinical response, improvement in attrition rates, and if successful are more likely to get the product approved. For the drug developer, having a companion diagnostic can extend the drug’s life cycle thus producing higher revenue. Dr. Powderly calculates that companion diagnostics can save drug companies as much as $1.8 billion in waste associated with developing drugs without companion diagnostics.

Dr. Powderly shared his experience with CTCs, what he calls the substrate of personalized medicine. After providing the scientific rationale for CTCs as a surrogate marker, Dr. Powderly was pleased to announce that they had some success presenting CTC data in prostate cancer patients at the recent ASCO GU meeting. Using prostate specific membrane antigen (PSMA) as a marker, they delivered an experimental antibody drug conjugate and saw a significant reduction in CTC percentage, perhaps indicating that they have identified a new prostate cancer marker and perhaps showing that CTCs can be used a surrogate.

Next Dr. Powderly shared the problem they had with CTCs on the business end. Originally they were on the frontier, bought a veridex machine, and were reimbursed enough with standard codes to make the machine slightly profitable. In 2008 Medicare called CTCs investigational (despite a FDA approval) and reimbursement vanished until Medicare created a NDC code but at that point reimbursement was less than the cost of the test. In the long run the Institute had to change the model and only offer CTC testing in clinical trials where the test is specified as part of the protocol and paid for. Unfortunately a testament to one of the problems with personalized medicine today – a lack of infrastructure  and standardized systems to support development and clinical trials.

Novel Opportunities for Engagement Utilizing In-House Pharmacy Services

Angel Aslo, Pharmacy Director, The Zangmeister Center, Columbus, OH

Ray Bailey, Pharmacy Director, Florida Cancer Specialists

First a few facts:

  • The cancer drug category is experiencing a 32% - 42% growth rate
  • Oral oncolytics represent 35% of the oncology pipeline
  • FDA approvals of oral oncology meds is surpassing the IV approvals

As the shift toward oral chemotherapy grows, so does the need for efficient in-house pharmacy functions. In this presentation the faculty discussed their unique pharmacy logistics, and contrasted them between the largest independent practice in the country – Florida Cancer Specialists -  and a stand alone multidisciplinary cancer center – The Zangmeister Center in Columbus, OH.

Both presenters talked about “speed to therapy”, the need to get the medication in the hands of the patient as quickly as possible. The difference is that Zangmeister is a stand alone cancer center where the patient can fill the prescription within the walls of the cancer center, while Florida Cancer Specialists is a network of offices demanding a central pharmacy serving all the satellite offices.

Regardless of the setting, both presenters stressed the importance of proper pharmacy workflows, integration with the EMR, and in the case of FCS, downstream logistics to fill prescriptions get the medication directly to patients throughout their network of practices in Florida.

Not to be overlooked is the importance of compliance/persistence workflows, and great financial counseling.  All patients are followed, whether the prescription is filled through the in-house pharmacy or a different pharmacy, with a pharmacy care plan. There is usually a contact at one week for a review of the care plan, and every 30 days for refills or to assess adherence. There are also considerations for dose reductions or holidays, side effects, or any physician directed changes to therapy.

Other services provided by in-house pharmacies can include:

  • Developing SOPs for handling of oral oncolytics in the practice
  • Develop practice support tools to understand the SOP
  • Identify pharmaceutical specific assistance programs

Finally, great financial counseling is also a service provided by the in-house pharmacy. It is vitally important to know the help that is available such as copay assistance foundations, local foundations, copay cards, pharma “free goods”, and practice copay assistance programs.

Community Oncology 2.0 Information Technology

A Practical Guide to Where We Are Today and Where We Need to Go

Lucio Gordan, MD, Co-Director of Integrated Clinical Services and Medical informatics, Florida Cancer Specialists

Dr. Gordan is a self-described geek, due to his interest at a young age in computers, software, and programming. He began by describing the bright future for oncology, but contrasted that bright future with many challenges too. Dr. Gordan emphasized how information overload is making medicine in general challenging, but also pointed out that oncology is the ideal model for an IT solution.

In Dr, Gordan’s viewpoint, IT can help oncology with

  • EMRs
  • Patient portals
  • Pathways
  • Data harvesting

But unfortunately adoption of EMRs is ot going well so far. According to an article published in medical Economics in February 2014, in a survey across all medical specialties:

  • 73% of largest practices would have chosen a different EMR
  • 50% said that “cost is too high”
  • 45% said that “care is worse”

So far there is about 70% adoption of an EMR in oncology, with about 50% adoption of an oncology-specific EMR. The functionality of EMRs should include:

  • Visit notes
  • Ordering
  • Billing
  • Metrics
  • Content such as diagnosis, regimens, laboratory orders, ancillary medications
  • Research protocols
  • Alerts
  • Connections to resources like uptodate.com, NCCN guidelines, and medical journals
  • Printing of educational materials

Dr. Gordan also provided some ideas to help choose an EMR such as KLAS Research, the ASCO EMR lab, Oncology Electronic Health Record Field Guide, GPOs, and referrals from other practices. He also said that making sure the vendor does a demo in your office is critically important.

Is there a best EMR in oncology? Probably not because you need an EMR that fits your unique practice dynamics. The decision could be based on the practice size, number of clinics, and involvement with the local hospital and other local specialties.

When thinking about the future of EMRs, Dr. Gordan wants to see:

  • Mobile adaptability
  • Improvement in ability to collect data and export metrics
  • Built-in pathways
  • Pre-populated clinical trials
  • Increased efficiencies within offices

The end of Dr. Gordan’s talk discussed data harvesting. Regarding big data, he said that today big data is a big headache. Right now we have too much data, and it is going to grow 8 fold in 10 years.

To demonstrate the headache, it is estimated that poor data is costing businesses 20-30% of their revenue and wrong data is costing US business $600 billion annually. “Lack of understanding of data” is cited as the #1 reason for over running project costs.
The challenge is that much of the data is unstructured i.e. physician notes, but also radiology reports, some labs, and pathology.

Many physicians think their data is worth something, but don’t understand the nature of unstructured data. So who wants the data?

  • Pharmaceutical R&D
  • Payers
  • Oncologists
  • Research networks
  • Practice management companies
  • GPOs

It is estimated that the total market value of data is in excess of $300 billion. But Dr. Gordan does not think that data is the gold mine that many think it is.

by Don Sharpe

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