The Cancer Care Ecosystem – Evolution or Revolution?

Coverage of a Panel Session at the National Comprehensive Cancer Network (NCCN) Annual Meeting in Hollywood, FL on March 15, 2103

In the delivery of cancer care, there are tectonic forces shifting beneath our feet said Clifford Goodman, SVP and Principal of the Lewin Group, who moderated a roundtable titled “The Changing Oncology Landscape: Evolution or Revolution?” at The National Comprehensive Cancer Network® (NCCN®) 18th Annual Conference: Advancing the Standard of Cancer Care™. The expert panel represented a variety of stakeholders that included Roy Beveridge, MD, Chief Medical Officer, McKesson Specialty Health; John Fox, MD, MHA, Associate Vice President of Medical Affairs, Priority Health; Susan Higgins, MD, MS, Associate Professor, Department of Radiation Oncology, Yale University School of Medicine; Martin Kohn, MD, MS, Chief Medical Scientist, Care Delivery Systems, IBM Research; John J. “Jack” Mahoney, MD, MPH, Chief Medical Officer, Florida Health Care Coalition; Lee N. Newcomer, MD, MHA, Senior Vice President, Oncology, Genetics and Women’s Health, UnitedHealthcare; and Andrew von Eschenbach, MD, President, Samaritan Health Initiatives.

The panel discussed topics of interest that at first seemed unconnected, but by the end of the discussion the topics revealed a connectedness that is detailed below. The first theme centered on disparity in the cancer care landscape, and segued into cancer services such as palliative care. Big cancer data was also discussed which then led to how data are being used to evolve into the future of how cancer care will be decided upon and delivered to patients.

The Haves versus The Have Nots

According to Goodman, until the issue of looking at the “haves” versus the “have nots” as supplements to cancer care is addressed, “we will not have made progress.” This thought was exemplified by Dr. Higgins, whose clinical expertise lies in the areas of cervical and breast cancers. In one of the wealthiest states in the nation, Connecticut, where Dr. Higgins has a clinical practice, she informed that she still sees patients with stage IV cervical cancer “which really at this point should be a third-world country disease.” The disparity in income in that area of her state ranges from those who make well over $100,000 annually to the underprivileged with an income of less than $25,000. “What we see is that poverty and socio-economic class is tied to the stage of presentation and the type of disease,” she said.

Because of the disparities in care that do exist, private insurance companies such as Priority Health, a group-based insurance company located in Michigan, have a specific interest in cancer care. With the financial squeeze being placed on the shoulders of the middle class, Dr. Fox attributes some of the disparity to the healthcare exchanges and subsidies providing more economic support for the low-income population, not only with the premium subsidies but also with the cost-sharing subsidies. For instance, a plan member from the middle class could have up to $6,000 individual out of pocket expenses a year and $12,000 for a family, whereas low-income and even Medicaid patients will have much smaller cost burden.
According to Jack Mahoney from the Florida Healthcare Coalition, they are hearing from employers that new hires are falling into a higher risk profile category than new hires before the recession. They are presenting at a later stage of disease than they were in the past. “I think this is a reflection of the fact that in economic down times, people by-pass preventive care, they by-pass screenings, and then suddenly they’re in a health plan and have access to care.”

Considering the broad populations that Dr. Higgins’ sees and the diverse set of employees going back to work, the question becomes: How will healthcare reform solve this disparity problem? Different levels of plans that are going to be offered through exchanges, such as the bronze, silver, or gold plans, are not going to be as richly designed as what was seen in the past. For example, Dr. Mahoney described, the bronze plan is designed to pay 60% of a patient’s costs, “so people will think that they have coverage, and indeed they do for preventive care, and for some routine things.” But the reality is for the middle class they’re going to see a higher out of pocket if they’re in one of these bronze or silver plans, as 40% is a very large out of pocket expense, especially for someone who’s making less than $30,000 annually.
So while healthcare reform may broaden access to care, it may not amount to much with the escalating costs of care and most people being unable to afford their deductibles.

One of the things that come to mind for Dr. von Eschenbach with the disparity issue is from the point of view of outcomes. According to him, people who don’t have access to and are not familiar with the digital world, are going to be significantly disadvantaged. “[Disparity] is not simply a socio-economic issue,” he said, “It’s also a cultural issue.”

The Discussion of Palliative Care

There are a host of experiments going on around the country that are focused on how to better pay for cancer care. Traditionally, Dr. Fox explained, “we have just paid whatever has come across the claim system.” But in Priority Health’s way of thinking he said, “We need to become more focused on the outcomes that are valuable for the patients.” This would include palliative care which according to Dr. Higgins is a neglected aspect of care. As physicians, “we spend a lot of healthcare dollars in the last six months of life, and we’re doing all the talking, which is not reimbursed,” she said.

Because having the end of life discussion is a very hard thing to have, Dr. Beveridge encourages the absolute training of physicians on how to have this discussion with patients and their families. Palliative care is a very new specialty. “We don’t have the manpower to do it. It’s going to take us years to train up. We’ve actually found that it’s frequently better to have a nurse practitioner or social worker introduce the topic and say to the patient, it’s ok to talk to your doctor about this, because we as physicians are not trained to do this; we don’t do it particularly well and I think you need almost to have that intermediary to start the discussion.”
Lee Newcomer, MD, reflected on this sentiment and discussed the philosophical barrier in the United States that suggests that “Americans don’t think death is an option. We struggle with facing that and quite frankly, the whole nomenclature about the war on cancer suggests that this is a battle that we can’t give up on. We have a whole culture that says it’s wrong to stop.”

Cancer Big Data

In turning the conversation to outcomes data and personalized medicine, Dr. Goodman questioned the panel about cancer big data. Will big data provide the information needed to influence prescribing habits and eventually get the right medicines to the right patient? Dr. Kohn led this part of the discussion by describing Watson – the IBM artificial intelligence computer system that is capable of answering questions posed in natural language. A version of Watson played Jeopardy! Watson can read and understand 200 million pages of text in three seconds. And if that’s not impressive enough, Watson can read and understand whatever text-like information is made available to it.

In development with Memorial Sloan Kettering Cancer Center and Wellpoint Inc., Watson is being taught to understand the critical attributes of the history of a patient with cancer, and then search through data (such as the NCCN guidelines) and come back with suggestions for the oncologists that patients can consider as personalized, because the brain understands the full history of the patient and the difficult co-morbidities of the patient. In other words, if there’s something relevant, Watson can bring it to a practitioner’s attention.
Dr. Kohn also pointed out that “Big data isn’t just lots of data. It’s often described as the four V’s which is Volume, Velocity, Variety, and Variability. It’s unique to deal with the four of those V’s if you’re going to do anything useful with the information.”

With Lee Newcomer, mining big data at UnitedHealthcare involves the collection of data on 70 to 80 million people and placing that data in a basic research center where physicians of any type will have access after putting forward their proposal. “On the cancer basis, we’re trying to create a cancer registry that combines clinical data from state tumor registries with our claims data. What that allows us to do is basically create a longitudinal record for the patient.” In the two or three years, United intends to start profiling chemotherapy regimens. “We can tell when a patient started on a given regimen, we can tell when they’ve progressed – we do that by assuming progress when a new drug is added and the others are dropped – and we can actually calculate real world progression free survivals for a given chemotherapy regimen.” According to Newcomer, “What you are going to get out of big data are a lot of hypotheses that need to be tested. But, you’re going to get good hypotheses that help you find a better population of patients for a given treatment.”

For Dr. Beveridge, the whole concept of big data is crucially important, “but I look at it as much as an attempt to begin to change how we look at quality in the care that we render.” At McKesson, an immense amount of data can be acquired, “but the data integrity is remarkably important and as we’re putting together data in the next number of years, we really have to begin to codify how we put data in and how we talk with various electronic health records to get these data out. When we look at quality that’s based on processes, this amalgamation of data is going to allow us to get to understanding what outcomes are. Once we get there then I think we have collectively a definition of quality which I think is good for everyone.”

Moving Forward Into a Brave New World

Goodman moved the conversation towards the evolving ecosystem that is needed to transform cancer care. Dr. Fox warned to be careful about big data because “I think what big data will tell us, is what appropriate options are, or better options are for patients, but we can’t use that information in a vacuum – it really depends on what the patient wants.” Dr. von Eschenbach felt “we’re falling into a trap. The trap being that this is going to enable us to take 8 treatments down to 2 treatments.” To von Eschenbach, it’s not a matter of going from 8 treatments to 2 treatments, but of the 8 treatments, which of those is the right treatment for the right patient for the right reason. “We don’t have to restrict our options for what we can do for patients, what we do is apply those options much more rationally to the variations to the patient population that we’re dealing with.” That’s the difference, he said, between “rational” medicine and “rationed” medicine.
As for the evolving cancer care ecosystem, “We’re not there,” von Eschenbach said. “We haven’t yet emerged with regard to being able to understand how to truly do this.” He thought that the four components needed to deal with this complex solution are targeting, payload, delivery, and a monitor. “We haven’t figured out yet how to put that all together. We don’t have a way of bringing the discovery components together.”
When Goodman asked him if the research establishment is organized in a way to achieve that goal, von Eschenbach said, no. “I think that the problem has been that we were all trained to play golf – it’s been a highly egocentric, individualistic kind of culture and the game has now switched from golf to basketball, which means it’s not only about individual excellence, that’s essential – but it’s also about interoperable performance, how we can work together in a way that I can’t be as good as I need to be without Lee [Newcomer]. And if you think about the ecosystem of healthcare, especially led by oncology, we need that transformation in the ecosystem. We don’t even have the right with regard to regulation. We’re still struggling with how you can put a diagnostic and a therapeutic together into an interoperable system, let alone a much more complex product coming out of regenerative medicine.”

by John McCleery, OBR Managing Editor

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