At ASCO, a Guide to Relieve Mounting Practice Pressures

Cary A. Presant, MD


June 16, 2017

At the 2017 meeting of the American Society of Clinical Oncology (ASCO) in Chicago, there were 5000 presentations and 49,000 registered participants. During the 2-day premeeting Economics of Cancer Care seminar and the 5-day meeting, I averaged 12,000 steps per day (as recorded on my iPhone®), and it was well worth it. See the Medscape ASCO 2017 Live Blog from the meeting to prove it to yourself as well.

Hematology/oncology practices are now under significant pressure to improve their performance as they move from volume-based care to value-based care, adapt to new insurance plans for their patients, consider how to deal with mergers and acquisitions or personnel changes, and still implement the practice-changing science from such meetings as ASCO. ASCO 2017 offered novel opportunities to guide these transitions.

At the economics seminar, excellent presentations and networking discussions emphasized how practices in the Oncology Care Model (OCM) needed to have more coordination within the oncology practice (or departments of an institution) and with supportive specialists and/or departments, such as palliative care, infectious disease, pain management, social services, and others. New software programs and personnel are necessary to be able to submit patient costs of care and other required data fields in a currently imperfect reporting system at the Center for Medicare & Medicaid Innovation (which is running the OCM). The presentations stressed that participants in OCM should attend every networking opportunity (such as the ASCO, Association of Community Cancer Centers, and Community Oncology Alliance meetings, and in Washington) and also participate with groups where best practices can be discussed.

For those not in OCM or an alternative payment model, the Medicare Access and CHIP Reauthorization Act (MACRA) requires participation in the Merit-based Incentive Payment System (MIPS). Elements of MIPS currently include quality (50% of the MIPS score; this is similar to the Physician Quality Reporting System and is satisfied by participation in ASCO's Quality Oncology Practice Initiative), advancing care information (25%, which includes electronic prescribing, electronic communication with patients, coordination of care, and clinical data registry reporting), clinical practice improvement (15%, with practices having to perform one of 90 activities), and clinical cost (10%, based on overall resource use).

The ASCO 2017 meeting suggested opportunities to understand and implement practice changes, including participation in ASCO and state oncology societies, where best practices and barriers to performance are discussed; using practice consultants to evaluate performance deficits and electronic medical record meaningful use; identifying new therapeutic results that can lower drug and emergency department and hospital use; and implementing standard operating procedures to improve patient interactions and patient satisfaction. Remember, 2017 is the first year of the performance period, and such meetings as ASCO 2017 help in the decision-making process.

Because "value" has become the buzzword of current oncology practice, it is important to review what we know about value determinations. At ASCO 2017, many presentations focused on this issue. One of the most interesting was delivered at a clinical science symposium. Sierra Cheng, MD, MPH, and colleagues presented their study of the value frameworks that oncologists, patients, and payers are using to compare new therapies.

The commonly used frameworks that were studied included ASCO version 1 (2015), ASCO version 2 (2016), and the European Society for Medical Oncology (ESMO). The correlation coefficients among these frameworks were very poor: 0.36, 0.17, and 0.5. Furthermore, the correlation coefficients between the framework valuations and the ultimate coverage recommendations of the National Institute for Health and Care Excellence in the United Kingdom and the pan-Canadian Oncology Drug Review were also poor: 0.53 and 0.19 respectively. Of note, the correlation between ESMO and ASCO value determinations did not improve between ASCO version 1 and version 2 a year later.

This suggests that practices should review the value determinations of ASCO, the Institute for Clinical and Economic Review, the National Comprehensive Cancer Network, ESMO, and others very critically and await consensus between these organizations before adopting them. Of course, individual insurance companies are developing their own guidelines and pathways, which further increases the difficulty of optimal compliance with the best pathways, whichever they may be. New data from ASCO 2017 will need to be incorporated into payer pathways and guidelines, as well as into ASCO and other value frameworks. ASCO and state societies are urging more unanimity of these data and value-based guidelines to reduce the confusion that oncologists and patients are facing.

At the meeting, one study reviewed the attitudes and experiences of oncologists with MACRA. In abstract 6613, barriers to participation in the new value-based care systems in MACRA were drug costs (58%), data transparency (42%), human resources (33%), and technology resources (29%). Oncologists reported the inability to track costs of care (76%), difficulty in implementing quality improvement activities (56%), lack of patient engagement tools (52%), and problems in meeting meaningful use requirements (33%). Practices should be using these data to focus their current management plans and changes.

Because costs of care are now being tracked by Medicare as part of MIPS and OCM, oncologists should be looking for data that would allow them to reduce their costs of care. Although most ASCO 2017 presentations focused on new therapies that would increase the costs of care with new drugs or combinations, some presentations actually indicated opportunities to reduce the intensity or length of care and lower costs. Data from these studies should be reviewed in detail on the ASCO website, where the abstracts are published.

Abstract LBA1 showed that for most colon cancer patients, 3 months of adjuvant chemotherapy with FOLFOX/XELOX was as good as 6 months, with less neurotoxicity. Also in colon cancer patients, abstract 3506 showed that giving a large daily dose of vitamin D3 remarkably increased overall survival compared with control participants. Furthermore, abstract 10006 showed that in colon cancer, complying with the American Cancer Society national guidelines for maintaining a normal weight, including exercise and diet (eating fruits and vegetables and less red meat), was associated with a 42% reduction in mortality.

Although there is considerable enthusiasm for doing comprehensive genomic profiling or next-generation sequencing, abstract 102 showed that results were poor in patients with low performance status, and they should not be tested. Supportive care interventions were suggested to reduce patient fear, depression, and distress in abstracts LBA10001 and LBA10000. Abstract LBA2 showed that frequently using an online patient symptom report form, sent by the oncologist's office, resulted in better quality of life—and, unexpectedly and importantly, a 15% reduction in death.

In metastatic breast cancer, patients may not always need to take palbociclib with letrozole because overall survival was shown to be the same with or without palbociclib, reported in abstract 1001. In abstract 1002, it was shown that palbociclib did not have activity as a single agent. In abstract 1003, for HER2-positive metastatic breast cancer, overall survival was equal if Kadcyla® was given early in a patient's course compared with using less expensive trastuzumab and paclitaxel first. In primary treatment of ovarian cancer, lymphadenectomy with tumor resection was found to be unnecessary in abstract 5506.

In diffuse large B cell lymphoma, after CHOP/rituximab therapy, abstract 7506 showed that patients with a negative PET scan after chemotherapy did not require radiation therapy to previously bulky sites of disease. Finally, abstract LBA10004 demonstrated that a single dose of radiation therapy for epidural cord compression was as effective as standard fractionated dosing.

By paying attention to research results such as these, oncologists can more wisely choose therapies for their patients, reduce costs of care, and bring better value to patient care. More efficient care, as well as adapting to new payment processes that stress value, can help create a more sustainable professional environment for the entire treatment team and patients.


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