COMMENTARY

Linking Community and Academic Oncologists: Creating a Team-Based Model

H. Jack West, MD

Disclosures

March 08, 2019

When I started as a thoracic oncologist nearly 20 years ago, platinum doublet chemotherapy using one of a few very comparable regimens represented the standard treatment for just about everyone. For the next several years, a general oncologist could practice without opening a journal, let alone changing their treatment approach, and still remain current on the optimal treatment.

I don't even make a pretense of keeping up with the developments in breast cancer, gastrointestinal cancers, sarcomas, or lymphoma.

But over the past 10-15 years, not only have the management algorithms become more complex, but the pace of change has accelerated dramatically. The previously monolithic population of "advanced non–small cell lung cancer (NSCLC)" patients splintered first by histologic subtype, then further into side branches of mutation-based subgroups. It is now to the point that the algorithms have become like a giant banyan tree, sprawling in all directions on the basis of histology, an ever-growing collection of driver mutations, and, most recently, layers of immune biomarkers like PD-L1 (and potentially tumor mutational burden and other parameters, such as the rate of progression). Developments happen so quickly in this field that you need to follow social media for the latest press releases on new data with potentially practice-changing implications; the National Comprehensive Cancer Network guidelines in NSCLC now weigh in at more than 200 pages.[1]

A colleague in my practice who has a secondary interest in lung cancer highlighted this growing complexity by noting that, upon our return from ASCO 2018, he no longer felt that he was able to stay up to speed on it. Meanwhile, I have felt this with my own secondary focus on genitourinary (GU) oncology, which I have practiced alongside thoracic oncology to serve the needs of my institution. It has been a boon for patients to have so many new treatments in GU oncology, but with limited bandwidth and ongoing clinical demands, it is increasingly challenging to maintain expertise in even two fields of oncology. I don't even make a pretense of keeping up with the developments in breast cancer, gastrointestinal cancers, sarcomas, or lymphoma. And yet, general oncologists are seeing 10-15—or more—different cancers in their clinic every day. It must be remarkably challenging to keep up with anything close to the latest developments across so many cancers.

Even the most motivated and dedicated oncologist can no longer keep current on the latest evolving changes across a wide range of cancer types.

A recent paper in the Journal of Thoracic Oncology reviewed National Cancer Database outcomes in terms of 2-year survival for patients with advanced NSCLC who were treated at academic versus community centers between 1998 and 2010.[2] Results were modestly superior for patients treated at academic centers (2-year survival 11.5% vs 9.2% for academic vs community care, respectively) and were limited to patients with adenocarcinoma, the population in whom nearly all advances were made in that interval. Despite attempts by the investigators to control for as many confounding variables as possible, unmeasured factors are likely, particularly in a large retrospective database review. But considering that the time interval included in this study precedes the more recent, current complexity of managing advanced NSCLC, I strongly suspect that the differences would be more pronounced now.

I would argue that we have entered an era in which patients are increasingly likely to experience suboptimal outcomes without the benefit of subspecialist input. Even the most motivated and dedicated oncologist can no longer keep current on the latest evolving changes across a wide range of cancer types.

I hope we see the evolution of a new system that links subspecialists at larger referral centers with community-based general oncologists.

It is not realistic to expect that every patient will be directed to an academic center even for a consultation, let alone for care. Patients have limitations in their abilities and motivation to travel, and community oncologists may be concerned that patients evaluated at a larger referral center may be "poached" and never seen again. At the same time, academic centers that currently deliver care to less than 20% of cancer patients in the United States do not have the capacity to directly oversee the care of a much larger proportion of patients. And it is painfully inefficient to have hordes of patients drive vast distances in city traffic, then funnel into the (typically pricey) parking lots of the larger centers, only to take the same oral therapy or receive IV infusions of the exact same medications they can receive at the local cancer center 5 minutes from their home.

I hope we see the evolution of a new system that links subspecialists at larger referral centers with community-based general oncologists, to work more as teams within a network. This needs to be achieved by creating partnerships that ensure efficient care delivery as well as the viability of both academic and community-based care, all while optimizing patient outcomes. Specifically, I envision patients receiving as much care as possible at centers close to home. At the same time, the vast majority of patients can avail themselves of an occasional live visit with a subspecialist, as needed, while also integrating intermittent telemedicine visits with the subspecialist every few months to reinforce or alter the trajectory as needed.

Of course, oncologists at referral centers, like myself, see many patients who receive much of their actual care closer to home. But there are also vast numbers of patients who drive past five cancer centers to get treated by me with approaches and regimens that can be delivered just as capably at a more convenient location for them—and who might be inclined to do just that if I could work through a telemedicine-based visit with them, and perhaps their local oncologist, every few months to ensure that I remain directly involved in their care.

I am eager to hear the perspectives of oncologists in the community and academic settings.

Of note, I don't see working with a subspecialist as diminishing the role of the general oncologist. Instead, I view it as enabling the general oncologist to follow their particular skillsets of caring for the patient with whom they have a real relationship, honing goals of care, and managing the day-to-day issues of patients, all with the partnership of a subspecialist who is "on demand" to provide support on more specific issues when needed. This system keeps patients receiving care at the locations most convenient to them, where they can continue to get labs, scans, and treatments available locally, but with the assurance that they also have a subspecialist as part of their care team, even if that doesn't require a painful drive to see them. Increasingly, novel strategies are emerging to align these partnerships in ways that allow for collaboration rather than competition over patients as a "zero sum" game.

Having patients connected to a subspecialist along the way will also increase access to clinical trials for eligible patients, and this may require some to travel a significant distance for protocol-based treatments. We should continue to work with sponsor companies and regulatory authorities on ways in which patients can receive far more of their trial-based care through community-based centers, with telemedicine connections integrated along the way.

I am eager to hear the perspectives of oncologists in the community and academic settings, and whether they feel that it is becoming increasingly difficult to cover a broad range of cancers. I'm also interested to know whether community oncologists in particular feel that the aforementioned system would be helpful or make them feel less valued, and whether telemedicine is a needed development or just one more overhyped concept that may never deliver on its promise.

Please share your thoughts. I would love to discuss this with you in the comments.

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