Notion of Academic and Community Oncology 'Tribes' Needs to End

'We're Getting Siloed and Speaking Different Dialects'

H. Jack West, MD; Edward B. Garon, MD, MS; Mark A. Lewis, MD


June 14, 2019

This transcript has been edited for clarity.

H. Jack West, MD: Hello. I'm Dr Jack West, associate clinical professor and the executive director of employer services at the City of Hope Comprehensive Cancer Center in Duarte, California. Welcome to Medscape Oncology Insights. Joining me today is Eddie Garon, associate professor of medicine at University of California in Los Angeles, and Dr Mark Lewis, director of gastrointestinal oncology at Intermountain Healthcare in Utah. Thanks so much for being here.

Mark A. Lewis, MD: Thanks for having us, Jack.

Edward B. Garon, MD: Thank you.

We Are 'Speaking Different Dialects'

West: We're going to talk about general impressions of the state of oncology and some of the challenges we're facing. One thing I'm struck by in general practice—and at this meeting [ASCO 2019], I fear—is a growing disparity between the availability of resources and the knowledge base at more specialized centers. People may just not have the same opportunities and the same subspecialization as they get further out into the community setting, and this may translate into real challenges in terms of delivering what we would consider the best care to patients. I think it's a really frustrating issue.

I find myself thinking back to college, when I happened to be taking a couple of different humanities classes after my premed requirements. The professors would assign some ridiculous amount of outside reading—400 pages or so a week. It was so much that I would just give up and say, "I can't do this. This is not attainable, and it's not fair for professors to expect that that's the only thing I'm going to be doing." My concern is that we are getting a bit like that when the people talking about what everyone should be doing are more narrowly specialized and say, "We should be doing repeat biopsies and get 12 different kinds of molecular marker studies and know what to do." Do you have any sense that it's getting or has become unwieldy or unmanageable for the docs who are seeing 12 or 15 kinds of cancer a day? It's hard for many of us to keep up with all of the developments in one or two kinds of cancer, let alone 10 or more.

Lewis: I totally agree. You and I are kindred spirits. I was a double-major in classics and biology. I did biology just in case classics didn't pan out. I was trying to be like my father, who was a scholar and knew multiple languages. One semester I overburdened myself by trying to take Greek and Hebrew at the same time. Those were two different languages and I immediately found myself out of my depth. I was getting my alephs and my alphas mixed up. I sort of feel like that now. In oncology, it's a wonderful problem to have so much discussion in these increasingly different areas, but I feel like it's almost a Tower of Babel where breast cancer is now a different language, if you will, than, say, lung cancer. And it's incredibly difficult to be a polyglot and master all of these different disciplines.

'Torrid Pace' of Information

West: That is my concern: We're getting siloed and speaking different dialects. It becomes increasingly difficult for a general oncologist to keep up with what is not even feasible. We have not yet translated [things or made] the CliffsNotes version of what you need to know. What I'm seeing in the actual data and practice, as we look at real-world evidence, is that it's not getting executed the way that we hoped. We can roll our eyes and say, "Why can't they keep up?" but I don't think that is necessarily realistic when it's at such a torrid pace.

Garon: Personally, I only see thoracic oncology, outside of the time when I do inpatient service, and I wonder how people will be able to deal with all of the information. One of the things that then becomes frustrating is that people have to be given sort of an explanation. Next-generation sequencing (NGS) is probably the best example. You can't expect everyone to be familiar with all of the [information] across all of the histologies. So the reports come back and they simplify it and, in the end, they really have a lot of power over what patients actually receive, right or wrong. They will come back and they are interpreted for the patients, and sometimes the interpretations make sense. But of course, as we all know as medical oncologists, oftentimes context is important. And that, obviously, is not going to come in those reports, and it can't come in those reports.

There is this concept that if you just squint hard enough at the NGS reports, there will be some pill there for them.

West: NGS is, of course, a new world of molecular oncology, but very few practicing oncologists who are that well versed came into it with that the level of knowledge. And I'm afraid that what we're actually seeing in these reports is an arms race of, "We're going to deliver so many markers that we're going to find something for everybody." To me, that is really a mistake. If you lower the bar enough, yeah, you can find something or some pill to give somebody, but it's often going to be predicated on preclinical data or something very tenuous. And the problem is, if you give that to the hapless oncologist trying to deal with this 70-, 90-page report on all of these patients when they come back with 20 biomarkers and very little context, it's not clear what should bubble up to the top. It's not very easy to obscure something that really matters, because it's surrounded by a whole lot of junk. But there is the potential that you are going to give someone everolimus for that very tenuous biomarker based on dubious data instead of the treatment that really could have helped them. There is this concept that if you just squint hard enough at the NGS reports, there will be some pill there for them.

Lewis: The oncologist is having to deal with not one but two torrential data streams. Again, we have the nice problem that research is continuing at breakneck speed, but who can really wrap their arms around literature that is changing in real time? Second, you are getting just an absolute torrent of data points on each individual patient. When you're [using] NGS, you find all these things, like variants of unknown significance. How do you act on those appropriately and conscionably in clinic? And the third party here is actually the patients themselves, who are getting so savvy and demanding this testing, sometimes in clinical contexts where it may not be appropriate.

Can We 'Narrow the Gap' Between Academic and Community Oncologists?

West: Eddie, do you have any thoughts on how we can potentially narrow the gap between how subspecialists interact at meetings like this—at the very bleeding edge of new information—and getting the core concepts and the most established treatments out to the communities and the patients where they are often getting treated?

Garon: Some places are looking at putting together molecular tumor boards and even doing some things remotely. I always think about [a case] in ALK gene rearrangements, for instance. There was a very nice paper out of the group in Boston,[1] where they had a patient who got a sequence of different ALK inhibitors. By x-ray crystallography they were able to show that you would be able to use crizotinib again and that the patient would now be sensitive to it. Even for me, who is specialized, that was a great example. I would love to talk to them and see where the reality is for that. I don't have a great relationship with my x-ray crystallographer. [Laughter] How exactly can I apply this in a real-world setting? I have a feeling that the way I feel on that specific topic is probably how people in the community feel very frequently.

West: Some of this reminds me of Marie Antoinette. "Well, you just do a ninth repeat biopsy, and then you cobble together a regimen based on the four investigational agents you have. Then you find the one-in–a hundred case report and publish it."

Lewis: Well, I know these two guys, Watson and Crick. I'll get you their names—they're great. [Laughter] I think the era of paternalism needs to end. But I also think that there is this notion that oncology is in two tribes. One is sort of the ivory tower, academic elite, and the other—I've heard this phrase more than once at this meeting used almost as an epithet—is the community oncologist, which is often said with some disdain. You know, we're on the same team. There should not be an "us" versus "them." I think we're living in an era where it's almost like the Gutenberg press has come back around. Yes, traditional, peer-reviewed publications matter. But let's be honest: It's getting increasingly difficult for the very busy practicing oncologist out in the community or in an academic setting to sit down and really dissect every journal paper with the rigor that they might want.

Again, [we need to] get rid of this notion that one group is better than the other and realize that we can only work in synergy. And we have an opportunity. You and I are very interested in the effects of social media on patients and practice. I think there is a way there to disseminate important information almost in bite-size pieces. Twitter is, obviously, one way of doing that. I actually think YouTube is another way of doing that. The pathologist Jerad Gardner has sort of revolutionized teaching other pathologists about very specialized cases. I think his exact quote was, "My YouTube videos teach while I'm asleep." We're sometimes a little tentative about using these new means of communication, but they are there and they are incredibly powerful if we just harness them correctly.

West: My concern is that the bottleneck is less what to do for that third acquired resistance development, but more on just getting people access to the things that have proven value much earlier on. That is very high-yield. It's the concept of the cancer groundshot as opposed to the cancer moonshot. Bishal Gyawali kind of introduced this in a Lancet editorial,[2] and it elegantly explains the concept that we need to make sure that we're covering the basics before worrying about getting everyone first to the moon.

Garon: Got to crawl before you can walk.

West: Exactly. We need to deliver the treatments that are unquestionably of proven value. We need to make sure that people are getting the molecular testing that is clearly valuable and, if they have an ALK rearrangement, EGFR mutation, etc, that they get those treatments delivered to them. That is certainly going to be a high priority.

I think it's about education and partnering with the docs in the community (and not as a pejorative term). We need to be part of a team now. I don't do my taxes, plumbing, or electrical work. I hire or work in partnership with people when I need to, and it would be perfectly great if we had more partnerships as part of a team. For example, when someone in the community needs a thoracic oncologist on demand, they could see you or do a remote consult. At City of Hope, we're increasingly doing remote consults around the country and video, potentially. It's not a risk of the patient getting seen at a distant place or never coming back. People can get treated close to home with the confidence that they are getting what they would get at a subspecialty center. That can even be a longitudinal relationship as things change. There can be a dialogue about what to do. It's become complex enough that it would be really helpful to have a subspecialist in various things available. Intermountain is a network. There are a lot of networks, and it would be attractive to be able to work together and not have this "us" versus "them" concept that we're working in opposing forces.

I've practiced in both community oncology and 'academic oncology' and I see both sides. I just hate the thought that they might be warring factions.

Lewis: I'll say two things. I think the "academic oncologists" have to be in some manner incentivized to share their knowledge, to help us deal with the fact that diagnostics are outpacing therapeutics. I feel like they are often living in a publish-or-perish environment. They are applying for grants. They are judged on their paper output. There will always be a need for very rigorous, robust manuscripts. But at least in terms of getting the message out, I would personally like to see more academics getting recognized for their efforts on social media and sort of virtual education.

The second thing is, I work at a system—Intermountain. I am supposed to be the lead gastrointestinal oncologist. And what has been really wonderful about that is that I've seen it in fact, both with my colleagues, who I'm not condescending to—they are wonderful docs practicing across a very large geographic area—and also patients. We have used virtual technology. It sounds almost silly, but sometimes I video into an appointment just to kind of observe and reassure a patient hundreds of miles away that yes, what they are getting is the current standard of care. Sometimes that is very reassuring.

Garon: We have a set-up that sometimes works. On many of our trials, people at our satellite sites, and even community practices that affiliate with us for research, can accrue on studies of mine. And that does incentivize me, as you can imagine. They also enroll patients and soon will be able to bank specimens on my R01. Responsibility goes both ways: They help me in things that are of value in academia and I need to be available to them for specific questions on complex cases in my area because they have a practice with a whole bunch of different histologies.

Patients: A Powerful Resource

West: Patients are a great and increasingly powerful and important resource. We've seen many examples at the ASCO 2019 meeting of the power of online patient groups, particularly the narrower molecularly defined subgroups that are geographically dispersed. They aggregate online and they are highly motivated to get trials done so that they can move the field forward. They partner with a lot of the leading physicians to try to make this happen. They have been a real force for providing a level of information that is just unattainable any other way, and ideally we should partner with them. Eddie, you have worked with me on the Global Resource for Advancing Cancer Education (GRACE), a nonprofit for patients, and it's kind of a belt-and-suspenders approach to get that information to the docs and the patients out in the world.

Lewis: We underestimate the sophistication of our patients at our peril. I've often said that the self-advocating patient is becoming the strongest force in healthcare. Like you gentlemen, I help run a group online for people with multiple endocrine neoplasia, a rare tumor syndrome with an instance of about 1 in 30,000. You're absolutely right—they are geographically dispersed across the United States and across the world, but they gather online and have very sophisticated discussions about treatment and are well aware of new findings. Again, I think our job is to help interpret research coming out of conferences like this. We had a major cautionary tale of this yesterday at the ASCO 2019 plenary session about acting on a phase 2 trial before the phase 3 data were mature, with the expenditure of more than a billion dollars on a drug in the meantime. We have to be careful. It's the classic cliché of a balancing act between hope and hype.

We have a responsibility here. There is a conversation, and the conversation is happening whether we are engaged or not, so it's important that we raise our voices. We need to have a united front. I've practiced in both community oncology and "academic oncology" and I see both sides. I just hate the thought that they might be warring factions.

West: I think that is absolutely right. We need to change the dynamic as well with patients. Because it's high stakes and it's chronic, oncology is extremely amenable to finding good information online, as long as it's made available to docs and to patients. But for these narrower subsets (and we're increasingly redefining how narrow is narrow), it's ridiculous to think that an oncologist in the community who might see one MET exon 14 mutation-positive non–small cell lung cancer patient in 5 years, or a career, should retain that information in their mind. Of course, patients who are looking at everything written about this are going to know about that. But that also means that you are going to need to work in a partnership with the doc, and it does not make your doctor ignorant for not knowing everything there is to know about that 0.5% subset.

Garon: The complexity presumably will go up, and it's a problem that won't get easier. Starting to think about solutions now makes a lot of sense.

West: Absolutely. Eddie, Mark, thank you so much for joining me—great discussion, as I would have expected from you two. Also, thank you, the audience, for joining us. This is Jack West for Medscape.

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