City of Hope Spinoff Offers Remote Second Opinions

Christina Frangou

December 23, 2021

A new program that is a spinoff from City of Hope Comprehensive Cancer Center is offering remote second opinions from oncologists concerning management plans for lung cancer patients.

In a new study of initial data from the program, the expert-on-demand service recommended significant changes to treatment plans for more than one quarter of patients and smaller refinements in more than 90%.

The program, called AccessHope, is primarily provided as a supplemental benefit for payers and employers. When a patient's case is reviewed, a subspecialist examines the treatment plans and offers recommendations to the treating oncologist. The expert does not see the patient in-person or remotely.

"The goal is to be a resource for the local oncologist, and with an intent to have the patient get their scans, their labs, and treatments close to home and by the oncologists who have been caring for them," said Howard (Jack) West, MD, medical director of AccessHope and associate professor at City of Hope Comprehensive Cancer Center.  

A subsidiary of City of Hope Comprehensive Cancer Center, AccessHope was launched in 2019 and expanded over the pandemic, said West.

In a study published online in JCO Oncology Practice, West and colleagues retrospectively evaluated the recommendations for 110 patients with lung cancer between April 2019 and November 2020.

Patients were selected for review after being diagnosed with a cancer on a trigger list of diagnoses. In this study, 82% of patients had non-small cell lung cancer (12% stage I or II, 16% stage III, and 57% stage IV) and 17% had small cell lung cancer (4% limited and 14% extensive). They had a median age of 62.5 years and 55% were male.

At the time of the review, 13% of patients had not initiated treatment, 62% were receiving or had received their primary treatment without progression, and 25% had disease progression and were receiving or planned to receive a second-line or later treatment.

Once a patient is selected or requests a review, an AccessHope oncology nurse writes a summary narrative based on the patient's medical records and delivers it to a thoracic oncology specialist. Then, the specialist makes recommendations for testing and treatment that they detail in a report sent to the primary medical team. The specialist also discusses the recommendations during a call with the local oncologist.

In 28% of cases, the subspecialist disagreed with the treatment strategy and proposed an alternative approach associated with better survival based on available data. The subspecialist also suggested refinements to the strategy in 92% of cases.

The recommendations had the potential for cost savings in 14 patients with a total savings of $149,776 per patient. This translated to a projected cost savings of $19,062 per patient for the cohort, the authors reported.

West said the program has the advantage of a rapid turnaround time compared with traditional tumor boards or arranging an in-person visit. The median time for the expert to send the report to the local oncologist after receiving the case summary was 5 days.

Commenting on the study, Michael Diaz, MD, the incoming president of Florida Cancer Specialists & Research Institute and past president of the Community Oncology Alliance, said that there are too few details in the study to draw conclusions about the program's value.

It isn't clear from the study that the expert takes into account the patient-specific factors that affect decisions about cancer treatment, especially in the context of shared decision-making between patients and providers, said Diaz.  

For instance, the study found that PET scans were pursued or planned by local oncologists in 11% of cases, despite the lack of demonstrated benefit over CT scan surveillance. But some patients with lung cancer also have kidney disease and shouldn't be exposed to contrast from a CT scan, he pointed out. "It's not as black and white with some of those things," he said.

The study did not report if local oncologists changed their treatment strategy after the subspecialist's recommendations, nor did it report on any potential cost increases related to recommendations, said Diaz.

He said that he encourages patients to seek a second opinion and welcomes programs that help patients access additional expertise. "A second opinion helps relieve some ambiguity, especially when the situation is a little grayer," he said.

The investigators acknowledge their work has several limitations: it is based on a small cohort of patients who are insured and have a high level of support from an employer or insurance payer. It did not assess patient or local physician satisfaction, nor clinical outcomes associated with any recommendations that were followed.

The study was designed to evaluate the feasibility of a remote approach to second opinions, said West.

"This isn't the only way to try to deliver expertise out to people," he said. "But this is our effort to come up with a program that is very time-sensitive and doesn't require patients to travel."

H. Jack West, MD, regularly comments on lung cancer for Medscape. He is directly employed by AccessHope and City of Hope Comprehensive Cancer Center.

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