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Obtaining quality cancer care in Alaska is often difficult and expensive owing to the sparse highway network and the scattered nature of the stateâ€™s population of 736,000 people, who are spread out over more than a half-million square miles.
Eugene Huang, MD
Obtaining quality cancer care in Alaska is often difficult and expensive owing to the sparse highway network and the scattered nature of the state’s population of 736,000 people, who are spread out over more than a half-million square miles. For oncology practices, the use of local primary care providers to aid oncologists and recent advances in telemedicine have helped to overcome these barriers and increase the availability of cost-effective, evidence-based medicine.
For radiation and chemotherapy treatment spanning several weeks to months, patients may have to travel to one of the major population centers, such as Anchorage or Juneau, and live out of a hotel room throughout that time. Coupled with the medical expenses and the long-term leave from their job, the extended hotel stay puts an economic and emotional toll on patients and their families.
“Patients are in an unfamiliar environment and are going through one of the most difficult times of their lives,” said Eugene Huang, MD, medical director of the Southeast Radiation Oncology Center in Juneau. “The logistics are quite humbling.” Twenty-three of Alaska’s 27 boroughs and census areas are medically underserved areas/populations or governor-designated medically underserved populations, and they account for about 59 percent of the state’s residents.2
In addition, about 75 percent of communities in the state do not have road access to a community with a major hospital, meaning that many people need to travel by airplane, boat, or ferry to get treatment. Huang stated that some women with breast cancer will choose to undergo a mastectomy because it is less time-consuming and expensive than traveling to an urban center for radiation therapy, even if a less-invasive option is more appropriate.
Most medical and radiation oncologists are located in Anchorage, according to Matthew Olnes, MD, medical director of Hematology and Medical Oncology at Alaska Native Medical Center (ANMC), which treats a majority of the state’s far-flung native population, members of whom travel via complicated routes to reach centers of care. “A very typical pathway for them is to take a snow machine to get to the closest village that has an airstrip, then get on a propeller plane and fly to the largest regional city that has a jet, then get on the jet to fly to Anchorage,” said Olnes. “It’s literally a 12-hour trip for them, and they’re doing it every couple weeks for long-term treatment. It really wears them down.”
For the handful of independent oncology practices in Alaska, the patient base is more urban-suburban; however, a large proportion of those patients still must travel for treatment, making accommodations and rapid, well-coordinated care a priority for oncologists and other healthcare specialists who are a part of the effort.
Juneau is the third largest city in Alaska, with an estimated 32,406 residents in 2014;3 yet there is no road access from Juneau to the rest of the state. Before Huang opened his clinic in 2013, the closest radiation center was in Anchorage and required travel by plane or ferry. His $7 million center is located near the Bartlett Regional Hospital, which has an infusion center for patients undergoing chemotherapy.4 “Before we came to Juneau, patients would often omit doing their treatment because, logistically, it was too hard to travel or afford,” said Huang.Because most of Alaska’s oncologists are in Anchorage and Fairbanks, primary care providers often perform tasks that, outside of Alaska, are typically done by oncologists. Larry Daugherty, MD, director of Radiation Oncology at the Alaska Cancer Treatment Center in Anchorage, described a situation in which a local primary care provider was tasked with administering prostate-specific antigen tests after radiation treatment for one of Daugherty’s patients who lived in Valdez (a town approximately 300 miles east of Anchorage).
Medical oncologists based in larger cities, such as Anchorage or Seattle, in Washington, also travel to small Alaskan communities once or twice per month and prescribe chemotherapy, which internists or trained nurses administer under an oncologist’s supervision. Between chemotherapy treatments, the primary care providers also manage side effects, such as chemotherapy-induced nausea, and monitor blood counts. “Primary care physicians are excellent up here,” said Huang. “They don’t always have specialists on hand, so their scope of practice is much broader than it might be in the lower 48 states.”
For patients who live far from his Juneau location, Huang regularly relies on primary care doctors and nurse practitioners to provide follow-up care after his patients have completed radiation treatment. He also speaks with patients by phone to ensure that they know how to care for themselves after radiation treatment. “It is my responsibility that when a patient is done with their treatment here, that they have all the necessary education and follow-up care,” said Huang.
Oncology specialists in Alaska have a more diverse scope of practice than those in the lower 48. Whereas Daugherty’s previous experience as a radiation oncologist at the Mayo Clinic in Rochester, Minnesota, focused on gastrointestinal cancers, in Anchorage his practice has expanded to include any type of cancer. “In Alaska, I’ve gone back to ‘bread-and-butter’ oncology,” said Daugherty. “I see and treat the whole spectrum of cancers that need radiation.” Daugherty also tends to see a greater proportion of late-stage cancers in his Anchorage practice than he did at his previous practice at the Mayo Clinic, possibly due to patients in Alaska having less access to regular healthcare services and cancer screenings, he said.Although Olnes and Daugherty stated that staffing is adequate in their respective Anchorage-based locations, adequate healthcare staffing is problematic for many rural areas. Olnes stated that the six regional hospitals in the state have high turnover and staff shortages largely due to difficulty recruiting qualified individuals to work in these remote locations. If the only nurse trained to administer chemotherapy leaves and the hospital cannot find a replacement, the infusion center is forced to shut down and patients are forced to travel elsewhere for treatment. The Alaska Health Workforce Coalition published a Healthcare Workforce Plan in 2010 in a statewide effort to improve recruitment and retention of healthcare staff in rural areas.5 According to the Alaska Physician Supply Task Force, the need to care for an increasingly older population means that maintaining a sufficient workforce and providing adequate services, such as cancer screening, is a priority.6 The population of Alaska is aging rapidly, with a 54% increase in the number of people older than 65 years from 2000 to 2010.7The Alaska Federal Health Care Access Network (AFHCAN) was developed in 1998 to improve access to specialized healthcare in rural Alaska using telehealth technologies.8 Data from 2013 show that AFHCAN connects approximately 180 Alaska Native community village clinics, 25 subregional clinics, 4 multiphysician health centers, 6 regional hospitals, and the ANMC in Anchorage, primarily for primary care-related concerns in the native population.9
Oncologists at ANMC began incorporating video teleconferencing in 2012 to provide supportive care for former patients who have run out of treatment options or choose not to continue with treatment. Currently, patients who are receiving active treatment may use video conferencing in place of interim visits that do not require extensive physical examination. Olnes also indicated that some patients with prostate cancer have relied on telemedicine if they can be treated with hormonal therapies that are available in their community. Overall, telemedicine is important for reducing costs for patient and their health insurers and reduces stress on the patients and their families by saving them from unnecessary travel. “The biggest priority has been patient satisfaction, because they appreciate not having to come into Anchorage,” said Olnes.
However, Olnes stated that many patients who use telemedicine for follow-up appointments miss the one-on-one interaction with the physician, nurses, and office staff. Olnes stated that after a private video conference with a patient he often invites nurses and other staff members to exchange pleasantries with the patient via the teleconferencing system. “Patients get to know the nurses and support staff [during their treatment period in Anchorage] and they miss that experience,” said Olnes. “We also give them the option to come into the office in person.”
Video teleconferencing also benefits remote-based primary care providers who manage patients with cancer. Olnes stated that physicians and providers from multiple cancer care centers in Anchorage conduct weekly multidisciplinary conferences to view and discuss cases and develop an evidence-based treatment plan for patients. Primary care providers in rural areas can join the conference from a remote computer to see their patients’ tests, hear the discussion, and ask questions.Overall, unique geographical features and lack of road access to health care in Alaska have required increased reliance on primary care providers and greater use of telemedicine in rural areas to maintain adequate quality of care for patients with cancer. According to Daugherty, a key goal for providers in Alaska in the near future includes ensuring availability of modern treatments to all individuals in need and simplifying the process of obtaining cancer treatment. Huang opened his clinic to meet the demand for radiation oncology in Juneau and the surrounding areas, thereby easing patient travel burdens and allowing them to work and stay near their family and friends.
Daugherty stated that the comprehensive approach to the Alaska Cancer Treatment Center, which includes a medical oncologist, radiation oncologist, surgeons, primary care providers, a nutritionist, and a naturopathic oncologist, also helps to overcome barriers by enabling patients to complete all visits in one or two days. He also stated that the incorporation of traditional and alternative medicine has had an unexpected benefit in improving patients’ openness to receiving treatment. “Many patients in Alaska are interested in holistic and alternative approaches, said Daugherty. “To have a naturopathic oncologist on staff who can help mingle that with traditional medicine helps patients understand that natural approaches may be helpful as an adjunct but that they can’t be cured with herbal remedies alone.” According to Daugherty, the Alaska Cancer Treatment Center has a multispecialty cancer treatment team much like the larger, more renowned Mayo Clinic, and he stated that patients do not have to go to the lower 48 states to get high-quality cancer care.
Overall, working in Alaska has been fulfilling for both Huang and Daugherty because they feel that their work has a direct effect on patients and their community. “I get the warmest, sincerest thanks from our patients,” said Huang. “[Working in Juneau] was a great chance to work as I might have imagined in medical school—by having a visible impact on a community.”