Consciously or unconsciously, all oncologists develop some sort of system for managing the growing complexity of cancer care.
Sumanta Kumar Pal, MD
Consciously or unconsciously, all oncologists develop some sort of system for managing the growing complexity of cancer care. The growing number and diversity of treatments may be a boon for patients, but for doctors and treatment centers, this flood of increasing choices is identified with constant adaptation and physician burnout.
Sumanta Kumar Pal, MD, has his own system for sidestepping the voluminous information associated with these advancements, while reducing the risk that he overlooks something important. When he wants to find out about the latest developments in cancer care, he doesn’t go to an esteemed journal, he doesn’t randomly search through news articles, and he doesn’t rely on a Google search: He counts on social media postings by trusted peers to direct him to news articles and journals that contain updates most likely to supply the most recent information that’s of greatest value.
This solution might seem strange to those accustomed to the plethora of irrelevant and often self-gratifying postings found on social media. “Paradoxically, most people don’t have time to avoid social media,” counters Pal, codirector of the Kidney Cancer Program and head of the kidney and bladder cancer disease team at City of Hope, Duarte, California. “The actual time I spend on social media is pretty brief, because I use it as a conduit to get to the meaty articles.” Those who pore through every journal or type key words into Web search engines will have a harder time fishing out what’s new and important, he said.
The complexity of cancer care is compounded by growing demand for care and a limited workforce, rising costs of care, and an increasing number of considerations that must be incorporated into each treatment decision. In a 2013 report, the Institute of Medicine (now the Health and Medicine Division of The National Academies of Sciences, Engineering, and Medicine), concluded that “the cancer care delivery system is in crisis” due in part to this complexity of care.
The message resonated with cancer treatment associations, such as the American Society of Clinical Oncology (ASCO), which collaborated with the National Cancer Institute (NCI) in 2016 on a series of workshops and papers to develop team approaches to cancer care that would help overcome the complexity barrier, which the NCI described as contributing to a 45% rate of high emotional exhaustion and burnout among oncologists.1 Team approaches may involve designating individual practice members to become specialized in certain areas of treatment, or holding regular group meetings to discuss individual cases, protocols, and advances in care. These activities support physicians who otherwise would not be able to keep up.“I’m past the point where I can keep all the necessary medical information in my head,” said Randall A. Oyer, MD, an oncology generalist and the medical director of the Oncology Program at Penn Medicine Lancaster General Health in Lancaster, Pennsylvania. To solve this problem, he turns to point-of-care decision- support tools to look up treatments and treatment-related adverse events (Table).2 He also relies on other drug information sources as well as guidelines from the National Comprehensive Cancer Network (NCCN), which he checks every time he sees a new patient or makes a treatment choice, unless it involves something he prescribes multiple times daily. “You want to make sure your patient doesn’t miss out because you don’t know something,” he said. For example, a new combination therapy might have been added to the guidelines since he last checked. The NCCN guidelines are a standard place to look, but sometimes these are considered too conservative or don’t align with the treatment goals of a private payer. Partly for those reasons and for simplification, Cancer Care Specialists, based in central and southern Illinois, uses a set of clinical pathways from New Century Health, a healthcare system manager headquartered in Brea, California. These pathways provide evidence-based and cost-effective treatment options for providing value to patients, said Mark A. Walshauser, MD, a medical oncologist and hematologist with Cancer Care Specialists practicing in Swansea, Illinois. Owing to its role as a nonprofit standard setter, “the NCCN has to be more careful about what they say and not consider cost,” he said. New Century Health’s pathways are regularly updated by expert physicians. Walshauser said he appreciates the NCCN guidelines but finds New Century’s pathways “a little more biased toward value.”
Audio and video presentations that provide continuing medical education, online oncology publications and their email blasts, and print journals were cited by oncologists interviewed by OncologyLive® as tools and resources that help them to stay focused on essential information and avoid too much clutter. In addition, although some physicians may not want to carve out time for drug company representatives from days that are already packed with patient visits, administrative chores, and electronic record keeping, sales representatives often have information to share that can be valuable, said Bijoy P. Telivala, MD, an oncologist hematologist who works with Baptist Health in Jacksonville, Florida. “They do bring good information,” he said, citing representatives’ knowledge of drug combinations and adverse events. “Some are very honest about the data—the advantages and disadvantages.”Conferences can reduce a blizzard of treatment updates and clinical trial findings to useful essentials, but physicians should understand what they want to get out of these before signing up, Pal said. “These days, for better or worse, we learn about the highlights through press releases months ahead of seeing the full data sets at meetings,” he noted. Pal uses conferences to network with physicians he follows on social media, getting to know them better through face-to-face encounters and their presentations.
Large conferences have the potential to overwhelm due to the sheer volume of material presented, physicians said. The annual conference of the American Society of Clinical Oncology (ASCO) in Chicago is considered authoritative in its scope and its ability to serve the interests of oncologists who are narrowly focused on certain types of care. However, that very breadth can compound the sense that the field is moving too fast for a working oncologist to keep pace. The 2018 ASCO Meeting, attracted more than 39,000 attendees and thousands of abstracts; of necessity, multiple presentations were staged simultaneously. “It’s impossible to grab all the highlights, especially as a general oncologist,” Telivala said. Some oncologists in search of simplification prefer smaller symposia that encapsulate the larger findings presented at megameetings. “It’s practical advice with easy take-home messages,” Telivala said.City of Hope includes several research institutions that serve as a vital resource for community clinics that otherwise lack the knowledge and academic base to keep up with advancements in care, Pal said. “I have a large Rolodex of community oncologists who call me for advice. It’s a fulfilling partnership,” he explained. “They can get the advice they need, and I can identify patients who would be good candidates for clinical trials we’re running.”
More broadly, community oncologists have many routes to working with academic centers and taking advantage of learning opportunities, Pal noted. Community practices and hospitals can develop informal or contractual relationships with cancer centers, paying for various levels of services such as access to virtual or in-person tumor boards. Faculty visits to outlying clinics, as well as clinical trial access, also can be arranged. In addition, these larger centers often host multidisciplinary lectures.In addition, tumor boards at hospitals and community practices are good ways to share information and learn. Telivala said tumor boards at Baptist Health use a team approach and bring aboard medical oncologists, radiation oncologists, surgeons, pathologists, and others for case reviews. Each specialist contributes a unique perspective, and together they determine a single treatment path, which is reassuring for the patient.
Such a team approach is used at Lancaster General Health, Oyer said. They have different disease teams depending on the cancer type. “I need a pathologist to know what tumor markers to look for, to give the diagnosis and prognosis for brain cancer, for example,” he said. During team meetings, they share information on the amount of biopsy tissue needed and determine the timing for various tests and what testing to do. The teams may include nursing staff and a social worker, chaplain, research nurse, or financial counselor. By involving so many professionals, the practice is able to dilute the complexities of care, while also making it clear to everybody involved that modern cancer care requires interdependence and patient hand-offs. The practice also works closely with local hospital emergency departments, so emergency doctors can recognize problems as possible treatment-related adverse events.
Community practices have other ways to share medical updates. Walshauser’s group of 20 oncologists spends 90 minutes every Friday discussing protocols and reviewing the latest research. Queens Medical Associates in Fresh Meadows, New York, has a daily huddle over lunch for 15 to 20 minutes. One of the 7 participating oncologists might present a challenging case, ask for treatment recommendations, or discuss new FDA approvals or emerging data, said oncologist/hematologist Abhisek Swaika, MD. Oyer’s group appoints a lead physician for each cancer type. Each month, 1 physician presents updates to the group on recent changes, pathways, and recommendations for the practice’s research agenda.With the increasing amount of information on different cancers, some community oncologists are choosing to subspecialize. For the last 15 years, Gladys Rodriguez, MD, t reated most ly lymphoma, myeloma, and breast, lung, colon, and genitourinary cancers. In October 2018, she decided to focus mainly on breast cancer, as it was getting too difficult to stay on top of treatment trends for all the disease types. Her practice at the START Center for Cancer Care, serving patients in San Antonio and rural southern Texas, was already 50% patients with breast cancer, and breast cancer was her main research interest, so that made the transition easier. “I tell my patients, if you come to me, I want to make sure I’m giving you the best advice and treatment possible;” and if she can’t, she will refer patients elsewhere. A few of the 14 colleagues in her group are subspecialized, but most are not.
“Especially with the larger groups in major cities, we’re beginning to see more community oncologists subspecializing,” Rodriguez said. She defined larger groups as those with at least 7 oncologists, enough to divide the cancer types among themselves. “For smaller practices, especially with only 1 or 2 oncologists, it’s not possible,” she said.
Several oncologists interviewed for this article agreed that, despite mounting complexity, sometimes it’s not practical to subspecialize. “We see anybody who comes through the door,” Walshauser said. “Everyone sees everything. Because we do a lot of rural medicine, we don’t have the luxury of being subspecialized.”
At Queens Medical Associates, each oncologist’s practice is based not on a subspecialty but on a language type. Swaika explained that each oncologist represents a different ethnicity and may speak Russian, Korean, Bengali, Spanish, or another language. “It’s unique to Queens. It’s a lot like the United Nations here,” he said.