For Louis Potters, MD, FASTRO, FABS, FACR, World Cancer Day is more than an annual observance—it’s a timely reminder of what oncology teams must recommit to every day: earlier detection, reduced stigma, equitable access, and sustained investment in research.
At Northwell Cancer Institute, Potters and his colleagues have built a system-wide model to deliver consistent, evidence-based radiation therapy across a rapidly expanding network through standardized treatment pathways known as “directives.” Now numbering more than 170, these directives are designed to reduce variability, improve efficiency, enhance patient safety, and ensure patients receive the same high-quality care whether they are treated at a flagship cancer center or a community site.
As health care continues shifting toward value-based models, Potters believes these directives may also provide a scalable roadmap for improving outcomes, reducing risk, and expanding access beyond the New York metropolitan region.
“If the CEO calls me to help treat a friend at one of the community sites, they’re going to receive the same high level of care as they would at the mothership cancer center,” Potters said, alluding to the significance of the directives in an interview with OncLive®.
In the interview, Potters, chair of the Department of Radiation Medicine, as well as senior vice president and deputy physician-in-chief of Northwell Cancer Institute in Lake Success, New York, reflected on the meaning of World Cancer Day and explained how Northwell’s treatment directives have transformed radiation oncology delivery through standardization, collaboration, and equity-driven innovation.
Key Takeaways: Standardizing Radiation Oncology Care at Scale
- Northwell has developed approximately 170 treatment directives to reduce variability, improve safety, and ensure consistent delivery of radiation therapy across its growing geographic footprint.
- Faculty buy-in was achieved through a culture of collaboration, evidence-based review, and consensus-building, allowing directives to evolve alongside new data and clinical advancements.
- The directive model supports efficiency, decentralization, and value-based care, positioning Northwell to expand access and potentially share standardized pathways with other systems worldwide.
OncLive: What does World Cancer Day mean to you and how will you be spending it?
Potters: In some ways, every day is World Cancer Day, but it does give us an opportunity and an inflection point to highlight things like early detection and screening and the importance of being able to get that information out into the community. It helps us think about reducing the stigma of cancer, the diagnosis, the effects of treatment, and the effects on survivors. It [also] gives us an opportunity to think about equitable access to care, not just in the United States, but worldwide and it’s a time to honor survivors. Keep in mind, from the day of diagnosis, [the patient is] a survivor going through the treatments and sequelae associated with managing their cancer.
The last thing I like to think of is the importance of research and the importance of funding, especially in this time. Congress is slated to return money back to the National Institutes of Health, but the importance of funding clinical trials and research is so critical to the successes that we've had over the past number of years, and it's something that we should feel pride with and a need to continue. Those are the things that I think about when I think about World Cancer Day and I always look forward to it.
How have treatment directives helped Northwell ensure that patients receive the same high-quality care regardless of which geographic location they visit?
At Northwell and the Department of Radiation Medicine, about 16 or 17 years ago, we decided to create treatment pathways that we call directives. The directives are meant to enhance safety, utilize best practices, and improve some of the efficiencies in the operations within the department. It's well recognized the variability in the way patients can be treated for the exact same condition, which can create all sorts of risk, in terms of mistakes. It also creates variability in outcomes. As a faculty, including our physics staff, we decided that we would develop these directives so that we had a pathway for treatment at Northwell, and we've been utilizing these for the past 14 or 15 years. We have a library of [approximately] 170 of these [directives], and as Northwell has grown geographically in the New York metropolitan area and now up into the Hudson Valley, it creates a level of consistency of care across the entire network. If the CEO calls me to help treat a friend of his who's going to be treated at one of the community sites, they’re going to receive the same high level of care that they would receive at the mothership Cancer Center.
To date, we have [approximately] 91% to 92% compliance for 170 of these directives, and they evolve and change as the evidence changes, as new discoveries are made. As evidence evolves, these directives are edited, so there's a level of scientific evidence and then there's a degree of consensus among the faculty to create the homogeneity in the care that we offer.
How were these directives developed and implemented, and what did it take to achieve clinician buy in?
[It has been] an interesting opportunity to build culture within the department, because if you trained in Boston, if you trained at [The University of Texas] MD Anderson [Cancer Center] or UCLA, or any of these world class cancer centers, there are nuances to the way that you may come out of training to treat patients. We all take a sense of pride in the way that we were trained and what we want to do. But the way that MD Anderson [approaches care], the way that [Memorial] Sloan Kettering [Cancer Center] or UCLA [approaches treatment] can be standardized a little bit more. It does create for some interesting discussions when the evidence doesn't lock you into any one way and creates, say, 2 or 3 different pathway opportunities to develop a consensus. Sometimes those conversations are hard. Sometimes they're straightforward.
One of the things that we've learned over the years is that we always allow new faculty joining the practice to express their opinions and have just as much of a right to try and sway the faculty if they think that there's a better way of doing something. That's not to say necessarily that these directives are the only way or the best way to treat [patients], but they do use the evidence as a means of driving the direction of the directives. The fine tuning is what creates the standardization, which has allowed us to operate the department way more efficiently. [The result is that] patients at all our sites are receiving the same level of care.
It's very rare that we have a technology-specific directive that would require a patient to travel. We have been fortunate at Northwell to have a fleet of technology across the geography. For a physician who's working in the community setting, where they're seeing a bit of everything, rather than just the genitourinary [specialist] or the breast or lung [specialist] in the main center, that means that physician is going to be able to write a prescription of care that is as detailed and important in terms of the outcome for that patient in that community setting.
What measurable improvements have you seen since standardizing care through these directives?
We look at all sorts of outcomes. We look at toxicity or adverse effects [AEs], and [we] will [update] the directives based on certain things that we're seeing. A perfect example of that is the changes in how we treat [patients with] breast cancer. We've just recently gone through a review of our breast cancer directives to address the issue of some of the AEs that radiation can cause. Years ago, breast cancer radiation was delivered over 6 weeks. That's evolved down to 3 weeks, and now there are multiple regimens delivering treatment in 5 sessions over one week or so. The nuances of the AEs that patients may experience help us decide which of these directives may or may not be best for them. [Through this evolution] we've assessed outcomes and then pulled back a bit based on what's going to be best to personalize care for each of our patients.
How do you balance that consistency with the need for individualized treatment decisions?
We don't have directives for 100% of what we do, so we're still able to personalize care. For certain diseases we have different directives that allow us to make decisions based on the type of cancer the patient presents with. For breast cancer, we have close to 11 directives. For prostate cancer, we have close to 8 or 9 directives. That allows us to personalize what might be best for that patient based on the cancer they present with, the comorbidities that they have, and or other conditions that may help us decide [the best treatment course]. There's still a personalization that occurs in terms of choosing which directive is right, but then once you've done that, you can take that directive and then personalize it for each individual patient based on the treatment planning that is necessary to deliver radiation therapy. Everybody's anatomy and bodies are different, and we plan treatment on a personal level for each of the patients that we treat.
There's a lot of art in medicine and a lot of art [that goes into] the directives committee room when we're hammering out the consensus and having those discussions. We have one of the largest faculties in radiation medicine in the region, and that creates a great working culture amongst the faculty to feel that we can come together and develop [and apply] this approach.
What lessons has Northwell learned about scaling these best practices across sites that other oncology programs or health systems could apply to reduce their own variability in care?
There are a number of lessons. By distributing and using these [directives] across [our geographic] network, it's allowed us to decentralize a lot of the back-office work that goes into treatment planning. This became readily apparent during COVID-19. When we minimized the number of staff that were going in daily, we were able to keep things going at a relatively good [pace] because all our dosimetry and physics staff were completely decentralized. They knew exactly what was going to happen because of the directives, [so there was] less variability between [the physicians], which is what creates confusion and risk when you're treatment planning. That has been a huge win for the way we run and operate the department and lowers risk and improves efficiencies.
There are a number of other advantages that we've seen. The culture of the physicians coming together [is another benefit]. [It can be] hard to bring in a new recruit that's just out of training, but we've hired a number of physicians over the years that have been in practice for 3, 5, 7, 10 years, and to watch them evolve from, ‘You’re telling me this is how we're supposed to be doing it,’ to 3 months later saying, ‘I can't live without these’ and [in tandem grow] their sense of feeling involved in [how the treatment plans come together and] the editing process, has created a real learning experience for the faculty, which is huge. I have spoken with a number of other chairs around the country and there are a lot of egos, and it can be difficult. [We’re] lucky, [because this process has] become second nature to what we do.
The last thing is that [our directives] have set us up for a value-based world in which health care is evolving from a fee for service to value-based approaches. We know that we provide less expensive care based on the way that we manage and utilize the directives. As radiation oncology has evolved toward fewer treatments, the use of the directives has lessened the effect of physicians feeling like they have to take advantage of continuing long courses of care. We've evolved into a higher value proposition in terms of the patients being treated in the system.
How do you envision these system-wide directives evolving further to improve access, quality, and equity in cancer care?
As Northwell continues to grow, and it has in the past year by taking on Hudson Valley and Western Connecticut hospitals, we will be implementing the directives in those facilities, improving access in those hospitals and those clinics. We also see an opportunity to work in rural areas and internationally and share the directives as an opportunity to allow for complex treatment plans to be developed in places where the physicians or physicists don't have the specialization to come up with contemporary treatment approaches.
Lastly, we're working with several vendors to see whether we can distribute the directives for other facilities to utilize. From an equity perspective and from an access perspective, this makes a lot of sense. We will continue to utilize the [directives at Northwell], but there are opportunities beyond Northwell for this type of program, [which] fits well with World Cancer Day and the aspects of improving access and creating equity in terms of the treatments that are going to [result in improved] outcomes.
