By William Barrett, MD
Cancer is an extremely burdensome disease that carries multiple physical, mental, psychosocial, and financial burdens with complex medical challenges. Not infrequently, patients with cancer seek a second opinion to help them select the course of disease management. Usually, second opinions are sought from health care systems, whether academic centers or community practices, that face the same challenges as primary oncology practices in terms of financial and administrative requirements. Administrative and bureaucratic distractions to clinicians providing clinical care are substantial. Time spent documenting for billing purposes, peer-to-peer requests for diagnostic and therapeutic procedures and pressures to see large volumes of patients in short amounts of time distract from useful clinical activities.
In light of these challenges, and in order to help more patients access a second opinion to guide their cancer care, in 2015, I began offering second opinions after hours and on weekends—a service that came to be known as Cincinnati Cancer Advisors (CCA). The motivation for this service came from the observation that diagnoses are sometimes not accurate and clinical recommendations are sometimes either not well informed or not particularly objective with clinicians sometimes being biased towards recommending their particular modality. In early 2020, CCA recruited a senior medical oncologist with more than 30 years of experience in the community and a nurse practitioner, turning the service into full-time practice. Today, CCA employs 13 clinical and administrative staff, including a second oncologist with over 25 years of experience as a consultant, an executive director who was originally a patient at CCA and is now a cancer survivor, and a director of strategic community engagement who is also a cancer survivor.
In founding Cincinnati Cancer Advisors, our aim was to free oncology providers from many of the constraints of the classic practice of medicine, focusing on the concept, “great care begins with a great plan.” We wanted to explore and develop a model that would help patients and their physicians have an excellent plan of care from the start to maximize the patient’s chance of being rendered disease-free with as little toxicity as possible. No one wants the diagnosis of cancer, but if one has to face this adversary, we want ours to be the safest and most effective possible community.
CCA demonstrates that a truly patient-centered model of health care for second opinions is possible. Our service provides a comprehensive evaluation and recommendation with rapid communication with the treating oncologist. We offer consultations only, with no attempt to recruit the patient for care or diagnostic services. The consultation starts with a physician referral or self-referral followed by compiling all available medical records from all previous care settings. The extended 2-hour first evaluation visit covers all domains of the patient’s care, including psychosocial, financial, medical, and cancer-related issues. We approach our patients as generalist physicians first, then as specialists, knowing that any detail, related directly to cancer or not, can impact the patient’s care and outcomes. The visit is finalized by detailed education and counseling of the patient and care providers and extensive explanation of all potential options. Timely, detailed communication with the treating oncologist is essential, documenting the detailed encounter outcome and recommendations for the patient and treating physician to discuss, and to be considered by the treating oncologist to adopt (or not) at their discretion.
Crucially, the service is offered at no cost. With no billing or collection, both patient and physician are spared the administrative and bureaucratic distractions frequently associated with conventional medical care. Second opinions are often costly, particularly if there are travel and lodging expenses associated with seeking the opinion out of town. Patients with limited financial means have particular difficulty seeking second opinions and our service obviates that concern. This is a pilot project that is off to an outstanding start. How it can expand and potentially be offered in other communities remains to be seen. The supporting philanthropic foundation has allowed a novel and highly beneficial service taking advantage of our expertise and objectivity. Conventional medicine has an ever-increasing focus on the financial aspects of clinical care and our project is immune to those pressures. Widespread application of this model is a consideration and potentially could be advantageous to health care expenditure in general if it saves money by avoiding unnecessary expensive testing and treatments, by improving outcomes, and by returning patients to productive and durable employment. These cost analyses have not yet been performed but are very much in our plans.
Our goal is to raise the level of care throughout our region by directly helping patients and their physicians with an optimal plan of care and motivating the oncology practices throughout the area to raise their level of care. CCA saw 229 patients with cancer in 2020, 305 in 2021, and we are on pace to see more than 400 patients in 2022 on our way to our long-term goal of serving 1,200 patients annually. Follow-up surveys of the patients and treating physicians have revealed overwhelmingly positive feedback, so we know we are making a difference. The most important aspects in organizing this, both for ourselves and for others that may consider similar services in other communities include having practitioners with a high level of expertise and experience, commitment to objectivity in considering all reasonable management options, effective organization, and a truly altruistic spirit.
It Takes a Village: Perspectives from CCA Team Members
CCA would not be able to offer its services to our community without the work, expertise, and dedication of every member of our team. When I set out to write about our consultation model and the importance of second opinions, I sought perspectives from across our staff. Instead of paraphrasing their words, I wanted to share them here and acknowledge the important work of these individuals and the entirety of our care team.
“Once you remove the barriers of burdensome documentation for billing and compliance, allow enough time, remove money from the physician-patient relationship, value and respect your team, and have the resources to connect to the science and technology available globally while knowing that all your effort is to just do good for the patient, families, other physicians, and the community, you have what defines us.” —Phil D. Leming, MD, consultant
“A cancer diagnosis can often leave patients and families feeling frightened and uncertain. CCA allows us to slow down and take the time that patients and their families need. Our first focus is the patient and being oncology servants. In addition to serving the patient, this new role also allows us to serve the oncology medical community and to fill in the gaps where they don’t have time. Our second opinion service is not about pointing out what is right or wrong, it’s about empowering all who are involved.” —Jill Hunt, NP
“I first experienced the CCA model as a patient in June 2020, when I had an uninterrupted 2+ hour session with consultants and had their undivided attention for the entire time. At the conclusion of my consultation, I pulled out my insurance card only to learn that the service was entirely free of charge, funded by private donors. I was stunned. I was so impressed with the care I received that I was determined to become a part of it, and in September 2020, I was fortunate to begin my work as the executive director. I can think of no more noble, rewarding, or impactful work at this stage of my career.” —Steve Abbott, executive director and cancer survivor
“The CCA model of care is based on an innovative and disruptive approach to caring for patients with cancer as it removes the challenges that have plagued the prevalent health care model by truly offering patient-centered care. The model enables providers to concentrate their efforts into addressing all issues that enhance the patient’s experience and outcome in a collaborative mode with primary oncology teams and national experts.” —Abdul Rahman Jazieh, MD, consultant
“Working at CCA with the team dedicated to patient care and developing the best care plan possible, has enabled us to experience different aspects of cancer care including in-depth patient assessments. With the guidance of the team, we are learning more on how to apply various oncology concepts in delivering care. The patients and families can spend ample time with the clinical team to have all questions answered and feel empowered regarding their diagnosis. This makes our hearts happy.” —Sally Hellard, RN, nurse
“Being a part of a patient-centric health environment that exists solely to help patients with cancer survive by providing potentially lifesaving information about their diagnosis, at no cost, is what makes this work so extraordinary. As a cancer survivor myself, being tasked with spreading this great news in our community is humbling and so encouraging for those fighting cancer every day.” —Sherry Hughes, director of strategic community engagement and cancer survivor
Dr. Barrett is co-director of the University of Cincinnati Cancer Center and professor and chair of the Department of Radiation Oncology. He is the founder of Cincinnati Cancer Advisors. Disclosure.