From sub-specialization to QOPI®, the goal of providing excellent patient care remains constant  

By Faith Hayden, Senior Writer/Editor

Throughout 2014, ASCO Connection will be running a series of articles marking the Society’s 50th anniversary. In this column, ASCO volunteers share their thoughts on some of the major changes that have affected the practice of oncology.

The evolution of oncology practice over the last 50 years has been remarkable. It is hard to imagine, but medical oncology was not a subspecialty recognized by the American Board of Internal Medicine (ABIM) when ASCO was established in 1964. In fact, ASCO’s volunteer leaders at the time were instrumental in encouraging ABIM to accept medical oncology as a subspecialty. In 1970 and 1971, an ASCO committee chaired by Emil Frei III, MD, FASCO, met with ABIM to promote medical oncology accreditation, and on February 9, 1971, ABIM wrote to ASCO President Jesse L. Steinfeld, MD, FASCO, relaying its decision to offer an examination in medical oncology.¹

“Finally, after all these years we are as legitimate as the cardiologists,” wrote B.J. Kennedy, MD, FASCO, in a letter dated September 13, 1971.¹ The first medical oncology board exam was given in 1973, two years after U.S. President Richard Nixon signed into law the National Cancer Act of 1971, which created the National Cancer Program and established the National Cancer Institute director as a presidential appointee.²

Since then, oncology has become an umbrella for numerous subspecialties, including radiation and surgical oncology, solidifying the field as a true multidisciplinary team–oriented specialty.

“The sub-specialization of oncology simply reflects our science,” said John V. Cox, DO, MBA, FACP, FASCO, Editor-in-Chief of the Journal of Oncology Practice. “The categorization of malignancies and the appreciation of the complexities of all the diseases of cancer has defined new therapeutics and new specialties in terms of therapy. This reflects the success of our science. The complexity of what oncology practice has become simply reflects a better understanding of the many diseases we treat.”

Treatments for those diseases have vastly improved, becoming less toxic and more accessible. The digital age and rapid exchange of information ensure oncologists have access to the most current clinical data, regardless of geography. Oncologists are now business people in addition to clinicians. And in recent years, ASCO’s Quality Oncology Practice Initiative (QOPI®) has revolutionized and redefined quality patient care.

The evolution of treatment and accessibility

When Dr. Cox entered oncology fellowship in 1983, patients with cancer generally had to travel to the “big city” to receive chemotherapy in a hospital because of the marginal antiemetic and supportive therapies available. When cisplatin became the treatment of choice for testicular and small cell lung cancers, the chemotherapy drug was extremely emetogenic. “You had to keep patients in the hospital for a couple of days to recover from that before they could go home,” Dr. Cox explained.

W. Charles Penley, MD, FASCO, Chair of the Conquer Cancer Foundation Board of Directors and partner at Tennessee Oncology, had a similar experience treating patients during that time period. “The toxicities limited what we could do in the 1980s,” he said. “The nausea was horrendous. On an average day, I might have 10 or 15 people at the hospital either getting treatment or dealing with the ill effects of treatment.”

But now, thanks to better therapeutics and supportive care, many cancer therapies are delivered in an outpatient setting, allowing patients to go back to work immediately if desired. The toxicities are much more manageable, which Dr. Cox called a “striking difference” in patient care. Dr. Penley remembers vividly the turning point for patients with chemo-induced nausea: “It was ondansetron, and that was in the early 1990s. It just really changed the whole landscape [of supportive care],” he said.

Dr. Penley has also witnessed a tremendous shift in how chemotherapy is used to treat patients. When he finished his oncology fellowship in 1987, chemotherapy treatment was evolving rapidly. Adjuvant chemotherapy for breast cancer was approved in the late 1970s, and a number of other chemotherapy agents were being developed.

“The focus at that time seemed to be on intensifying chemotherapy with the hope that the model of multidrug chemotherapy would overcome resistance and somehow lead to more breakthroughs,” Dr. Penley said. “The notion was that we were going to change the face of cancer care by giving moredrugs and more intensive therapy. But in many cases that strategy just didn’t pan out.”

The optimism for dose intensification for solid tumors began to diminish in the 1990s, however, and oncologists recognized they needed to be more sophisticated in their treatment approach. “We realized we had to understand some of the molecular events that led to developing the cancer phenotypes so that we might be more precise in our therapeutics and develop more targeted therapies. I think that’s where the focus is now,”Dr. Penley said.

The digital age and rise of rapid information exchange

In 1964, ASCO’s seven founders couldn’t have fathomed the amount of information oncologists and patients have at their fingertips and the speed at which information travels in 2014. It was even difficult for oncologists to imagine a mere 20 years later.

“In the 1980s, community oncologists might not have access to things happening in the large cancer centers for months because of the pace at which information was distributed,” Dr. Penley said. “Information exchange happens almost instantaneously now. People who are getting care in nonurban settings can feel confident that their physicians will have access to much of the same information as physicians in the large cancer centers in major urban and metropolitan areas.”

The rapid information exchange has also altered the patient-physician relationship. The physician used to be the primary source of information for patients, but that model has clearly changed.

“Folks come in with reams of printed paper from the Internet, sometimes from reputable Web sources and sometimes from shaky Web sources,” Dr. Penley said. “We have to provide the filter, separating the good information from the bad. That’s the analytic element the oncologist has to provide.”

Patients in 2014 have also become accustomed to instantaneous answers, greatly reducing the amount of time the oncologist has for reflection and treatment planning.

“In the early days of my practice, I would get reports from the radiologist, and then see the patient a few days later to discuss them. There would be time to process information,” Dr. Penley explained. “Now people expect to come to the medical center, get their PET scan in the morning, and sit down with the oncologist in the afternoon and have a well-thought-out plan of care. To a certain extent that’s good, but it puts a lot of pressure on the physician to process a large amount of information and arrive at complex decisions without a lot of time to reflect.”

Despite these challenges, the digital age seems to have had a positive effect on the patient-physician relationship overall. “Patients as a group seem to be more engaged and informed,” Dr. Cox said. “They have a better idea of what to expect and they can ask informed questions. On the whole, this improves communication between the physician and patient.”

The consolidation of community practice

One of the greatest challenges facing modern-day oncology practice is the increasing cost of care and reduced revenues, which is making it difficult for all oncologists, and particularly those in solo community practice, to stay in business. It also requires the oncologist to focus more and more on the operational details of the practice.

“We as a nation cannot afford the health care system that we have inherited,” said Peter Yu, MD, FASCO, Director of Cancer Research at Palo Alto Medical Foundation and 2014-2015 ASCO President-Elect. “If it is not affordable, then it cannot be sustained or scaled up sufficiently to achieve equitable access to care. Health care is an irrational combination of parts that exist in a highly regulated space and parts that operate in a largely unregulated free market. As a consequence, patients and providers are disadvantaged and bear a disproportionate share of the need to reduce health care expenditures through reductions in coverage and reimbursement.”

Because of these imbalances, oncology is seeing a consolidation of the small physician-owned community practice into larger groups. Elaine L. Towle, CMPE, Director of Consulting Services with Oncology Metrics, a division of Altos Solutions, and Thomas R. Barr, MBA, General Manager of Oncology Metrics, have written extensively on the evolution of oncology practice through the analysis of the National Practice Benchmark (NPB) reports. The NPB is a national survey of oncology practices that has examined oncology trends such as staffing and financial data for the last eight years. The results from the latest survey are available in the November 2013 issue of the Journal of Oncology Practice.³

Although Ms. Towle and Mr. Barr have found the optimum size of a community practice to be market-specific, practice size is key to affording the necessary electronic medical records and business software and management.

“From the point of view of operating efficiently, when you get a strong business sensibility aligned with good clinical practice, that’s the best of all possible worlds,” Mr. Barr explained. “I think that happens primarily in practices that have six to 15 physicians with one to four sites. If the practice gets bigger than that you start having layers—although necessary layers—of managerial bureaucracy.”

“There are still some solo practitioners out there, but the number has dwindled,” Ms. Towle said. “If you have a market environment where you have a good payer mix and the contracts are healthy, it may be reasonable for a solo practitioner to survive for some time. It is a dying breed, but it is not gone and will never disappear completely.”

Ms. Towle and Mr. Barr have also witnessed an increasing awareness among physicians of the need for managerial expertise as reimbursement issues have become more complex. “We’ve seen practices get much better at managing inventory,” he continued.“ Concurrent with that, we’ve seenthem become a lot smarter at how they purchase drugs. Back in the day, it wasn’t unusual to have a month of drugs on hand on the inventory shelf. Now, if you have six days of drugs on hand that’s fat.”

The effects of QOPI® on patient care

Established by ASCO in 2006, QOPI is an oncologist-led, practice-based quality improvement initiative based on retrospective chart reviews conducted within oncology practices. QOPI has had a tremendous effect on oncology practice already. Case in point, Carolyn B. Hendricks, MD, PA, of the Center for Breast Health and Chair of ASCO’s Quality of Care Committee, recently pulled two medical records from 1995 and 2005 to see how she would have performed if those charts were submitted to QOPI today. The results, she said, were eye-opening.

Upon review of the 1995 chart, Dr. Hendricks realized her documentation did not have complete staging or any formal pain assessment. Furthermore, there was no documented plan for chemotherapy, including the number of cycles and length of treatment, nor any indication that Dr. Hendricks emphasized to the patient that the treatment was of curative intent.

Dr. Hendricks noticed similar gaps in treatment and communication with the patient from 2005, including incomplete cancer staging and no initial pain assessment. The patient had advanced disease, but there was no documentation that the palliative nature of the treatment was explained. The patient was not referred to hospice within the last two months of life; she died in 2006 within an intensive care unit setting without hospice or palliative care.

Looking back, Dr. Hendricks sees quite a few areas where QOPI has altered how she would have communicated with these patients today. “End-of-life and location of death are key, and that would have never been brought up in the 1990s,” she said. “It would have been shocking if we sat down with a patient and said, ‘You’re near the end of your life. Let’s look at the various scenarios.’” According to Dr. Hendricks, the QOPI measure set has helped physicians learn how to have those conversations with patients with metastatic disease.

“The quality of my practice has improved significantly from the attention and awareness of what’s important in terms of quality care,” said Dr. Hendricks. For example, now all patients leave her office with written recommendations for chemotherapy and a chemotherapy calendar detailing the number of cycles. There’s also a separate consent visit that provides patients with an exhaustive review of treatment side effects.

“It’s an evolution,” she said. “It’s almost a checklist in my mind. I now think about fertility and pain scores. We never had chemotherapy treatment summaries, we never had survivorship care plans, and we do that now for all of our patients. I believe that is of value to the patient.”

The future of oncology practice

Oncology practice has come a long way since 1964, and it will continue to evolve and improve. Rapid learning systems such as CancerLinQ™ and the concept of patient-reported outcomes will unquestionably transform the oncology landscape.

“We’re going to be getting a lot of data, and we’re going to have to learn how to manage it in terms of time and quality care,” Dr. Hendricks said. “But we can’t give ourselves up to digitalization and automation. We need the personal aspect.”

One facet of oncology practice that has not and will never change is the commitment to caring for patients with cancer.

“There’s been a huge growth of knowledge and refinement of our specialty,” Dr. Penley said. “But when I think back to when I started medical school, we were still concerned about the same things. When I sat down with a patient in 1987, I had to explain the illness, the potential therapeutic options, and the impact it was going to have on his or her life. We discussed anxieties and fears, and the impact on the family as a whole. And we often shed a few tears. The drugs may have changed, the outcomes are generally better, and how we measure and report things may be different, but that human interaction hasn’t changed at all. That’s the constant.”

References

1. 40 Years of Quality Care: A History of ASCO Monograph. American Society of Clinical Oncology; 2004.

2. The National Cancer Act of 1971. National Cancer Institute website. legislative.cancer.gov/history/phsa/1971.

3. Towle EL, Barr TR, Senese JL. J Oncol Pract. 2013;9:20s-38s.