One of my favorite aspects of my job is giving Continuing Medical Education (CME) talks around the country and getting the opportunity to speak to a broad range of oncologists about what they do in practice. While I treat lung cancer patients at an academic center, traveling gives me the chance to speak with folks at Veterans Affairs Medical Centers (VAMCs), community hospitals, private clinics, and busy metro hospitals far removed from academic ivory towers. It is at these events that I get an appreciation for how hard it is to keep up with rapidly changing guidelines and recommendations while somehow providing care for every possible variety of cancer.
I recently gave two talks in two days, one at a large private cancer center that serves most of the rural areas of a Midwestern state and the second at a smaller community hospital in the suburbs of a large city in the same state. I was speaking about the 2013 CAP/IASLC/AMP guidelines for the molecular testing in lung cancer patients (recently endorsed by ASCO), which, in short, recommends rapid, routine testing of every new lung adenocarcinoma patient for EGFR mutations and ALK gene translocations to help guide targeted therapy. At both talks, I polled the audience about what was done at their site, and the answers were highly illustrative of the variability in care in centers only two hours apart.
At one center, oncologists had divided up into subspecialized groups, and the lung cancer doc (who looked to me to be about 12 years old) had open on her iPad the NCCN Guidelines while she asked me about their recommendation for even broader testing for multiple genetic targets. She had worked with pathology at her center to send out all new biopsy samples for next-gen sequencing of multiple actionable targets, and they had identified a commercial vendor to get results in about a one-week turnaround. Their center was a participant in all major cooperative group trials. It is safe to say patients at this center were receiving cutting-edge care comparable to any institution in the country, and it all came about by defining the goal of optimal testing for patients and working together as a team to make it happen.
At the other center, though, my questions were met with looks of frustration and comments about barriers to ordering tests, lack of understanding of which tests were recommended and in what setting, and complaints about lack of insurance coverage. There, oncologists could only order the testing after seeing the patient (no reflex testing), with a much longer turnaround time. Should they order just those markers, or perform broader testing? One person commented that all their patients were smokers so why even bother (the guidelines state patients should be tested regardless of clinical characteristics including smoking). I spent most of my time trying to convince them that this was important and to share with them how working with administration and pathology together could save a lot of time while making their lives more efficient. It was clear that they wanted to do what was right but simply didn’t know where to start to make it happen.
This is becoming a critically important issue across all fields of oncology, as numerous new drugs are being approved by the FDA with indications only in patients positively selected by a biomarker, and not just in lung cancer but breast, melanoma, colon, and the lymphoid malignancies, to name a few. This is further complicated when the field moves faster than regulatory agencies and insurers can keep up, with oncologists being asked to judge how important a test is when recommended in a national guideline but not yet routinely reimbursed by insurance (e.g., ROS1 fusions in lung cancer).
As care becomes more complex while at the same time reimbursement is being increasingly tied to quality metrics and appropriateness of care, we cannot simply hope oncologists will always know what to do (even after attending my lecture, although that is a good start!).
Care pathways from organizations such as NCCN or from other leading institutions can help guide patients to appropriate high-quality, cost-conscious care. As the above example illustrates, an increased focus on teams and teamwork among all the involved parties, such as those promoted by the National Cancer Institute–ASCO Teams in Cancer Care Delivery initiative can make a big difference in the practical application of complex care algorithms across the continuum of care. Doctors and patients shouldn’t have to wonder if they are delivering or getting the most up-to-date care, and we owe it to them to work together to make sure the same high level of care is available everywhere.