By Christina Bennett, MS
Amidst an ever-changing healthcare landscape, academic cancer centers and community cancer centers have come together to form partnerships, such as the Duke Cancer Network, MD Anderson Cancer Network, and Fox Chase Cancer Center Partners Program. The model of each partnership is different, but generally the academic partners provide their community oncology counterparts with access to consultative services, treatment protocols, research, and clinical trials.¹
Experts, such as Patricia Ganz, MD, professor of health policy and management in the Fielding School of Public Health and professor of medicine in the David Geffen School of Medicine at UCLA, agree that academic centers have been under pressure to conduct clinical trials with large, diverse patient populations since the advent of precision oncology.
“In order to be able to conduct any kind of meaningful trials, you had to have a very large catchment of patients to even identify people who had significant mutations that might be potentially treated,” Dr Ganz said.
Yet, paradoxically, most cancer patients are not treated at academic centers, but in the community setting.
“That's really what's driving the academic cancer centers to work with the community centers,” said Emanuel Petricoin, PhD, Chief Science Officer, Perthera, Inc., and Co-Director, Center of Applied Proteomics and Molecular Medicine at George Mason University.
Furthermore, academic centers are trying to get away from the selection bias that tends to come with enrolling patients at an academic center, who are often white.
While the idea of such partnerships may have merit, the reality has yet to deliver because the community centers chosen for partnerships may have the same affluent population and they may already be instituting good quality care and participating in clinical trials. Also, Alison Evans Cuellar, PhD, MBA, professor of health administration and policy at George Mason University, explained that at this point we don’t know yet whether patient outcomes are going to improve faster or whether research will move along faster because of these partnerships.
“A lot of this has been business-driven rather than necessarily the motivation to improve the quality of care,” said Dr. Ganz. The partnerships are more of a marketing effort to attract patients to community centers, and according to evidence in the literature, the marketing efforts work.
About half of surveyed individuals in a study believed that when an affiliated hospital included the name of a top-ranked hospital in their name, the care was identical at those hospitals.² Another study found that patients who underwent cancer surgery were about 1.4 times more likely to die at the affiliate hospital compared with the top-ranked hospital.³
“There are differences in care that do not correspond to patient and public expectation—that's concerning,” said Daniel Boffa, MD, professor of thoracic surgery at Yale School of Medicine, who authored both studies. “However, the networks provide a critical connection between some of our best hospitals, and hospitals with more room to improve. Networks are an amazing potential resource for change.”
Ultimately, these networks, or academic-community partnerships, provide a way that expertise, resources, and best practices can be shared. “The question is, how do you leverage that?” Dr. Boffa asked.
A Resource for Change
The Memorial Sloan Kettering Cancer Center (MSK) Cancer Alliance appears to be one partnership that is more than just brand sharing and passive access to expertise. MSK announced its partnership program in 2013 and gradually selected three Alliance members to join based on their track record of being able to conduct clinical trials and successful delivery of quality care.⁴
The Alliance members each pay MSK an undisclosed fee based on the size of the Alliance member and MSK in turn actively engages with the Alliance members by having faculty physically travel to Alliance sites to teach about various topics, such as bone marrow transplants and administration of chimeric antigen receptor T cell (CAR T) therapies. Alliance sites are also invited to participate in weekly, disease-specific tumor boards with MSK faculty. In addition, MSK shares their standards of care, which are a set of detailed evidence-based guidelines.
Although the evidence is largely anecdotal, the efforts on behalf of MSK appear to be affecting real change in the way community oncologists at the Alliance sites care for patients and could address the current lag in adoption of practice-changing research by community oncologists.
In fact, a recent survey among community oncologists at the three participating Alliance sites revealed that more than half of community oncologists who responded (49 of 84) have changed their practice as a result of being an Alliance member. Also, one-third of oncologists reported that while their practice did not change, they saw other providers at their institution who did change practice. The interaction that contributed most to a practice change was the MSK standards of care assessment and process of aligning with those standards of care.¹
“MSK isn’t telling you how you have to practice, but it might point out gaps,” said John Diaz, MD, lead physician for Gynecologic Oncology Clinical trials and medical director of Gynecologic Minimally Invasive Surgery, Miami Cancer Institute. Miami Cancer Institute in South Florida is one of the three MSK Alliance members. The other two are Hartford HealthCare Cancer Institute in Connecticut and Lehigh Valley Cancer Institute in Pennsylvania.
According to Dr. Diaz, sentinel lymph node mapping during surgery for gynecologic malignancies is one such example of a practice that has taken time for community oncologists to adopt. In fact, it was only with the guidance of MSK that physicians at Miami Cancer Institute who hadn’t adopted the practice began to reevaluate their thinking. “Sometimes if you’re a busy community oncologist and if things are working for you, you may not necessarily be open to change,” said Dr. Diaz.
Dr. Diaz explained that the MSK standards of care are particularly useful because they are so specific in what they recommend. “If you look at the NCCN guidelines, for example, the management of any disease is going to give you several different options—sometimes almost too many options,” he said.
For Peter Yu, MD, physician-in-chief at the Hartford HealthCare Cancer Institute, a practice change that was perhaps overdue was giving hypofractionated radiation treatments to women with breast cancer, which evidence suggests has the same efficacy but lower toxicity than conventional radiation treatments.⁵
“When we look at that use of hypofractionation treatments, we found that some of our hospitals were moving very quickly towards that and some of them were not quite moving to adopt that,” he said. After evaluating the evidence and MSK standards of care, the institution decided to adopt the practice.
The survey also showed that most community oncologists found value in the MSK tumor boards.¹ For Suresh Nair, MD, physician-in-chief for the Cancer Institute at Lehigh Valley Health Network, access to the tumor boards made all the difference for one of his recent patients, a young woman with advanced melanoma. Her cancer did not respond to combination immunotherapy so Dr. Nair requested an emergency tumor board with MSK. Genetic testing revealed that she had a very rare mutation not normally seen in melanoma, and no FDA approved treatments were available for that mutation site.
However, a medicine has been approved for that mutation, but in bladder cancer. The tumor board discussed the patient's case and felt that even though the drug was not FDA approved for use for the melanoma mutation, it was in the best interest of the patient, who had a one-month prognosis, to try the drug. Her disease responded to the drug.
“Now we have hope that she’s going into remission,” said Dr. Nair. “In the MSK alliance, this kind of close collaboration has become the norm.”
Beyond changing practice, the partnership appears to be delivering, at least in part, on the benefits of expanding clinical trial access beyond an academic center. For example, the clinical trial that led to the FDA approval of the tumor-agnostic NTRK inhibitor, larotrectinib, included one patient that was recruited from an Alliance site.
Also, although two Alliance members—Hartford HealthCare Cancer Institute and Lehigh Valley Cancer Institute—serve patient populations that are similar to MSK, Miami Cancer Institute offers a much needed source of patient diversity. In fact, through Miami Cancer Institute, MSK was able to initiate a trial for cervical cancer, a disease that’s favors minority patients with low socioeconomic status.
“The benefit to our patients is now they can get free-of-cost analysis of their tumors and see exactly which gene may be mutated and could potentially be a target for treatment,” said Dr. Diaz. “The benefit to Sloan Kettering is now they had a cohort of patients that they otherwise wouldn't see in their institution.”
“It’s a collaborative, two-way street where both institutions benefit,” said Dr. Diaz.
References
Lipitz-Snyderman A, Kennington J, Hogan B, et al. Engaging community-based cancer physicians: Experience of the Memorial Sloan Kettering Cancer Center Cancer Alliance. J Natl Compr Canc Netw. 2019;17(9):1083-1087.
Chiu AS, Resio B, Hoag JR, et al. Why travel for complex cancer surgery? Americans react to 'brand-sharing' between specialty cancer hospitals and their affiliates. Ann Surg Oncol. 2019;26(3):732-738.
Hoag JR, Resio BJ, Monsalve AF, et al. Differential safety between top-ranked cancer hospitals and their affiliates for complex cancer surgery. JAMA Netw Open. 2019;2(4):e191912.
MSK Cancer Alliance Fact Sheet. Memorial Sloan Kettering Cancer Center. https://www.mskcc.org/about/innovative-collaborations/msk-alliance/msk-alliance-fact-sheet. Accessed November 3, 2019.
Gilbo P, Potters L, and Lee L. Implementation and utilization of hypofractionation for breast cancer. Adv Radiat Oncol. 2018;3(3):265-270.
