JCO Oncology Practice Podcast

Dr. Pennell and co-authors Drs. Abel and Frosch discuss their editorial on public expectations in a shifting therapeutic environment.

Read the related article.

Support for JCO Oncology Practice podcasts is provided in part by AstraZeneca-- dedicated to advancing options and providing hope for people living with cancer. More information at AstraZeneca-us.com.

Hello, and welcome back to the ASCO Journal of Oncology Practice podcast. This is Dr. Nate Pennell, medical oncologist at the Cleveland Clinic and consultant editor for the JOP. What do most people think today when they think about a cancer diagnosis, about cancer's prognosis and treatment? Even if they've never had cancer themselves, most people either know someone who has had cancer, or they've been exposed to stories about cancer through the media. How do patient's preconceived notions about cancer impact their understanding of their own cancer diagnosis and their willingness to get treatment?

Joining me today to talk about this topic are Doctors Zach Frosch, Instructor in Medicine at Harvard Medical School and an Oncology Hospitalist at the Dana-Farber Cancer Institute and Brigham and Women's Hospital, and Dr. Greg Abel, Associate Professor of Medicine and Director of the Older Adult Hematologic Malignancy Program at the Dana-Farber Cancer Institute. We're going to be discussing their paper titled "What does a cancer diagnosis mean-- public expectations in a shifting therapeutic environment."

Doctors Frosch and Abel, thanks so much for joining me today.

Absolutely.

Nice to be here.

So given that oncology seems to be having a little bit of a renaissance in the media these days, with popular books such as Emperor of all Maladies and When Breath Becomes Air, this is a very timely topic to put this paper out here. How did you come up with this idea?

So Dr. Frosch and I were working on a survey where we're aiming to understand what the public knows about drug shortages in oncology, and we thought that a good question to have as a covariant for that survey was what the public thinks about cancer, in general, because we thought it would affect their answers to questions about drug shortages and what they would want to know and what they do know.

And when we ended up getting the results from the survey, we started to think about the question about how was cancer perceived, and we realized that it really is an important question in its own right. I'm have a lot more experience at this point than Dr. Frosch does, who's starting out his oncology career, but from both viewpoints it's interesting to think about what patients perceive, or potential patients perceive, about cancer can affect the interactions with oncologists and the interactions with the medical system.

I think that makes perfect sense. When I read this, it really resonated with me, although I don't often think about this when I'm starting to talk to a newly diagnosed patient, but maybe I should. Can you guys give me some example of how patient's perception about cancer before their diagnosis might impact their decisions on how to approach their own diagnosis and treatment?

Absolutely. And so you mentioned even before diagnosis, and I think it's important to think about how it starts even before a patient knows they have cancer, potentially even before they suspect that they have cancer. Because when people are worried about a cancer diagnosis, we know that they can potentially avoid physician visits or screening procedures that might make an early diagnosis when they're still asymptomatic. Or even when they have symptoms themselves, is their worry going to make them avoid going to see the doctor to get the diagnosis? And then even once the diagnosis itself has been made, if they have an unrealistically negative impression of what a cancer diagnosis means, if they believe it to be rapidly fatal no matter what they do, then they may defer potentially beneficial treatment.

And so it's really important to understand what they know and what they think they know about a cancer diagnosis. Actually interestingly, conversely, if they have an unrealistically positive impression of what can come out of cancer treatment, then they may make unrealistically aggressive decisions about their cancer care as well. I'm sure you and many of the listeners are aware of Dr. Week's paper on advanced GI and lung cancer from a number of years ago about patients who thought that their metastatic cancer was terrible, and so how was that, then, impacted. So it's really key to understand what patient's past experiences and what they believe their cancer diagnosis or potential cancer diagnosis could mean.

And something that actually just occurred to me when I was thinking about this is perhaps not even just the patient's perception, but even other ...

Dr. Pennell and Dr. Jan Franko discuss Dr. Franko’s article, “Effect of surgical oncologist turnover on hospital volume and treatment outcomes among patients with upper gastrointestinal malignancies”

Hello, and welcome to the latest JCO Oncology Practice podcast, brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content and offering enriching insight into the world of cancer care. You can find all recordings, including this one, at podcast.asco.org. My name is Dr. Nate Pennell, medical oncologist at The Cleveland Clinic and consultant editor for the JCO OP.

I have no conflicts of interest related to this podcast, and a complete list of disclosures is available at the end of the podcast. Today, I'd like to talk a little bit about the impact that physician shortages can have on cancer care in the United States.

While there are some parts of the country, for example Boston or New York, where you can't turn around without tripping over a specialist in some field or another of medicine, for much of the vast geographic expanse of the United States, especially outside of larger cities, there's areas that lack adequate specialty physician coverage, perhaps having either small numbers or even a single practitioner covering large areas.

Now, this is very important for patient care because most cancer patients get their treatment in community settings closer to their home and not at large academic centers. But how does this impact care when, for example, specialized surgical services are needed and no one's available close to home?

With me today to discuss this topic is Dr. Jan Franko, chief of the division of surgical oncology at Mercy One Medical Center in Des Moines, Iowa. We'll be discussing his paper, Effect of Surgical Oncologist Turnover on Hospital Volume and Treatment Outcomes Among Patients With Upper Gastrointestinal Malignancies, which is currently in press at the JCO OP. Welcome, Dr. Franco, and thank you for joining me on this podcast.

Thank you for this opportunity, Dr. Pennell. It's my pleasure. I do not have any conflicts of interest with this work.

Thank you for that. So we hear in the media about shortages of physicians, especially in underserved areas. How common would it be that a larger community hospital would lack access to, say, a surgical oncologist?

Just to give you an example, the city where I practice currently has about 750,000 people with surrounding suburbs. And we had a shortage of surgical oncologists for about two years, where I can recall that one of the large hospital systems lost entire radiation oncology department. So for nearly two years, until they hired three new radiation oncologists, they actually could not do any radiation. We ourselves have been a flagship for many decades for gynecologic oncologists.

We lost one about three or four years ago and since then we can't hire, and then on top of that, I recall that about three years ago, we had one year where 90% of urologists left the town. After 12 urologists, about eight or nine had to leave, and they came back for different practice within the same locality. But it was about a year plus without adequate urology workforce. So these things do happen.

No, I could imagine, especially for specialties that are relatively small to begin with. And just to put this in perspective, can you explain a little bit about what exactly is a surgical oncologist, and how does that differ from, say, a general surgeon who may also do some cancer surgeries?

So thank you for this question. I mean, I myself am a surgical oncologist. And I suspect there will be a lot of different definitions. For me, it's would be a general surgeon who is focused on a cancer treatment. General surgeons do treat both cancers but also trauma and general surgical conditions, common gallbladders, hernia.

But a subset of surgeons have focused on cancer. And the majority of those have accredited fellowship. These surgeons, in my opinion, should maintain a broad spectrum of practice. For example, not only liver and pancreas but liver, pancreas, and stomach and esophagus and other organs.

And what's also very important for them is to cultivate multi-specialty understanding of how to transition the care between an operation, systemic therapies, and radiation oncology so they can maintain a momentum of cancer control and [INAUDIBLE] surgery or avoid an operation. And when it comes to the question be able to execute even the complex operations.

And given the complexity of cancer care these days and how multidisciplinary it is, I would imagine that most surgical oncologists are centered around academic university hospitals as opposed to working out in more rural areas or community hospitals. Is that the case or are they pretty much available everywhere?

So indeed, you are right. It...

Dr. Blase Polite discusses the latest State of Cancer Care in America report, and the opportunities and challenges confronting the cancer care community.

Read the related article "The State of Oncology Practice in America, 2018: Results of the ASCO Practice Census Survey" on JOP

Support for JCO Oncology Practice podcasts is provided in part by AstraZeneca, dedicated to advancing options and providing hope for people living with cancer. More information at AstraZeneca-us.com.

Welcome back everyone to the ASCO Journal of Oncology Practice podcast. This is Dr. Nate Pennell, medical oncologist at the Cleveland Clinic and consulting editor for the JOP. It's that time of year again, when ASCO releases their annual report titled The State of Cancer Care in America, which has a goal of increasing awareness among policymakers and the larger cancer community about opportunities and challenges in the delivery of cancer care for the United States. The 2017 version is being released this month, and is always one of the most popular manuscripts and, to be honest, one of the most popular podcasts we do here at the JOP.

Joining me today is Dr. Blase Polite, associate professor of medicine and deputy section chief for clinical operations, as well as the executive medical director for cancer accountable care at the University of Chicago. Dr. Polite is a past chair of both the ASCO cost of cancer task force and the government relations committee, as well as being a fellow of ASCO. Today we'll be discussing the State of Oncology Practice in America, 2017, Results of the American Society of Clinical Oncology Practice Census Survey. Dr. Polite, thanks for joining me.

Nathan, good morning. It's great to be on with you again.

So why don't we start out just by talking a little bit about the background and the purpose of this annual State of Cancer Care in America report. How does ASCO get this data, and really what's the intended purpose?

So we're very excited this year. There's actually been a change to the way we do things. So in addition to the standard survey that we send out the practices, we've also been able through the work of our excellent team at ASCO to use something called the physician compare website and database from the Center for Medicare and Medicaid Services, CMS, that allows us for the first time to really get a sense of the true number of oncologists practicing across the United States, where they're located, how big their practices are, et cetera. So now we have two sets of data, one that gives us a nice sense of the geography of the total census of care of practices, and then our more detailed in-depth look of our survey practices.

And you know, this is really one of the most important things for those of us who work at the ASCO level, because this gives us a true pulse of what's going on out there, what are the market trends, and really, most importantly, what is it that is bothering practices on a day to day basis that we at ASCO then can try to figure out from a policy standpoint, can we work to make things better?

So one of the things that the State of Cancer Care in America always does is look at sort of the demographics and the makeup of the different practices. And have there been any significant changes this year? And is this something that is part of a trend, or anything that surprised you?

Well, the one thing that we continue to see, and we've gone back to 2013 and we've looked at the numbers of the-- using the physician compare, where we really get a sense of all of the oncology practices out there, is we're starting to see more and more consolidation. And specifically what I mean by that is we continue to see more oncologists every year, but a fewer number of total practices. So again, we're beginning to see more practices consolidate into larger groups. Not surprising, given the economic pressures and everything else that we see. But that that's probably a more consistent trend that we're seeing over the years.

Well, that certainly makes sense, I think, with the payer issues. And that kind of brings us to our next part here. One of the main purposes of this is for oncology practices to be able to list their top sources of pressure and concerns. So can you talk a little bit about what the concerns of the oncology practices were for 2017?

Yeah. So we were able to look at concerns within the census, both at an overall level, and then we're able to look at it specifically by how we break up the practices, which are academic, hospital, or health system owned, and physician owned. And what shop really to the top this year and wasn't really even a contest, was payer pressures. So this is the one thing that people are screaming from the rooftops, 70% of practices were physician owned, and really over half of other practices are saying that p...

The authors discuss the first in a series of articles exploring principles and topics relevant to teams guiding clinicians involved in cancer care. They did not see evidence that multidisciplinary teams affect patient survival or cost of care, and say further research should focus on the association between team processes and structures, efficiency in delivery of care, and mortality.

Dr. Pennell and Dr. Schapira discuss the risks and benefits of online communities and provide recommendations for improving communication between clinicians and patients about the use of online resources.

Hello, and welcome back to the ASCO Journal of Oncology Practice podcast. This is Dr. Nate Pennell, Medical Oncologist at the Cleveland Clinic and Consultant Editor for the JOP. So it won't be news to any of the listeners of this podcast that living with cancer and dealing with the sequelae of cancer treatment is a terribly stressful proposition and that cancer patients and their caregivers benefit from support services and survivorship programs. Most of us, however, think of providing these support services for cancer patients in terms of in-person interventions, but increasingly, people are looking online for these kinds of support. I suppose that's probably true for many other aspects of our lives as well. Online communities have been forming in an effort to improve access to support for cancer survivors. But how much do we really know about these communities, and what evidence is there that they are genuinely helpful? Joining me today to talk about this fascinating topic is Dr. Lidia Schapira, Associate Professor of Medicine at the Stanford University Medical Center and Director of Cancer Survivorship at the Stanford Comprehensive Cancer Institute. Dr. Schapira is also the Editor in Chief of ASCO's patient information website, cancer.net, and is a fellow of ASCO. Today we'll be discussing her paper titled Online Communities as Sources of Peer Support for People Living With Cancer-- A Commentary. Lidia, thanks so much for joining me today. Thank you so much for the invitation. So first, this is obviously too big a topic for this podcast, but explain a little bit about why cancer support services in survivorship is important for cancer survivors. And I guess more importantly, where is there an unmet need, that people might need to seek that somewhere else, such as online? Sure. So we think of support as something that is delivered in person. And certainly in traditional medical settings, we offer support, I hope, through empathic communication, through referrals to social services, through programs. We are very much aware that going through cancer alone is much harder and that support is both important just strategically to get through it but also emotionally. I think that increasingly we also realize that people are seeking support in other ways that are not traditional and have been less well studied, and that's where the online services and supports really are playing a very important, an increasingly important, role for many patients and caregivers as well. This is coming up actually a lot among patients of mine, especially younger patients. So can you just tell us a little bit, when we talk about an online community, what exactly is that? So there are two words and each one is really important here. Community means, really, a group, so it's not just a one time exchange, but belonging to something, a sense of belonging to a group. And the group shares a common interest. In this case it's something related to cancer. And online refers to where this group, or this community, meets. It could be through instant messaging. It could be through other new media or platforms. It could be through email. It could be through a website. And that is going to change as technologies change. What we're basically saying as a way of meeting people not in person but meeting over time and through a shared expressed common interest. And there's lots of different examples of kinds of online communities that you described in your paper. Can you tell us a little bit about them? I know that there's some that are a little bit more formal and structured and others that are really kind of left up to the patients to moderate themselves. Exactly. And to somebody who is not a digital native, like myself, this has been a real interesting process of discovery. We tend to think, perhaps incorrectly, that online means improvised, and it's anything but improvised. A good online community that is mature, that keeps the interest of its members over time, requires some management, requires some decision, requires some effort on the part of the people who are starting the community. And so we learned that there are different types. There are different media. Some have actually some formal facilitation with social workers and really function similarly to the way an in-person support group functions. And some are much more informal, people sort of coming together. So there are some online communities that are sort of offered through large advocacy organizations like the American Cancer Society or CancerCare. And there are others that are not, and those typically occur in spaces like Twitter or Facebook. And now there are even some privately sponsored online communities such as Smart Patients. And we reference Smart Patients bec...