Podcasts about oncology practice

Listen to JCO Oncology Practice's Art of Oncology Practice article, "Did I Mess Up Today?” by Dr. John Sweetenham, ASCO Daily News Podcast host and recently retired after 40 years of practice in academic oncology. The article is followed by an interview with Sweetenham and host Dr. Lidia Schapira. Dr Sweetenham shares his reflections on his shrinking clinical comfort zone. TRANSCRIPT Narrator: Did I Mess Up Today? By John W. Sweetenham  Reflections on My Shrinking Clinical Comfort Zone Hindsight and the passage of time have made me realize how much this question began to trouble me after each clinic as my clinical time reduced to one half day per week. After 40 years in oncology, I had reached the point where I had to ask myself whether a minimal commitment to clinical cancer care was best for my patients. I decided that it was not. Reluctantly, I left the world of direct patient care behind. Despite the identity crisis that resulted from giving up the foundational bedrock of my career, I felt substantial relief that I would no longer have to ask myself that question after each clinic—I felt that I had made the decision before (hopefully) I really did mess up. Reflecting on this in the past few months has made me question whether we have devoted sufficient resources to asking the question of how much clinical time is enough to maintain the clinical skills, knowledge, and competency that our patients deserve and should expect from us. Although we can continually refresh our clinical knowledge and understanding through continuing education and maintenance of certification, we mostly rely on our own judgment of our clinical competency—few of us receive outside signals that tell us we are not as sharp as we should be. There are many reasons why we may choose to reduce our clinical commitment over the course of a career and why it may be important to us to maintain some level of practice. The spectrum of reasons extends from being truly altruistic, through being more pragmatic to those driven by career advancement and self-interest. Many of those have played into my own decisions about clinical commitment, and I will use my own story to describe my journey of changing motivation and growing (I hope) self-awareness. I entered oncology fellowship in the United Kingdom in 1984. I chose oncology as a specialty because of the unique opportunity it provided then (and now) to combine new scientific discovery and understanding of this disease with compassionate, patient-centered care, which might improve lives for patients and their caregivers. I was trained in the UK tradition, which placed an emphasis on clinical experience and clinical skills, backed up by knowledge of emerging scientific discovery and data from clinical trials. Like many others at that time, I undertook a laboratory-based research project and was inspired by the work of true physician scientists—they became role models for me, and for what I thought would be my career trajectory. Once I finished fellowship and became junior faculty with a growing clinical and clinical research practice, I quickly began to realize that to make a meaningful contribution, I would not be able to sustain a clinical and laboratory presence—I admired those who could do this, but soon decided that I would need to make a choice. I knew that my primary passion was the clinic and that I did not have the skill set to sustain a laboratory project as well—it was an easy choice, and when I left the United Kingdom for the United States, I left my physician scientist ambitions behind but felt confident in my chosen clinical career path and had no sense of loss. I experienced many examples of culture shock when I moved to the United States. One of the least expected was the attitude toward clinical practice among many of my colleagues in academic oncology centers. Many sought to minimize their clinical commitment to give more protected time for research or other professional work. I found this puzzling initially, but have since observed that this is, to some extent, a reflection of the overall institutional priorities and culture. There is often tension between the perceived need for protected time and the expectations of academic departments and health systems for clinical revenue generation. Protected time becomes a contentious issue and increasingly has become the subject of negotiation during the recruitment process. In my early years in the US system, I found this difficult to grasp—why wouldn't trained physicians want to spend as much of their time as possible doing what we were trained to do? I could understand the need to achieve a balance in commitment for those with labs, but not the desire to do the absolute minimum of clinical work. After all, I was not aware of anyone who thought that they could be competent or competitive in bench research with a half day per week commitment to it, so why would anyone think that level of time commitment would be adequate for a clinical practice, especially for those coming straight out of fellowship? Over the next few years, as I began to take on more administrative responsibilities, my perspective began to change. The earliest signs that my clinical skills might be dulling came to me while on a busy inpatient service—I was beginning to feel that I was moving out of my comfort zone—although I was comfortable with the day-to day care of these patients, I wondered whether there were nuances to their care that I was missing. I had also started to realize that I was taking more time to make decisions than I had earlier in my career and started to wonder whether I was losing my edge. I decided it was time to leave the inpatient service. I continued with 2 full days in clinic for several years, which fitted well with my administrative commitment, and I felt fully back in my comfort zone and working at the top of my game although I no longer felt like quite the same, fully rounded clinician. The next step in my career took me to a new leadership position, a reduced clinical commitment of 1 day per week, and a growing sense of unease as to whether this was adequate to stay sharp clinically. I was still gaining great enjoyment and satisfaction from taking care of patients, and I also felt that as a physician leader, clinical practice earned me credibility among my physician colleagues—I could still relate to the issues they faced each day in taking care of patients with cancer. I was also strongly influenced by a former colleague in one of my previous positions who advised me to never give up the day job. That said, there were warning signs that I was becoming an administrator first and a clinician second—I was spending less time reading journals, my time at conferences was being taken up more with meetings outside of the scientific sessions, my publication rate was falling, and the speaker invitations were slowing down. I had to face the reality that my days as a KOL in the lymphoma world were numbered, and I should probably adjust my focus fully to my administrative/leadership role. As I made the decision to drop to a half-day clinic per week, I realized that this marked the most significant step in my shrinking clinical role. I became increasingly conflicted about this level of clinical practice. It was much more compatible with my administrative workload, but less satisfying for me as a physician. I began to feel like a visitor in the clinic and was able to sustain my practice only because of the excellent backup from the clinic nurses and advanced practice providers and the support of my physician colleagues. My level of engagement in the development of new trials was diminishing, and I was happy to leave this role to our excellent junior faculty. As with my inpatient experience, I started to feel as though my comfort zone was shrinking once again—some of my faculty colleagues were developing particular expertise in certain lymphoma subtypes, and I was happy that they were providing care for those groups, leaving me to focus on those diseases where I still felt I had maintained my expertise. Looking back, I think it was the credibility factor which persuaded me to continue with a minimal clinical commitment for as long as I did—I was concerned that giving up completely would result in a loss of respect from clinical colleagues. Subsequent experience confirmed that this was true. When I ultimately decided to hang up my stethoscope, I felt some relief that I had resolved my own internal conflict, but there is no question that it diminished the perception of me as a physician leader among my clinical colleagues. There is little published literature on the issue of clinical commitment and skills in oncology. In his wonderful perspective in the New England Journal of Medicine, Dr David Weinstock1 describes his experience of withdrawing from clinical practice and compares this process with bereavement. His account of this process certainly resonates with me although my feelings on stepping down were a mixture of regret and relief. Recognizing that oncology practice remains, to some extent, an art, it is difficult to measure what makes any of us competent, compassionate, and effective oncologists. We have to rely on our own intuition to tell us when we are functioning at our peak and when we may be starting to lose our edge—it is unlikely that anyone else is going to tell us unless there is an egregious error. For me, one half day per week in clinic proved to be insufficient for me to feel fully engaged, truly part of a care team, and fully up to date. Giving up was the right decision for me and my patients, despite the loss of credibility with my colleagues. There was a sense of loss with each stage in the process of my dwindling clinical commitment, but this was offset by the knowledge that I had not waited too long to make changes. Dr. Lidia Schapira: Hello and welcome to JCO's Cancer Stories: The Art of Oncology, which features essays and personal reflections from authors exploring their experience in the field of oncology. I'm your host, Dr. Lidia Schapira, Professor of Medicine at Stanford University. Today, we are joined by Dr. John Sweetenham, whom you may recognize as the host of the ASCO Daily News podcast. Dr. Sweetenham has recently retired or partly retired after 40 years of practice in academic oncology, and in this episode he'll be discussing his Art of Oncology Practice article, “Did I Mess Up Today?”  At the time of this recording, our guest has no disclosures.  John, welcome to our podcast and thank you for joining us today. Dr. John Sweetenham: Thank you for having me. Dr. Lidia Schapira: I'd like to start just by asking a little bit about your process and perhaps why you wrote this. Was this inspired sort of by a conversation? Did this just gush out of you when you saw your last patient? Tell us a little bit about the story of this article. Dr. John Sweetenham: Yeah, it didn't really gush out of me. In fact, I originally started to write this probably back eight or nine months ago, and I wrote a couple of paragraphs and then I'm not quite sure what happened. I didn't think it was very good. Life took over, other things were going on, and then I revisited it about a month to six weeks ago. So the process has been actually fairly slow in terms of putting this down on paper, but it wasn't really the result of a conversation.  A couple of things spurred me on to do it. The first was the most obvious one, that it really did occur to me, particularly as I hung up my stethoscope and walked away completely from clinical practice, that I did have some sense of relief. Because I didn't have that nagging voice in the back of my head saying to me anymore, “I just want to make sure that I did everything right today.” And so I think that was a part of it.  And then it was also partly inspired by something which I read a few years back now. And I actually referenced it in my article, which was that wonderful article by Dr. David Weinstock, who had a somewhat different but parallel experience. And that had really resonated with me. And particularly over the last two or three years of my clinical career, like I said, I began to feel uneasy. And so it wasn't really a kind of blinding flash or anything. It was really just over time, wanting to get it down on paper because I felt that I can't be the only person who feels this way. Dr. Lidia Schapira: John, let's talk a little bit about some of the themes that I found so compelling in your article. The first is your experience of how we value clinical activity in the United States. And you contrast that very much with your experience in the UK. You talk about having started your fellowship in oncology in the ‘80s in the UK and then transitioning to the academic culture in the US. Can you reflect a little bit on that for us, both how it was then and how it is now? Dr. John Sweetenham: I preface that by saying it is 25 years since I practiced in the UK, so I don't really know whether it's now as it was back then. As I mentioned in that article, I think at the time that I went through medical school and undertook my fellowship, the training at that time and the culture was very, very clinically based. I always remember the fact that we were taught very heavily, “Don't rely on tests. Tests are confirmatory. You've got to be a good diagnostician. You have to understand, listen to the patient, he'll tell you the diagnosis,” and so on and so forth. So that the grounding, particularly during med school and early fellowship, was very much based on a solid being as a clinician. Now, in 2024, I think, that's actually a little unrealistic, we don't do it quite that way anymore.  And for me, the contrast when I moved to the US was not so much in terms of clinical skills, because I think that clinical skills were very comparable. I don't think that's really a difference. I would say that clinical skills and clinical time are not always consistently valued as highly from one institution to the other. And I think it is an institutional, cultural thing. I've certainly worked in one or two places where there is a very, very strong commitment to clinical work and it is very highly valued. And I've worked in one or two places where that's less so. There isn't really a right or wrong about that. I think different places have different priorities. But I did find certainly when I moved and was probably somewhat naive moving into the US system because I didn't really realize what I was coming to, and there were definite culture shock elements of that. But at that time, in 2000, when I made the transition, I would say that at that time, overall, I think that clinical medicine was probably more highly valued in the UK than it was in the US or clinical skills. I think that's changed now, almost certainly. Dr. Lidia Schapira: Interesting that you referred to as a clinical culture, a term that I will adopt going forward. But let's talk a little bit about this process of having your time basically devoted more to administrative governance, leadership issues or tasks, and going from being comfortable in the inpatient setting to giving that up and then going to outpatient two days a week, one day a week, half a day a week. And then this moment when you say, “I just can't do this,” is there, you think, a point, a threshold? And how would we know where to set that, to say that below that threshold, in terms of volume and experience, one loses competence and skills? Dr. John Sweetenham: I certainly don't have the answer. And I thought really hard about this and how could we improve on this. And is there some way that we would be able to assess this? And the thing that I thought back to was that back in the early 2000s, when I first moved to the US. At that time, for ECFMG purposes, I had to do something that was called the Clinical Skills Assessment, where you went to Philadelphia and to the ECFMG offices and you saw actor patients and you had to do three or four of these and someone had a camera in the room and so they were watching and assessing your clinical skills. And honestly, I slightly hesitate to say this, but it was probably pretty meaningless. I can't imagine my clinical skills could have been judged in that way. I think it's made me believe that there probably isn't an outside way of doing this. I think it's down to all of us individually and our internal compass. And I think that what it requires is for, certainly in my case, just to be aware. I think it's a self awareness thing. Dare I say it, you have to recognize as you get a little older you probably get a little less sharp than you were, and there are signals if you're prepared to listen to them.  I remember on the inpatient service, and I used to love the inpatient service. I love teaching the house staff and so on. It was really good fun. But then I got to a point where I was on a very, very busy hem malignancies inpatient service and started to have to think about which antibiotics to use just a little bit longer than I had done in the past. And it was little things like that. I was not so familiar with the trials that some of these patients could be able to get on when they were inpatient. And so little signals like that started to ring in my ear and tell me, “Well, if you're taking longer and if you're thinking harder, then maybe it's time to move on from this.” And I would say the two most difficult things for me to do overall were obviously giving up clinical work entirely. But before that, giving up the inpatient service was a big deal because I never really felt fully rounded as an oncologist after that. As the hem malignancies docked back 15 years ago, a very big component of the care was still inpatient, and I wasn't doing that part of my patient care anymore. And that was kind of a big change. Dr. Lidia Schapira: So many things to follow up on. Let me try to take them apart. I'm hearing also two different themes here. One is the competence issue as it relates to aging. And there have been some recent articles about that, about whether or not we actually should require that physicians above a certain age demonstrate their competence. And this is, I think, an ongoing theme in academic medicine. But the other that I hear relates to volume. And even if you are sort of at the top of your game and very young, if you're only in the clinic half a day a week, you can't possibly have the clinical experience that just comes from seeing a lot of patients. Can you help us think through the difference between these two sort of running threads that both, I think, contribute to the idea of whether or not one is competent as an expert in a field? Dr. John Sweetenham: I think that the discussion around age and clinical competence is a very interesting one. I just don't know how you measure it other than your own internal system for judging that. I'm not sure how you would ever manage that. I suppose in some of the more procedure based specialties, maybe there would be skill based ways that you could do this, but otherwise, I just don't know. And I certainly wouldn't want to ever be in a position of making a judgment based on age on whether somebody should or shouldn't be working. I just felt that for me, it was the right time.  In terms of this issue of volume and time in the clinic, I actually do feel that there are some important messages there that maybe we need to think about. And I say this with total respect, but I think straight out of fellowship, a half a day in a clinic, to me doesn't feel like it's going to give that individual the experience they need for 30 years of clinical practice. I may be wrong about that. I'm sure there are exceptions to that and highly competent individuals who can do that. But I worry that someone who starts out their clinical oncology career with a minimal clinical commitment, I worry as to whether that is the best way for them to develop and maintain their clinical skills. Dr. Lidia Schapira: And this brings me to another question, which is sort of our oncology workforce and the investment that we all have in our excellent clinicians and experts in diseases. If we are to pluck some of our best to perform more and more leadership, administrative and governance roles, aren't we doing a disservice to our patients and future patients? Dr. John Sweetenham: I think that in terms of our oncology leadership, both clinically and academically, it could use a bit less gray hair and I think that there are enormously talented mid-career folks who aren't necessarily advanced and getting the opportunities that they should have to really shine in those areas to develop full time clinical and academic practices and be the ones who are really clinically engaged. And then the people of, I won't say my generation, maybe the generation below me now, it seems to me that there is a benefit to gaining administrative leadership roles for those who want to go in that direction as you advance further through your career and that perhaps making sure that those people in their mid-career role, where they're probably at their most productive, are able to do clinically the things that they want to do. What I'm trying to say is I think that you're quite right that we do pick off people who are going to be really talented in a specific direction and distract them from their clinical practice. Maybe we just have to be a bit more reserved about how we do that and not distract those people who are really strong clinicians and pull them in directions that they may, indeed, be attracted to, but perhaps it's a little bit early for them to be doing it. Dr. Lidia Schapira: It's an interesting question and dilemma because on the one hand we say we don't want people who just have business degrees administrating in medical spaces. But on the other hand, we don't want to distract or pluck all of our clinical talent for administrative roles that take them away from what we prize the most and what our workforce actually needs. And that sort of brings me to my next question, which is something I'm sure you've thought about, which is, as we get older and as we have more gray hair, those of us or those of you who choose to allow yourself to be seen as gray, some of us still cover, how do we present interesting career tracks also that acknowledge the fact that perhaps people want to pivot or take on new roles and still keep them engaged in actively seeing patients because they have so much to offer? Dr. John Sweetenham: I think the key there is that there has to be a balance between how much of somebody's time, a physician's time should be taken up in those roles. I'll only speak for myself here, but when I got into a more administrative role, it was quite seductive in a way and I quite enjoyed it. It's a very different perspective. You're doing very different things, but you do get this feeling that you're still having impact, you're just doing it in a different framework. It is intriguing and it's a lot of fun. In a way, I think it comes down to time. I think that somewhere around, for me, a 40% clinical commitment, I think I could have continued that. And I think if I could have resisted the temptation to be drawn more into the administrative side, or if somebody had said to me, “No, you're not going to do that,” then I would have resisted the temptation to do that. I think that there are people who would say, “Well, you can't take on a physician leadership role in a busy academic center and do it as a part time job.” Well, there's probably an element of truth in that, but you certainly can't take care of patients as a part time job either. And I do think that one of the things that we should ask ourselves maybe in terms of developing physician leaders is should we insist that there is a minimum amount of clinical time that the individual still has to commit to? And that may be the answer. I think that it does help to maintain credibility among colleagues, which, I think, is very important, as I mentioned in the article. So that's my only perhaps suggestion I would make is just don't allow your physician leaders to get so wrapped up in this that they start to kind of walk away from what we were all trained to do. Dr. Lidia Schapira: I'd love to hear you talk a little bit more about your experiences, reflections on what you call the ‘art of oncology' and the ‘art of practicing in oncology.' Dr. John Sweetenham: I think that many of us, myself included, tried throughout my career to be evidence-based. I tried really hard to do that, and I hope for the most part, I succeeded. But I think there are times when that does get challenged. Let me give you one example that comes to mind, and that would be just occasionally, from time to time, I had the good fortune to take care of people of some power and influence. And there is, I think, in that situation, a temptation to be drawn into doing what those people want you to do, rather than what you think is the right thing to do. It can be very, very difficult to resist that. And so to my mind, part of the art is around being able to convince those folks that what they're suggesting would not necessarily be in their best interest. That would just be one example.  I think the other thing also that strikes me is you can't walk away from the emotion of what we do. And I still think back to some of the folks that I took care of when I was practicing bone marrow transplantation. This would be even back in the UK and folks would contact me some years afterwards. Some of my former patients from the UK would contact me and would still keep in touch and had medical complications, oncology complications, that followed them. And it struck me then, they were 5,000 miles away. I had no useful advice to give them, really, other than to listen to their physicians and get second opinions and those kinds of practical things. But it did strike me that part of the art is, and perhaps art is the wrong word, but there is a big emotional commitment when people feel 20 years on that they're still wanting to keep in touch with you and let you know what's happening in their lives, you know. And so I think that however much we try to be scientific and detach ourselves from all of that, our interactions with folks, I think sometimes we don't realize how impactful and long lasting they can be. Dr. Lidia Schapira: I would say that that speaks to your success in establishing a therapeutic alliance, which is probably one of the things that we often undervalue, but is a huge element of truly human-centered, compassionate practice, whatever we want to call it.  But I do have one last question, and that is how you have dealt with or how you have learned to deal with in your practice, with some of these feelings of regret and relief that you mentioned that came with hanging up the stethoscope but the huge emotions that accompany making decisions about one's practice. Dr. John Sweetenham: It has almost been a natural sort of stepwise progression. So it's almost a journey for me. And so like I mentioned to you earlier on, I struggled around the time when I gave up inpatient practice. I struggled again a little bit when I gave it up completely. Although it was very much balanced by this sense that I didn't have to worry if I was kind of screwing up anymore, so that was good. But I think the other thing is there are other things going on. And so rather than dwelling on that, I've stayed active to some extent in the oncology world by some of the other things I do. I'm still trying to write one or two other things at the moment. And I guess it's partly a kind of distraction, really that has helped me to get through it. But I think in the end doing other stuff, I've actually traveled a fair bit. My wife and I have traveled a fair bit since I actually stopped working. And the other thing, I guess it sounds a bit lame and corny, but after 40 years or so, there are a lot of good memories to think back on. And again, it sounds very cliched and corny - I console myself with the fact that I hope for some of the folks that I took care of that I made a difference. And if I did, then I'm happy with that. I have closure. Dr. Lidia Schapira: What a lovely thought. I was thinking of the word distraction as well before you said it. Well, listen, I look forward to reading what you write and to being inspired and to continue to be in conversation with you. Thank you so much for joining our show today. And for our listeners, until next time, thank you for listening to JCO's Cancer Stories: The Art of Oncology. Don't forget to give us a rating or review and be sure to subscribe so you never miss an episode. You can find all of the ASCO shows at asco.org/podcasts.   The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions.  Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Show Notes: Like, share and subscribe so you never miss an episode and leave a rating or review.   Guest Bio: Dr. Sweetenham, host of ASCO Daily News podcast, has recently retired after 40 years of practice in academic oncology.

In part 3 of this 3-part podcast series, HMP Executive Vice President Lee Blansett and special guest John Hennessy—health system, provider and oncology strategist—conclude their conversation on oncology practice economics, discussing emerging models for success (e.g., utilization of advanced therapies) and manufacturer implications.

In part 2 of this 3-part podcast series, HMP Executive Vice President Lee Blansett and special guest John Hennessy—health system, provider and oncology strategist—continue their exploration of oncology practice economics, focusing on practices' operational realities.

In part 1 of this 3-part podcast series, HMP Executive Vice President Lee Blansett and special guest John Hennessy—health system, provider. and oncology strategist—explore the current state of oncology practice economics.

Dr. Natash Leighl and Dr. Jyoti Patel are back on the podcast to discuss the update to the living guideline on stage IV NSCLC with driver alterations. This guideline includes recommendations for first-, second-, and subsequent-line therapy for patients with driver alterations including: EGFR, ALK, ROS1, BRAFV600E, MET exon skipping mutation, RET rearrangement, NTRK rearrangement, HER2, and KRAS G12C. They highlight the key changes to the recommendations, addition of recent trials, the importance of biomarker testing, and the impact of this guideline for clinicians and patients living with advanced NSCLC. Stay tuned for future updates to this continuously updated guideline. Read the full update, “Therapy for Stage IV Non-Small-Cell Lung Cancer With Driver Alterations: ASCO Living Guideline, Version 2023.3” at www.asco.org/living-guidelines. TRANSCRIPT This guideline, clinical tools, and resources are available at http://www.asco.org/living-guidelines. Read the full text of the guideline and review authors' disclosures of potential conflicts of interest in the Journal of Clinical Oncology, https://ascopubs.org/doi/10.1200/JCO.23.02744.    Brittany Harvey: Hello, and welcome to the ASCO Guidelines podcast, one of ASCO's podcasts delivering timely information to keep you up to date on the latest changes, challenges, and advances in oncology. You can find all the shows, including this one, at asco.org/podcasts.    My name is Brittany Harvey, and today I am interviewing Dr. Jyoti Patel and Dr. Natasha Leighl, co-chairs on “Therapy for Stage IV Non-Small-Cell Lung Cancer With Driver Alterations: ASCO Living Guideline, Version 2023.3.” Thank you for being here, Dr. Patel and Dr. Leighl.  And before we discuss this guideline, I would like to note that ASCO takes great care in the development of its guidelines and ensuring that the ASCO conflict of interest policy is followed for each guideline. The disclosures of potential conflicts of interest for the guideline panel, including Dr. Patel and Dr. Leighl, who have joined us here today, are available online with the publication of the guideline in the Journal of Clinical Oncology, which is linked in the show notes. So, to start us off on this living clinical practice guideline, Dr. Leighl, this guideline for systemic therapy for patients with stage four non-small cell lung cancer with driver alterations is being routinely updated. What new data was reviewed in this full update to the living guideline? Dr. Natasha Leighl: Thanks so much, Brittany. So, we looked through the literature for publications between February and the end of October 2023, and also any novel agents that were approved, in particular by the United States FDA, to really incorporate this update in the current guidelines. In particular, we had updates in EGFR-driven tumors, BRAF and RET-driven tumors. And we also worked very hard to make this more digestible. In particular, it was turning into a bit of a laundry list of all of the things that we had ever recommended. So we really wanted to shorten things, pare them down, and really make them helpful and very, very current for the treatment of people with lung cancer in 2023 and 2024. Brittany Harvey: Excellent. Thank you for providing that overview of the evidence reviewed and the key updates that we will address in this guideline. So then I would like to talk about some of those key updated recommendations from the expert panel. You mentioned both EGFR, BRAF, and RET. So starting with patients with stage IV non-small cell lung cancer with EGFR alterations, Dr. Leighl, what are the key changes to those recommendations? Dr. Natasha Leighl: So, as I said, we really started to get quite a long list of things we recommended, including drugs that, to be honest, we no longer think are what we should lead with first-line. So we updated the recommendation to recommend first-line osimertinib in patients with sensitizing mutations. We were also able to capture in this update for patients with EGFR exon 20 insertion mutant lung cancer, the data from the randomized PAPILLON trial, recommending amivantamab plus chemotherapy for progression-free survival benefit. Not yet an overall survival benefit, but we will see how these data mature.  The other thing that we did was we moved all of the- I don't want to call them "legacy agents" because, in many countries, these are still very important. But older agents such as gefitinib, approaches such as gefitinib plus chemotherapy, and drugs like dacomitinib and other agents where we truly believe as an international panel that we would prefer a third-generation kinase inhibitor like osimertinib. We moved all of those to our discussion, just to recognize that, around the world, not everybody may have access. And we also specified that things are different in different countries. So, for example, in China, there are other third-generation kinase inhibitors with randomized data to support their use. And those are approved and used in China. And also, for example, in Korea, there are other agents that are used. So, we have really tried to be both inclusive and yet keep things simple at the same time. And hopefully, we have succeeded.  One of the challenges was that, with all of the updates that we made, we did not have all of the publications out yet at the end of October to make recommendations about moving beyond osimertinib in the first-line setting. So, please stay tuned for the next guideline update, where we're going to tackle whether we should give osimertinib alone or combination therapy. Brittany Harvey: Excellent. Thank you for providing those updates and clarifications for those patients with non-small cell lung cancer and an EGFR alteration. And we will look forward to the guideline panel's review of that evidence and future updates as well. So then, Dr. Leighl, you had previously mentioned that additional recommendations were updated, such as those for patients with BRAF alterations and RET alterations. So, Dr. Patel, what are the other key updated recommendations from the expert panel? Dr. Jyoti Patel: Thanks so much, Brittany. So certainly, I think we have seen many of these trials mature over time, which has been fantastic. I think one remarkable achievement was the reporting of a phase III selpercatinib trial. This was a trial in the front-line setting, in which patients who were RET-positive were randomized to selpercatinib versus carboplatin-based chemotherapy. And the selpercatinib significantly outperformed platinum-based chemotherapy, and I think really demonstrated a significant improvement in progression-free survival. So, based on that phase III trial, the recommendation for selpercatinib was elevated. Many of these agents that are used in clinical practice are approved initially on smaller phase I or phase II trials. And so, seeing the maturity of these phase III trials gives clinicians and patients greater certainty that these agents are really effective. And so, the evidence was increased for that, and that's now a preferred agent over another TKI, pralsetinib, in which there is only phase II data. So, certainly, those kinds of real things that we can explain to patients are important in these guidelines.  Another thing that we were able to update was another doublet for BRAF V600E non-small cell lung cancer. So, the combination of the two TKIs, encorafenib and binimetinib, was also included in the guidelines.  One thing that we tried to help was really identifying the best therapy post-progression on these first-generation TKIs. And again, there is a paucity of data, but often we went back to carboplatin-based doublets, and there is some data regarding whether or not patients with driver alterations should get immunotherapy in the second-line setting. And so, certainly, I think we have a number of randomized studies for patients with classical EGFR mutations, and our recommendation is generally avoidance of immunotherapy for these patients and treating many of these patients with carboplatin and pemetrexed when appropriate. I do not think we have the data for a lot of other subsets of patients. So, again, stay tuned as these data evolve. Brittany Harvey: Thank you for reviewing those updated recommendations and the supporting evidence. I think it's helpful for our listeners to understand the level of evidence behind these recommendations as well.  So then, Dr. Leighl, what should clinicians know as they implement these new and updated recommendations? Dr. Natasha Leighl: It's really important, first of all, to make sure that you have the information that you need to get your patients to these great new treatments as part of the shared decision-making process. So your patients need biomarker testing. You need to get that as quickly as you can. As Dr. Patel has highlighted, you really want to get that before they start their first-line therapy, if at all possible. We also really tried to bring out in this guideline that when things are delayed, I mean, this is the real world that we live in, just to be very cautious of immunotherapy with chemotherapy for that first cycle. That obviously, again, is a discussion with your patient, but this concept that the approach of a cycle of chemotherapy while you wait for the next-generation sequencing testing. And then if the patient does not have a driver alteration, adding any other therapy as appropriate is okay. It's something that people do. We believe it's important as we talk about the balance between benefits and harms. And so I think that's in there for clinicians, and I hope that they and patients can really benefit from that to avoid toxicity and also to really improve the ability to get molecular testing results first line.  Also, I think it's really important that when people read the wording of the guidelines, that this really follows GRADE, which is a type of system that we use to develop our recommendations. And so things like "may" do not mean that you shouldn't do it. So sometimes we'll hear back from clinicians and say, "Well, you said that they may use alectinib or lorlatinib, for example, with ALK, and I can only get coverage for one or the other." And so I think it's really important that clinicians and patients recognize that all of the things that we do recommend, even if we do use the word "may" or the recommendation is more conditional, we do think that these agents should be available for patients and clinicians, and that they go through this shared decision-making process together.  And so I think that's something that clinicians, we hope, can help take forward as they advocate for their patients to get access to these different and new and emerging treatments that have clearly shown benefit. Even when we say patients and clinicians may use this or that, there may be excellent reasons for using something newer, that's emerged, perhaps for toxicity benefits or benefits in terms of efficacy, even though we can't compare directly. And so we really want clinicians and patients to be empowered to access these new compounds and these new exciting agents that are in our guidelines. Brittany Harvey: Absolutely. Thank you for reviewing those key points. And, yes, that's a great comment that the level of obligation in the recommendations may be based on the evidence quality, but that doesn't mean that clinicians and patients shouldn't have access to all of the recommended treatment options to offer patients based off their individual patient and clinical characteristics.  So then, Dr. Patel, in your view, how will these changes affect patients with non-small cell lung cancer, with driver alterations?  Dr. Jyoti Patel: A lot of this echoes the points made by Dr. Leighl. I think there are opportunities for patients to assess toxicity or what it means for intensification of therapy. So, particularly for EGFR patients, for example, we have data that chemotherapy with osimertinib can improve progression-free survival, or the incorporation of a bispecific antibody, amivantamab, can improve progression-free survival over the TKI alone. It certainly comes with increased toxicity. And so how we weigh this in the absence of a known survival benefit at this juncture is one that, again, really gives patients the opportunity to prioritize what's important for them. And so I think this guideline affects patients and that we have multiple options, we help with the weight of the evidence so they may be able to better discern what treatment makes sense for them. Brittany Harvey: Understood. Yes, this guideline provides lots of options for different patients based off their driver alterations. So it's helpful to have that information for shared decision-making with their clinicians.  So then finally, to wrap us up, Dr. Leighl, what current research is the living guideline expert panel monitoring for updates to the guideline recommendations? Dr. Natasha Leighl: This process of the living guidelines has really been to help us stay on top of the amazing and incredibly rapid progress that we're making in lung cancer and other cancers. And even with this process, where we're trying to stay up-to-the-minute, there have already been some changes in the literature between the start of November and now. And so we're already working on some additional commentary and options for the first-line treatment of patients with EGFR-mutant lung cancer. Also, the subsequent treatment of patients with EGFR-mutant lung cancer, depending on what they've had before. Also, a great new study in patients with ROS1 fusion-driven lung cancer. And so these are some of the things that we're looking at.   Also, a bit more discussion about the importance of molecular testing. In our companion article, the Journal of Oncology Practice, along with Dr. Patel, we're going to be talking a bit more about new ways to genotype, for example, using both liquid biopsy and tumor tissue at the same time, and some of the support for that and how it gets us with our patients to the answers that they need faster.  Brittany Harvey: Absolutely. The pace of research in non-small cell lung cancer has moved quite quickly. So we definitely appreciate the panel's efforts to review all of this evidence on a continuous basis and take the time to develop these guideline recommendations for both clinicians and patients with non-small cell lung cancer.  So I want to thank you so much for your work to update these guidelines, and thank you for your time today, Dr. Patel and Dr. Leighl. Dr. Natasha Leighl: Thanks so much. It's a real pleasure to be here. Dr. Jyoti Patel: Thank you.  Brittany Harvey: And thank you to all of our listeners for tuning in to the ASCO Guidelines podcast. To read the full guideline, go to www.asco.org/living-guidelines. You can also find many of our guidelines and interactive resources in the free ASCO Guidelines app, available in the Apple App Store or the Google Play Store. If you have enjoyed what you've heard today, please rate and review the podcast, and be sure to subscribe so you never miss an episode.  The purpose of this podcast is to educate and inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions.   Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.      

Drs. John Sweetenham and Lawrence Shulman discuss the challenges that oncologists will be confronting in 2024 and share insights on how to build clinician resilience and optimize the oncology workforce to provide better, safer care for patients with cancer. TRANSCRIPT Dr. John Sweetenham: Hello, I'm Dr. John Sweetenham from the UT Southwestern Harold C. Simmons Comprehensive Cancer Center and host of the ASCO Daily News Podcast. I'm thrilled to welcome my friend and colleague, Dr. Larry Shulman, to the podcast today. Dr. Shulman is a professor of medicine, associate director of special projects, and the director of the Center for Global Medicine at the University of Pennsylvania Abramson Cancer Center. Dr. Shulman is also the immediate past chair of the Commission on Cancer, and also serves on the National Cancer Policy Forum of the National Academies of Science, Engineering, and Medicine. His acclaimed research has led to the development of models of clinical care to improve the patient experience and quality of care in the United States and internationally. His activities have also included innovations in health information technology, cancer survivorship care, and some other related areas. Today, Dr. Shulman will be sharing his valuable insights on some of the growing complexities and challenges that we'll be grappling with in oncology in 2024 and beyond, and potential solutions to address these issues. You'll find our four disclosures in the transcript of this episode, and disclosures of all guests on the podcasts are available at asco.org/DNpod. Larry, it's great to have you on the podcast today. Dr. Lawrence Shulman: Thank you so much, John. Dr. John Sweetenham: To start with Larry, as you know, the growth in the number of patients with cancer and cancer survivors in the U.S. is greatly outpacing the number of clinicians available to care for them. The American Association for Cancer Research, for example, estimates that there will be nearly 2 million new cancer cases in the U.S. alone this year and that the number will increase significantly in the years to come. The number of cancer survivors in total in the U.S. is predicted to grow to around 20.3 million by 2026. So, the question our community has been grappling with for some time now is: “How do we confront these realities and provide optimal care for patients, while at the same time building the resilience of the clinicians who need to care for them?” This is an area I know that you've focused on for a long time and you've published several papers in recent years as well as the great work that you've done as co-chair of the National Cancer Policy Forum workshop on the oncology workforce. Can you share your insights into some of these challenges? Dr. Lawrence Shulman: Sure, John. Thank you very much. As you mentioned, the number of oncologists in this country is pretty stable. There's consistent but relatively low number entering the workforce and those of us who were really in the first wave of oncologists in the 1970s are beginning to retire. A number of years ago we thought, well, we need to figure out ways to recruit more medical students and trainees into the field of oncology, but that's clearly not going to happen. And as you also mentioned, the number of cancer patients is rapidly increasing in this country, partly because of the aging population and partly because frankly we're better at treating them. The cure rates are better, and the number of survivors is going up. So, the math is pretty straightforward. We have a relatively stable number of oncology providers trying to care for a rapidly increasing number of patients and that's just not going to change. So, we need to have plan B; we need to figure out how we can better meet the needs in this country. And I think all of us who practice are feeling the strain of trying to take care of these increasing number of patients. I think there are a few things that are contributing to this as well. One—the good news is we have lots of new therapies, we have lots of genomics, which are leading us to better tailor therapies for our patients. But this is all complicated and it's a lot for us all to learn and keep abreast of and to manage on a day-to-day basis in the middle of a busy clinic. But the other thing is that I believe our care has become progressively more inefficient, making it harder every day that we go to clinic to care for the number of patients we need to. And that really has to change. For those of us who've been doing this for a long time, and I know you have as well, this has been a trend really over decades. It's gone in the wrong direction. It was a lot easier to practice a number of decades ago. Now, the requirements for documentation and pre-authorization and many other administrative tasks has just grown progressively over these years. And we need to figure out how to change that. And in addition, our electronic health records, which is where we live in clinic, have been remarkable and wonderful in many ways, but are also inefficient to use and we need to do a better job in optimizing their functionality. Dr. John Sweetenham: Great, thanks Larry. I do agree with you there and I think that in addition to the challenges of running the electronic health record and using that at the point of care, of course the other thing that many of our clinicians face now is an increasingly complex treatment landscape and a greater need for clinical decision support tools, which of course are not always at the moment quite as facile as we would like them to be. And I think partly because of that, many oncologists are feeling overburdened partly with these various administrative tasks they have, partly with frankly keeping up with their own specialty areas or if they're community-based general oncologists, just keeping up in general with the new information that's coming at them. And then add on top of all of that the emotional toll of caring for patients with cancer. And not surprisingly, perhaps I think we have started to see, certainly we have experienced an exodus of some oncologists in recent years who've decided to pursue careers outside of direct patient care and oncology. And those included some moving into other areas of academia, some going into industry, some going into various tech companies and so on. Are you concerned that we all struggle in the effort of building and support a resilient oncology workforce to meet the needs of this growing population that you mentioned? Dr. Lawrence Shulman: Yeah, I'm very concerned about that, John. And I think one way to think about this is that as you say, the practice of oncology inherently is a stressful and difficult, though quite rewarding way to spend your professional career. But we layer on top of that a lot of frustration and difficulties that really don't need to exist. And when I think about this, I think about really two buckets. There's a bucket of factors that are within our control in an individual institution or an individual practice, and I'll come back to that in a minute. The other bucket are external forces, things that are required by the government regulators, by the payers that need to be done in routine practice. We have less direct influence over those, though I think it's a profession, we need to think hard about how to influence the external factors as well. At the practice level, there are a lot of things that we can do. One has to do with optimizing our electronic health record, which does have, in most cases, the ability to have it customized by institution in a way that would make it optimal. And some of that again, is external because we're dealing with a vendor product that has some limited ability to be customized, but we need to do a better job of the technology that underlies our practice every day when we go to clinic. The other major factor in support, whether it's advanced practice providers, nurses, medical assistants, navigators, and other personnel who can in fact help to support the patients, help to support their families, and help to support the clinicians who are on the front line trying to care for these patients. And we all use the term, practicing at the top of your license and aspire to that. But I think frankly we don't do a great job in that regard, and we need to really think harder about how we do have the appropriate team around us. In addition, I would say that there are a lot of other things at the practice level that we need to think about, including the facility of ordering radiologic studies and consultations and so on, all of which are often more cumbersome than they should be. We really need to not put these obstacles in the way of our clinicians. Externally, I think we need to get the payers and to get the government CMS to understand that the current state, it's just not going to be viable going forward and they need to make some big changes. And I think one of the ways to think about this is that rather than doing something differently, you want to do a different thing. I mean, they really need to make some paradigm changes and what's required day in and day out from our clinicians. Dr. John Sweetenham: Absolutely. So, I want to pick up on something that you mentioned there, which is the role of navigators and the benefits that navigation, patient navigation, can have in several domains, but certainly it can help to reduce the burden on oncologists and strain in the system in general. But to take that a little bit further, I wonder if we could talk a little bit about how navigation can help in reducing care disparities. You were saying before we came on the podcast today, the concept of using patient navigators to reduce disparities in care is not new. It's been around for many, many years, but it seems like we almost have to keep relearning that they really help in terms of reducing various disparities which may be rural disparities, racial and ethnic and so on. There are plenty of data out there, as you've mentioned, just to quote a couple of studies, there was the ACCURE trial published a couple of years ago now, which was really a multi-pronged intervention to help Black patients overcome obstacles to completion of treatment. And it included navigation along with a number of other interventions, electronic health record flags to alert caregivers to missed appointments, providers to missed appointments, I should say. It also included physician champions to help engage the health care teams and some educational interventions as well with a significant impact on the access to care from Black patients. The Levine Cancer Institute in the Carolinas conducted a study in my own world, in aggressive large B-cell lymphoma a number of years ago, where they showed that they were able to navigate all of their patients into guideline-concordant care, which essentially eliminated the disparity in outcome between Black and White patients in their population. And then more recently, a study from the University of Maryland looked at Black men with prostate cancer and demonstrated that with the intervention from a navigator, the number of those patients who had their appropriate genetic testing was increased enormously to levels which were comparable with the White patients in their community. No clear evidence yet that that's impacted outcome, although intuitively, I think it would, but nevertheless, as you've already pointed out, there is a ton of evidence that navigation can help us to eliminate disparities. Could you talk a little bit about your own insights into that area and the work that you've done? Dr. Lawrence Shulman: Sure. A few years ago, the National Cancer Policy Forum held a workshop on navigation in cancer and we spent a couple of days in Washington going over many of the studies you've mentioned. And one of our speakers was Harold Freeman, who was a surgeon in Harlem. About 60 years ago, he showed that patient navigation could reduce disparities in cancer care in his setting. And I think the surprising and somewhat disappointing aspect of this is, well, we have a new therapy, whether it's immunotherapy or whatever that is shown to improve overall survival and outcomes. We adopt that, and we start using it. And yet here something that's relatively straightforward, patient navigation, which has been shown as you say, to improve access to care, to improve guideline-concordant diagnostics, guideline-concordant treatment, patient satisfaction, and ultimately improve outcomes and reduce disparities, but has not been embraced in the same way that new therapies have been embraced. And from my point of view, these factors are equally important. They translate in the patient outcomes ultimately just like the therapies that we choose to. And we need to really buy into that. We need to understand that this really affects our patient outcomes as much as our therapies do. So, a couple of things. One is that you've already mentioned the different ways that navigation might improve outcomes, and that's clearly the case. But there are other aspects which are really critical to a lot of conversations we've been having, and that is that navigators fill vital roles that when they're not present are often filled by the treating physician, trying to make sure that the diagnostic tests, the genomics are all done, trying to make sure that the patient is getting their radiologic studies on time, trying to make sure that the appropriate appointments are being set up. Navigators are very, very good at doing this. They're very good at bonding to the patients and helping the patients feel secure through this cancer journey. But if they're not there, either those things don't get done or the clinician, the treating physician or the advanced practice provider is doing that. And so, it has the dual effect of both burdening clinicians who really have another role in the care of the patients doing these other scheduling and navigation functions as well as improving the overall care. I will say that in my own experience, it's important to have navigators who are skilled in their areas, that understand the diseases that we're treating, that understand the patient's needs in relation to those diseases and the treatments and diagnostics that we have to offer. So, there is a real skill to navigation, but a skilled navigator really makes a huge difference to the patient. And again, not only in the very tangible ways that you mentioned, but also frankly in the psychological security of the patient. And patients will tell you this and there are surveys out there that show this, that patients who are undergoing a new diagnosis of cancer are terrified, do much better psychologically when they have a navigator at their side through this journey. But it has tremendous benefit to the clinicians as well. And why haven't we embraced navigators? I can only speculate, but one of the comments that I get from health system administrators is, “Well, they cost a lot of money, and their work is not reimbursed as part of health care reimbursement.” But there is, again, overwhelming evidence to show that the return on investment for navigators is substantial. And it's substantial because it keeps patients in your practice, it provides more efficient care at all levels. And we published out of the National Cancer Policy Forum work, an article that basically shows from a variety of different centers, including mine at Penn, that there is a tremendous ROI for having navigators. So yeah, it's a little bit of money upfront to hire them, but ultimately, it's a good thing financially as well as clinically. Dr. John Sweetenham: Yeah. So often with these kind of wraparound services that are so important to our patients showing and being able to clearly demonstrate the kind of downstream revenue from those services is difficult, but is I think probably evident to those of us who are in the clinic and see what happens. So, maybe we need some more sophisticated financial models to be able to highlight that to our leaders in the health systems, I think that the evidence is really quite clear. So, Larry, one of the disparities that you've mentioned, and perhaps we haven't focused on quite so much in this discussion, has been the issue of cancer care for rural versus urban communities. And I think it's important that we highlight the challenges that oncologists are facing in rural communities across the country in caring for patients who live many miles away from a hospital or clinical practice and where the oncologists do not have the kind of support system that you'd find in an academic center in a major city. Can you comment a little on that? Lawrence Shulman: Sure, John. This is a real problem. I and others have published on cancer survival statistics in rural settings and in small community hospitals and they are in fact inferior to larger academic cancer centers, probably for a multitude of reasons. And one of our colleagues, Dr. Otis Brawley, made the comment a number of years ago and still repeats it, that your likelihood of surviving cancer in the U.S. is more tightly linked to your ZIP code than your genetic code. And there is some truth to that. Now, there are tremendous challenges for providing cancer care in a small, rural hospital. We practice in academic medical centers; I'm a breast cancer doctor and I spend all of my time trying to stay current in breast cancer. And it's a field that's changing rapidly. It's hard for me to imagine how my colleagues who are generalists in the community are keeping up with the advances in so many different diseases. And I think frankly, it's really, really hard to do that. In addition, all of us at academic centers have weekly tumor boards. We get to ask our colleagues what their thoughts are about our difficult cases. We get a lot of input from pathologists, radiologists, and other colleagues. And frequently clinicians, physicians, oncologists, practicing in rural hospitals don't have that constituency around them for them to bounce difficult patients off of to try to figure out what the best approach might be for a patient. So, the differences are terrific, and the support is just not there. This is something that our country has not really confronted. We have a very big country geographically. Some of the areas of the country are quite rural. A patient can't be expected to travel four hours in each direction to an academic cancer center. We need to figure out how to better partner between our academic cancer centers and our community colleagues to support their care in ways that we've not done routinely up to this point. I know that the National Cancer Institute is very interested in this and trying to figure it out. But again, I think we have to feel a collective responsibility to support our colleagues in the community. They try really hard, they're working really hard, they're doing the best they can, but they just don't have the support that we have in academic cancer centers. Dr. John Sweetenham: Yeah, sure. Before we wrap up the podcast today, I'd like to circle back a little to something that you said earlier and a topic that I know that you've published about quite extensively in the past and that's the issue of health care technology. And I think we probably all agree that health care's been a little bit slow to capitalize on technology to improve our care processes and outcomes. And your research has highlighted that technology can facilitate patient-clinician interactions in a number of ways through augmented intelligence, texting, chatbots, among other things. Can you tell us a little bit about this, how you think that AI might be able to help us in the future to streamline the management of some of these medical and administrative issues that we've been talking about today? Dr. Lawrence Shulman: Sure, John. It's hard to turn the TV on or read a newspaper without an article on artificial intelligence. But the word you used is the word that I use, which is augmented intelligence. I don't think we're looking to replace clinicians with technology, but we're looking to in fact make their jobs easier, to remove some of the tasks that they don't need to do themselves as really an assistant, if you will, another assistant. We have used technology extremely poorly in the medical profession overall. I'm not quite sure why that is. But if you look at the banking industry or other industries, they've used technology tremendously well with great benefit, benefit not only for the people who are using the services, in our case, the patients, but also those who are providing the services, in our case, the clinicians. So, I think we need to do a better job. We need to have electronic health records that are in fact helping rather than sometimes hindering or making frustrating the care of the patients. We need to use artificial intelligence or augmented intelligence to interact with patients and help to manage them. We're using augmented intelligence chatbots to manage patients who are on oral chemotherapy able to do a lot of the tasks that normally the clinicians would be doing without in any way jeopardizing the safety or the well-being of the patients. The patients actually tell us that they like this, that it's just another way to feel connected to their practice in a way that's efficient and easy for them through texting rather than sometimes trying to call the practice, which can be frustrating. But there are lots of other things as well in analyzing data, bringing data forward that will help us to make the appropriate decisions. And one of the things that I often use as an example is the airline industry. And they have a remarkable safety record as we all know, thank goodness. But if you sit in the cockpit of an airplane and you look at the instruments, all the critical data is right in front of them, unencumbered and very clearly presented because they need those data to fly the plane, and they need those data to be rapidly and easily accessible. They can get all the data they need; you look at the cockpit ceiling, it's got a thousand switches on, everything they need is there, but the critical data is never hidden and always presented. I don't think that that in fact is the way our electronic health records are set up. In fact, quite the contrary. And all of us spend a fair amount of time looking for data and so on because the records are complicated, and they're used by a lot of different specialists. But we can use augmented intelligence to bring all the critical data up, just like the cockpit in an airplane, to make sure that we have what we need rapidly accessible, and we don't miss anything. We don't go looking for the genomic test and can't find them and then assume they weren't done and make a decision without critical data when in fact they were done, but the data is hidden. So, I think we have a lot of options to use technology to improve our daily lives. I think it will take away some of the frustrations that lead to burnout, and we'll also make practice not only more efficient, but frankly also much safer. I think we have to work hard on this. We could partner with that technology colleagues. We at Penn are trying to do that. I know others are trying to do it as well. And I think the patients will benefit, will all benefit. Practice will be better, safer, less frustrating, and the outcomes of the patients will be better. Dr. John Sweetenham: Yeah, thanks Larry. I think your analogy with an aircraft cockpit is so perceptive and I think that that's something if we could unclutter our electronic health records and what we're seeing in front of us in at the points of care in the clinic, I agree 100% that will be such a step forward. So, thanks for sharing that. Thanks also, Larry, for discussing some of these challenges that we're going to be confronting in the next year and beyond, as well as the potential solutions. I think one thing that is really important to remember despite these challenges is something that I mentioned in the introduction to the podcast today. So, when we are all feeling a little bit disheartened because of the challenges ahead of us, it's important to remember that in 2026 there will be an estimated 20.3 million cancer survivors in the United States, which really does underline how far we've come, certainly in the time that you and I have been practicing oncology, and really important not to lose sight of that. We had a lot of challenges, but really the achievements of the last 50 years or so are pretty remarkable. It's been a real pleasure to have you on the podcast today, so thank you again for joining us and for sharing your thoughts with us. Dr. Lawrence Shulman: Thanks so much for having me, John. Dr. John Sweetenham: And thank you to our listeners for your time today. If you value the insights that you hear on the ASCO Daily News Podcast, please take a moment to rate, review, and subscribe wherever you get your podcasts. For more information on Dr. Shulman's research discussed in this episode, please see the articles below: The Future of Cancer Care in the United States—Overcoming Workforce Capacity Limitations | Health Care Workforce | JAMA Oncology | JAMA Network Developing and Sustaining an Effective and Resilient Oncology Careforce: Opportunities for Action - PubMed (nih.gov) Re-envisioning the Paradigm for Oncology Electronic Health Record Documentation by Paying for What Matters for Patients, Quality, and Research | Health Care Reform | JAMA Oncology | JAMA Network Survival As a Quality Metric of Cancer Care: Use of the National Cancer Data Base to Assess Hospital Performance - PubMed (nih.gov) Establishing effective patient navigation programs in oncology - PubMed (nih.gov) Patient Navigation in Cancer: The Business Case to Support Clinical Needs Cancer Care and Cancer Survivorship Care in the United States: Will We Be Able to Care for These Patients in the Future? - PMC (nih.gov) Disclaimer: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity or therapy should not be construed as an ASCO endorsement. Find out more about today's speakers:      Dr. John Sweetenham  Dr. Lawrence Shulman     Follow ASCO on social media:       @ASCO on Twitter    ASCO on Facebook    ASCO on LinkedIn       Disclosures:      Dr. John Sweetenham:   Consulting or Advisory Role: EMA Wellness     Dr. Lawrence Shulman: Consulting or Advisory Role: Genetech Research Funding (Inst.): Celgene, Independence Blue Cross

“I think the key in effective communication is building trust, because without trust, patients are not likely to engage in their care as effectively, which can influence patient well-being and their overall health outcomes. Building trust is, I think, crucial,” Deb Christensen, MSN, APRN, AGCNS-BC, AOCNS, founder and chief patient officer at the Cancer Help Desk, a nonprofit that provides personalized cancer treatment resources, told Jaime Weimer, MSN, RN, AGCNS-BS, AOCNS®, manager of oncology nursing practice at ONS, during a discussion about strategies oncology nurses can use when approaching difficult conversations with patients across all populations.   You can earn free NCPD contact hours after listening to this episode and completing the evaluation linked below.   Music Credit: “Fireflies and Stardust” by Kevin MacLeod  Licensed under Creative Commons by Attribution 3.0  Earn 0.75 contact hours of nursing continuing professional development (NCPD), which may be applied to the oncology nursing practice ILNA category, by listening to the full recording and completing an evaluation at myoutcomes.ons.org by November 24, 2025. The planners and faculty for this episode have no relevant financial relationships with ineligible companies to disclose. ONS is accredited as a provider of NCPD by the American Nurses Credentialing Center's Commission on Accreditation.  Learning outcome: The learner will report an increase in knowledge related to difficult conversations in cancer care.  Episode Notes  Complete this evaluation for free NCPD. Deb Christensen's ONS Voice articles about communication  Oncology Nursing Podcast:  Episode 14: Having Difficult Conversations in Oncology Practice  Episode 208: How to Have Fertility Preservation Conversations With Your Patients  Episode 235: Self-Advocacy Skills for Patients  Episode 253: The Ethics of Caring for People You Know Personally  Clinical Journal of Oncology Nursing articles:  Tools for Communication: Novel Infrastructure to Address Patient-Perceived Gaps in Oncology Care  Breaking Bad News: An Evidence-Based Review of Communication Models for Oncology Nurses  ONS Resources:  Palliative Care Communication Strategies  Shared Decision Making in Prostate Cancer  Journal of Oncology Practice article: Role of Kindness in Cancer Care  SPIKES: A Framework for Breaking Bad News to Patients With Cancer   Ask-Tell-Ask method  City of Hope: The Interprofessional Communication Curriculum  Center to Advance Palliative Care   Agency for Healthcare Research and Quality's Health Literacy Universal Precautions   To discuss the information in this episode with other oncology nurses, visit the ONS Communities.    To find resources for creating an ONS Podcast Club in your chapter or nursing community, visit the ONS Podcast Library.  To provide feedback or otherwise reach ONS about the podcast, email pubONSVoice@ons.org.  Highlights From Today's Episode  “Patients tend to be less anxious when they have a trusting relationship with their providers, with their oncology team on a whole, and they tend to follow through better on their treatment plan because they trust what you're saying. It's not easy to establish a trusting relationship when you first meet someone. But what I found in my practice is that anticipating their needs and really listening to their story has made a world of difference in establishing that trusting relationship—and admitting if I don't know the answer to something or if perhaps I've gotten something wrong.” TS 2:32  “Intellectual empathy asks you to imagine yourself in that person's place. And we've all had challenging experiences; we just don't get through life without them. And as a result, we can generally think of a time when we might have been in a similar situation, maybe not exactly the same, but a similar situation, and garner that empathy for the patient and, importantly, for the caregiver, too. Because we genuinely, genuinely want to understand somebody. Intellectual empathy really comes from listening carefully to what's being said and what's not being said, analyzing different people's perspective, knowing your own bias, and asking open-ended questions.” TS 4:41  “I think that the first thing that an oncology nurse needs to do is recognize that patients have their own autonomy to make their own decisions and not go into a conversation expecting a specific outcome. So going in with the intention to do your best, but also be open to what the patient wants to do.” TS 8:30  “Our biggest foe in all of this communication, these communication strategies, really is time. We just do not have the amount of time. I mean, we love the luxury of time to be able to sit and really get into these kind of deeper conversations with people, but we may only have 30 minutes. We may only have 15. So, how do we do that? That is still a question that's out there that there's a lot of investigating. Are there techniques that can help? And there are.” TS 13:47  “All of these points in the continuum have one thing in common, and that's uncertainty. That's really a whirlpool—uncertainty—for people. One of the communication strategies that I've used with people is letting them know that this is a very common emotion to experience—a sense of loss of control, uncertainty—and that in my experience, that people generally, once they have a plan, the anxiety settles. So, giving them kind of a guidepost, hope in the future, that the anxiety will settle. Because I would say 98% of the time it does, once people gain a sense of control, because they have a plan of action to move forward.” TS 16:10  “The setting is really, really important, especially when you're having these challenging conversations. Always checking for understanding: What is that perception? What is the patient perceiving? What is the caregiver family perceiving? Are they understanding you correctly? And being respectful of what people want to know, because sometimes they don't want to know specific things.” TS 21:57  “Oncology nurses need to be aware of their own biases and their own emotional state when they're going into these emotional conversations, these difficult conversations they really need to be in. You might not always be the right one for the conversation. I think that's an important thing to note too, and be able to admit that you may have had a personal life experience that just is not going to allow you to get around a bias or an emotional reaction to the conversation, and so you might not be the right one.” TS 23:11  “I've always felt like if you can help someone find joy and peace in the moment, then that moment was made better. Life is a series of moments. That's kind of how I get through that piece of it.” TS 26:20 

Drs Patel, Wright, and Devoe revisit their involvement in the SWOG S1801 trial to highlight available resources that can expand the reach of cancer care in the community oncology setting. Relevant disclosures can be found with the episode show notes on Medscape (https://www.medscape.com/viewarticle/989040). The topics and discussions are planned, produced, and reviewed independently of advertisers. This podcast is intended only for US healthcare professionals. Resources Malignant Melanoma https://emedicine.medscape.com/article/280245-overview Neoadjuvant-Adjuvant or Adjuvant-Only Pembrolizumab in Advanced Melanoma https://www.nejm.org/doi/full/10.1056/NEJMoa2211437 Event-Free Survival https://www.cancer.gov/publications/dictionaries/cancer-terms/def/event-free-survival National Cancer Institute Community Oncology Research Program (NCORP) https://prevention.cancer.gov/major-programs/nci-community-oncology-research-program-ncorp SWOG Cancer Research Network https://www.swog.org/ ECOG-ACRIN Cancer Research Group https://ecog-acrin.org/ NRG Oncology https://www.nrgoncology.org/ Children's Oncology Group https://childrensoncologygroup.org/ Effectiveness of Adjuvant Pembrolizumab vs High-Dose Interferon or Ipilimumab for Quality-of-Life Outcomes in Patients With Resected Melanoma: A Secondary Analysis of the SWOG S1404 Randomized Clinical Trial https://jamanetwork.com/journals/jamaoncology/article-abstract/2798988 Melanoma Margins Trial-II: 1cm v 2cm Wide Surgical Excision Margins for AJCC Stage II Primary Cutaneous Melanoma (MelMarT-II) https://clinicaltrials.gov/study/NCT03860883

Resources such as facilities, equipment, medications, and trained healthcare professionals are essential to provide proper care. Yet, many areas in the US and around the globe have challenges providing some of such resources. This ASCO Education podcast will explore oncology practice in low resource settings.  Dr. Thierry Alcindor, a medical oncologist at the Dana-Farber Cancer Institute and Brigham and Women's Hospital in Boston, Dr. Richard Ingram, a Medical Oncologist at Shenandoah Oncology in Winchester, Virginia, and Chair of the Appalachian Community Cancer Alliance and Dr. Sana Al Sukhun, an Adjunct Professor of Medical Oncology and Director of Oncology Practice at Al-Hayat Medical Center in Jordan will discuss the barriers they face providing cancer care in low resource areas in the US (1:48) and Jordan (11:52) and the one challenge that is key to solve in order for proper treatment to be administered in the US (29:07) and Jordan (31:42). Speaker Disclosures Dr. Sana A. Al-Sukhun: Honoraria – Novartis; Speakers' Bureau – Novartis, Roche, Pfizer; Travel, Accommodations, Expenses – Roche, BMS Dr. Richard Ingram:  None Dr. Thierry Alcindor: Consulting or Advisory – Merck, Bayer, BMS, Astra Zeneca, Astellas Scientific and Medical Affairs Inc.; Research Funding – Epizyme, EMD Serono, Karyopharm Therapeutics, Springworks, Astellas Pharma, Deciphera Resources  If you liked this episode, please follow the show. To explore other educational content, including courses, visit education.asco.org. Contact us at education@asco.org. TRANSCRIPT Disclosures for this podcast are listed on the podcast page. Dr. Thierry Alcindor: Hello, dear ASCO audience, welcome to this episode of the ASCO Education podcast. Today, we will examine practicing oncology in a low-resource setting. Managing cancer patients is a multifaceted challenge. Resources such as facilities, equipment, medications, and trained healthcare professionals are essential to provide proper care. Yet, many areas in the US and around the globe have challenges providing some of such resources. I'm Dr. Thierry Alcindor. I'm a medical oncologist at the Dana-Farber Cancer Institute and Brigham and Women's Hospital in Boston. Joining us are Dr. Richard Ingram, a Medical Oncologist at Shenandoah Oncology in Winchester, Virginia, and Chair of the Appalachian Community Cancer Alliance. He is, as well, the current president of the Virginia State Oncology Society. We are also very pleased to be joined by Dr. Sana Al Sukhun. She is an Adjunct Professor of Medical Oncology and Director of Oncology Practice at Al-Hayat Medical Center in Jordan. She is also the past president of the Jordanian Oncology Society.  So, I'll begin with Dr. Ingram. You have experience with patients in the Appalachian region of the US by practicing medical oncology in rural northwestern Virginia for the past 25 years. Can you describe this unique region for our listeners and detail some of the challenges you face when providing care there? Dr. Richard Ingram: I have been practicing here in Northwestern Virginia for the past 25-ish years, and have seen over time barriers to care that I think could be applied anywhere. And, I think we'll hear some interesting stories today from our colleague from Jordan also, in that regard. The main barriers I think are somewhat slightly stereotypical but real where I am. There is a diverse population here, meaning a big geographic area and a somewhat underpopulated area. So, resources are scattered and scarce sometimes and located in concentrated areas. So, patients have difficulty with access to cancer screening, imaging, and sometimes downstream or tertiary care where I am. I have patients that will travel an hour and a half to two hours one way i.e., a three to four-hour round trip - sometimes over some difficult terrain, meaning some difficult roads out our way, both with mountains and some geographic challenges just to get to us. You can imagine the difficulty that is with either coordination of care with a multidisciplinary patient having to see multiple providers or more practically, a patient receiving radiotherapy on a daily basis. And, this not only is time but money because you're trying to make a decision about follow-up appointments and missing work at an hourly wage versus working that week and paying your bills. I have patients currently who are working around that. I have several concurrent chemo-radiotherapy patients - currently, actually two I saw this morning - in clinic, both of which live in a town called Petersburg, West Virginia, which is about an hour and 45 minutes one way. So, three and a half hours from us. And, we've had to connect them appropriately with resources around transportation to make sure they stay compliant with their care.  You have this empathy and drive to care for patients and try to apply the same care you would across the continuum. That socioeconomic status is not unique to Appalachia but I think is somewhat emblematic in our area - lovely, hardworking people and diligent in their craft. But, when you have barriers such as cancer diagnosis and now superimposed strain and stress on your family life and work life, it can throw things out of balance.  A similar patient of mine that I saw today actually in clinic, same area, same concurrent diagnosis, their big access issue is that they're also the primary caregiver for some grandchildren that are staying at home. They've taken in their grandchildren and, not unique to Appalachia, but somewhat in that we have a lot of multigenerational families living together. So, you're trying to help that person get through their therapy and still be the homemaker for grandchildren and try to battle their cancer diagnosis and at the same time not bankrupt them financially from a socioeconomic standpoint. Dr. Thierry Alcindor: What's the insurance coverage pattern like? Dr. Richard Ingram: In my area, about half to 60% of our patients are on either uninsured or they are on public insurance, whether that be Medicare or state Medicaid or exchange programs. From the private sector, there are private plans, but a lot of those are self-funded, meaning they are local municipalities, teachers' unions, first responders, and then a small pocket of what you and I would call traditional commercial insurance coverage. And so, for us, we for a lot of our patients have built relationships, for instance, we know this gastrointestinal group will take that insurance of a Medicaid or uninsured patient and this one won't, or vice versa. So, there is some fragmentation of care if you're not very conscious and deliberate at the medical oncology and radiation oncology side, which is in my practice about making sure the patient can get access to care. Dr. Thierry Alcindor: I understand. So you talked about the lack of adequate or complete primary care coverage. Do you have enough medical oncologists? Dr. Richard Ingram: Excellent question. I appreciate that. Yes. So we do, in that my group does and my region does. So we are very strong, as I like to say, the end of the funnel. You know, I consider cancer care screening a funnel you've got to screen through. I imagine you have a giant funnel of trying to screen through patients for the screening program appropriately and then the positive screens come out at the end of the funnel.  At the end of the funnel, we can receive these patients and take care of them and provide all of the touch points of surgical, radiation, medical oncology, genetic counseling, survivorship. My biggest passion and what I've tried to do in the Appalachian Community Cancer Alliance is raise awareness on the screening and getting the screening activities out into these rural communities so we can get stage migration to an earlier stage of cancer. Still take care of the people who develop positive screens and downstream disease, obviously, but it'd be nice to start getting stage migration to the left, meaning to earlier stages for patients.  What we really have out here is a lack of primary care doctors and stability of primary care doctors because it's a very difficult area to practice primary care with geography, very difficult area, with the payer mix and the socioeconomic status, and a difficult area for people to desire to live in when you're trying to practice primary care, not surrounded by every specialist. A rural primary care provider really has to be, in essence, a true solo practitioner in Appalachia. They have to have a broad skill set because they just don't have a cardiologist sitting next door or a neurosurgeon immediately available.  We have a full complement of surgical oncology specialists, radiation, three-dimensional stereotactic, clinical trials, genetic counseling, eight medical oncologists, a well-equipped ICU, and care. But our catchment area we serve is a geographic radius of two to two and a half hours, of which there's not much in between. There are some rural clinics, some community outposts, some critical access hospitals. And really creating that infrastructure of navigation has been the key success in our area of trying to navigate a patient through the system and trying to support these single clinics or smaller critical access hospitals from afar, support them intellectually with cognitive capabilities over the telephone to help work a consult up and trying to navigate the patient in.  But again, the physical or the geographic, or distance barriers are real, and the socioeconomic barriers are real. Even once we can make a link with the primary care doctor and be more than willing to see the patient, sometimes just physically getting them to us can be a challenge. Dr. Thierry Alcindor: So what is the Appalachian Community Cancer Alliance doing to improve cancer screening, cancer care outcomes in the region? Dr. Richard Ingram: Excellent question. So the Appalachian Community Cancer Alliance started organically. So myself, as president of Virginia, got together with other state presidents, West Virginia, Tennessee, South Carolina, North Carolina, Kentucky, and said, “Gosh, what could we do collectively? Or what are our collective issues and problems?” Because we kind of serve a similar population and geography. And out of that was born kind of a homebrewed alliance, which formalizes the Appalachian Community Cancer Alliance.  And I want to kind of just start with a quick story, and then I'll explain where we launched. I had a patient that really resonates with me personally. So it was a patient I met in the emergency room, happened to actually be kind of mid-pandemic. I was on call, very nice patient, presented with severe dyspnea orthopnea platypnea, came to the ER, had a large pleural effusion lung mass, medial spinal mass, worked them up, ended up being metastatic non-small cell lung cancer stage IV. Got them plugged into treatment and took care of them.  And then when I had a moment, I went back through their files as we usually do when we're taking a history and I had noticed that they had had a low-dose chest CT several years earlier at a community center out in their rural area of West Virginia. And I asked the patient about it and he kind of recalled getting the CAT scan. But bottom line, the area had set up a screening program but had not set up an actual mechanism or a flow of navigation. And/or if they had, the patient was unaware. So basically, the patient dutifully went through a screening program. There was the pandemic, there was a turnover of staff and it wasn't the patient was forgotten, but the patient never got navigated to work things up. And lo and behold, that positive low-dose CT screen turned into stage four cancer years later.  So I wanted to focus on cancers we could make an intervention with in Appalachia and what was formed was called the Lung Cancer Screening Task Force. That was our first successful endeavor of the alliance. So this task force was formed after about a year and a half or so of work of the states I mentioned. It has become its own task force that reports to the alliance and we're very proud of it because it has been recognized in President Biden and Jill Biden's Moonshot Initiative for Cancer. It's actually obtained funding and we've worked backward to work on a navigation program as well as screening in the most underserved and lowest-screened areas in Appalachia. Dr. Thierry Alcindor: Well, that sounds exciting. Like, I feel that there is a nice infrastructure as well as projects coming along and I'm quite eager to hear from Dr. Al Sukhun whose practice is based in Jordan.  Dr. Alsukhun, in 2022 you gave a presentation where you highlighted how low-income countries had experienced greater increases in breast cancer incidence and mortality compared to high-income countries in the last decade. What challenges are patients and doctors facing and what should be prioritized? Dr. Sana Al Sukhun: Interesting question. First, thank you so much for inviting me to take part in this very interesting discussion. Pleasure to join, listen, learn, and reflect. Indeed, I've enjoyed listening to Dr. Ingram very much. He was speaking about his area and indeed discussing most of the issues, believe it or not, we face in different parts of the world referred to as countries with limited resources. When you refer to limited resource environments or countries, you're really referring to two different types of limited resources: very low-income countries or middle-income countries. The challenges are a bit different. The first challenge we generally face is access to the application of knowledge. For example, in Jordan, we have access to the knowledge. We have excellent infrastructures, we have an excellent health workforce. The problem is the application of the knowledge, application of what we have learned to help our patients. However, the challenge in different limited resources goes across the theme of a multidisciplinary approach. It starts from prevention, early detection, where, as you mentioned, we are facing a significant increase in the number of cases diagnosed with breast cancer. The proportion of patients diagnosed with breast cancer in countries of limited resources is 62% of the worldwide new cancer cases. Why do we have such a significant increase in the number of cases? Most countries undergoing what's called socioeconomic transition, they are facing increasing risk factors to develop breast cancer. One of those which is significant not only when it comes to breast cancer but to most kinds of cancers is indeed a significant increase in the proportion of the population suffering from obesity. The highest absolute increase in the prevalence of obesity worldwide over the past couple of decades has been seen in the Middle East, Central Asia and North America. That by itself is a significant risk factor for the development of breast cancer and other long lists of cancers.  In addition, of course, to smoking. For example, last year, unfortunately, and I'm not proud to say Jordan ranked among the highest in terms of smoking prevalence among men in the region. So these two important risk factors, in addition to the westernization of lifestyle, less physical activity, you know, all these risk factors, most important is awareness that these risk factors are important in terms of attributing to cancer. This is not common knowledge across all countries. We do not have enough campaigns across all countries to emphasize the importance of prevention. Then comes early detection. When it comes to early detection, you know, the challenge is not homogeneous. For example, in Jordan, a couple of decades back, most cases with breast cancer were diagnosed at an advanced stage. Barely one-quarter to one-third of cases were diagnosed at stages I to II. Right now, almost 60% of the cases diagnosed annually are really stage I or II early breast cancer. Thanks to the campaigns from government, non government organizations, NGOs, college society, all people are working together to emphasize the importance of prevention and early detection. That was quite successful in Jordan, and as you can see here almost two-thirds of cases are diagnosed early. However, contrast that with neighboring countries. I'm referring to Iraq, Sudan, Yemen, and if you notice I'm mentioning countries with conflict. Those countries not only suffer from limited resources but also instability. And when Richard was referring to the access transportation challenge, indeed, we in Jordan treat so many of the patients diagnosed with cancer coming to Jordan seeking treatment from Iraq, from Yemen, from Sudan, that by itself is a challenge. And at the same time, it reflects the status they suffer from, they suffer from lack of health workforce, lack of enough oncologists. Very few, if any, oncologists are available there. And not only you're referring to oncologists, you need pathologists, enough well-trained pathologists, surgeons, radiation oncology service. Those are quite limited when it comes to many of the surrounding countries and many countries actually with limited resources.  For example, in Africa, same challenges, the multidisciplinary approach that's quite vital for the proper treatment of patients with cancer is indeed also lacking in many countries. The infrastructure takes not only having hospitals but also a multidisciplinary workforce. Then when it comes to treatment, you are faced by a common belief across many cultures that a diagnosis of cancer is equated to a death sentence. Very few, if any, believe that they can be treated from cancer or at least live with cancer in some situations. With breast cancer, patients with metastatic breast cancer deserve to be treated and can survive for years with excellent quality of life as well, still contributing to their society. Especially more than 50% of patients in countries of limited resources when diagnosed with breast cancer, they are younger than age 55, which is ten years younger than patients diagnosed in countries of high income. So they are still in the prime time of their life. They are needed by their family, their society. That's a huge actual economic impact on society and not only on the family. So these are issues to be tackled, to be emphasized across societies so that they can seek treatment when they have access to it. Dr. Thierry Alcindor: Can you tell us about access to cancer medicine, whether chemotherapy, targeted therapy, or immunotherapy? Dr. Sana Al Sukhun: We are living in a fantastic area where precision medicine has really revolutionized our approach to the treatment of many tumors. But at the same time, while we are talking about equity, improving access, it created another challenge and it created, unfortunately, disparity and made equity even more difficult.  Right now, we do have, there is a huge difference between access, availability, and affordability. Most of these new medications, whether basic chemotherapeutics or recently approved targeted therapeutics or immunotherapy are available, but the problem is they are not affordable. Some of them are available in certain institutions, while in the same country, other institutions, if the patient's insurance happens to be in another institution, they cannot access it. So even within the same country, across different institutions, so many of the recently approved targeted therapeutics or immunotherapeutics are not offered. So equity is lacking even within the same country, in many countries with limited resources.  Sometimes the irony is you will have the very highly-priced medications while out of the blue you are faced with the challenge of shortage of basic therapeutics, platinums, for example. And I learned from colleagues, the states suffered from a similar shortage the last few weeks. And you can imagine not being able to access platinum to treat your patients can make a huge difference and impact. Even if you have immunotherapy, you don't have it. That's ironic.  And another challenge, most patients with the availability of social media and Google, thanks to Dr. Google, you check Dr. Google, and the first option you get is very pricey options, immunotherapy, targeted therapy. So the patient comes to you and he's getting the recommendation of having basic chemotherapy, sometimes because the indication is chemotherapy, sometimes because they cannot afford- you offer them the higher price medications, but they cannot afford it still. You still advise chemotherapy because it does work, but the patients are under the belief that if they do not take the very pricey medication, they are doomed and they cannot be treated. So they put treatment off altogether.  These are conflicting concepts. They need awareness campaigns, they need explanation. Social media needs to do a better job improving what it markets. It usually markets the very pricey medications as life-saving, while talking about chemotherapy as something that really hurts patients, while in reality, sometimes this is all we have and it does make a difference.  Another challenge we face, our region, for example, it's a conflict region with so many refugees. To give you a very simple example, I had a patient coming from a Syrian camp, hemoptysis, worked her out, and it looks like lung cancer, and I managed - she cannot afford any kind of treatment - but I managed with the hospital to get the CT scan free. We got the biopsy, and the good news is that companies, pharmaceuticals can and do help. They offered to test the biopsy for EGFR, and it turned out to be positive. Of course, we have no access to EGFR-targeted therapy. So what can we do? Indeed, that patient, we offered her platinum, but at that time we didn't have platinum. Within a couple of months, she presented with a very advanced-stage disease. And unfortunately, we lost her before we could start treatment because platinum was not available. Not only EGFR inhibitors, but we're talking about the simple things. Basic chemotherapeutics are important, those we need to emphasize availability. We keep talking about cutting-edge therapeutics. They're very fascinating to use, to treat, they made a huge difference, but still, our old friend, basic chemotherapy can and does make a difference, something we need to talk about more and more.  Dr. Thierry Alcindor: I agree with you, and that's true of even high-resource countries. I mean, cytotoxic chemotherapy remains the backbone of treatment for many cancers, even in 2023.  But I'd like to ask you a question following up on what you just described so well regarding availability, access. Do you have research infrastructure that would allow you, like for example, they have done in India at Tata Memorial Hospital, to conduct research with lower doses of those expensive agents? I think that this is quite a promising direction for low-resource countries. What do you think?  Dr. Sana Al Sukhun: You touched on a very dear subject to my heart, actually. Right now we're working with ASCO discussing a policy, discussing clinical trials in limited resource environments. Indeed, this is one of the very important aspects that can improve truly access to medications and contribute to the knowledge worldwide. Unfortunately, there are so many barriers.  A short answer to your question is very few centers, if any, in the region do have infrastructure that can facilitate enrollment in phase three randomized trials. Investigator-initiated trials, particularly like the ones you're alluding to, more or less similar to the FinHer trial when we learned that short courses of trastuzumab six months versus twelve months can be reasonable for patients with a limited number of risk factors. Such trials, unfortunately, so far the infrastructure does not allow having such investigator-initiated trials. Not only the infrastructure, pharma needs to be more open for the support of such trials in these environments. Most governments in the region are still struggling with the concept of having human subjects enrolled in clinical trials. That needs awareness, not only at the level of the society or the patients or the physicians, by the way, who also, we struggle because we do not have protected time or appreciation. Dr. Thierry Alcindor: So you're talking with such passion about those challenges, and I feel that there is quite a lot of effort that you're putting in. So maybe you can tell us about the improvements that you have noted. Dr. Sana Al Sukhun: It's interesting when you look over the past couple of decades how things have moved. Particularly in Jordan, having a cancer center, the first comprehensive cancer center in the region, really set a good example for Jordan itself where other institutions improved to try and compete, improve their services similar to what King Hussein Cancer Center currently has. Also, they managed to have an infrastructure for clinical trials. And as I mentioned, they do have some of the phase III clinical trials already running, participating in large multinational clinical trials. That's a huge improvement, a huge step. Still, investigator-initiated clinical trials is something we are working with the government to support and start and encourage. Our screening program really succeeded and we are more or less similar to high-income countries when it comes to the rate of early detection. Still, we are working on improvement. We don't have a national screening problem. We have a national awareness campaign problem.  Dr. Thierry Alcindor: Okay, so that's a lot of success.  Dr. Sana Al Sukhun: That's huge success. Not only that, in October, now you come to Jordan. It's not only one government-run program. You see all clinics offering mammography services, either free or 50% off for patients across the kingdom. That actually did reflect positively on neighboring countries. Egypt, for example, right now started the last couple of years a similar national awareness downstaging program with excellent numbers of cases caught up early. The region is really improving - I'm talking about our region in the Middle East - if it were not for the conflicts. That's not the case when it comes to, unfortunately, countries with conflict, we all struggle. Jordan, Lebanon, even Syria, we all struggle with the refugee problem. Still, the refugees do not have enough funding, but a lot of NGOs are trying to help them. Along with what Richard described, you find many NGOs, they start themselves to help with access, to help with transportation, to help with medical fees for early detection. I believe we are moving far ahead when it comes to cancer, in particular over the past decade or so, as compared to many other diseases. Still, I believe we need contribution or cooperation between all stakeholders. That's what we still need. Dr. Thierry Alcindor: Okay, excellent. So I have a couple of questions that I would like to address to the two of you. Which barrier do you feel is the most difficult to solve when providing cancer care in low-resource settings? Is that the infrastructure? Is that the personnel who has not been properly trained? Equipment? Which would it be? Dr. Richard Ingram: Yeah. I appreciate it. And I really have been reflecting on Dr. Al Sukhun's heartfelt passion and comments. And thank you for sharing that, Sana. I think that's something we all need to be aware of. And a compliment to you and your team for being so inclusive in that region. I mean, cancer is a difficult enough diagnosis, but yet alone in a conflict zone, I can only applaud and empathize with you and a sincere tip of the cap to you and your team. That's incredible work. Dr. Sana Al Sukhun: Thank you. Dr. Richard Ingram: In general, you have to change the culture. You have to build trust in the process, the medical process, because that medical system may have let patients, family members, or neighbors down previously. So, I think building trust around screening and building trust around that there is an infrastructure that's going to take care of you if you have a positive screen.  I have several patients, but one comes to mind a very complicated trimodality disease, esophageal cancer. But the long and the short of it is, the patient presented to a rural outside emergency room with obstructive symptoms. The emergency room doctor was savvy enough to have some resources in their area but stabilize the patient. The test they could get; they could just get really kind of a barium swallow at the facility, saw there was a problem, but then called an oncology nurse navigator program that we've instituted in our region to cover this wide footprint. The nurse navigator was able to basically navigate this patient very successfully into a GI endoscopy program, which then got them in the cancer program and worked hand in hand with a social worker arm that we've instituted also to help assist the nurse navigation program. So the social worker was able to work on food insecurity, getting the patient actually applied for and got them Medicaid and got them transportation, barriers lifted.  So, it was a very successful anecdote compared to my unsuccessful anecdote earlier around lung cancer. So, to me, it's an example of a playbook that the Appalachian Community Cancer Alliance is trying to develop. So, maybe we can aggregate best practices in some way, shape, or form as the alliance and get those across the world, get those to Dr. Al Sukhun and the King Hussein Center in Jordan, and get it to wherever we need to in the world to help patients because the patient's problems are not unique to Appalachia. They're just unique to under-resourced and geographically spread out areas. Dr. Sana Al Sukhun: Absolutely. Dr. Thierry Alcindor: Yeah. That's well explained. Dr. Thierry Alcindor: Sana, which barrier would you say is the most difficult one for you?  Dr. Sana Al Sukhun: We all get involved and cancer is an emotional diagnosis. It's completely different from all other diagnoses. No matter what, all illnesses are challenging, but the word 'cancer', nobody can deny it. It still carries a lot within those few letters. So, good infrastructure, not only in terms of building - this is very important - it's also a multidisciplinary team within that infrastructure.  The other day, a patient came to the emergency room of the hospital across the street from where I practice. He was 25 years old, healthy, just some fatigue lately, and he collapsed. Actually, they found him pancytopenic. So, looking at the blood film, long story short, was highly suspicious for acute leukemia. The patient cannot afford admission to a private hospital, but he had insurance in the Royal Medical Services. In Jordan, we have different kinds of insurance depending on which section you belong to. It's more like the VA in the States. I talk to my colleague over there, tell them high suspicion for leukemia and he's like, "Send him right away." He was admitted simply because he had coverage; he had insurance. They do have also a good cancer center there. So, they had him admitted, had his bone biopsy done, diagnosed, and started treatment. That is an excellent example of how a good infrastructure, when available with good access to that infrastructure - so it's infrastructure and good access to that infrastructure - can make a huge difference.  Dr. Thierry Alcindor: That's right. So, the two of you have offered plenty of potential solutions, which is, in fact, to a certain extent, the point of this podcast. But if you had to state what would be your first step, which one would it be? Rich? Dr. Richard Ingram: I think if I could not pick one thing but a collection of things, it really would be, top of mind, would be just an awareness that we have gaps in our infrastructure. Cancer care and navigation, even in the most resourced areas of probably the most resourced country in the world here in the United States, yet alone in some of our under-resourced portions of the United States. So you can only imagine in an underserved or under-resourced other part of the world. So I think awareness of the issues, awareness that we need to create a somewhat seamless infrastructure throughout the entire continuum from the screening of cancer to diagnostic studies to therapeutic studies to survivorship to palliative care and counseling. And then along the way layer in clinical research, which is the only way we're going to move the needle, and services such as genetic counseling along the way. So I would say awareness of the issues and then starting with the key stakeholders in your area, all coming around to the awareness of the issues, then you can start to build the infrastructure. And I think once you build the infrastructure, it will become easy to recruit and retain healthcare staff in a sound infrastructure - meaning I think that will get over the barrier of understaffing rural areas like Appalachia or other underserved areas in this country, in that if you have a great infrastructure, I think I know, as Sana alluded to, once you create this infrastructure, you as a provider want to practice there. You want to be part of something that has a great infrastructure because A) you're proud of the work done, B) the patient gets state-of-the-art comprehensive care, and C)  you're making a difference in your community. Patients aren't having to travel, patients are safe and have their arms around them with a program right in their backyard. Dr. Thierry Alcindor: Excellent. Sana, what would be your first step? Dr. Sana Al Sukhun: Thank you, Thierry, and thank you, Richard. You know Richard, every time you speak, you speak my mind. It just speaks for how much we are alike across the globe rather than we are different. We share the same challenges, we share similar barriers, and indeed solutions are more or less similar. After all, we're all human. If I were to think of one important thing, it's awareness. Awareness campaigns targeting the society, discussing the importance of early detection, prevention, and treatment. Awareness campaigns targeting all stakeholders, policymakers, number one, emphasizing the importance of infrastructure to be supported, to be environment-attractive for a good workforce to work together, build it forward, treat patients in a safe environment. Also targeting industry to collaborate with other NGOs in the society to support that infrastructure and empower it to start clinical trials for each community. Not only targeting the community needs but also the way you describe it, Thierry, using the new therapeutics in a society-adapted approach to improve access to treatment. Those infrastructures, once empowered and doesn't have to be one, once empowered, they can be infectious. They can contribute to elevating the medical care in different settings in each society. So, one good infrastructure can set the example for other institutions to improve their care and collaborate as well. So, it's awareness campaigns putting all key stakeholders together including the society. Dr. Thierry Alcindor: Okay. Well, I think we had a very insightful and lively discussion so I would like to thank both Dr. Sana Al Sukhun and Dr. Richard Ingram for having joined us for a discussion about practicing oncology in low-resource settings. And for the audience to know, the ASCO Education podcast is where we explore topics ranging from implementing new cancer treatments and improving patient care to oncologist well-being and professional development. If you have an idea for a topic or a guest you'd like to see on the ASCO Education podcast, please email us at education@asco.org and to stay up to date with the latest episodes and explore other educational content, please visit education.asco.org. Many thanks again. A pleasure to talk with you. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions.  Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.  

People who live in major cities in the US and abroad tend to benefit from better cancer care due to having access to more doctors, facilities and equipment. In contrast, those who live in rural areas face many challenges accessing consistent and quality care.  In Part Two of this ASCO Education Podcast Dr. Jack Hensold, a hematologist/oncologist in Bozeman, Montana and Chair of the ASCO Rural Cancer Care Task Force, Dr. Chris Prakash, Medical Oncologist in Paris, Texas and Medical Director of Texas Oncology and President of the Texas Society of Clinical Oncology, and Professor Sabe Sabesan, a Medical Oncologist in Townsville, Australia and the President-Elect of the Clinical Oncology Society of Australia will examine the realities of practicing oncology in rural areas.  They will discuss the need for rural populations to access clinical trials (1:42), using telemedicine for chemotherapy and clinical trials (3:00) and using political advocacy to improve cancer care in rural areas (13:00). Speaker Disclosures Sabe Sabesan: Speakers Bureau - Merck Sucharu Prakash: Speakers Bureau - Myriad Genetics   Jack Hensold:  Consulting or Advisory Role Company - Vibliome Therapeutics Resources Policy Recommendations for Improving Rural Cancer Services in the United States                                If you liked this episode, please follow the show. To explore other educational content, including courses, visit education.asco.org. Contact us at education@asco.org. TRANSCRIPT Disclosures for this podcast are listed on the podcast page.  Dr. Jack Hensold:  Hello and welcome to this two-part episode of the ASCO Education podcast. Today we will explore some real-time and real-world issues that oncologists face while practicing in rural areas in the US and abroad. I'm Dr. Jack Hensold, a Methodologist Oncologist in Bozeman, Montana, and chair of the ASCO Rural Cancer Care Task Force. I also serve as Medical Director of Regional Outreach at Bozeman Health. Joining me is Dr. Chris Prakash, an Oncologist and Medical Director of Texas Oncology and the President of the Texas Society of Clinical Oncology. Chris is also the Director of Quality Services for the statewide group and leads Texas Oncologist Precision Medicine Initiative.  Also joining me is Professor Sabe Sabesan, a Medical Oncologist in Regional, Australia. He's the President-elect of the Clinical Oncology Society of Australia and the Clinical Director of the Australian Teledyne Health Program, led by the Queensland State Department of Health. Professor Sabazin is an internationally recognized expert in the area of teleoncology and has developed and evaluated various oncology models to deliver cancer care closer to home.  In part one, our guests were explaining what got them into rural practice and the issues they face in patient transportation, telehealth, getting access to the latest information on treatments, and connecting with other colleagues to get insight on patient cases. Here, I ask Dr. Prakash about one issue that does not get talked about very often. Dr. Chris Prakash: I think we don't talk enough about access to clinical trials for rural populations. And that's a hard problem. These are regulated. But I wonder about real-world trials. Those are a little easier to do. Maybe we can put more patients on those, the hub-and-spoke model, that would be helpful in that. And I know people are trying and many societies are trying to enroll more rural populations in trials, but it continues to be a challenge. Dr. Jack Hensold: Correct. And actually, ASCO has a workforce right now that's trying to address this problem. That includes patient representatives, as well as, I think, people from National Cancer Institute and people from the pharmaceutical industry who've been on that task force and really is trying to address what are the barriers that keep us from getting trials out to our patients in rural areas because it is identified as a real problem. I think, as we all know, excellent cancer care requires access to clinical trials, and limited access means quality of care is going to be less.  Dr. Sabesan, you've been working on improving chemotherapy access in rural parts of Australia. Do you think your programs like tele-chemotherapy could be implemented in other regions and even in this country, the United States, and can they be applied to clinical trials and teletrials essentially? Dr. Sabe Sabesan: This is where I get really excited because the use of telemedicine, beyond providing consultations and then using it for chemotherapy and clinical trials, actually that's what keeps me up in the morning and keeps me awake at night as well. What I see these things as they are system solutions for a chronic problem. In tele-chemotherapy, it's simple, really. It's rural nurses. They are not chemotherapy nurses, they are general nurses. They administer selected chemotherapy regimens under the direct supervision of doctors, nurses, and pharmacies from larger centers through telemedicine, tele-nursing, and tele-pharmacy. So all we need for tele-chemotherapy to happen, if you have a larger center willing to supervise a smaller center or a larger center is now expected to do that through Health System directives, then I think we can implement that throughout the system.  And what we have done in Queensland, we got the Queensland State Government to implement that because we got a governance document called “Queensland Remote Chemotherapy Supervision Model and Guide for Implementation.” Basically, that articulates how to set up these services safely. But we already published that in the Journal of Oncology Practice in 2018, so that was a rewarding experience. But then what we found, we could do immunotherapy infusions, toxic chemotherapy like that and all those things in smaller centers, but we couldn't do clinical trials because, as Chris said, it's highly regulated. So then we said, “How come you can do toxic intensive chemotherapy but not clinical trials?” So that's how the Australasian teletrial model was born.  So we thought we will use the teletrial model to connect larger centers with smaller centers to create trial clusters so that you can really distribute the clinical trials activity to the regional, rural, and remote areas. So now we have an Australian teletrial model and a national teletrial principle as a government policy to enable that. Through some pilots we published in the Journal of Telemedicine & Telecare, the Australian government actually funded $125 million to transform the Australian clinical trial sector as a network and a national system, so that patients from regional, remote, and rural areas can access clinical trials, some or all aspects of clinical trials closer to home. So that is exciting because it's about one year into the program and already we could see the narrative is changing, and we are saying clinical trials need to be offered as networks, not as silos anymore, because of social justice and equity. So that's been becoming powerful.  And also, we've been now pushing the Ethics Committee to mandate that clinical trials need to be done as clusters because it is an ethical social justice issue. So I think if you have good governance and government support, I feel that we can actually implement these models in larger parts of the rural sector. Not all of them, but in larger parts. But I just wanted to highlight before I finish that the decentralized trials becoming popular and I feel like the decentralized trials are kind of hijacking the rural narrative here because they are not decentralized trials in my observation, they should be decentralized trial systems. And rather than bypassing hospitals and directly dealing with patients at home, in a lot of the trials, it seems that most of those patients are actually metropolitan patients. And I think any decentralized trial systems have to focus on partnerships with rural sectors, capability or capacity building of rural sectors so that you could really deliver clinical trials in a distributed network system to really fix this problem once and for all. Dr. Jack Hensold: Sabe, it sounds like there's much that we can learn from paying attention to what's going on in Australia. It seems like your group is well ahead of the curve in terms of what needs to happen in rural areas. Chris, comments about that as well? Dr. Chris Prakash: Yeah, I was going to say, I think excellent job, Sabe. Kudos to you for doing this in Australia. It's a clinical dilemma. It's an ethical dilemma. Sometimes clinical trials are fundamental to providing good quality care for our patients. But the American healthcare system is complex. Clinical trials, sad to say, I mean, that they're money makers for a lot of big institutions or pharmaceutical companies for sure. So what these companies are looking for is if they have a new drug, they want to get a trial done as quickly as possible, get positive data, and then get it approved. It's really hard to find a good phase III, randomized, placebo-controlled trial anymore. They're just nonexistent. They're all phase I, II, quick one year, get the data, and file for approval with the FDA. So I get your point. I think I would love to have a good trial where we can put patients on, rural patients on, but I don't know if that's going to be possible.  Now, what I'm doing in Texas Oncology, I'm the director of Quality Services, so that is my goal; is to give quality care to the whole state population wherever we can. And clinical trials is the most difficult task, I'm finding. I can make testing consistent, I can make treatment protocols consistent, but getting patients on clinical trials is a very difficult task. So, kudos to you, Sabe. You're doing an excellent job. Dr. Jack Hensold: It's actually the main enabler for us is actually the government intervention, because what we felt was the rural sector has been left in the hands of clinicians and local health managers for far too long, but no one was in charge of that gap. So now, by the governments coming to the party and trying to implement some policies and funding mechanisms, things are changing. But really still, I found the advocacy hasn't stopped and there's still a long way to go, even in Australia, but it's pure advocacy from rural oncologists like us. Dr. Chris Prakash: Yeah, I think that kind of highlights the difference in American and Australian healthcare systems probably. I know the American healthcare system is still very private. I mean, we have a big Medicare part of the equation, but again, a lot of health care is really delivered by private companies, hospital systems that are for profit, pharmaceutical companies really have strong lobbying systems. So it's a complex situation here. Dr. Jack Hensold: Yeah, I would agree with that fully in that, when I was hearing Sabe talk about things and comparing it to our experience in this country, we are very fragmented in terms of our care delivery systems, and trying to get a coordinated approach to how we address this rural health problem is difficult because we're bringing so many different people to the table who all have different points of view in terms of how they look at this. So, again, this may be a much harder piece to try to achieve just simply because of the fragmentation of the way we provide care in this country.  So, Dr. Prakash, you're a member of several groups that address the needs for rural cancer care in the United States including ASCO's Rural Cancer Care Task Force, as well as the work you do with the Texas Oncology Society. Can you be a little bit more specific about those efforts?  Dr. Chris Prakash: Thanks, Jack. As you know, I was a member of the ASCO Task Force on Rural Cancer Care. This was put together in 2019, and then the pandemic happened. The timing was just right. But we were tasked with finding and really defining what the challenges of rural cancer care are and what are the solutions that we can come up with. It was a very hard job, but we did come up with some solutions on that, mainly increasing provider education, workforce enhancement. We have talked about a few of these things already - telehealth, promotion, and of course, research. But as you know, these solutions are easier said than done, and work continues on these fronts. And thank you, Jack, for taking the lead on many of these issues in the US.  So currently, as you know, I'm the President of the Texas Society of Clinical Oncology, and I'm doing a lot of advocacy work at the state capitol in Austin regarding various bills and provisions, but especially to garner support on a new biomarker bill. So this bill, if passed, will help pay for all biomarker testing in cancer. So there are disparities and rural disparities in cancer care. So if this bill is passed with the biomarker testing, this may go a long way in removing some of the disparities that our patients face in terms of testing biomarkers and payment for those tests as well. And I firmly believe that quality of care should be consistent no matter where a patient lives. I'm the Director of Quality Services for Texas Oncology. I'm leading the Precision Medicine initiative for the state, and I'm developing protocols for consistent biomarker testing, mutational analysis, and tumors and treatment protocols. So efforts continue, and please stay tuned. Dr. Jack Hensold: Thank you for that and all the work you do, Chris. I think it's an important point, and I've been involved through the Montana State Oncology Society, which is our society in terms of doing advocacy at the state level as well. And I think that's very important, particularly for states that have large rural populations, because I'm not sure nationally, people fully understand some of the difficulties that those patients face. And advocating for improved health care across the board is critical. And the rural patient needs to be considered. As we think about any changes to how we invest in healthcare in this country, the laws are regulated. Dr. Chris Prakash: You're exactly right. I mean, advocacy is very, very important. And our Congressmen and representatives, they do listen. As a physician, you go and talk to them and express concerns about what the constituents are going through and the hurdles they're facing in their care. They will listen and you can make a change. And that's what fascinates me about practicing in a rural setting, is that I can make a difference. I can see a change. Just over the last 20 years that I've been here, things have changed. Not all for the better, but you can be a part of the whole process. Dr. Jack Hensold: Yes, I would completely concur. I think our legislators nationally and statewide are very responsive to our voices. If there's something that's impacting their constituents in terms of the care that they're receiving, they're going to want to know about that. And they're happy to look like the champions, I think, to support improving their care. It's something we all can do a better job at nationally. Sabe, not to leave you out of that conversation, any thoughts about that? Dr. Sabe Sabesan: I mean, the advocacy is the key. That is also one of our jobs as doctors. But the main thing about advocacy is actually self-care, I found. As long as we don't burn out and we keep our energy level going and focus on recharging and minimizing energy discharge, we stay strong and take our colleagues with us. I think that's what I learned in advocacy is to make sure we don't drain our energy in that process. Dr. Jack Hensold: The quality of care should be the same for every patient, no matter where they live. And that really is kind of one of the driving principles for me in terms of why I got into this rural cancer care task force and the initiatives that we're taking on. And I'd like to describe a project right now that I've undertaken with ASCO and with our local regional health center and a medium-sized hospital in our area. Actually not in our area, it's 125 miles away, but an area that we service, and patients regularly come to our regional center for their cancer care, I think, was the appreciation that this 250-mile round trip, particularly to receive things like chemotherapy, was just a tremendous burden for patients from that area.  And in addition to the problems with the financial aspects of traveling long distances to receive that care, there was also the issue that we were sending patients back to fairly distant sites to experience the toxicities associated with our treatments without sufficient support in those sites locally in terms of understanding what needed to be done. That really led to this initiative with ASCO and Barrett Health in Montana, as well as Bozeman Health. And we've now been funded as part of a multi-year pilot program to increase high-quality and equitable cancer care at this site in rural Montana. And the work in this area was based on, again, the prior work on the task force that Dr. Prakash talked about in terms of identifying what barriers were in place to getting care to patients in their own community and how we could overcome these barriers.  And really, the concept of this program is to enable patients to receive care in their own community through what's described as a hub-and-spoke care delivery model. This is an established method for extending access to cancer care in remote rural areas. In fact, I think, as Dr. Sabesan talked about, I think much of the published work in this area has actually come out of Australia. So again, kudos again to that health system in terms of taking the initiative on these things.  And the initiative that we were talking about aims again to keep patients in their own community for as much of their cancer care as feasible, not to rely on that long drive to our regional site to get care. We understand this will require education and training of primary care physicians, advanced practice providers, pharmacists, and nurses at what we would refer to as the spoke site. And specifically, this needs to focus on education regarding how to properly administer infusion services and also how do we provide adequate supportive care for the cancer patients.  We do appreciate that those providers at that distant site, we can never really expect them to have full knowledge to appreciate what treatment cancer patients will need at any given point in time. But that really is where the expertise of the oncologist comes in. And oversight from the hub site will be provided by oncologists both by telehealth and supplemented, by regularly scheduled onsite visits by the oncologist to ensure just a seamless integration of care at both the hub and the spoke site and also to ensure the shared culture of cancer care between those two sites.  So that is the intent of the pilot that we're setting up. As we achieve function of that site, we will be doing quality measures to ensure that the care that's being administered at the spoke is really equivalent to what they would be receiving at the hub. So hopefully this will become a model for how we can deliver care to more remote rural areas in this country. I'd like to give Dr. Sabesan and Dr. Prakash an opportunity to make further comments regarding that model and any suggestions they may have; I'm willing to take in terms of how we can achieve this end. Dr. Chris Prakash: Yeah. Thank you, Jack. And again, kudos to you for being so passionate about taking care of patients in rural areas with their cancer care. But I think you highlighted the most important thing: we've got to be passionate, we've got to care, we have to do everything possible, find solutions. There are many challenges in this realm. So the hub-and-spoke model, that's very helpful, but again, we may need more multi-hub models or regional hubs, so to say on that. Education, keep developing the workforce, retain the workforce that we have, provide access to research, promote telehealth as much as possible. I think these are all pieces to the puzzle. Keep doing advocacy and just work and hopefully not get burnt out. So yeah, it's a work in progress, but again, that's why I'm doing this because I'm passionate about this, and thank you so much for having me as a part of this conversation. Dr. Jack Hensold: Well, thank you for participating. Sabe, any comments? Dr. Sabe Sabesan: Yeah, thank you. I really enjoyed being part of this conversation and I think it looks like it's almost good to have a community of international rural practice like this so that we can share and implement within our sector. And I'm really looking forward to seeing how your pilot project evolves, Jack, and how that can become a model for the whole of the country. Good luck to you. Dr. Jack Hensold: Thank you very much for that. And again, just a comment about the international working on this. We do have someone from Romania on our current task force. There's a group there that's very interested in providing kind of hub-and-spoke model care. So these are topics that I think are really getting on everyone's radar internationally. Again, I think the more buy-in we get internationally as well as nationally, the more wind we will have at our backs in making some improvements in this. Thank you, Dr. Prakash, for your insight into this topic and also to Professor Sabesan for his perspective from his practice in Australia. I'm Dr. Hensold and I would like to thank all of our listeners of Cancer Topics and ASCO Education Podcast. This is where we explore topics ranging from implementing new cancer treatments and improving patient care to oncologist well-being and professional development. If you have an idea for a topic or a guest you'd like to hear on the show, please email us at education@asco.org. To stay up to date with the latest episodes and explore other educational content, visit education.asco.org.  The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions.   Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.      

People who live in major cities in the US and abroad tend to benefit from better cancer care due to having access to more doctors, facilities and equipment. In contrast, those who live in rural areas face many challenges accessing consistent and quality care.  In Part One of this ASCO Education Podcast Dr. Jack Hensold, a hematologist/oncologist in Bozeman, Montana and Chair of the ASCO Rural Cancer Care Task Force, Dr. Chris Prakash, Medical Oncologist in Paris, Texas and Medical Director of Texas Oncology and President of the Texas Society of Clinical Oncology, and Professor Sabe Sabesan, a Medical Oncologist in Townsville, Australia and the President-Elect of the Clinical Oncology Society of Australia will examine the realties practicing oncology in rural areas.  They discuss the difficulties of having to travel long distances for treatment (5:30), the effectiveness of telehealth (8:07) and solutions to recruiting a supportive care workforce in rural areas  and facilitating access to imaging facilities and specialized treatment (18:12). Speaker Disclosures Sabe Sabesan: Speakers Bureau - Merck Sucharu Prakash: Speakers Bureau - Myriad Genetics   Jack Hensold:  Consulting or Advisory Role Company - Vibliome Therapeutics Resources  Policy Recommendations for Improving Rural Cancer Services in the United States  If you liked this episode, please follow the show. To explore other educational content, including courses, visit education.asco.org. Contact us at education@asco.org. TRANSCRIPT Disclosures for this podcast are listed on the podcast page.  Dr. Jack Hensold: Hello and welcome to this two-part episode of the ASCO Education Podcast. Today we will explore some real-time and real-world issues that oncologists face while practicing in rural areas in the US and abroad. Cities tend to benefit from having more doctors, facilities, and equipment to address the health needs of the population. In contrast, people who live in rural areas – estimated to be about 25% of the US population – face various challenges to obtaining consistent health care, including scarce medical personnel and infrastructure. Transportation of that care may involve considerable time and financial expense.  I'm Dr. Jack Hensold, the Hematologist/Oncologist in Bozeman, Montana, and Chair of the ASCO Rural Cancer Care Task Force. I also serve as Medical Director of Regional Outreach at Bozeman Health. Joining me is Chris Prakash, Oncologist and Medical Director of Texas Oncology and President of the Texas Society of Clinical Oncology. Chris is also the Director of Quality Services for the statewide group and leads Texas Oncologist's Precision Medicine Initiative.  Also joining me is Professor Sabe Sabesan, a Medical Oncologist in regional Australia. He is the President-Elect of the Clinical Oncology Society of Australia and Clinical Director of the Australian Teledyne Health Program, led by the Queensland State Department of Health. Professor Sabesan is an internationally recognized expert in the area of tele-oncology. He has developed and evaluated various oncology models to deliver cancer care closer to home.  Providing healthcare is a very involved career, more so in rural areas. Dr. Prakash, you finished your oncology training in Detroit, yet you practice primarily in rural Texas. Can you detail the factors that led to your decision in practicing oncology in a rural setting?  Dr. Chris Prakash: Thank you, Jack, for having me as part of this podcast. I finished my fellowship at Wayne State in Detroit, Michigan, and we were looking for a place to raise our kids and family and to find a good practice for myself. My daughter was two years old at that time. We were looking for a quiet, safe place with a laidback lifestyle, but at the same time a dynamic oncology practice. That's how I found East Texas, which is primarily a rural area. The small community here, good schools, and nice, accepting people really appealed to us. So we decided to give it a chance. We are still here almost 23 years later. My daughter has grown up and is in medical school. My son, who was born in Paris, Texas, is planning to go to med school next year.  Over the last couple of decades, I've found that practicing oncology in a rural setting is indeed very rewarding. You can make a difference in people's lives here. People are simple. They have faith and respect and follow doctors' advice. Practicing here, I've had a real chance to make a difference in not only people's lives but also in the overall healthcare system and in health policy. As you know, Jack, about 18% to 20% of the population lives in rural areas in the US. But only 3% of oncologists are available to provide care for them. So I'm not only fulfilling a need but also satisfying a desire to contribute.  Dr. Jack Hensold: Chris, could you clarify the nature of your practice? Are you a solo oncologist within a much larger group spread out over the state, or is there more than one oncologist on your site? Dr. Chris Prakash: Yeah, so I'm part of Texas Oncology, which is a statewide large group with multiple sites of service. In my location, there are three medical oncologists and one radiation oncologist. So we serve the catchment area of Northeast Texas and Southeast Oklahoma. But within Texas Oncology, we have locations spread out all over the state. Dr. Jack Hensold: Thank you for that clarity. Professor Sabesan, you started in Sri Lanka and are now in a rural area of Australia. How did that happen?  Professor Sabe Sabesan: I grew up in northern Sri Lanka in a village but moved to Australia because of the war in Sri Lanka in ‘90. So I did my med school in Adelaide, Australia. During my med school, we had to do a lot of rural clinical placements. And also as a result of that, I did my internship in a central Australian town called Alice Springs. Throughout that journey, I saw firsthand the difficulties these communities face in accessing healthcare, basic healthcare. So when I finished my training in medical oncology, I was looking for a place where I could contribute to minimizing these difficulties, but also taking an academic angle to this. So I chose a regional center called Townsville in North Queensland as our home that actually serves a large rural and indigenous population, but also it is an academic hub for rural medicine. So it kind of served my clinical and academic needs, and we've been there last 20 years now. Dr. Jack Hensold: A significant hurdle for patients in rural areas is transportation. Patients sometimes travel an entire day or stay overnight near the clinic, where they will be examined or treated. What resources have been developed to assist with transportation to help patients come back for test results, appointments, and treatments? Chris?  Dr. Chris Prakash: Transportation, that's a big hurdle for many patients across the country, but mainly for the rural population. So, as I just said, my practice is in Paris, Texas, but the draw is about a quarter of a million. So patients come to see us here to receive their medical care from all over Northeast Texas as well as Southeast Oklahoma, and there is no public transportation in many of these areas. The average time to commute for many of my patients is in excess of an hour and a half each way. Patients do travel sometimes an entire day. They sometimes have to stay overnight to receive their treatments the next day.  I recall a patient with tonsillar cancer last year who was receiving concurrent chemotherapy and radiation. So he lived almost three hours away. This was too cost prohibitive for him to travel back and forth on a daily basis for radiation therapy. So what he did was set up his camper right behind the cancer center, which certainly made it a lot easier for him to get his treatments that way. I would not recommend that as a routine practice for everybody, but it did work out for him   Close by there is a community of Choctaw Indians here in Southeast Oklahoma also, and they do have some options for transportation for just their citizens. And locally, some local church groups and volunteer organizations provide assistance with transportation for some patients as well. But that is a problem. Transportation is a big access issue for my population. Dr. Jack Hensold: Thank you. And just to make a comment, there's actually a fair amount of literature regarding what we refer to as financial toxicity associated with the need to travel. Sabe, do you have some transportation problems in your area? I would assume… Professor Sabe Sabesan: This is similar to what Chris and you are describing, Jack. Our area is 2000 by 1000 kilometers with about 650,000 population. There are scattered rural hospitals, but really there's no consistent public transport. But the government does pay for transport and accommodation. I heard that it doesn't fully cover it. But one of the disappointing things is that if you're traveling for clinical trials, that subsidy is not there for them. So that's probably one of the reasons why the governments have gone for the telehealth investment.   Dr. Jack Hensold: Thank you. Telehealth is a critical tool for providing healthcare in many areas, including rural areas. How do you manage the health literacy problems of ethnically, educationally, and socioeconomically diverse populations using telehealth? Chris? Dr. Chris Prakash: Telehealth has been around for a long time, but during the pandemic, that's when we needed to keep our patients safe and away in their homes and still continue to give healthcare to them. So we conducted many visits through telemedicine at that time. Telehealth is especially used for many patients in rural areas because they have problems with access. But there are many challenges. As you know there is a broadband divide in the US. About 1 in 4 Americans do not have a good broadband connection so it is very difficult for them to perform a video telehealth visit. Audio works out okay a lot of times, but to do a good video telehealth visit, that's a difficulty.   Also, as you know, many of the flexibilities that we were afforded during the pandemic regarding telemedicine, they are slowly going away. So that's making telemedicine even more difficult to do. But telemedicine is a boon for many of the patients who live in rural areas. I remember just the other day I saw an elderly couple, the man had just been diagnosed with advanced lung cancer. In the room, he requested that his children join the conversation via FaceTime on his phone so that they can listen in to what I had to say and what I had to tell them. This was indeed very helpful for them. I was able to explain to the patient, his wife, as well as his children who joined via FaceTime about the diagnosis, which was new, the treatment plan, expectations moving forward, and all of that.   So even though this was not a true televisit, it really demonstrates how technology can help us deliver good communication and good oncology care in many situations. But still, I would say that for many patients, telemedicine is not ideal. It's especially true given the devastating diagnosis of cancer. Patients want to see their doctors face-to-face. As a doctor, I want to examine them. And also, body language is very important. It is important for my patients to trust me as a physician, and that's hard to do sometimes via video chat.  So right now my nurse practitioners do a lot of chemo teaching through telemedicine. Now that is really helpful for them because this can be done over multiple teaching sessions, it makes it a lot easier for the patient. Because rather than coming into the clinic for all these visits, they can learn from the comfort of their homes before they really start the toxic chemotherapy.  Dr. Jack Hensold: Chris, thank you for that. I think that you make a very valid point and one that I've made, which is that telehealth is a great tool for overcoming geographic barriers in rural areas. But I think we just simply have to accept the fact that it's not as good as a face-to-face visit. So how we blend the use of telehealth with face-to-face visits I think is going to be a challenge moving forward. Dr. Chris Prakash: Yeah, I totally agree. I think toxicity management is great. I mean, it's a great tool to call and see how patients are doing after treatment. But that initial visit, there's something to be said about establishing a rapport and faith and trust in your doctor when you're treating cancer. Dr. Jack Hensold: I completely agree. Sabe, you sound like you're one of the experts in Australia regarding telehealth. I wonder if you have some comments about your experience. Professor Sabe Sabesan: Yeah, I would say it's an evolving experience which has evolved over 15 years. So in terms of the health literacy needs, my observation is actually the same whether it's in person or in telehealth. What we observed is that we just need to tailor to the patient's needs. When we first developed the telemedicine, we had the same issues, developing rapport and seeing first consultations in person. But what we did, we started doing a lot of shared care models and tele supervision models with rural facilities rather than directly into homes. So what that meant, we had patients' families can attend, especially the primary care physicians, and the rural nurses were able to sit in with the patients. So that means if there were any communication issues or any translation aspects, language-wise or explaining medical lingo, there was a system in place in the rural sector that is close to home that was provided by the primary care physicians and the families.  And also then from that experience, we did some research and the patients actually said they were happy to continue initial consultations on the telehealth consultation, provided there were families involved, the primary care physicians were in there, and also the aboriginal health workers. So for some regions now we do the initial consultation purely on telehealth because what also what telehealth does for the first consultation, if we need to then bring them to our center, then we would be able to coordinate the whole trip rather than coming back and forth. So that's actually probably the difference in a couple of the larger centers. But the other main benefit I actually found for indigenous patients is that we can involve the whole family in the patient care and normally that means they are able to ensure compliance and compliance with clinic visits. So it's been evolving but really it is what our models, some of them are tele-oncology replacing face-to-face, some of them are hybrid, some of them are treatment-related. So it's really based on the needs of that little communities. That's what we've been doing. Dr. Chris Prakash: If I can ask you a question Sabe, on that, do you experience barriers to practice across state boundaries in Australia? Because I know in the US that's a big issue, that's a hurdle. Licensing is an issue across state boundaries and also broadband issue because a lot of my patients, they simply don't have the broadband width to get on a video chat. Do you experience that in Australia as well? Professor Sabe Sabesan: So we definitely have the broadband divide in Australia, but luckily the state governments have actually invested heavily on fiber. So all the health facilities, whether they are small or large, they are all connected on fiber. So if you do video calls or telehealth within that system, it is pretty good. But as soon as you go outside to a primary care facility that is not part of a state facility or home, you run into trouble with broadband. But in terms of the state boundaries, I think it is a bit loose. I don't know whether there's actually a strict monitoring of the systems, but because the whole Australian system is funded by Medicare, it really doesn't matter where the patient lives as long as you bill the patient based on the consultation. Dr. Jack Hensold: And I'd like to just respond to something you said, Sabe, too, which is the involvement of primary care doctors and local healthcare workers in the care of patients, is something I will return to later in this conversation. But I think it's important that we consider when we're keeping patients out of our larger centers and treating them in their own home areas, that we are relying on supportive care by those primary care providers. Any other comments regarding the telehealth issue?   Professor Sabe Sabesan: In terms of the primary care shared care models and collaborations, that is actually one of the important aspects of telehealth because we have in the rural sector, the turnover of the staff is pretty high. So then what happens if we want to provide consistent medical service on telehealth? Something needs to be consistent so we become the consistent aspect of the partnership. So then that gives us bit more safety that there's a shared care model, but also what we found now that in terms of educating on oncology topics, the shared care models actually give you an opportunity for case-based discussion. I think there is a benefit for workforce development as well, as well as connecting the rural workforce with a network of workforce. Dr. Chris Prakash: Involving primary care physicians in the total care of the patient is vital, especially in rural areas because they really depend upon their PCPs and often these are APPs providing their primary care. You've got to manage their diabetes and hypertension and go through all their medications, antiemetics pain medications, work with the local pharmacy. There are so many issues that go into treating a patient with cancer and as an oncologist sitting 100 miles away, I'm not going to be able to take care of every detailed aspect of their care. So what I do is involve their primary physician from the very beginning. So when the patient first comes to me, it could be via telemedicine or not, I'm calling them back and saying, “Hey, I saw so and so. This is my diagnosis, this is my plan. I'm going to do all the treatments here at my center. But whatever's possible you can do locally, I would appreciate that.” If there's labs that can be drawn, imaging that can be done locally, any testing that can be done locally, patients really value that because they don't want to travel 2 hours just for a CT scan if they can avoid it. That's my practice.   Dr. Jack Hensold: Thank you. You mentioned something that we're going to touch on next, which is that in rural areas it is often difficult to access labs, imaging facilities, and other specialized treatments, certainly CAR T therapy and other highly technical therapies. There are other services that may be limited in a rural area such as mental health, fertility preservation, palliative care, access to social workers. Do you have solutions to address that really supportive care and those needs? Dr. Chris Prakash: Yeah, I think, Jack, you touched on a very, very critical challenge right now. It's a workforce issue. It's very hard to hire and keep good support staff not only in rural areas but all over the country right now. So you mentioned social workers, nurses, nutrition specialists, mental health providers, even fertility services. They're very hard to find in rural areas. There's a big workforce problem, right, all over the country. But the pandemic really exacerbated that. I mean, it's hard to find good staff anywhere and there's no easy solution to fix this problem. So what we need to look for is maybe provide incentives such as loan forgiveness programs or tuition payment programs, or repayment. Really anything that keeps professionals in rural settings. And we need to find people who like working in these areas because that's a very difficult problem as well.  And as you know, many specialized treatments, stem cell transplants, CAR T cell therapy, specialized neurosurgeries or cardiothoracic surgeries, or many oncologic surgeries, they can only be done at big tertiary centers in big cities often. So patients have got to travel a few hours to go there. So what we can do to make it easier on them is provide the first consultations with those specialists via telemedicine. And if they're thought to be good candidates for the procedures, then they can make a trip that's necessary to the city, let's say. But also you mentioned consistency, that is the key. It's very important to be consistent if you want to provide quality cancer care. It could be imaging, it could be diagnostics, molecular testing, or any kind of therapy that you deliver. They should all be consistent no matter where a patient is being treated. So that brings into question provider education. Many oncologists in rural areas, they're generalists, they treat all cancers. They do not specialize in one area. It's really hard to keep up with all the latest information that's coming out. So it's important that we provide all educational tools possible to keep them up to date.  I just moderated a meeting called Oncology Congress. So this is geared towards cancer care providers in rural areas. It's a free CME webcast, various topics on cancer, excellent faculty, and the main thing is that the discussion is geared towards improving multidisciplinary care in those rural settings. So I think another thing that we could think of as a solution to this problem is virtual tumor boards. I mean, they're very helpful where somebody can get on and get an opinion regarding a difficult case. But I think most helpful is if you have a network of doctors or specialists that you can rely on, you can call somebody, a quick consult or say, “Hey, I have a problem, a challenging case, what would you recommend?” Because sometimes we just don't have time to wait for that tumor board or wait for an official consultation. So, yeah, it's a difficult challenge. Dr. Jack Hensold: Yes. And again, a point that you made that I'd like to respond to is the virtual tumor boards and basically shared education with maybe a larger group. As we've kind of in Montana looked at a development of hub and spoke models, we've realized it may make sense to consider a hub and spoke communicating with a spoke and hub. In other words, a larger center with what becomes the hub for a smaller community, and then that reaches out. So there's a series of educational connections that need to be made. Dr. Chris Prakash: Yeah, I think you almost need multiple hubs. One central big hub in this day and age is probably not going to help solve that problem. So you got to have a big hub and then maybe a series of regional hubs where patients can easily access and doctors can access information. Dr. Jack Hensold: Yes, I think that's absolutely correct. The education piece, too, is, I think, something that keeps oncology practitioners out of smaller communities where they may be practicing by themselves. Because it's difficult, as you know, as an oncologist, to feel like you're staying current with everything you need to stay up to date with, and therefore practicing in a larger group where you can turn to someone else for some immediate education.  Dr. Chris Prakash: That's very true. And if you really look at what these CME programs or educational programs are geared to, none of them are geared towards rural practice. They talk about big clinical trials. And those populations are really not my patient population, for sure. So you really need a program where people who know rural medicine, who have experienced it firsthand, like you, me, and Sabe, and say, “Okay, this is what really happens. You cannot give CAR T therapy to every Lymphoma that walks in.” I think those are the kind of educations we are talking about. There's so many educational programs that are available, but not many for rural practitioners. Dr. Jack Hensold: Right. And it does speak to whether or not we need to be thinking about developing some type of education that's easily accessible to those very busy practitioners who may be a solo practitioner with no one around for hundreds of miles, I guess.  Dr. Chris Prakash: And not to throw in a plug for my conference, but the Oncology Congress that I do twice a year, that's the sole purpose. We will have faculty from big centers. But I make sure that the conversation moves towards rural settings where we do not have all the latest technologies and the therapies available. And we had a really good turnout this past weekend, so I'm happy to share information if anybody's interested.  Dr. Jack Hensold: Yes, that would be great. Again, I think this conversation has been terrific because I've really become focused on the issue of the inadequate education we have not only for our oncologists who are out in practice in smaller areas but also for the primary care providers who need a better understanding of what's required for supportive care of oncology patients. And there's very limited material that focuses on that as well.  Dr. Chris Prakash: Totally agree. Just one last point I want to make is with the checkpoint inhibitors. That's a perfect example. Many of these toxicities are multi-organ, and the patients in the community, the docs in the community sometimes are not aware of the skin rash or lung symptoms, or pneumonia is really related to the therapy. So very important to involve the whole team in their care. Dr. Jack Hensold: Completely agree. Sabe, what about your experience in this regard? Professor Sabe Sabesan: Exactly the similar experience Chris has been describing. Another group of rural people, there are actually smaller rural communities. Sometimes they are like 500 or 1000 population maximum. So those kinds of places, they completely miss out because they are too small even for standard general medicine specialties. What we've been observing over time or focusing on is really how do we build those capabilities at rural sites because if they keep doing the same stuff, then they are not going to grow or build. So what we've been doing is let's build some rural capabilities and let's also focus on expanding the scope of practice. So to do that, we actually have to start shifting specialist services like chemotherapy administration or rheumatology infusions back to those smaller towns. And then we have to utilize tele-supervision and share care models with allied health and the rural health workforce. So when that happens, we need more staff because there are more activities happening.  And what we found in the western Queensland town of Mount Isa before 2007, maybe a few chemotherapy patients had to travel for everything. Over time we shifted all the chemotherapy and biotherapy to that 20,000 population town. That meant that over that ten years they had more resources from the government, more staff like registrars and residents, and also needed infrastructure. So that gave us some confidence that maybe we have to leverage the telemedicine technologies to build rural systems, not just seeing patients.  Dr. Jack Hensold: Thank you Dr. Prakash, for your insight into this topic and also to Professor Sabesan for his perspective from his practice in Australia. In part two of this podcast, we will explore how the difference between American and Australian healthcare systems impact care for rural patients, the need for advocacy from doctors in a pilot project in Montana I'm working on with ASCO.  I'm Dr. Hensold and I would like to thank all of our listeners of the Cancer Topics ASCO Education Podcast. This is where we explore topics ranging from implementing new cancer treatments and improving patient care to oncologist well-being and professional development. If you have an idea for a topic or guest you'd like to hear on the show, please email us at education@asco.org. To stay up to date with the latest episodes and explore other educational content, visit education.asco.org. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions.   Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.        

Drs. Nathan Pennell and Nancy Lin discuss emerging data on the growing problem of prior authorization and insurance denials in cancer care, their potentially harmful impact on patient outcomes, and what can be done to fix the problem. TRANSCRIPT Dr. Nathan Pennell: Hello, I'm Dr. Nathan Pennell, your guest host for the ASCO Daily News Podcast today. I'm the co-director of the Cleveland Clinic Lung Cancer Program and vice chair of clinical research for the Taussig Cancer Institute. More importantly, today, for this podcast, I'm also the editor-in-chief for the ASCO Educational Book. On today's episode, we'll be discussing the growing problem of prior authorization and insurance denials, and how that impacts both providers and patients in their ability to access cancer care.  Joining me is Dr. Nancy Lin, a breast cancer medical oncologist at the Dana-Farber Cancer Institute and associate professor of medicine at Harvard Medical School. She's addressed this problem in a recently published article in the 2023 ASCO Educational Book, and she's joining me today to highlight some emerging data on the possible harms from prior authorization and insurance denials, and what we can do to fix this problem.  Nancy, thanks so much for coming on the podcast today. Dr. Nancy Lin: Thank you for inviting me. Dr. Nathan Pennell: Some of our listeners may have noticed that we also did a podcast a number of years ago on a similar topic when we were with the Journal of Oncology Practice, and I was kind of hoping that prior authorizations would not be as big a problem, now, probably 8 or 9 years later, and unfortunately, it seems like it has gotten even worse.  Before we begin, I should mention that our disclosures are available in the transcript of this episode, and disclosures relating to all episodes of the podcast are available on our transcripts at asco.orgDNpod. So prior authorizations were, of course, originally intended as a cost control on the overuse of expensive medical care. However, in recent years, it seems like prior authorization has been extended to, more or less, all medical care, including supportive care medications and essential cancer care interventions that we need to use in almost every patient. We're also hearing more and more reports on patients who are denied coverage, and I think the doctors can sympathize with this, with their increasing peer-to-peer requests. And this is leading to patients being forced to wait to receive second-best options, impacting their out-of-pocket costs. And potentially, we all fear this is impacting patient outcomes, although we really would like to learn more about how this is really impacting their care. So, Nancy, can you talk to us a little bit about how prior auth is impacting patient access to cancer care today? Dr. Nancy Lin: Of course, we all have to acknowledge that part of the impetus for prior authorization is just the increasing cost of cancer care. There are some recent statistics that the U.S. spends over $200 billion annually on cancer care and that oncology drugs are a huge part of the overall drug cost in the nation and a large part of the oncology drug budget. So, I think we can't deny that the increasing costs of cancer care are in part driving this drive for more prior authorization. But this has costs, and there are costs in terms of direct patient costs as far as their quality of care, and also costs in terms of the health care providers and health care system.   And so we, as part of our article, actually solicited patients to provide their stories. And in fact, in our article, we have selected, with their permission, 3 patients who share their experiences. And these are experiences that, as a practicing oncologist, you'll be very familiar with. A patient wrote that she had been on capecitabine for a year, her disease is responding, and all of a sudden, on a Friday late in the day, she's told, “No, you need a prior authorization now, and you can't get your drug refilled.” And that led obviously to stress and delay and whatnot. And then another example is of a patient whose oncologist requested what sounds like next-generation sequencing, some sort of tumor panel and was denied. And the peer-to-peer here had apparently indicated that they are not aware of the data for the use of genomic testing and cancer treatment, which clearly there is a role for the use of genomic testing in cancer treatment. And in fact, we now have many articles that show that there's unequal access and, if we look at underrepresented minorities or other marginalized groups, that there is a dramatic difference in the utilization of advanced molecular testing. And then just the overall experience on patients and their families feeling like, at a time when they're sick, need to take charge of all of this paperwork and back and forth with insurers that is very stressful.   And then, from a provider or health care system standpoint, many, many hours are expended on prior authorizations for things like very new drug approvals that are maybe not on a pathway yet, or very commonly, simple things like a CAT scan for restaging of somebody who has advanced breast cancer where every scan requires prior authorization or antiemetics, or somebody receiving highly immunogenic chemotherapy and these kinds of death by a thousand cuts I think is how people in the health care experience the aspect of prior authorization.  Dr. Nathan Pennell: It's one of these things where we used to get a peer-to-peer for say, atypical reason for a PET scan, which made perfect sense, and you'd have to talk to an experienced expert to explain what you were doing and try to get a good rationale for that. And now, it's come to the point where a routine 2-month, 3-month CT scan is getting denied and having to be talking to someone who's not as experienced in this. Again, it feels still like a collection of anecdotes though in many ways. Is there any sort of published data on denials of care and prior auths and how this is impacting approvals and patient access? Dr. Nancy Lin: There are survey data, which one has to admit is not necessarily gold-standard data, but there are data from the American Medical Association, as well as a 2022 ASCO member survey. And in that ASCO member survey, over 90% of oncologists reported that they had personally experienced, in their patients, a delay in treatment related to prior authorization. Over 90% had issues getting needed diagnostic evaluations. Over 90% reported that they were, "forced to go to a second choice of therapy." And about a third of oncologists reported that they believed that the prior authorization, either delays or denial of care, led to changes or worsening of patient survival, which I think is the most concerning statistic of all.  Now, I think that one can argue that these are essentially physician self-report and what's the gold standard as far as whether there has been an impact? But I think that the fact that these reports are so prevalent means that, even if the reality is half of what has been reported, it's still a lot. And I think that  the power of these kinds of surveys is just enormous, that a high prevalence of the problems have been reported, I think, points to something even if we don't have gold standard quote data now.  Within our institution, Dana-Farber, we have done an analysis of oral medication prescribing. So, we do have gold standard and very granular data on patients that we've seen. And we've seen denials and requirements of prior authorization not only for expensive cancer medications and growth factors but also for even medicines like generic tamoxifen, which, honestly, how does that need prior authorization in this day and age? Medications like supportive care, antiemetics, and really things that ultimately, we were able to get approved 97% of the time, but [prior authorization now] introduces a delay and introduces stress. And although one may not be able to measure a so-called negative outcome from a patient recurrence standpoint, I think that there are other kinds of negative outcomes that are important, including just the experience of a cancer patient undergoing treatment, the stress of all of the denial letters and the delays that can occur as a result. Dr. Nathan Pennell: And it's not just patients. Obviously, we want to be patient-centered in our care and focus on how this impacts them. But this is also significantly impacting practitioners and cancer centers and physicians and the administrative burden of having to do the prior authorizations, which of course are not standardized in any way and vary from payer to payer and geographic area to geographic area. Is there data on how the changes in prior auth have impacted practices and physicians? Dr. Nancy Lin: Yes. In fact, there have been several surveys as well as in the practice types of studies trying to understand the staffing that is required to manage the prior authorization requests. And some of the estimates are an additional 40 hours per week per oncologist, that's a full-time position. Some of these tasks can be carried out by non-oncology-trained providers but many of them do require either the oncologist or a nurse practitioner equivalent to be on the phone for the peer-to-peer or a full-time clinical provider and you are given a 4-hour window to do a peer-to-peer in the middle of clinic, that's very disruptive. And I think that that's fine if it's every now and then for drugs that we all agree are perhaps outside of their usual indication. But if this is every CAT scan and every brain MRI and every time we prescribe an oral drug, it really does affect both clinic workflow, and just the psychology; I think it really contributes to burnout.  There was a very interesting survey actually of oncology trainees who, not even to the point where one is an attending physician, but at the trainee level indicating that this was something that was causing them a lot of distress, and in some cases, questioning the whole idea of going into medicine. And then when you think with the attrition that we're seeing in the health care workforce, we do really have to be careful about these burnout issues because we really can't afford to lose a lot of oncology staffing as the patient population ages and we're seeing higher prevalence of cancer. I think it's imperative that we take care of our oncology workforce. And I think this survey was very interesting because it went beyond the attending physician to other levels of oncology care, all of which are affected.  And there have been, as you know, many growing or nascent attempts at various residency programs to think about unionizing and what are the kinds of concerns or complaints that trainees bring up. And one of [the complaints] that  comes up a lot is, “We have to do these prior authorizations and there's all this administrative paperwork that doesn't require an entry-level person.” I'm not saying that they should or shouldn't do it - I'm not going to take a position on that - but the fact is that somebody has to do it in the current system, and whoever does it, it causes burnout. And I think that that is important. And the other piece of it has to do with equity and access to care because we're coming from academic institutions. We have a staff of people who help with prior authorization. That's not true in every practice in the United States. And I really worry about not so much denial of care but even a step beyond that, which is if you are in an under-resourced office and it's too hard to get certain things done, you don't do them because you just don't have the ability or you don't have the staffing to be able to find insurance. And I think that is very concerning to me in terms of access to care, access to some of our immune-targeted therapies, and access to the optimal support of care medications. We come from very well-resourced places as far as the administrative staff, relatively speaking, and that's just not true everywhere.  Dr. Nathan Pennell: This whole idea kind of falls under the idea of creating friction in the system to try to slow things down. I've seen data suggesting that things like peer-to-peer requests for appeals actually lead to a majority of physicians not having time or taking the time to actually do that. And that may be sometimes because they know it's indefensible and don't want to go through the process. But probably a lot of the time it's just because they don't have time to do it in their busy day and those patients then don't get their care covered. So, it's really a problem.  Now, the other thing that is really remarkable to me is, this is 2023 and everything is so technologically advanced. You can make major financial transactions electronically on your phone in just a few seconds, really complicated things. And yet this kind of [prior authorization] process really is still often done over the phone and by fax and with 100 different systems that don't talk to one another. And at the same time, oncology is becoming more and more guideline-driven where what we do actually have is really good evidence behind it. And there are even published guidelines for almost every disease and line of care about everything that we do from scan intervals to what kinds of treatment and how often and what supportive care is necessary. So, this would seem like an optimal situation for a technology solution where we tie in guidelines to what should and shouldn't be covered. What's going on out there in terms of trying to fix this? Dr. Nancy Lin: Some important questions are: Who makes the guidelines? What are the regulations as far as which guidelines insurance might adopt - their own internal guidelines or NCCN or comparable organizations? And what do you do when somebody wants to deviate from the guideline or pathway? And then finally a practical question, which is you don't really want to have a different platform and a different guideline for every insurance plan for every patient. And I think that is a little bit of even if we move to a purely electronic system, that will still be a problem.  The state of Florida had done this pilot study that tried to use or incorporate the NCCN guidelines as part of their approval or review process for prior authorization requests and at least based on the report that's published, saved $15 million in costs. And we would hope if the care was more NCCN guideline-concordant, which has been shown to improve outcomes, that would have been done without a detriment to patient outcomes. I don't think we have enough granular information to be 100% sure of that, but I would assume that that's most likely the case. I do think that some amount of guideline use could be useful.   And one of the things that we proposed in our article was the idea that one could create a sort of gold card system such that if a provider or a practice, for example, adheres to certain pre-agreed-upon guidelines or pathways more than 80% of the time, which is sort of considered good adherence and taking into account patient preference and comorbidities and whatnot, that that practice or provider could be sort of gold carded, so to speak, and actually have many of the prior authorization requirements go away so long as that is adhered to. And so that's one idea.  One of the concepts that Dario Trapani, who was the first author of our paper, put forward is that you don't necessarily need every person to be compliant with every guideline. Generally, you need for there to be compliance and that there could be different categories of treatment so that supportive care medications, pain medications for cancer-related pain, could potentially be exempt from prior authorization requirements completely. And then at the same time for other kinds of prior authorization requests, it's not enough to just change a fax form to an electronic form. That's an improvement from having faxes going back and forth by paper, but really isn't a fundamental change in the prior authorization process or vision. And so, this idea of the pathways and then only when something is deviated in some sort of major way in various categories to be determined that sort of triggers a peer-to-peer review that would both hopefully serve the purpose of reducing overuse of unnecessary or non- indicated treatments and save money. But also, in a way, I think that is less burdensome to the health care system. And I fully acknowledge that I am not a policy expert, I mostly research metastatic breast cancer, but this issue really affects us all very personally every day.   Dr. Nathan Pennell: I know you just said you're not a policy expert, but can you talk to us a little bit about what Congress and ASCO are doing to help from a legislation standpoint or a regulatory standpoint to help make this a little bit less painful? Dr. Nancy Lin: Yeah. So ASCO has endorsed the so-called “Improving Seniors Timely Access to Care Act.” And for those out there listening, particularly patients, you might say, “Well, I'm not a senior.” But it's important because how Medicare deals with issues often is then adopted by private insurers. And so starting with “Improving Seniors Timely Access to Care Act,” the intent is that it will also affect people with cancer at all age groups. But some of the provisions or the proposals are to convert to an electronic prior authorization system, to put systems in place for timely and efficient communication between providers and insurers, to ensure a process for real-time decisions that have some timeframe or timeline or deadline associated with it, to facilitate guidelines and pathway-informed decisions, and to also, importantly, be fully transparent about approvals and denials, portions that are denied, these sorts of reasons for denials, to really have transparency in that process which at the moment does not really exist. I think these are all very, very important steps with the overarching goal to promote timely and appropriate access to medications, procedures, and evaluations for oncology patients. Dr. Nathan Pennell: I'm just curious, in your opinion, do you think that there is actual inertia to try to change some of these things from a policy perspective? It can be kind of frustrating sometimes. It seems like the insurance industry has really kind of taken command of this by implementing these and we see the problems and we talk about them. But from a regulatory standpoint, it really seems like things are kind of maybe being a little bit neglected. Dr. Nancy Lin: I think that this is really something where I do think there will be some movement; maybe it's that I'm an optimist and that's what you need to be to be an oncologist.  I think that a big part is going to be really a focus on the impact on patients because although we certainly feel the impact on ourselves as providers and our staff, I don't know that that in and of itself is going to be enough to move the needle, like doctors complaining that they are having to spend too much time on the phone. I think the real impact is really related to the impact on patients. And as I said, I think that the AMA survey and the ASCO survey, those are very important because they really put the focus on [assessing] the impact on patients living with cancer.  Again, the limitations of a survey-based study are profound. And I do think that the current [White House] administration is very, very engaged in improving care for people with cancer. And in fact, part of this revised Cancer Moonshot [initiative] is not only better science around cancer and better molecular understanding of cancer but at the end of the day, if we can't get the right treatment to the right patient, it doesn't really matter how good the science is. And part of getting the right treatment to the right patient is not just training, guidelines and education. Part of it is just the practical aspect of insurance coverage as one important aspect of that. And so, I do think that there will be some movement on this because I think that it's really gotten to a point where this is not just inconvenient for doctors. I don't think that that's enough to drive anything forward personally, but I think that when you start to see impact on patients, that is really a big deal.  I was struck that one of the studies that we had identified was a study looking at over 13,000 chemotherapy requests and understanding how many were denied and why they were denied. And basically, about 11% of the requests ultimately were denied after peer-to-peer and all sorts of other appeals. And this was essentially the gold standard, so to speak. In this study was the oncologist's opinion as assessed by the so-called board certified oncologist, which is what was described in the publication employed by the insurer. We have these competing narratives and that is ultimately the problem: We have the AMA and the ASCO surveys which are survey-based asking the oncologists, and we have these data which are based on the insurer essentially as the gold standard arbiter. So it's hard to reconcile those two pieces of information because they're not really coming from the same place. And then I think you could also argue that, think about 13,000 chemotherapy requests, that means that essentially 90% were fine.  When we looked at our pathways employed at Dana-Farber where we check to make sure that our physicians are adhering to the pathways, we basically want to aim at about 80% with the idea that some patients decline a standard regimen, and we go to something else. They don't want alopecia with the idea that some patients have comorbidities, that you don't want to micromanage how oncologists are managing their patients. And honestly, in most pathway programs, we consider 80% to be pretty good. In this study, 80% were approved. And you might argue, is it worth reviewing 13,000 requests to this level of scrutiny for 90% to be approved? And again, I think that that really raises this idea of like rather than just switching a fax system to an electronic system to really rethink where's the low-hanging fruit? Where would prior authorization really serve a positive purpose? I think there are places where it could serve a positive purpose and where is it just adding unnecessary friction. Dr. Nathan Pennell: Yeah, it's a complicated picture and there are valid arguments on both sides. One of the things that is very appealing to me about the proposed legislation is requiring the payers to actually report and disclose their levels of denials and prior authorizations and this allow us to maybe take it beyond the anecdotal evidence to actually being able to document what they're doing. Because once you shine a light on things, sometimes it becomes a little bit harder to abuse the system.  Dr. Nancy Lin: Yes, I agree.  Dr. Nathan Pennell: Well, Nancy, thanks so much for coming on the podcast today to discuss this challenging problem. I know we could have talked about this for an hour or more. We really appreciate your work to highlight the impact of this problem both on providers and on patients, as well as outlining some efforts to find solutions. Dr. Nancy Lin: Great, thank you for having me. Dr. Nathan Pennell: I also want to thank our listeners for joining us today. If you value the insights you hear on the ASCO Daily News Podcast, please take a moment to rate, review, and subscribe wherever you get your podcasts. Have a great day. Disclaimer:   The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions.  Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.   Find out more about today's speakers: Dr. Nathan Pennell @n8pennell Dr. Nancy Lin @nlinmd   Follow ASCO on social media:     @ASCO on Twitter   ASCO on Facebook   ASCO on LinkedIn     Disclosures:  Dr. Nathan Pennell:   Consulting or Advisory Role: AstraZeneca, Lilly, Cota Healthcare, Merck, Bristol-Myers Squibb, Genentech, Amgen, G1 Therapeutics, Pfizer, Boehringer Ingelheim, Viosera, Xencor, Mirati Therapeutics, Janssen Oncology, Sanofi/Regeneron  Research Funding (Inst): Genentech, AstraZeneca, Merck, Loxo, Altor BioScience, Spectrum Pharmaceuticals, Bristol-Myers Squibb, Jounce Therapeutics, Mirati Therapeutics, Heat Biologics, WindMIL, Sanofi  Dr. Nancy Lin: Stock and Other Ownership Interests: Artera Inc. Consulting or Advisory Role: Seattle Genetics, Puma Biotechnology, Daichi Sankyo, Denali Therapeutics, AstraZeneca, Prelude Therapeutics, Pfizer, Olema Pharmaceuticals, Aleta Biotherapeutics, Artera, Johnson & Johnson/Janssen, Blueprint Medicines, Genentech, Pfizer, Seattle Genetics, Merck, Zion, Olema Pharmaceuticals        

In this episode of How This Is Building Me, Drs Camidge and Weickhardt discuss the span of countries and institutions Dr Weickhardt's medical training and career has led him to, the ins and outs of becoming a practicing oncologist in Australia vs the United States, and the importance of discerning patient needs and preferences to earn patient trust and deliver effective, personalized care across the globe. 

World-renowned oncologist D. Ross Camidge, MD, PhD, sits down with guests to discuss the highs and lows, ups and downs of all those involved with cancer, cancer medicine, and cancer science across the full spectrum of life's experiences. 

Dr. Barbara Andersen delves into the newly updated guideline for management of anxiety and depression in adult survivors of cancer in this ASCO Guidelines podcast episode. This guideline affirms prior guidance regarding screening and assessment of anxiety and depression, and updates evidence-based recommendations for management of both anxiety and depression. Dr. Andersen reviews the principles of the recommended stepped-care model, along with recommended treatments, including options such as cognitive behavior therapy, cognitive therapy, behavioral activation, structured physical activity and exercise, and mindfulness-based stress reduction. Challenges regarding managing anxiety and depression in adult survivors of cancer are also discussed. Read the full guideline update, “Management of Anxiety and Depression in Adult Survivors of Cancer: ASCO Guideline Update” at www.asco.org/survivorship-guidelines. TRANSCRIPT This guideline, clinical tools, and resources are available at www.asco.org/survivorship-guidelines. Read the full text of the guideline and review authors' disclosures of potential conflicts of interest disclosures in the Journal of Clinical Oncology, https://ascopubs.org/doi/10.1200/JCO.23.00293. Brittany Harvey: Hello and welcome to the ASCO Guidelines Podcast, one of ASCO's podcasts delivering timely information to keep you up to date on the latest changes, challenges, and advances in oncology. You can find all the shows, including this one, at asco.org/podcasts.  My name is Brittany Harvey, and today I'm interviewing Dr. Barbara Andersen from the Ohio State University, lead author on “Management of Anxiety and Depression in Adult Survivors of Cancer: ASCO Guideline Update.”  Thank you for being here, Dr. Andersen.  Dr. Barbara Andersen: Thank you. Thank you for the invitation. Brittany Harvey: And then, just before we discuss this guideline, I'd like to note that ASCO takes great care in the development of its guidelines and ensuring that the ASCO conflict of interest policy is followed for each guideline. The disclosures of potential conflicts of interest for the guideline panel, including Dr. Andersen on this episode, are available online with the publication of the guideline in the Journal of Clinical Oncology, which is linked in the show notes.  So then, to jump into the content of this guideline, Dr. Andersen, what prompted an update to this guideline, and what is the scope of this updated version of the guideline?  Dr. Barbara Andersen: Well, as your listeners probably know, guidelines are routinely updated, primarily due to new accumulated evidence that suggests a change in diagnostic or treatment procedures. The first guideline from ASCO was in 2014. They made this important first step, which alone made that an important advance. The prior scope was on assessment, that is, which measures at what time points were important for assessing patients' depressive or anxiety symptoms. We then provided treatment pathways thereafter, noting currently available evidence for treatment. But a systematic review of the literature wasn't done at that time. So what this guide does is first affirm the prior recommendations regarding the measures to use for assessment, the PHQ-9 and the GAD-7. But the departure for these guidelines is based on a systematic review of the intervention and treatment literature, and from that review, we recommend particular treatments. Brittany Harvey: Understood. So, focusing on that intervention and treatment aspect of this updated guideline, I'd like to review the key recommendations starting with, what are the key general management principles for people with cancer and anxiety and/or depression?  Dr. Barbara Andersen: Well, one key principle is that of education. Your listeners probably are familiar with the fact that many hospitals or centers provide patient-tailored cancer treatment-related information, treatment information on surgery, chemotherapy, immunotherapy, and other topics. But we recommend that general first-level materials on coping with stress, anxiety about treatment, and depression be routinely provided as well. What that does is for individuals with elevated symptoms, it validates what they're experiencing and normalizes the patient experience. So we hope that all patients with cancer and any patient-identified caregiver, family member should be offered the information. We have so many ways we can give information to patients these days. Verbally, material, whatever mode is easy for you and the patient, but please choose one to give information to patients.  Another characteristic of the guideline is our recommendation that treatment follow the principle of stepped care. So what this means is you match the assessment of the severity, level of depression or anxiety, and you match that data to the selection of treatment contexts. This is most clearly seen in the recommendation that group treatment formats be used for those with moderate severity of symptoms versus individual or face-to-face therapy for those with severe symptoms. And this is the case for both anxiety and depressive disorders. This is a principle that's cost-effective and tailors the treatment recommendations. Another principle that we offer is when making a referral of a patient for further evaluation or psychological care; we plead with you to make every effort to reduce the barriers and facilitate patient follow-through. We say it's essential because low motivation, for example, is a symptom of depression. And that low motivation and low mood can conspire to reduce the likelihood that patients will pursue treatment. So just keep that in mind when referring patients.  Brittany Harvey: Absolutely. Those are key points for general management across anxiety and depression symptoms. So, moving beyond those principles, what are the recommendations from the expert panel for treatment and care options for patients with depressive symptoms?  Dr. Barbara Andersen: For depressive symptoms, we recommend cognitive behavior therapy or cognitive therapy, behavioral activation, psychosocial interventions using empirically supported components, and moderate structured physical activity and exercise. All of those are efficacious, empirically supported treatments for moderate depressive symptoms. And it might be easiest to offer group therapy for individuals with these problems.  Brittany Harvey: Great. Thank you for reviewing those recommendations for patients with depressive symptoms.  So, in addition, what does the expert panel recommend for treatment and care options for patients with anxiety symptoms?  Dr. Barbara Andersen: Many of the same treatments are used. Cognitive therapy, cognitive behavior therapy are the most efficacious treatments out there for cancer patients or individuals without cancer coping with anxiety symptoms or depressive symptoms. Again, behavioral activation would be useful. Mindfulness-based stress reduction has garnered significant support in the recent years, as well as interpersonal therapy.  Brittany Harvey: Understood. So thank you so much for going through each of those recommendations.  But in your view, Dr. Andersen, what is the importance of this guideline, and how will it impact both clinicians and patients with cancer and symptoms of anxiety and/or depression?  Dr. Barbara Andersen: An important element to this guideline is it names the specific empirically supported standard therapies for treatment of anxiety and depression. There's a departure, though, from our prior guideline, and in this one, pharmacotherapy is not recommended as a first-line treatment, neither alone nor in combination. It's simply not supported by the evidence. However, clinicians might consider pharmacotherapy when there's low or no availability of mental health resources. Perhaps a patient might have responded well to pharmacotherapy in the past, and patients with severe neurovegetative, or agitated symptoms of depression, those patients, as well as patients with psychotic or catatonic features, would be ones for which pharmacotherapy might be appropriate.  Brittany Harvey: Understood. And then you've just mentioned that sometimes there is no or low availability of mental health resources, so that leads to my next question. But what are the both outstanding research questions and challenges regarding managing anxiety and depression in adult survivors of cancer?  Dr. Barbara Andersen: The largest challenge is that we're in the midst of a mental healthcare crisis, and COVID has made that abundantly clear. There are problems with access to psychological care due in part to workforce problems, maybe organizational ones, but there is a shortage of mental health professionals, and that, in turn, limits referral networks from managing depression and anxiety. So that's one significant issue that is in place right now.  Since the 2014 guideline, screening is a care aim that has been disseminated, but the principles and procedures remain to be fully implemented. I was just looking at a 2022 article in the Journal of Oncology Practice. It was a study examining screening for lung and ovarian cancer patients, two very important groups because the frequency of depressive and anxiety symptoms is perhaps highest of any other groups. So they looked at more than 20 CoC-accredited facilities that studied the electronic records to see if there was screening for the patients. And the troubling finding, from my perspective, was that there was no screening for 45% of the patients in this study. So we know that there are disparities in the use of screening and its management. Those disparities exist across race, ethnicity, cancer type, stage, and facilities. And so, that remains a challenge for many sites, including CoC hospitals, to achieve a rigorous screening program. Having said that, I want to say what some might disagree with, but from my standpoint, it's a myth that screening takes a long time. The measures that we recommend probably would take a patient maybe five, maybe ten minutes to complete. But what's time-consuming or what's troublesome in many places is the infrastructure is not in place to do the screening and interpret it in an efficient manner. The other perspective on screening is that it is the effort thereafter, which is, in fact, time and resource intense - that is, finding referral sources, making referrals. But that's the most important step because when that's not done, when patients continue with symptoms, it really incurs the greatest cost for the patients. Brittany Harvey: Absolutely. Screening and then further management of anxiety and depressive symptoms is key for maintaining quality of life.  So I want to thank you so much, Dr. Andersen, for coming on today and sharing your insights and also for all your work you did to update this guideline.  Dr. Barbara Andersen: Thank you so much. Brittany Harvey: And thank you to all of our listeners for tuning in to the ASCO Guidelines Podcast.  To read the full guideline, go to www.asco.org/survivorship-guidelines. You can also find many of our guidelines and interactive resources in the newly redesigned ASCO Guidelines app, available for free in the Apple App Store or the Google Play Store. If you've enjoyed what you've heard today, please rate and review the podcast and be sure to subscribe, so you never miss an episode.  The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.      

People with cancer face significant side effects - both from their cancer and their chemotherapy, immunotherapy or radiation treatments. They often seek out complementary or integrative approaches alongside their conventional medical treatments, but they may have to figure out what to use without any medical guidance. The ideal scenario would be for the integrative approach to be folded into the oncology practice itself!In this episode of The Integrative Palliative Podcast we'll talk about the WHY, WHAT and HOW of adding integrative medicine into an oncology practice.Check out our website and sign up to learn more about how to provide whole person care for people with serious illness using all the tools that work! www.integrativepalliative.com- Dr. ChiaramonteFollow me on LinkedIn  linkedin.com/in/deliachiaramonte When your patient is crying do you know just what to do? Can you confidently help patients manage anxiety or pain without controlled medications? Come learn with Dr. Chiaramonte and improve your integrative symptom management skills!- evidence supported patient care skills- self care for you- patient resources for your office- group case-based discussionswww.integrativepalliative.com/training

Go online to PeerView.com/PYK860 to view the activity, download slides and practice aids, and complete the post-test to earn credit. Small cell lung cancer (SCLC) is known as an aggressive, rapidly progressing, and challenging thoracic malignancy. After lacking progress for decades, recent advances have finally led to approvals of new therapies that can improve outcomes and quality of life of patients with SCLC. Chemoimmunotherapy has become the new standard of care in the first-line setting, a novel transcription inhibitor has expanded very limited options in the second-line setting, and many ongoing trials and innovative approaches are anticipated to further escalate progress in this challenging subtype of lung cancer. These developments have also provided new hope to patients with SCLC, which makes it important to ensure that all patients have access to these therapies and have the opportunity to benefit from them, as well as being encouraged to consider clinical trial participation. This activity focuses on evidence and practical guidance to help clinicians make the most of the latest treatment advances in SCLC. Essential data and best-practice recommendations are framed with cases to illustrate how to integrate the new therapeutic options into clinical practice. Investigational therapies and key ongoing trials are also highlighted to continue to better understand the biology of SCLC and the expanding the treatment options. Upon completion of this activity, participants should be better able to: Apply the latest efficacy and safety data on novel systemic therapeutic options for SCLC taking into consideration their characteristics, mechanism of action, most recent treatment guidelines, clinical activity, and adverse event profile, Integrate the latest therapies into preferred prescribing protocols and formularies accounting for prior treatment history, duration of chemotherapy-free interval, disease presentation, sites of recurrence, comorbidities, and other treatment- and patient-specific features for patients with SCLC, particularly in the second-line setting, Implement individualized treatment plans for patients with SCLC that leverage team-based approaches to shared decision-making, patient education and counseling, and adverse event management and monitoring.

Go online to PeerView.com/PYK860 to view the activity, download slides and practice aids, and complete the post-test to earn credit. Small cell lung cancer (SCLC) is known as an aggressive, rapidly progressing, and challenging thoracic malignancy. After lacking progress for decades, recent advances have finally led to approvals of new therapies that can improve outcomes and quality of life of patients with SCLC. Chemoimmunotherapy has become the new standard of care in the first-line setting, a novel transcription inhibitor has expanded very limited options in the second-line setting, and many ongoing trials and innovative approaches are anticipated to further escalate progress in this challenging subtype of lung cancer. These developments have also provided new hope to patients with SCLC, which makes it important to ensure that all patients have access to these therapies and have the opportunity to benefit from them, as well as being encouraged to consider clinical trial participation. This activity focuses on evidence and practical guidance to help clinicians make the most of the latest treatment advances in SCLC. Essential data and best-practice recommendations are framed with cases to illustrate how to integrate the new therapeutic options into clinical practice. Investigational therapies and key ongoing trials are also highlighted to continue to better understand the biology of SCLC and the expanding the treatment options. Upon completion of this activity, participants should be better able to: Apply the latest efficacy and safety data on novel systemic therapeutic options for SCLC taking into consideration their characteristics, mechanism of action, most recent treatment guidelines, clinical activity, and adverse event profile, Integrate the latest therapies into preferred prescribing protocols and formularies accounting for prior treatment history, duration of chemotherapy-free interval, disease presentation, sites of recurrence, comorbidities, and other treatment- and patient-specific features for patients with SCLC, particularly in the second-line setting, Implement individualized treatment plans for patients with SCLC that leverage team-based approaches to shared decision-making, patient education and counseling, and adverse event management and monitoring.

Go online to PeerView.com/PYK860 to view the activity, download slides and practice aids, and complete the post-test to earn credit. Small cell lung cancer (SCLC) is known as an aggressive, rapidly progressing, and challenging thoracic malignancy. After lacking progress for decades, recent advances have finally led to approvals of new therapies that can improve outcomes and quality of life of patients with SCLC. Chemoimmunotherapy has become the new standard of care in the first-line setting, a novel transcription inhibitor has expanded very limited options in the second-line setting, and many ongoing trials and innovative approaches are anticipated to further escalate progress in this challenging subtype of lung cancer. These developments have also provided new hope to patients with SCLC, which makes it important to ensure that all patients have access to these therapies and have the opportunity to benefit from them, as well as being encouraged to consider clinical trial participation. This activity focuses on evidence and practical guidance to help clinicians make the most of the latest treatment advances in SCLC. Essential data and best-practice recommendations are framed with cases to illustrate how to integrate the new therapeutic options into clinical practice. Investigational therapies and key ongoing trials are also highlighted to continue to better understand the biology of SCLC and the expanding the treatment options. Upon completion of this activity, participants should be better able to: Apply the latest efficacy and safety data on novel systemic therapeutic options for SCLC taking into consideration their characteristics, mechanism of action, most recent treatment guidelines, clinical activity, and adverse event profile, Integrate the latest therapies into preferred prescribing protocols and formularies accounting for prior treatment history, duration of chemotherapy-free interval, disease presentation, sites of recurrence, comorbidities, and other treatment- and patient-specific features for patients with SCLC, particularly in the second-line setting, Implement individualized treatment plans for patients with SCLC that leverage team-based approaches to shared decision-making, patient education and counseling, and adverse event management and monitoring.

Go online to PeerView.com/PYK860 to view the activity, download slides and practice aids, and complete the post-test to earn credit. Small cell lung cancer (SCLC) is known as an aggressive, rapidly progressing, and challenging thoracic malignancy. After lacking progress for decades, recent advances have finally led to approvals of new therapies that can improve outcomes and quality of life of patients with SCLC. Chemoimmunotherapy has become the new standard of care in the first-line setting, a novel transcription inhibitor has expanded very limited options in the second-line setting, and many ongoing trials and innovative approaches are anticipated to further escalate progress in this challenging subtype of lung cancer. These developments have also provided new hope to patients with SCLC, which makes it important to ensure that all patients have access to these therapies and have the opportunity to benefit from them, as well as being encouraged to consider clinical trial participation. This activity focuses on evidence and practical guidance to help clinicians make the most of the latest treatment advances in SCLC. Essential data and best-practice recommendations are framed with cases to illustrate how to integrate the new therapeutic options into clinical practice. Investigational therapies and key ongoing trials are also highlighted to continue to better understand the biology of SCLC and the expanding the treatment options. Upon completion of this activity, participants should be better able to: Apply the latest efficacy and safety data on novel systemic therapeutic options for SCLC taking into consideration their characteristics, mechanism of action, most recent treatment guidelines, clinical activity, and adverse event profile, Integrate the latest therapies into preferred prescribing protocols and formularies accounting for prior treatment history, duration of chemotherapy-free interval, disease presentation, sites of recurrence, comorbidities, and other treatment- and patient-specific features for patients with SCLC, particularly in the second-line setting, Implement individualized treatment plans for patients with SCLC that leverage team-based approaches to shared decision-making, patient education and counseling, and adverse event management and monitoring.

Go online to PeerView.com/PYK860 to view the activity, download slides and practice aids, and complete the post-test to earn credit. Small cell lung cancer (SCLC) is known as an aggressive, rapidly progressing, and challenging thoracic malignancy. After lacking progress for decades, recent advances have finally led to approvals of new therapies that can improve outcomes and quality of life of patients with SCLC. Chemoimmunotherapy has become the new standard of care in the first-line setting, a novel transcription inhibitor has expanded very limited options in the second-line setting, and many ongoing trials and innovative approaches are anticipated to further escalate progress in this challenging subtype of lung cancer. These developments have also provided new hope to patients with SCLC, which makes it important to ensure that all patients have access to these therapies and have the opportunity to benefit from them, as well as being encouraged to consider clinical trial participation. This activity focuses on evidence and practical guidance to help clinicians make the most of the latest treatment advances in SCLC. Essential data and best-practice recommendations are framed with cases to illustrate how to integrate the new therapeutic options into clinical practice. Investigational therapies and key ongoing trials are also highlighted to continue to better understand the biology of SCLC and the expanding the treatment options. Upon completion of this activity, participants should be better able to: Apply the latest efficacy and safety data on novel systemic therapeutic options for SCLC taking into consideration their characteristics, mechanism of action, most recent treatment guidelines, clinical activity, and adverse event profile, Integrate the latest therapies into preferred prescribing protocols and formularies accounting for prior treatment history, duration of chemotherapy-free interval, disease presentation, sites of recurrence, comorbidities, and other treatment- and patient-specific features for patients with SCLC, particularly in the second-line setting, Implement individualized treatment plans for patients with SCLC that leverage team-based approaches to shared decision-making, patient education and counseling, and adverse event management and monitoring.

Go online to PeerView.com/PYK860 to view the activity, download slides and practice aids, and complete the post-test to earn credit. Small cell lung cancer (SCLC) is known as an aggressive, rapidly progressing, and challenging thoracic malignancy. After lacking progress for decades, recent advances have finally led to approvals of new therapies that can improve outcomes and quality of life of patients with SCLC. Chemoimmunotherapy has become the new standard of care in the first-line setting, a novel transcription inhibitor has expanded very limited options in the second-line setting, and many ongoing trials and innovative approaches are anticipated to further escalate progress in this challenging subtype of lung cancer. These developments have also provided new hope to patients with SCLC, which makes it important to ensure that all patients have access to these therapies and have the opportunity to benefit from them, as well as being encouraged to consider clinical trial participation. This activity focuses on evidence and practical guidance to help clinicians make the most of the latest treatment advances in SCLC. Essential data and best-practice recommendations are framed with cases to illustrate how to integrate the new therapeutic options into clinical practice. Investigational therapies and key ongoing trials are also highlighted to continue to better understand the biology of SCLC and the expanding the treatment options. Upon completion of this activity, participants should be better able to: Apply the latest efficacy and safety data on novel systemic therapeutic options for SCLC taking into consideration their characteristics, mechanism of action, most recent treatment guidelines, clinical activity, and adverse event profile, Integrate the latest therapies into preferred prescribing protocols and formularies accounting for prior treatment history, duration of chemotherapy-free interval, disease presentation, sites of recurrence, comorbidities, and other treatment- and patient-specific features for patients with SCLC, particularly in the second-line setting, Implement individualized treatment plans for patients with SCLC that leverage team-based approaches to shared decision-making, patient education and counseling, and adverse event management and monitoring.

Go online to PeerView.com/PYK860 to view the activity, download slides and practice aids, and complete the post-test to earn credit. Small cell lung cancer (SCLC) is known as an aggressive, rapidly progressing, and challenging thoracic malignancy. After lacking progress for decades, recent advances have finally led to approvals of new therapies that can improve outcomes and quality of life of patients with SCLC. Chemoimmunotherapy has become the new standard of care in the first-line setting, a novel transcription inhibitor has expanded very limited options in the second-line setting, and many ongoing trials and innovative approaches are anticipated to further escalate progress in this challenging subtype of lung cancer. These developments have also provided new hope to patients with SCLC, which makes it important to ensure that all patients have access to these therapies and have the opportunity to benefit from them, as well as being encouraged to consider clinical trial participation. This activity focuses on evidence and practical guidance to help clinicians make the most of the latest treatment advances in SCLC. Essential data and best-practice recommendations are framed with cases to illustrate how to integrate the new therapeutic options into clinical practice. Investigational therapies and key ongoing trials are also highlighted to continue to better understand the biology of SCLC and the expanding the treatment options. Upon completion of this activity, participants should be better able to: Apply the latest efficacy and safety data on novel systemic therapeutic options for SCLC taking into consideration their characteristics, mechanism of action, most recent treatment guidelines, clinical activity, and adverse event profile, Integrate the latest therapies into preferred prescribing protocols and formularies accounting for prior treatment history, duration of chemotherapy-free interval, disease presentation, sites of recurrence, comorbidities, and other treatment- and patient-specific features for patients with SCLC, particularly in the second-line setting, Implement individualized treatment plans for patients with SCLC that leverage team-based approaches to shared decision-making, patient education and counseling, and adverse event management and monitoring.

Go online to PeerView.com/PYK860 to view the activity, download slides and practice aids, and complete the post-test to earn credit. Small cell lung cancer (SCLC) is known as an aggressive, rapidly progressing, and challenging thoracic malignancy. After lacking progress for decades, recent advances have finally led to approvals of new therapies that can improve outcomes and quality of life of patients with SCLC. Chemoimmunotherapy has become the new standard of care in the first-line setting, a novel transcription inhibitor has expanded very limited options in the second-line setting, and many ongoing trials and innovative approaches are anticipated to further escalate progress in this challenging subtype of lung cancer. These developments have also provided new hope to patients with SCLC, which makes it important to ensure that all patients have access to these therapies and have the opportunity to benefit from them, as well as being encouraged to consider clinical trial participation. This activity focuses on evidence and practical guidance to help clinicians make the most of the latest treatment advances in SCLC. Essential data and best-practice recommendations are framed with cases to illustrate how to integrate the new therapeutic options into clinical practice. Investigational therapies and key ongoing trials are also highlighted to continue to better understand the biology of SCLC and the expanding the treatment options. Upon completion of this activity, participants should be better able to: Apply the latest efficacy and safety data on novel systemic therapeutic options for SCLC taking into consideration their characteristics, mechanism of action, most recent treatment guidelines, clinical activity, and adverse event profile, Integrate the latest therapies into preferred prescribing protocols and formularies accounting for prior treatment history, duration of chemotherapy-free interval, disease presentation, sites of recurrence, comorbidities, and other treatment- and patient-specific features for patients with SCLC, particularly in the second-line setting, Implement individualized treatment plans for patients with SCLC that leverage team-based approaches to shared decision-making, patient education and counseling, and adverse event management and monitoring.

Join us for an excerpt from a webinar hosted by executives from Utah Cancer Specialists, XIFIN, Inc. and Infinx, on common revenue cycle obstacles facing oncology practices. The panelists provide proactive ways to optimize prior authorization, eligibility verifications, appeals management, financial reporting, and analytics workflows to yield increased reimbursements and profits.

Dr. Rebecca Johnson is a pediatric oncologist/hematologist at Mary Bridge Children's Hospital in Tacoma, Washington. She specializes in treating childhood blood disorders and cancer in kids, teens, and young adults. While at Seattle Children's Hospital, she founded the adolescent and young adult oncology program and is now building a similar program at Mary Bridge.  Dr. Johnson was diagnosed with breast cancer when she was 27 years old. This personal experience helped shape her research interests, which include patient engagement, cancer epidemiology, and unmet needs and barriers to care among adolescents and young adults. Earlier this year, Dr. Johnson and colleagues wrote a clinical review of breast cancer in adolescent and young adult women that was published in the Journal of Oncology Practice. Listen to the episode to hear Dr. Johnson discuss: why the number of younger women diagnosed with breast cancer is going up, as well as the size of the increase issues that are more challenging for younger women with breast cancer reconstruction options for very young women her advice for a newly diagnosed adolescent or young woman

Hypercalcemia of malignancy (HCM) affects about 30% of all patients with cancer. Patients with breast cancer that has metastasized to bone and patients with squamous cell lung cancer together account for more than half of all HCM cases. ONS member Marcelle Kaplan, RN, MS, CNS, CBCN®–Emeritus, AOCN®–Emeritus, breast oncology clinical specialist and member of the Long Island/Queens ONS Chapter, and Stephanie Jardine, BSN, RN, oncology clinical specialist at ONS, discuss hypercalcemia of malignancy and its current treatment strategies. This episode is part of a series about oncologic emergencies; the other episodes are linked in the episode notes. Music Credit: "Fireflies and Stardust" by Kevin MacLeod Licensed under Creative Commons by Attribution 3.0 Earn 0.5 contact hours of nursing continuing professional development (NCPD) by listening to the full recording and completing an evaluation at myoutcomes.ons.org by January 28, 2024. The planners and faculty for this episode have no relevant financial relationships with ineligible companies to disclose. ONS is accredited as a provider of NCPD by the American Nurses Credentialing Center's Commission on Accreditation. Episode Notes Check out these resources from today's episode: Complete this evaluation for free NCPD. Previous Oncology Nursing Podcast episodes on oncologic emergencies ONS Voice article: Diagnose and Treat Hypercalcemia of Malignancy ONS Voice article: Oncology Nurses' Role in Recognizing and Addressing Oncologic Emergencies Clinical Journal of Oncology Nursing article: Hypercalcemia of Malignancy: Part I Clinical Journal of Oncology Nursing article: Hypercalcemia of Malignancy: Part II ONS book: Understanding and Managing Oncologic Emergencies: A Resource for Nurses (third edition) ONS course: Essentials in Oncologic Emergencies for the Advanced Practice Provider ONS course: Oncologic Emergencies ONS course: Treatment and Symptom Management—Oncology RN Journal of Oncology Practice article: Cancer-related hypercalcemia To discuss the information in this episode with other oncology nurses, visit the ONS Communities. To provide feedback or otherwise reach ONS about the podcast, email pubONSVoice@ons.org.

For many, the world of radiation therapy and oncology is relatively unknown. So, in this episode, I'm taking you behind the scenes of my radiation oncology practice to bring more awareness to radiation therapy and give you an idea of how it works and what a radiation oncologist really does. Listen in as I dive into what my day-to-day work life looks like, including what a full patient assessment consists of and how follow-up appointments with patients take place. I'll also be discussing how a treatment plan is made and approved, what happens before treatment begins, and what the experience is like for patients who get radiation therapy. You can find show notes and more information by clicking here: https://cancerfromatoz.com/episodes/8

Go online to PeerView.com/DJB860 to view the activity, download slides and practice aids, and complete the post-test to earn credit. What's new in the treatment of small cell lung cancer (SCLC), and how can healthcare professionals make the most of the accelerating therapeutic progress to maximize benefits for patients? For many years, SCLC was viewed as a challenging subtype of lung cancer, with limited treatment advances and poor outcomes, but recent developments have brought new options and hope for improved outcomes for these patients. This educational activity provides a grand tour through the exciting changes in the treatment arsenal for SCLC, including the impact of chemo-immunotherapy in the first-line setting and the emergence of the transcription inhibitor lurbinectedin as the new standard of care in the second-line setting, as well as a sneak peek into the future, focusing on what's looking promising on the horizon based on findings from ongoing research efforts. The exploration of the treatment advances are framed by cases to illustrate how to integrate the new therapeutic options into practice and what factors to consider when constructing individualized treatment plans. Progress is inconsequential if it doesn't rapidly translate into practice. Are you prepared to take all the necessary steps to improve outcomes for your patients with SCLC? Upon completion of this activity, participants should be better able to: Review the role and rationale for integrating novel therapies into the SCLC treatment arsenal, Assess the safety and efficacy data evaluating established and newly approved treatment options, including transcription inhibition as a novel therapeutic approach, for patients with SCLC, Integrate approved and emerging therapies into individualized management plans for patients with SCLC taking into consideration the latest findings, current guidelines and recommendations, and patient needs and preferences.

Go online to PeerView.com/DJB860 to view the activity, download slides and practice aids, and complete the post-test to earn credit. What's new in the treatment of small cell lung cancer (SCLC), and how can healthcare professionals make the most of the accelerating therapeutic progress to maximize benefits for patients? For many years, SCLC was viewed as a challenging subtype of lung cancer, with limited treatment advances and poor outcomes, but recent developments have brought new options and hope for improved outcomes for these patients. This educational activity provides a grand tour through the exciting changes in the treatment arsenal for SCLC, including the impact of chemo-immunotherapy in the first-line setting and the emergence of the transcription inhibitor lurbinectedin as the new standard of care in the second-line setting, as well as a sneak peek into the future, focusing on what's looking promising on the horizon based on findings from ongoing research efforts. The exploration of the treatment advances are framed by cases to illustrate how to integrate the new therapeutic options into practice and what factors to consider when constructing individualized treatment plans. Progress is inconsequential if it doesn't rapidly translate into practice. Are you prepared to take all the necessary steps to improve outcomes for your patients with SCLC? Upon completion of this activity, participants should be better able to: Review the role and rationale for integrating novel therapies into the SCLC treatment arsenal, Assess the safety and efficacy data evaluating established and newly approved treatment options, including transcription inhibition as a novel therapeutic approach, for patients with SCLC, Integrate approved and emerging therapies into individualized management plans for patients with SCLC taking into consideration the latest findings, current guidelines and recommendations, and patient needs and preferences.

Go online to PeerView.com/DJB860 to view the activity, download slides and practice aids, and complete the post-test to earn credit. What's new in the treatment of small cell lung cancer (SCLC), and how can healthcare professionals make the most of the accelerating therapeutic progress to maximize benefits for patients? For many years, SCLC was viewed as a challenging subtype of lung cancer, with limited treatment advances and poor outcomes, but recent developments have brought new options and hope for improved outcomes for these patients. This educational activity provides a grand tour through the exciting changes in the treatment arsenal for SCLC, including the impact of chemo-immunotherapy in the first-line setting and the emergence of the transcription inhibitor lurbinectedin as the new standard of care in the second-line setting, as well as a sneak peek into the future, focusing on what's looking promising on the horizon based on findings from ongoing research efforts. The exploration of the treatment advances are framed by cases to illustrate how to integrate the new therapeutic options into practice and what factors to consider when constructing individualized treatment plans. Progress is inconsequential if it doesn't rapidly translate into practice. Are you prepared to take all the necessary steps to improve outcomes for your patients with SCLC? Upon completion of this activity, participants should be better able to: Review the role and rationale for integrating novel therapies into the SCLC treatment arsenal, Assess the safety and efficacy data evaluating established and newly approved treatment options, including transcription inhibition as a novel therapeutic approach, for patients with SCLC, Integrate approved and emerging therapies into individualized management plans for patients with SCLC taking into consideration the latest findings, current guidelines and recommendations, and patient needs and preferences.

Go online to PeerView.com/DJB860 to view the activity, download slides and practice aids, and complete the post-test to earn credit. What's new in the treatment of small cell lung cancer (SCLC), and how can healthcare professionals make the most of the accelerating therapeutic progress to maximize benefits for patients? For many years, SCLC was viewed as a challenging subtype of lung cancer, with limited treatment advances and poor outcomes, but recent developments have brought new options and hope for improved outcomes for these patients. This educational activity provides a grand tour through the exciting changes in the treatment arsenal for SCLC, including the impact of chemo-immunotherapy in the first-line setting and the emergence of the transcription inhibitor lurbinectedin as the new standard of care in the second-line setting, as well as a sneak peek into the future, focusing on what's looking promising on the horizon based on findings from ongoing research efforts. The exploration of the treatment advances are framed by cases to illustrate how to integrate the new therapeutic options into practice and what factors to consider when constructing individualized treatment plans. Progress is inconsequential if it doesn't rapidly translate into practice. Are you prepared to take all the necessary steps to improve outcomes for your patients with SCLC? Upon completion of this activity, participants should be better able to: Review the role and rationale for integrating novel therapies into the SCLC treatment arsenal, Assess the safety and efficacy data evaluating established and newly approved treatment options, including transcription inhibition as a novel therapeutic approach, for patients with SCLC, Integrate approved and emerging therapies into individualized management plans for patients with SCLC taking into consideration the latest findings, current guidelines and recommendations, and patient needs and preferences.

Go online to PeerView.com/DJB860 to view the activity, download slides and practice aids, and complete the post-test to earn credit. What's new in the treatment of small cell lung cancer (SCLC), and how can healthcare professionals make the most of the accelerating therapeutic progress to maximize benefits for patients? For many years, SCLC was viewed as a challenging subtype of lung cancer, with limited treatment advances and poor outcomes, but recent developments have brought new options and hope for improved outcomes for these patients. This educational activity provides a grand tour through the exciting changes in the treatment arsenal for SCLC, including the impact of chemo-immunotherapy in the first-line setting and the emergence of the transcription inhibitor lurbinectedin as the new standard of care in the second-line setting, as well as a sneak peek into the future, focusing on what's looking promising on the horizon based on findings from ongoing research efforts. The exploration of the treatment advances are framed by cases to illustrate how to integrate the new therapeutic options into practice and what factors to consider when constructing individualized treatment plans. Progress is inconsequential if it doesn't rapidly translate into practice. Are you prepared to take all the necessary steps to improve outcomes for your patients with SCLC? Upon completion of this activity, participants should be better able to: Review the role and rationale for integrating novel therapies into the SCLC treatment arsenal, Assess the safety and efficacy data evaluating established and newly approved treatment options, including transcription inhibition as a novel therapeutic approach, for patients with SCLC, Integrate approved and emerging therapies into individualized management plans for patients with SCLC taking into consideration the latest findings, current guidelines and recommendations, and patient needs and preferences.

Go online to PeerView.com/DJB860 to view the activity, download slides and practice aids, and complete the post-test to earn credit. What's new in the treatment of small cell lung cancer (SCLC), and how can healthcare professionals make the most of the accelerating therapeutic progress to maximize benefits for patients? For many years, SCLC was viewed as a challenging subtype of lung cancer, with limited treatment advances and poor outcomes, but recent developments have brought new options and hope for improved outcomes for these patients. This educational activity provides a grand tour through the exciting changes in the treatment arsenal for SCLC, including the impact of chemo-immunotherapy in the first-line setting and the emergence of the transcription inhibitor lurbinectedin as the new standard of care in the second-line setting, as well as a sneak peek into the future, focusing on what's looking promising on the horizon based on findings from ongoing research efforts. The exploration of the treatment advances are framed by cases to illustrate how to integrate the new therapeutic options into practice and what factors to consider when constructing individualized treatment plans. Progress is inconsequential if it doesn't rapidly translate into practice. Are you prepared to take all the necessary steps to improve outcomes for your patients with SCLC? Upon completion of this activity, participants should be better able to: Review the role and rationale for integrating novel therapies into the SCLC treatment arsenal, Assess the safety and efficacy data evaluating established and newly approved treatment options, including transcription inhibition as a novel therapeutic approach, for patients with SCLC, Integrate approved and emerging therapies into individualized management plans for patients with SCLC taking into consideration the latest findings, current guidelines and recommendations, and patient needs and preferences.

Go online to PeerView.com/DJB860 to view the activity, download slides and practice aids, and complete the post-test to earn credit. What's new in the treatment of small cell lung cancer (SCLC), and how can healthcare professionals make the most of the accelerating therapeutic progress to maximize benefits for patients? For many years, SCLC was viewed as a challenging subtype of lung cancer, with limited treatment advances and poor outcomes, but recent developments have brought new options and hope for improved outcomes for these patients. This educational activity provides a grand tour through the exciting changes in the treatment arsenal for SCLC, including the impact of chemo-immunotherapy in the first-line setting and the emergence of the transcription inhibitor lurbinectedin as the new standard of care in the second-line setting, as well as a sneak peek into the future, focusing on what's looking promising on the horizon based on findings from ongoing research efforts. The exploration of the treatment advances are framed by cases to illustrate how to integrate the new therapeutic options into practice and what factors to consider when constructing individualized treatment plans. Progress is inconsequential if it doesn't rapidly translate into practice. Are you prepared to take all the necessary steps to improve outcomes for your patients with SCLC? Upon completion of this activity, participants should be better able to: Review the role and rationale for integrating novel therapies into the SCLC treatment arsenal, Assess the safety and efficacy data evaluating established and newly approved treatment options, including transcription inhibition as a novel therapeutic approach, for patients with SCLC, Integrate approved and emerging therapies into individualized management plans for patients with SCLC taking into consideration the latest findings, current guidelines and recommendations, and patient needs and preferences.

Go online to PeerView.com/DJB860 to view the activity, download slides and practice aids, and complete the post-test to earn credit. What's new in the treatment of small cell lung cancer (SCLC), and how can healthcare professionals make the most of the accelerating therapeutic progress to maximize benefits for patients? For many years, SCLC was viewed as a challenging subtype of lung cancer, with limited treatment advances and poor outcomes, but recent developments have brought new options and hope for improved outcomes for these patients. This educational activity provides a grand tour through the exciting changes in the treatment arsenal for SCLC, including the impact of chemo-immunotherapy in the first-line setting and the emergence of the transcription inhibitor lurbinectedin as the new standard of care in the second-line setting, as well as a sneak peek into the future, focusing on what's looking promising on the horizon based on findings from ongoing research efforts. The exploration of the treatment advances are framed by cases to illustrate how to integrate the new therapeutic options into practice and what factors to consider when constructing individualized treatment plans. Progress is inconsequential if it doesn't rapidly translate into practice. Are you prepared to take all the necessary steps to improve outcomes for your patients with SCLC? Upon completion of this activity, participants should be better able to: Review the role and rationale for integrating novel therapies into the SCLC treatment arsenal, Assess the safety and efficacy data evaluating established and newly approved treatment options, including transcription inhibition as a novel therapeutic approach, for patients with SCLC, Integrate approved and emerging therapies into individualized management plans for patients with SCLC taking into consideration the latest findings, current guidelines and recommendations, and patient needs and preferences.

What is the art involved in developing a personalized seamless IO approach that marries traditional local therapies with other complementary therapies from other traditions? In this podcast, Judith Lacey interviews Prof Ben Arye exploring the overlap between integration of traditional Medicines of the regions we work in and the more well-established complementary therapies from other traditions such as traditional Chinese medicine, yoga ( ayurvedic medicine, and other fields). Can we integrate traditional practices, herbs, and foods into holistic integrative oncology care? We also look at embedding research into clinical care and the developments of the global task force for the Society for Integrative Oncology and the vision of how we develop a global community in this rapidly growing and important field of cancer care. Prof Eran Ben Arye, director of Integrative oncology service in Haifa and the Western Galilee service, Israel, former chairperson of the Israel Society for complementary medicine, primary researcher for IO in the middle east cancer Consortium (MECC) and member of the board of Society for Integrative Oncology. Prof Ben Arye has published extensively in the field of Integrative oncology and co directs the SIO international and online taskforces and is a leader in the field. He works in the unique setting with a multicultural team in a multicultural community in the north of Israel working with Jewish and Arab populations and learning from their traditions of healing and the role of medicinal herbs and food in supporting patients living with cancer.

As the need for oncology services increases and the predicted shortage of oncologists draws near, the number of locum tenens positions is expected to increase. How can advanced practitioners help with the hiring and onboarding of locum tenens physicians while supporting patients and ensuring their continuity of care? In this episode, we address checklists for locum tenens, how to explain the AP role to physicians, and keeping an open line of communication with patients and the entire health-care team.Resources:Association Between Treatment by Locum Tenens Internal Medicine Physicians and 30-Day Mortality Among Hospitalized Medicare Beneficiaries. JAMA. 2017 Dec 5; 318(21): 2119–2129. The Quality and Safety of Locum Doctors: A Narrative Review. J R Soc Med. 2019 Nov; 112(11): 462–471. Use of Locum Tenens Physicians in Oncology Practice. J Oncol Pract. 2010 May; 6(3): 161–163. Checklist for Hiring a Great Locum. Can Vet J. 2011 Apr; 52(4): 439–441. General Practice Locum Improvement Tool. BMJ Qual Improv Rep. 2014; 3(1): u202980.w1397.

Go online to PeerView.com/GAQ860 to view the activity, download slides and practice aids, and complete the post-test to earn credit. In this activity, an expert in immuno-oncology discusses modern management of patients with a range of cancers using immune checkpoint inhibitors, focusing on dosing and administration schedules based on the latest safety and efficacy considerations. Upon completion of this activity, participants will be able to: Describe the mechanisms of action, rationale, pharmacokinetic and pharmacodynamic profiles, and established and updated dosing recommendations for available immune checkpoint inhibitors and combination therapies for patients with cancer, Identify key safety and efficacy considerations among other pros and cons related to immunotherapy dosing and dose schedules, particularly with regard to extended-interval dosing, flipped dosing, dosing based on tumor type, and dose modification to minimize toxicity, Develop a plan to personalize immunotherapy selection, dosing, and administration for patients with cancer, taking into account pros and cons of relevant standard and alternative dosing approaches, current recommendations, appropriate immune-related adverse event monitoring strategies, and the clinical constraints that have been exacerbated by the COVID-19 pandemic.

Go online to PeerView.com/GAQ860 to view the activity, download slides and practice aids, and complete the post-test to earn credit. In this activity, an expert in immuno-oncology discusses modern management of patients with a range of cancers using immune checkpoint inhibitors, focusing on dosing and administration schedules based on the latest safety and efficacy considerations. Upon completion of this activity, participants will be able to: Describe the mechanisms of action, rationale, pharmacokinetic and pharmacodynamic profiles, and established and updated dosing recommendations for available immune checkpoint inhibitors and combination therapies for patients with cancer, Identify key safety and efficacy considerations among other pros and cons related to immunotherapy dosing and dose schedules, particularly with regard to extended-interval dosing, flipped dosing, dosing based on tumor type, and dose modification to minimize toxicity, Develop a plan to personalize immunotherapy selection, dosing, and administration for patients with cancer, taking into account pros and cons of relevant standard and alternative dosing approaches, current recommendations, appropriate immune-related adverse event monitoring strategies, and the clinical constraints that have been exacerbated by the COVID-19 pandemic.

Go online to PeerView.com/GAQ860 to view the activity, download slides and practice aids, and complete the post-test to earn credit. In this activity, an expert in immuno-oncology discusses modern management of patients with a range of cancers using immune checkpoint inhibitors, focusing on dosing and administration schedules based on the latest safety and efficacy considerations. Upon completion of this activity, participants will be able to: Describe the mechanisms of action, rationale, pharmacokinetic and pharmacodynamic profiles, and established and updated dosing recommendations for available immune checkpoint inhibitors and combination therapies for patients with cancer, Identify key safety and efficacy considerations among other pros and cons related to immunotherapy dosing and dose schedules, particularly with regard to extended-interval dosing, flipped dosing, dosing based on tumor type, and dose modification to minimize toxicity, Develop a plan to personalize immunotherapy selection, dosing, and administration for patients with cancer, taking into account pros and cons of relevant standard and alternative dosing approaches, current recommendations, appropriate immune-related adverse event monitoring strategies, and the clinical constraints that have been exacerbated by the COVID-19 pandemic.

Go online to PeerView.com/GAQ860 to view the activity, download slides and practice aids, and complete the post-test to earn credit. In this activity, an expert in immuno-oncology discusses modern management of patients with a range of cancers using immune checkpoint inhibitors, focusing on dosing and administration schedules based on the latest safety and efficacy considerations. Upon completion of this activity, participants will be able to: Describe the mechanisms of action, rationale, pharmacokinetic and pharmacodynamic profiles, and established and updated dosing recommendations for available immune checkpoint inhibitors and combination therapies for patients with cancer, Identify key safety and efficacy considerations among other pros and cons related to immunotherapy dosing and dose schedules, particularly with regard to extended-interval dosing, flipped dosing, dosing based on tumor type, and dose modification to minimize toxicity, Develop a plan to personalize immunotherapy selection, dosing, and administration for patients with cancer, taking into account pros and cons of relevant standard and alternative dosing approaches, current recommendations, appropriate immune-related adverse event monitoring strategies, and the clinical constraints that have been exacerbated by the COVID-19 pandemic.

Go online to PeerView.com/GAQ860 to view the activity, download slides and practice aids, and complete the post-test to earn credit. In this activity, an expert in immuno-oncology discusses modern management of patients with a range of cancers using immune checkpoint inhibitors, focusing on dosing and administration schedules based on the latest safety and efficacy considerations. Upon completion of this activity, participants will be able to: Describe the mechanisms of action, rationale, pharmacokinetic and pharmacodynamic profiles, and established and updated dosing recommendations for available immune checkpoint inhibitors and combination therapies for patients with cancer, Identify key safety and efficacy considerations among other pros and cons related to immunotherapy dosing and dose schedules, particularly with regard to extended-interval dosing, flipped dosing, dosing based on tumor type, and dose modification to minimize toxicity, Develop a plan to personalize immunotherapy selection, dosing, and administration for patients with cancer, taking into account pros and cons of relevant standard and alternative dosing approaches, current recommendations, appropriate immune-related adverse event monitoring strategies, and the clinical constraints that have been exacerbated by the COVID-19 pandemic.

Go online to PeerView.com/GAQ860 to view the activity, download slides and practice aids, and complete the post-test to earn credit. In this activity, an expert in immuno-oncology discusses modern management of patients with a range of cancers using immune checkpoint inhibitors, focusing on dosing and administration schedules based on the latest safety and efficacy considerations. Upon completion of this activity, participants will be able to: Describe the mechanisms of action, rationale, pharmacokinetic and pharmacodynamic profiles, and established and updated dosing recommendations for available immune checkpoint inhibitors and combination therapies for patients with cancer, Identify key safety and efficacy considerations among other pros and cons related to immunotherapy dosing and dose schedules, particularly with regard to extended-interval dosing, flipped dosing, dosing based on tumor type, and dose modification to minimize toxicity, Develop a plan to personalize immunotherapy selection, dosing, and administration for patients with cancer, taking into account pros and cons of relevant standard and alternative dosing approaches, current recommendations, appropriate immune-related adverse event monitoring strategies, and the clinical constraints that have been exacerbated by the COVID-19 pandemic.

Go online to PeerView.com/GAQ860 to view the activity, download slides and practice aids, and complete the post-test to earn credit. In this activity, an expert in immuno-oncology discusses modern management of patients with a range of cancers using immune checkpoint inhibitors, focusing on dosing and administration schedules based on the latest safety and efficacy considerations. Upon completion of this activity, participants will be able to: Describe the mechanisms of action, rationale, pharmacokinetic and pharmacodynamic profiles, and established and updated dosing recommendations for available immune checkpoint inhibitors and combination therapies for patients with cancer, Identify key safety and efficacy considerations among other pros and cons related to immunotherapy dosing and dose schedules, particularly with regard to extended-interval dosing, flipped dosing, dosing based on tumor type, and dose modification to minimize toxicity, Develop a plan to personalize immunotherapy selection, dosing, and administration for patients with cancer, taking into account pros and cons of relevant standard and alternative dosing approaches, current recommendations, appropriate immune-related adverse event monitoring strategies, and the clinical constraints that have been exacerbated by the COVID-19 pandemic.

Go online to PeerView.com/GAQ860 to view the activity, download slides and practice aids, and complete the post-test to earn credit. In this activity, an expert in immuno-oncology discusses modern management of patients with a range of cancers using immune checkpoint inhibitors, focusing on dosing and administration schedules based on the latest safety and efficacy considerations. Upon completion of this activity, participants will be able to: Describe the mechanisms of action, rationale, pharmacokinetic and pharmacodynamic profiles, and established and updated dosing recommendations for available immune checkpoint inhibitors and combination therapies for patients with cancer, Identify key safety and efficacy considerations among other pros and cons related to immunotherapy dosing and dose schedules, particularly with regard to extended-interval dosing, flipped dosing, dosing based on tumor type, and dose modification to minimize toxicity, Develop a plan to personalize immunotherapy selection, dosing, and administration for patients with cancer, taking into account pros and cons of relevant standard and alternative dosing approaches, current recommendations, appropriate immune-related adverse event monitoring strategies, and the clinical constraints that have been exacerbated by the COVID-19 pandemic.

Go online to PeerView.com/GAQ860 to view the activity, download slides and practice aids, and complete the post-test to earn credit. In this activity, an expert in immuno-oncology discusses modern management of patients with a range of cancers using immune checkpoint inhibitors, focusing on dosing and administration schedules based on the latest safety and efficacy considerations. Upon completion of this activity, participants will be able to: Describe the mechanisms of action, rationale, pharmacokinetic and pharmacodynamic profiles, and established and updated dosing recommendations for available immune checkpoint inhibitors and combination therapies for patients with cancer, Identify key safety and efficacy considerations among other pros and cons related to immunotherapy dosing and dose schedules, particularly with regard to extended-interval dosing, flipped dosing, dosing based on tumor type, and dose modification to minimize toxicity, Develop a plan to personalize immunotherapy selection, dosing, and administration for patients with cancer, taking into account pros and cons of relevant standard and alternative dosing approaches, current recommendations, appropriate immune-related adverse event monitoring strategies, and the clinical constraints that have been exacerbated by the COVID-19 pandemic.

Go online to PeerView.com/GAQ860 to view the activity, download slides and practice aids, and complete the post-test to earn credit. In this activity, an expert in immuno-oncology discusses modern management of patients with a range of cancers using immune checkpoint inhibitors, focusing on dosing and administration schedules based on the latest safety and efficacy considerations. Upon completion of this activity, participants will be able to: Describe the mechanisms of action, rationale, pharmacokinetic and pharmacodynamic profiles, and established and updated dosing recommendations for available immune checkpoint inhibitors and combination therapies for patients with cancer, Identify key safety and efficacy considerations among other pros and cons related to immunotherapy dosing and dose schedules, particularly with regard to extended-interval dosing, flipped dosing, dosing based on tumor type, and dose modification to minimize toxicity, Develop a plan to personalize immunotherapy selection, dosing, and administration for patients with cancer, taking into account pros and cons of relevant standard and alternative dosing approaches, current recommendations, appropriate immune-related adverse event monitoring strategies, and the clinical constraints that have been exacerbated by the COVID-19 pandemic.

Go online to PeerView.com/GAQ860 to view the activity, download slides and practice aids, and complete the post-test to earn credit. In this activity, an expert in immuno-oncology discusses modern management of patients with a range of cancers using immune checkpoint inhibitors, focusing on dosing and administration schedules based on the latest safety and efficacy considerations. Upon completion of this activity, participants will be able to: Describe the mechanisms of action, rationale, pharmacokinetic and pharmacodynamic profiles, and established and updated dosing recommendations for available immune checkpoint inhibitors and combination therapies for patients with cancer, Identify key safety and efficacy considerations among other pros and cons related to immunotherapy dosing and dose schedules, particularly with regard to extended-interval dosing, flipped dosing, dosing based on tumor type, and dose modification to minimize toxicity, Develop a plan to personalize immunotherapy selection, dosing, and administration for patients with cancer, taking into account pros and cons of relevant standard and alternative dosing approaches, current recommendations, appropriate immune-related adverse event monitoring strategies, and the clinical constraints that have been exacerbated by the COVID-19 pandemic.

The Oncology Podcast - An Australian Oncology PerspectiveThe Oncology Podcast, brought to you by www.oncologynews.com.au, is proud to present the latest edition of The OJC Meets, in which Professor Eva Segelov and Dr Craig Underhill chat with Dr Steven Vogl.Steve is famous for his iconic introduction 'Vogl, New York' and the tough questions he asks presenters at key meetings such as ASCO and San Antonio. This year, with the necessity for Virtual Meetings, we felt Steve's voice was sorely lacking. He therefore appeared in all of our ESMO special episodes of The Oncology Journal Club. The Art of Medicine vs The Business of MedicineIn today's episode, we have a rare, in-depth interview with this truly cult figure in the oncology world. In Steve's famously acerbic style, we learn more about his long career as a generalist oncologist, have a detailed discussion of trial design and delve deeper into the intricacies of The Art of Medicine vs The Business of Medicine. It's an honest, insightful and entertaining episode so if you've ever wanted to know more about 'Vogl, New York!' you are in for a treat with this special interview. For full bios, please visit our website.For the latest oncology news visit www.oncologynews.com.au and for regular oncology updates for healthcare professionals, please subscribe to The Oncology Newsletter.