Advanced Cancer Treatments Far from Big-Name Hospitals

Community health-care systems are taking steps to embrace genetic testing in treating
cancer, a cutting-edge approach offered at most major academic medical centers.
The changes mean patients can get treatment close to where they live. The hospitals and
small practices treat most cancer patients but may be far from major research centers
and have fewer resources than them.
 
Programs that standardize the use of genetic testing in cancer care are ongoing at
Carolinas HealthCare System’s Levine Cancer Institute and Sanford Health in the
Dakotas. Multistate health-care systems Dignity Health, Catholic Health Initiatives and
Ascension are developing programs slated to roll out this year and 2018.
 
“I don’t feel like anybody with cancer should have to travel when they’re as sick as they
are,” said Steven Powell, an oncologist at Sanford Health practicing in Sioux Falls, S.D.
Dr. Powell is leading the health system’s programs, which have recently begun to offer
patients cutting-edge testing to help guide treatment, also called precision medicine.
“We have to do a better job of expanding [cancer research] in the community,” he adds,
because “that’s where patients are.”
 
In cancer care, precision medicine refers to the idea that finding the genetic mutations
in an individual patient’s tumor can point to a personalized treatment. Tests for single
abnormalities paired with drugs that target those abnormalities have been approved by
the U.S. Food and Drug Administration and are part of standards of care for a few types
of cancer. Newer tests screen hundreds of genes for mutations at once, which doctors
are increasingly using to look for potential treatments when patients with advanced
cancer have run out of standard options.
 
The movement to test tumors for hundreds of genetic mutations at once began in research-focused academic centers about a decade ago. But about 80% to 85% of cancer
patients receive care in community settings, said Richard Schilsky, chief medical officer
of the American Society of Clinical Oncology, a professional organization for cancer
specialists.
 
Companies such as Caris Life Sciences and Foundation Medicine have made testing for
hundreds of gene mutations widely available, but many community oncologists are
“adrift,” without the resources to interpret the complicated results, Dr. Schilsky said.
“The doctor ends up sitting there scratching his or her head wondering what to do.”
 
In community-based practices, challenges include the sheer volume of emerging
research for doctors to follow, complicated logistics for sending biopsy specimens to
testing labs, patchy reimbursement from insurance companies and limited patient
access to off-label drugs and clinical trials.
 
Using such tests, however, can be expensive, especially if testing leads to patients taking
unproven off-label treatments outside of clinical trials, says Howard West, an oncologist
at the Swedish Cancer Institute in Seattle, a nonacademic research-oriented cancer
center, who goes by the nickname Jack. “I’m concerned too many doctors and patients
may decide to chase down a rabbit hole,” he said.
 
Catholic Health Initiatives, a 104-hospital nonprofit system in 18 states, surveyed
approximately 30 of its oncologists and pathologists representing primarily community
practices a year ago. All the physicians knew of broad genomic testing and felt that some
types were important to making decisions. But only about a quarter were routinely
using such testing, says Dax Kurbegov, a physician and vice president of the health
system’s Institute for Research and Innovation. Physicians thought the tests were
important but “too chaotic and time-demanding to apply in day to day practice,” he says.
 
In response, Catholic Health Initiatives has joined Dignity Health, a California-based
health system with more than 400 care centers in 22 states, to develop a technological
infrastructure for precision medicine. Once a doctor orders a test, the system will track
its status, receive the results, supply educational materials to aid decisions and then
streamline the process of ordering off-label drugs or matching patients to clinical trials.
The program will collect data on how testing affects patients’ treatment and outcomes
for doctors to learn from the experience.
 
For doctors trying to use large-scale genetic tests, it can “feel like you’re on an island,”
says Edward Kim, chairman of solid tumor oncology and investigational therapeutics at
Carolinas HealthCare System’s Levine Cancer Institute, which has 20 sites in North and
South Carolina. His institution convened a molecular tumor board of experts to review
patients’ test results and help their doctors make decisions. The doctors also get the raw
data from genomic test results to help match patients to clinical trials.
Sanford Health, a 45-hospital health system in nine states, began standardizing its
method of collecting tumor samples to send off for multi-gene testing as part of its own
precision medicine clinical trial that began in 2014 at its four major cancer centers in
Sioux Falls, S.D., Bismarck and Fargo, N.D., and Bemidji, Minn. The next, wider iteration
of its program, which also includes a genomic tumor board, opened in 2016 and
expanded to smaller practices with single oncologists.
 
Jonathan Bleeker, an oncologist in Sanford Health’s Sioux Falls cancer center, says
testing now happens more quickly. He can get patients with advanced cancer treatment
they “wouldn’t typically be able to get in a place like Sioux Falls” without genetic testing.
One of Dr. Powell’s patients in Sioux Falls, Dale Kogel, had undergone surgery and
radiation treatment for skin cancer, but the cancer kept growing into his eye and spread
to his lungs. With few appealing options, in July 2015 he got his cancer tested for genetic
mutations. The results suggested an immunotherapy drug approved for a different type
of skin cancer. He began infusions of the drug right away.
 
A CT scan six months ago showed the tumor in his eye was gone and the ones in his lungs
were unmeasurable, says Mr. Kogel, who for most of his 68 years lived in Huron, S.D., a
two-hour drive from Sioux Falls. “At last they found something that worked,” he says.
Stories like Mr. Kogel’s aren’t the experience of every patient, Dr. Powell says, but for
some patients “we’re able to offer them something when they didn’t have any other
options available.”
 
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