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ASCO President Dr Daniel F. Hayes Applauds Recommendations for Cancer Moonshot

Surabhi Dangi-Garimella, PhD
Daniel F. Hayes, MD, FASCO, 2016-2017 president of the American Society of Clinical Oncology, shares his vision of how the recommendations of the Blue Ribbon Panel will impact cancer care.
The Blue Ribbon Panel (BRP)—a committee of scientific experts, patient advocates, and representatives from the phar­maceutical industry, appointed by the National Cancer Institute (NCI) to lead the White House Cancer Moonshot initiative—re­leased a preliminary report1 with important recommendations that can support faster, more precise treatments for patients diagnosed with cancer, with potential for much improved outcomes. The American Journal of Managed Care® reached out to Daniel F. Hayes, MD, FASCO, 2016-2017 president of the American Society of Clinical Oncology (ASCO), to understand his perception of how these recommendations would impact cancer care in the United States.

AJMC: One of the suggestions of the BRP is to better link databases to assimilate patient information across systems, with the potential to recruit patients to participate on trials. Since interoperability remains a significant challenge for our healthcare system, do you foresee this as a more long-term recommendation?

HAYES: Widespread interoperability for sharing electronic health information is critical for optimal cancer care. It’s incredible that we have a standardized method for streaming TV shows, but not for taking care of sick patients. I’m pleased that the Panel included this recommendation in the report. Frankly, this is the kind of innovation that we cannot put on the long-term track. The cancer community—the entire medical community, actually—needs to put our full support behind interoperability so that it is achieved more quickly. The American public does not suffer lack of access and interoperability when it comes to other potentially sensitive information (eg, financial informa­tion). We should expect no less when it comes to the medical information needed to stay healthy and treat illness, especially a serious diagnosis like cancer. This is the kind of innovation that the Moonshot requires. ASCO is fully supportive of this transformative idea.

AJMC: How are individual clinics and smaller practices adopt­ing interoperability?

HAYES: There are 2 issues embedded in this question: 1) the adoption of electronic health records (EHRs) and 2) interopera­bility among them. Individual clinics and smaller practices are having a very difficult time, especially with the first. The problem isn’t isolated to just small practices, however. Even large, inter­nationally recognized cancer institutions may be in a situation where they’re using multiple electronic records systems that do not talk across clinics and departments—whether they are across town, in different states, or right next door to one another. This is a major concern in oncology, where we routinely work with pa­tients going to multiple medical providers across the continuum of care, eg, radiation therapy, surgery, chemotherapy, imaging, pathology, etc. Gaining access to medical information and seam­lessly integrating and analyzing it for patients across multiple providers takes more effort than it should.

Because of this, ASCO has called on Congress to address this issue directly. ASCO issued the following 4 recommendations, which should be part of the Moonshot initiative:
  • Congress should enact legislation as quickly as possible to ensure widespread interoperability is achieved.
  • Congress should pass legislation to remove barriers to interop­erability, especially information blocking.
  • Policy makers should ensure that cancer patients, oncologists, and other oncology providers do not bear the costs of achieving interoperable EHRs and of companies refraining from informa­tion blocking.
  • Federal officials should work with ASCO and other stakeholders to ensure that healthcare providers have the information nec­essary to be prudent purchasers and users of health informa­tion technology systems.
We are pleased that the BRP included the idea of a National Can­cer Data Ecosystem. ASCO is building this with CancerLinQ and working with patient organizations and our colleagues across the medical professions to integrate data.

AJMC: Although pediatric cancers have received specific recommendations from the panel to improve clinical outcomes, geriatric cancers have not. Your thoughts on that?

HAYES: You raise a very important point. It is admirable that the BRP recognized unique issues facing children with cancer, which ASCO supports. We also need to put focus on older adults with cancer because oncology clinicians face tremendous challenges in meeting their cancer care needs.

Patients over 65 make up 60% of those diagnosed with cancer and 70% of cancer deaths. ASCO issued a statement in October 2015 that includes recommendations on improving the evidence base for treating older adults with cancer.2 ASCO’s Moonshot recom­mendations to the NCI BRP included many items from the state­ment, including broadening eligibility criteria to facilitate greater participation of older adults in research, conducting pragmatic trials that focus on broader patient populations, and conducting research with real-world data.

Many of the Moonshot initiative’s recommendations are likely to improve care for older patients, even if the specific recommenda­tions are much broader. As efforts are made to implement these recommendations, however, it will be important to ensure that they consider the needs of geriatric patients.

Examples of the Panel’s recommendations that have the potential to improve care for older adults:
  • The network for patient engagement has the potential to in­crease older adults’ participation in clinical trials by matching patients based on the tumor profile to appropriate trials.
  • The National Cancer Data Ecosystem for Sharing and Analysis could provide data on older adults from real-world settings, which would complement research from randomized clinical trials that often exclude older adults.
  • The focus on research into symptom management is particular­ly relevant to older adults because this population often places great value on endpoints other than overall survival (eg, func­tional independence).
AJMC: With the rapid rise in the number of oral anticancer agents, monitoring patient adherence can prove to be a significant challenge that ultimately impacts patient outcomes. Do you think the panel should have proposed ways to improve patient adherence to treatment? How can we address this issue in cancer patients?

HAYES: Orally administered anticancer agents allow many pa­tients to undergo treatment outside of a hospital or doctor’s office and go about their daily lives with minimal disruption, providing significant advantages over more traditional intravenous (IV) or injected medications.

Patient adherence to oral anticancer agents can pose a signifi­cant challenge, because obviously, medicines don’t work in the bottle—they only work in the patient! Poor adherence leads to reduced rates of response, more complications from the cancer, and increased medical costs. Among the many barriers to oral cancer therapy adherence, cost is a significant barrier. Some health plans impose significantly higher cost-sharing require­ments on patients who receive oral anticancer medications. (Cancer medications delivered by IV are covered under the med­ical benefit provision, while cancer drugs taken orally are often covered under the outpatient prescription drug benefit.)

To address this issue, ASCO has continued to advocate for states and the federal government to pass legislation that ensures patients can access oral cancer drugs under the same general cost-sharing rules as other cancer drugs.

In addition to cost, side effects and forgetfulness in every­day life can lead to poor adherence and persistence with oral medications. In this regard, ASCO’s recommendations to the NCI highlighted the need to enhance our patient-reported outcomes (PRO) measurement tools so that we can determine what toxicities patients are actually experiencing—financial, physical, or psychosocial. NCI and the oncology community have made a huge investment in developing a PRO tool that measures the common toxicity criteria in cancer clinical trials (PRO-CTCAE). We are pleased that the BRP recognized the val­ue of the PRO-CTCAE. However, ASCO further strongly recom­mends that the NCI invest in:
  1. Implementing the PRO-CTCAE, which will require invest­ment in enhancing the way we conduct trials to regularly capture toxicity information from trial participants.
  2. Enhancement of the PRO-CTCAE to incorporate additional factors that patients may consider when making a treat­ment decision, in addition to the “important medical and clinical conditions” already included in the PRO-CTCAE.
Although various methods for measuring and improving ad­herence are available, additional research is needed to identify optimal methods that will work across diverse practice settings. Indeed, ASCO has supported such trials through our Conquer Cancer Foundation grants system. Other organizations, includ­ing NCI, are doing so as well, but we need more resources to address this critical issue.

AJMC: As we transition toward precision healthcare, there is no dearth of diagnostic tests or molecular data on tumors. However, interpretation of this data seems to be a significant hurdle. Does the report address this issue?

HAYES: Several sections of the report include provisions that would help advance our understanding of diagnostic testing and molecu­lar profiling data:
  • Network for direct patient engagement: making testing accessi­ble and enabling data sharing and participation in molecularly driven clinical trials
  • Fusion oncoproteins in pediatric cancer: improving under­standing of the role of oncoproteins in pediatric cancers and identifying therapeutic targets
  • Retrospective analysis of biospecimens from patients treated with standard of care: we may discover molecular biomarkers for response or resistance
  • Generation of human tumor atlases: documenting genetic lesions and cellular interactions that guide the development of each tumor as it evolves from a precancerous lesion to advanced cancer
Many of these recommendations build on important work that the NCI is already engaged in, such as genomic testing and inves­tigation of molecularly driven therapies in the adult and pediatric MATCH trials and Lung-MAP trial, biospecimen banking and analysis through the National Clinical Trials Network and the Co­operative Groups before it, the Exceptional Responders Programs, and The Cancer Genome Atlas (TCGA) that advanced basic science understanding of common tumors.

 
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