Joseph Alvarnas, MD

The expression, to “pull a rabbit out of a hat,” can mean different things, from doing something unexpected or surprising, to solving a problem through unorthodox but eff ective means, to surprising others with a sudden act of skill.

Of course, the expression comes from the act of the magician bringing a furry friend seemingly from nowhere. 

I recently had the chance to visit The Magic Castle at the invitation of a patient. For those of you who have never been there, The Magic Castle is a grand chateau located in Hollywood, California, that is the performance center and clubhouse for the Academy of Magic Arts. Expert magicians come to perform everything from close-up magic to grand illusions, and their extraordinary skill and mastery is breathtaking.

I visited The Magic Castle the same week that I spent most of my time reviewing the most recent proposed CMS Inpatient Prospective Payment System (IPPS) rule. To say that these 1700 pages made for less than magical reading would be a profound understatement. While the skill and nowledge of those preparing this document is indisputable, a page turner it is not.

 Yet, something beyond the absurdist level of contrast between the “castle” and “the rule” began to gnaw at me as I reread portions of “the rule.” It eventually came to me: in a time when innovations in cancer care can produce breathtakingly better outcomes for patients and their families, nothing in the draft rule speaks to the future of oncology. Much of the IPPS rule remains grounded in care and payment models beholden to the past; little of what is here speaks toward a future in which innovative treatments, delivered through the rapidly evolving paradigm of precision medicine, will change patient lives for the better.

Watching a magician literally pull a rabbit out of a hat is an apt metaphor for how we might want to think about the future of oncology, as it is where we embrace a bold, unorthodox mindset to reimagine cancer care delivery. Iterative tweaks to Titanic-sized systems designed for patients without cancer will not bring us closer to the patient-centered/valuebased systems needed to ensure equitable, sustainable access to life saving care. Nor will it provide a means to remediate the continued, profound disparities in access and outcome, faced by toomany patients who must navigate a cancer journey.

This quantum leap will require not only great skill and knowledge, but it will also require clinicians and other stakeholders in cancer care to pursue unorthodox and innovative approaches in care delivery at a pace that cannot be replicated by government payers. In our quest to create the new oncology care paradigm, not every new model will be successful. Some will fail. Some will represent incremental improvements. Some will succeed. There will, however, be little progress until we are emboldened to “fail fast, fail often, but always fail forward.”

, we feature oncology thought leaders who are forging new paths forward toward the realization of more effective, more equitable cancer care by working with commercial payers and employers now that CMS is ready to let the Oncology Care Model lapse without a replacement. They are not waiting for instructions or permission to innovate. 

What is most striking about the world of magic, is not the superficial glamour of the performance, rather it is the iterative practice, skills, and craft that go on almost invisibly in the delivery of what we see. For our patients and their families, the system mechanics should be just as invisible, as they experience innovative care that is delivered with humility, kindness, and  compassion. It is the knowledge, insights, skills, and experiences of cancer care leaders like you that will help bring us to a deeper understanding of how to build the future of oncology. We invite you to share your knowledge and experience with us by submitting an article for publication. Become a part of these conversations that can help drive innovative and unexpected solutions to the question of how to deliver the best, most innovative care possible our patients and their families.


1. The idioms.com.https://www.theidioms.com/pull-a-rabbit-out-ofthe-
hat/ Accessed June 2, 2022.
2. Star Wars: Episode VIII – The Last Jedi.https://www.imdb.com/title/
tt2527336/?ref_=fn_al_tt_12017. Accessed June 2, 2022.
3. John C. Maxwell.https://www.goodreads.com/quotes/1309491-failearly-
fail-often-but-always-fail-forward

Articles

Pulling a Rabbit Out of the Hat

The hardest journeys in this world begin with the words, “You have cancer.” As a physician who has uttered these words too many times to patients and families, I have a full realization of their weight. For many patients across this country, this transformational moment is one of profound disempowerment, often shrouded in fear and deep uncertainty. As clinicians we must bring both compassion and a deep-seated humility when guiding a patient through a time in which everything that they and their family knew before has been irrevocably changed. Their hopes, dreams, expectations, ambitions, and milestones are now predicated upon vanquishing a foe that is far too often shrouded in mystery, mythology, and implacability.

As patients and families begin their respective cancer journeys, often they must combat both cancer and a health care system that can be indifferent or hostile to their needs. At these times, the readily deployable tools of health care efficiency—narrow networks, step therapy, prior authorizations, utilization management, appeals processes—all present an existential threat to their well-being and make an already arduous journey even more painful and dehumanizing. Truth be told, when the cost-centered, relentless quest to improve value in health care turns into an obsessive and relentless pursuit of the lowest cost care, the patient’s journey becomes all the more difficult. Physicians should never be forced to become gatekeepers instead of caregivers. The quest for a cure should not be a journey measured in the number of appeals and denials that it takes to get there.

The dynamic nature of a cancer journey is unlike any in health care. Although data from the American Cancer Society show survival rates improved by 31% between 1990 and 2018, too many patients still lack a path toward a cure. The profound value of access to innovative therapeutics and the dynamic evolution of genomics-informed treatments portend a future of continued dramatic improvements in care outcomes. Yet disparities in care access and outcomes abound. As the 2020 American Association for Cancer Research Progress Report made so clear, these disparities persist across racial, ethnic, economic, and geographic lines. For patients who are Medicaid beneficiaries, care outcomes continue to lag those of patients with commercial insurance. For the most vulnerable members of our society, the journey to wholeness is more difficult, more fraught, and more unpredictable.

It is time to ensure that the needs of patients with cancer and their families become the central guiding principle of value-based care. Late in 2021, the California State Assembly became the first in the US to pass a Cancer Patient Bill of Rights (See SPXXX). In a time of political polarization and hyperpartisanship, the resolution was passed by both houses of the assembly in a unanimous vote. Cancer recognizes no party affiliation, and the enormous human toll of this set of diseases has touched virtually everyone in the country with an indiscriminate brutality. As such, we are inescapably united in our desire to defeat cancer.

The Cancer Patient Bill of Rights aims to ensure that all patients understand their diagnoses, have access to the latest care insights and precision medicine solutions, have access to necessary subspecialty care, have scalable access to whatever site of care can best address their needs during that part of their treatment journey, and can enroll in potentially lifesaving clinical trials without delay or undue barriers to access.

™ we have reviewed the dynamically evolving nature of cancer care, spoken with experts on care disparities, and listened to health care transformation leaders point toward sustainable solutions for better systems of care. Each journey begins with a first step. The Cancer Patient Bill of Rights is one of those first steps. As we move toward the realization of more equitable care, care without barriers or unnecessary delays, and better outcomes for more patients, we look toward the community of cancer leaders and stakeholders, including community and academic physicians, systems leaders, diagnostic and therapeutic innovation creators, and policy makers to make this goal a reality.

From the editor-in-chief of Evidence-Based Oncology.

We Need a Cancer Patient Bill of Rights

On February 2, President Joseph R. Biden Jr. announced the next arc of the Cancer Moonshot initiative and emphasized key deliverables in the battle against cancer. He noted that advances in cancer care, including those in genomics, immuno-oncology, and targeted therapeutics, had resulted in a 25% reduction in cancer mortality over the past 25 years. Goals of the reinvigorated Cancer Moonshot include accelerated and broader deployment of screening, a renewed focus on improving the equity of care delivery and survival outcomes, and a reorganization of key governmental leaders to speed up success. The president’s aim is a 50% reduction in age-adjusted cancer deaths by 2047.


These goals seem audacious, but they are likely achievable. The importance of early and effective systems for cancer screening cannot be overstated. The COVID-19 pandemic has exacerbated the issue of access to screening in unprecedented ways. Data from an Epic system analysis show that “screening appointments for breast, cervical, and colon cancers in March 2020 decreased between 86% and 94% compared with average volumes in the prior 3 years.”

The administration’s focus on improving screening rates, especially in underserved communities, is likely to produce an outsized impact on cancer survival rates over the next 2 decades.


Reinforcing our new therapeutic pipeline is also an essential component of ensuring the Moonshot initiative’s success. Data show that some of the greatest recent improvements in cancer survival have occurred in cancer types that respond to advanced care technologies. Increasing the depth and diversity of our anticancer portfolio will empower countless cures and extraordinary progress in improving quality of life for patients with cancer.
In this issue of 

™, we examine some of these new care technologies and their evolving role in improving outcomes. Mary Caffrey reviews the implications of the approval of chimeric antigen receptor T-cells as second-line treatment for relapsed and refractory aggressive non-Hodgkin lymphoma. In our interview with Nicholas McAndrew, MD, MSCE, a medical oncologist and breast cancer specialist at UCLA Health, we evaluate the use of CDK4/6 inhibitors in metastatic HR+/HER2-negative breast cancer.
Beyond technology, however, we cannot get onto a path toward better, more equitable care without creating systems that can deliver that care in more sustainable, patient-centered ways. In this issue, Stephen Schleicher, MD, MBA, discusses his new role at Tennessee Oncology that will focus on building systems of care that integrate palliative care and genetics counseling into a more patient-centered model. We also focus upon how to leverage models of telehealth to ensure continuity of cancer care in an era of COVID-19–related disruptions.

I believe that we are at the brink of realizing the promise of the Moonshot. That realization, however, will require that we bring our efforts down to earth. Discovery alone cannot ensure care equity absent ensuring that all patients, including the underserved, benefit from these advances. Ultimately, we cannot technologize our way to lower cancer mortality rates. We must ground these advances in the reality of the human experience. President Biden noted that, “Despite all the progress, there’s still a sense of powerlessness, guilt..., and fear.”

 Our systems and aspirations must ensure that the vulnerable person whom we are privileged to treat is at the center of our innovation and systems building. That is a challenge that lies here, back on earth: The place where lofty aspirations and high rhetoric must ultimately land if it is to succeed. 




1. Remarks by President Biden at an event to reignite the Cancer Moonshot. The White House. February 2, 2022. Accessed February 3, 2022. https://www.whitehouse.gov/briefing-room/speeches-
remarks/2022/02/02/remarks-by-president-biden-at-an-event-to-reignite-the-cancer-moonshot/
2. Fact sheet: President Biden reignites Cancer Moonshot to end cancer as we know it. The White House. February 2, 2022. Accessed February 3, 2022. https://www.whitehouse.gov/briefing-room/statements-releases/2022/02/02/fact-sheet-president-biden-
reignites-cancer-moonshot-to-end-cancer-as-we-know-it/
3. Cavallo J. How delays in screening and early cancer diagnosis amid the COVID-19 pandemic may result in increased cancer mortality: a conversation with NCI Director Norman E. “Ned” Sharpless, MD. The ASCO Post. September 10, 2020. Accessed February 3, 2022. https://ascopost.com/issues/september-10-2020/how-delays-in-screening-and-early-cancer-diagnosis-amid-the-covid-19-
pandemic-may-result-in-increased-cancer-mortality/

The president’s aim is a 50% reduction in age-adjusted cancer deaths by 2047. 
This goal seems audacious, but it is likely achievable. 

From the Editor-in-Chief: From the Earth to the Moon (and Back)

As a high school student, I learned 2 important things in my physics class: the first was that I was never going to be a physicist, and the second was the idea that objects in motion and at rest were governed by a set of simple and
defi nable rules. Sir Isaac Newton’s characterization of the universe was compelling.


The idea that there was an inherent simplicity to the motion of bodies great and small, and that this was knowable within a defi ned set of rules was
comforting. This mindset was not limited to my physics class. Physicians and teachers throughout my years of medical school and residency referenced the Gordian knot as an ideal cognitive approach toward identifying the inherent simplicity in the most complex situations. Yet, the discovery of a more wonderous set of insights regarding movement, light, matter, and time that came with the advent of quantum mechanics and relativity revealed that the world was really built upon multiplicity and confusion rather than simplicity.


In cancer care, as in physics, we need to avoid the trap of false simplicity when facing a reality that can be wondrous, fascinatingly complex, and confusing to the best of us.


The breadth of basic and clinical research performed in the domain of malignant diseases over the past 40 years have opened our minds to revelatory insights regarding cancer biology, patient clinical risk  segmentation, neoantigen targets for therapeutic development, and avenues for immunological disruption of cancer cell survival. Millions are alive today thanks to the rapid evolution in state-of-the-art cancer care. Therapies developed from the insights gleaned through genomic testing of tumor samples has led in the past 2 years to the most rapid decline in cancer mortality ever achieved.

™, we take a pause at the end of this year, to examine the state of our progress and to look toward an increasingly complex future in cancer care.


As we move toward 2022 and beyond, the rich pipeline of candidate anticancer therapeutics and the relentlessly accelerating pace of innovation portends a future in which the prospects for patients and families who are aff ected by a cancer journey grow brighter. Yet, research and innovation are not enough. A cancer journey is a human process, not a technological one. There is a tendency in health care to try to reverse-engineer care around the dollar, rather than re-engineer care around the needs of patients and families. As a result, disparities in care access and survival outcomes persist. The tendency in policy making and payment model development to conflate cancer care with other easily commodifi able care services leads to deficient policies and unsustainable payment models. We need to grow past these barriers to care and develop more robust, patient-centered systems for ensuring equitable access to optimal cancer care for each and every patient.


In the pursuit of achieving better, more equitable cancer care, we may experience increasing tensions among those who make policy, those who
pay for health care, and those who deliver care. These creative tensions are a necessary part of growing beyond the present. The best model for delivering and paying for optimal care to cancer patients has yet to be invented. To create that system, the diverse set of cancer care stakeholders must embrace the full complexity of the creative journey, while remaining cognizant of the urgency in getting this right.

™, I wish you and your families a happy, safe, and healthy holiday season. May the peace of the season and the hopefulness of a new year move us closer toward the ideal of greater health and wellness for all. 

Truth is ever to be found in simplicity, and not in the multiplicity and confusion of things.

FROM THE EDITOR-IN-CHIEF: Objects in Motion

As we live through these strange, tragic, extraordinary times, the phrase, “Trust the science” has become a mantra. The ubiquity of this phrase, with its intertwined messages of imploration and admonition, reflect the evolution of the power of social media and messaging driven by an infinitely expanding cyberspace universe. For all the silly ways in which this message has been communicated in a time when 30-second TikTok videos represent the level of discourse, there is value in acknowledging the power of science to unlock the unknown—and there is transformative value in that knowledge. Over the course of my career, progress in understanding the genetic, genomic, and epigenetic underpinnings of cancer, as well as our growing understanding of the role of the immune system in eradicating cancer cells, has unleashed a wealth of innovative and effective anti-cancer treatments. The last 2 American Cancer Society (ACS) Cancer Statistics reports demonstrated the greatest decrements in cancer mortality ever reported. In reality, the aforementioned advances in science are leading to improved survival outcomes for patients with cancer.

Not all Americans, however, realize these benefits. While it is reasonable to "Trust the science,” we need to do much more. This includes the creation of better systems of ensuring that this care is equitably available to all who need it, when they need it. Moreover, we need to ensure that the barriers of geography, distance, poverty, scientific literacy, and other social determinants of health impede equitable access to this level of care innovation. At this year’s Patient Centered Oncology Care®(PCOC) conference, presented by 

®, we heard about both advances in the science of care and exciting new models for ensuring that the life-saving benefits of cancer care advances are better realized by more patients and families. Throughout the two-day conference we heard from speakers and panelists who, while noting the growing impact of precision medicine, also described the ways in which underserved populations remained underserved. These gaps in care include access to clinical trials, trial design that fails to incorporate the needs of a diverse population, biospecimen banking practices that failed to include sufficient human diversity for the creating of new genomic analytics, the challenges of improving health literacy, and limited patient access to the requisite care expertise. Beyond the science, we need better care models that more accessible and sustainable for the underserved; we also need more effective reimbursement models that incentivize more patient access and align with greater investment into holistic and humanized care delivery. Moreover, if we are to achieve better patient outcomes and ensure more equitable patient access, our system will need to grow beyond its current ”bricks and mortar” mindset. During the PCOC meeting our discussants embraced that creative challenge and described the ways in which wearable devices, the Internet of Things, and more effective use of artificial intelligence tools to create more powerful means of engaging patients and their communities in the support of life-saving cancer care.

This year’s PCOC meeting marked a shift in our thinking. Beyond reviewing the extraordinary assets of cancer science and technology, which we have discussed for the past decade, this year began a reconsideration of the types of systems that we will need to build to find the way up beyond the limitations of our current care delivery models. As the ACS data show, the life dividend of getting better care to the millions of patients who fail to benefit fully from our current cancer care revolution is enormous. The shift toward an equitable realization of the culminated fruits of our scientific endeavors is where we venture forth toward the challenge of making the science a reality for those who need it most.

From the Editor-in-Chief: The Way Up

Yet, at times like these, the moment seems less than miraculous. As the scientific underpinnings of oncology advance well past the frontiers of
what I might have imagined possible when I graduated from medical school 32 years ago, the ability to ensure that all patients and families benefit consistently and equitably remains as distant as it has any time in the past. No matter how far knowledge and innovation can take us, we remain beholden to systems that lack the plasticity to grapple with this time of immense change. So, as we revel in the potential of all the ways in which we have advanced well past the limitations of prior decades, we remain beholden to seemingly intransigent barriers based on ossified systems of care.

Following its passage in March 2010, the Affordable Care Act promised to change so much,
but expanded coverage has yet to translate fully into equitable access to the kinds of care that represent the hallmarks of the precision medicine revolution. As we embrace a transformational pipeline of innovative, life-altering therapeutics, we continue to struggle to create a sustainable model of how best to pay for these therapeutics. Inasmuch as advanced technology, such as chimeric antigen receptor T-cells, portend the ability to effectively treat patients with relapsed and refractory cancers, we struggle to create the requisite care networks and payment models to ensure that patients who need these treatments actually receive them.

It is easy to become deluded that there are simple fixes or magical remedies for the challenges that we face in making the full breadth of cancer innovation available to the patients and families that need them most. There is no single program, piece of legislation, CMS demonstration project, or “shiny new object” that will cure the ills of our system. I have heard the word “value” bandied about in careless ways that distracts from the hard work and intradisciplinary collaboration that will be essential to fully define and subsequently realize a value-centered system of cancer care.

™, we see both the future of what can be, and the prosaic
bumps in the road that will make a full realization of that future difficult. Mary Caffrey provides a
summary of a recent webinar, “Genomic Testing Creates Opportunities for Collaboration Between
Academic Centers, Private Sector.” This conversation covered potential steps in fostering and advancing more effective cancer care that is built upon the foundations of genomic testing and precision medicine delivery. We also examine what a more effective ecosystem for delivering care to cancer patients might look like in our review of the updated standards for an Oncology Medical Home between the Community Oncology Alliance and the American Society of Clinical Oncology. At the same time, the limits of our current system, including limitations in coverage for the care of patients with blood cancers and our continued struggle with the creation of meaningful, actionable metrics for assessing oncology physician performance remind us of the ways in which our system struggles to adapt to this period of hyperdynamic change.

I remain an optimist that the lives of cancer patients and their families will continue to evolve in ways that will bring better outcomes, better patient experience, and more sustainable care costs. I do not, however, underestimate the extraordinary amount of work, collaboration, blood, toil, tears and sweat that it will take to get us there. Wherever we are, we will be there as a community of the community, trying to find the best path forward, a struggle in which we will strive, “to seek, to find, and not to yield.” 

"No matter where you go, there you are." 
Buckaroo Banzai

From the Editor-in-Chief: Shiny New Objects Within a Struggling System

 Dan Ariely and Jeff Kreisler argue that as most of us ponder our purchases, we are driven far more by emotion than by a fully objective approach to decision-making. The goal of the book is to guide readers through a process of stepping back from emotion-driven financial decision-making toward a model based upon rational economic choices. That road is tougher than it seems.

We are in the midst of a period of immense national legislative energy around making systemic changes to our health care system with the conjoined goals of expanding access and reducing costs. The lessons of Dollars and Sense are worth keeping in mind as we prepare to navigate this complex and convoluted journey. Before getting pulled into the rapids of change, it is essential to take a brief pause to understand the potential unintended risks of moving forward on the tide of emotional energy to get things done quickly.

™, authors from Florida Cancer Specialists and AmerisourceBergen (Weidner et al) look at a piece of the health care payment tapestry, the current Medicare Part B drug reimbursement methodology. They present a data-centered vision of what works, what might be lost by moving forward with the types of dramatic changes seen in recent proposals, and what alternatives might be preferable to those proposed models.

The heart of their analysis criticizes the practice of looking only at the cost of cancer treatment
without a deeper understanding of the context in which these pharmaceuticals are delivered. Such an examination must look at what resources are required to maintain a sustainable system for delivering high-complexity, high-quality, patient-centered care to patients and families affected by a cancer diagnosis. As our nation prepares to tackle the issue of rising drug costs (especially for single-source biologics, targeted anticancer drugs, and immuno-oncology drugs), American Cancer Society data demonstrate that cancer survival has improved by the greatest increments ever for 2 consecutive years, based upon targeted treatments for previously chemorefractory cancers, such as non–small cell lung cancer. These improvements have been achieved within a care ecosystem that has permitted access to Medicare Part B drugs through the “buy and bill” model, or average sales price (ASP) + 6%. Proposals that risk undermining sustainable care delivery through this model risk undermining these extraordinary outcome advances.

Weidner et al make a persuasive, data-based argument that mechanisms built into the ASP+6
model for drug acquisition actually help to control the growth of drug costs. An implicit challenge the authors critique is that prior to embarking upon dramatic reactive changes directed at managing drug costs, we need to think far more carefully and critically about some essential, seemingly unanswered questions. For example, how do we define value in cancer care delivery? How do we drive value and enhance the value of cancer care? How do we create a better patient experience and more humanized care delivery? What role do high-cost therapeutics play in improving patient survival and quality-of-life outcomes? How do we enhance safety, cost effectiveness, and the financial sustainability of care delivery without undermining any of these essential elements? A hasty rush to change the existing oncology care model that would shift clinical resources away from doctors who are actually delivering care may undermine the integrity and sustainability of that care.

Fundamentally, Weidner et al make a strong argument that we should not create systems in which oncologists assume disproportionate risk in matters outside their control. Moreover, they show that a singular focus upon an isolated financial transaction (drug acquisition) within a continuum of highly complex care delivered over months and years is myopic. Further, it risks making non–data-based leaps of faith into a chasm that may prove inhospitable to patients and oncology practices alike. In the midst of a tremendous push to do doing “something” in health care, we should move carefully and think through the potential unintended consequence of reverse engineering our care delivery systems around the dollar. Such a model risks a lurch toward potentially reckless change that makes little sense in the context of the high-risk, high-complexity care delivery to patients facing what could be a life-ending illness. 


Ariely D, Kriesler J. Dollars and Sense: How We Misthink Money and How to Spend Smarter. HarperCollins Publishers; 2017.

Dollars and Sense

On my desks at home and at work, I keep copies of a 2012 internal medicine text written by several esteemed professors from my medical school. It is not there to remind me what they got right, but rather, to remind me how, in retrospect, so much of what we took as indisputable knowledge is now plainly wrong. As Joshua Y. Yang, MD, notes, few of his fellow medical students appreciated the prescience of their professor’s first-year prediction that, “Ninety percent of what you will learn over the next 4 years will be wrong in a couple of decades from now.”

This misalignment is especially true in the domain of cancer care. From the perspective of
someone practicing oncology in the late 1990s, there was no way to accurately predict how radically oncology and hematology would be transformed in the subsequent 2 decades by advances in genomic diagnostics/risk stratifi cation, targeted therapeutics,  immuno-oncologic drugs, and gene-modifi ed therapeutics. My 2012 textbook serves as a reminder to remain humble and embrace a broader perspective when making sweeping pronouncements about the future of cancer care.

Instead, we must embrace this hyperdynamic period of innovation with the perspective that the
best way to create a system path that ensures these discoveries are delivered sustainably, equitably,
and effectively may only become clear in time through the persistence of those who are passionately engaged in bringing care to patients and families. There are more than 8000 new medications in development; up to 75% may represent new therapeutic classes. The failure to embrace this dizzying pace of change will exacerbate care disparities, produce more misaligned payment systems, and erect more barriers to life-saving, life-transforming care.

In 1984, CMS created the Prospective Payment System. Inasmuch as this represented an advance
from prior payment systems, it now seems antiquated in light of the dramatic advances in cancer
care. In 1984, 5-year relative cancer survival rates were only 52.74%. Since then, cancer survival rates
have risen by the greatest increments ever, fueled by the impact of novel targeted therapeutics and
immuno-oncological agents. Our payment systems have not kept up. CMS’ slow response in creating a payment model for chimeric antigen receptor T cells should not set the precedent for how our systems adapt to this era.. The profound differentiation of cancer care from other care types needs to be more effectively integrated into payment design models, lest existing care disparities grow in the face of misaligned models for payment.

Neither systemic inertia nor the quest for a “perfect” model of care payment should paralyze
the pace of progress, nor should it result in patients and families encountering additional barriers to
life-saving access in their respective cancer journeys. In this issue of 

™,
we look forward, humbly, toward how our systems may more effectively evolve to become more patient-centered, more effective, more innovative, and more sustainable.

As we move forward through this unprecedented period in cancer care innovations, the quest for
grand strategies and elegant systems should not be our principal goals. The growing disparities in care access coupled with a growing portfolio of therapeutics require that we act now to ensure that patients, oncologist, and health systems can move with unfettered speed in bringing hope to those whose lives have been affected by a cancer diagnosis.

As long as we keep this as our truth north and continue to push past the systemic imperfections
and incorrect assumptions that stand in our way, the connected dots of a robust care delivery system will become increasingly clear in time. The first step is to humbly embrace this level of uncertainty—and to then move with speed. 

Path to Better Payment System to Be Clear Over Time

We are in the greatest period of innovation cancer care to date. Each day, there is an advance in genomic testing, patient risk stratification, a targeted therapeutic or an immuno-oncologic agent, a cellular therapeutic, or a new approach to care. This astounding rate of innovation is far outpacing our ability to systematically assimilate these treatments into practice and align payment in an effective way to incentivize an ever-evolving definition of best practice. As current systems struggle to adapt to this new reality, the culture of medicine and systems of care are, thankfully, inherently conservative. There is a sense of caution around new technologies and payment models that is frequently at odds with the ever-accelerating pace of innovation. The “plan-do-check-act” culture is deeply embedded in our systems of care. Far too often during my residency and fellowship programs, I heard senior attending physicians use the term “bold” as a pejorative indictment rather than a compliment. This desire to ensure patient safety is essential; yet, there are enough patients whose unmet needs might be served by rapid integration of new technologies that we find ourselves at a tension point in the evolution of cancer care.

In Silicon Valley, where former apricot and cherry orchards now burst with silicon wafers and lines of code that have changed human experience, innovators rally around the idea of ‘flying the plane while you build it.” This paradigm is “rooted in the idea of ‘iterative’ software development—ship it and fix it and ship it again—in contrast to the earlier approach of tinkering for years and finally shipping.”

 This model does not ignore safety, functionality, or investor dollars; instead, it is grounded in the need to transcend the limitations of a slower, more plodding model of producing change. The metaphor is an apt one for bringing innovation at a faster pace to cancer care—while we should never undermine safety, our patients’ urgent needs demand that we move faster and even embrace a sense of “boldness” in moving forward.

™ we see a foreshadowing of what this future could look like and how we may learn to move forward, safely at an ever-accelerating pace. With this issue of EBO, we shift from cover themes to regular departments; both our Targeted Therapies & Immuno-Oncology section, featuring an interview with Tanya Siddiqi, MD, and our AJMCtv section cover advances in treatment technology that promise more effective, less toxic treatments for patients with unmet needs. In our Precision Medicine section, we review advances in lung cancer treatment, empowered by innovations in genomic testing, that have improved patient survival and quality of life for patients with advance cancer. Our Payment Model feature reviews the challenges of bringing cost transparency and predictability to cancer care in the area of radiation oncology. In our Pathways interview with the health care quality visionary and former CMS Administrator Don Berwick, MD, MPP, we learn about the importance of using carefully curated clinical data to create a more robust risk-segmentation model to discern the relationship between the individual clinical risk of a patient and the cost of care.

Given the transcendent technologies arriving in the cancer care domain, we need to embrace a new boldness in integrating and incentivizing patient access to care. This demands evolution of our payment systems to recognize the unique risk and clinical needs of patient care, while reducing low value care in our system. It is possible to create a system that brings speed, safety, access, and innovation to patients impacted by a diagnosis of cancer. The ability to navigate the opportunities and challenges of this new paradigm brings with it the ability to improve care disparities, increase the value-centricity of care, and ensure that care becomes iteratively and more deeply patient-centered.

1. Walker R. Build the plane while you’re flying it. 

. Published March 24, 2016. https://www.csmonitor.com/The-Culture/The-Home-Forum/2016/0324/Build-the-plane-while-you-re-flying-it. Accessed February 4, 2021.

In this issue of Evidence-Based Oncology™ we see a foreshadowing of what the future of cancer care innovation could look like and how we may learn to move forward, safely, at an ever-accelerating pace. 

Flying the Plane While You Build It

The human impact of cancer is staggering. The American Cancer Society (ACS) estimates that in 2019, 1,762,450 individuals received a diagnosis of cancer, with the number of cancer deaths projected to exceed 606,000.

 The good news for patients and families, however, is that we are living in the midst of a period of extraordinary innovation in oncology.

More importantly, the pace of integration of new diagnostic, risk stratification, and therapeutic knowledge is translating into improved survival outcomes. A 2020 ACS report found that the “death rate from cancer in the US declined by 29% from 1991 to 2017, including a 2.2% drop from 2016 to 2017, the largest single-year drop ever recorded.”

Stunningly, some of the most dramatic gains in cancer survival rates have occurred among patients with certain cancer types, such as metastatic non–small cell lung cancer (NSCLC), for which survival outcomes were poor historically. At this time, however, our abilities to effectively deliver these extraordinary advances are challenged by the rapidly escalating costs of care, continued disparities in cancer survival outcomes, and care payment and deliver systems that erect barriers for patients and families trying to access the care they need.

Rising costs are a significant challenge to the financial sustainability of health care payers, including state and local governments, private health plans, and employers. One major success story in cancer care has been the rapid pace of development of novel, innovative anticancer therapeutics and immuno-oncological agents. Authors of the IQVIA report, “Global Oncology Trends 2019,” note that between 2016 and 2018 the number of patients who were treated with immuno-oncologic treatments doubled to over 200,000 patients in 2018.2 Additionally, they write:

The pipeline of drugs in late-stage development expanded 19% in 2018 alone, and 63% since 2013. Within the pipeline, across all phases of clinical development, the most intense activity is focused on nearly 450 immunotherapies with more than 60 different mechanisms of action. Ninety-eight next-generation biotherapeutics—defined as cell, gene and nucleotide therapies—are also under clinical investigation and leverage 18 different approaches. The combined immunotherapies and next-generation biotherapeutics are targeting almost all cancer tumor types with over 80 mechanisms of action.2

The IQVIA authors, however, make the sobering observation that in 2018 the average cost of a new oncology drug was $140,000, with new drug costs potentially exceeding $300,000 annually.2 Moreover, a survey of Medicare Part B oncology drug pricing, the pricing of 24 index anti-cancer drugs rose an average of 25% between 1996 and 2012 (18% after adjustments for inflation), even after generic drugs became available.

Another contributing factor to higher, nonvalued added health care costs is the impact of low-value care delivery. This includes the issue of interclinician variability in treatments for patients. A 2019 analysis of CMS/Medicare data for claims related to 3,159,834 Medicare beneficiaries found that physician practice may contribute substantially to the delivery of low value care.

 While this CMS data analysis was performed for patients receiving care in from generalist physicians, the issue is also present in the domain of cancer care. In an analysis of 5651 women with stage breast cancer with secondary metastatic disease, nearly 1 in 5 received care that was not concordant with treatment guidelines adopted by the National Comprehensive Cancer Network. “Nonconcordant treatment was associated with higher health care utilization and costs, with mortality differences observed by the type of guideline deviation.”

Enormous disparities exist in the cancer care domain, with many patients, including those from historically underserved minority communities, have worse cancer survival outcomes and a lower likelihood to receive such care advances equitably.

 Moreover, significant disparities in clinical outcomes are also evident. These include disparities for patients from underrepresented minorities, patients in rural and underserved areas, and members of the LGBTQ population. Patients who are beneficiaries of state Medicaid programs may also have particularly poor cancer care outcomes.

In response to escalating drug and care costs for oncology patients, many commercial, government, and private payers have focused upon lowering the inflation rate in cancer care costs by applying the same tools that they have used with varying degrees of success in primary care. The Institute for Healthcare Improvement Triple Aim of Care model proposes that population health can be delivered more effectively and in a more patient-centered way while, in the process, provide for care that is delivered at a lower per-capita cost.

 The “Triple Aim” is meant to drive increasingly effective, efficient, equitable care, but in cancer care, it is a blunt instrument. Failing to account for challenges that are specific to cancer can drive false choices and a fatal misalignment between value-based reimbursement and care delivery. Narrow networks and limited provider networks may contain costs in primary care, but in cancer care, they may block access to disease-specific care expertise, which may raise the risk of disparate survival outcomes. It is worth noting that the doubling time for new knowledge in the cancer domain is less than 3.5 years.

 Systems focused on cost and simplistic models of value—that fail to account for survival and patient experience—frequently fall short in valuing innovation and the importance of survival outcomes. The drive to lower costs does not, by necessity, lead to better care decision-making nor does it lead to more equitable access to the fundamental knowledge needed to effectively wield the rapidly growing armamentarium of anticancer therapeutics. Avoidance of, or delay in, the use of newer, more effective targeted therapies may reduce short term expense, but does not optimize a patient’s chance of survival. This approach may not achieve long term cost savings when taking into account total lifetime cost and productivity.

Simple solutions far too often culminate in simplistic systems that over promise and underdeliver. In places like California, the delegated risk model demonstrates how well-intentioned attempts to place accountability for cost and use upon clinicians can actually result in less efficacious, less equitable care that undermines the effectiveness of care in the cancer domain. Much of the focus upon increasing cost efficiency in care, including cancer care, has been placed upon shifting risk from payers toward those delivering care. When care expertise and the knowledge base from which care is delivered is relatively stable, frequency of disease is high to allow risk amortization and predictability, and the year over year cost of therapeutics are consistent with inflation, this can be achieved by leveraging care pathways, guidelines, nurse-based support systems, and patient engagement strategies that do not require continuing evolving treatment strategies. This same care model, when applied to the cancer care domain, however, is likely to result in less effective care, less patient-tailored care delivery, and less effective integration of new knowledge into the care delivery model.

In a world where death rates from cancer vary by ZIP code and distance from an National Cancer Institute-designated or academic center, there is little evidence that the traditional levers of the population health model are producing the best outcomes or reducing disparities in cancer care. Disease management, case management, narrow networks and Centers of Excellent (COH) for cancer have been in place for over 25 years. Yet, while the science continues to evolve, disparities in health care based on race and geography persist; enrollment in clinical research trials remains at 4% for all patients, and lower for minorities; practice and institution-specific survival rates for cancer are not transparent to patients and families and are largely invisible to even the most engaged of consumers; and there is ample evidence that genomic testing to guide selection of targeted therapy is poorly or underused.

While many wait for CMS to clarify its reimbursement and care delivery policies, employers are currently taking an active, innovative role in improving patient access, care effectiveness, patient experience, and more sustainably managing health care costs and value for their respective member populations.

 It is hard to overstate the impact of American employers upon patient access to care and health care coverage. As of 2019, 68% of Americans had private insurance coverage; 55.4% of the American population received their health care coverage through employer-provided health care coverage.

Their role as guarantors of patient access to health care comes at a significant cost. In 2020, the average annual employer contribution per employee (not including the portion paid by the employee) “was $7188 for single coverage and $20,576 for family coverage.”

More startling, the Kaiser Family Foundation finds that, “the average premium for employer-sponsored family health coverage increased 22% over the [past] 5 years and 54% over the last 10 years.”

Employers may provide health care benefits to their members (representing their employees, family members, and defined beneficiaries) through 2 models.

 Under a fully insured model, employers pay a monthly fee to a health plan that assumes subsequent financial risk for the care of the population. At the end of the year, there is no opportunity for the employer to receive money back should the aggregate health care expenditures for the population prove to be less than the sum of the premiums as part of their expenditure management strategy, many employers have moved toward a self-funding model. Under this strategy, the employer assumes the financial risk for the costs of health care delivery to their population, while contracting with a third-party administrator to administer their health care benefits. Self-funding is a model that may be more suitable for larger employers for whom creation of a trust fund financial pool may be more feasible. As part of their financial management strategy, self-funded employers may purchase re-insurance for stop-loss coverage for high cost outliers. Employers who choose the self-funded model may also be exempt from some federal and state regulations related to plan design. Such employers need to develop a summary plan description that details covered services and member benefits. In an article for the Business Benefits Group, Brandon Downs noted the 4 key benefits of the employer self-funded model: (1) Cost savings from benefit design changes; (2) increased flexibility and control of the plan; (3) Enhanced flow of cash, and (4) Cost savings from reduced premiums.

Among the breadth of health care issues encountered by employers, cancer care represents a particularly important area of focus. Inasmuch as health care costs continue to rise at significant pace, rising cancer care costs represent a significant challenge for many employers. Moreover, authors of an NEBG presentation noted that, “Employers report a level of complexity in managing employees’ cancer-related needs beyond that associated with any other type of disease or condition.”

 The authors further note that although cancer care accounts for only 1% of their health care claims, this consumes 12% of more of their annual health care expenditures.19 Employers therefore face a series of significant challenges related to cancer care including those of equitable care delivery to their members, the financial sustainability of their model, and ensuring that their expenditures are not wasted in the delivery of low value care.

Employers have embraced an innovation mindset in meeting the challenge of cancer care. While definitions by government payers of what constitutes value-centric care focuses primarily upon health care costs or relative weak process-based metrics of assessing care quality, employers are able to focus upon factors, that include a much more expansive view of patient outcomes, the quality of patient experience (including patient and family input on the human experience of the care), duration of disability, and long-term costs associated with care (rather than just the short-term transactional costs of care). Using the flexibility afforded under the self-funded model, employers have creatively explored benefit design to ensure for more effective, equitable, and financially sustainable care for the beneficiaries.

This innovation mindset has taken a number of directions. Some employers have begun direct contracting with academic cancer centers to provide services to their employees and members. These include General Electric, Boeing, Walmart, and Lowe’s all of which have used this model to reduce costs, improve quality, and to carefully define a patient experience so that care delivery model.

 Part of the benefit of this direct contracting model, is that it allows for more transparent tracking of patient experience and outcomes that may be achieved through a standard care payment model. One example of such a program is Walmart’s collaborative Centers of Excellence Program that includes a partnership with Mayo Clinic in the care of patients with certain cancer types, joint replacement, spine care, and transplant services.

In line with this model, a number of employers have partnered with the Pacific Business Group on Health (PBGH) to deliver more transparent, effective, and more patient-centric care through the Employers Centers of Excellence Network (ECEN). On January 1, 2019, ECEN expanded their care models to include cancer care. City of Hope Comprehensive Cancer Center was the first center included in the program.

 The ECEN model aims to provide a robust care ecosystem where employer members can immediately access advanced care expertise that is delivered in a manner that includes interdisciplinary care collaboration, psychosocial care needs assessments and support, and behavior health care and support. Under this offering patients may benefit from clinical expertise in supportive/palliative care medicine, cancer genetics, genomic diagnostics, and survivorship that is delivered through a unique patient and family centric care model. For the employer, this addresses the needs to ensure that transformative care expertise is made easily available to patients and families, that patients may be screen for relevant clinical trials in a robust and consistent manner, and that care is delivered in a way that minimizes burdens to patients and their families.

Yet, the center of excellence model does have a number of limitations, not the least of this is that for many patients extended travel away from their home is not a sustainable model for receiving cancer care. In reality, approximately 55% of patients with cancer in the United States receive their cancer care in the community practice setting.

 As such, developing more effective decision support tools for community clinical, assistance in identifying relevant clinical trials for patients at high risk or those for whom the existing standard of care may be ineffective or unsuitable to a particular patient, and assistance in supporting clinicians in the interpretation and clinical decision-making related to the interpretations of genomic and molecular testing results.

Employer innovation has also involved pushing the boundaries of knowledge access and disease-expertise access. AccessHope is a subsidiary of City of Hope that is working within this innovation space.

 A key part of the model for AccessHope is the belief that transformational clinical knowledge is exportable even across geographic barriers in which the capacities of “bricks and mortar” care represent a challenge to patient access to essential care (

). At present, AccessHope is working with more that 34 employers that represent 2 million covered lives through models that are geared toward forming supportive, collaborative relationships with local clinicians that is focused upon keeping patients closer to home, with their community-based clinician.

Through multiple innovation models, employers are beginning to have a significant impact upon cancer care access and care delivery. Part of their engagement strategy includes a clear value proposition for what they seek from cancer care experts and cancer centers. This includes the expectation that high complexity care is delivered in increasingly patient-centric ways that enhance timely patient access to transformation care knowledge. It also includes higher demands for significantly more transparent reporting of cancer care outcomes. In addition, as employers work with cancer care delivery thought leaders and centers of expertise, it will be feasible for multidisciplinary team of clinicians, health care plan executives, patients and the employers’ internal health care benefits leadership to define the rights of all patients with cancer and define a list of critical or complex cancer conditions or situations for which the patients would be allowed to seek expertise beyond their HMO, medical group or accountable care organization and how their internal cancer care ecosystem can be enhanced to ensure that all patients, regardless of wherever they live, have the opportunity to benefit from the full breadth of cancer care innovations.

Employers have the focus, innovative mindset, analytical tools, and drive to partner effectively with innovative cancer care entities to bring better care to their respective members. Under the balanced model of wanting better, more innovative care made available in ways that reflect best practice and knowledge-driven stewardship over the rapidly growing portfolio of anticancer therapeutics, employers and their clinical partners are best positioned to define best in class access, care, and patent-center models for cancer care.

. American Cancer Society; 2019. Accessed December 3, 2020. https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2019/cancer-facts-and-figures-2019.pdf

Global Trends in Oncology 2019: Therapeutics, Clinical Development And Health System Implications

. IQVIA Institute for Human Data Science. Published May 30, 2019. Accessed December 3, 2020. https://www.iqvia.com/insights/the-iqvia-institute/reports/global-oncology-trends-2019

3. Simon S. Facts & Figures 2020 reports largest one-year drop in cancer mortality. American Cancer Society. Published January 8, 2020. Accessed December 3, 2020. https://www.cancer.org/latest-news/facts-andfigures-2020.html.

4. Simon S. Study Shows US cancer drug costs increasing despite competition. American Cancer Society. https://www.cancer.org/latest-news/study-shows-us-cancer-drug-costs-increasing-despite-competition.html. Published November 8, 2017. Accessed December 3, 2020

5. Hahn EE, Gould MK. Drivers of low-value care. 

. 2018;178(3):433. doi:10.1001/jamainternmed.2017.8528

6. Rocque GB, Williams CP, Kenzik KM, et al. Concordance with NCCN treatment guidelines: Relations with health care utilization, cost, and mortality in breast cancer patients with secondary metastasis. Cancer. 2018;124(18):4231. doi: 10.1002/cncr.31694

7. American Association of Cancer Research. 

AACR Cancer Disparities Progress Report 2020: Achieving the Bold Vision of Health Equity for Racial and Ethnic Minorities and Other Underserved Populations. 

American Association of Cancer Research. 2020. Accessed December 3, 2020. https://cancerprogressreport.aacr.org/disparities/

8. Physicians for a National Health Program (PHNP). Cancer care access and outcomes worse for Medi-Cal patients. PHNP. Published November 5, 2015. Accessed December 3, 2020. https://pnhp.org/news/cancercare-access-and-outcomes-worse-for-medi-cal-patients/

9. McCarthy D, Klein S. The Triple Aim journey: improving population health and patients’ experience of care, while reducing costs. Commonwealth Fund. Published July 22, 2010. Accessed December 3, 2020. https://www.commonwealthfund.org/publications/case-study/2010/jul/triple-aim-journey-improving-population-health-and-patients

10. Corish B. Medical knowledge doubles every few months; how can clinicians keep up? 

 Published April 23, 2018. Accessed December 3, 2020. https://www.elsevier.com/connect/medical-knowledge-doubles-every-few-months-how-can-clinicians-keep-up.

11. Unger JM, Cook E, Tai E, Bleyer A. Role of clinical trial participation in cancer research: barriers, evidence, and strategies. 

 2016;35:185-198. doi: 10.14694/EDBK_156686

12. Many patients with lung cancer do not receive treatment. 

 . Healio. Published April 7, 2017. Accessed December 3, 2020. https://www.healio.com/news/hematology-oncology/20170407/manypatients-with-lung-cancer-do-not-receive-treatment

13. Miller S. High-value care, workplace flexibility aid employees with cancer: employers are working with centers of excellence to tackle cancer’s challenges. SHRM. Published October 26, 2020. Accessed December 3, 2020. https://www.shrm.org/resourcesandtools/hr-topics/benefits/pages/high-value-care-and-workplace-flexibility-aid-employees-with-cancer.aspx

. Health Insurance Coverage in the United States: 2018.

 United States Census Bureau. Report number P60-267 (RV). Published November 8, 2018. Accessed December 3, 2020. https://www.census.gov/library/publications/2019/demo/p60-267.html

15. eHealth. Average cost of employer-sponsored health insurance. Updated November 23, 2020. Accessed December 3, 2020. https://www.ehealthinsurance.com/resources/small-business/average-cost-of-employer-sponsored-health-insurance

Employer Health Benefits Annual Survey 2020

. Kaiser Family Foundation Published October 8, 2020.Accessed December 3, 2020. http://files.kff.org/attachment/Report-Employer-Health-Benefits-2020-Annual-Survey.pdf

. Accessed December 3, 2020. https://www.wmimutual.com/publications/presentations/Self-Funding_101_(9-17).pdf

18. Downs B. Top 4 reasons employers are switching to self funding insurance. Business Benefits Group.. Published August 17, 2018. Accessed December 3, 2020. https://www.bbgbroker.com/self-fundinginsurance-switch-4-reasons/

Employers and Cancer Care Quality: A Closer Look

. North Eastern Business Group on Health. Published April2016. Accessed December 3, 2020. https://nebgh.org/wp-content/uploads/2016/04/NEBGH_CancerRoundtable-FINAL-flat.pdf

20. Slotkin JR, Ross OA, Coleman MR, Ryu J. Why GE, Boeing, Lowe’s, and Walmart are directly buying health care for employees. 

. Published June 8, 2017. Accessed December 3, 2020. https://hbr.org/2017/06/why-ge-boeing-lowes-and-walmart-are-directly-buyinghealth-care-for-employees

21. Mayo Clinic. Walmart Centers of Excellence Model. Accessed December 3, 2020. https://www.mayoclinic.org/centers-of-excellence/walmart

22. Pacific Business on Health. The Employers Centers of Excellence Network expanding to include ‘best of both’ cancer care. Accessed December 3, 2020. https://www.pbgh.org/news-and-publications/pbgh-in-the-news/491-the-employers-centers-of-excellence-networkexpanding-to-include-best-of-both-cancer-care

23. Community Oncology Alliance (COA). Fact sheet: what is community oncology? COA. Published 2017. December 3, 2020. https://communityoncology.org/wp-content/uploads/2017/08/What-is-Comm-Onc.pdf

24. AccessHope. Accessed December 3, 2020. https://www.myaccesshope.org

Employers have the focus, innovative mindset, analytical tools, and drive to partner effectively with innovative cancer care entities to bring better care to their respective members. 