Investigators in Canada are studying whether a drug developed to enhance the effects of immunotherapy can be used to protect vulnerable patients with cancer from the worst effects of coronavirus disease 2019 (COVID-19), especially severe respiratory infections.

People with cancer are at higher risk of infection with severe acute respiratory syndrome coronavirus 2 (SARS-2-CoV), the virus that causes COVID-19, and if they develop the disease, it’s deadlier. Add in deferred care and the fact that those who receive a new diagnosis of cancer are typically older with comorbidities, and it’s no wonder that the National Cancer Institute projects that the US streak of improved cancer mortality is likely to end after more than 25 years.

An investigational drug, IMM-101, may help. Under development by Immodulon, IMM-101 is a heat-treated Mycobacterium preparation that is being studied for its ability to both increase the effects of immuno-oncology agents and allow them to be used in combination with fewer toxic effects.

 This new study, to see if the drug can prevent or lessen the effects of COVID-19 among those with cancer, got under way in late August, and the first results could be known by the end of the year.

Chris O’Callaghan, PhD, senior investigator at the Canadian Cancer Trials Group, explained that Rebecca Auer, MD, MSc, FRCSC, a colorectal surgeon at Ottawa Hospital Research Institute, conceived of the idea that IMM-101, could be used in other ways to boost patient immunity. First, Auer studied the use of IMM-101 post-surgery, and then she suggested it could protect cancer patients from COVID-19’s respiratory wrath, O’Callaghan said. In an interview with 

™, O’Callaghan said the mechanism of IMM-101 makes it a particularly good candidate to give patients a measure of protection against respiratory ailments, even though it’s not being developed as a vaccine against SARS-2-CoV.

“IMM-101 is a mycobacterial cell preparation, and it’s very analogous to something called the BCG vaccine,” O’Callaghan said, referring to Bacillus Calmette-Guérin, a tuberculosis vaccine developed in the 1920s that is still used worldwide, although not in the United States. “That vaccine has been noted to have a side effect in not only preventing or reducing the risk of tuberculosis, but it also reduces the risk of multiple other respiratory infections. “So it’s not specifically targeting what most vaccines that we’re familiar with are deriving, what we would call ‘specific immunity’ in the context of the BCG vaccine,” O’Callaghan continued. The BCG vaccine, he explained, is known to have a “side effect of immunity,” in “innate immune response,” or the part of the immune system that reacts any time it encounters a bacterial or viral infection.

“We’re capitalizing on the fact that we know that the BCG vaccine has this side effect, if you will,” he said. And, he said, it should not be a surprise that the century-old BCG vaccine is also in clinical trials asking the same question about COVID-19 protection.

But the BCG vaccine has been administered to healthy people. Those with cancer are already immunocompromised. Isn’t that a risk?

O’Callaghan said the key difference is that IMM-101 is a killed vaccine, one that has already been tested in more than 300 cancer patients. “It’s very, very safe, and it has been used with very
minimal side effects,” he said.


Articles

An investigational drug, IMM-101, already being studied for its ability to increase the effects of immuno-oncology agents, may be able to prevent or lessen the effects of COVID-19 among those with cancer.

Drug That Boosts Immunotherapy Studied as Tool to Battle COVID-19 in Patients With Cancer

After this article went to press, CMS announced that the Radiation Oncology Model will be delayed until July 1, 2021. For more,

A new alternative payment model (APM) for radiation oncology (RO) has drawn fire from providers, who say a mandatory shift to bundled payments in the middle of a pandemic is unfair. 

Transitions cost money, and many have none to spare. CMS Administrator Seema Verma vowed full steam ahead when she finalized the RO Model on September 18, claiming the change that takes effect January 1, 2021, would save $230 million over 5 years and likely mean lower out-of-pocket costs for Medicare beneficiaries.

“Today, Medicare payment for radiotherapy is based on the number of treatments a patient receives and where they receive it, which can lead to spending more time traveling for treatment with
little clinical value,” she said in a statement.

Radiation oncologists have been bracing for a move to a bundled payment model for a while. But they say the timing—in the wake of staffing shortages caused by the coronavirus disease 2019 (COVID-19) pandemic—could not be worse. The American Society for Radiation Oncology (ASTRO) argues that the planned start date is too aggressive for a model that would be mandatory for 30% of providers, and the group said it would go to Congress to seek relief.

“The transition to value-based payment will require significant practice changes and investments to comply with the model’s requirements. ASTRO strongly urges CMS to significantly delay the start date rather than foster unnecessary chaos and burden for the practices this model is designed to support,” the group said in a statement.

The American College of Radiology echoed these concerns.

The RO Model was in the works well before COVID-19, as CMS has been determined to create a payment structure that is site neutral and rewards outcomes, not how many times a patient
receives radiation. Historically, payments have been doled out bit by bit, giving providers an incentive to keep treating and billing. CMS argues that evidence shows “for some cancer types and beneficiary characteristics, a shorter course of [radiotherapy] treatment with more radiation per fraction may be clinically appropriate.”


The RO Model calls for bundled payments over a 90-day episode of care, which would go to radiotherapy providers who treat 1 of 16 cancer types. CMS said it would require participation from
physicians in randomly selected geographic areas covering 30% of all current Medicare fee-for-service episodes (the initial proposal was 40%). The model has a 5-year performance period that would run through December 31, 2025.

According to a CMS fact sheet, the episode payments would be split into 2 components: the professional and technical pieces, which would allow the existing claims systems for the Physicians’
Fee Schedule (PFS) and the Hospital Outpatient Prospective Payment System (OPPS) to be used to pay claims.

A chief mission of the model, according to CMS, is to emphasize “site-neutral payment by establishing a common, adjusted national base-payment amount for the episode, regardless of the setting where it is furnished.”

Payment will be linked to quality through performance measures, clinical data reporting, and patient experience factors. The model allows providers to meet Advanced APM requirements under the Quality Payment Program. Beneficiaries must be notified their provider is taking part in the RO Model.


The RO Model calls for participant-specific payments that take into account a mix of national base rates, trend factors, and “adjustments for each participant’s case mix, historical experience, and geographic location.” CMS then applies a complex system of discount factors. But CMS will be basing 90% of the payment on a practice’s historical payments from 2016 to 2018, even though an ASTRO survey released in May found that 85% of members reported a decline in visits due to COVID-19, by an average of one-third.

“While these volume declines won’t impact the historical experience data, they likely will impact other aspects of the model, most notably the payment adjustment that accounts for case mix, as we
expect more patients to present with more complex disease due to delayed screening. These issues will likely confound at least the first year of CMS’ evaluation of the model,” Dave Adler, vice president for Advocacy, ASTRO, told 

“Skewed results in the first evaluation report would start the program off on the wrong foot and jeopardize the future of the model. This is an important reason to delay the model until after the pandemic.”

asked if the amounts of bundled payments in the early part of the model could be under valued, as most experts predict a wave of patients with advanced cancers will be diagnosed in late 2020 or early 2021 due to missed screenings. Adler said this is possible. In their statement, ASTRO providers said they remained committed to working toward a value-based payment model, but under the current circumstances they believe a voluntary phase is needed first.

“ASTRO has worked with CMS and bipartisan legislators for several years toward a viable payment model for radiation oncology that would support stable and fair payments, drive adherence to nationally recognized clinical guidelines, and improve patient care,” the statement said. “We are hopeful that CMS and Congress are open to reconsidering a start date that would be realistic and not derail this unique opportunity.”

Adler said ASTRO will seek a delay of implementation until July 1, 2021—and potentially later if the pandemic persists—and to reduce the discount factor payment cuts to 3%. This would put the discount factor cuts in line with other models from CMS, he said.


CMS’ details suggest that along with bundled payments to providers, the current 20% coinsurance paid by beneficiaries would be configured differently. “Since CMS applies a discount to each
component of the bundled payment, the agency expects that beneficiary cost sharing would be, on average, lower relative to what typically would be paid under Medicare’s fee-for-service system,” the fact sheet states.

The model covers 16 diagnoses that account for the vast majority of solid tumor cancers: anal cancer, bladder cancer, bone metastases, brain metastases, breast cancer, cervical cancer, central nervous system tumors, colorectal cancer, head and neck cancer, liver cancer, lung cancer, lymphoma, pancreatic cancer, prostate cancer, upper gastrointestinal cancer, and uterine cancer.


1. CMS announces innovative payment model to improve care, lower costs for cancer patients. News release. CMS. September 18, 2020. Accessed September 18, 2020. https://www.cms.gov/newsroom/pressreleases/
cmsannouncesinnovativepaymentmodelimprovecarelowercostscancerpatients
2. ASTRO responds to CMS Radiation Oncology Model: implementation delay and more reforms needed. News release. ASTRO. September 18, 2020. Accessed September 18, 2020. https://www.astro.org/NewsandPublications/NewsandMediaCenter/NewsReleases/
2020/ASTROrespondstoCMSRadiationOncologyModelImp
3. ACR joins ASTRO in urging CMS and Congress for changes to RO Model. News release. ACR. September 21, 2020. Accessed September 23, 2020. https://www.acr.org/AdvocacyandEconomics/AdvocacyNews/
AdvocacyNewsIssues/IntheSept262020Issue/
ACRJoinsASTROinUrgingCMSandCongressforChangestoROModel
4. Radiation Oncology (RO) Model fact sheet. CMS. September 18, 2020. Accessed September 18, 2020. https://www.cms.gov/newsroom/factsheets/radiationoncologyromodelfactsheet
5. ASTRO survey: fewer patient visits despite enhanced COVID19 safety measures for radiation oncology clinics. News release. ASTRO. May 20, 2020. Accessed September 23, 2020. https://www.astro.org/NewsandPublications/NewsandMediaCenter/
NewsReleases/2020/ASTROsurveyFewerpatientvisitsdespiteenhanced

A discussion of the final Radiation Oncology Model; after this article went to press, CMS announced a delay until July 2021, reflecting concerns of radiation oncologists.

Too Much, Too Fast: Providers Push Back on CMS’ Final RO Model

Shortly after his biography of Steve Jobs, Walter Isaacson wrote an article summarizing the leadership lessons gleaned from his experiences with this visionary. Some imperatives that Isaacson identified: the importance to “focus, simplify, take responsibility end to end, when behind leapfrog...bend reality, impute, combine the humanities with the sciences, stay hungry/stay foolish, know both the big picture and the details.”

 At this time of immense innovation in cancer care, these lessons are both timely and essential. We are living through a hyperdynamic period of change in how we define cancer types and how we select therapeutics. Advances in genomic testing, targeted therapeutics, and immuno-oncology have fundamentally changed how we practice.


Yet all is not well. Disparities in care access and patient survival outcomes persist. These include barriers to care for patients living in rural areas and barriers due to poverty and educational gaps.


Moreover, the challenge of how to sustainably manage the escalating care costs of managing oncology patients remain unresolved.

 Attempts to bend the cost curve, such as CMS’ Radiation Oncology Model, may bring unintended consequences and increase the complexity of care delivery. And now, as we try to manage all of these existing systemic challenges, coronavirus disease 2019 (COVID-19) has increased demands upon health systems and clinicians to serve patients for whom delays in care may translate into a reduced chance of survival.

How can we transcend these challenges and ensure that our system evolves so that it can more equitably, effectively, and sustainably serve the needs of patients and families? A wise first step may be following the wisdom of Mr. Jobs in better connecting the immense resources and capacities of our system in ways that make care more accessible to those who need it, more patient-centric, and ensure more effective stewardship over care resources. To some extent, this will require that we simplify our system so that unnecessary barriers to care and care delivery are removed. It will require that systems more effectively leverage communication technologies to improve patient access while ensuring that payers grant reimbursement parity for clinicians who use these technologies effectively. In this edition of 

™, we examine current barriers in cancer care delivery and identify opportunities for moving us above and beyond today’s systemic challenges. In this issue, we review the impact of COVID-19 upon oncology practice and potential paths forward. We examine challenges of access to cancer care in rural areas and continued gaps in access to palliative care. Finally, in our conversation with Kashyap Patel, MD, we seek a rehumanization of care, particularly when a cure may not be possible.

There is some optimistic naiveté in believing that by creating greater connectedness and transparency across the breadth and depth of our cancer care ecosystem that we can change the nature of cancer care. Yet as we navigate the seemingly impossible, endless pain and uncertainties of the COVID-19 pandemic, what is truly striking is the extraordinary resilience and near-infinite adaptability of the clinicians, systems leaders, patients, and families who have persisted in their pursuit of life-saving care. We have witnessed an untold level of creativity in how clinicians have managed through this crisis. This is powerful evidence of where we might go. Inasmuch as the iPhone revolutionized so much about knowledge access, communication, and the creation of robust virtual communities, we have this perspective to remind us of the immense opportunity to similarly re-envision cancer care delivery to improve access, quality, and sustainability. As Steve Jobs said, “Simple can be harder than complex: You have to work hard to get your thinking clean to make it simple. But it’s worth it in the end, because once you get there, you can move mountains.”. 


1. Isaacson W. The real leadership lessons of Steve Jobs. Harvard Business Review. April 2012. Accessed October 6, 2020. https://hbr.org/2012/04/the-real-leadership-lessons-of-steve-jobs
2. Simoens S, et al. What happens when the cost of cancer care becomes unsustainable? 

. 2017;13(2):108–13. doi: https://doi.org/10.17925/EOH.2017.13.02.108
3. Maringe C, Spicer J, Morris M, et al. The impact of the COVID-19 pandemic on cancer deaths due to delays in diagnosis in England, UK: a national, population-based modelling study. 

. 2020;21:1023. doi: https://doi.org/10.1016/S1470-2045(20)30388-0

FROM THE EDITORS

Creativity is just connecting things--Steve Jobs

Connecting the Dots

Coronavirus disease 2019 (COVID-19) has had catastrophic effects on all aspects of health care, including cancer care. Oncology practices, just like all health care providers, have focused on reorganizing their operations to adjust to the changes driven by the pandemic. Providing a safe and protected environment for both patients and employees during a worldwide pandemic has become the number-1 priority over the past several months. While quality care is still being delivered to 

patients with cancer during this chaotic time, it is fair to say that continued practice transformation to meet value-based care initiatives has not been top-of-mind. Indeed, COVID-19 has had a dramatic impact on the significant progress being made regarding value-based cancer care, adding uncertainty and postponing the introduction of new reimbursement models. With no quick fixes on the horizon to prevent or cure COVID-19, the pandemic will linger. Although some bandwidth previously dedicated to advancing value-based care may have been momentarily absorbed by the pandemic, that does not mean value-based care should be forgotten. Providers still must think about value. With the initial emergence of the virus in the rear-view mirror, it is time for practices to consider how value-based care can work in and around disruptions caused by the pandemic.

COVID-19’s Impact on the Oncology Care Model


COVID-19 has created a significant distraction from normal practice operations. Real transformation to value-based care and performing at a high level in the Oncology Care Mode (OCM) takes time, energy, and dedicated resources, and that focus can be easily blurred when dealing with a pandemic.

The uncertainty that comes along with the pandemic is a huge worry. The OCM is a very detailed, complex model that requires a predictable environment in which practices have control. It is built around the concept of baseline practice patterns and measuring quality and cost metrics over time. However, comparing performance during this crisis against performance in a normal year is problematic. Another major element of the OCM is data collection and reporting. These activities require time and resources, much of which have been diverted to COVID-19 response. Expecting practices to have improved outcomes while spending less in the middle of a pandemic is simply not a realistic goal.

COVID-19 has greatly altered the landscape, making it very difficult—if not impossible—for practices to predict and control what happens to their patients. Cancer providers are well aware of the disruption the pandemic has caused when it comes to delivering care. A recent survey of cancer patients and survivors verifies what was already suspected

1. 51% of all respondents reported some impact on their care due to the virus.
2. Of those whose care was affected, nearly 1 in 4 reported a delay in care or treatment. The most common delays included:
• in-person provider appointments (50%);
• imaging services to see if a cancer had grown or returned (20%); and
• supportive services, such as physical therapy or mental health care (20%).

Some surgical procedures have been classified as nonessential and, therefore, postponed; this has been especially true of diagnostic procedures. Unfortunately, this can delay the start of treatment, and with some aggressive cancers, a delay of just a few weeks can negatively influence outcomes. This, in turn, can affect performance in the OCM. Some patients are canceling appointments because they are fearful of being exposed to the virus. These patients are not getting the care they need, and many will end up in the emergency department or the hospital. Others may not even be able to get to the hospital when it is necessary, so their condition worsens at home. These situations, which greatly increase the cost of care, have an impact on performance in the OCM.

Adjustments Made to the OCM in Response to COVID-19 

and other stakeholders have been working hard over the past several months to inform the Center for Medicare and Medicaid Innovation (CMMI) about the interruption to patient care that COVID-19 has caused and how it might impact OCM results. There is a strong likelihood that COVID-19 could disadvantage practices beyond their control. Many are operating under the 2-sided risk option and may have to return funds if expenditures are higher than benchmark.

Fortunately, CMMI has been receptive, and it recently announced adjustments to the OCM for performance periods affected by the COVID-19 public health emergency (PHE). The adjustments pertain to financial methodologies, quality reporting, and model timelines. To the credit of CMMI, these relief options add greater flexibility to the program and will be an enormous help to practices that want to remain in the OCM but are concerned about their results due to the pandemic.
On June 3, CMMI announced these changes


1. Practices in the OCM can elect to forgo upside and downside risk for performance periods affected by the PHE.
2. OCM practices that remain in 1- or 2-sided risk for the performance periods affected by the PHE will have COVID-19 episodes removed from reconciliation for those performance periods.


1. Aggregate-level reporting of quality measures and beneficiary-level reporting of clinical and staging data are optional for the affected periods.
2. The requirement for cost and resource utilization reporting and practice transformation plan reporting in July/August 2020 is removed.


1. The OCM is extended for 1 year through June 2022, allowing for a delay of the Oncology Care First (OCF) model.

The Network is pleased that CMMI recognized the concerns that were raised, then took action. Although we are several months into the pandemic, the impact on practice performance in the OCM is still unknown. Consequently, the adjustments that provide some flexibility, particularly concerning downside risk, are greatly appreciated.

The launch of the OCF model has been postponed for at least a year due to the pandemic. This is in line with a request made by The Network and a number of other stakeholders. We felt that extending the OCM was important, as practices in The Network were worried about rapidly transitioning into a new model during this chaotic time. Out of anxiety caused by the uncertainty of the pandemic, practices would be reluctant to participate in a new model that might add even more unpredictability. A lack of participation would not be in the best interest of either the practices, who want to lead the way in payment reform, or CMMI, which has a vested interest in ensuring that value-based care models evolve and succeed.

A year from now, if some sort of normalcy has not returned, practices may still have reservations about participating in the OCF. Whether they are willing to take on this new voluntary model will largely depend on what remnants of the pandemic still exist. If the virus is still widespread, practices will likely be hesitant to take on more risk, particularly if the way they must manage risk is not clearly defined.

CMMI may choose to hold off launching the OCF until the PHE is completely over, although its leaders are anxious to shift away from the OCM to a model with an approach that focuses more on bundled payments. If CMMI proceeds while the pandemic is lingering, many aspects of the program will need a second look. Must COVID-19–positive patients be factored into the equation, or not? Obviously, proceeding while the virus is still present would add to the complexity of developing and managing the model. The PHE would drastically change the model CMMI originally envisioned.

Practice-level decisions about whether to participate in the OCF will ultimately depend on what the model looks like. All that is known so far comes from a preliminary 12-page document that is limited on details and difficult to fully and accurately assess. However, from this brief information, practices across The Network have expressed concerns. Consequently, we offer the following suggestions to CMMI on how the model could be improved:

1. Provide greater transparency into the calculation of the OCF baseline, benchmark,and trend factor;
2. Improve transparency of the Monthly Population Payment (MPP) methodology and provide practices with an estimate of the MPP prior to application;
3. Provide more data on a real-time basis to improve both patient care and physician satisfaction with the model;
4. Allow all participating practices to start with 1-sided risk and continue through at least 2 full performance periods before deciding whether to continue as 2-sided;
5. Allow OCF practices that are participating in 2-sided risk the ability to opt out of other
CMMI demonstration models if there is a clear conflict in model scope; and
6. Allow another opportunity for stakeholder feedback after more details of the OCF model have been released.

We are hopeful that CMMI will consider our suggestions, as over the past several years, the agency has been very collaborative in dealing with issues surrounding the OCM. On a number of occasions, they have listened to our concerns and made significant adjustments that improved the model.

They deserve credit for their willingness to seriously consider our input, and, hopefully, they will take this same approach when building out the OCF. Practices will be more likely to participate if they feel their voices have been heard.

Value-Based Cancer Care in the Time of a Pandemic

While COVID-19 may have interrupted progress on the road to value-based care, practices need to continue delivering high-quality, high-value care through value-based models—even if the pandemic persists. It can be done. Across The Network, OCM practices are circumventing obstacles created by the virus by using personal protective equipment, Plexiglas shields, social distancing, and new policies to protect patients and staff. Furthermore, The Network practices readily employed telehealth to stay connected with patients but to minimize exposure to others in busy clinic settings. This strategy is working, as infusion volume is down less than 5%, and radiation volumes, although decreased, are down less than predicted.

Shying away from value-based care in turbulent times is not the answer, as value-based care is not going away. We know the CMS is strongly committed to transforming the health care landscape away from fee-for-service, and the models we are seeing now are simply stepping stones to the future. The OCF delay is merely a temporary interruption in the path forward. Looking ahead, the need for value-based care will only become more important and urgent as the government looks for ways to recoup the trillions of dollars spent on the COVID-19 response. Arbitrary cuts can be imposed, but the more thoughtful way is to pursue reimbursement models that incentivize good care but do so in a value-based manner that promotes buy-in from the physician community. Hopefully, common sense will prevail.

The OCM is an example of a successful value-based program in oncology. It attempts to drive
genuine transformation in how cancer care is delivered to Medicare beneficiaries by incentivizing practices to provide more comprehensive, cost-effective care. The 15 practices in The Network that are participating in the OCM have greatly enhanced their patient care. For example, OCM patients receive comprehensive care management and treatment plans, assistance from navigators and social workers, advance care planning, survivorship advice, information on estimated total out-of-pocket costs, and enhanced team care.

Across The Network, these reforms and investments have:
1. reduced hospital admissions by 7%;
2. reduced emergency department visits by 4%; and
3. driven a 5% increase in hospice stays longer than 3 days.

A key component of this success is adherence to evidence-based Value Pathways powered by the National Comprehensive Cancer Network, which have been proven to lower the overall cost of care with equal or better outcomes.

 Collectively, The Network practices alone have realized more than $80 million in savings for Medicare through participation in the OCM, while being able to appropriately manage all aspects of care delivery, including drug utilization. Many practices have also shared in the cost savings provided by delivering high-value care, helping them maintain financial stability in the challenging health care landscape.

Commercial Payers Can Help Drive Value-Based Care

As an integral component of the health care system, commercial payers are playing an important role in responding to COVID-19.  They must keep up with the evolving needs created by the pandemic. Once the PHE has passed and the dust has settled, we are hopeful they will follow the lead of CMS in driving and participating in value-based cancer care. In the past, commercial payers have expressed an interest in value-based models, but legacy claims systems designed around fee-for-service make it difficult for commercial payers to implement bundled case rates or episodic payment structures.

Hopefully, payers and providers can collaborate to build value-based arrangements.

Generally what works for Medicare can successfully be pursued by commercial payers. This
approach would help avoid some of the draconian measures upon which payers often rely to control costs, such as expanded prior authorization, utilization management, restrictive formularies, and fail-first/step-therapy policies. The cost savings they are seeking can be achieved through value-based care, while also providing a more patient-friendly experience that recognizes the critical role physicians play in delivering quality care.

Flexibility and Collaboration Are Critical for Value-Based Care Success

Over the past several years, great progress has been made in transitioning cancer care to value-based models. While COVID-19 has created many challenges, providers are working around the obstacles, getting back into the rhythm of delivering high-quality, value-based care. CMS has set a goal of increasingly tying reimbursement to value, and the pandemic has not diminished the desire to reach this objective. Consequently, we must keep moving forward despite the pandemic, so the significant progress made so far is not lost.

Value-based care works best in a predictable setting where practices have control over outcomes, but unfortunately, COVID-19 has added an enormous layer of uncertainty. Providers are patiently waiting to see what the true impact of the pandemic is, especially concerning patient behavior patterns and other factors that directly impact performance in value-based models. The US Oncology Network encourages CMMI to continue to maintain an open dialogue with providers. Value-based care in today’s ever-changing landscape can only succeed with high levels of adaptability, collaboration, and continuous stakeholder engagement. 



Neubauer is the chief medical officer of The US Oncology Network in The Woodlands, TX. Jones is the US Oncology Network’s vice president of government relations and public policy.

1. Survey shows COVID-19 pandemic is affecting patients’ access to cancer care. ASCO Post. April 21, 2020. Updated April 30, 2020. Accessed August 26, 2020. https://ascopost.com/news/april-2020/survey-shows-covid-19-pandemic-is-affecting-patients-access-to-cancer-care/

2. CMS Innovation Center models COVID-19 related adjustments. CMS. June 3, 2020. Accessed August 26, 2020. https://www.cms.gov/files/document/covid-innovation-model-flexibilities.pdf

3. Neubauer MA, Hoverman JR, Kolodziej M, et al. Cost effectiveness of evidence-based treatment guidelines for the treatment of non-small-cell lung cancer in the community setting. J Oncol Pract. 2010;6(1):12-18.doi:10.1200/JOP.091058

4. Miller J. 4 ways to adapt to new oncology value-based models. Managed Healthcare Executive. November 4, 2019. Accessed August 26, 2020. https://www.managedhealthcareexecutive.com/view/4-ways-adapt-new-oncology-value-based-models.

COVER FEATURE

COVID-19 has created a significant distraction from normal practice operations. The uncertainty that comes along with the pandemic is a huge worry, and can distract from practice transformation.





Uncertainty From COVID-19 Delays Progress on the Road to Value-Based Cancer Care

In the months since the Oncology Care First (OCF) informal Request for Information (RFI) comment period closed in December 2019, America’s health care system has faced a reckoning. A series of alternative payment model (APM) updates made by the Center for Medicare & Medicaid Innovation (CMMI) in the wake of coronavirus disease 2019 (COVID-19) included a yearlong extension to the Oncology Care Model (OCM) and a delayed start of the OCF program.

 While downside risk exposure in voluntary APMs might give potential participants pause as they recover from the impact of COVID-19, there are 3 important ways this public health emergency ultimately makes this model and others like it more appealing.

Prospective Management Fees Bring Reliable Payment

Providers in capitated or semi-capitated payment arrangements are paid predetermined amounts to care for a population of patients. In these prospective payment arrangements, providers have incentives to deliver the most efficient care possible and benefit from a predictable source of funds amid fluctuation in volume.

A long-standing barrier to adoption of these and other value-based payment arrangements has been the sheer convenience of fee-for-service (FFS) reimbursement. However, COVID-19 showed that, in a matter of weeks, complacency in fee-for-volume payment was upended as elective services plummeted. While most providers faced debilitating drops in previously reliable revenue, organizations participating in prospective or global budget types of payment  arrangements were better positioned to weather the impact of COVID-19.

The revenue impact of COVID-19 on oncology is less severe than in clinical service areas such as orthopedics and primary care, but oncology is not immune. Data from the COVID and Cancer Research Network (CCRN), published by the 

 in July, “clearly suggest a significant decrease in all cancer-related patient encounters as a result of the pandemic.”

In retrospect, the OCF RFI reads as poetical foreshadowing in its description of CMMI’s goal to “eliminate reliance on volume-drive, FFS revenue cycle management” and test whether “predictable revenue streams through an alternative payment mechanism”

 improve care coordination and management for cancer patients. As conceptualized, the model would pay participants a prospective, monthly payment for an assigned population of patients being treated for cancer. This fixed amount would cover evaluation and management (E/M) services, drug administration services, and other enhanced services such as care management and coordination. Participants also would be eligible for performance-based payments for quality and total cost of care accountability. Amid ongoing challenges to control the pandemic, a more reliable source of revenue may be welcome.

Legislation to Better Support APM Participation

COVID-19 provided real time feedback on the importance of value-based care (VBC) initiatives. Much of the care redesign activity and care management infrastructure that providers put in place for the purposes of being successful in VBC models enhanced providers’ ability to provide ongoing care for patients during the pandemic. While working with hundreds of providers across the country, Archway Health found that VBC participants were more likely to have in place hotlines staffed 24 hours a day, 7 days a week, with registered nurses; remote patient engagement tools; standardized use of a risk assessment tool to identify higher-risk patients; a process to review admit-discharge-transfer feeds from PatientPing or MemberMatch to determine which patients need follow-up; and other population health management strategies.

To inform these activities, VBC participants were more likely to have analyzed data for their patient populations and had a better understanding of the risk profile and prevalence of comorbidities among their patients.

CMS recognizes the crucial role VBC has played in meeting patient needs during this pandemic. During a Deep Dive webinar on the “Future of APMs,” hosted in May by America’s Physician Groups (APG), CMMI Director Brad Smith noted, “The public health emergency we’re going through shows the importance of value-based care.”

 He also emphasized that because of the “type of skills and type of capabilities that organizations have built up as part of being part of value-based [models],” continuing to stay in these programs is “the right thing to do for patients.”

In June, 6 former CMS leaders, including Mark McClellan, MD, PhD; Don Berwick, MD; and Andy Slavitt wrote congressional leadership calling for financial relief to help providers “adapt to the continuing threat of the virus and to rebuild care that keeps the best ideas for improving care in the pandemic.”

 They also recommended that relief funding be tied to provider efforts to move into value-based payment (VBP) models, and they “expect longer-term savings and better outcomes from greater participation in payment approaches that are better alternatives to FFS.”


Calls for legislative reform to help drive adoption of APM participation have resonated. In late July, the Value in Health Care Act of 2020 (Value Act) was introduced in the House of Representatives.

The bipartisan bill aims to accelerate Medicare’s move to VBP and increase participation in APMs through a number of legislative priorities, including extending the 5% bonus for advanced APM participation for an additional 6 years and lowering the Qualifying APM Participant (QP) thresholds for performance year 2021 and onward. Specifically, the Value Act would set the QP payment threshold at 50% in performance year 2021 and limit the increase to no more than 5% each performance period thereafter—a substantial improvement compared with the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) payment threshold of 75% in performance year 2021, and an opportunity for OCF participants to earn additional upside revenue beyond the prospective monthly management payments and performance based payments.


Leveraging Forced Innovation in Care Delivery

Ready or not, COVID-19 forced providers to adopt innovative ways to deliver care more efficiently. A prime example is the rampant adoption of telehealth, which allows cancer patients with compromised immune systems and high risk of infection to safely receive health care services. A McKinsey COVID-19 consumer survey found that telehealth adoption more than quadrupled between 2019 and April 2020, growing from 11% to 46% of US consumers using telehealth.

 During the virtual Community Oncology Association (COA) 2020 Conference in April, a virtual panel of leaders from oncology practices all agreed telehealth was a key pillar of their organization’s strategy to provide safe critical care for their patients under crisis conditions. Sibel Blau, MD, medical director of Northwest Medical Specialties, noted that telemedicine “improves patient care in ways that we couldn’t have imagined.”

 With implementation accomplished and plans for CMS to permanently expand telehealth for E/M Services,

 practices can leverage their existing infrastructure for care coordination in OCF.


Other COVID-19 initiated investments made to care redesign, such as home-based chronic care management, remote patient monitoring, partnerships with pharmacies that can deliver medications to patient homes, optimization of a rotating remote workforce, and ways to address lack of transportation for patients, may also generate earnings in OCF.


The reasons America’s health care system needs to implement a better way to pay for services are well-documented; the most disruptive pandemic in modern history may be what forces real reform.


Needing a crisis of this scale to bring broadscale change is regrettable. Worse would be our failure to continue moving in a better direction. In an April Health Affairs article, Mark McClellan, MD, PhD, and coauthors explained, “Continued payment reform progress is in the current interests of public health.”

 If designed well, OCF could be 1 of many worthwhile steps to take in that journey. 

Keely Macmillan, MSPH, is senior vice president, Policy and Solutions Management, Archway Health.


1. Verma S. New CMS payment model flexibilities for COVID-19. Health Affairs blog. June 3, 2020. Accessed June 3, 2020. https://www.healthaffairs.org/do/10.1377/hblog20200602.80889/full/
2. APM participants appear better positioned for COVID-19. Archway Health blog. May 7, 2020. Accessed September 26, 2020. https://www.archwayhealth.com/bundled-payments-blog/2020/5/apm-participants-appear-better-prepared-for-covid-19.
3. London JW, Fazio-Eynullayeva E, Palchuk MB, Sankey MB, McNair C. Effects of the COVID-19 pandemic on cancer-related patient encounters. JCO Clin Cancer Inform. 2020;4:657-665. doi:10.1200/CCI.20.00068
4. Oncology Care First Model: informal request for information. CMS. November 1, 2019. Accessed November 1, 2019. https://innovation.cms.gov/files/x/ocf-informalrfi.pdf.
5. CMMI director Brad Smith underscores Medicare’s commitment to value-based care. Archway Health blog. May 26, 2020. Accessed September 26, 2020. https://www.archwayhealth.com/bundled-payments-blog/2020/5/cmmi-director-brad-smith-underscores-medicares-commitment-to-value-based-care
6. Former CMS leaders write to Congressional leaders about payment and regulatory flexibility in COVID-19. Primary Care Collaborative. June 12, 2020. Accessed September 26, 2020. https://www.pcpcc.org/2020/06/12/former-cms-leaders-write-congressional-leaders-about-role-payment-and-regulatory
7. HR 7791. Value in Health Care Act of 2020. 116th Congress. 2nd sess.
8. Bestsennyy O, Gilbert G, Harris A, Rost J. Telehealth: a quarter-trillion-dollar post–COVID-19 reality? McKinsey & Company. May 29, 2020. Accessed September 27, 2020. https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/telehealth-a-quartertrillion-dollar-post-covid-19-reality
9. Doyle C. Cancer versus COVID-19: telemedicine, financial fallout, and the future of community oncology care. May 2020. https://obroncology.com/article/cancer-versus-covid-19-telemedicine-financial-fallout-and-the-future-of-community-oncology-care/
10. Trump administration proposes to expand telehealth benefits permanently for Medicare beneficiaries beyond the COVID-19 public health emergency and advances access to care in rural areas. News release. CMS. August 3, 2020. Accessed September 27, 2020. https://
www.cms.gov/newsroom/press-releases/trump-administration-proposes-expand-telehealth-benefits-permanently-medicare-beneficiaries-beyond
11. Bleser WK, Singletary E, Crook HL, Gonzalez-Smith J, Saunders RS, McClellan MB. Maintaining progress toward accountable care and payment reform during a pandemic, part 1: utilization and financial impact. Health Affairs blog. April 14, 2020. doi:10.1377/hblog20200410.281882.

COVID-19 has delayed the transition to Oncology Care First, but the forthcoming model could help.

Three Ways COVID-19 Makes the Oncology Care First Model More Attractive

Paris, Texas, with a population of about 25,000, is a long way in both miles and culture from Detroit, Michigan, where Sucharu “Chris” Prakash, MD, completed a fellowship in oncology and hematology. The city near the Red River that forms Texas’ boundary with Oklahoma offered an easier pace of life, friendly people, and a good place to raise a family, so 20 years ago Prakash and his wife made it their destination.

Prakash joined the Paris office of Texas Oncology, which serves patients across Texas’ Northeast corner, as well as some from Oklahoma. Now the area medical director, Prakash is passionate about bringing better care to his patients, and he serves on state and national-level committees to address the challenges of rural health care, including the American Society of Clinical Oncology’s Rural Cancer Care Task Force.

Rural health care delivery faces many challenges—from logistics, to finances, to keeping abreast of the scientific revolution in cancer care. Prakash points out that 60 million people, or about 19% of the US population, live in areas considered rural based on the Census Bureau’s definition, and that’s too many people too ignore.

From his vantage point, he sees the many disparities among rural patients—the residents are older, with less education and income than their urban counterparts. When cancer occurs, the outcomes are generally worse.

 “They are diagnosed later,” so mortality is higher, he said. “Access to care is a major issue—that impacts screening and treatment. There are major barriers to insurance coverage and transportation.”

And, within the population are pockets that are particularly high risk: Native Americans, for example, have above average rates of alcohol abuse and higher rates of obesity.

 Veterans often cannot travel long distances to the nearest VA center for care.


Work by the ASCO task force that Prakash joined in 2019 led to a report in June 2020,

 “Closing the Rural Cancer Gap: Three Institutional Approaches,” which identified the same disparities that Prakash sees every day, and more:

• While death rate from cancer are have fallen in both rural and urban areas, they are falling more slowly in rural areas.
• Rural patients have worse health outcomes in survivorship than their counterparts elsewhere, and this is especially true in the South, Appalachia, in tribal communities, and along the US-Mexico border.

• Rural patients are diagnosed later and less likely to receive stand-of-care treatment, follow-up or supportive services than patients in metropolitan areas.

In addition, the ASCO report highlighted the challenge of geography is connecting patients with providers. While the percentage of oncologists in rural counties has expanded somewhat since 2014, data from 2019 show that 12% to 15% of oncologists work in rural settings, and about 20% of rural Americans live more than 60 miles from an oncologist.

“These higher percentages of oncologists practicing in rural areas, however, remain smaller than the share of US population residing there,” the report said.


A major challenge, for both patients and providers, is insurance coverage and reimbursement. The Affordable Care Act (ACA), passed in 2010, was designed with the idea that Medicaid expansion would reach every household with incomes up to 138% of the poverty level. When the Supreme Court allowed states to decide whether or not to expand Medicaid, only half did in 2014, and 12 still have not as of October 1, 2020—including Texas.

 In states with Medicaid expansion, safety-net hospitals saw large drops in uncompensated care, but this was not so in non-expansion states

 Over the past decade, the closure of rural hospitals has been a story across the South

—and Northeast Texas has been hit especially hard, according to data from the University of North Carolina.

Even when patients have Medicaid, it might not be enough. Depending on where patients live, if reimbursements are too low, not all doctors will accept this form of coverage.

Prakash sees these effects at the individual patient level, as well as the snowball effect that lack of coverage creates across the health system. Many families do not qualify for the tax credit that would allow them to buy coverage on the ACA exchanges, but either they cannot afford coverage, or they do not get it through an employer. “This lack coverage limits access,” he said. “They cannot get their basic  screenings.”

When these patients are eventually diagnosed with cancer, providers must figure out how to absorb the costs, whether it’s through foundation help or patient assistance programs. Add in pressures from the 340B program and pharmacy benefit managers, and the situation can make it hard to attract the best talent, despite the good quality of life in the area. “The hospital is struggling to recruit, because everyone is aware of the problem,” he said.


Historically, fewer patients from rural areas have taken part in clinical trials because they lived too far from academic centers.

 Being part of the Texas Oncology/US Oncology network has allowed Prakash to enroll his patients in clinical trials, and he finds them eager to participate. Rural patients, he said, “are tough and smart and highly adaptable—they reach down and gather strength. If they trust in God, they trust their physician,” he said.


Willingness on the patients’ part is only part of the equation. Trials need enough patients to support a research nurse, for example. Prakash said that ASCO recognizes the inequity that rural patients have experienced, and leaders have worked with rural providers to ease eligibility criteria and protocol design, so that rural patients can participate.


CMS has experimented with rural health care models, but past efforts were limited to certain states. In August, as part of an effort called “Rethinking Rural Health,” the agency updated payment rules under the Inpatient Prospective Payment System (IPPS) to take effect for fiscal year 2020 (October 1, 2020), which officials said were designed with rural providers in mind.

 Although not specific to cancer care, the rule changes purport to address financial disadvantages that rural providers experience. And CMS then launched a payment model, called CHART, that addresses a long-standing complaint about the definition of “originating site” in telehealth, which had been a barrier for providers.

• address wage index disparities by improving the accuracy of the calculation, and change the way the “rural floor” is calculated;
• increase the wage index for hospitals below the 25th percentile; and
• implement a required increase for hospitals taking part in a quality reporting program.

With CHART, which stands for Community Health Access and Rural Transformation, CMS will provide funding to support new payment models, regulatory flexibility, and technology support to implement value-based capitated payment models that will allow an outpatient department or emergency room to be reimbursed as if they were a hospital.


The latest game changer has been the coronavirus disease 2019 (COVID-19). The pandemic has opened the door to telehealth on a scale not seen previously. Not every visit is appropriate for telehealth, as some patients still use a flip phone or want to see their doctor in person. But like many others, Prakash believes there’s no going back, and CMS has proposed making some aspects of the telehealth rule change permanent.

Telehealth is poised to have “a profound impact,” beyond patient care and research, he said, because it offers possibilities for provider education and training for rural physicians, to “reduce the isolation, especially for early career oncologists.”

He sees virtual training as a tool to ensure there is better mentorship and support, and opportunities for young oncologists to more fully participate in major scientific meetings when they simply cannot take time off.

Long term, Prakash sees a need for development of the oncology work force in rural areas; this will require regulatory relief to improve the clinical trial staff and provide the psychological, nutrition, and support services that patients should expect. Meeting the needs of patients who often cannot afford their care is not easy, he said. “It is challenging. They need someone who is dedicated.”

But spending time with each patient, and learning their social and psychological needs has its benefits, too. “You do make a difference in the community. And people appreciate what you do.” 


1. Dr. Chris Prakash joins national rural cancer care task force. Texas 
Oncology website. Published October 21, 2019. Accessed September 27,
2020. https://www.texasoncology.com/who-we-re/news/2019/cancercare-
task-force.
2. United States Census Bureau. Rural America. October 1, 2020. https://
gis-portal.data.census.gov/arcgis/apps/MapSeries/index.html?appid=
7a41374f6b03456e9d138cb014711e01.
3. Henley SJ, Anderson RN, Thomas CC, et al: Invasive cancer incidence,
2004–2013, and deaths, 2006–2015, in nonmetropolitan and metropolitan
counties — United States. MMWR Surveill Summ 2017;66(14);1–
13. DOI: http://dx.doi.org/10.15585/mmwr.ss6614a1
4. Risk of alcohol use among Native Americans. American Addiction
Centers. https://americanaddictioncenters.org/alcoholism-treatment/
native-americans. Updated January 2, 2020. Accessed
September 29, 2020.
5. VA updates veterans’ choice program to consider driving distance.
News release. April 14, 2015. Accessed September 29, 2020. https://
lamalfa.house.gov/media-center/press-releases/va-updates-veterans-
choice-program-to-consider-driving-distance
6. Levit LA, Byatt L, Lyss AP, et al. Closing the rural cancer care gap: three institutional approaches. J Oncol Pract. 2020;16(7):422-430. doi: 10.1200/OP.20.00174
7. Trump administration finalizes policies to advance rural health and
medical innovation. News release. Published August 2, 2020. Accessed
September 30, 2020. https://www.cms.gov/newsroom/press-releases/
trump-administration-finalizes-policies-advance-rural-health-andmedical-innovation.
8. CHART model. CMS website. Updated September 17, 2020. https://
innovation.cms.gov/innovation-models/chart-model.
9. Proposed policy, payment, and quality provisions changes to the
Medicare physician fee schedule for calendar year 2021. CMS website.
News release. Published August 3, 2020. Accessed October 1, 2020.
https://www.cms.gov/newsroom/fact-sheets/proposed-policy-payment-
and-quality-provisions-changes-medicare-physician-fee-schedule-
calendar-year-4
10. The Cecil G. Sheps Center for Health Services Research. 174 rural
hospital closures: January 2005 to present (132 since 2010). UNC
website. Accessed October 1, 2020. https://www.shepscenter.unc.edu/
programs-projects/rural-health/rural-hospital-closures/
11. Holgash K, Heberlein M. Physician acceptance of new Medicaid patients.
Medicaid and CHIP Payment and Access Commission. Published
January 24, 2019. Accessed October 1, 2020. http://www.macpac.gov/
wp-content/uploads/2019/01/Physician-Acceptance-of-New-Medicaid-Patients.pdf

A look at the special challenges of delivering cancer care in rural areas, as ASCO seeks to address this issue.

Understanding the Challenges of Rural Cancer Care

Kashyap Patel, MD, had known for years that he would write about dying.

The longtime oncologist, now CEO of Carolina Blood and Cancer Care Associates of Rock Hill, South Carolina, had addressed the topic head on with patients, family members, and caregivers. He took a special course in palliative care at Northwestern University so that he could train others. Patel knew
there was a great, unmet need to teach medical students and young physicians how to guide patients through the end-of-life process in a meaningful way.

And yet, despite a decade of movement toward greater quality in cancer care, dying remained a mostly taboo subject.

As Patel describes it, his own brush with mortality—a cardiac event in 2008—convinced him that the time had come to finish a book he had long contemplated. Patel turned to his extensive
notes and his diary, and he began compiling the stories that became B

etween Life and Death: From Despair to Hope 

(Penguin Random House India). Drawn directly from patient stories—in particular, the tale of a former British pilot named Harry Falls—the book is a roadmap for the journey every human being takes, and how we can all do so with greater purpose, and less fear. (A review
appeared in the April issue of 

The journey to publication took some unexpected turns. In the winter of 2020, Patel expected his book would reach readers sometime in April. But first the coronavirus disease 2019 (COVID-
19) hit China, disrupting the book’s initial printing, and then Patel’s publisher feared the original title would fall flat during a pandemic. After finally arriving on August 1,

 about a topic he now hopes to make a theme of his coming tenure as president of the Community Oncology Alliance. This interview has been edited and condensed for clarity.

 How and when did you decide, ‘I need to write a book on this subject?’

: As an oncologist, having lived on 3 continents and having practiced for 3 decades, what I found was that every time I had to break bad news to a patient, we had to shift gears to comfort care.

The common questions were, why? How? What will happen to my loved ones? Then, as I started getting involved in the health care policy space, I realized that one of the biggest challenges that we have as oncologists is that our patients are not getting prepared for end-of-life care.

After becoming a trainer and conducting retreats for other doctors, I realized that there’s not a single medical school in America that has [a] dedicated course on communications for the
end-of-life care.

Tell us about the patient who appears in the book as Harry Falls.

This patient came to see me, and he was a straight talker. He was a British pilot who fought in the Second World War. And he said, “Doctor, I’m not afraid of my death, but I want to see how
it will happen—I want to be prepared for it, I want to prepare my family.” This patient had terminal lung cancer and said, “I don’t want to take chemotherapy.” From then on, I told him, “Your life expectancy is going to be less than 3 months.” He said, “All I want to know is, what will happen to me? What will happen to my body? How do diff erent faiths deal with death and dying? How will my wife and my children deal with that? Will I have enough time to [bring] closure to everything? Will I be in pain?”

I started narrating stories from a few of my patients, so that I could be mentally ready for the whole process of understanding the transition between this life and wherever we’re heading for after life.

How are audiences responding to the book?

Among all those who’ve read it so far, I’ve received about 15 different written reviews. It’s incredible.…They are incredibly moved and touched by it; there are very moving accounts, saying,
“I wish I’d read this book before my father passed away. I wish I had this book before my mom was on her death bed.”

Do the responses vary somewhat—do your physician friends have one type of reaction and
patients have a different type of reaction? 

 My physician friends are all excited, because this is something that I think people are hesitant to bring up—but when they see that there’s a way that you can openly communicate
about it—dealing with the finitude of life, this conversation could start happening more. A lot
of my colleagues are encouraging me to look into even starting a movement. And I’m seriously
looking at taking this on….I want to bring openness to the conversation; how do we bring this
topic up while we talk about extending life as well?

One other person who read it is actually a current patient; he also gave testimony about [the] interaction with this book. So patients who have active cancer are seeing this book as one of the roadmaps to finding peace in your own life as well.

It sounds like the book is a good way for physicians to start the conversation with patients, to open the door for those who are struggling with beginning a conversation about the end of life.

Absolutely. And one of the senior leaders of a large pharma company saw that and said, “We want to have all of our leadership see this, because when we talk about [these] issues across the country, we don’t talk about the poor quality of death.” If you look into the Institute of Medicine, they always say that the quality of death is not the best in the United States (

If you look into the published studies [in 

, there was a phase 3 randomized study
where they looked into the type and place of death of the cancer patients, those patients who died
in the hospital, in the ICU [intensive care unit] or active acute care setting—their loved ones had much worse psychiatric issues, because of not being able to put it closer to what [the patients] wanted to do. So there are studies that show that dying in a place where patients would not have desired is fraught with adverse outcomes for the family as well as caregivers.…But when you bring up the conversation, how do you bring up conversation?

 What do you hope is the chief message that people take away from your book?

I want everyone to know that you have a choice of living this life to the fullest no matter what comes. What I don’t control is what way my finitude will reach me—whether I’ll be dying of cancer, heart disease, Alzheimer [disease], or kidney failure. What I can choose is, how do I react to that? What I cannot control is, what comes my way. The only thing that’s certain in my life is that I’m going to leave this world. From the day I am born, I’m counting one less day toward that horizon of finitude, and why can’t I be ready for that instead of worrying about it? If I take the fear of death away, I can enjoy life to the fullest.


1. Bourg FC. One oncologist’s journey with a patient to the outcome we all face. Am J Manag Care. 2020;(4 spec no):SP106-SP108. doi:10.37765/ajmc.2020.43004
2. Institute of Medicine.Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. Washington, DC: The National Academies Press, 2015. doi:10.17226/18748

INTERVIEW

Kashyap Patel, MD, CEO of Carolina Blood and Cancer Care, associate editor of Evidence-Based Oncology, and vice president of the Community Oncology Alliance, discusses his new book. 

When the Topic Is Dying: A Conversation With Kashyap Patel, MD

Strong. Vulnerable. Open. Closed off. Depressed. Angry. Optimistic. Happy. Humorous.
Spiritual. Together, these describe just a portion of the emotions patients with metastatic breast
cancer(MBC) face when they receive a diagnosis of what is the most advanced stage of the disease.

No matter the site, or sites, of metastasis—bones, brain, even liver—cancer that originates
in breast tissue before spreading is treated as breast cancer because of where it originated

 At
diagnosis, approximately 6% of breast cancers are metastatic.

 Experts predicted that 276,480
women and 2620 men would receive such a diagnosis in 2020.

For men especially, MBC can be difficult to talk about, much less open up about. Men represent only 0.95% of the full number of cases of MBC in women. Kirby Lewis of West Virginia, now a stage II breast cancer survivor, had a mastectomy in 2012—but not before firing his first doctor who told him men don’t get breast cancer. However, in 2016, his cancer recurred, spreading to his spine and both lungs. He had MBC from which his “lungs lit up like Christmas trees,” he said.

Lewis has managed to remain optimistic despite his diagnosis, which brought with it 15 weeks of
treatment with chemotherapy and various other medications, followed by a switch to a different oral medication and a years-long remission before a small tumor began to grow again. He attributes his attitude to his years of experience as an embalmer for a funeral service. Lewis said he understood that death is a part of life.

 “My perspective all along has been that we don’t really get to choose or pick things the way we would like things to be in our life,” he said. “We are dealt this hand and what really matters is how we live it. I’ve tried to be a realist.”

Lewis also credits his faith and his combat experience in the military with helping him realize how precious life is and making it easier for him to cope with his MBC diagnosis.

He is 1 of 9 patients, and the only male, with MBC who serve as the faces of Facing MBC Together from Athenex Oncology, a US-based division of global biopharmaceutical giant Athenex, “to provide accessible information and multiple resources to oncology customers, including health care professionals, patients, and caregivers, who may benefit from Athenex’s broad pipeline of innovative oncology products.”

Both the website and mobile app of Facing MBC Together were built to address the isolation patients with MBC often feel by providing practical and emotional support in the forms of educating patients and the public on:

• What the disease is: it’s stage IV, or advanced breast cancer

At diagnosis, approximately 6% of breast cancers are metastatic breast cancer (MBC), which although treatable is not curable. Experts predicted that 276,480 women and 2620 men would receive such a diagnosis in 2020.

October 2020