Alexa Simon Meara, MD, MS, on Immunotherapy Collaboration Beyond Silos

Immunotherapy has transformed oncology, but it has also created a new frontier of complexity that many community practices weren’t built to navigate alone. At the recent Community Oncology Conference, Alexa Simon Meara, MD, MS, rheumatologist in the Division of Oncology at The Ohio State University Comprehensive Cancer Center–The James, joined co-presenters Sibel Blau, MD, of Northwest Medical Specialties, and Harsha Vyas, MD, FACP, of Cancer Center of Middle Georgia, for the session “Multidisciplinary Physician Collaboration Driving Innovation in Community Oncology.”

Together, they explored how to build referral frameworks for shared patient care between academic and community practices across both rural and urban settings. In this interview with The American Journal of Managed Care^® (AJMC^®), Meara discusses the most common barriers to collaboration, how immunotherapy’s unique toxicity profile demands a paradigm shift in care delivery, and why, as she puts it, “just because it’s hard doesn’t mean it has to be miserable.”

This interview has been lightly edited.

AJMC: Your work at The James cancer hospital sits at the intersection of highly specialized immunotherapy management and broad oncology care. When you think about building referral frameworks between academic centers and community practices, what are the most common barriers you've encountered, and how do you work around them?

Meara: This is a loaded question, and I think we could spend hours discussing that. I think that this is a novel approach in the idea of oncology having a copilot or dyad system of taking care of patients from the beginning of cancer treatment as a comanagement system and through. For example, there are barriers in education in the sense [that] the newer drugs in oncology are changing the immune system, so how do we help focus the immune system? How do we understand what drugs already exist rather than having to rebuild them? What is on what silo than the other? Who are those people?

Two, for patients, this isn’t chemotherapy, and if you’re anchored to how you’re supposed to feel for chemotherapy, you may not even know what you don’t know, so you don’t know what symptoms to report, what symptoms to not report, and how to do that—so there’s a barrier in how to communicate with patients, and then triage tools and nursing tools, because again, if we’re anchored to chemotherapy, this is a whole different space.

Then, 3: it is also this area of, how do we educate all of the above people to find the right solutions? It’s a huge paradigm shift. We couldn’t have this conversation 10 years ago, we couldn’t have this conversation 20 years ago, so this paradigm shift of creating evidence for extension of life and of the quality and what we mean by that, so everyone is on the same page.

AJMC: Community oncology looks very different in a rural Appalachian setting than it does in a suburban Columbus practice. From your experience, how should referral frameworks be adapted to account for those differences, especially when patients face certain social determinants, like travel burdens or limited access to specialty care to begin with?

Meara: I think there are 2 answers. One is for the community practices that have multispecialty care. For a community oncology practice that buys or works with a rheumatology practice because they share an infusion center, I think there’s an opportunity to work together in a space. They probably don’t share the same room, but that doesn’t mean that they can’t, and how to work about that.

I can’t make the hard go away, but I can make patients feel better, and we can make this easier. We’ve gotten lost in precision medicine, and we’ve lost personalized medicine.

Then 2, I think, is a little bit of this education, which I know is overwhelming. I’m not suggesting we have to retrain everyone, but if we understand how immunotherapy works, the bispecifics, the cellular therapy, and how [they modulate] or change the immune system, then the idea of these drugs causing long-term autoimmune-like syndromes or autoimmune diseases is pretty expected. So now it becomes a question of, how do we have early recognition and how do we take drugs and repurpose them? In the advent of AI [artificial intelligence] and all these different things, there are better triage tools that we can use to educate nurses to get to simple answers. The idea is then that maybe your rheumatologist is for the really difficult cases, but we can be able to do that. We can train nurse practitioners and physician assistants and APPs [advanced practice providers] and nurses on how to take care of these patients in a simpler pathway and a triage pathway to be able to use the guidelines more as guidelines rather than step-by-step treatment, so you can actually take care of the patient in front of you.

Some of the work that I’ve done is create the nonprofit, the Foundation for Autoimmune Cancer Support, as a 501(c)(3), and the idea is, if you have a patient and you Google you have melanoma and joint pain, you’d get the Arthritis Foundation, the Melanoma Foundation. There’s no way to find each other. So, how do you create a patient space so they know how to ask the questions? How do you create a space for community oncologists to be able to ask for help when they need help? How do they find who are the experts?

My hope is maybe to have a premeeting one day at a meeting like COA, where you bring the immunotherapy treatment experts, and we give a lecture, and then you have the Research Consortium, the ASPirE Group that has the Alliance for Support and Prevention of Immune Related-Adverse Events. How do we drive the evidence and the clinical trials for extension of life?

Unfortunately, it all has to happen at the same time to drive advocacy and to drive funding, but the model is about 1, being curious, and 2, how do you not reinvent the wheel? What do you already have at your disposal? How can we do this a little differently and a little better?

AJMC: Your Immunotherapy Management Clinic addresses a highly nuanced area: immune-related adverse events that many community oncologists may not feel equipped to manage independently. How do you design shared care protocols so that physicians feel supported and confident rather than that they're just handing their patients off to you?

Meara: Most internists, even oncology, we get board certified in internal medicine. Even most internists don’t want to be a rheumatologist. I’m not trying to make all community oncologists or oncologists rheumatologists, but we have to learn how to ask those questions. There are systems that we could put in place, such as: if a patient brings up joint pain, there are easy questions, like, “Do you have morning stiffness?” or “Is there swelling vs what’s the worst part of the day for you?” to figure out if it’s more inflammatory vs more noninflammatory. That can then help triage who needs to do what and where.

The other thing that we can do is, how you think about what subspecialties you have and who you can use to help, and what education actually is useful and meaningful to do that. Again, I don’t become this bottleneck that I have to see all these patients, because there are some wonderful physicians out there who are both internists, rheumatologists, subspecialists, dermatologists, and different things that can help do this, so you don’t have to feel like you’re alone. I think it’s just about connecting, because the silos have become so profound right now.

Just because it’s hard doesn’t mean it has to be miserable. I can’t make the hard go away, but I can make patients feel better, and we can make this easier. We’ve gotten lost in precision medicine, and we’ve lost personalized medicine.