Equity and Innovation in Value-Based Precision Oncology: A Q&A With Tina Bhatnagar, DO

Bhavana (Tina) Bhatnagar, DO, an associate professor of medicine and director of hematology and medical oncology at West Virginia University Cancer Institute at Wheeling Hospital, is a leading voice in the integration of precision medicine and equity within oncology. Specializing in hematologic malignancies, she is well-versed in the impact of targeted therapeutics in value-based care. She advocates for the strategic use of artificial intelligence (AI) to assist clinicians in synthesizing data, emphasizing that AI should enhance, rather than replace, clinical expertise in both academic and community settings.

A significant portion of her focus is on closing the diversity gap in clinical research, and she points out that although organizations like the National Institutes of Health (NIH) have prioritized representation, structural barriers—such as the concentration of trials in academic centers and restrictive eligibility criteria—often exclude minority and “real-world” patients who may have various comorbidities.

“I think it’s a multilevel problem that will involve addressing barriers at the patient level, the provider level, the institution level, and the national level as well,” she emphasizes.

To achieve true equity, she argues for expanding trial infrastructure into local communities and involving those sites in the initial design phases. This approach ensures that researchers collect data on a broad patient base, leading to a deeper understanding of how specific gene mutations affect different populations.

In this interview with The American Journal of Managed Care^® (AJMC^®), Bhatnagar delves into these critical challenges and the necessary investments required to bridge the equity gap.

This transcript has been lightly edited for clarity.

AJMC: Where has precision medicine achieved the most success to date, and where is there still much work to be done?

Bhatnagar: In my mind, I think the biggest successes of precision medicine are the ability to be able to provide targeted therapies that usually have fewer toxicities than our standard chemotherapy regimens, because they go directly after the cancer cells as opposed to chemotherapy that is kind of like a blanket treatment for the cancer and also unfortunately affects healthy cells as well. I think it’s paved the way for lots of new therapeutics that have really helped our patients.

The other area where precision oncology has been really helpful is with prognostication. We’ve been able to use next-generation sequencing studies in order to better risk-stratify patients across a broad range of cancers, and that’s helped modify or given us a better understanding of how a patient’s cancer is likely to behave beyond just the clinical data that we routinely collect.

AJMC: How have biomarker-driven targeted therapies changed survival outcomes or quality of life across different cancer types?

Bhatnagar: I think precision oncology has changed the lives of many patients. It’s always gratifying for me as an oncologist to be able to offer patients treatments that are specifically targeted toward their disease. One particular patient who comes to mind is a gentleman I took care of who had acute myeloid leukemia [AML], which is a very aggressive blood cancer. At the time of this patient’s diagnosis, he was admitted to the hospital concurrently with a new heart attack, some type of severe infection, and a new diagnosis of AML. He was clearly not a candidate for our frontline therapy, which is very intensive and usually involves a 4- to 6-week hospital stay.

We ended up testing his leukemia cells for the presence of certain genetic mutations and found out he had a mutation in a gene called FLT3, which is mutated in about one-third of people with AML. Fortunately, there are medications directed toward the FLT3 mutation called FLT3 inhibitors. I was able to obtain an FLT3 inhibitor for this patient and get him safely out of the hospital and into full remission, with an excellent quality of life and a very long remission on a pill for a cancer that would have otherwise been fatal.

AJMC: How do you use AI currently, and what are potential future applications?

Bhatnagar: For me right now, AI is a very hot topic. It is coming into all aspects of our lives, and so we do have to know how to work with it and make sure that we are partnering with AI so that everybody kind of wins and so that we’re providing efficient care for all of our patients. Currently, I use AI in only a couple of different contexts. I use it for my workflow to assist with clinical documentation, and I also use it sometimes for various decision-making tools. If there is a particular clinical scenario where I need to get a quick answer about what the right next step might be, I have found various AI platforms to be helpful in terms of assisting me with my decision-making, but not necessarily making the decision for me.

I think in the precision oncology space, too, I do believe that AI will work its way into that space as well, with the goal of ultimately synthesizing all of this information that we have about our patients, their clinical data, their tumor data, their genomic testing, and any sort of multiomic testing into 1 treatment plan that you can follow to take care of patients. I think that will be helpful. Particularly, I think it will be helpful in the academic medical centers, but I think it may be even more helpful in community practices, where physicians are responsible for knowing about all kinds of different cancers, and I think it will allow them to stay up-to-date.

AJMC: What are some of the principal bottlenecks limiting equitable access to precision medicine?

Bhatnagar: All these precision oncology platforms are amazing, but they become limiting when people aren’t able to access them. I think one of the biggest challenges is being able to make sure that patients in rural populations have access to precision oncology and are getting their tissue tested for the presence of various gene mutations. We also talked a lot about the underrepresentation of minorities in precision oncology and large data sets. Sometimes that limits the applicability of specific gene testing to certain populations, and that can also affect outcomes, especially if there’s a knowledge gap in terms of how specific gene mutations affect certain minority populations. Also, it will help inform whether those populations are able to respond to some of the treatments that we have available.

I think, as a community, we need to make sure that we are focusing our efforts. We have to work collectively with policymakers, with our institutions, and with our patients to make sure that equitable access is achieved for patients regardless of where they live and that various social determinants of health and barriers are also addressed. Patients come from all different walks of life, and I think, as their physician, it’s important to know who they are as a person and what kinds of challenges they might have that might prevent them from being able to get really what’s considered gold-standard care.

AJMC: How can the oncology community ensure that data sets and clinical trials best reflect patient diversity, especially underrepresented populations?

Bhatnagar: It’s a big topic right now, and even the NIH has put in a plug to make sure that there is diversity in the clinical trial space. I think it’s a multilevel problem that will involve addressing barriers at the patient level, the provider level, the institution level, and the national level as well. I think trying to enroll patients from underrepresented populations in clinical trials is a really important first step. In order to do that, it’s going to involve educating both physicians and patients, particularly physicians who do not work in academic medical centers and may not know the ins and outs of clinical trials, and also educating patients about the importance of clinical trials and why they are important to enroll in, too. I think there needs to be some education at that level.

Then, also, institutional buy-in, making sure that the infrastructure at trial sites outside of academic medical centers will help enroll minorities. In my own practice, whenever I do bring up clinical trials, there’s a lot of hesitation for patients to go somewhere else to receive their care. We try to open clinical trials at our own hospital, but that requires having the infrastructure built in because there’s a lot that goes into running a clinical trial, and so it’s important to invest in the resources and the personnel that are necessary to do them properly.

Also, the sponsors of clinical trials need to design studies that represent a broad range of patients. Most clinical trials are designed with the intent of enrolling only the fittest patients, but in the real world, patients have other medical problems. They have other medical comorbidities. Sometimes there are barriers to being able to enroll because of the time commitments or the frequency of the visits, and I think taking those into account as the clinical trials are being designed is important. Also being sure to include community sites in the initial process of designing the trial with the intent of opening that trial in the community. So there’s that.

Then, of course, on the institutional level, building the infrastructure just on a grand scale to support clinical trial structure is going to be really important to ensure that we have patients from all backgrounds in trials. That will ultimately feed into the precision oncology space because, as we’re collecting data on those patients over time, we’ll have a better idea of how specific gene mutations influence certain populations and how those populations respond to treatments.