Making Oncology Innovation Work for Every Patient

Author(s)Maggie L. Shaw

Fact checked by: Christina Mattina

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Key Takeaways

Routine tissue NGS at metastatic presentation and serial liquid biopsies for emerging ESR1 mutations are becoming operational norms, alongside increased emphasis on quantitative HER2-ultralow reporting.
Antibody-drug conjugates have outperformed standard chemotherapy in relapsed metastatic TNBC, yet sequencing remains uncertain, and real-world outcomes after a second ADC show short PFS.
Operational toxicity strategies are evolving, including practical measures for ocular and oral adverse events, while payer constraints on supportive care approvals create downstream monitoring and outcome risks.
Immunotherapy expansion in leukemia/lymphoma is constrained by “choke points” in diagnosis, referral, and social determinants, compounded by prior-authorization friction and annual insurance benefit resets.
Trial equity gaps reflect low screening uptake, shifting nonsmoker lung cancer demographics, restrictive eligibility, and logistical barriers; e-consent, telehealth, and community-based trials are key levers.

Delivering value-based oncology care requires both scientific breakthroughs and deliberate system redesign, experts concurred during this February IVBM in Los Angeles.

Across expert panels spanning breast cancer, leukemia and lymphoma, clinical trial diversity, and academic community partnerships at the Institute for Value-Based Medicine^®’s Pioneering the Next Era of Oncology Care event in Los Angeles, California, on February 12, some of the most pressing issues facing oncology today were addressed. In a symposium that brought together clinicians, researchers, and health care leaders from leading regional institutions, discussions tackled breaking down systemic barriers to care, the critical importance of equity and access, the transformative potential of new targeted therapies and immunotherapies, and the persistent challenge of aligning clinical innovation with the realities of payer systems and community practice.

These discussions did not shy away from the structural tensions that define modern oncology. Whether a conversation centered on next-generation sequencing (NGS) for metastatic breast cancer, the logistical hurdles of delivering chimeric antigen receptor (CAR) T-cell therapy outside academic walls, the underrepresentation of diverse populations in clinical trials, or the misaligned financial incentives that complicate transitions between academic and community care, the path to success was distinct: Delivering value-based oncology care requires both scientific breakthroughs and deliberate system redesign. The insights shared offer a timely and actionable road map for the field.

Targeted Success: Operationalizing Therapies in Breast Cancer

This first panel brought together 4 breast oncology specialists to examine how leading academic medical centers are translating advances in metastatic breast cancer into everyday clinical practice. Their discussion opened with NGS, and the panelists concurred that tissue-based NGS at the onset of metastatic disease has become standard practice. Liquid biopsy is increasingly routine as well, particularly for tracking emerging ESR1 mutations.

“We have begun, in patients with metastatic disease, to actually get NGS on the tissue at the onset of metastatic disease and then also upon progression,” said panelist Saeed Sadeghi, MD, clinical professor of medicine at David Geffen School of Medicine at University of California, Los Angeles (UCLA). “By habit, we are now getting liquid biopsies as well.”

Tempus was a common platform used among the panelists—this technology allows customizable molecular profiling via liquid biopsy of circulating tumor DNA¹—alongside internal molecular panels, with pathologists now being asked to quantify HER2-ultralow status, a refinement that is opening new therapeutic doors.

“Two years ago, she was like, ‘I’m not dealing with ultralow/low; I will give you a percentage,’” said Yuan Yuan, MD, PhD, director of breast oncology at Cedars-Sinai Medical Center in Los Angeles, about the forward-thinking Sophia K. Apple, MD, of Huntington Health Medical Center-Pasadena in California, who adopted quantitative HER2 reporting well ahead of guidelines from the American Society of Clinical Oncology and the College of American Pathologists. This guidance was most recently updated in 2023.²

The panelists also spent considerable time on antibody-drug conjugates (ADCs), which have reshaped the treatment of metastatic triple-negative breast cancer. They emphasized that ADCs such as sacituzumab govitecan and trastuzumab deruxtecan are now superior to standard chemotherapy in the relapsed setting, but community uptake remains inconsistent.

“When you have disease progression within 6 to 12 months, you really are quite resistant to chemotherapy,” Daphne Brooks Stewart, MD, clinical professor of medicine at Keck School of Medicine at the University of Southern California in Los Angeles, explained. “Thankfully, we have the ADC; that’s a different payload and will have a different response.”

Sequencing ADCs against each other remains an open clinical question, as real-world progression-free survival data hover around 2.5 to 2.9 months after the second ADC.

Toxicity management dominated the latter portion of the discussion, with the panelists addressing oral mucositis and ocular toxicity from datopotamab, the hair loss associated with sacituzumab, and the hyperglycemia and diarrhea risks of capivasertib. Moderator Joanne Mortimer, MD, FACP, FASCO, director of the Women’s Cancers Program at City of Hope in Duarte, California, highlighted one practical innovation: “I had a patient who had the worst ocular toxicity from sacituzumab, which is a known complication, but it’s very rare, and when I gave her the data, she froze her eyes and she had no problems at all.”

In the context of chemotherapy, ocular cryotherapy is a procedure in which extreme cold—typically liquid nitrogen—is used to treat small tumors in the eye.³ Cold compresses can also be used to reduce ocular toxicity by restricting blood flow and thereby reducing the amount of a chemotherapy drug that reaches the eye.⁴

Payer barriers also surfaced, particularly around granulocyte colony-stimulating factor approvals and the logistical burden of monitoring, challenges that the panel agreed require better systems-level solutions to protect patient outcomes.

Advancing Frontiers in Leukemia and Lymphoma: Breakthroughs and Barriers

Discussion during the second panel examined how immunotherapy innovations are transforming the treatment of leukemia and lymphoma as well as the formidable logistical, financial, and systemic barriers that still stand between these breakthroughs and the patients who need them most. The experts agreed that the emergence of CAR T-cell therapy and bispecific antibodies represents a turning point.

Idoroenyi Amanam, MD, assistant professor in the Division of Leukemia in the Department of Hematology & Hematopoietic Cell Transplantation at City of Hope, called immunotherapy a game changer. “Obviously not just allogeneic stem cell transplant, but the monoclonal antibodies, the bispecifics, [and] CAR T [have] really expanded our ability to offer treatments to more patients,” he said. This is especially true for patients previously considered poor candidates for aggressive therapy.

Yumei (Melody) Chang, MBA, RPh, BCOP, vice president of pharmacy operations at American Oncology Network, pointed to the shift toward earlier lines of therapy as equally transformative. “I would say probably most transformative is going to be the earlier line of therapy for the CAR T as well as bispecific outpatient usage,” she said. “I think that’s going to be what I see as the most impactful, at least for outpatient practice.”

Real-world data are already shaping practice. Chang noted that a network chart review of 40 patients revealed that routine tocilizumab premedication for bispecific therapy was not significantly reducing cytokine release syndrome rates, which prompted a protocol update.

The panel spent considerable time on access and equity. Amanam outlined 3 systemic “choke points” for patients with acute leukemia: timely diagnosis, referral to a transplant center, and overcoming social determinants, such as lack of transportation, housing instability, and caregiver availability. Payer-driven authorization delays compound every one of these challenges, he noted, describing situations where double-authorization requirements between institutions effectively delay lifesaving care.

Insurance benefits reset at the start of each calendar year, adding yet another layer of disruption. “January 1 is usually a day of celebration,” moderator Tycel Phillips, MD, associate professor in the Division of Lymphoma in the Department of Hematology & Hematopoietic Cell Transplantation at City of Hope, said. “But in the hospital system, it’s probably another day of discomfort and discord, because that’s when the insurance benefits shift over, so it’s almost like resetting the clock.”

Chang built on this by advising that financial counselors and pharmacy teams need at least a week of advance notice before treatment milestones to prevent gaps in authorization or coverage. Speaking through a value-based lens, she was direct in saying, “It should be the right care at the right place for the right patient. Sometimes, the insurance looking for the cheapest site for care is not always cheap. Because if patients are high risk and end up getting treated but come back again, the total cost of care is going to be higher.”

Telemedicine, the panel concluded, is emerging as one practical tool for bridging geographical gaps and improving access to targeted therapies for patients who cannot easily travel to academic centers.

From Vision to Reality: Building Diversity in Clinical Trials

Two thoracic oncologists and a clinical trial access director convened to confront one of oncology’s most persistent failures: the gaps among who is diagnosed with cancer, who is enrolled in clinical trials, and who ultimately benefits from the therapies those trials produce. The conversation opened with cancer screening, where the news remains sobering.

Amy L. Cummings, MD, PhD, director of lung cancer screening and clinical trial access at UCLA’s Jonsson Comprehensive Cancer Center, who led the discussion, noted that even before the COVID-19 pandemic, California was screening less than 1% of patients with lung cancer who were eligible. The pandemic compounded existing barriers—medical distrust, insurance silos, transportation challenges, and immigration-related fears—making an already difficult landscape worse. “The best lung cancer is the one we can cure,” Cummings said, underscoring the urgency of early detection. “There’s still a community reluctance that we’re dealing with in terms of getting back to our screening numbers.”

Shifting patient demographics are adding another level of complexity. Aaron Lisberg, MD, thoracic medical oncologist at UCLA, noted that a growing share of his patients are nonsmokers, a population that current screening criteria miss. “Even if we were screening 100% of people who were eligible, we’ve missed 100% of the people whom I’m talking about right now,” he said. “It’s a huge issue. I think we are biased in terms of the populations we see.”

Lauren Antrim, MD, from City of Hope, echoed this, noting that 35% of her patients are younger nonsmokers—she also has patients in their 50s and 60s who have never smoked—with her youngest patient diagnosed with metastatic lung cancer at the age of 28 years. She pointed to a marketing gap as well. “I think we just need a better marketer, like Susan G. Komen [or] Race for the Cure. When I went to do a presentation on lung cancer, I had to look up what color the ribbon was.”

Clinical trial enrollment faces its own set of structural barriers. The panelists emphasized that overly restrictive inclusion and exclusion criteria routinely screen out the very patients who will ultimately use the drugs being evaluated.

Lisberg advocated strongly for engaging sponsors before trials open, saying, “The goal is to make the inclusion/exclusion as liberal as possible.”

E-consent and telehealth were highlighted as meaningful innovations for reducing access barriers, as long as they do not slow the patient journey. The panel agreed that progress on diversity requires advocacy at every level, from clinic protocols to regulatory policy to patient education and moving clinical trials into community practices.

Bridging Worlds: Academic-Community Partnerships in Value-Based Oncology

The final panel tackled one of the most structurally complex challenges in oncology today: how academic medical centers and community practices can effectively partner—rather than work in isolated simultaneous tracks—to deliver value-based cancer care.

Scalability is the defining test of any partnership model, the speakers concurred, including Joseph Alvarnas, MD, professor of hematology and vice president of government affairs at City of Hope. He framed it plainly, noting, “If the system lacks scalability, then it has no relevance. By uniting these different domains of care, you can really achieve something scalable and, hopefully, at the end of the day, equitable to people who are deeply in need.”

City of Hope’s catchment area covers 19.8 million people across 5 counties—a population that simply cannot be served from a single campus. The answer, he argued, is a hub-and-spoke model, in which complex therapies such as CAR T-cell therapy and phase 1 trials remain anchored at academic centers and standard-of-care treatment is deliberately pushed closer to where patients live.

Sepideh Shayani, PharmD, BCOP, executive director of pharmacy at City of Hope, described how City of Hope has operationalized this through a unified system formulary—approximately 95% standardized across all sites—ensuring that patients receiving care at smaller satellite sites receive the same treatment options as those treated in Duarte.

“We call it democratizing cancer care,” she said. “We have all of these cutting-edge treatments at Duarte. We have all of these cutting-edge treatments at some of our major sites across the country. But what about those patients who don’t live close to City of Hope? We want them to be able to be treated close to home.”

Moderator Yale Podnos, MD, MPH, FACS, chief medical officer and president of practice at The Oncology Institute of Hope & Innovation, noted that cost must be part of the value conversation as well. “Any discussion of value without at least some acknowledgment of cost is really just a discussion on quality.”

The discussion grew sharper when it turned to pharmacy benefit managers (PBMs) and reimbursement misalignment. Shayani described how PBM “lockouts” force patients to obtain specialty medications from PBM-owned or -contracted pharmacies, often delaying treatment initiation by 2 to 3 weeks and severing the care coordination benefits of an in-house pharmacy.

On the reimbursement side, Jessica Sims, MD, MPH, medical director of managed care at UCLA Health, identified a fundamental structural flaw. “It’s like a game of musical chairs. Who’s stuck out at the time the $2 million is due?” she said. “Where the whole health system may benefit from cost savings, but there’s going to be one loser in that equation the way it’s designed right now.”

She and Alvarnas argued that seamless patient repatriation—transitioning patients from academic centers back to community settings once complex care needs have stabilized—is nearly impossible under current Medicare and commercial payer models. Shayani pointed to communication as the essential foundation for change: “If you don’t have effective communication strategies, you cannot get to a point where you’re building sustainable and strong community and academic relationships.”

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