Oncology Innovation Meets the Realities of Access, Cost, and Coordination

How can increasingly complex cancer therapies reach patients without overwhelming them or the systems that deliver them? At the Institute for Value-Based Medicine^® event in Nashville, Tennessee, on July 14, presented by The American Journal of Managed Care^®, physicians, nurse practitioners, pharmacists, and others explored this question across 4 panels spanning breast cancer, hematologic malignancies, bladder cancer, and pharmacy operations. Panelists agreed that the science is arriving faster than the infrastructure built to deploy it. Across specialties, they discussed how to match the right therapy to the right patient at the right site of care, how to bridge academic and community settings, and how to contain cost while expanding access.

Biomarkers Push Breast Cancer Toward Personalized Escalation and De-escalation

The opening panel, moderated by Kate Baker, MD, MMHC, medical oncologist and medical director of value-based care at Tennessee Oncology, focused on operationalizing targeted therapies in breast cancer. Denise A. Yardley, MD, associate director of breast cancer research at Sarah Cannon Research Institute (SCRI), described a field in which the treatment “pendulum” has swung away from broadly applied chemotherapy toward tumor biology–driven decisions. She pointed to recent OPTIMA data suggesting that patients with high clinical risk but low Prosigna risk of recurrence scores may safely avoid chemotherapy. However, she also noted that interpreting the trial’s findings remains difficult because chemotherapy was mandated in the control arm. This leaves open the critical question of whether observed outcomes stem from chemotherapy’s direct cytotoxic effects or from chemotherapy-induced ovarian function suppression.

Genetic nuance dominated much of the discussion. Tuya Pal, MD, a clinical geneticist and professor of medicine at Vanderbilt-Ingram Cancer Center (VICC), warned that de-escalation frameworks may not translate cleanly to BRCA carriers, whose genomic assay scores tend to run higher and whose optimal cut points remain undefined. Large observational cohorts, she argued, may answer the question faster than new randomized trials. She also flagged persistent testing gaps, as approximately half of patients with metastatic breast cancer undergo BRCA testing, and coverage falls off sharply for older adults.

“You cannot get coverage for genetic testing once you hit the age of 65 if you don’t have cancer,” she said, calling the Medicare gap a barrier to prevention.

Justin M. Balko, PharmD, PhD, Ingram Professor of Cancer Research and coleader of the Breast Cancer Research Program at VICC, offered a translational lens on circulating tumor DNA (ctDNA) and antibody-drug conjugates (ADCs). Together with Baker, they discussed the SERENA-6 trial (NCT04964934), in which switching to camizestrant upon ctDNA detection of an ESR1 mutation, prior to clinical or radiographic progression, significantly improved progression-free survival. Yet Balko cautioned that detecting ESR1 mutations months earlier may not, by itself, change outcomes. On ADCs, the panelists agreed that the drugs have supplanted chemotherapy in many settings but have created new sequencing dilemmas as they are used earlier in treatment, leaving clinicians with more questions than answers, as Yardley put it.

Closing the Access Gap for CAR T-Cell Therapy and Bispecifics in Blood Cancers

The hematology panel, moderated by Hans Lee, MD, director of myeloma research at SCRI, noted that most patients eligible for chimeric antigen receptor (CAR) T-cell therapy and bispecific antibody therapy never receive them. Eden Biltibo, MD, MSCI, a hematology-oncology fellow at Vanderbilt University Medical Center (VUMC), said she sees only a fraction of candidates, constrained by insurance, referral patterns, and geography. Many patients simply cannot commit to the extended monitoring that CAR T-cell therapy has traditionally required, whether because they cannot take 30 days off work or lack a caregiver.

Bhagirathbhai Dholaria, MD, FACP, a transplant and CAR T-cell therapy physician and associate professor of medicine at VUMC, described psychological and logistical barriers that include driving hours to an unfamiliar city, finding parking, and leaving family and support systems—all layered on top of financial uncertainties. However, he also argued the toxicity landscape has shifted, as proactive management now allows discharge as early as day 2 or 3, expanding the pool of patients who can be treated safely. Olalekan O. Oluwole, MD, MPH, MBBS, an associate professor of medicine at VUMC, urged community oncologists to refer earlier and to leverage telemedicine, noting that patients are often “pleasantly surprised” by how quickly they can be seen.

On sequencing, the panelists favored CAR T-cell therapy in second-line myeloma for its potentially curative, 1-time profile, while acknowledging bispecifics’ role as accessible, community-deliverable options with step-up dosing increasingly managed outside academic centers. Looking ahead to allogeneic, or “off-the-shelf” cell therapies, Oluwole predicts they are “for sure the future” but will face “very stiff competition from the existing autologous” products, which have grown safer and faster to manufacture. Any new platform must clear a high safety bar, the panel agreed.

Matching Treatment Intensity to Disease in Bladder Cancer

Benjamin Garmezy, MD, associate director of genitourinary cancer research at SCRI and medical oncologist at SCRI Oncology Partners, moderated a wide-ranging bladder cancer discussion that repeatedly circled back to resource allocation. Gautam Jayram, MD, a urologist at Urology Associates of Nashville, framed value as this question: “How can we match the intensity of our treatments to the intensity of disease?” He noted that not every patient with non–muscle-invasive disease needs a cystectomy, and that community uptake of neoadjuvant chemotherapy has climbed from approximately 10% a decade ago to 50% to 60% today through multidisciplinary bladder cancer clinics and physician champions.

Ruchika Talwar, MD, MMHC, urologic oncologist and medical director in the Episodes of Care Office at VUMC, emphasized biomarker-guided sequencing in the Bacillus Calmette–Guérin (BCG)-unresponsive space, where multiple options now exist. Urinary biomarkers, she said, could let clinicians tailor therapy up front rather than by trial and error so “the right patient will be getting the right treatment up front, and it won’t be in a fail-first fashion.” Patient experience must also factor into value, she added.

Meredith Donahue, DNP, APRN-BC, a nurse practitioner at VUMC, underscored that BCG remains highly effective when properly administered but is hampered by ongoing shortages. Adverse effect management and continuity of care, she said, keep patients on protocol. Turning to muscle-invasive disease and the shift toward ADC-immunotherapy combinations, Garmezy said that he thinks “we’re curing metastatic disease now,” at least in a subset of patients. However, he also cautioned that the field still lacks answers on optimal duration, dose reduction, and how to translate metastatic gains into earlier settings.

Integrated Pharmacy and PBM Reform Take Center Stage

The closing panel, moderated by Joey Hollenbeck, PharmD, senior director of pharmacy services at OneOncology, examined how pharmacy operations can extend access and reduce waste. Brooke Looney, PharmD, CSP, clinical pharmacist at VICC, described the advantages of medically integrated dispensing, where pharmacists embedded in the clinic can see labs, scans, and upcoming appointments before releasing high-cost oral oncolytics. A single year-long look back at her institution found that pharmacist interventions preventing unnecessary fills saved approximately $900,000. These savings were the result of initiatives such as holding a $20,000-per-month prescription when a dose change or discontinuation was imminent.

Toral Patel, PharmD, director of clinical practice operations at SCRI, emphasized that self-monitoring programs and telehealth are helping decentralize complex therapies, including bispecifics, so patients can be managed closer to home. The recurring value proposition was speed and continuity, as integrated pharmacies can turn refills around in 1 day vs a week or more for external pharmacy benefit manager (PBM)-owned pharmacies.

Much of the panel’s energy centered on policy. Hollenbeck walked through Tennessee’s Freedom, Access, and Integrity in Registered Pharmacy (FAIR Rx) Act, signed in May 2026 and modeled on an Arkansas law that has been tied up in litigation, which bars PBMs from owning or being licensed to dispense through pharmacies in the state and requires affected companies to divest pharmacy holdings by July 1, 2028. The measure is already drawing lawsuits. The panelists supported curbing PBM steering but voiced concern about unintended consequences. Patel stated that the goal is patient choice, yet outlawing PBM-owned pharmacies could itself remove an option some patients rely on. The better path, the panelists agreed, is broad access that lets patients—not their benefit design—decide where care is delivered.