The Science Is Here, But the Systems Are Not: Experts Chart a Path Forward in Oncology Care

Philadelphia, Pennsylvania, served as the backdrop for an illuminating evening of expert-led discussion at an Institute for Value-Based Medicine event hosted by The American Journal of Managed Care^®, where 4 panel discussions brought together leading oncologists, pharmacists, and researchers from the region’s top academic medical centers. Spanning topics from biomarker testing in lung cancer to breast cancer treatment, multiple myeloma management, and clinical trial access, the event surfaced both the remarkable advances shaping modern oncology and the systemic challenges that continue to limit equitable care delivery.

Comprehensive Biomarker Testing in Non–Small Cell Lung Cancer

The first session opened with a discussion of the gap between guideline recommendations and the real-world implementation of biomarker testing in advanced non–small cell lung cancer. Moderator Christopher A. D’Avella, MD, thoracic oncologist, section chief of hematology/oncology, and co-director of the Cancer Diagnostics Clinic, Penn Presbyterian Medical Center, and assistant professor of clinical medicine, Perelman School of Medicine, set the tone by acknowledging that despite long-standing consensus on the importance of comprehensive molecular profiling, testing rates remain inconsistent across institutions.

Lova L. Sun, MD, MSCE, assistant professor of medicine at Penn Medicine, described the progress her institution has made through a reflex testing pathway—a protocol in which the pathologist automatically initiates a suite of tests, including PD-L1, next-generation sequencing, and fusion panels, upon a lung cancer diagnosis without requiring a clinician to intervene. “Things are getting better,” she noted, while also acknowledging that patients with insufficient tissue remain a persistent challenge, for whom liquid biopsies offer an important but imperfect alternative.

Working in a more community-based setting painted a starker picture, according to Tracey L. Evans, MD, medical oncologist/hematologist at Jefferson Health. Her patient population, which is largely underserved and underinsured, often lacks access to in-house testing, requiring her to rely heavily on liquid biopsy, which frequently returns molecular results faster than standard PD-L1 testing.

“You have a poor performance status patient who still could have an actionable mutation, where they would be a candidate for treatment even in an impaired state, and yet you can’t do that testing for 14 days if they’re covered by Medicare, for instance,” Evans explained.

She emphasized that patients who are sick enough to be hospitalized but lack access to timely molecular results can be discharged to rehabilitation facilities with untreated metastatic disease—a situation she called deeply alarming. “If I put an untreated lung cancer patient in a rehab, they’re going to come back even less eligible for treatment,” she said.

Parth A. Desai, MBBS, MD, assistant professor of thoracic medical oncology/head and neck medical oncology at Fox Chase Cancer Center (Fox Chase), described a practical innovation his team has implemented: a Monday morning “mini huddle” that brings together medical oncologists, pulmonologists, and thoracic surgeons to review all patients in the system with suspected or confirmed lung cancer. Running the huddle for the past 4 to 5 months, he noted improvements in up-front staging and biomarker testing, crediting early multidisciplinary awareness as a key driver.

The panel also wrestled with financial toxicity as a quiet barrier to testing. Although the panelists agreed that testing companies often absorb out-of-pocket costs, Evans shared a case of a physician-patient who received an unexpected bill because her deductible had not yet been met. Concurrent testing—ordering both liquid and tissue biopsies simultaneously—also emerged as a cost concern, with some patients being billed for what appears to be duplicative molecular work.

“I do think, in the future, that we’re getting to a place where it’s probably just going to be reflex testing for everyone,” D’Avella said. “That’s probably what will happen, as it just seems to be getting more complex.”

Patient Identification and Biomarkers in Breast Cancer Treatment

The second session turned attention to breast cancer, where an expanding array of biomarkers is transforming patient stratification and treatment selection, often faster than clinical infrastructure can adapt. Joyce G. Habib, MD, assistant professor at Fox Chase, moderated the discussion, framing the conversation around several emerging tools: ESR1 mutation tracking in the metastatic setting, HER2-low and HER2-ultralow classifications, circulating tumor DNA (ctDNA), and germline testing.

Payal D. Shah, MD, assistant professor of medicine (hematology-oncology), Hospital of the University of Pennsylvania, noted that genomic and liquid assay testing is now being used at multiple points throughout a patient’s disease course—at diagnosis of metastatic disease and periodically thereafter—and that the estrogen receptor–positive subtype has become an especially “crowded” space in a positive sense, with ESR1 and PTEN mutations now representing actionable findings that simply did not exist as treatment guides a decade ago.

Hayley M. Knollman, MD, assistant professor of clinical medicine (hematology-oncology) at the Hospital of the University of Pennsylvania, reflected on her experience with the SERENA-6 trial (NCT04964934), which used serial ctDNA testing to detect ESR1 mutations in patients on first-line endocrine therapy and CDK4/6 inhibition. She noted that none of the 10 patients she enrolled developed an ESR1 mutation during the trial, but patient interest in serial molecular monitoring remains high. “Patients really like the idea of being able to do ctDNA testing at these intervals,” she said, raising an important tension about how to manage results when actionability is uncertain.

Saya L. Jacob, MD, medical oncologist and assistant professor of medicine (hematology-oncology) at the Hospital of the University of Pennsylvania, acknowledged the significant emotional burden that ctDNA testing can place on patients in the adjuvant setting. She described an ongoing case in which a patient’s ctDNA is positive while scans remain negative. “It causes quite a lot of anxiety without a clear path forward,” she said, calling for more trial infrastructure around ctDNA-guided therapy to give monitoring efforts meaningful direction.

The session also covered germline and somatic BRCA1/2 mutations, with Habib underscoring the enduring importance of germline testing for all patients with breast cancer, given treatment implications across PARP inhibitor eligibility, risk management, and family counseling. In the metastatic HER2-positive space, the panelists grappled with sequencing challenges as treatments like trastuzumab deruxtecan (Enhertu; Daiichi Sankyo) are moving earlier into the treatment course, raising concerns about what options remain for patients who eventually progress.

Innovation and Decision-Making in Multiple Myeloma

The discussion on multiple myeloma offered a window into a disease area experiencing an almost unprecedented pace of therapeutic innovation, as well as the practical and philosophical challenges that accompany it. Moderator Edward A. Stadtmauer, MD, the Roseman, Tarte, Harrow, and Shaffer Families’ President’s Distinguished Professor and director of hematologic malignancies clinical/translational research in the Division of Hematology/Oncology at the Perelman School of Medicine’s Perelman Center for Advanced Medicine, opened by situating the discussion: Regimens anchored by CD38 monoclonal antibodies, proteasome inhibitors, and lenalidomide have produced impressive long-term outcomes in the PERSEUS study (NCT03710603) among others, yet the majority of patients still ultimately relapse. At first relapse, he noted, the decision landscape has become genuinely complex, with chimeric antigen receptor (CAR) T-cell therapy, bispecific antibodies, and novel combination regimens all competing as rational options.

Asya Nina Varshavsky-Yanovsky, MD, PhD, associate professor, Department of Bone Marrow Transplant and Cellular Therapies at Fox Chase, described her first-relapse approach as beginning with a fundamental question: Is this patient a candidate for CAR T-cell therapy, and would the patient tolerate the logistics and potential complications? Given growing evidence that B-cell maturation antigen (BCMA)-directed CAR T-cell therapy is more effective when given before BCMA-directed bispecifics, she prioritizes sequencing thoughtfully. Sandra P. Susanibar-Adaniya, MD, MS, assistant professor of medicine (hematology-oncology) and hematologist at Penn Medicine, added a geographic lens, noting that although bispecifics can increasingly be initiated in community settings, CAR T-cell therapy remains largely confined to academic centers, particularly outside major metropolitan areas.

Patient values should drive treatment selection when efficacy appears equivalent across options, emphasized Gloria Espinosa, PharmD, MAT, BCOP, BCPS, an advanced patient care oncology pharmacist at Thomas Jefferson University Hospitals. Does a patient want a “once-and-done” approach with a treatment-free interval, or would they prefer a continuous therapy that may carry fewer up-front adverse effects? She described proactively counseling patients during remission so that when relapse arrives, the conversation is already partially underway.

Stadtmauer raised the evolving question of treatment-free intervals, noting that he attended a recent patient panel at which it became clear that time off therapy is a defining dimension of quality of life. “They understand that if you really have a treatment that induces a long-term response and gets them off treatment for a real period of time, that is a major benefit,” he said. The panel also discussed outpatient delivery of bispecifics and CAR T-cell therapy, with Susanibar-Adaniya detailing the criteria her institution uses to identify appropriate outpatient candidates based on proximity to the center, the presence of a capable caregiver, and the patient’s ability to recognize and respond to early toxicity signs such as cytokine release syndrome (CRS). Espinosa described how prophylactic tocilizumab has been used in their program to reduce the incidence of grade 1/2 CRS, lowering hospital utilization and making the outpatient model more feasible.

Breaking Down Barriers to Clinical Trial Enrollment

The final session brought a population-level perspective to clinical research, exploring why fewer than 5% of patients with myeloma—and even fewer patients with cancer broadly—ever enroll in a clinical trial, and what structural changes could change that reality. Moderator Andrew Chapman, DO, FACP, professor of medical oncology; Thomas Jefferson University; director, Sidney Kimmel Comprehensive Cancer Center (Kimmel); and executive vice president of oncology services, Jefferson Health, framed the challenge as one of execution as much as science.

Henry Chi Hang Fung, MD, FACP, FRCPE, chair of the Department of Bone Marrow Transplant and Cellular Therapies at Fox Chase, agreed emphatically. With more than 35 years as a clinical investigator, he offered a blunt assessment: “The bottleneck in oncology trials is no longer science—it’s execution and delivery.” He advocated for a shift in language and accountability from “collaboration” to “shared ownership,” arguing that genuine partnership among Jefferson, Penn Medicine, Fox Chase, Temple University, and St Luke’s would make the Philadelphia region far more attractive to industry sponsors seeking robust, diverse trial sites if there were shared investment and shared infrastructure.

Speaking to the promise and practical friction of digital health tools, Arturo Loaiza-Bonilla, MD, associate professor of medicine, Lewis Katz School of Medicine at Temple University, and network chief of hematology and oncology, St Luke’s University Health Network, discussed remote consent and telemedicine-enabled trial visits. He argued that comanagement of the standard of care within a multisite network is already FDA permissible but underutilized, largely due to institutional inertia. He called on sponsors to build budget templates that explicitly account for social determinants of health, noting that many Hispanic patients he offers trials to decline not because of cultural reticence but because missing work is economically impossible.

“Stop talking about disparities,” Loaiza-Bonilla said. “Invest the money to do something about it.”

Amy E. Leader, DrPH, MPH, research faculty in medical oncology and associate director of community outreach and engagement at Thomas Jefferson University and Kimmel, whose work centers on community outreach and engagement at Jefferson, argued that trust must be cultivated over years before clinical trial conversations can be productive. Her team has embedded research opportunities in churches and community gathering spaces, offering simpler biomarker or epidemiological studies that demystify research participation for populations with historically warranted skepticism of medical institutions. “It’s a long game,” she acknowledged. “When you do things like that, people recognize that research is not scary,” Leader said. “We may break down a few barriers, we may dispel a few myths.”

Fung raised a pointed equity issue. Asian communities, including Philadelphia’s sizeable Chinese population near Jefferson Einstein Philadelphia Hospital and in the Temple catchment area, have been almost entirely excluded from culturally targeted outreach. Conditions like nasopharyngeal carcinoma, disproportionately prevalent among Southern and Southeast Asian patients, are virtually absent from regional trial portfolios. He advocated for disease portfolio design that matches the true demographics of local catchment areas.

Bridging Science With Equity and Patient-Centered Oncology Care

Across all sessions, a consistent theme emerged: The science of oncology is advancing rapidly, but its benefits will only reach all patients if the systems, structures, and partnerships that support it are built with the same intentionality. From reflex biomarker testing pathways in lung cancer to ctDNA-guided breast cancer trials to treatment-free interval protocols in myeloma to culturally designed clinical trial outreach, the evening’s conversations pointed toward an oncology that is not only more precise but also more equitable and more patient-centered. The work, as every speaker made clear, is far from finished.