Communication Is Key in Era of Oncologist Shortages, Experts Say

As 2024 came to a close, experts from the realms of oncology, pharmacy, and dermatology gathered to discuss avenues for elevating value in cancer care at The American Journal of Managed Care’s final Institute for Value-Based Medicine event of the year, which was held on December 12, 2024, in Seattle, Washington. The session featured discussions about the concept of value in oncology, the importance of interdisciplinary collaboration, and the need to keep patients, their finances, and their well-being at the center of care.

When it comes to elevating value in cancer care, Sara J. Grethlein, MD, MBA, FACP, a medical oncologist and executive medical director at Seattle’s Swedish Cancer Institute, placed streamlining payer–health system collaboration and balancing personalized care with clinical guidelines at the forefront. She outlined how duplicated work and needless competition, such as “AI fighting AI” during prior authorizations, unnecessarily bogs down patient care. “Why are we wasting resources? Why are we wasting time and treasure on fighting a battle where we have answers, and we know at the end of the day we’re going to wind up covering what’s on the [National Comprehensive Cancer Network] guidelines?”

Incorporating tools such as ClinPath can accelerate these processes, she added, as they include both cost factors and clinical guidelines in decision-making. As a result, health systems can effectively strike a balance between cost-conscious and evidence-based care.

“The problem with these guidelines is that most of the clinical care that we deliver just does not come in a textbook format,” an audience member said. “So, isn’t relying on guidelines really taking the nuance out of medicine?”

Although Grethlein agreed, she stressed the workforce crisis currently happening in oncology: More clinicians are leaving and retiring from the field than are entering. Furthermore, data project a 40% increase in cancer care demand in the coming years. Relying on guidelines will play a big role in addressing these shortages and supporting team-based care among pharmacists, nurse practitioners, physician assistants, and others; however, guidelines should not be taken at face value, and there should always be room for questioning and flexibility. Clinicians know well that certain cases require more tailored care than guidelines can account for.

As the oncology workforce continues to evolve, anticipated demands in patient care underscore the need for a cultural shift in care delivery. Moving forward, partnerships that prioritize communication and complement one another’s strengths, rather than offloading responsibilities entirely, are what will ensure that high-quality care remains the standard.

A panel of pharmacists built on Grethlein’s points by highlighting the benefits of their multidisciplinary, integrative medicine service at the Fred Hutchinson Cancer Center (Fred Hutch). Beginning in 2018, the service has grown from 3 to 13 members, including embedded pharmacists, naturopathic doctors, and an acupuncturist, among other health professionals who provide patient-driven and evidence-based care.

“One of the benefits of having an integrative medicine service in your organization is [that] it’s really easy for us to communicate with each other…[and] the patients,” said Rachel Feaster, PharmD, BCOP, BCPS, a clinical oncology pharmacist at Fred Hutch.

Ivan Huang, PharmD, BCOP, clinical oncology pharmacist, Fred Hutch, continued the discussion by highlighting the potential of their recently implemented outpatient-specific model, for which value-based medicine has been a driving influence. “The several types of value that I see include patient value—how can we maximize their quality of life, financial value, and resource value,” he said.

The true purpose of the model is to optimize patient value by transitioning therapies that are commonly prescribed in inpatient settings (eg, bispecific antibodies) to outpatient care. This way, patients can be administered care in familiar settings with more consistent support and less stress, all while reducing hospitalization time and improving resource allocation, such as freeing up hospital beds. At the end of the day, Huang added, less time admitted to inpatient care also benefits patients financially.

Grace Baek, PharmD, a clinical pharmacist specializing in hematology at Fred Hutch, also spotlighted the growing interest in expanding programs like this to facilitate accessible care delivery in more rural and community settings. Calling back to Grethlein’s talk, Baek reinforced how critical partnerships are “in terms of working with nursing colleagues on the clinical and infusion sides, working with physician champions and advanced practice providers to build a collaborative approach…[and] ensuring that there are no opportunities for things to fall through the cracks.”

As the evening concluded, skin cancer experts and the panel’s lone dermatologist, Song Park, MD, assistant professor, Department of Dermatology, University of Washington Medicine/Fred Hutch, spotlighted the best practices in their field and their efforts to implement value-based care for more accessible, cost-friendly, and efficient therapies.

Sylvia Lee, MD, an oncologist and associate professor at the University of Washington Medicine, kickstarted the conversation by focusing on the value of tumor-infiltrating lymphocyte (TIL) therapy. “To be able to offer someone a 31% chance of response, with some having long-term responses, is pretty exciting and meaningful—especially for patients who have progressed on PD-1, CTLA-4, and BRAF therapies, essentially exhausting their treatment options,” Lee said.

However, TIL therapy’s post–FDA approval integration came with its own set of challenges, as Lee detailed the extensive contract, legal, and pricing considerations that came into play. Furthermore, the involvement of numerous institutions left departments contending for certain control. Lee Cranmer, MD, PhD, FACP, of Fred Hutch, likened this experience and integrating the therapy regularly to “building a TILs machine. This is the hard part of building the machine.”

In this process, Cranmer hearkened back to the value of interdepartmental collaboration for elevating care delivery. “We were able to do it on the hospital floor, and that’s what made all the difference. Having the nursing staff and the mid-levels be familiar with the therapy and allowing its administration on the floor, and transfer to the [intensive care unit] if you needed, made it economically viable,” he said.

Ineffective cancer care, Cranmer posed, is a primary concern due to the large financial burden it places on society at large, especially considering the US practice of investing large amounts of money into drugs and therapies that are yet to have proven benefits and may have toxic effects.

“Do you think it’s worth it to have reduction in toxicity but similar efficacy, and do we have to pay double the cost of care to have some reduction in toxicity?” asked moderator Shailender Bhatia, MD, director, Melanoma and Renal Cancer team, and professor, Fred Hutch.

“I’m on the side of seeing those long-term [toxicities] as a dermatologist,” Park said as she argued that reducing toxicity is, in reality, a cost-saving venture. “Because when that kind of toxicity happens and no traditional drug works, then dermatologists apply for even more expensive drugs.” For this reason, Song asserted that more research efforts should be dedicated to exploring novel developments, such as tert-butyl acetate, that remain high cost and require appropriate treatment candidates.

Other perspectives explored by the evening’s panelists and audience members alike were the promises that artificial intelligence (AI) holds for oncology care; however, clinicians expressed a hesitancy to delve too deeply into this technology just yet. The inability to “see under the hood,” as Grethlein put it, and to understand how AI comes to conclusions has left many hesitant to place clinical decision-making into the hands of these systems. As this technology grows, there will be a need for refined guidelines and a deeper trust in AI processes, especially for patient cases that do not fit into the guidelines’ mold.