Decisions and Precision in Value-Based Cancer Care

An Institute for Value-Based Medicine regional event was held in Houston, Texas. | Image credit: Kovacs – stock.adobe.com

Precision medicine is transforming cancer care by tailoring treatments to the genetic profiles of patients, but logistical and systemic barriers persist, particularly in implementing widespread biomarker testing. A recent panel at the Institute for Value-Based Medicine (IVBM) event in Houston, Texas, explored how academic and community oncology practices are navigating these challenges, with speakers sharing insights into improving access, turnaround times, and collaboration.

The integration of precision medicine into oncology practices remains inconsistent, largely due to varying workflows and infrastructure.

“From a community oncology perspective, a lot of times each hospital does their physician medicine a little bit different, so it's not like a one size fits all,” said Bhuvana Sagar, MD, practicing oncologist, Oncology Consultants. She highlighted the delays that often occur in community settings, such as deciding when to order tests and addressing issues like insufficient tissue samples.

Academic centers face different barriers in implementing precision oncology care, including bureaucracy and strict guidelines for off-label drug use. “The definition of precision is really getting the right drug for the right patient at the right time, and I think that sometimes academic medicine is more governed by more bureaucratic things than actual private practice,” Ahmed Elkhanany, MD, assistant professor of medicine, Baylor College of Medicine. Despite these constraints, though, academic institutions benefit from robust frameworks for conducting clinical trials and utilizing next-generation sequencing (NGS).

Turnaround times for biomarker testing are a significant concern in both community and academic settings. These delays can impact treatment decisions, particularly in urgent cases like advanced lung cancer. With this in mind, Sagar noted that partnership with labs is key, explaining that proactive communication about insufficient samples can prevent delays.

Lori Brisbin, vice president of precision medicine at Texas Oncology, described her organization’s success in leveraging information technology (IT) tools to streamline workflows, noting how Texas Oncology implemented a cloud-based database that allows physicians to access real-time test results and identify patients who may qualify for clinical trials. It also helps physicians track patients with specific mutations, making it easier to match them with appropriate trials or treatments. According to Brisbin, this has led to improved speed and accuracy of clinical trial enrollment, ensuring that eligible patients receive timely care.

Effective communication and data integration are also critical factors in advancing precision medicine. Elkhanany emphasized the importance of having a dedicated team to manage workflows and coordinate with external vendors. He shared a recent example where a lab alerted him to a patient with a rare TP53 mutation, enabling quick enrollment in a clinical trial. “This kind of integration is what we hope for,” he said, underscoring the value of real-time data sharing.

Access to biomarker testing is often limited by payer policies and financial barriers, which can exacerbate disparities in cancer care. Sagar emphasized that coverage policies are key to ensuring timely and equitable access, pointing to her previous work with insurers to streamline prior authorization processes for NGS. Brisbin highlighted a recent bipartisan law in Texas that mandates insurance coverage for broad NGS testing in metastatic solid tumors. This law removes the fear of patients facing a $3000 bill and encourages providers to order the necessary tests. However, she cautioned that payer partnerships must include clear guidelines to prevent billing issues and ensure financial assistance for patients.

The panelists agreed that while policies like the Texas law are steps in the right direction, more work—especially alignment between payer policies and clinical guidelines—is needed to standardize precision oncology protocols across the country and improve both the quality and cost of care.

Advancing Treatment Pathways for Multiple Myeloma

The treatment landscape for multiple myeloma has undergone dramatic evolution in recent years, driven by innovative therapies and the growing complexity of treatment regimens. This evolving landscape prompted a discussion among another set of panelists on how advancements such as quadruplet therapies, anti-CD38 monoclonal antibodies, and chimeric antigen receptor (CAR) T-cell therapy have reshaped both first-line and relapsed/refractory settings.

Multiple myeloma treatment has become increasingly complex, with the field moving from doublets to triplets, and now quadruplet-based induction therapy as the standard of care. According to the panelists, data from recent clinical trials like the PERSEUS, GRIFFIN, and IMROZ trials have solidified the role of quadruplet regimens in both transplant-eligible and ineligible patients. Adeel Khan, MD, MPH, MS, assistant professor of internal medicine and director of myeloma epidemiology research, UT Southwestern Medical Center, described this evolution as an “embarrassment of riches.”

“The addition of more and more drugs to existing regimens and the fact that there are further drugs in the pipeline mean the permutations have gotten pretty complicated,” Khan noted. “So the mantra of how to treat has been to add another drug in, add another drug in. In general, it's actually proven to be very efficacious, so I don't think there's anything necessarily harmful to it, but I do think it has added a lot of complexity to the landscape.”

The introduction of anti-CD38 monoclonal antibodies, such as daratumumab and isatuximab, has been transformative for improving progression-free survival and achieving minimal residual disease (MRD) negativity. “We're looking at almost 90 months or so, which is really unprecedented for a transplant ineligible patient population,” said Hans Lee, MD, director of multiple myeloma clinical research and associate professor of lymphoma and myeloma at the University of Texas MD Anderson Cancer Center. “This would be unheard of 5 to 10 years ago.”

Brian Primeaux, PharmD, BCOP, clinical manager and clinical pharmacy specialist at the MD Anderson Cancer Center, praised the development of subcutaneous formulations of these therapies, noting their benefits for both patients and providers. Subcutaneous regimens reduce the need for intravenous (IV) access and have limited toxicities, improving both patient convenience and safety, he explained.

MRD testing is increasingly used to guide treatment decisions and align with value-based care principles, as MRD results help determine whether to pursue upfront transplant or delay it in standard-risk patients. During the discussion, Lee noted how MRD negativity allows for discussions on deferring transplants and even de-escalating maintenance therapy, which ultimately reduces costs and side effects. However, Khan urged caution in over-relying on MRD as a sole endpoint.

“If someone flips from MRD negative to positive, but biochemically they're still doing well and clinically they're still doing well, it does beg the question of is that still meaningful,” he said. “So I tend to think of [MRD testing] as one tool in the toolbox, by no means the end all be all.”

As novel therapies like CAR T-cell therapy and bispecific antibodies revolutionize the management of relapsed/refractory multiple myeloma, long-term cost-effectiveness remains a critical concern. Panelists highlighted the importance of prioritizing CAR T-cell therapy for high-risk patients, especially those with early disease progression, as administering it earlier in patients with lower disease burden can result in better outcomes and fewer toxicities. They also praised bispecific antibodies as “off-the-shelf” therapies with significant potential to achieve deep and durable responses.

Pharmacy Decision-Making in Value-Based Cancer Care

As value-based care models continue to shape oncology, pharmacy teams play a pivotal role in navigating site-of-care mandates, managing treatment costs, and optimizing workflows. At the IVBM event, panelists shared insights into strategies for minimizing fragmented care, improving equity, and supporting novel therapies like bispecific antibodies and CAR T-cell treatments.

The shift to alternative care models, such as home or outpatient clinics, has introduced both opportunities and challenges. Site-of-care mandates can reduce travel burdens for patients and improve compliance, but they also pose the risk of fragmented care due to limited communication across providers. Additionally, prescribers may lack authority at infusion centers, and home health services often require third-party pharmacies, adding extra layers of complexity and warranting a streamlined processes to ensure patient safety and continuity.

When asked how their practice is providing value through its pharmacy service models, Binita Patel, PharmD, MS, CPEL, vice president of pharmacy services at Memorial Hermann Health System, detailed a hub-and-spoke model her institution is developing to reduce fragmentation. With this strategy, outpatient clinics, home infusion pharmacies, and hospital-based infusion clinics are tied to the same EMR system with pharmacists embedded in both inpatient and outpatient clinics.

“Having those different types of care settings within your own health system allows you to provide the highest level of care with loss fragmentation,” Patel said.

Megan McGugan, PharmD, MS, BCPS, specialty pharmacy manager at MD Anderson Cancer Center, and Karen Wang, PharmD, BCOP, clinical pharmacy specialist in thoracic/head and neck medical oncology at MD Anderson Cancer Center, highlighted how their practice is addressing care gaps by launching a prior authorization pilot and implementing a drug donation program. This initiative enables repurposing unopened medications to help patients facing financial or logistical barriers, improving equity and access to costly therapies.

Wang further emphasized the importance of follow-up phone calls in ambulatory clinics, which monitor patient well-being after immunotherapy or chemotherapy. These calls also provide education and help reduce readmission rates by improving toxicity management and home care preparedness. At Houston Methodist Hospital, Karen Abboud, PharmD, BCPS, BCOP, clinical specialist in solid tumors, explained how using a pilot program with collaborative practice agreements allows pharmacists to manage supportive care autonomously, therefore reducing physicians’ workloads while ensuring timely, expert care for patients.

The Impact of SDOH on Cancer Care

Conversations around social determinants of health (SDOH) are common at IVBM events across a range of disease types. At the Houston regional event, panelists discussed how SDOH factors such as transportation, financial toxicity, and systemic inequities hinder equitable cancer care and proposed solutions for creating a more inclusive health care system.

“I think of [SDOH] like a chain, and the chain is only as strong as its weakest link,” said John Lin, MD, MSHP, medical oncologist and assistant professor of health services research at MD Anderson Cancer Center, explaining how factors like food insecurity, transportation barriers, and medical mistrust can prevent patients from accessing necessary treatments. “There are so many different facets of this, and any one of them could be the breaking point at which this patient is not getting their care because of that one thing.”

Susan Escudier, MD, FACP, medical oncologist and vice president of value-based care and quality programs at Texas Oncology, added that a patient’s zip code can often predict their cancer prognosis. Radiation treatments, for instance, require daily visits, but transportation costs and time off work create significant burdens. These challenges can be compounded by language gaps, education barriers, and limited access to public health resources, particularly in rural areas.

Insurance coverage—or lack thereof—is another major contributor to disparities in cancer care, with Lin noting that even patients with Medicare can face unaffordable out-of-pocket costs, particularly for Part D medications. He cited research showing improved cancer mortality rates in states that expanded Medicaid, but emphasized that commercially insured patients often experience better outcomes than those on Medicaid.

To address these disparities and others, the panelists agreed that systemic changes and targeted interventions are necessary. Lin, who advocated for widespread implementation of patient navigators, shared how care navigation has consistently proven to reduce disparities by providing patients with tailored support. Scherezade Mama, DrPH, associate professor of health disparities research at MD Anderson Cancer Center, echoed the sentiment, saying navigators help patients manage complex systems and are especially effective in improving clinical trial enrollment among underrepresented populations.

Escudier emphasized the importance of data collection on SDOH, as mandated by the Oncology Care Model. However, she stressed the need for actionable follow-up. “We had to quadruple the number of social workers we had, but we don't have any more resources to deal with it,” she said.

Looking ahead, the panelists called for policy reforms to better support underserved communities and improve cancer care outcomes.