Putting Patients First by Extending the Reach of World-Class Care

To hear Joseph Alvarnas, MD, tell it, the fight against cancer was once seen as a mission to create increasingly powerful drugs—as much as the human body could handle—and pummel the disease into submission.

Joseph Alvarnas, MD | Image: City of Hope

“The paradigm for how oncology was going to evolve was based on finding a bigger hammer,” said Alvarnas, vice president for government affairs for City of Hope Comprehensive Cancer Center, a National Cancer Institute (NCI)–designated center based in Duarte, California, and chief clinical adviser for AccessHope.

Eventually, the focus on toxic drugs pivoted to precision medicine, which showed how genetics drives cancer in individual patients and caused “all that hubris to come crashing down,” Alvarnas said. The results have been sharp drops in cancer mortality and improvements in patients’ quality of life.¹

But more can be done, said Alvarnas, who chaired the September 19, 2024, session of the Institute for Value-Based Medicine®, held in Garden Grove, California, with the theme, “Prioritizing the Patient in Value-Based Oncology Care.”

Making care more patient-centered has caused City of Hope to look outward over the past decade, and Alvarnas shared ways the world-famous research and treatment center has brought this approach to a new academic center in Orange County, California, as well as sites in Gilbert, Arizona; Chicago, Illinois; and Atlanta, Georgia.²

There’s also AccessHope, which now reaches 7 million members through 400 employers, offering expertise on challenging cases wherever they may occur. Through AccessHope, City of Hope physicians provide expertise to local doctors to help keep patients close to home. Then, if necessary, patients come to a City of Hope facility for specialized care.³

Clinical advances in cancer, Alvarnas said, have “evolved at such a breakneck pace that it’s impossible to keep up in so many ways.” The current challenges, he said, involve delivering care in an equitable way, by ensuring access to patients who are poor, are minorities, or live far from a comprehensive cancer center.

The push for value-based care can sometimes focus too heavily on what medications cost, at the expense of what is right for the patient, he said. Finding the right balance, he said, involves as follows:

• Delivering precision medicine for each patient close to home,
• Not treating oncology care as a “technological arms race,” but instead recognizing that “a cancer journey is a human journey,” and
• Integrating the other domains of oncology care, which includes communicating with the patient and the family in a way that is compassionate.
  

Fighting Ageism in Treating Blood Cancers
If cancer is a disease of aging, would it not make sense for older individuals would have access to the best care?

Eileen P. Smith, MD | Image: City of Hope

Despite significant clinical advances in treating patients with blood cancers, ageism stubbornly lingers for individuals who receive a blood cancer diagnosis when they are older than 65 years, according to City of Hope’s Eileen P. Smith, MD, a professor and the Francis & Kathleen McNamara Distinguished Chair of the Department of Hematology and Hematopoietic Cell Transplantation.

Smith highlighted data from the NCI’s Surveillance, Epidemiology, and End Results Program showing that 54% of new cancer diagnoses and 70% of cancer mortality occur among individuals older than 65 years.⁴ And yet, “older populations have been underrepresented in clinical trials of oncology,” and changing this is a priority for comprehensive cancer centers, she said.

“There has been a tendency for clinicians to not deliver care outside of the population that was defined as eligible in the clinical trials,” she said. “Older patients are less likely to even receive standard-of-care cancer therapy because often they are assessed as too fragile to undergo intensive care.”

Decision-making may be affected by an older person’s functional, cognitive, or nutritional status; their level of psychosocial support; untreated depression; and most critically, polypharmacy, “which is something that adversely impacts the outcome for many older patients and really needs to be taken into consideration in planning for their cancer care,” Smith said.

Clinical guidelines from multiple groups—such as the American Society of Clinical Oncology (ASCO), the National Comprehensive Cancer Network (NCCN), and the International Society of Geriatric Oncology—call for a comprehensive geriatric assessment for these patients to reveal challenges that can be managed. “Comprehensive cancer centers have been leading the way in these kinds of assessments,” Smith said.

In hematologic malignancies, she said, “the impact of aging ageism is very, very striking,” and City of Hope has worked to help patients who are not being referred for care.

One shocking statistic, Smith said, is that 40% of patients with acute myeloid leukemia (AML) “are never referred for intensive therapy.⁵ They are directly referred for supportive care or palliative care.” Although allogeneic transplant offers the only curative modality for many patients with intermediate or high-risk acute leukemias, she said, “Older patients are routinely not referred for allogeneic transplant or referred late in the course of their illness, when they are no longer a candidate for transplant.”

Patients with AML who are older than 65 years and do not receive intensive therapy “have a less than 5% 5-year survival,⁶ and that is partly because many clinicians are still thinking in terms of the treatment paradigm that existed more than 10 years ago,” Smith said, referring to when anthracycline-based regimens were too difficult for older patients to tolerate.

Today, she said, clinicians can use less-intensive, “hypomethylating agents and targeted therapies, which can be selectively used based on the molecular profile of the disease, that can very easily be used in an outpatient setting and around the community [for] these patients.”

Smith noted that Andrew Saul Artz, MD, MS, professor in the Division of Leukemia and director of the Aging and Blood Cancers Program at City of Hope, runs a multidisciplinary team that completes a geriatric assessment to learn how older patients can receive prehabilitation to make them eligible for regimens that would otherwise be off-limits. Artz was coauthor of a 2021 paper that stated that older patients who have transplants have better long-term survival outcomes.⁷

“Study after study has shown this, and yet it still hasn’t changed the treatment paradigm in the community, where the assumption is that if you’re over 65 years old, you’re too old to have a transplant,” Smith said. “So the educational message that we’re trying to get out to our community sites is to refer your older patients early…so they can have a comprehensive geriatric assessment, and we can partner with our community physicians to find out what is the ideal treatment for that patient.”

In multiple myeloma, there have been similar challenges, she said, despite the fact that the disease now has FDA-approved bispecific therapies—teclistamab (Tecvayli) and talquetamab (Talvey)—as well as 2 chimeric antigen receptor (CAR) T-cell therapies, idecabtagene vicleucel (Abecma) and ciltacabtagene autoleucel (Carvykti). The challenge is deciding the appropriate sequencing of these therapies vs an autologous transplant, she said, which calls for the expertise of a comprehensive cancer center.

City of Hope, Smith said, is bringing this expertise to the community by opening a center in Orange County, sparing patients a drive of more than 2 hours in busy traffic. And when doctors at City of Hope’s Chicago site performed the site’s first CAR T-cell procedure, Elizabeth L. Budde, MD, PhD, a City of Hope associate professor, flew to Chicago to be there for the patient. Budde is well-known not only for leading clinical trials but also for publishing on the process of developing a CAR T-cell program.⁸

“The concept is to democratize cancer care by bringing the care to the community where the patient lives. And if we can do that by building cancer centers or by having virtual consults with individuals in the treatment centers where they live, that’s the way forward,” Smith said.

Supportive Care and Integrative Oncology
Appointed chair of City of Hope’s Department of Supportive Care Medicine in April 2023,⁹ Andrew Leitner, MD, leads a team that was one of the first of its kind in recognizing supportive care as a specialty and developing models it shares across the world.

Andrew Leitner, MD | Image: City of Hope

“One of the things we believe at City of Hope, and you can see it sort of manifest throughout our comprehensive cancer centers, is there are some fundamental things that all patients with a cancer diagnosis ought to have access to,” Leitner said. These include education about their condition, care coordination, and help with navigation, which CMS at long last is recognizing through reimbursement codes,¹⁰ although these need refinement, he said.

Although supportive care focuses on quality of life, “The survival impact is also important,” he said, referencing a 2010 lung cancer study that showed how early supportive care could produce survival outcomes on par with some new drugs.11 “The field really was revolutionized,” he noted.

“Quality of life and survival need not be mutually exclusive,” Leitner said. “Patients who have better functional status and have a holistic approach to their care can do better on cancer-directed therapy, including in outcomes like survival. And then, of course, there are a number of unmet needs as patients are going through their cancer treatment journey. Supportive care is not just a collection of services, but really a treatment approach about how to address those needs.”

The questions around supportive care have been whether it works and who pays for it, as the savings are seen in reducing health care utilization. Leitner reviewed results from multiple studies highlighting the value of supportive care, from Ma et al, which found early palliative care for adults with serious illness could reduce admissions to the intensive care unit (ICU) by 22% and reduce costs by 15%,¹² to work by Ethan Basch, MD, which showed monitoring of patient self-reported symptoms improved outcomes,¹³ to those of the GAIN-S intervention presented by City of Hope’s William Dale, MD, PhD, at ASCO 2024, which brought a significant drop in grades 3 to 5 chemotherapy toxic effects without dose reductions or reductions in overall survival.¹⁴

A multipart supportive care framework at City of Hope features a 4-part assessment and initial delivery phase, followed by assessments and alignment with institutional goals. The key is acting early, Leitner said. “Patients don’t want to die in the hospital. Patients don’t want to be in the ICU unless there is a meaningful opportunity for recovery. And yet, too many patients are in the ICU, so an ability to intercept upstream of an ICU admission is very meaningful,” he said.

Tailoring the amount and design of supportive care services to patient need is essential. “The most underutilized resource in all of health care is the patient, and the more we utilize the patient, the better we will do,” Leitner said.

Beyond supportive care, City of Hope has launched its Cherng Family Center for Integrative Oncology thanks to a $100 million gift from Andrew and Peggy, the founders of Panda Express.¹⁵ Richard T. Lee, MD, who is the program’s chair and medical director for Supportive & Integrative Medicine at City of Hope Orange County and the Departments of Supportive Care Medicine and Medical Oncology ​at City of Hope, outlined how the center is blending Eastern and Western approaches to develop a new standard of care involving integrative therapies to address pain, nausea, neuropathy, and other effects of cancer treatment.

Lee explained there are many ways that physicians think about integrative, complementary, and alternative medicine (ICAM), but the most important feature at City of Hope is that it is evidence-based. This helps Lee keep patients who are interested in alternative therapies from trying things that could be ineffective or even harmful.

“When I tell my colleagues I do integrative oncology, I get a lot of funny looks, but my patients bring me all sorts of reading materials on how they can cure themselves of cancer,” he said. “And I agree, unfortunately, in the field, there’s a lot of variability.”

The field includes natural products such as shark cartilage, herbs, and supplements; mind-body interventions such as meditation; body-based approaches such as massage, chiropractic, and osteopathic manipulation—“and then they kind of catch all of the other whole medical systems, like traditional Chinese medicine, Ayurvedic energy therapies, and other categories,” he said.

More than 100 institutions now have integrative medicine programs, and City of Hope has joined a consortium to discuss reaffirming the practice, what Lee called “thinking about the whole person.”

“What separates integrative medicine from what I would consider complementary or alternative medicine is that it has to be evidence-based. It has to be appropriate. So not everything out there is appropriate for every patient, and that is, I would say, entirely true when we think about cancer care,” he said.

The approaches are very popular with patients, both at City of Hope and elsewhere. Surveys from the CDC starting in 2012 showed that at least one-third of patients had used some type of ICAM approach in the prior 12 months, and data Lee shared from The University of Texas MD Anderson Cancer Center showed that 50% of patients were using an ICAM therapy and 75% had heard of them. Often, Lee said, the problem is that patients don’t tell their physicians that they are using supplements or other ICAM treatments.

Another challenge is that ICAM approaches are often available only at a main campus, which City of Hope is trying to address by having services at both Duarte and Orange County. Lee said the infrastructure is being equipped to handle research at multiple sites, and City of Hope wants to offer fellowships and training for more integrative oncologists.

Lee explained how integrative oncology complements supportive care. “They’re both focused on a holistic approach, focusing on improving quality of life, and managing symptoms,” he said, but integrative oncology takes an additional step toward optimizing well-being.

“When I was in my early career, I would send people to physical therapy, and they would say, ‘Oh, they can do their activities of daily living.’ But I would say, ‘Well, are they actually meeting the American Cancer Society guidelines on exercise? Are they exercising 150 minutes a week?’ Because we know that it can reduce certain types of cancer. So we really want to go the extra step, and we are interested in anticancer properties of natural products as well as those that could help with symptoms,” Lee said.

He added, “But can we discover new therapies through plants? And I think there’s opportunity there. We have the patient at the center with their family, their culture, their background, that they bring together. We have the great modern therapies that City of Hope has pioneered, from stem cell transplant and immunotherapy CAR T, but we want to surround that with all the right supportive care services. We have great supportive care programs already, and integrative oncology brings in more options and therapies in the different dimensions of health, [such as] integrative medicine consultation, acupuncture, massage, music, art therapy, yoga, meditation group programs, and healing spaces.”

Lee went through a roster of services offered at both locations, including oncology massage, which helps patients experiencing anxiety about receiving therapy. He also counsels patients who show up with a dozen different herbs and gets them to focus on whether the supplements will really help or cause a drug-drug interaction. Lee works with patients to guide them to treatments for anxiety or depression that meet NCCN guidelines or those of the Society for Integrative Oncology.

“I had a patient who has metastatic breast cancer and was thinking about chemotherapy, but ultimately she really wanted a more holistic approach,” Lee said. After a discussion, the patient agreed to connect with a breast cancer oncologist and start chemotherapy while Lee worked on other integrative therapies.

“And I said, that’s exactly what we want to do, rather than her going [to another country for treatment] and doing things that just aren’t safe and aren’t going to help her,” he said.

Keeping Care Consistent Across Multiple Sites
Providing world-class cancer care is not easy. Providing the same world-class care at every site across a vast network is an even bigger challenge, which Linda Bosserman, MD, FASCO, FACP, addressed.

Linda Bosserman, MD, FASCO, FACP | Image: City of Hope

Bosserman, a professor of medical oncology and therapeutics research, also is medical director for value-based care and for the Center for International Medicine. She explained that City of Hope now has more than 600 physicians at 40 sites, including 34 in California. Through partnerships, Bosserman said, City of Hope’s reach spans the globe.

“I spent a week teaching [about] breast cancer in China, seeing patients, working with doctors, and talking about standards and treatment,” she said. “We have a partnership with Brazil, the No. 1 cancer center in Latin America. We just signed an agreement with doctors in the Philippines who have come over. We exchanged fellows and physicians and training. We work on genomic programs and cellular therapies. Our hematologists work together. We have tumor boards jointly with these programs to share…our expertise with people all over the world, not just throughout the United States.”

How does City of Hope ensure high-level care across its many sites and partnerships? Bosserman outlined the elements as follows:

Clinical trials. Trials ensure access to the best care, and they save money, she said. “Clinical trials provide the experimental treatments at no cost—and these run $100,000 or $200,000 for our cellular therapies. Those are provided at no cost when you’re on that arm of a trial or an oral therapy, while the standard arm is paid for by your insurance.” However, she noted that trials are labor intensive and require their own staff.

Genomic testing. Getting patients to the center requires that they receive the right diagnosis, she said, “and, increasingly, that means genomic testing.” Bosserman emphasized that it’s essential to have not only access to testing but also an infrastructure to read the results and get information back out to physicians quickly.

Clinical pathways. Bosserman described the layout of City of Hope’s EPIC medical records system and data collection tools, which allow clinicians to see the first, second, and third choices for treatment, along with clinical trial options and where trials are being offered. Using these electronic tools ensures “that all patients’ needs are considered when we order a plan—we don’t just order drugs,” she said.

City of Hope’s pathways are consistent from site to site, and the network also uses patient-reported outcome tools to track symptoms and social determinants of health, and guide treatment based on a patient’s goals of care. Beyond the pathways, Bosserman said, City of Hope faculty are very connected in their work processes, through tumor boards, and even via informal means. City of Hope faculty are also involved in creating national guidelines.

All this pays off. Bosserman shared data for City of Hope across sites that show that in patients between stage I and III disease, City of Hope had a 93% to 97% 5-year survival rate, and if breast cancer was diagnosed at stage IV, the 5-year rate was 78%.

The faculty examine outcomes by biomarker to find areas where they can improve, she said. “We challenge ourselves when we see something we might do better. We know how to delve into it and how to restructure our programs and our approaches and our trials for continued improvements,” Bosserman said.

“This is happening in all of our tumor types, and it’s something we’re really proud of—the systems we’re putting in place give us information to show that we’re doing better,” she said. “It’s based on these very comprehensive approaches. This is really what we are.”

References
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10. CMS-1784-F. CMS. November 16, 2023. Accessed January 19, 2024. https://www.cms.gov/medicare/medicare-fee-service-payment/physicianfeesched/pfs-federal-regulation-notices/cms-1784-f
11. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733-742. doi:10.1056/NEJMoa1000678
12. Ma J, Chi S, Buettner B, et al. Early palliative care consultation in the medical ICU: a cluster randomized crossover trial. Crit Care Med. 2019;47(12):1707-1715. doi:10.1097/CCM.0000000000004016
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14. Phillips T, Sun CL, Chien LC, et al. Geriatric assessment–directed supportive care intervention (GAIN-S)-implementation via telehealth in a lower-resourced community. Presented at: ASCO 2024; May 31-June 4, 2024; Chicago, IL. Abstract 1510. https://www.citedrive.com/en/discovery/geriatric-assessment-directed-supportive-care-intervention-gain-s-implementation-via-telehealth-in-a-lower-resourced-community/
15. Logsdon Z. City of Hope receives $100 million gift to create first of its first-of-its-kind national integrative oncology program. News release. City of Hope. September 12, 2023. Accessed October 23, 2024. https://www.cityofhope.org/city-of-hope-receives-100-million-gift-to-create-first-of-its-kind-national-integrative-oncology