Optimizing oncology care in the United States will require making state-of-the-art care more accessible to all. Delivering quality, equitable cancer care is undoubtedly a challenge in a country as large, diverse, and disparate as the United States, but if it is to be achieved, it will entail the efforts of all involved stakeholders, according to Nancy E. Davidson, MD, Executive Vice President at Fred Hutchinson Cancer Center and Head of the Division of Medical Oncology at the University of Washington School of Medicine, Seattle.
“If the past 2 years of COVID have taught us anything, it’s how to make very rapid changes in health care when we have the opportunity and the incentive,” she said in a plenary lecture at the 2022 Summit on Cancer Health Disparities in Seattle.1 “Now, we can take advantage of the insights we’ve developed and capture them in the cancer care continuum.”
According to Dr. Davidson, achieving these goals—and doing so expeditiously—will involve learning from the research as well as considering the viewpoints of all stakeholders, including patients and their families, providers, third-party payers, regulatory entities, and pharmaceutical companies.
Nancy E. Davidson, MD
First, the Research Perspective
A 2016 study on the use of adjuvant trastuzumab in Medicare beneficiaries with early HER2-positive breast cancer identified significant racial disparities in the provision of the drug.2 According to Dr. Davidson, although these data are now fairly outdated, the findings are useful in this context.
“First, the study was conducted on Medicare beneficiaries,” she noted. “So everyone should have had access to the same insurance coverage.”
The study evaluated claims data for the use of trastuzumab in the 12 months after breast cancer diagnosis, and almost 1,400 women treated between 2010 and 2011 were identified in the database. Although Dr. Davidson acknowledged that oncologists are now more comfortable with this treatment regimen than when the data were collected, scientific evidence still supported the use of adjuvant trastuzumab for early HER2-positive breast cancer at the time. However, the study found that about half of the patients identified did not receive trastuzumab, and Black women were 25% less likely to receive the treatment than White women.
“Why didn’t those women get it, and why was there such a big racial discrepancy?” she asked. These questions remain to be answered, and further research is needed to identify these barriers.
Other data from the Hutchinson Institute for Cancer Outcomes Research at Fred Hutch3 revealed wide institutional variation in the use of breast cancer tumor markers in early breast cancer survivors in the state of Washington. However, neither the ASCO guidelines nor the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology (NCCN Guidelines®) recommend the use of tumor markers for routine follow-up of survivors of early-stage breast cancer in the absence of signs or symptoms of metastasis.
“There’s no value associated with [the use of breast cancer tumor markers] in these patients,” she explained. “But, in some institutions, we’re doing this a lot more than we should be. This is an example of care that we shouldn’t be giving, which costs millions of dollars.”
Considering the Stakeholders: What Does the Patient Need?
“First and foremost, patients and families are people who have been shocked by the diagnosis of cancer,” said Dr. Davidson. “They need the education required to support informed decision-making and to honor their preferences.”
However, patients and their families also need expanded access to cancer care (bringing it closer to their homes), as well as a stronger presence from community health workers and oncology navigators (particularly in the prediagnostic and diagnostic phases), she suggested.
“One challenging thing over the past couple of decades is that care has largely devolved to the family, but families are different in the United States now,” she noted. “Often, they’re small, blended, or distant. Some of the things that were easier to do in the conventional nuclear family are much more difficult now; frequently, people just don’t have the support system necessary for longitudinal care.”
Patients also require more support for the financial toxicity of cancer care as well as more attention to symptom control. “We are very focused on the treatment of the cancer, but we’re not always thinking about how the patient feels,” she added.
What Does the Provider Need?
According to Dr. Davidson, one of the biggest challenges currently faced by providers is staying contemporary—adopting the new and discarding the old—in a rapidly changing medical landscape.
Staying on top of constantly changing electronic health records pathways, certification maintenance, tumor boards, and guidelines is incredibly time-consuming for providers. Additional issues such as dealing with preauthorizations and co-pays, as well as facilitating oral therapies and ensuring adherence, add an additional burden of responsibility. Finding methods of streamlining these issues will be imperative to elevating cancer care in the United States, she emphasized.
“Time is our most precious commodity,” Dr. Davidson commented. “And I think that’s what we have to optimize for ourselves if we’re going to be able to stay contemporary—as well as content—in our practices.”
Payers, Regulatory Agencies, and Pharma: Challenges and Considerations
In the context of a coverage plan, minimizing the burden to both patients and providers is paramount. Dr. Davidson noted that patients often don’t pick their own plans and can be caught off guard by gaps in coverage when faced with a serious illness such as cancer. Additionally, where appropriate, reducing preauthorization requirements would contribute to the timeliness of care for patients, she noted.
However, Dr. Davidson did acknowledge the payers’ plight when it comes to the complexities of off-label use in oncology. “We are definitely a specialty of off-label use,” she said. “I can see where it’s complicated to figure out what does and doesn’t make sense to cover.”
From a regulatory stance, she also acknowledged the great strides made by the U.S. Food and Drug Administration (FDA) over the past several decades toward achieving the right balance of rapid drug approval with attention to efficacy and safety (and in the context of the current FDA framework). However, regulatory issues can sometimes lead to confusion for providers, she added, noting the FDA withdrawals of bevacizumab and atezolizumab in the breast cancer setting.
Notably, in the post-COVID era, the possibility of using real-world evidence in the context of cancer clinical trials has gained traction. “In this area, we’re going to have to interact with the FDA and other regulatory agencies in a very real way,” she said.
Challenges currently facing the pharmaceutical industry include developing novel approaches vs refining current approaches (ie, another checkpoint inhibitor), as well as the complexities involved in developing novel tests or imaging techniques in a field that relies on them heavily. The pricing structure in the United States vs the rest of the world also continues to present an enormous challenge to the field of oncology.
Finally, Dr. Davidson pointed out the relative lack of interest in prevention or interception vs treatment in the U.S. health-care system. “The best cancer is the one you don’t get or that is diagnosed very early and taken care of rapidly,” she said. “So, prevention approaches might have the most benefit over the long term.”
DISCLOSURE: Dr. Davidson reported no conflicts of interest.
1. Davidson NE: Elevating cancer care in the U.S. for all. Plenary Lecture: Expediting adoption of practice-changing research in community practice—Current challenges and potential solutions. 2022 Summit on Cancer Health Disparities. Presented May 1, 2022.
2. Reeder-Hayes K, Hinton SP, Meng K, et al: Disparities in use of human epidermal growth hormone receptor 2–targeted therapy for early-stage breast cancer. J Clin Oncol 34:2003-2009, 2016.
3. Fred Hutch: Community Cancer Care in Washington State: Quality and Cost Report 2021. Available at https://www.fredhutch.org/en/research/institutes-networks-ircs/hutchinson-institute-for-cancer-outcomes-research/reports.html. Accessed June 2, 2022.