Jame Abraham, MD, FACP, has been in the field of oncology for more than 2 decades, he and says this is both one of the most exhilarating and challenging times in cancer care. “What excites me the most are the innovations in treatment that are literally transforming the lives of our patients and allowing them to live long, high-quality years after cancer,” said Dr. Abraham. “However, physician burnout and workforce shortages, as well as an aging population and increasing rates of cancer incidence, are all conspiring to make this a difficult time in the practice of oncology.”
Jame Abraham, MD, FACP
A specialist in the treatment of both early and metastatic breast cancers and a leader in the development of novel clinical trials in the disease, from 2013 to 2019, Dr. Abraham served as Director of the Cleveland Clinic Breast Oncology Program and Co-Director of the Cleveland Clinic Comprehensive Breast Cancer Program. He is currently Chairman of the Department of Hematology and Medical Oncology at the Cleveland Clinic and Professor of Medicine at the Cleveland Clinic Lerner College of Medicine; Vice Chair for Research Strategy at NRG Oncology; Vice Chair of the Research Review Committee of the National Surgical Adjuvant Breast and Bowel Project; and a member of the National Comprehensive Cancer Network (NCCN) Breast Cancer Committee.
In 2020, Dr. Abraham was named Deputy Editor of ASCO’s JCO Oncology Practice. Earlier this year, Dr. Abraham took on the role of Deputy Editor of The ASCO Post, where he is also a contributing editor for the columns Living a Full Life and View From the Top.
Recently, The ASCO Post talked with Dr. Abraham about the advances in treatment for patients with both early and metastatic breast cancers, which are leading to more cures and longer high-quality years for survivors, as well as the challenges ahead for the oncology community, including physician burnout and the looming workforce shortage.
Transforming Care for Patients With Breast Cancer
Please talk about the progress that is being made in the detection and treatment of early, metastatic, and triple-negative breast cancers.
I divide the advances made in breast cancer into four main areas. First, the development of genomic predictor tools, including the Oncotype DX Breast Recurrence Score and MammaPrint, has given us insight into which patients will benefit most from chemotherapy or endocrine treatment; these tools also have allowed us to tailor therapy based on the biology of a patient’s tumor and the chance of recurrence. These personalized approaches have helped our patients avoid unnecessary chemotherapy and spared them from long-term side effects.
Physician burnout and workforce shortages, as well as an aging population and increasing rates of cancer incidence, are all conspiring to make this a difficult time in the practice of oncology.— Jame Abraham, MD, FACP
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Second, we are performing more germline testing on patients at high risk for developing breast and ovarian cancers to determine whether they are carriers of the BRCA1 and BRCA2 gene alterations. There are several options we can now offer high-risk patients to prevent these cancers by early aggressive screening or through prophylactic measures, such as mastectomy and salpingo-oophorectomy, or reduce their risk by using medications. BRCA testing also allows us to select PARP inhibitors as a treatment option in high-risk, early-stage breast cancer and in metastatic breast cancer.
Third, there are many novel targeted agents approved for breast cancer by the U.S. Food and Drug Administration (FDA). For example, treatment of HER2-positive breast cancer now includes such options as tyrosine kinase inhibitors and antibody-drug conjugates (eg, fam-trastuzumab deruxtecan-nxki [T-DXd]). Also, many new antihormonal treatments and CDK4/6 inhibitors in the estrogen receptor–positive setting (eg, palbociclib, ribociclib, and abemaciclib) as well as oral selective estrogen receptor degraders (eg, elacestrant) are transforming treatment for the largest subset of breast cancer. These treatments, as well as the immunotherapy agent pembrolizumab for triple-negative breast cancer, are all major advances in managing breast cancer.
And fourth, I am very happy to see improvement in the quality of life for patients with metastatic disease. Ten years ago, if you had a patient with estrogen receptor–positive metastatic breast cancer with lesions in the lungs and liver, the patient would be treated with intravenous chemotherapy, would have multiple side effects, and would be tied to an infusion center. Today, treatment has completely changed with the advent of oral antihormone and CDK4/6 therapies, which have dramatically improved the quality of life for patients with metastatic breast cancer; this is huge. We need to continue to pay attention to optimizing treatment and addressing the challenges faced by the large number of cancer survivors. FDA-approved antibody-drug conjugates such as T-DXd and sacituzumab govitecan-hziy as well as others that are emerging will continue to offer novel treatment options for our patients.
Understanding the Contributing Factors in Cancer Disparities
Despite the progress being made in both early and late-stage breast cancers, research shows that although breast cancer incidence rates among Black and White women are similar, mortality rates are vastly different, with Black women experiencing a 40% higher death rate from the disease than White women, a statistic that has been stagnant for decades.1
In addition to the socioeconomic issues that limit access to high-quality cancer care, new research is showing that differences in tumor biology are also contributing to this disparity.1 What are you learning about the differences in tumor biology between Black and White women with breast cancer?
The fact that Black women have a 40% higher death rate than White women is unacceptable. The reasons are multifactorial, including lack of access to treatment, lower clinical trial participation, lack of trust in the health-care system, and socioeconomic challenges. Through research, it is clear that tumor biology also plays a role in outcome disparities. Black women tend to be affected by more aggressive subtypes of breast cancer, such as triple-negative breast cancer, which can develop at a younger age and may be more refractory or more advanced at diagnosis.
We need to continue to focus on the many factors contributing to poorer outcomes in Black women, including tumor biology. But we also need to think about how breast cancer affects White women in poor, rural communities, where there may be distrust in the health-care system and where lack of access to medical care often leads to delayed diagnosis and worse outcomes. Thus, we need to continue to focus on disparities in cancer care for all patients.
Maintaining the Edge in Cancer Research
You are involved in multiple organizations conducting practice-defining multi-institutional phase I and III trials, primarily sponsored by the National Cancer Institute (NCI). Please talk about the need for greater and consistent federal funding for cancer clinical trials.
What differentiates the United States health-care system from other health-care systems around the world is our ability to pursue more effective therapies for cancer. I strongly believe that clinical trials are the gold standard for producing the treatments that are saving more lives of people affected by cancer.
Over the past 15 to 20 years, there has been a shift away from mostly NCI-funded clinical trial research to more industry-launched trials; that can be a good thing because a number of innovations are coming from pharma-driven studies. However, if we do not provide the NCI with consistently increased funding, we will not continue to maintain our edge in transformative research.
NCI-funded clinical trial mechanisms through the cooperative groups have a unique position in developing novel treatments, because it is a consortium of clinical investigators who clearly know and prioritize patient needs and gaps in care. This mechanism allows us to maintain intellectual independence in innovations in cancer care.
Recovering From the COVID-19 Pandemic
What do you see as among the biggest threats to oncology practices over the next 5 years?
To begin, I would say we have to look at the oncology landscape divided by the time before and after the COVID-19 pandemic as well as both the internal and external threats as a result of the biggest health disaster in more than 100 years. Among the internal factors is provider burnout, and we are still recovering from the exhaustion and great resignation caused by the COVID-19 crisis.
External factors include workforce shortages, inflation, skepticism about medical facts, and substantial increases in financial pressures. During and after the COVID-19 pandemic, use of patient portals, including MyChart, and electronic medical records by patients has increased substantially, forcing health-care providers to spend more time on their computers. Studies have shown a significant association between physician burnout and the number of after-hours time spent on electronic medical records.2
We do not get burned out from taking care of our patients. We get burned out from the internal and external pressures caused by the health-care system.— Jame Abraham, MD, FACP
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We are getting burned out from external factors caused by insurance payers and their requirements for time-consuming efforts, such as prior authorization, before we can provide a specific service for our patients. This is a huge dissatisfier for the entire medical community, especially for oncologists, because we are dealing with a lot of death, dying, and suffering, which take a toll on us.
We do not get burned out from taking care of our patients. We get burned out from the internal and external pressures caused by the health-care system.
Overcoming Threats to the Practice of Oncology
Currently, 22% of practicing oncologists are nearing retirement age, and less than 14% of the oncology workforce is aged 40 and younger.3 As you mentioned previously, burnout in oncology has contributed to provider shortages. The causes of burnout range from increased administrative and financial burden from payer policies. What are some solutions to these issues?
Workforce shortages are a huge problem for oncology practice and for all medical specialties. As I mentioned, the COVID-19 pandemic contributed greatly to the decision by many physicians and nurses to leave the health-care field for another profession or to retire early. Many health-care systems today are still operating with shortages of physicians, nurses, advance practice providers, as well as other health-care providers, and it is putting extra pressure on patient care, safety, and quality as well as on those of us remaining in the health-care system.
As policymakers and as a society, we need to decide how to increase the pipeline of health-care providers, including training more physicians, nurses, allied health-care workers, and advance practice providers in all medical specialties. We appreciate the efforts by ASCO and the American Society of Hematology to encourage more medical students and residents to decide on a career in hematology and medical oncology as a specialty.
In addition to increasing the number of oncologists and other medical professionals to care for the coming tsunami of an aging population and increases in cancer rates, we also need to look at our immigration policy and how it is contributing to medical workforce shortages.
We have a lot of work to do to overcome these challenges—not just in oncology but throughout the whole health-care system. It is good to see the Centers for Medicare & Medicaid Services and medical societies such as ASCO are taking steps to modernize and streamline the prior authorization process. These steps should help to eliminate care delays and patient harms as well as relieve the administrative burden on oncology practices, but there is more work to be done.
DISCLOSURE: Dr. Abraham reported no conflicts of interest.
1. Breast Cancer Research Foundation: Black women and breast cancer: Why disparities persist and how to end them. January 25, 2023. Available at www.bcrf.org/blog/black-women-and-breast-cancer-why-disparities-persist-and-how-end-them/. Accessed September 11, 2023.
2. Li C, Parpia C, Sriharan A, et al: Electronic medical record-related burnout in healthcare providers: A scoping review of outcomes and interventions. BMJ Open 12:e060865, 2022.
3. Pierce LJ: ASCO Statement prepared for the U.S. House Committee on Energy and Commerce Subcommittee on Health; Examining Existing Federal Programs to Build a Stronger Health Workforce and Improve Primary Care. Available at https://old-prod.asco.org/sites/new-www.asco.org/files/content-files/advocacy/documents/2023-SFTR-EandC-Workforce%20Shortages.pdf. Accessed September 11, 2023.