publication date: Jan. 26, 2018
Trials and Tribulations
Hybrid cancer centers exploring links with NCI-designated institutions
President, Levine Cancer Institute at Carolinas HealthCare System
Bank of America endowed medical director, Helen F. Graham Cancer Center and Research Institute at Christiana Care Health System
Donald L. Trump
CEO and executive director, Inova Schar Cancer Institute
Despite the many advances in oncology, important problems continue to beset the field, including rapidly rising costs, uneven patterns of care, and poor access to (and participation in) cancer trials. A model that has been recently developed and tested to address these issues is the so-called academic hybrid community cancer center.
Although there are variations on this theme, the general concept involves the creation of a community-based oncology center with a multiple hub-and-spoke model that is geographically distributed throughout the community, not tied specifically to a major university program, and which facilitates access to trials, collection of bio-specimens at multiple sites, and creates mechanisms to assess adherence to standards of care and to lower costs compared to centers based solely at major academic centers.
Each center has been developed with central or institutional IRB control over trials, centralized clinical trial operations, an extensive menu of conventional and molecular tumor boards, and electronic or computer-based tools to allow symmetrical distribution of physician support across the system.
Three instances of this approach are provided by the Helen F Graham Cancer Center/Christiana Care Health System, the Levine Cancer Institute/Carolinas HealthCare System and the Inova Schar Cancer Institute. Each center has arisen in a multi-site healthcare system with large patient numbers, and despite loose associations with a university for training and other educational purposes, each has been focused on care delivery, translational research and clinically related activities and less on classical university functions, such as basic science research, general medical student and resident training and the focus on publication to achieve promotion.
One of the unique characteristics of these centers has been the recruitment of internationally and nationally prominent leaders in medical, surgical, radiation and supportive oncology, as well as faculty members from university-based cancer centers who are clinician-investigators or translational researchers. These recruits have been incorporated into clinical teams integrated with established community oncologists. Thus management and trial menus, in addition to evidence-based clinical management pathways, have been or are being created by integrated tumor-specific teams, comprised of oncologists with both a community practice as well as university cancer center experience.
These teams have been linked electronically, facilitating active participation by more isolated members of the team. In parallel, all academic activities, conventional and molecular tumor boards, research meetings, protocol review sessions, and lectures are electronically accessible using tools like Skype and other electronic conferencing facilities.
The issue of rising costs of care has been addressed, in part, by the creation of multiple outreach programs that provide access to IRB-approved cancer trials, allowing structured research to be conducted in an office setting. This reduces the overhead costs per patient dramatically, while still providing many of the services available in a conventional quaternary referral center. Because the academic hybrid centers have not distinguished between uninsured, inadequately insured and well insured patients, they have served as safety net organizations and are thus able to leverage 340B drug pricing.
In turn, this has facilitated the provision of a broad range of ancillary services, such as genetic counseling, complementary and integrative cancer medicine, and extensive supportive medicine services that are often not available in standard community practices because of the time commitments involved, expense and the complexities of administering them. Furthermore, the widespread distribution of these centers has substantially reduced the need for travel by patients and families, as well as time away from work, further reducing costs of care. Because of active integration of cancer trials into treatment algorithms, free medications are often available, a major benefit in an era of expensive targeted therapy.
Community-wide geographical distribution facilitates addressing the issue of disparities of care. Under-served populations, including African Americans, Asian, Hispanic patient communities, the elderly and geographically isolated and rural poor can be managed close to home in this distributed system, once again gaining access to resources that would often require substantial travel.
To date, this model seems to be gaining traction and working effectively. At each center, high patient satisfaction scores have been recorded, cancer trial accruals have increased dramatically, clinician engagement and alignment have increased, and increased numbers of under-served populations have been offered screening, education and treatment and have gained access to cancer trials.
Having established this paradigm, and having shown efficacy in cancer trial recruitment, improved access to care, broader distribution of supportive oncology facilities and resources, and a range of cancer education and prevention activities, these centers are now exploring whether it is feasible to link these centers with established NCI-designated cancer centers, to broaden the impact of NCI funding and make NCI-based resources more accessible to the community at large. One of these centers, as the next step in its evolution, has established a partnership with an NCI- designated basic science center as a new model.
The other two centers are involved in negotiations to assess whether formal relationships with nearby NCI-designated cancer centers will strengthen the model and be of mutual benefit for the centers and the local community by further increasing community access to the resources of the larger centers. Whether it would be feasible for the NCI to become directly involved in this model, and to offer funding independent of quaternary referral centers will be up to the leadership of the NCI.
Corresponding author: Derek Raghavan