The Gene Upshaw Memorial Tahoe Forest Cancer Center has established a cancer care model to address disparities in lung cancer in rural areas. By partnering with the UC Davis Comprehensive Cancer Center and their UC Davis Cancer Care Network, they have been able to address a large issue in cancer care, where 20% of the American population is living in a rural area without access to a National Cancer Institute (NCI)-designated cancer center.
Laurence Heifetz, MD, FACP, medical director at the Gene Upshaw Memorial Tahoe Forest Cancer Center, says 80% of all cancer cases are made up by gastrointestinal (GI), genitourinary (GU), lung, and breast cancers. With virtual tumor boards established between the experts at UC Davis and the smaller, local cancer centers and hospitals like Tahoe Forest Cancer Center, physicians are able to present specific patient cases and, in turn, give their patients the best treatment at hospitals local to them.
In an interview with Targeted Oncology, Heifetz discussed the process of bringing this program into his community center. He also advises other community oncologists on how to set up similar programs and shares the benefits of doing so.
TARGETED ONCOLOGY: Can you begin by giving us an overview of what you’ve done in managing the disparities in lung cancer at your institution?
Heifetz: About 20% of the American population lives in a rural area. By definition, they have less access to state-of-the-art medical care, in terms of any medical care, but specifically cancer care. Cancer care is expensive, it’s difficult, and when you’re living a long distance from a thought center, which is in every large city, you are going to get delayed state-of-the-art care.
What we put together was a system by addressing the 4 major cancers that make up 80% of all cancers, which are GI, GU, lung, and breast cancer. Partnering up with the UC Davis Comprehensive Cancer Center, which is 2 hours away. Our facility is in the middle of the Sierra Nevada Mountains. It’s a ski resort, it’s wonderful, but it’s pretty far away. We partnered up with UC Davis to be in their UC Davis Cancer Care network. That network has 4 remote facilities, one in Bakersfield, one in Marysville, one in Merced, and one in Truckee, that’s the facility we’re in.
Every Monday, we have a virtual tumor board for GI, every Tuesday is GU, every Wednesday is lung, and every Thursday is breast. When we started this program in 2008, we had no idea what was going to happen with these virtual tumor boards. They became a cultural definer for our program. We were able to grow it from 1 doctor to 5 doctors. We have 4 medical oncologists and 1 radiation oncologist. We had no cancer services in 2006. That means that in our community of 50,000 people, they had to drive long distances to get cancer care, so many of them just didn’t get cancer care. That’s a huge disparity, right?
When we started this program, we had 100% out-migration of all cancer patients. Now, because of this virtual tumor board culture that we do, we have 52% in-migration from patients in areas outside of our primary catchment area and we’re getting all of our patients from within our catchment area, so the program has grown significantly. We believe that it is a measure of our relationship with a thought leader. In this situation, it’s in lung cancer, but it’s in any cancer at an NCI-designated comprehensive cancer center. There are many of those in the United States.
There’s about 69 NCI-designated cancer centers in the United States. All of them could have the same system. All they have to do is recognize the fact that these 4 cancers – colon, prostate, lung, and breast – occupy 80% of all cancer cases. In the remote area, focusing on those will build the infrastructure in being able to manage almost everything else. They can manage head and neck cancer, they can manage lymphomas, they’ll be able to manage melanomas, because they will have built the infrastructure.
We also have built-in relationships with academic thought centers, so that the ease with which they can present a case at a tumor board is very, very fast. This means there is ease within which they can get the consult done and send the patient down for advanced surgery or something that they can’t do locally. The communication relationship between the faculty at the academic center and the doctors at the community center is much more enhanced.
It becomes a friendly, welcoming way to be a doctor. We think that it will address an ASCO goal, which is to decrease cancer care disparities by increasing the quality of care at the local level.
TARGETED ONCOLOGY: Can you walk us through how you got to where you are today in terms of this program?
Heifetz: When we first started this program in 2006, we didn’t know what we were going to do. We said let’s get started and let’s develop some relationships. We reached out to UC San Francisco, UC Davis, and Stanford, which are 3 large big-name, high-end cancer programs in northern California. Davis is about 2 hours away, San Francisco is about 3 hours away, and Stanford is about 4 hours away. Additionally, Davis had developed a very, very functional telemedicine program. With its sphere of influence being the foothills of the Sierra Nevada Mountains, it was very appropriate for us to get the tightest relationship with Davis. It was the shortest drive for our patients, and they had a lot of investment in technology.
We were able to hitch a ride off of that and work with them in a way to run this experiment, which was to see what virtual tumor boards do for ongoing medical education. There’s no way that the community oncologist can keep up with every unpronounceable mib, nib, and mab that the pharmaceutical industry comes out with, with new indications in what feels like almost every 3 months. There’s no way we’re going to know where truth lies, so we count on the academic centers where doctors take care of just one disease. You have a team that is really focused on lung cancers, and another team that’s really focused on prostate cancer. You relay to those people and expect that that’s where the knowledge is going to be the highest. If you’re dialed in with those guys, you’re going to get that knowledge.
What we did after that was that we got real comfortable in front of cameras so that we could then develop our own medicine outreach clinic in very remote spots in the Sierra Nevada Mountains, about 2 hours away in a snowstorm, and have follow-up visits done where the patient can stay at their local hospital, really small 4-bed hospitals. Patients can go to those places, they’ll have a nurse practitioner there, and we talk to them. They love it, except they miss the hugs from the doctors.
It’s just a wonderful system. We now have 4 of these remote telemedicine offices where we see patients side by side with our regular patients that we can touch and feel in our office.
TARGETED ONCOLOGY: Can you expand on how the virtual tumor board works?
Heifetz: The tumor boards have very structured formats. If you have a case you want to present on the tumor board, you just send a notice in, such as “I want to present Mrs. Jones,” and then, you’ll get back “Sure, Larry, you’re on next week.” Your job is to then get the images together, if necessary, the pathology slides, and have that organized so that when it is your time to present, you can present.
The subject is always an active patient. That’s what a tumor board requires, it’s not some hypothetical. It’s a real patient decision situation. What we’ve experienced is as the new indications for therapy change, both diagnostic studies, as well as therapeutic tools, the academic partner knows that and is able to validate that with a higher degree of quality than what you would get from a drug rep who has an interest in really pushing that drug. You get a much better sense of security about what is ok and what is not ok, what you can do and what you shouldn’t do. It really, really works.
TARGETED ONCOLOGY: What kind of advice would you give to other community centers out there?
Heifetz: My advice is that every oncologist should find an academic partner. There must be an academic partner that they can relate to. Meet with the academic partner and review these 4 diseases, which will get you 80% of your cases. See if they can adjust their tumor boards to enable remote access.
The mothership – the academic center – is going to get something out of that. They’re going to get more patients enrolled in clinical trials. They’re going to get advanced surgeries and complex cases, like bone marrow transplants and things like that which are not usually being done in the community practices.
The local doctor is going to feel better about what he or she is doing, and is going to be providing a more transparent delivery of state-of-the-art therapy, and that practice is going to flourish. The institution that the doctors are working with will get more patients coming in. The spin-offs to the institution’s diagnostic imaging department and surgical department are going to be significant. In the ideal world, that is what should be done.