Standard of care hits close to home

Karen Titus

May 2013—Town versus gown: It’s a long-standing source of tension in medicine. In November 1963, JAMA published a piece on the pathology of this so-called syndrome. The disease was characterized as both chronic and acute, with the author blaming social forces, the structure of medical practice, philosophical differences in medical education, and the rise of specialization, as well as a host of secondary etiologic factors. After much hand wringing, the author called for a renewal of spirit to end this classic divide.

Medicine was not blessed by a Great Awakening, as it turns out—unless you count the molecular revolution. The potent pairing of molecular diagnostics and targeted cancer therapies has helped erase the line separating town and gown. It’s enabled smaller community practices to take advantage of cutting-edge treatments that are becoming the baseline of good care, such as ALK and EGFR testing for Xalkori and Tarceva, and HER2 testing for Herceptin. As one oncologist puts it, the most up-to-date molecular diagnostics and treatment selection should be an everyday practice for everyone. “That is community medicine,” says Randall Oyer, MD, medical director, oncology program, Lancaster (Pa.) General Hospital.

The speed with which these changes have occurred has further blurred the line. Certainly there are still cases where a community center might deliver care that is overruled, so to speak, when the patient subsequently seeks care at a second, academic center. But it’s hardly a one-way pipeline filled with errors. “It’s a learning curve for everybody,” says Shuko Harada, MD. “It’s not necessarily that the community hospital doctor is wrong. Everybody is still getting consensus on what test needs to be done for what patient,” says Dr. Harada, assistant professor and head of molecular diagnostic laboratory, and director, molecular genetic pathology fellowship program, Department of Pathology, University of Alabama at Birmingham. In that sense, denizens of both town and gown are migrating to a sprawling exurb, one filled with intellectual wealth but a slightly disorienting layout.

Geography has historically had an outsized influence on patient care. While large academic centers have traditionally offered the most advanced testing and treatments, that’s not where most patients actually cluster. “We have to understand that the vast majority of patients are right here in the community,” says Pranil Chandra, DO, director of molecular pathology services and interim medical director, clinical pathology, PathGroup, a Tennessee-based pathology group.

Yet for years, that was an operating structure in medicine. The past four decades gave rise to 40 National Cancer Institute-designated comprehensive cancer centers in the United States. A laudable achievement, to be sure, but one that didn’t fully address a stark fact: 85 percent of patients with cancer receive treatment in the community, says Dr. Oyer, who is also a member of the board of trustees for the Association of Community Cancer Centers and of the advisory board for an ACCC study looking at molecular testing in the community oncology setting (www.accccancer.org/education/pdf/MolecularTesting­Gatefold.pdf).

A shift in thinking was in order. Instead of trying to get all patients to NCI-designated centers, Dr. Oyer says, the goal became to shift NCI-style care to the communities. That was the genesis of the NCI’s Community Cancer Centers Program, which launched in 2007.

Against this changing backdrop, what is the current state of town-gown relations? How well is care being delivered in community settings? Is the town-gown moniker still relevant?

“Town-gown is always a useful label, because there is always pushing and pulling between academic medical centers and the practicing physicians in the field,” says former JAMA editor George Lundberg, MD, who’s now editor in chief of CollabRx (www.collabrx.com), a San Francisco-based data analytics company. “But it’s important not to generalize.” In some places, the conflicts are strong; in others, they don’t even exist.

For all the advances and high hopes, differences in care are real and persist to a distressing degree. It’s not strictly a town-gown issue, though that can’t be overlooked as one influential element.

A study presented at the Society of Gynecologic Oncology annual meeting in March, for example, found that only slightly more than one-third of patients with ovarian cancer receive optimal treatment. The reason? Most patients are seen by physicians who see few cases of ovarian cancer. Less experience, less expertise, lesser care.

In the study of 13,321 women, 37 percent received care that followed National Comprehensive Cancer Network clinical practice guidelines. Surgeons and hospitals who saw more patients with the disease were more likely to follow the guidelines than those who saw fewer cases (surgeons with 10 or fewer cases; hospitals with 20 or fewer). As the study noted, women are 30 percent less likely to die of this dis ease if they have guideline-recommended treatment.

Care disparities are not limited to ovarian cancer. David Spigel, MD, program director for lung cancer research, Sarah Cannon Research Institute, and an oncologist with Tennessee Oncology (where he also directs the phase II/III clinical research program), sees discrepancies in lung cancer testing. At his hospital, in Nashville, he’s fortunate. Thanks to reflexive testing for EGFR and ALK (among other things), he typically has molecular testing results available when he talks to his patients. “But at some of the other facilities in the region, including the more rural areas of Tennessee, that isn’t done at all.” Tennessee Oncology is a practice with 75 medical oncologists and hematologists serving middle Tennessee, Chattanooga, and northwest Georgia.

Dr. Spigel benefits from having a large research network—his center is heavily invested in qualifying patients for clinical trials, so unlike some of his colleagues from rural or more isolated clinics, he has the advantage of interacting with colleagues around the country who work in larger practices. “In places where somebody has seen an ALK rearrangement once a year or once every two years, it’s hard to get comfortable with the idea of testing, much less how to use the medications.” That’s true even for more established molecular tests and targeted therapies, he says, such as HER2 testing.

It seems hard to believe. Or, as Dr. Spigel puts it, “Shouldn’t this message already be known? Yes.” But messages need to travel and sink in, and it’s not a swift journey. Every meeting, article, guideline, tumor board, panel, and discussion “sparks new and repeat conversations of the importance of testing, and what to test, and how to do it,” he says. “Even at large, busy urban centers, like where I work, we’re not immune to these challenges.”

There’s also the complicated reality of how people seek care, and how their physicians respond.

As the ovarian cancer study showed, there were women who did not receive surgery from gynecologic surgeons (as recommended) because they preferred to receive care from their current physician—the obstetrician who delivered their children, for example.

“It’s usually not the best choice,” says James R. Jett, MD. It’s frequently less a choice than a mind-set, he goes on to say. “I know people who are like that. They had one GP and they love him or her and don’t venture outside of that,” says Dr. Jett, professor of medicine, National Jewish Health, Denver.

On the other hand, GPs can and do push back against that way of thinking. “I think a lot of those GPs nowadays will say, ‘I’m not the best one for you. Go to this center or that center to get the next level of care,’” Dr. Jett says. GPs are more comfortable referring in part because the rapid changes in medicine make it impossible for any one doctor to know everything; 30 years ago, physicians might have been more confident in the breadth of their knowledge, he suggests. Then, too, physicians practicing today are accustomed to specialization, in training and in care.

Nevertheless, he says, a wide gap remains in thoracic surgery for lung cancer cases. Patients in a community setting are more likely to be operated on by a general surgeon who doesn’t do many cases a year, he says. Those patients should be encouraged to travel to a large center. They don’t always make that journey, however. The reasons can be hard to untangle.

“Quite honestly, sometimes patients don’t like to travel,” Dr. Jett says. “It’s hard to know how much of that is driven by the patient. Sometimes people, especially older individuals, who live in small towns are petrified at the idea of driving into a big city.”

Moreover, not all patients are able or willing to ask the questions that might funnel them to the best care. “Medical knowledge by the general public is not real high,” says Dr. Jett, noting that the Internet remains a double-edged sword.

“On the other hand, how much is driven by the doctor saying, ‘Oh, we can do that locally’”? he asks.

In many cases, of course, community physicians can handle matters locally.

Dr. Chandra takes a broad perspective, literally. PathGroup, based in Nashville, Tenn., is a physician-directed, privately held group of more than 70 pathologists. It serves an area within a nearly 500-mile radius of Nashville, from northern Indiana to southern Alabama and North Carolina to Arkansas. PathGroup provides molecular diagnostics for patients from community-based medical oncology and hematology practices and at the more than 70 hospitals where the group’s members serve as pathology medical directors. “We are purely a community-based practice,” Dr. Chandra says.

That’s plenty of towns, in short. Dr. Chandra’s mission is to maintain gown-level care—as it relates to molecular pathology—in all of them.

To bring the right tests to all these practice sites, Dr. Chandra and his team discuss tests at weekly molecular meetings. When they decide to add a new test, it’s based on recommendations from groups such as the NCCN, CAP, and American Society of Clinical Oncology; input from pathologists at PathGroup; and market demand, among other considerations.

Dr. Chandra, a molecular oncologic pathologist and hematopathologist by training (at MD Anderson Cancer Center and NYU Langone Medical Center), puts together a list of recommendations and guidelines, which he distributes to the group’s pathologists and medical directors. It’s less a matter of him telling his colleagues what to do, he says, and more of him sharing what, in his opinion, are the best clinical molecular practices. From there, he says, each medical director has to decide—ideally in concert with his or her clinical colleagues and executive leadership—whether and how to add a new test.

“I encourage pathologist-driven testing, and encourage the testing to be done reflexively,” Dr. Chandra says, citing EGFR and ALK testing as an example. But he’s well aware that every institution is different and will have its own approach to implementation. “In central Tennessee, where we implemented reflex testing over a year ago, we’ve agreed that we want to do reflex testing of EGFR and ALK on all nonsquamous, non-small cell lung cancers. But there are other institutions where the oncologists want to make that decision. You have to be mindful and respectful of that,” he says.

That highlights one of the key issues in bringing standard care to all practices—it’s never a given, even when everyone belongs to the same group. Here medicine has taken a page from the European Union. Every institution wants to make its own decisions, cherishing its own autonomy despite its collective bent.

“I thought it would be easy to standardize testing across the board,” Dr. Chandra says. He quickly learned otherwise.

Such heterogeneity is typical in health care, says Lee James, MD, PhD, a medical oncologist, a senior medical director at Pfizer, and team leader for Xalkori. Differences are regional, demographic, and stylistic. Uniformity is as attainable as consensus on the federal budget. But, says Dr. James, there should be a baseline for what “good” looks like.

Getting to that baseline takes education, pure and simple.