Standard of care hits close to home

Community practice oncologists may not have the same knowledge as those who practice in cutting-edge academic medical centers, Dr. Chandra says. That means pathologists have a responsibility to educate physician colleagues on standard of care. “It’s very time-consuming,” he acknowledges. “But it’s extremely important.”

Oncologists aren’t alone in their knowledge gaps. At one time pathologists may have found it reasonable to leave treatment matters strictly to oncologists. But that no longer works, says the UAB’s Dr. Harada. “We all have to keep up,” she says. “That’s the best way to tell oncologists whether a test request is reasonable.” Moreover, she adds, oncologists receive sales pitches from diagnostics makers and reference labs. Unless pathologists are up to date about targeted therapies, she says, they won’t be able to help oncologists know whether those tests are worth considering.

Dr. Harada suggests that current residents are more likely than more established physicians to be aware of current treatments, though she takes pains to say she doesn’t want to sound critical of her pathologist colleagues.

One pathologist who is less concerned about sounding critical is Dr. Lundberg. In a video editorial (www.medpagetoday.com/Columns/At-Large/36944) he posted in January, he goaded pathologists to become “knowledge engineers” in molecular testing as opposed to “shipping clerks.”

Oncologists stay on top of treatment options “very, very well,” Dr. Lundberg told CAP TODAY. That’s not as true for pathologists. “I hear from local oncologists that their pathologists are often not helpful,” he says. An oncologist might ask for guidance on a patient who has a certain mutation, for example, and the pathologist replies he or she has never heard of it. “I weep—metaphorically, of course—when I hear that. Because that’s a shame.” When pathologists come up short, oncologists will turn elsewhere for assistance, including places that transcend the town-gown paradigm. Dr. Lundberg cites his company, CollabRx, as an example. It blends molecular oncology and diagnostics information with artificial intelligence and medical experts to help providers interpret results and guide decisions. Oncologists are the biggest users of CollabRx apps, Dr. Lundberg says.

Pfizer’s Dr. James takes the middle ground. Oncologists may have more knowledge about treatments, he says, but pathologists have a better handle on what tests work and whether they belong in a particular practice. As long as one of these physicians leads molecular discussions, he’s happy. You need a champion, he says. “But it’s less critical who that champion is.” He’s seen successes with both models. The worst-case scenario is easy to spot, too. “It’s when neither of those people is engaged.”

Sometimes the best source of education is the most old-fashioned: tumor boards. Technology, as well as molecular advances, has breathed new life into these gatherings.

Lancaster Hospital, where Dr. Oyer practices, has an academic partnership with the University of Pennsylvania. Pairings such as this make it easier for community cancer centers to follow and adopt new developments from academic centers, as well as to obtain second and third opinion consultations and access to highly specialized services. At Lancaster and Penn, electronic connections between the two have transformed tumor boards, letting physicians from both places look at slides, talk about tests, and discuss standard treatments as well as new research.

Tumor boards are crucial, Dr. Spigel agrees. “At least at my center, that simple kind of venue has led to a sea change in how we practice,” including reflexive EGFR and ALK testing, he says. But physicians need to build on tumor boards. “This idea that we’re in a separate part of the cancer center and that we only see each other at tumor boards is not realistic.” Pathologists and oncologists need to talk about patient management daily, he says.

Dr. Chandra, too, is a fan of tumor boards, as well as of educational seminars. He’s given plenty himself and finds he learns from them, too—specifically, where the knowledge gaps are. At a recent seminar he gave, he says, the audience knowledge of molecular testing was all over the map. “It was very new to some physicians,” he says.

Clearly, some small practices have found ways to circumvent the limitations of small practices. Both involve attachments, either with a large academic center or through consolidation. Small, unattached practices face a tougher road, and it’s here that the traditional town-gown divide may be strongest.

Pfizer’s Dr. James traces it to physician experience. It’s a matter of volume. Community physicians tend to be less specialized—they may see a lung cancer case followed by a breast cancer case followed by a colon cancer case. In large academic centers, on the other hand, physicians may be thinking more broadly, not just about currently available tests and drugs but also what might be available via clinical trials.

For Dr. James, the biggest help comes from guidelines. The recent lung cancer guideline, for example (see “New guidance on lung cancer testing,” CAP TODAY, April 2013), addresses physicians in every type of practice, who experience every type of volume, and establishes a basic level of care for all.

He also sees an almost natural growth to how information spreads. Almost all patients with breast cancer are getting a HER2 test, he estimates; that’s also the test that’s been around the longest. EGFR and ALK testing for lung cancer may be happening in only 60 percent of patients, he guesses. But the lung cancer community is learning from the HER2 experience, particularly the need for standardization based on evidence and the need for routine testing. “That’s why there’s so much emphasis now being placed on guidelines,” Dr. James says.

Groups such as the NCCN, CAP, and ASCO are also critical, he says. (Dr. Lundberg agrees. “Physicians tend to change as groups rather than individuals,” he says.)

There are always early adopters, Dr. James notes, regardless of whether they’re in a community or academic setting. What separates mid-level from slow adopters? Dr. James attributes it to a willingness to be open to guidelines.

But an open mind can’t close the volume gap. “There are probably practitioners who know about Xalkori and know about ALK positivity and are looking for that first patient they can treat,” says Dr. James. The math supports him: Only about four percent of patients with lung cancer have an ALK translocation, so physicians may have to test plenty of cases before they encounter an ALK-positive sample. “Sometimes that waiting can be frustrating.”

That brings Dr. James back to the importance of guidelines and routine testing. “You know you’re not going to leave any patients behind,” he says. Otherwise, the one time a physician fails to order the test could be the one case that’s ALK positive. He also likes the potential of EMRs, which can link physicians to guidelines, pathways, and evidence and prompt them to consider tests and other steps they might otherwise overlook.

Dr. Jett has spent his life practicing in larger settings. Before arriving at National Jewish Health, he spent three decades at Mayo Clinic. But he’s familiar with practices in community settings, in part because he makes a point of finding out what goes on in them. He and his colleagues at National Jewish give medical grand rounds at community hospitals and occasionally attend their tumor boards. Again, it’s simple, and it works. “It’s just honest discussion of the science and state-of-the-art treatments.” It makes subsequent discussions easier, too. After he gives grand rounds at another site, says Dr. Jett, physicians feel much more comfortable calling him to ask about a case.

There’s also opportunity for discussions when a physician sees a case that he or she might have handled differently from the referring physician. “Sometimes we see an operation that we think is less than optimal,” says Dr. Jett, “where they haven’t adequately sampled and staged the mediastinal lymph nodes.”

How do physicians handle those conversations? “Um, it’s always difficult,” says Dr. Jett. He’s used to it from his experiences on tumor boards, where there’s plenty of discussion, and often disagreement, over what to do. “The problem is, a lot of people who are not doing state-of-the-art treatment aren’t going to tumor boards for discussion. Obviously, you don’t send a letter to a physician you don’t know, at another hospital, saying, ‘You’re not up to speed.’ That sort of policing and education needs to come from within that institution.”

He recalls a situation many years ago when one of his patients did not have adequate sampling of the mediastinal lymph node—the procedure was done by a cardiac surgeon rather than a cardiothoracic surgeon who specialized in cancer. Dr. Jett’s response was to stop referring patients to that physician—an easy decision, since he had the luxury of many options at Mayo. At smaller institutions, there may be no other choice.

This touches on a topic few physicians want to talk about: What if physicians don’t even know, or want to admit, a gap exists in their knowledge? How do you pluck them from that river called denial?

Dr. Spigel offers a glimmer of hope to go along with a stark assessment. “Nobody wants to feel like they don’t do things in the best possible way at their center,” he says. “I’m the same way. If I’m listening to somebody talk and they say, ‘Here’s the way you should practice,’ I don’t like to hear that. Because immediately there’s going to be a scenario where I didn’t practice that way. And I think I’ve been practicing good care. I don’t like somebody suggesting that I haven’t been.

“But whenever I’m having a discussion with different tumor boards or different centers, there’s often a feeling that more can be done,” he continues. “That’s a good thing. It sparks discussion about how to change what’s happening. I think sometimes there’s a light bulb moment where people appreciate that there’s gaps in their program. The nice thing to see is it’s not too late to start to change things.”

There’s a negative and a positive way to educate, in other words. “And in some ways you’re not going to have a choice, right?” Dr. Spigel says. “Insurance companies are going to require you to have proof of a certain result before you can prescribe a certain pill.”

Physicians are slow to change behavior, a trait both good and bad. Medicine is no place for a wing and a prayer. Tests and treatments, no matter how promising, don’t belong in clinical practice until evidence proves they work. On the other hand, says Dr. Jett, “It’s always easier to do what you’ve done in previous cases.” That’s why knowledge must be shared: “Doctors out there practicing need to know that things have changed,” he says. “What we’re doing in lung cancer now is not what we were doing five years ago. So if your knowledge is five years old, you’re behind in how you think about these things.”

He also thinks there’s a role in playing on physicians’ natural competitiveness. “If you showed me I was performing significantly under the average, you can bet that would be motivation to change,” says Dr. Jett. “If you get a report card from the lab saying, ‘On the last 10 cases of lung cancer you saw with adenocarcinoma, you got EGFR testing one time, and on average your colleagues got it seven or eight times,’ that would be a wake-up call.”

The solutions to closing the town-gown gap, then, are big as well as small, perhaps a fitting answer for a gap that’s both big and small.

For patients, however, the payoff will always seem big. Dr. Spigel recounts a letter he received recently from the husband of one of his current patients. The husband sent the letter to a colleague at an academic medical center as well as to Dr. Spigel, commenting on an advanced therapy his wife had received. The letter read, in part, “We feel like we’re getting state-of-the-art care in our hometown.”

It was a gratifying letter. Patients in community settings deserve such care, says Dr. Spigel. More importantly, he adds, “It’s something they should actually be able to get.”

Karen Titus is CAP TODAY contributing editor and co-managing editor.