Patients with cancer are often forced to choose between seeking specialized medical treatment at facilities located a significant distance from their homes or accepting less rigorous care at local treatment centers. This dilemma frequently occurs among patients with hematologic malignancies, for whom curative treatment regularly involves difficult-to-perform procedures such as hematopoietic cell transplantation (HCT).1
Prior research has shown that patients with hematologic cancers who are treated by disease-specialized physicians experience improved overall outcomes compared to patients treated by general oncologists,2 and that better transplant outcomes are associated with high-volume HCT practices.3 However, many patients cannot afford or are unwilling to travel to specialized treatment and transplant centers, and thus risk dying from potentially curable diseases.
The Levine Cancer Institute (LCI)—a subsidiary of Carolinas HealthCare System—opened its department of hematologic oncology and blood disorders in September 2012. The department provides subspecialized care in hematologic malignancies and benign blood disorders, housing a dedicated HCT program and a 16-bed protected-environment inpatient facility..4
LCI is located in Charlotte, the largest city in North Carolina and second-largest city in the southeastern United States. Yet prior to the department’s establishment, individuals residing in the Charlotte metro area had virtually no access to a subspecialized hematologic oncology facility, with the closest HCT program located more than 90 minutes away.
Since opening its doors, the department’s faculty has grown from four general hematologists to 23 physicians, 14 of whom are specialists in leukemia, lymphoma, plasma cell disorders, bleeding disorders, or HCT. The HCT program performed its first transplantation in March 2014, and expected to perform more than 100 procedures in 2016. The program received accreditation from the Foundation for the Accreditation of Cellular Therapy in 2016.5 The facility’s patient volume has grown six-fold since 2012, and the department regularly attracts patient referrals from across the state of North Carolina. Nearly all patients referred to HCT through after treatment in a disease-specific department section at LCI.
To learn about the requirements for such an undertaking, Journal of Clinical Pathways spoke with Edward A Copelan, MD, FACP, chair of the department of hematologic oncology and blood disorders at LCI. A transplantation specialist who regularly treats patients with leukemia, Dr Copelan served as director of the acute leukemia program at Cleveland Clinic’s Taussig Cancer Institute (Cleveland, OH) prior to joining the department at its inception. Dr Copelan offered a presentation on the rapid and continuing rise of LCI’s hematologic oncology and HCT programs at the 2016 ASH Annual Meeting & Exposition in San Diego, CA.
What are some of the major challenges patients face when they lack access to subspecialized care close to home?
Patients must first decide whether to travel to see a subspecialist. Then, they must decide whether to receive care—and continue receiving care—at a significant distance from home. Frequent travel can often strain family resources, financial and otherwise. A patient who may not be working due to their disease must rely on family members or friends for care and transportation to treatment, which can compromise the other individual’s financial and social situations.
What caused the development of the department of hematologic oncology and blood disorders at LCI?
In 2010, Derek Raghavan, MD, PhD, FACP, FASCO, was recruited from Cleveland Clinic to be president of LCI. A large part of Dr Raghavan’s vision was to bring subspecialized care in solid tumor oncology and malignant hematology to Charlotte. I was recruited to the department along with Belinda Avalos, MD, the department’s vice-chair, who came from The Ohio State University (Columbus, OH). Together with Dr Raghavan, we have worked diligently to carry out this mission.
The department has grown exponentially since its inception 4 years ago. What are some of the factors attracting hematologic oncologists to Charlotte?
Our incredibly talented and hardworking physicians are the most critical factor in the department’s success, and a variety of factors have attracted them here. The potential to build an entire department, along with individual sections, from scratch was very appealing. Our section chiefs—Saad Z Usmani, MD, FACP, director of plasma cell disorders; Jonathan M Gerber, MD, director of leukemia; Nilanjan Ghosh, MD, PhD, director of lymphoma; and Mary Ann Knovich, MD, director of bleeding disorders—have approached constructing their sections very differently, but they have all been remarkably successful both clinically and academically. They have worked together and with the individual providers in their sections collaboratively and constructively, with superb patient care serving as the critical goal.
Our program has become increasingly attractive, and we have recruited many excellent doctors who are happy with their situations here. Our physicians have been confident that the system would provide them the resources needed to offer excellent patient care and carry out their academic work. Additionally, Charlotte is an incredibly appealing city for doctors and their families, and the ability to live and work in such a productive area has been appreciated.
The HCT program has particularly grown in recent years. Given that other transplantation programs have often struggled to establish themselves, why do you think LCI’s has taken off in such a way?
Charlotte is the 17th-largest city in the country, with a metro-area population approaching 2.5 million. Generally, people in the immediate area are happy to receive their care close to home. As physicians from the surrounding area have become more familiar with our program’s superb clinical results in transplantation and other areas—as well as our access to cutting edge clinical trials—our referral network has rapidly grown beyond the immediate area of Charlotte alone. For example, our referral network for patients with acute leukemia has exponentially grown, and most of those patients will receive allogeneic HCTs. Two years ago, most of the calls I received about allogeneic transplants were from doctors in the Charlotte area. Now, we are all regularly receiving calls from physicians who practice an hour away or more. When patients do travel to us from a distance, we work closely with their local physicians to maximize the extent of care they receive locally.
Do you think that the remarkable growth that has been possible at LCI can serve as a model for establishing subspecialized care in other cities?
I do, although in smaller cities this might occur on a smaller scale. What I think is the main advantage for our HCI program as a model is that it allows transplantation to occur at an appropriate time, and allows for continuity of care before and after the procedure.
What future developments can we expect from the department of hematologic oncology and blood disorders at LCI?
We are working to improve transplantation and other treatments through a number of studies with high clinical impact. Dr Avalos and colleagues are collaborating on studies to analyze the influence of pharmacogenomics and pharmacokinetics on immune reconstitution and clinical outcomes, in order to improve the dosing of drugs used in the preparative regimen and for supportive care. Dr Gerber is analyzing the ability of a unique leukemia stem cell assay to better select patients for transplantation. There are several cutting edge trials ongoing in the department that have been incredibly successful in accruing patients and advancing treatment options. We will continue to grow, but will maintain the collaborative environment which has been so important both within LCI and in our relationships with external physicians.
References
1. Gratwohl A, Pasquini MC, Aljurf, et al. One million haemopoeitic stem-cell transplants: a retrospective observational study. Lancet Haematol. 2015;2(3):e91-100.
2. Go RS, Bottner WA, Gertz MA. Making the case to study the volume-outcome relationship in hematologic cancers. Mayo Clin Proc. 2015;90(10):1393-1399.
3. Loberiza FR Jr, Zhang MJ, Lee SJ, et al. Association of transplant center and physician factors on mortality after hematopoietic stem cell transplantation in the United States. Blood. 2005;10(7):2979-2987.
4. Levine Cancer Institute expands its hematologic oncology services, bringing first-of-its-kind unit to patients with aggressive types of blood cancer. Carolinas HealthCare System website. Published January 28, 2013. Accessed November 22, 2016.
5. Copelan EA, Gerber JM, Usmani SZ, et al. Establishment of subspecialized care in hematologic malignancies and a hematopoietic cell transplantation program. Presented at: ASH Annual Meeting and Exposition; December 3-6, 2016; San Diego, CA.
