Journal of Clinical Pathways (JCP) spoke with faculty at the University Hospitals Seidman Cancer Center, Cleveland, OH, regarding their unique positioning for cancer treatment in the greater Cleveland area and within the Midwest. Joel Saltzman, MD, department of medical oncology; Theodoros Teknos, MD, president and scientific officer; and John Shanahan, director of cancer informatics, discuss standardized care, a commitment to clinical trials, Oncology Care Model (OCM) participation, and other pertinent topics.
Can you explain the extent to which cancer treatment is standardized at University Hospitals Seidman Cancer Center? Are clinical pathways a part of your everyday treatment plans?
Dr Saltzman: In general, the cancer center network-wide features a multidisciplinary approach in which each subspecialty cancer has a team and a tumor board. Each subspecialty team has a standardized approach across the continuum of care. We have incorporated clinical pathways, particularly within medical oncology, through use of Via Oncology. Pathways integration was helpful in our participation in the OCM and also ensures our patients have access to clinical trials and novel therapies.
Dr Teknos: We like to refer to ourselves as a high reliability medicine organization. We are very focused on removing variations in care. That is why we use Via Oncology—to both promote evidence-based guidelines as well as to identify clinical trials.
We have 11 wholly owned hospitals and 8 joint venture hospitals. Our health system owns the entire continuum of care—from primary care throughout the 19 hospital system to home health, rehab facilities, and hospice. Thus, we are able to track patients throughout the entire continuum of care.
We employ a care transitions team that ensures patients move appropriately to their next place of care. This focus on optimal care delivery and reduction of costs has allowed UH-Seidman Cancer Center to be well prepared in the inevitable transition to value-based cancer care and bundled payments.
What are some of the largest challenges in treating patients with cancer in the greater Cleveland area (ie, complexity of disease, travel time, patient financial toxicity, etc)?
Dr Saltzman: The biggest challenge is providing the right care to the patient at the right place. Dr Teknos described the 19 community-based cancer centers. These cover about a 150-mile area from the city of Cleveland. My office is in Mentor, which is approximately 30 miles away from the primary site—the freestanding cancer hospital in Cleveland. When I see a patient in Mentor, my goal is to decide the best place for that patient to receive their cancer care. For the vast majority of my patients who are receiving chemotherapy, they can be treated right there.
For the patients who need a specialized surgery or type of radiation therapy, they may be best treated at the freestanding hospital. For those patients, transportation is always a significant consideration.
The same is true if I have a patient who is a candidate to enroll in one of our phase 1 clinical trials. These trials are only being offered at the main center, which often requires multiple trips back and forth from Mentor to Cleveland. We have social workers and volunteers dedicated to helping patients with these transportation arrangements.
Dr Teknos: There is quite a mix of demographics in Cleveland and the surrounding areas. A third of Cleveland’s residents live below the poverty line. These treatments are becoming increasingly more expensive, especially the oral chemotherapy agents and other novel treatments, namely immunotherapy options. Being able to provide patients these medications and lifesaving treatments without invoking financial toxicity has been a major challenge. We have hired many financial counselors and do what we can to make sure our patients are optimally insured, so that we can help them with their financial burden.
Another major challenge we face as a system is centered around the macroeconomics of health care. We have embraced value-based cancer care and have eliminated significant costs while improving overall patient satisfaction, safety, and quality of care. While we are incredibly proud of these results and feel it is the right thing to do, it has further challenged our financial margins and ability to grow innovative programs.
How much priority is given to clinical trials at University Hospitals Seidman Cancer Center? Are patients regularly encouraged to enroll in trials, and is this encouragement built into the Via Pathways that you employ?
Dr Teknos: We are an National Cancer Institute-designated comprehensive cancer center, so encouraging clinical trial participation and advancing scientific discovery is central to our mission. We have over 100 clinical full time equivalent physicians devoted to our clinical trial unit. Accrual has been robust, and our cancer program remains one of the top accruing centers nationally for cooperative group studies.
We also have one of the largest phase 1 programs in the United States. We are leaders in the state of Ohio for development of new cancer drugs, bringing several of the compounds from our bench researchers to the bedside. The biggest area of focus for us regarding clinical trials is in the immuno oncology space. We are able to generate CAR-T therapies in our own on-site GMP-certified cellular therapy lab, rather than having to rely on remotely located commercial partners. Our phase 1 clinical trial using a novel CD-19 targeted CAR-T has already accrued 12 patients, with several more in the queue.
Clinical trial accrual is a system-wide initiative. Almost 33% of our clinical trial patients are enrolled and treated at our community sites. Unlike many other programs that screen patients in the community and send them to the main academic hospital for the clinical trials, we accrue one-third of our patients outside of the main hospital.
Dr Saltzman: We try to map our own clinical trials within the Via dashboards. This is especially important for our community-based studies because the principal investigator at our institution is often not the person who is offering the trial to our patients. Not only are the trials mapped within the pathway program itself, the user of the pathways in real time will often see prompts on the screen that say, “This study is open. Is there a reason why you’re not enrolling your patient?” If a clinician identifies their patient as potentially suitable for a clinical trial, there is typically an on-site clinical trials nurse who is called into the room to begin the screening process.
Mr Shanahan: We have also developed in-house tools that use artificial intelligence (AI) to identify patients who may be coming into the clinic that week prior to them actually coming in and which of these would qualify for certain clinical studies. We have a staff member ready to talk to them about particular clinical trials before we go through Via to view the options. Once patients come in, the staff nurse can inform them that they may be a good fit for a particular clinical trial, they can go through the consent process electronically and capture all of the necessary patient information at that time rather than ask them to come back in at a later date.
