CPC + CBEx 2024: Integration of Medical Oncology and Surgical Specialties
At the 2024 Clinical Pathways Congress + Cancer Care Business Exchange, a panel of experts spoke about working in integrated health care systems in oncology. The session was moderated by John E. Hennessy, MBA, BCPA, principal, Valuate Health Consultancy Speakers, and the panelists included William Jordan, Jr, MBA, MHA, Independent Oncology Consultant; Douglas Ackerman, MD, Urologist, Kaiser Sunnyside Medical Center; and, Sukumar Ethirajan, MD, Founder, KanceRx.
For this session, the panelists focused within the area of genitourinary (GU) cancers as the science of these cancers is “exploding at a tremendous rate,” according to one of the presenters. Each presenter discussed how their institutions integrate medical oncology and surgical specialties for GU cancers and some of the challenges they face both clinically and organizationally in taking care of this patient population. Dr Ackerman shared an example of an integrated patient flow for prostate cancer at Kaiser Permanente. In this process, patients are referred to the urology department for elevated PSA or an abnormal prostate scan. At this point in the flow, the urologist is the lead doctor. If there is a cancer diagnosis, the patient will have a counseling session (oftentimes with family present) and surgery will be discussed. If they need surgery, they will be referred to medical oncology as well.
The majority of the patients at Kaiser Permanente fit into National Comprehensive Cancer Network (NCCN) guideline algorithms that they abide by. For those that do not, they have developed a multidisciplinary tumor board that meets once a week. The board consists of urologists with different areas and levels of expertise, including teams that specialize in robotic cystectomy and surgeons who are specially trained in different approaches to robotic partial nephrectomy. Diagnostic radiologists, medical oncologists, and a scribe who takes notes also participate in the meeting. “The tumor board recommendations are put in the chart, the presenting surgeon will sign them, but the recommendations are just recommendations and final treatment plans are always to be determined between the patient and their clinician,” said Dr Ackerman.
Kaiser Permanente also has a Nurse Navigator as part of the patient flow. They serve as a patient advocate and liaison between all of the patient’s physicians and the patients. Their responsibilities include coordinating patient care, ensuring patients are complying with prescribed medications, ensuring patients are followed up on in appropriate clinics, answering patients’ queries, helping to address social needs issues, and initiating discussion of potential clinical trials for the patient.
William Jordan noted that depending on the type of institution and the structure of the program, there are varying responsibilities—including economic stresses—between the medical oncologists and urologists. As such, how patients move back and forth between the two experts varies. For example, if urology is not embedded in the program, the patient would go into the medical oncology program or into radiation, so that department would take care of the patient. If the patient is treated and goes into remission they will be discharged and sent back to the urologist or back to primary care and then they will follow up with them. “If it's a program where urology is embedded, the patient's pretty much in the program for life. And so, the patient comes in and then the different specialties are working together on collaboration if they don't have a tumor board,” said Jordan.
He also emphasized the importance of patient navigators and technological tools to help with the patient flow. Patient navigators help take a load off of the urologists by getting patients where they need to be, get their scans scheduled, get their procedures scheduled, and whatever else they need. With having am electronic medical record (EMR) system, such as Epic, if a patient is handed off to another specialty or another division, you can still see their notes and communication in the charts. “Our [patient navigator] worked with the urologist, the medical oncology team, and the patients. There was patient satisfaction because they felt like they weren't lost in a system,” said Jordan.
Dr Ethirajan also argued for the financial benefits of an integrated system. He noted that institutions that use these systems have evidence that they can bring to payers to show how integrating is cheaper, faster, and patients live longer and better. Whereas, if the system is siloed money will be lost and there will be more complications.
He concluded the session with a reminder that at the center of these integrated health care models is patient-centered care. “We're holistic. We're integrated. We'll take care of you wherever you want to go, whether it's one part of the town or somewhere else with at home 24/7 call availability. The holistic component needs to expand into the community side versus a silo of just urology or a silo of just medical oncology,” he said.
Reference
Hennessy JE, Jordan W, Ackerman D, Ethirajan S. Integration of Medical Oncology and Surgical Specialties. Presented at the Clinical Pathways Congress; September 8, 2024; Boston, MA.
