Oncology Service Line: A Change in Focus

From genetic testing to advanced chemotherapy procedures, hospitals and health systems are changing the focus of oncology from merely ensuring survival to, in many cases, providing comprehensive long-term care and even cures.

This article appears in the March 2014 issue of HealthLeaders magazine.

The prognoses delivered in hospital oncology departments around the country are decidedly less grim than they were a decade or even five years ago. The rate of technological innovations in cancer care is speeding forward like never before, leading to better results, fewer treatment side effects, and an improved quality of life for patients.

From genetic testing to advanced chemotherapy procedures, hospitals and health systems are changing the focus of oncology from merely ensuring survival to, in many cases, providing comprehensive long-term care and even cures.

Success key No. 1: personalized medicine

At Inova Health System, a seven-hospital system based in Falls Church, Va., researchers are trailblazing ways to treat cancer more efficiently and detect it sooner via enhanced personalized medicine.

The Inova Translational Medicine Institute aims to move the healthcare industry from a reactive to a predictive model using technological innovation, research, and information management. Its goal is an ambitious one: to provide the right treatment for the right patient at the right time, and ultimately prevent disease in the first place.

"We are working on a comprehensive plan to personalize the care for cancer patients in a number of ways," says John Niederhuber, MD, CEO of ITMI. "There is much work to be done, and here at Inova we're helping lead the way into this new era of personalized cancer care." Niederhuber is also executive vice president of Inova Health System; CEO and director of Inova Comprehensive Cancer and Research Institute; adjunct professor of oncology at Johns Hopkins University School of Medicine in Baltimore; and deputy director of the Johns Hopkins Clinical Research Network.

Inova is creating a comprehensive plan to personalize care for cancer patients using four main strategies:

• Genetic testing of tumors. For patients diagnosed with cancer and determined to need chemotherapy, ITMI is looking to do genetic testing of the tumor to help select the drug that will best treat the cancer.
• Genetic testing of patients' genomes. Because each person absorbs and metabolizes drugs differently, ITMI plans to test the cancer patient's genome so physicians can better determine the best dose of chemotherapy. Genome testing would allow doctors to choose the right drug for each patient.
• Radiation research. ITMI is pursuing research into the genetics of radiation therapy to help determine which patients are best served by the treatment compared to patients who might not be. By doing this, they are hoping to determine who is at higher risk for the toxicities from radiation therapy so physicians can better treat those patients with appropriate supportive measures.
• Identifying high-risk patients. By exploring the genetics of who is at risk to get cancer—especially breast cancer—ITMI hopes to someday be able to better screen patients and detect cancers at an earlier stage, or even prevent them altogether. By documenting high-risk mutations found through genomic methodologies and helping to manage these patients within the health system through its clinical genomics team, ITMI hopes to make sure patients and research participants receive the best possible counseling and care.

"This is really cutting-edge work in the field of cancer," Niederhuber says. "Molecular analysis utilizes genetics and genomics to provide information about the biology of a cancer that can be exploited by using drugs that target these processes and pathways. Patients that undergo therapies targeted by genomics often go into remission for a time. While often the cancer finds another path that can result in recurrence, we're continuing to gain a better understanding of what drives cancer progression and are finding new ways to optimally treat it."

The implementation of these strategies may seem far-off, but ITMI is currently deploying three main components that will allow large-scale personalized medicine to be seamlessly integrated into a working healthcare system.

First, it is creating a clinical infrastructure that can interact efficiently with patients, providers, and the health system as a whole to help integrate physicians and patients in the practice of genomic medicine. Second, it is developing a laboratory to generate the highest-quality clinical-grade DNA sequence data possible; the lab will be certified by CMS' Clinical Laboratory Improvement Amendments program. And finally, ITMI is assembling a biobank for storage of samples and an informatics-analysis team that can use and develop cutting-edge tools to unravel the molecular underpinnings of human health, Niederhuber says.

"This is a truly forward-thinking effort that will require an enormous amount of dedication and work, but is an effort that will pave the way for what is anticipated to become inevitable as technologies evolve and improve," he says. "We have been able to find better options for patients with advancing diseases to new molecularly targeted drugs that we would not have normally thought to be helpful—for example, using a drug commonly used for melanoma to gain a response in a patient with a different tumor."

Success key No. 2: hyperthermic intra-peritoneal chemotherapy

For years, cancers that spread to the lining surfaces of the peritoneal (abdominal) cavity were considered untreatable and incurable. Recently, however, surgeons have been using hyperthermic intraperitoneal chemotherapy (HIPEC) to treat certain types of cancers with promising results.

According to Martin Goodman, MD, of Tufts Medical Center in Boston, during the procedure, surgeons remove the tumor, insert two catheters for fluid input and two for fluid removal, close the incision, and then add 2.5–3 liters of fluid to the abdomen, heated to 42ºC–43ºC. Research has found that cancer cells die at 40ºC while normal cells die at 44ºC, creating a small window. Then, the patient is given a high dose of chemotherapy, which is possible because very little gets absorbed into the bloodstream through this method, especially compared to delivering chemo through the veins. The surgery lasts anywhere from eight to 14 hours, says Goodman, director of the peritoneal surface and advanced malignancy program at Tufts Medical Center, a 415-bed academic medical center.

HIPEC has been studied the most with appendiceal cancers and pseudomyxoma peritonei caused from peritoneal carcinomatosis, but it has also proven effective on colorectal cancer, ovarian cancer, gastric cancer, and mesothelioma, Goodman says.

"HIPEC has been around 25–30 years, but hadn't really taken off until the last five years, and the reason for that is the literature and all the studies weren't mature enough for people to determine if it was helpful or not. But now it's proven to be very helpful," he says.

Tufts Medical Center, which started its HIPEC program seven years ago, has performed about 200 procedures under Goodman's leadership. Depending on how aggressive the cancer is, appendiceal cancer, which had previously been untreatable and incurable, has reached a 60% five-year survival rate when treated with HIPEC, Goodman says.

"Depending on what type of cancer it is and the biology of the cancer and how aggressive, the outcomes are variable," he says. "For ... an appendiceal cancer that's not very aggressive, you can potentially cure some of those patients, when it used to be multiple surgeries and then the patient ultimately died."

Patients with colon cancer who otherwise would live two years with standard chemotherapy now can live from four to seven years after HIPEC, Goodman says.

"Unfortunately we're not going to cure these patients for stomach cancer or colon cancer or ovarian cancer, but we do know HIPEC prolongs patient survival with good quality of life much better than standard chemo," Goodman says. "And if you do the surgery and regular chemotherapy afterward, the patient can live even longer—almost doubling or tripling their life expectancy."

While HIPEC is more common in Europe and South America, the procedure is becoming more prevalent in the United States. The procedure has been slow to catch on partially because of the difficulties of getting a program up and running due to the complexities of these patients and the costs, Goodman says.

In addition to having a surgeon trained in the procedure, a hospital looking to start a HIPEC program needs to be sure its ICUs and regular floors can handle these patients, who are more at risk for complications than typical surgical patients. A number of ancillary services will be needed, such as interventional radiology, CT scans, pathology, cardiac perfusionists, and an anesthesiologist skilled in fluid management.

"One of the hardest parts is convincing the hospital to make the investment in high-risk patients who might not have any other options. Usually it's recommended to do some type of pilot study to evaluate outcomes and help improve the program," Goodman says. "Then it comes down to surgeon comfort level. I was trained in doing these procedures, but if someone isn't trained, or is not comfortable with complex cancer surgery, they might have an increased complication rate. You're going to get complications that are higher than most other types of surgeries and [you] have to know how to deal with it."

Another difficulty in starting a HIPEC program is attracting new patients.

"Initially it's difficult to attract patients to a new program when there's already a number of established programs available to them," Goodman says. "You need a number of physicians in their organizations who are willing to refer this type of patient."

Once an organization does manage to attract patients and has a HIPEC program in place, it's critical to log results with a national database so researchers and surgeons can further hone the technique.

"Most patients with this procedure should be on a research database to help improve our knowledge of this particular disease and how we can better improve outcomes," Goodman says. "The biggest issue is the biology of the tumors—there are patients with nonaggressive tumors that recur in six months and some very aggressive tumors that might never recur. We are unable to distinguish this subset of patients. Currently, we are looking at different tumor receptors to see if there is a difference. This is similar to other types of cancers and trying to give personalized treatment versus a one-treatment-fits-all approach to everyone."

Success key No. 3: low-dose CT scans

Cancer Treatment Centers of America, a five-hospital system headquartered in Schaumburg, Ill., has been pioneering ways to improve baseline low-dose CT screening to better detect lung cancer.

Following the National Comprehensive Cancer Network's guidelines to identify those patients at high risk for lung cancer, CTCA uses the CT scan results to study anatomy of the lungs and surrounding tissues to diagnose and monitor tumor growth. A landmark National Cancer Institute–sponsored study found that annual screening for three years with low-dose CT scanning under the guidance of a dedicated comprehensive lung cancer screening program resulted in a 20% decrease in deaths related to lung cancer.

"Utilizing these tools has allowed us to potentially identify lung cancer at an earlier stage, which can decrease lung cancer mortality and improve the quality of life for those we serve," says Derek Strader, director of perioperative and cardiopulmonary services at Western Regional Medical Center, a CTCA hospital in Goodyear, Ariz., 25 miles outside Phoenix.

Screening chest CT scans are done with low doses of radiation, considerably less than the dose in a regular CT scan. And it's worth the risk, because screening individuals who are at an elevated risk of developing lung cancer in this manner can prevent one in five deaths from lung cancer, Strader says.

"In the right population, the risk related to the small amount of radiation from the scan is outweighed by the overall benefit in preventing lung cancer death," he says. "CT scanning allows us to detect small lung abnormalities that a normal chest x-ray cannot identify. If a screening CT results in a diagnosis of lung cancer, it's more likely it will be at an early stage and less likely to be at an advanced stage."

For a CT screening program to be successful, a hospital or health system must make a commitment to acquire the top talent to support clinical excellence and a multidisciplinary approach, Strader says. This approach includes thoracic radiology, pulmonary medicine, thoracic surgery, clinical research, pathology, medical oncology, and radiation oncology.

"It's critical to not only identify and diagnose at the earliest stage possible but to also have the expertise to provide the needed treatment for the best possible outcome," he says. "The true payoff and reward is the impact that identifying earlier-stage cancers will have on our patients' quality of life."

CTCA is already looking to the future of lung cancer detection and treatment and is open to the possibility of another technology or device emerging that may be used for cancer screening.

"There may be other imaging modalities or noninvasive tests that could help determine those individuals most likely to benefit from screening and intervention," says Glen Weiss, MD, MBA, director of clinical research at Western Regional Medical Center. "It's also possible that with improved computational power and algorithms, the amount of radiation required for CT scans will probably decrease in the future. We may also see additional types of testing such as blood, exhaled breath, and saliva that may give a readout of our health status. These types of tests may be used up front and help medical providers determine if and when CT scans or other imaging are necessary."

Success key No. 4: digital mammography

Digital mammography has proven to be more sensitive than traditional x-ray in detecting lesions and calcifications in certain groups of women, specifically those who are in perimenopause and those with dense breast tissue. As an added benefit, the digital scans use 20% less radiation per view.

"With any radiation exposure, you have to weigh out the pros and cons of if it's worth being exposed, so being able to offer patients the absolute lowest radiation with the best possible results is ideal," says Jennifer Logan, MD, a physician with Jefferson Radiology, a private practice group based in East Hartford, Conn., with 10 private offices and affiliations with seven regional hospitals, including Hartford Hospital, where she serves as radiology director for the Division of Breast Imaging. Hartford Hospital is a 867-bed teaching hospital associated with the University of Connecticut Medical School. "If you don't get enough radiation, you don't get good photos and you don't pick up disease; with digital, you get to pick up clearer pictures and it's less radiation, so it's a win-win."

Hartford has been using digital mammography since 2007 and in April 2012, with the acquisition of a portable digital mammography unit and a mobile van, the hospital began taking its imaging technology to corporate sites, mental health institutions, and community sites, such as churches, to improve patient compliance.

"We're reaching an important and vulnerable population, and it's such a dramatic improvement reading the digital images," Logan says. "We're doing the absolute best for these patients, and we're bringing our state-of-the-art equipment out there to people who don't have the resources to get to an imaging facility or can't get to an imaging facility. It's coming to them, so our hope is to catch more women, bring them in, and make it as easy as possible."

While the van and its digital mammography equipment were expensive, Logan says it was worth the investment. Since the van was deployed, 2,200 patients who may not have otherwise gone to Hartford for their care received screening mammograms. Those who needed follow-up care were scheduled at the hospital's imaging center.

"In general," she says, "digital mammography helps to increase the efficiency of a mammography department—saving time by not having to do film processing—so you can increase the capacity of your units to get more patients in. It's expensive equipment to buy, but you have to invest to have state-of-the-art equipment; so it's worth it for the benefit for patients."

Logan believes the next diagnostic technology coming down the line for breast care is tomosynthesis, a 3D mammogram that uses x-rays and can provide a higher-quality diagnostic image compared to conventional mammography.

"It's the same modality as mammography, but eliminates some limitations of even digital mammograms," she says. "It's been approved by the FDA for clinical use. At this point it's not clear if it'll be used with the screening population or to work up abnormalities that were detected. Once the best clinical use for 3D mammography is determined, it may prove to be the next big thing."

Reprint HLR0314-6

This article appears in the March 2014 issue of HealthLeaders magazine.