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Practice Matters
News about health policy and practice management issues of importance to oncologists
Saturday, October 25, 2014


If the first day of the Palliative Care in Oncology Symposium had the exuberance of a toddler, the second day had the emotional roller-coaster of the teenage years.


Everyone in the Grand Ballroom started the day with a good laugh when palliative care expert Charles Von Gunten, MD, from OhioHealth, shared a satirical video that highlighted the never-say-die mentality of modern medicine.


But refusing to offer palliative care services that could alleviate suffering is not funny, and the room turned somber when Ira Byock, MD, now Chief Medical Officer for the Institute for Human Caring of Providence Health and Services and Professor of Medicine and Community & Family Medicine at the Geisel School of Medicine at

Dartmouth, expressed frustration that so many physicians refuse to give their patients access to palliative care services.


“We are doing brink-of-death care, not end-of-life care, let alone concurrent care,” he said. “It is time to call out bad care” when physicians are not being honest with their patients about their prognosis and letting them benefit from palliation.


A little later, a wave of tension lilted through the ballroom when Dorothy Keefe, MD, Clinical Director of the Royal Adelaide Hospital Cancer Centre in Australia, discussed the terms “supportive care” versus “palliative care.” While the term “palliative care” is used throughout the continuum in the U.S., she suggested that “supportive care”—which is used more prominently in some other countries—is a less frightening term that should be used for services provided to patients who are being treated for cure.


That idea did not sit well with one of her fellow panelists nor with the Twitter crowd, one of whom tweeted: “Pallcare should not get involved with patients whose care is curative." Really? #pallcare likes to help people live too.”


In the afternoon abstract session, a study about burnout among specialty palliative care clinicians generated the most interest—and it seemed to depress the entire audience.  Arif Kamal, MD, from Duke University Medical Center, presented results of a survey of members of the American Academy of Hospice and Palliative Medicine that showed palliative care physicians suffer higher levels of burnout than medical or radiation oncologists and other clinicians. In fact, 62 percent of respondents reported burnout; and more than half said they intend to leave the field within 10 years.


Next year’s conference is already scheduled: Oct. 9-10 at the Westin Copley Place in Boston.

Friday, October 24, 2014


BOSTON -- Since this is the first Palliative Care in Oncology Symposium, several presenters in the opening session presented historical overviews to show why four co-sponsors—American Society of Clinical Oncology, American Academy of Hospice and Palliative Medicine, American Society for Radiation Oncology, and Multinational Association of Supportive Care in Cancer—came together to produce this event.


During his remarks, Conference Chair Michael Fisch, MD (@fischmd), who represents ASCO, reminded me how fast the world is changing. It was only two years ago that ASCO issued the provisional clinical opinion that palliative care should be part of standard care. And more than 500 people are attending this symposium!


But, like a two-year-old trying to run, the barriers to success are painful to watch. No oncologist attending this conference would dare question the appropriateness of concurrent palliative care, but several podium presentations and posters allude to the fact that oncologists are not all on board. (For example, when the study I wrote about in this article was published, I tried without success to find an oncologist who would tell me why he or she does not support concurrent palliative care. This morning, I sat next to a nurse practitioner who said she must practice “under the radar” because the four oncologists she works with are not supportive. In fact, she wanted to get certified in palliative medicine but opted not to because she feared the credential might hurt her career!)


For more on this theme, check out OT’s article about the new Institute of Medicine report on the U.S. health system’s failure to meet patients’ end-of-life needs.


Other takeaways from today’s sessions:

·    Little is known about the biological causes for many cancer-treatment side effects, including fatigue (the most common symptom). Why do some patients suffer severe symptoms while others on the same regimen do not? Lots of research under way, but I didn’t get the sense that breakthrough understanding about any symptom is upon us.

·    Patients under-report the incidence and severity of symptoms. One reason: They fear complaining might lead to treatment adjustments that would imperil a cure. It is impossible to create effective interventions if clinicians do not know baseline data about prevalence and severity of the problems.

·    The term “palliative care” needs ambassadors. Too many people, including oncologists, think it is synonymous with end-of-life care.


Check out the abstracts from the meeting and let me know which ones you would like to learn more about. Leave a comment here or tweet me @lolabutcher

Wednesday, October 22, 2014


When I attended the first American Society of Clinical Oncology Quality Care Symposium in 2012, I overheard an oncologist say “This could be a palliative care conference” because so many posters and presentations focused on palliative care as an element of high quality care.


The ASCO meeting planners must have been eavesdropping along with me because they have now helped organize the first Palliative Care in Oncology Symposium, which kicks off Friday in Boston. Co-sponsors include the American Academy of Hospice and Palliative Medicine, the American Society for Radiation Oncology and the Multinational Association of Supportive Care in Cancer.


One clue that the time is right for this event: Registration so far exceeded expectations that it had to be cut off. More than 500 attendees are expected, and approximately 250 abstracts were accepted.


I listened to this week’s presscast highlighting some of the studies that will be presented, and two themes emerged: The cost of cancer treatment is a big concern for palliative care researchers (see here and here) and best practices for implementing palliative care are not yet known.


In fact, one of the highlighted abstracts described a “co-rounding” partnership between medical oncologists and palliative care specialists that seems like such an obvious idea that it should be standard practice—but the presenting author, Robert Riedel, MD, of Duke University Medical Center, believes it is in fact unique. I intend to write more about that in a future issue of OT.


In the meantime, I’ll be following the conference via Twitter using #PallOnc.

Tuesday, October 21, 2014


As I was reporting the articles for the OT series, “UNINTENDED CONSEQUENCES: How Government Policies Have Increased the Cost of Cancer Care,” I was eagerly awaiting the release of the Community Oncology Alliance’s (COA) annual update of how these policies have affected physician-owned cancer care practices.


The report, released today, shows that 25 cancer treatment facilities closed and 75 physician-owned oncology practices were acquired by or affiliated with hospitals since COA’s last report in June 2013.


“It required close to 50 years to build this country’s cancer care delivery system, but misguided policy in Washington is destroying it at an alarming pace,” COA Vice President Jeffrey Vacirca, MD, CEO at North Shore Hematology Oncology Associates, said in a news release. “Hospitals are contributing to the escalating cost of cancer care — where the same cancer care is more costly for patients and their insurers. To truly stand up for cancer patients is to stop this destruction, or we will lose the war on cancer.”


Since COA started tracking eight years ago, 313 cancer treatment facilities have closed and 544 have joined hospitals. Whether this is good or bad depends on one’s perspective. The final installment of the “UNINTENDED CONSEQUENCES” series, expected to be published in the Nov. 25 issue of OT, examines this from various viewpoints.


One new data point from this year’s COA report:  Nearly 75 percent of the private practices that have been acquired or affiliated with hospitals in the past two years have been with hospitals that are eligible for 340B drug discount pricing. Click here to see the OT article about this phenomenon.


COA says that, in addition to the 340B program, the consolidation has been fueled by insufficient Medicare reimbursement and the ongoing sequester cut to cancer drugs. Click here to see the OT article on that topic.


Community Oncology Alliance

Sunday, October 19, 2014



BOSTON -- Several takeaways from the American Society of Clinical Oncology’s third Quality Care Symposium, which wrapped up here yesterday afternoon:

·    Frustration with electronic health record systems is increasing. One of the major drivers for EHR technology is that, at the theoretical level, it should improve the quality of patient care. Representatives from four major EHR vendors shared their perspective of how this works, but I got the sense that the audience wasn’t with them. Douglas Blayney, MD, chair of the session, asked why smartphones can be so easy to use when EHRs are so clunky. Barry Brooks, MD, said some EHRs are a patient-safety hazard. The vendors said they are working it, but nobody pushed back against the criticisms.

·    Value (quality divided by cost) is not always intuitive. Although academic medical centers are considered the most expensive—and best quality—healthcare providers, Christine Marie Veenstra, MD, presented results from a study that found that the cost of care for Stage II and Stage III colon cancer patients was not more expensive at an academic hospital than a community hospital. And, by the way, overall survival time was the same, regardless of academic or community hospital.

·    There are so many standards—and yet not enough. The importance of standardization in cancer care has been a drumbeat in recent years, but Monika Krzyzanowska, MD, MPH, made an excellent presentation on the lack of standards for oral therapies that are sent home with patients. Who knows if the medicines are taken as directed? (I noticed at least three abstracts that dealt with this topic as well, and I’m going to wade into them for an upcoming article for OT.)

·    Big data to the rescue? After seeing presentations about PCORnet, the Integrated Cancer Information and Surveillance System, the National Cancer Institute’s Surveillance, Epidemiology and End Results program, the Commission on Cancer’s National Cancer Database, and CancerLinQ, I was so dizzy I can’t remember exactly what any of them do. However, the excitement by each of the presenters made a big impression on me; each believes that data gathered, analyzed, and shared in new ways will lead to cancer treatment breakthroughs heretofore unimaginable. This was also the only session I saw in which ASCO’s minute-by-minute schedule went off the rails, leaving ASCO President Peter Yu, MD, with exactly zero minutes to give his update on CancerLinQ. (No worries--the session was extended into the break.)


If you are eager to attend the next Quality Care Symposium, so am I. But we will have to wait a while: There won’t be one in 2015; the next one will be scheduled in early 2016.

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About the Author

Lola Butcher
LOLA BUTCHER, MPA, MA, an award-winning Contributing Writer for Oncology Times, writes about health policy and business trends. She is a frequent contributor to Hospitals & Health Networks, Modern Physician, Neurology Today, and other health care trade publications. This blog was recently recognized with an APEX Award for Publication Excellence.