June 2010, Vol 3, No 4 by Green Hill Healthcare Communications, LLC

JUNE 2010

www.JOMCC.com

VOL 3, NO 4

ONCOLOGY ADVOCACY

CANCER CENTER PROFILE

ACCC President Focuses on Evidence-based Medicine and the Impact of Healthcare Reform An Interview with Al B. Benson III, MD, FACP By Daniel Denvir

l B. Benson III, MD, FACP, took the helm as president of the Association of Community Cancer Centers (ACCC) at its 36th annual meeting, held March 19, 2010, in Baltimore, Maryland. Dr Benson, Al B. Benson III, MD, a member of the ACCC board since 2003, is a professor of FACP medicine in the Division of Hematology/Oncology at Northwestern University Feinberg School of Medicine, Chicago. He is an advocate of comparative effectiveness research (CER) and evidence-based medicine, and

Left to right: radiation oncologist Joel Braver, MD; urologist Joel Fischer, MD, chair of the Prostate Cancer Institute; Kathleen Toomey, MD, medical director of the Steeplechase Cancer Center; and Katrina Losa, RN, director of the Steeplechase Cancer Center.

Continued on page 8

CANCER CENTER–PHYSICIAN ALIGNMENT

Steeplechase Cancer Center Provides Patient-centered Care in Community Setting

Establishing Relationships between a Cancer Center and Private Practice Physicians An Interview with Nancy Harris

By Karen Rosenberg

By Dawn Lagrosa

teeplechase Cancer Center at Somerset Medical Center in Somerville, New Jersey, was established in 2007 in response to community needs for easily accessible high-quality cancer care. The center is named for the steeplechase horse race, held each October in the neighboring community of Far Hills, New Jersey. Proceeds from the race are donated to the center and go to support expanded facilities and services. The cancer center occupies a large, state-of-the-art facility and offers a full range of services. “It houses everything you need for diagnosis and treatment of cancer in one place,” notes Joan Perrone, RPh, one of four pharmacists who service the infusion center at Steeplechase. Somerset Medical Center is the only full-service hospital in the county, and “it’s an integral part of the community,” she says. “We do community fundraisers and are well supported by the community.”

any community cancer centers desire to offer prospective multidisciplinary case conferences for their patients. However, various business models can be set up to achieve this goal. In this interview, Nancy Harris, administrator of St. Joseph Hospital, The Center for Cancer Prevention and Treatment in Orange, California, discusses how her community center established relationships with its providers, all of whom are in private practice. Along the way, she notes some practical concerns for other administrators looking to use a similar practice model.

What type of practice model does The Center for Cancer Prevention and Treatment use? It is very much a cooperative relationship. We call the structure to this relationship “conditions of participation.” This terminology came up when we were look-

Continued on page 12

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CO M PL IM EN TA RY

Inside Reimbursement Smart money. Part 2: protecting oncology reimbursement By Cindy C. Parman, CPC, CPC-H, RCC page 10

Benchmarking Operational and financial benchmarking for oncology By Marsha Fountain, RN, MSN; and Karen Gilden

Oncology Drug Codes Medications used for the treatment of lung cancer

CE Credit

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Gynecologic oncologic management of widely metastatic serous carcinoma of the ovary

Fostering a Dialogue to Improve Patient Care & Outcomes

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Editorial Board EDITOR-IN-CHIEF

Mark J. Krasna, MD St. Joseph Cancer Institute Towson, MD Surgical Oncology

Scott E. Eggener, MD University of Chicago Chicago, IL Surgical Oncology

Arun Kumar, MD

Greg Pilat, MBA

VA Medical Center Huntington, WV Medical Oncology

Advocate Health Care Oak Brook, IL Oncology Administration

Shaji K. Kumar, MD

Cristi Radford, MS, CGC

Mayo Clinic Rochester, MN Hematology-Oncology

Sarasota Memorial Hospital Sarasota, FL Genetic Counseling

Ritu Salani, MD

John F. Aforismo, BSc Pharm, RPh, FASCP

Beth Faiman, RN, MSN, APRN, BC, AOCN

RJ Health Systems International Wethersfield, CT Oncology Pharmacy

Cleveland Clinic Taussig Cancer Institute Mayfield Heights, OH Oncology Nursing

Elizabeth Bilotti, RN, MSN, APNc

Mehra Golshan, MD

Terry Macarol, RT(R)(M)(QM)

John Theuer Cancer Center Hackensack University Medical Center Hackensack, NJ Oncology Nursing

Dana-Farber Cancer Institute Boston, MA Surgical Oncology

Advocate Health Care Oak Brook, IL Radiological Technology

Ohio State University Medical Center Columbus, OH Medical Oncology

Nicole A. Bradshaw, MS, CIC

Patrick A. Grusenmeyer, ScD, FACHE

Patrick Medina, PharmD, BCOP

Andrew Salner, MD

Mountain States Tumor Institute Nampa, ID Oncology Administration

Christiana Care Health System Newark, DE Oncology Administration

Oklahoma University College of Pharmacy Tulsa, OK Oncology Pharmacy

Hartford Radiation Oncologists Association Hartford, CT Radiation Oncology

Anna M. Butturini, MD

Marilyn Haas, PhD, CNS, ANP-BC

Patricia Molinelli, MS, RN, APN-C, AOCNS

Timothy G. Tyler, PharmD, FCSHP

CarePartners Asheville, NC Oncology Nursing

Somerset Medical Center Somerville, NJ Oncology Nursing

Comprehensive Cancer Center Desert Regional Medical Center Palm Springs, CA Oncology Pharmacy

Dawn Holcombe, MBA, FACMPE, ACHE

Judy A. Olson, RT(R), RDMS

Gary C. Yee, PharmD, FCCP, BCOP

Children’s Hospital Los Angeles Los Angeles, CA Medical Oncology

Minsig Choi, MD G. V. Montgomery VA Medical Center Jackson, MS Medical Oncology

Steven L. D’Amato, RPh, BCOP Maine Center for Cancer Medicine Scarborough, ME Oncology Pharmacy

www.JOmcc.com

DGH Consulting South Windsor, CT Oncology Administration

Patricia Hughes, RN, MSN, BSN, OCN Piedmont Healthcare Atlanta, GA Oncology Nursing

St. Luke’s Mountain States Tumor Institute Boise, ID Oncology Administration

University of Nebraska Medical Center Omaha, NE Oncology Pharmacy

Nicholas Petrelli, MD

Burt Zweigenhaft, BS

Helen F. Graham Cancer Center Christiana Care Health System Newark, DE Surgical Oncology

BioPharma Partners LLC New York, NY Managed Care

JUNE 2010 I VOL 3, NO 4

INTRODUCTION

PUBLISHING STAFF Publisher Philip Pawelko phil@greenhillhc.com Editorial Director Karen Rosenberg karen@greenhillhc.com Managing Editor Dawn Lagrosa dawn@greenhillhc.com Directors, Client Services John W. Hennessy john@greenhillhc.com Cristopher Pires cris@greenhillhc.com Production Manager Marie RS Borrelli Business Manager Blanche Marchitto blanche@greenhillhc.com Executive Administrator Andrea Boylston Circulation Department circulation@greenhillhc.com Editorial Contact: Telephone: 732-992-1891 Fax: 732-656-7938

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he Patient Protection and Affordable Care Act will add an estimated 15.9 million Americans to the Medicaid rolls by 2019, according to a new Kaiser Family Foundation report. In addition, the report estimates that 11 million low-income Americans will no longer be uninsured. The Urban InMark J. Krasna, MD stitute, which prepared the report for the Kaiser Family ST. JOSEPH CANCER Foundation, projected enrollINSTITUTE ment at two levels of participaEditor-in-Chief tion. The “enhanced outreach scenario” increases those numbers to 22.8 million people added to Medicaid and 17.5 million people newly insured. The cost of these expansions is estimated to be $464.7 billion by 2019. Only $443.5 billion will be covered by the federal government; state governments will need to pay the remainder. Under the enhanced scenario, the cost rises to $575 billion, with $532 billion paid by the federal government. For providers, this expansion of coverage will probably allot less payment on a per unit service, likely exacerbating the debt problem for providers that care for the underinsured. As you may know, my facility, St. Joseph Cancer Institute

CONTENTS EDITORIAL CORRESPONDENCE should be addressed to EDITORIAL DIRECTOR, Journal of Multidisciplinary Cancer Care®, 241 Forsgate Drive, Suite 205C, Monroe Twp, NJ 08831. E-mail: karen@greenhill hc.com YEARLY SUBSCRIPTION RATES: United States and possessions: individuals, $105.00; institutions, $135.00; single issues $17.00. Orders will be billed at individual rate until proof of status is confirmed. Prices are subject to change without notice. Correspondence regarding permission to reprint all or part of any article published in this journal should be addressed to REPRINT PERMISSIONS DEPARTMENT, Green Hill Healthcare Communications, LLC, 241 Forsgate Drive, Suite 205C, Monroe Twp, NJ 08831. The ideas and opinions expressed in Journal of Multidisciplinary Cancer Care® do not necessarily reflect those of the Editorial Board, the Editorial Director, or the Publisher. Publication of an advertisement or other product mentioned in Journal of Multidisciplinary Cancer Care® should not be construed as an endorsement of the product or the manufacturer’s claims. Readers are encouraged to contact the manufacturer with questions about the features or limitations of the products mentioned. Neither the Editorial Board nor the Publisher assumes any responsibility for any injury and/or damage to persons or property arising out of or related to any use of the material contained in this periodical. The reader is advised to check the appropriate medical literature and the product information currently provided by the manufacturer of each drug to be administered to verify the dosage, the method and duration of administration, or contraindications. It is the responsibility of the treating physician or other healthcare professional, relying on independent experience and knowledge of the patient, to determine drug dosages and the best treatment for the patient. Every effort has been made to check generic and trade names, and to verify dosages. The ultimate responsibility, however, lies with the prescribing physician. Please convey any errors to the Editorial Director. ISSN # 1949-0321. Journal of Multidisciplinary Cancer Care® is published 8 times a year by Green Hill Healthcare Communications, LLC, 241 Forsgate Drive, Suite 205C, Monroe Twp, NJ 08831. Telephone: 732.656.7935. Fax: 732.656.7938. Copyright ©2010 by Green Hill Healthcare Communications, LLC. All rights reserved. Journal of Multidisciplinary Cancer Care® is a registered trademark of Green Hill Healthcare Communications, LLC. No part of this publication may be reproduced or transmitted in any form or by any means now or hereafter known, electronic or mechanical, including photocopy, recording, or any informational storage and retrieval system, without written permission from the Publisher. Printed in the United States of America.

JUNE 2010 I VOL 3, NO 4

is a participating site with the National Cancer Institute Community Cancer Centers Program (NCCCP). Using $40 million in funds from the American Recovery and Reinvestment Act of 2009, the NCCCP has added 14 new sites to its existing 16. Even with this new funding, how are community cancer centers going to continue to deliver high-quality care to these new patients? This is not a question with simple answers. Various methods exist, and each method has multiple components. As a strong proponent of multidisciplinary care, I am pleased that more cancer centers will be implementing prospective case discussion for each patient focused on developing the best evidence-based care plan for that individual. But even this comes in a variety of designs. This issue highlights two centers in which the oncology nurse and the oncology pharmacist are active participants. If your center does not currently include them in prospective discussions, it is one method you may wish to try. As our multidisciplinary tumor board case study demonstrates, the expertise of these team members can contribute valuable information and improve our patients’ quality of life. However, as Al Benson points out, these team members are in short supply. As always, I hope this issue of the Journal of Multidisciplinary Cancer Care benefits your practice and provides ideas on how to move it forward. We look forward to your feedback.

JUNE 2010 • VOL 3, NO 4

FEATURE ARTICLES 4 Accreditation Is Commission on Cancer accreditation right for you? 10 Reimbursement Smart money. Part 2: protecting oncology reimbursement 11 Conference News: SIR New approach may freeze out breast cancer 12 16 18

Going for gold with a novel treatment for pancreatic cancer Breast Cancer CEP17 breast cancer tumors are more likely to respond to anthracyclines Benchmarking Operational and financial benchmarking for oncology Continuing Education Gynecologic oncologic management of widely metastatic serous carcinoma of the ovary Prostate Cancer Hypofractionated salvage radiotherapy may be beneficial for postprostatectomy biochemical recurrence Viewpoint No, you can’t keep your health plan

DEPARTMENTS 8 Recent FDA Approval 23 Oncology Drug Codes Medications used for the treatment of lung cancer

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Accreditation

Is Commission on Cancer Accreditation Right for You? By Dawn Lagrosa

he American College of Surgeons’ Commission on Cancer (CoC) is a consortium of professional organizations working to improve survival and quality of life for cancer patients. Through the CoC Accreditation Program, cancer programs achieve benefits for themselves and for the patients they serve. To help our readers determine if accreditation is right for them, the Journal of Multidisciplinary Cancer Care recently spoke with Robert Flanigan, MD, FACS, vice chair of the accreditation committee and chair of the recruitment and retention subcommittee of the CoC, about the steps involved in the accreditation process. At present, approximately 72% of newly diagnosed cancer patients are treated in CoC-accredited centers, and the number of accredited centers is just short of 1500 throughout the United States and Puerto Rico, which represents between 25% and 30% of hospital facilities. “I think we accumulated this expanse of attachment to these newly diagnosed cancer patients because many of our facilities are dominant in their areas in their communities, not speaking of the National Cancer Institute facilities and the academic medical institutions that are accredited,” Flanigan said. “We accredit institutions that attract medical oncologists, radiation oncologists, and other specialists, and they bring their cancer patients to these facilities, perhaps from other institutions or other outlying areas.” In short, CoC-accredited institutions have something to offer. “The CoC’s goal is to provide the best quality of care to the patients, which begins with a comprehensive multidisciplinary team approach to their care.” As Flanigan explained: “Some cancers can be dealt with by one board-certified individual. For example, a stage I melanoma does not require evaluation by a medical oncologist or radiation oncologist, any reasonably trained general surgeon can handle that particular case. However, the vast majority of cancers (lung, colon, breast, etc) require a multidisciplinary approach. The CoC has a diverse membership; it represents 47 organizations. Those disciplines address every potential facet of cancer care that a patient could require.” There are five key elements to the success of a CoC-accredited cancer program1: 1. The clinical services provide stateof-the-art pretreatment evaluation, staging, treatment, and clinical follow-up for cancer patients seen at the facility for primary, sec-

JUNE 2010 I VOL 3, NO 4

ondary, tertiary, or quaternary care. 2. The cancer committee leads the program through setting goals, monitoring activity, evaluating patient outcomes, and improving care. 3. The cancer conferences provide a forum for patient consultation and contribute to physician education. 4. The quality-improvement program is the mechanism for evaluating and improving patient outcomes. 5. The cancer registry and database is the basis for monitoring the quality of care. “For a physician to want a program with these attributes, he/she needs to be dedicated to the thought of providing the best possible care for that patient. And for a program to succeed, it needs a number of individuals with a passion for doing that and for wanting to follow through with the effort,” Flanigan explained. “It is a teamwork phenomenon, it cannot be just one individual,

nating the interested surgical specialists as well as medical and radiation oncologists. A center does not necessarily need to provide all the clinical services on its campus; these services can be provided by referral, according to Flanigan. “For instance, I just surveyed a hospital and the radiation facility was privately owned and located across the street. That setup is fine. As long as the services are available to the patients in that community, that is an acceptable approach.” In addition, most cancer programs already have a cancer committee or a group of individuals who are concerned about the delivery of cancer care to patients at that institution. According to Flanigan, “this is a major start point, as this is the leadership group who will develop the program and begin to address the 36 standards.” Developing a cancer conference is usually not a complicated issue, nor is developing a quality-improvement pro-

“For a physician to want a program with these attributes, he/she needs to be dedicated to the thought of providing the best possible care for that patient. And for a program to succeed, it needs a number of individuals with a passion for doing that and for wanting to follow through with the effort.” ——Robert Flanigan, MD, FACS that individual needs to seek others that want to be involved likewise and proceed with this effort.” Designing a program There is no one design model for CoC-accredited institutions. Each center develops its own approach to compliance with the CoC’s 36 standards. The standards provide a framework for developing a program up to the point of accreditation. They cover all the basics from the leadership model needed to the necessary diagnostics, therapeutics, support services, quality studies, activities, and registry management, according to Flanigan. “The path to accreditation is never exactly the same,” he said. Many programs that express an interest in becoming accredited already have a number of the required elements. It may be just a matter of making sure all the clinical services are available, and then coordi-

gram, Flanigan said. Most hospitals already have a manager to address quality-improvement concerns. Developing a cancer registry, however, is “probably one of the major hurdles when developing a program with the goal of accreditation because, though every state requires reporting of cancer incidence data, having a dedicated registry is a little bit different from having an individual in the medical records department assigned to accumulate that information.” Registry activity must be supervised by a certified tumor registrar, and certified individuals are limited. However, according to Flanigan, centers can enlist a consulting service that provides registrar services by contract. For accreditation, the CoC also requires programs to have a certain stream of reliable data from their established registry that has been reported to the National Cancer Database (NCDB) before a program can be sur-

veyed and accredited. Another important step is for the programs to be evaluated by a consultant, with a mock survey performed. This will give the programs a sense of whether they are in compliance with the 36 standards, Flanigan explained. “For new programs, the pass/fail bar is very high, with the CoC expecting them to be compliant on all 36 standards. They are given only one standard for noncompliance. Otherwise, they have to go back and start again.” Help is available, however. If a program is making progress but needs help with some remaining challenges, it can request a visit by a CoC ambassador. “This no-charge to the facility visit by a surveyor or state liaison chair consists of a site visit to meet with the cancer committee and administration. The ambassador first reviews the benefits of being an accredited program and then functions like a consultant, discussing some of the issues and problems that the center may be having in moving forward,” said Flanigan. The ambassador tries to provide the center help in reaching the point of accreditation. The timetable Developing a program requires leadership from within the facility, and it takes a number of physicians who have a passion to proceed with accreditation and who believe accreditation will benefit the patients, the community, and the institution. Depending on a center’s current operating procedures, the accreditation process may take 2 to 3 years, according to Flanigan. After a center has been cleared for a survey by a consultant, it is just a matter of getting the survey scheduled. As Flanigan described, “the survey process must include the surveyor attending a cancer conference as well as meeting with the cancer committee, having a tour of the facility, and reviewing some cases via medical records case reviews. The surveyors also meet separately with the administration.” Therefore, the survey process takes between 6 and 7 hours. Then, the turnaround time for receiving the performance report can be as short as 2 weeks. Benefits of accreditation This year the CoC is refocusing on one of the major benefits of accreditation. “I think everybody in the country is certainly aware of the fact that we need to be upfront with the quality of work that we are doing,” Flanigan said. “In particular, payers and the federal government are very concerned about Continued on page 7

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CONTINUING EDUCATION CREDITS Current activities at www.COEXM.com include:

ADVERTORIAL

OncoMed provided funding and editorial support for this article www.OncoMed.net

Evolution in

2 OF A SERIES PART

Oncology Practice Management

New Jersey Hematology and Oncology Center Partners with OncoMed Bayonne, New Jersey—As ications. If they followed the source the pharmacy funcspecialty pharmacies that demand for their services traditional practice of hema- tion to a pharmacy that was concentrate on more than grew and it became increastology and oncology pro- highly specialized in oncoloone class of pharmaceuticals ingly clear that their pracviders, they would “buy and gy medications. This pharis the OncoMed care mantice was becoming a regionbill” the medications, mean- macy would prepare the agement support team’s abilal center for patients battling ing they would have the drugs under the highest clinity to work with insurers to cancer, the medical staff at responsibility of sourcing and ical standards, deliver them get the authorizations that Colanta Hematology & purchasing the medications, just in time for treatment the Colanta Hematology & Oncology Center made the storing them, preparing and day (thereby eliminating Oncology Center’s patients decision to build and open sometimes compounding them waste), handle all the hassles need. OncoMed’s team inan outpatient infusion cen- Kevin Askari, RPh for patients, managing the of insurance prior authoriza- Burt Zweigenhaft cludes patient care navigater that could adequately President and Chief inventory on an ongoing basis, tion and reimbursement, CEO, OncoMed tors and patient reimburseand comfortably serve their Clinical Pharmacist and dealing with a bevy of and free the center from the ment specialists who have OncoMed patients. insurance prior authorization challenges of safely storing and dispens- extensive experience working with inThe result was a state-ofand reimbursement procedures ing the drugs and the huge, capital- surers, oncology drug manufacturers, and the-art infusion center with 20 recliners and requirements in order to get paid. intensive “carry costs” that maintaining medical foundations. These specialists in a patient-focused environment that is Although buy and bill traditionally such an inventory requires. always know where to go to search for open to serve patients 7 days a week. The had its benefits, including a substantial Dr Colanta and his colleagues needed funding for patients who are medical staff of three physicians and four margin paid by Medicare and other com- researched their options and chose banking on that expertise for their nurses, led by practice administrator recovery. Romel Colanta, MD, now delivers a OncoMed has become a pivotal part“The partnership with OncoMed has enabled broad array of outpatient oncology servicner to the Colanta Hematology & Onus to make better use of our capital.” es, including chemotherapy, albumin, cology Center by owning the pharmaantiemetic, and iron therapy infusions. ceutical worry and letting the physicians Additionally, the infusion center staff —Romel Colanta, MD focus solely on guiding their patients to provides supportive cancer care services, Practice Administrator remission. including therapeutic phlebotomy, antiWe sat down with Dr Colanta and Colanta Hematology & Oncology Center biotic infusion, and electrolyte replaceasked him about the new center and its ment. They also provide multidisciplipartnership with OncoMed. nary infusion services for patients referred to the center by gastroenteroloWhy did your infusion center choose gists, neurologists, and infectious disease mercial payers, changes that resulted OncoMed—The Oncology Pharmacy. to partner with OncoMed? specialists. from the Medicare Modernization Act OncoMed is an oncology pharmacy, The buy-and-bill model that oncoloWith the high volume of oncology lowered a margin that sometimes paid meaning that its sole business is oncologists have always worked under is no drugs required to treat their patient physicians 40% over the cost of the drug gy medications. Its specially trained and longer viable. Physicians can’t make an panel, the medical staff at Colanta had to to just 6%. certified oncology pharmacists work in a office run on a 6% margin. Under buy make the decision as to how they would The Colanta team decided there was a technologically advanced pharmacy built and bill, the average sales price (ASP) + supply their patients with oncology med- better way. They knew they could out- exclusively for oncology pharmaceutical 6% methodology can very quickly go to prescription processing and dispensing, ASP + 4%, +2%, or -2% if we run into including a USP <797>-compliant class any obstacles in getting reimbursed. And 5 clean room. To protect the supply with expensive drugs like chemotherapy, chain and ensure a complete and full we cannot take that risk. Plus, OncoMed drug pedigree, all inventories are pur- helps patients get funding for medication chased directly from pharmaceutical even after the patient’s insurer has manufacturers. The company’s “just-in- denied coverage. time treatment-day” service means that oncologists and hematologists in any In addition to this new center, you state in the nation are guaranteed deliv- now have two additional sites in New ery of medications and all therapy- Jersey. How has the partnership with specific administration supplies within OncoMed enabled you to successfully 24 hours of placing the order. Given the launch and grow the center? Colanta Hematology & Oncology When we opened, 90% of what we Center’s close proximity to one of infused in the clinic was oncolytics. As we OncoMed’s regional oncology pharmacy have grown, we infuse a far broader array sites, they were eligible to get same day of medications. The backbone of our pracand even emergency stat dose delivery tice is still chemotherapy, but we have increased our nononcolytic infusions. For The outpatient infusion center at Colanta Hematology & Oncology Center comfortably serves when needed. But what also set OncoMed apart from patients. Continued on page 7

JUNE 2010 I VOL 3, NO 4

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EVOLUTION IN ONCOLOGY PRACTICE MANAGEMENT™ Continued from page 6

patients referred by gastroa patient comes in and his or intestinal practitioners, we inher benefits are precertified, fuse infliximab, and for those we send the person’s case referred by infectious disease information to OncoMed, physicians, we provide antibiand the drugs are sent to us otic infusions. Some of those directly, along with all the drugs are still viable [under administration supplies. We buy and bill], but not all. We get them on a next-day have been able to devote basis, or sooner if needed, money that has traditionally and everything is clearly gone to purchasing medica- Ellen Scharaga, RPh labeled with patient-specific tion and instead expand our Senior Vice President information. That makes a services. The partnership with OncoMed huge difference to us when OncoMed has enabled us to dealing with OncoMed vermake better use of our capital. sus some specialty pharmacies that some insurers have imposed upon us to use, How does the medication ordering which get the drugs wrong, ship them and fulfillment process work with late, and have no idea of the correct OncoMed? administration supplies. Having an efficient and focused process in place is very important. We How does the relationship with have been able to institute a process OncoMed allow you and your team to where we have someone devoted to focus on what is important? being our liaison with OncoMed. When I will give you a “before-and-after”

example. Before we worked with OncoMed, 50% or more of our time was spent on managing drug costs and reimbursement. We had five people managing pharmacy at the three locations; we have been able to reduce that number of employees to one. Before, we had to continually make sure that we were not underwater on drugs, as reim- Pharmacists filling orders at the OncoMed facility. bursement rates and times fluctuated. such a move? OncoMed has made it possible to not It is definitely a relationship that every devote time and effort on that. infusion center or oncologist has to explore. When dealing with narrowing Based on your experience, what reimbursement margins and delayed would you say about OncoMed to he- reimbursement, ultimately it will be benmatologists and oncologists considering eficial to switch to OncoMed.

To learn more about OncoMed or to request a presentation, contact OncoMed at 1-877-662-6633, extension 1298 or marketing@oncomed.net, or go to www.oncomed.net.

Accreditation Commission on Cancer... Continued from page 4 the quality of care that we are giving.” Accredited institutions have access to the NCDB. The database, a joint project of the CoC and the American Cancer Society developed in 1989, is currently the largest cancer database in the world. It contains nearly 25 million records from hospital cancer registries across the United States and Puerto Rico. With their web-based, password-protected access, accredited cancer programs can use the database to access almost 8.3 million case reports of patients diagnosed between 2000 and 2007. The institution can generate reports showing data reported to the NCDB from the user’s cancer registry; aggregated data by hospital system, state, or region or at the national level; or a comparison of the cases submitted to the NCDB by the user’s cancer program and all the other programs identified by the user in the comparative group.2 Survival data are available on 51 cancer sites; supportive care; and detection, prevention, and risk reduction interventions. “Institutions can run their survival data and compare it with other institutions in the same accrediting category (there are 12 categories), so they can get an apples-to-apples comparison of their survival data,” explained Flanigan. Benchmarking is also available through the NCDB; again it is webbased, password-protected, and accessi-

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ble only by accredited programs. Flanigan, a former breast surgeon, described how this feature can be used: “A breast surgeon can look at the stage of disease for his/her breast cancer patients at diagnosis. One interesting phenomenon is the ability to look at stage 0, which is in situ disease that is only detectable mammographically, and to compare the percentage of his/her stage 0 patients against other community hospital or teaching institutions. That percentage against peers will give the surgeon an idea as to whether he/she is screening for breast cancer well in the community or not. This is a great example of how members can use NCDB data at a keystroke to demonstrate how effective they are in their community at screening for breast cancer.” In addition, “in a matter of seconds, surgeons can look at the percentage of surgical procedures and the types of surgical procedures performed for their breast cancer patients and see what percentage are having breast conservation surgery versus mastectomy. This can then be compared with outcomes at other institutions in the same category,” Flanigan continued. Another use of the NCDB deals with treatment guidelines. National Comprehensive Cancer Network (NCCN) clinical practice guidelines correlate with the 51 cancer sites and interven-

tions in the NCDB, which allows accredited programs to determine whether they are in compliance. According to Flanigan, the NCDB currently offers three breast measures and three colorectal measures, with the additional cancer measures being developed soon. “With the federal government and payers believing that guideline compliance is a better measure for quality of care than survival data alone, an institution can easily look at estimated performance rates in terms of how well it is following NCCN guidelines and get feedback on this quality of care measure and, just as importantly, the quality of the data coming out of its cancer registry,” Flanigan said. In addition to the NCDB, the CoC’s relationship with the American Cancer Society provides members a marketing boost. Flanigan provided this example: “On the American Cancer Society website, if a patient navigates through the website looking for a treatment center, the site links these inquiries for cancer treatment centers to the CoC, which allow the patient to search in his/her zip code. The treatment center identified will be a CoC-accredited cancer program.” So, is accreditation right for you? Each cancer program must make this decision for itself. For programs dedicated to the best patient care and a multi-

disciplinary approach, CoC-accreditation may be a good fit. Start by assessing where your program is in compliance with the CoC’s five elements to success. Follow that with developing an action plan to fulfill any currently unmet criteria. If you are willing to proceed with accreditation, accreditation can benefit your patients, your community, and your institution. l References 1. Commission on Cancer. Cancer program accreditation. October 12, 2009. www.facs.org/cancer/coc/ whatis.html. Accessed March 15, 2010. 2. Commission on Cancer. National Cancer Data Base (NCDB). December 18, 2009. www.facs.org/ cancer/ncdb/index.html. Accessed March 15, 2010.

Did You Know? Demand for large buildings on hospital and other medical sites is increasing as real estate investors seek stable investments. According to data presented at the 2010 Medical Office Buildings & Healthcare Facilities Conference in Chicago, in the first quarter of 2010, medical office buildings sold for an average of $230 per square foot, a 1% increase from 2009. In contrast, other offices sold for $165 per square foot, a 39% decrease in value.

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Oncology Advocacy ACCC President...Continued from cover says that oncology must take an active role in its implementation. Dr Benson has participated in organizations, including serving on a number of committees at the American Society of Clinical Oncology (ASCO) and as the immediate past-chair of the National Comprehensive Cancer Network board of directors. The Journal of Multidisciplinary Cancer Care spoke with Dr Benson about his plans for his upcoming year as president of the ACCC. What are your goals for the ACCC? What are the biggest issues for community oncology in the coming years? There are a lot of issues that will require continuing effort, and that includes understanding the impact of healthcare reform on the oncology community. I think continuing the theme from Luana Lamkin’s presidential year in terms of workforce issues must be an ongoing discussion. I think globally we need to make sure that the advances and innovations in oncology are maintained, and continuing pressures could greatly affect our ability to do that. That includes not only the workforce issue, but ongoing reimbursement issues, as well as the movement of oncology and practices to the hospital setting and what that might mean for access to care and the type of care that’s delivered. What challenges does CER pose for community oncology? We should begin to focus on the issue of evidence-based practice and the data acquisition requirements that we think we will face increasingly over time. Some of this is also related to the concept of CER, with pressure to make sure that oncologists who are participating in these databases have the necessary infrastructure to transmit data for these databases. As these pressures mount, what impact will that have on other activities and on the outpatient office, including clinical research? The pressure to increase accrual to clinical trials will be heightened the more we are encouraged to practice evidence-based medicine. This will also require the integration of guidelines into practice and the monitoring of practice in terms of the quality of care that is being delivered. I think much of this is driven by economics and the increased cost of delivering medical care. But my own bias is that the more we can practice evidencebased medicine, the more likely we will be able to use the dollars available for healthcare appropriately—it’s the concept of delivering the right care to the right patient at the right time. What led you to your current position?

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That started with the creation of the Illinois Medical Oncology Society (IMOS). I started out as vice president and eventually became president. Early on, we fostered ties with ACCC as well as ASCO, so through the years I got to know ACCC people very well. I was partly involved because ACCC helped our state society in passing legislation in the state of Illinois on both off-label drug use and clinical trials. Eventually, I was asked to run for the board and just continued to be active within ACCC even after I completed my term of office on the IMOS board. Healthcare reform is now law. What sort of changes should community oncology practices expect? I think that one extremely critical change is going to be the coverage of individuals with preexisting conditions—that is, insurance cannot be denied for preexisting conditions. That has been a major concern for cancer patients...even extending to the concerns about screening for cancer and genetic testing with the fear that there will be inability to obtain adequate insurance, as well as other issues such as job discrimination. The clinical improvements in cancer care have resulted in many more people either having been cured of

that unlike drug therapies, we don’t routinely conduct clinical trials, so there are far less data as to optimal imaging strategies. You also see huge variation in the use of imaging. One example is surveillance for patients who have completed cancer therapy. In my area of colon cancer, there have been trials conducted to look at surveillance strategies. But that is the exception rather than the rule. How significant is the mandate that payers cover the patient-care costs of clinical trials? It’s obviously something a number of members of the oncology community have strongly supported. We need to see how that plays out in terms of possible outcomes and in terms of increasing numbers of patients who are part of clinical trials. One of our concerns is that we really have not improved the numbers of patients who go on cancer clinical trials significantly over a number a years. We’re going to have to carefully look at strategies to improve our numbers of accrued patients. Given the workforce shortage, are there currently enough oncologists to meet the needs of the millions of newly insured patients? I think this is an extremely critical

My own bias is that the more we can practice evidence-based medicine, the more likely we will be able to use the dollars available for healthcare appropriately—it’s the concept of delivering the right care to the right patient at the right time. their cancer or living productively with their cancer. With these steps in the right direction, in terms of improved lives of cancer patients, we have to make sure there are not factors that will adversely affect their lives. These include the ability to have health insurance as well as the ability to be gainfully employed. What sort of changes do you foresee for radiation oncology? This actually gets us back to the discussion of evidence-based medicine. One of the discussion points that we’re hearing more and more is the very high cost of imaging. One of these particular areas of imaging that requires tremendous attention is positron-emission tomography scanning. Because of its extensive use, and many say overuse, and because it is quite expensive, it has really had an impact on healthcare expenditures. One of the problems with imaging is

component of the workforce discussion. Multidisciplinary oncology groups for years have emphasized the importance of patient access to quality oncology care. There are also concerns that many patients did not have such access and that issues such as reimbursement might affect patients’ access to care. We’ve also known that we have a growing crisis brewing in a projected shortage of oncologists as well as highly trained oncology nurses and other members of the healthcare team. We have a real potential threat to delivering adequate oncology care. It’s not only the fact that there may be more people with insurance benefits who will now have access, but if you look at the demographics of an aging population, we would expect our number of oncology patients to also increase. A good thing is that cancer survivorship is improving, but we have to have skilled professionals available to monitor survivors over time.

What got left out of healthcare reform? I think the huge issue is that the reform law does not adequately control the cost of healthcare. Many of us believe that this has to be the next step. It’s why I think the oncology community needs to emphasize evidence-based medicine. This is a concept of multiple components: it includes increasing our clinical research enterprise, being engaged in discussion of CER, and in discussion of where such a strategy might be appropriately integrated. It involves looking carefully at guidelines to try to make sure that people practice the very best based on the oncology principles available. It means we have to start paying attention to imaging. Getting back to clinical research, we need more investment in understanding human cancer biology so that we can better select patients for appropriate interventions. It also means to make sure that appropriate people are screened, so we can try to limit the number of patients who present with advanced cancers. It will also include having discussions, and these will really be societal discussions, about what may be more appropriate strategies for end-of-life care. There’s concern about how much is spent in delivering cancer therapeutics for patients who will have no benefit. In addition, we need to make sure that patients have access to appropriate hospice programs, so that they receive the very best in terms of end-of-life care. Of great concern is that most people who enter hospice programs do so within, literally, days of their deaths. l

Recent FDA Approval Trelstar Available in Twiceyearly Formulation The FDA has approved Trelstar (Watson Pharmaceuticals) 22.5 mg for injectable suspension, a new 6-month formulation of the intramuscular GnRH agonist for palliative treatment of advanced prostate cancer. This formulation can be stored at room temperature. Approval was based on a 12month phase 3 study in patients with advanced prostate cancer that showed >98% of patients were below castrate level at 6 and 12 months. In addition, prostatespecific antigen was reduced by 96.4% at the end of the study. l

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Reimbursement

Smart Money. Part 2: Protecting Oncology Reimbursement By Cindy C. Parman, CPC, CPC-H, RCC Principal, Coding Strategies, Inc, Powder Springs, Georgia

he days of plentiwith the procedure code, or Denials and appeals Even when a practice codes claims ful allowances from it may have specific docuhealth insurers, timementation requirements for correctly, health insurers may still inaply patient payments, and patient visits in addition to propriately deny, delay, or significantly minimal medical necessity the AMA or Centers for reduce payments.2 Many practices lose requirements are a fond Medicare & Medicaid Ser- revenue every day due to partially paid, delayed, and denied health insurance memory. In Part 1 of this vices guidelines. article (April 2010), we Tracking denials for claims that the practice does not chalreviewed patient payments bundling, and ensuring that lenge or may not even notice. When including coinsurance, dea modifier is applied when the practice or facility receives a denial ductibles, advanced benefi- Cindy C. Parman, CPC, required, may improve or rejection: • It should not be processed as a writeciary notices, and waivers of CPC-H, RCC practice reimbursement. In off unless it has been completely liability. In addition to paaddition, monitoring payinvestigated. tient payments, practices can streamline ments to verify that insurer discounts u If the claim is denied because the processes to protect oncology reimburse- were correctly applied and codes were patient is not enrolled in the ment. not altered can also guarantee appropriinsurance plan, investigate. ate revenue. Payment posting u Review for data entry errors, such Providers should audit their remit- Collections as transposed digits in the group Limit your patient statements to a tance advices and explanation of benenumber or patient identification fit documents every quarter. In doing so, maximum of two or three; sending more number. If the insurance card has many groups find and decipher their increases the practice’s cost and drags been scanned or copied, ensure payment problems, and often discover out the collection/bad debt cycle. that all information is legible. u Review the application of modihundreds of thousands of dollars of History shows that more mailings won’t fiers, procedure codes, and diagnounderpayments. In addition, providers lead to better collections. In addition, sis codes, and compare with payer should review payments posted on a make certain that the statement processing guidelines. regular basis to ensure that contractual includes a due date for the payment, not u Review for medical necessity adjustments are not applied in error for just the date the bill was sent. Last, denials. insurers where there is no contract or when the patient cannot pay the entire When responding to a medical amount, avoid questions such as “When participation agreement.1 Although each facility or practice can you pay?” Instead, request that the necessity denial, make certain that the may encounter different nonpayment patient provide full payment by a spe- appeal letter includes specifics relating situations, two common reasons charges cific date or before the next treatment is to the individual patient. Consider docare inappropriately reduced include the provided. umentation that supports the patient’s incorrect application of bundling guideE-mailing patient statements is current medical condition, chief comlines and services that are downcoded. known as “electronic presentment”; the plaint(s), physical examination findBundling occurs when a practice or telephone and credit card companies ings, and any correlating diagnostic test facility submits a claim for two or more procedure codes for a single patient on a The health insurer may base the downcoding on the single date of service, but the payer considers these multiple procedures to be diagnosis code(s) reported with the procedure code. represented by one procedure code. According to the American Medical Association (AMA): “Bundling has have been doing it for years. The results. Also include documentation of become more widespread, because patient will appreciate the cost reduc- medical management options that were health insurers have increased their use tion, and it may help further cement previously tried, but failed to adequately treat the patient’s medical condition. of code-editing software. Health insur- your patient relationships.1 Also watch for “rubber checks.” ers not only integrate these code-editing software programs into their claims During a tough financial time patients Operational review Now is the best time to evaluate review cycle, but also add another layer may bounce checks for copayments and of confusion by modifying the program’s deductibles. In addition to not receiv- overhead expenses, staffing levels, marstandard code-pair edits to fit their own ing the money due, the bank may keting practices, and the superbill. charge the practice a fee (such as $25) Evaluate current expenditures, includmedical payment policies.”2 Another potential problem is down- per bounced check. The medical prac- ing office supplies, kitchen supplies, and coding, which can occur when a health tice may want to consider a policy that other routine purchases, and look for insurer unilaterally reduces the level of appends an extra charge to the patient new ways to trim costs. It may also be complexity of a patient-visit service or a account when checks are returned by prudent to consider outsourcing certain procedure. For example: code 99204 the bank. According to the AMA, segments of the practice, such as human (level 4 new patient visit) was billed, medical practices may also have an resource functions and benefit plans. but code 99203 (level 3 new patient increased risk of receiving bad checks The silver lining to a cloudy economvisit) was paid by the insurer. The when there are high deductibles and ic forecast is the fact that there are plenhealth insurer may base the downcod- healthcare savings accounts and when ty of new opportunities on the horizon. ing on the diagnosis code(s) reported treating uninsured patients.3 Although the superbill or charge cap-

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ture document should be reviewed when diagnosis and procedure codes are updated, this is an excellent time to review all services performed by the practice. Are there services performed that are not being captured and billed? Are there services that the practice considered in the past that it should offer now? For example, tobacco cessation counseling (procedure codes 99406 and 99407) may be performed by the physician or a qualified nonphysician healthcare professional, but the practice may not have reviewed these codes to see if there is an opportunity to bill for this service. Consider offering cash-only services that will benefit the patient population in your location. For oncology practices, this may mean installing a massage therapist in an empty examination room. This may provide an activity that patients and/or caregivers would enjoy (for a small charge) and could lead to other services such as the sale of spa products for skin care. The massage therapist need not be a practice employee, but can lease space on a daily or hourly basis. Last, know your market today and be able to estimate tomorrow’s market. Assess your competition, determine what makes your practice different, and use that information to launch or redesign a marketing campaign. Work closely with referring physicians to ensure that they understand your commitment to patient care in addition to the services offered at your oncology practice. Position your practice to be their “partner” through an open house, fast and accurate updates on their patients, etc. Reimbursement realized It seems that we have already changed priorities, tightened our belts, stretched our budgets, and delayed implementing new technology. However, the current economic environment demands that we continue to become more efficient, even in areas where it seems impossible, and that we honestly address what we need and what we want for our practice. l References 1. Jakielo DF. It may not be the economy. HBMA Billing. Nov/Dec 2008. 2. American Medical Association. Appeal that claim. 2008. www.ama-assn.org/ama1/pub/upload/mm/368 /appeal-that-claim.pdf. Accessed March 10, 2010. 3. Caffarini K. Keeping rubber checks from clogging revenue flow. January 26, 2009. www.ama-assn.org/ amednews/2009/01/26/bica0126.htm. Accessed March 10, 2010.

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Conference News SIR 2010 The following articles are based on presentations at the Society of Interventional Radiology’s 35th Annual Scientific Meeting in Tampa, Florida.

New Approach May Freeze Out Breast Cancer By John Schieszer

TAMPA, FL—In the first reported study, researchers in Detroit have found that image-guided, multiprobe cryotherapy may be able to successfully freeze breast cancer in women who do not undergo surgery. They presented data that show this approach appears to be highly effective with minimal discomfort for the patient. Researchers conducted 13 cryotherapy sessions in which they treated 25 breast cancer foci in 13 patients. What makes this series unique is that it used multiple 2.4-mm cryoprobes. Using only local anesthesia with mild sedation, ultrasound guidance alone was used in six of the patients; seven patients required both computed tomography (CT) and ultrasound to better define ice margins. The researchers used saline injections to protect the skin and/or chest wall. Breast magnetic resonance (MR) imaging and/or clinical follow-up were available for up to 65 months after cryotherapy. The researchers found no significant complications. All the patients reported minimal discomfort and satisfaction with the cosmetic results. The investigators found that biopsies at the margins of the cryotherapy sites immediately after the procedure and at the cryotherapy sites in follow-up were all negative. No local recurrences have been noted at 18-month average follow-up. “Minimally invasive cryotherapy opens the door for a potential new treatment for breast cancer and needs to be further tested. When used for local control and/or potential cure of breast cancer, it provided safe and effective breast

conservation with minimal discomfort for a group of women who refused invasive surgery or had a local recurrence and needed additional management,” said study investigator Peter Littrup, MD, who is an interventional radiologist at Karmanos Cancer Institute, Detroit, Michigan. “This is the first reported study of successfully freezing breast cancer without having to undergo surgery afterward to prove that it was

of cryotherapy are its superb visualization of the ice treatment zone during the procedure. It also provides a low pain profile in an outpatient setting and has been shown to have excellent healing with minimal scarring, according to Littrup, who is also a professor of radiology, urology, and radiation oncology at Wayne State University. He said this approach is very attractive because of the dramatic improvements in

“This is the first reported study of successfully freezing breast cancer without having to undergo surgery afterward to prove that it was completely treated.” ——Peter Littrup, MD completely treated.” With this cryotherapy treatment, researchers used several needle-like cryoprobes that were evenly spaced and then inserted through the skin to deliver extremely cold gas directly to the tumor to freeze it. This technique has been used for many years by surgeons in the operating room. However, in the past few years the needles have become small enough to be used by interventional radiologists through a small nick in the skin, without the need for an operation. The “ice ball” that is created around the needle grows in size and destroys the frozen tumor cells. The major benefits

imaging that have occurred over the past 2 years. Breast imaging has markedly advanced through accurate improvements in breast MR imaging. This has paved the way for excellent treatment planning, because of clear determination of tumor size and extent within the breast. It also allows the clinician to see zones of destruction thoroughly covering the tumor after cryotherapy. Littrup said this current study confirmed sufficiently deadly temperatures when using two or more cryoprobes. Prior breast cryotherapy studies had “inexplicably” used only a single cryoprobe and suggested that tumors larger than 1.5 cm

could not be adequately treated. “This is incongruent with more than 10 years of treating an entire prostate, which is approximately 5 cm, with more than six probes in order to generate well-defined sufficiently deadly temperatures throughout the whole gland. We simply translated this concept to breast cancer to assure deadly temperatures well beyond all apparent tumor margins in order to generate successful use of cryotherapy in women,” said Littrup. He said more studies are now needed with larger numbers of breast cancer patients at multiple centers. Littrup said cryotechnology is now offering the promise of being more MR-compatible. This may allow for more accurate targeting of more difficult-to-see breast tumors. “With recent developments of powerful new cryotechnology, multiple directions for breast cryotherapy can be pursued, including translating the current, somewhat challenging procedure done with ultrasound and/or CT guidance to a more consistent and reproducible MRguided approach,” said Littrup. He noted this may turn out to be a cost-effective approach for some women presenting with breast cancer. Littrup said oncologists can now counsel their patients that this new approach may become much more widely available in the not too distant future. “In the future, I think there could be a broad utilization,” said Littrup in an interview with the Journal of Multidisciplinary Cancer Care. “Patients who have very few other options may be candidates.” l

Going for Gold with a Novel Treatment for Pancreatic Cancer TAMPA, FL—Pancreatic chemotherapy, radiation cancer, acknowledged as the therapy, and/or surgery. most fatal cancer with no However, none of these known effective treatment, methods result in effective requires a radical new therapy. treatment. “This cancer is Now, researchers at Norththe kiss of death,” said Reed western University in ChiA. Omary, MD, who is a cago think they have come up professor of radiology and with one. They presented for biomedical engineering at the first time a promising new Northwestern University approach in the form of gold Reed A. Omary, MD Feinberg School of Mednanoparticles. icine, Chicago. “The median Traditional attempts to treat this survival is less than 6 months, and the cancer include some combination of patients die on schedule.”

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So, he and his colleagues have come up with a new treatment they call “nanoembolization.” It involves extremely tiny particles made out of gold with cancerkilling agents attached to them. These nanoparticles, which measure only 13 nanometers in diameter, are so small that 8000 of them could be strung together and still occupy less than the width of a single human hair. “As the current treatments for pancreatic cancer offer minimal benefit, entirely new approaches are needed. We’ve developed a radically different

approach that might be able to overcome some of the obstacles that have hampered previous therapies for pan-creatic cancer,” said Omary. “Using nanoembolization, we dramatically increased the concentration of the nanoparticles in the tumor by 55 times over traditional methods that use a vein (such as at the elbow). That’s a massive improvement and a promising discovery for this dreadful disease.” He noted that pancreatic ductal adenocarcinoma is the most common type Continued on page 28

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Cancer Center Profile Steeplechase Cancer Center... Continued from cover Kathleen Toomey, MD, induced peripheral neuropamedical director of the canthy. There are also industry cer center, notes that paregistry trials in multiple tients are not only able to get myeloma and chronic lymtheir care close to home but phocytic leukemia and a are able to continue to see large annual screening trial their own doctors. “The docfor prostate cancer. “We tors who know the patients accrued 92 patients to trials best are here and can help last year, 23 on treatment coordinate their care with trials and 69 on the screenthe many specialists.” ing trial,” Toomey notes. Joan Perrone, RPh In addition to medical, A complementary mediradiation, and surgical oncology, Steep- cine suite provides a variety of services lechase’s services include plastic surgery, including yoga, meditation, and masa breast care center, genetic counseling, sage. Other resources include a patient a cancer registry, clinical trials, rehabil- library, an onsite wellness boutique, a itation medicine, palliative care and survivorship program, a healing garden, pain management, and nutrition coun- and educational and support groups for seling. “Besides the clinical trials that patients and their families. Toomey are available to patients, there are four notes that “it is a beautiful facility and multidisciplinary groups [breast, pro- patients appreciate that if they have to

“Besides the clinical trials that are available to patients, there are four multidisciplinary groups [breast, prostate, colorectal, and lung] that discuss cases.” ——Kathleen Toomey, MD state, colorectal, and lung] that discuss cases. In the case of breast and colon cancer, all new cases are discussed in a multidisciplinary forum,” Toomey says. The Tobacco Quitcenter, one of eight in New Jersey, is available to help patients stop smoking using a comprehensive approach. Somerset Medical Center is a clinical research affiliate of The Cancer Institute of New Jersey, allowing patients access to clinical trials. Currently, patients are enrolled in treatment trials for breast, prostate, renal, bladder, and colorectal cancers as well as chemotherapy-

have a terrible illness; the surroundings can help lift their spirits.” The Steeplechase Cancer Center earned its 3-year Community Comprehensive Cancer Program accreditation from the American College of Surgeons in 2008, and it ranks in the 99th percentile for patient satisfaction scores in New Jersey. Inpatient services are provided at the 35-bed Paul R. Nardoni Oncology Pavilion. In recognition of the importance of involving families in patients’ care, patient rooms have sofa beds for visitors wishing to stay overnight in

In the Frimmer Healing Gardens at Steeplechase Cancer Center. Back row left to right: Joy Dimagmaliw, RNC; Joann Signorino, RN-BC; Charlotte Bradley, RN, OCN; Robyn Rex, RN, OCN; Debora Velmer, RN, CCM; MS, RN, APN-C, AOCNS; Rita Messemer, RN; Janet Belmonte, RNC. Bottom row left to right: Amalia Apuzzio, RN-BC; Bozena Owsieniuk, RN; Erica Schermer; Kathy Wagle, PCT.

addition to amenities such as blanket givers as “an extension of the patient” warmers, lounge chairs, showers, refrig- and takes care to provide for their comerators, flat-screen televisions, and fort with a well-stocked pantry, games, DVD/VHS players. and DVDs for visitor use. “We try to Patricia Molinelli, MS, RN, APN-C, take a lot of the burden off the family,” AOCNS, is nurse manager she explains. She also of the inpatient and outpapoints to the latest technoltient oncology units. She ogy in evidence throughout came to the center from the center. “We rush to get large academic medical cenwhatever is available to ters in New York and values reduce medical errors and the intimacy afforded by increase patient safety.” Her working in a smaller setting current goal is to incorpo“I try to know one thing that rate genetics into the canis important to every pa cer program. tient,” she says. Her own Other plans include a Patricia Molinelli, MS, RN, father was treated at the new interdisciplinary group APN-C, AOCNS center, and she takes pride in for lymphoma, myeloma, providing the same quality of care for all and leukemias, and a head and neck patients. Care at the center is patient- group as well as gynecology-oncology centered. As Molinelli describes it, “I and palliative care programs, and a am the gatekeeper, the coordinator of all men’s cancer support group. A Day of these orbits. The patient is the sun.” She Hope is planned for cancer survivor views family members and other care- month. l

BREAST CANCER

CEP17 Breast Cancer Tumors Are More Likely to Respond to Anthracyclines By Jill Stein

BARCELONA—Breast cancer patients with the chromosome enumeration probe 17 (CEP17) alpha satellite abnormality are more likely to have good outcomes from chemotherapy involving anthracycline antibiotics than women without the abnormality, according to new data released at the Seventh European Breast Cancer Conference. John Bartlett, MD, with the Uni-

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versity of Edinburgh in Scotland presented the results of a meta-analysis of four adjuvant breast cancer trials that enrolled a total of nearly 3000 women. Women with CEP17 tumors that were treated with anthracyclines were roughly two thirds more likely to survive without recurrent cancer than those who did not receive anthracyclines. Recurrence-free survival was

67%, and overall survival was 63%. Prior research by the same investigators had shown that duplication of CEP17 predicts sensitivity to anthracyclines. “CEP17 can be readily assessed in fluorescent in situ hybridization analysis of human epidermal growth factor receptor type 2 [HER2] status and may represent a clinically useful biomarker for the selection of patients likely to benefit

from anthracycline-containing therapies,” Bartlett pointed out. He added that the research is important because there has been conflicting evidence on the best way to predict response to anthracyclines and because it has not been clear whether any of the known biomarkers like HER2 and topoisomerase 2 alpha were accurate indicators of response to these drugs. l

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Presents the Third Annual Curriculum for

CONSIDERATIONS IN MULTIPLE MYELOMA A Newsletter Series for Cancer Care Professionals Center of Excellence Media, along with Editor-in-Chief Sagar Lonial, MD, of Emory University, are pleased to offer your multidisciplinary cancer team this series of newsletters focusing on the challenges of treating patients with multiple myeloma.

SAGAR LONIAL, MD Associate Professor of Hematology and Oncology Emory University School of Medicine

# Earn Continuing Education Credits # 8-part newsletter series

CASE STUDY DISCUSSIONS: • Front-line therapy

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• Maintenance Settings

• Cytogenetics

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• Bone Health

Each newsletter will feature: • Contributions from thought-leading physicians, nurses, and pharmacists

• Continuing Education credits available to physicians, nurses, and pharmacists

PARTICIPATE TODAY at www.COEXM.com For complete learning objectives and accreditation information, please refer to each activity.

Target Audience These activities were developed for physicians, nurses, and pharmacists.

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These activities are supported by an educational grant from Millennium Pharmaceuticals, Inc.

Benchmarking

Operational and Financial Benchmarking for Oncology By Marsha Fountain, RN, MSN President, The Oncology Group, Waco, Texas Karen Gilden Executive Vice President, The Oncology Group, Alpharetta, Georgia

s healthcare coned standards or benchmarks sumes a significant to establish a baseline need portion of the US as they prepare a combudget, oncology services pelling (and successful) similarly consume a signifibusiness case for whatever cant portion of any hospiservice extension, facility tal’s budget. The need to improvement, or staff rerecruit qualified and wellcruitment challenge the paid clinicians, the continuprogram currently faces. ing medical arms race to Whereas certain benchensure the hospital remains Marsha Fountain, RN, MSN marks are well established, competitive by providing such as profitability, The physicians and staff with the latest tech- Oncology Group queried participants nical equipment, as well as the desire to on the Association of Cancer Execsatisfy increasing consumer demands for utives (ACE) listserve regarding what a reasonable clinical experience (eg, other oncology-specific benchmarks or physician office wait times, navigation metrics experienced administrators to traverse the physical confines of hos- found useful. An original survey was pitals and their many facility add-ons, conducted in November 2007, and a nontraditional treatment-hour exten- similar survey was conducted in early sions to enable individuals to continue 2010. Differences between the 2 years working) all converge to ensure an will be shown. active cancer program administrator is often in the position of requesting yet The survey The survey asked respondents (the additional dollars to improve cancer care services, upgrade oncology equip- ACE listserve) to answer this series of ment, or recruit new or additional spe- open-ended questions. As you work to position your cancer cialized staff. Although the term “benchmarking” center within the confines of the larger is ubiquitous in quality-of-care litera- hospital: • What are the three to five most ture, of immediate importance to canimportant benchmarks that you use cer program administrators is their to make your case for resources and ongoing challenge with internal hospisupport from senior administration; tal competition for acquiring access to or which benchmarks does your scarce or limited resources (eg, equipadministration require? ment dollars, capital budget funds). • What information/metrics/numbers Because it is a highly technical field do you need to sell the importance (often coupled with intense consumer/ of oncology to your senior team? patient/media scrutiny) without ade• What metrics or resources do you quate funding, cancer programs may use? Also, what has been successful? quickly fall behind and begin to bleed • What metrics do you track and patient volume to competitors. report on your oncology dashboard? Program leaders often ask for accept-

Table 1. Financial Benchmarks Used by Oncology Program Administrators • Cost per unit (whether it be treatments, patient day, etc) • Net margin per type of case; or for cancer patients overall • Service line profitability • Net revenue per patient visit • Program operating margin • Salary dollars per visit • Expense per statistic • Downstream referrals to radiation and surgical oncology from breast center • Profit margins—to include downstream revenue • Downstream revenue from medical oncology

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• And most importantly, what metrics have proven most useful to your team? • If the hospital uses a balanced scorecard, what specific measures does your team use to track oncology services (eg, productivity standards for radiation therapy, departmentbased profit margin, cost-per-case, etc). Survey findings Seventeen experienced hospital cancer program administrators responded to the survey in 2007. Fourteen (82%) of the respondents represented large community hospital cancer programs. The remaining respondents (3; 18%) represented academic center cancer programs. In 2010, eight administrators responded, all from community hospitals. Primacy of financial metrics As expected, when reporting to senior administration, most respondents focused on financial metrics. Seventysix percent (13) in 2007 and 85% (7) in 2010 of the program administrators used some type of financial metric for reporting. Whereas some used a full service line financial metric, others used departmental measures as a surrogate. This is not uncommon, as many hospitals find it difficult to roll up the total financial impact cancer has on a hospital/health

system (especially outpatient downstream revenue in pharmacy, radiology, surgery, and laboratory). In 2010, the trend was to use hospital-wide financials, which, in some cases, the respondents said “were not useful.” For example, financials were based on Medicare severity diagnosis-related groups (MS DRGs) and not ICD-9-CM codes or were for hospital inpatient only. Table 1 lists financial measurements oncology program administrators reported they use and find useful to achieve their objectives with senior administration. Patient volume also used by most The next most common metric, patient volume, is relatively easy to measure and was used by 65% (11) of the respondents in 2007 and 100% of the 2010 respondents. However, it must be cautioned that using volume only may not provide an accurate picture of program growth. If the market is growing and your institution’s or cancer program’s volume is not keeping pace with that growth, the hospital (or the program) may be losing market share. Table 2 lists typical patient volume measures respondents reported using. An interesting difference seen in 2010 was that half (4) of the hospitals monitored volume per physician (such as cases per medical oncologist; referrals

Table 2. Patient Volume Measurements Typically Used by Cancer Program Leaders • New analytic and nonanalytic patient volumes (cancer registry data) • New patient visits—radiation oncology or medical oncology • Number of patients enrolled in clinical trials • Number of cases presented to tumor board • Patient volumes by treatment specialty (ie, medical oncology, radiation oncology, surgical oncology) • Hospital (inpatient) cancer admissions (all but one respondent reported using ICD-9-CM codes rather than cancer diagnosis-related groups) • Room turns per day for outpatient oncology

Table 3. Physician Volume Metrics • New patient visits per medical oncologist • Oncology referrals to medical oncologist • Mammograms per radiologist • Breast surgeon visits • Office visit volumes

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Benchmarking

Table 4. Useful Productivity Benchmarks • Variance to budgeted full-time equivalents • Overtime utilization • Full-time equivalents per visit • Productivity compared with Solucient data • Billed units of activity per full-time equivalent

Table 5. Clinical Quality Guidelines/Metrics Program Leaders Report Using • Percent of analytic cancer patients enrolled on clinical protocols • Adherence to National Comprehensive Cancer Network clinical practice guidelines • Use of Physician Quality Reporting Initiative indicators • Percent of observed deaths and mortality index • American Society of Clinical Oncology’s Quality Oncology Practice Initiative metrics • Time from initial presentation to biopsy • 5-Year survival rates • Percent of patients diagnosed in stages 0 to II • Percent of patients receiving a pain assessment

Table 6. Treatment-specific Data Seen as Useful • Percent of radiation oncology patients receiving intensity-modulated radiation therapy • Treatments per field for radiation therapy patients • External-beam treatments per patient • Percent of breast cancer patients who have a sentinel node study • Ratio of new patients to all visits for medical oncology to breast surgeon). This indicates that a growing number of cancer programs have closer alignment models (including employment) for cancer physicians than were evident in 2007. Volume and productivity measures are listed in Tables 3. More than half report using clinical quality guidelines Just over half (53%; 9) of the respondents in 2007 and 25% (2) in 2010 reported using some clinical quality guidelines when preparing a business case. A number of programs used specific clinical quality guidelines and relied on numerous pages of quality measures and benchmarks, based on the American Society of Clinical Oncology’s Quality Oncology Practice Initiative, the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology series, and other groups. Other programs reported using very few (ie, 1-5) clinical quality measures. Table 5 lists a sample of clinical quality metrics that several program leaders noted are of value to them and to their senior administrators.

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Productivity benchmarks seen as valuable More than one third (35%; 6) of respondents in 2007 and up to 62% of the 2010 respondents indicated reporting operational productivity statistics carried weight with hospital administrators. These metrics appeared most often to be monitored for radiation therapy departments. Table 4 lists examples of these benchmarks. Patient satisfaction metrics important to some More than one third (35%) of respondents in each year also noted that they used measurements of patient satisfaction to make their cases for additional resources. Most respondents did not list specific patient satisfaction measurements, though some noted they compared themselves with local results from Press Ganey data. A few respondents also noted that they used department-specific patient satisfaction scores as opposed to hospital-wide or cancer patient–specific surveys. Survey analysts assume these were tailored to the specific business case being made, or

perhaps to what patient satisfaction tools or outcomes data were available in the institution. Treatment volumes spell revenue Surprisingly, less than one third (29%; 5) of respondents noted that they routinely used treatments per visit or types of treatment metrics in their operational or planning work in 2007. In 2010, that number was up significantly to 100%. Table 6 lists treatment-specific volumes

some respondents report as useful. Market share cited less often Survey analysts are surprised also by the low importance apparently given to market share. Only three (18%) respondents noted that they used market share as an ongoing tracked metric in 2007. Analysts surmised this may be because inpatient market share data (although almost universally available) is such a Continued on page 21

Operational and Financial Benchmarking Recommendations 1. Know your institution’s leaders • Lead with data that address their priorities • Educate as you go—gradually introduce new information to enable them to make better decisions about cancer care 2. Emphasize the obvious through data (be mindful that facts which may be obvious to insiders are unappreciated by broader hospital leaders) • Cancer care is expected to grow in their career lifetimes • It is heavily outpatient, and it is profitable (margin) • It is dependent on a strong physician referral base (track these data) • When done well, it generates goodwill in the community and repeat hospital business • When done poorly (and this can involve simple patient dissatisfaction), the results are evident and the experience is discussed widely • Breast, lung, colorectal, and prostate cancer (The Big Four) drive both margin and mission in the United States • Using diagnosis-related groups seriously underreports cancer care’s impact on the institution 3. Work with the primacy of financial data • Model expected revenue per patient • Lead with profitability and contribution data • Calculate site-specific financials when requesting site-based funds (eg, breast center, prostate-disease specific equipment, etc) 4. Measure hospital benchmarks, but develop cancer-specific metrics • Create specific cancer care benchmarks that are not only important but resonate with hospital leaders • Measure performance of major service components; track US cancer’s Big Four sites 5. Use benchmarks that have national comparables • Use national productivity and capacity benchmarks to ensure efficiency and staff/physician satisfaction or acceptance • Compare national and local data to jump-start quality or efficiency efforts 6. Focus on market data—and use data to communicate a broad respect for cancer care’s contribution • Track program growth in the context of community growth and competitor actions • Develop a reasonable model to report outpatient market share (and to show geographic markets for cancer and the hospital may differ somewhat) • Use data to your best advantage by marketing to the internal audience (including referring physicians, senior management, the board, the volunteer cadre, and foundation members) 7. Develop a benchmarking plan • Develop a recurring set of statistical benchmarks that will assist you and leaders to best understand the successes/challenges of the institution’s cancer care business and patient services model • Develop a consistent tracking and reporting data set and timetable

JUNE 2010 I VOL 3, NO 4

CONTINUING EDUCATION EDITORIAL BOARD

PROGRAM MCC3 • RELEASE DATE: JUNE 15, 2010 • EXPIRATION DATE: JUNE 14, 2011

Floor Backes, MD Division of Gynecologic Oncology Department of Obstetrics & Gynecology Arthur G. James Cancer Hospital and Solove Research Institute The Ohio State University College of Medicine M210 Starling Loving 320 West 10th Avenue Columbus, OH 43210

ESTIMATED TIME TO COMPLETE: 1.0 HOUR

Ritu Salani, MD, MBA Assistant Professor Division of Gynecologic Oncology Department of Obstetrics & Gynecology Arthur G. James Cancer Hospital and Solove Research Institute The Ohio State University College of Medicine M210 Starling Loving 320 West 10th Avenue Columbus, OH 43210 Greg Samijlenko, PharmD, BCPS Clinical Generalist Pharmacist Arthur G. James Cancer Hospital and Solove Research Institute The Ohio State University College of Medicine M210 Starling Loving 320 West 10th Avenue Columbus, OH 43210 Andrea Easley, MS, RN, WHNP-BC Nurse Practitioner Division of Gynecologic Oncology Department of Obstetrics & Gynecology Arthur G. James Cancer Hospital and Solove Research Institute The Ohio State University College of Medicine M210 Starling Loving 320 West 10th Avenue Columbus, OH 43210

Gynecologic Oncologic Management of Widely Metastatic Serous Carcinoma of the Ovary By Floor Backes, MD1; Ritu Salani, MD, MBA1; Greg Samijlenko, PharmD, BCPS2; Andrea Easley, MS, RN, WHNP-BC3 1Division of Gynecologic Oncology; 2Clinical Generalist Pharmacist; 3Nurse Practitioner, The Ohio State University College of Medicine, Columbus, Ohio STATEMENT OF NEED

TARGET AUDIENCE

Only two controllable factors can impact survival in metastatic ovarian cancer: extent of surgical effort and selection of chemotherapy agents. The choice of chemotherapy agents is complicated by the high rates of chemotherapy-induced peripheral neuropathy in patients receiving cisplatin and paclitaxel. This program will enhance comprehension of the thought processes involved in applying personalized medicine in ovarian cancer by elucidating the one team’s prospective discussion in their treatment decisions for a 67-year-old Caucasian woman with stage IIIC high-grade serous carcinoma of the ovary.

Medical, surgical, and radiation oncologists, and other interested healthcare professionals, especially those caring for cancer patients. LEARNING OBJECTIVES

After completing this activity, the reader should be able to: • Compare first- and second-line chemotherapy combinations and routes of administration in ovarian cancer. • Describe the impact of treatment side effects on agent choice. • Discuss the mechanisms of action and efficacy of supportive measures for chemotherapy-induced peripheral neuropathy.

Ovarian cancer affected an estimated 21,550 women in 2009, ranking it second among gynecologic cancers after cancer of the uterine corpus. Although its incidence has been declining since 2001 and its death rate has been stable since 1998, 14,600 women were expected to die from this disease in 2009. Two thirds of cases are diagnosed in the advanced stages; for metastatic disease, the 5-year survival rate is only 31%.1 The primary treatment for advanced ovarian cancer consists of surgical resection followed by chemotherapy. In these cases, only two controllable factors can impact survival: extent of surgical effort and selection of chemotherapy agents. The following article presents the thought processes behind the treatment of a patient with widely metastatic serous carcinoma of the ovary. This patient, like many who receive cisplatin and paclitaxel, also developed chemotherapy-induced peripheral neuropathy (CIPN). Supportive therapies were also discussed and implemented by the team.

Case Presentation Chief complaint: Abdominal bloating and discomfort. History of present illness: A 67-year-old Caucasian woman presented to her primary care physician complaining of bloating, abdominal discomfort, and some mild nausea. Because of her history of diverticulosis,

she was treated with antibiotics for a presumed episode of diverticulitis. The patient’s symptoms did not improve, but when asked, she would answer that she felt somewhat better, believing that the antibiotics should work. When the symptoms persisted, the patient was evaluated with a colonoscopy and computed tomography (CT) scan. The

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CT image showed bilateral 4-cm pelvic masses, omental thickening, and peritoneal nodularity. Secondary to a suspicion for an ovarian malignancy, a CA125 level was obtained and noted to be elevated at 1363 units/mL (normal, <35 units/mL). She was referred to the gynecologic oncology department.

FINANCIAL DISCLOSURES

Veritas Institute for Medical Education, Inc. is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Veritas Institute for Medical Education, Inc. designates this educational activity for a maximum of 1.0 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity. METHOD OF PARTICIPATION

1. Read the article in its entirety 2. Log on to www.JOMCC.com 3. Click on “CE Credits” 4. Click on “Click here to complete the posttest and obtain a CME certificate online” 5. Register to participate 6. Enter program number MCC3 7. Complete and submit the CME posttest and CME Activity Evaluation and Request for Credit Form online 8. Print your Certificate of Credit This activity is provided free of charge to participants.

Veritas Institute for Medical Education, Inc. is required to disclose to the activity audience the relevant financial relationships of the planners and faculty involved in the development of CME/CE content. An individual has a relevant financial relationship if he or she has a financial relationship in any amount occurring in the last 12 months with a commercial interest whose products or services are discussed in the CME/CE activity content over which the individual has control. In addition, all faculty are expected to openly disclose any unlabeled/unapproved/investigational uses of drugs or devices discussed in this activity. Disclosures are as follows: • Floor Backes, MD, has nothing to disclose. • Ritu Salani, MD, MBA, has nothing to disclose. • Greg Samijlenko, PharmD, BCPS, has nothing to disclose. • Andrea Easley, MS, RN, WHNP-BC, has nothing to disclose. The staff of Veritas Institute for Medical Education, Inc. and Green Hill Healthcare Communications, LLC have nothing to disclose. DISCLAIMER

The opinions expressed in this activity are those of the presenters and do not necessarily reflect the opinions or recommendation of Veritas Institute for Medical Education, Inc. Copyright © 2010 Veritas Institute for Medical Education, Inc. All rights reserved.

PLANNING COMMITTEE

JUNE 2010 I VOL 3, NO 4

Gloria Mui

Julie Ann Tagliareni

Anne L. Finger

Dawn Lagrosa

Karen Rosenberg

Medical Director Veritas Institute for Medical Education, Inc. 611 Route 46 West Hasbrouck Heights, NJ 07604

CME Director Veritas Institute for Medical Education, Inc. 611 Route 46 West Hasbrouck Heights, NJ 07604

President Veritas Institute for Medical Education, Inc. 611 Route 46 West Hasbrouck Heights, NJ 07604

Managing Editor Green Hill Healthcare Communications, LLC 241 Forsgate Drive Monroe Twp, NJ 08831

Editorial Director Green Hill Healthcare Communications, LLC 241 Forsgate Drive Monroe Twp, NJ 08831

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www.JOMCC.com Medical history: Hypertension and type 2 diabetes mellitus.

Medications: Metformin 500 mg twice daily and metoprolol extended release 50 mg daily.

Surgical history: Hysterectomy (leiomyomas) in 1974.

Allergies: No known drug allergies.

Family history: Father: diagnosed with prostate cancer at age 76. No family history of colon, breast, ovarian, or uterine cancers.

Physical exam (at initial presentation): Vital signs: Temperature, 97.7°F; blood pressure, 155/89 mm Hg; heart rate, 83 bpm; oxygen saturation, 99% on room air; height, 63 in; weight, 178 lb. General appearance: No acute distress, well-nourished, and appears stated age. Head, Ears, Eyes, Nose, Throat: No lymphadenopathy or thyromegaly.

Social history: She has a 30 pack-year history of tobacco use and reports quitting in 1990. She is a retired clerk and currently lives with her husband.

A 67-year-old Caucasian woman was referred to the gynecologic oncology department and underwent tumorreductive surgery. Prior to her referral, the patient experienced persistent symptoms of what she believed was diverticulitis. Her primary care physician evaluated her with a colonoscopy and CT scan. The CT image showed bilateral 4-cm pelvic masses, omental thickening, and peritoneal nodularity. Because he suspected an ovarian malignancy, a CA125 level was obtained and noted to be elevated at 1363 units/mL (normal, <35 units/mL). At the time of surgery she was found to have extensive disease, involving the ovaries, rectosigmoid colon, and upper abdomen. She underwent a bilateral salpingo-oophorectomy, rectosigmoid resection, omentectomy, diaphragm peritonectomy, and resection of tumor implants. Pathology findings revealed widely metastatic adenocarcinoma of the ovary, resulting in a final diagnosis of stage IIIC highgrade serous carcinoma of the ovary. Postoperatively, she was treated with a combination of intravenous and intraperitoneal cisplatin and paclitaxel for six cycles. Overall, she tolerated therapy well, with the exception of moderate neuropathy. In addition to supportive care measures, docetaxel was substituted for paclitaxel. Her neuropathy improved; however, she continued to have mild numbness and tingling in her fingertips, which did not limit her daily activities. After treatment, she had a complete clinical response with a normal CA125 level and negative imaging study. She continued routine follow-up with a pelvic examination and CA125 level every 3 months. At her 15-month visit, she complained of urinary frequency, changing bowel habits, and new lower abdominal pain. Her CA125 level had also increased to 98 units/mL. A CT scan of the abdomen and pelvis confirmed recurrent disease, consistent with platinum-sensitive disease. Because of persistent neuropathy, paclitaxel was avoided, and she began secondline treatment with carboplatin and liposomal doxorubicin for six cycles.

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She is almost 1 year out from completion of therapy and remains without evidence of disease. Physicians’ perspective In a typical presentation, this patient presented with the vague symptomatology of ovarian cancer, including abdominal discomfort and bloating, urinary urgency, and pelvic pain. A study by Goff and colleagues found that 89% of patients with Floor Backes, MD stage I/II and 97% of patients with advanced ovarian cancer presented with the aforementioned symptoms prior to diagnosis.2,3 Symptoms occurred more frequently and with increased severity in patients with ovarian cancer when compared with patients with benign ovarian masses and with healthy Ritu Salani, MD, MBA controls. When patients present for evaluation of these symptoms, however, they are often attributed to other conditions, such as diverticulitis. This, in conjunction with a lack of a reliable screening method for ovarian cancer, results in most patients being diagnosed in advanced stages. The mainstay of treatment for advanced ovarian cancer consists of surgical resection followed by chemotherapy. Factors affecting survival include stage, grade, and performance status; however, there are only two controllable factors that impact survival. One factor is the extent of surgical effort. Specifically, patients who undergo optimal cytoreductive surgery, defined as ≤1 cm of residual disease following surgical resection, have significantly improved disease-free survival and overall survival.4-8

Heart: Regular rate and rhythm, no murmurs or gallops. Chest: Normal excursions, lungs clear to auscultation bilaterally. Abdomen: Softly distended with a mild fluid wave and a firm mass at the epigastrum. Extremities: No edema, cyanosis, or clubbing. Normal strength and sensation. Laboratory values (at initial diagnosis): Hemoglobin, 12.3; platelets, 342; white blood cells, 5.2; sodium, 142; potassium, 4.3; creatinine, 0.8; glucose, 118; CA125 level, 1363 units/mL.

The other factor is the selection of chemotherapy agents. For the past several decades, the use of platinum with a taxane has been shown to have superior results and/or toxicity profiles when compared with other agents, thus making this combination the standard frontline regimen.9,10 Recently, the Gynecologic Oncology Group evaluated the route of chemotherapy administration, comparing cisplatin and paclitaxel given intraperitoneally versus intravenously. The results demonstrated a significant survival benefit of 16 months favoring the intraperitoneal group; however, only 42% of patients were able to complete the scheduled six cycles of this regimen.11 Patients often discontinued therapy secondary to toxicities, namely grade 3/4 neurotoxicity, which occurred in one fifth of the patients.

close observation with pelvic examination, with or without CA125 levels, is recommended.14 When recurrence is detected, the treatment is impacted by the time between clinical response and disease recurrence. If disease recurs ≥6 months after a complete clinical response, patients are classified as having platinum-sensitive disease. These patients generally have a better prognosis than those who are platinum-refractory or -resistant, defined as patients who have progressive disease or recurrence within 6 months after primary treatment. In the platinum-sensitive group, surgery and/or chemotherapy may be applicable. In regard to chemotherapy, the favored regimen consists of treatment with a platinum agent, which may be used as a single agent or combined with agents such as paclitaxel or gemcitabine.14 Recently,

Recently, the CALYPSO trial demonstrated that the combination of carboplatin and liposomal doxorubicin had similar survival outcomes in the recurrent setting and a lower rate of severe neuropathy when compared with carboplatin and paclitaxel. The development of CIPN can have a great impact on quality of life. Typically, most patients experiencing CIPN recover after the completion of therapy. In the aforementioned study, although more patients experienced neuropathy in the intraperitoneal arm, both groups had a similar quality of life at the 12-month follow-up. In addition, alternative treatment regimens are available for those patients who develop significant CIPN. The Scottish Randomized Trial in Ovarian Cancer (SCOTROC) evaluated the use of carboplatin with either paclitaxel or docetaxel in patients with advanced ovarian cancer.12 Those in the docetaxel arm were found to a have similar progression-free survival as those in the paclitaxel arm; however, patients reported significantly less CIPN with this regimen. Unfortunately, similar to our case, at least 60% of patients with ovarian cancer will have a recurrence.13 Therefore,

the CALYPSO trial demonstrated that the combination of carboplatin and liposomal doxorubicin had similar survival outcomes in the recurrent setting and a lower rate of severe neuropathy when compared with carboplatin and paclitaxel.15 Generally, response rates for second-line treatment in this group range from 30% to 64%,16 and selection, of the specific regimen is often based on the toxicity profile. After primary treatment, our patient was without evidence of disease for 15 months, indicating that her disease was platinum-sensitive. She was offered retreatment with a platinum drug (carboplatin) and liposomal doxorubicin, which was favored over paclitaxel due to her history of CIPN. She continues to be monitored closely for recurrent disease but is currently enjoying life without chemotherapy. Continued on page 20

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CONTINUING EDUCATION Continued from page 19

Pharmacist’s perspective When selecting a regimen for the treatment of ovarian cancer, a patient’s baseline health status and concurrent medical conditions should be assessed. This is particularly important, as the potential toxicity from chemotherapy may Greg Samijlenko, make symptoms PharmD, BCPS worse. For instance, patients with diabetes may have a preexisting neuropathy, which could impact the regimen administered.14 Although this patient did not have any barriers to receiving intraperitoneal treatment with cisplatin and paclitaxel, preventing/minimizing toxicities, along with curative treatment, was our main focus. Both cisplatin and paclitaxel are known to cause painful and disabling neurotoxicity.17,18 Paclitaxel causes large sensory fiber lesions leading to polyneuropathy, which consists of loss of vibration sense, proprioception, and muscle weakness.18 Cisplatin reduces fast axonal transport and induces apoptosis in dorsal root ganglion, resulting in paresthesias, sensory ataxia, loss of vibration, and loss of deep tendon reflexes.18

vitamin that may reduce the incidence or severity of peripheral neuropathy. Pace and colleagues randomized 47 patients to receive cisplatin with and without vitamin E 300 mg/day. Only 31% of patients in the vitamin E group developed CIPN compared with 86% of patients in the control group.22 Another study randomized patients who were receiving cisplatin, paclitaxel, or both to vitamin E 300 mg twice daily or no intervention. One fourth of patients in the vitamin E group developed CIPN compared with 73% in the no-intervention group.23 Although these results are promising, there is a concern that the antioxidant properties of vitamin E may reduce the effectiveness of chemotherapy, as seen in radiation therapy, and further studies are warranted.17 Glutathione has also been shown to help reduce peripheral neuropathy by preventing the accumulation of platinum in the dorsal root ganglia.17 Two studies, both placebo-controlled, double-blind trials, showed that the addition of glutathione resulted in a reduction of CIPN in patients receiving platinum therapy.24,25 In addition to glutathione, the use of N-acetyl-cysteine, which increases the whole blood concentration of glutathione, is of interest. However, to date, there are no studies evaluating its role with cisplatin-based regimens.17 Another agent that is theoretically

Although a patient’s self-report is an important part of the history, symptoms may be confounded by other side effects. Thus, it is also important to frequently assess and monitor the patient for early signs of CIPN. These symptoms may continue long term after therapy. Unfortunately, an efficacious agent for the treatment of CIPN has not been found. However, there have been some promising results in the prevention of neurotoxicity.17,18 Calcium and magnesium infusions have been shown to be effective in preventing neuropathy associated with oxaliplatin.18-20 Oxaliplatin increases the hyperexcitability of peripheral neurons and forms a neurotoxic metabolite oxalate.21 Increasing extracellular calcium is thought to help reduce hyperexcitability of peripheral neurons, and calcium and magnesium chelate oxalate.17,19,21 Because cisplatin and paclitaxel do not cause neurotoxicity by these mechanisms, calcium and magnesium infusions would not be helpful in this setting. Vitamin E has shown some promise in the prevention of CIPN, particularly in patients receiving cisplatin- and paclitaxel-containing regimens.17,22,23 Vitamin E is a fat-soluble antioxidant

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promising for the prevention/treatment of CIPN is amifostine. Amifostine is a prodrug that is dephosphorylated into free thiol, which binds and deactivates active metabolites of cisplatin and scavenges free radicals.26 However, two randomized controlled trials combining amifostine with paclitaxel and carboplatin regimens have not found significant effectiveness.27,28 The American Society of Clinical Oncology has released clinical practice guidelines that do not support the use of amifostine for prevention of CIPN.29 Despite the efforts being made to find appropriate agents to prevent CIPN, more data are needed before recommending any particular treatment. It is crucial to provide counseling to patients on all toxicities associated with chemotherapy and the rationale for related treatments to ensure optimal efficacy. This education allows patients to recognize toxicities early on and to report them to the clinical team for effective management. This form of

counseling empowers patients to be active participants in their disease and its management, ideally resulting in the best outcome. Nurse’s perspective CIPN is a common side effect of therapies used to treat patients with gynecologic malignancies. CIPN can affect sensory, autonomic, and motor system function. Sensory symptoms include diminished sensation, pain, and Andrea Easley, MS, RN, numbness or WHNP-BC tingling, which often begins in the toes and fingers then spreads proximally in a stocking-andglove pattern. Autonomic symptoms include constipation, urinary retention, and sexual dysfunction. Motor symptoms include weakness, gait disturbance, balance disturbance, and difficulty with fine motor skills.17,30,31 Because of a lack of a standardized measurement, the exact prevalence is difficult to determine, but CIPN is estimated to affect about 30% to 40% of patients.17,30 The symptoms can be debilitating, with a significant negative effect on quality of life. Although symptoms often resolve either partially or completely within 6 months to 2 years after completion of treatment, they can be permanent.32 The nurse plays a key role in providing care for patients with CIPN. With a focus on patient education, assessment, and monitoring, the nurse is instrumental in helping the patient identify early signs and symptoms of peripheral neuropathy leading to earlier diagnosis. Early identification is essential for appropriate adjustments/interventions to limit the progression of symptoms. Because of the potentially debilitating effects, CIPN may be a dose-limiting side effect, meaning the chemotherapy dose is reduced, the cycle is delayed, or the treatment is discontinued or changed entirely. There is currently no standard treatment that is both safe and proven to either prevent or reverse CIPN.30 Currently, the treatment options being used have varying rates of effectiveness. To limit the effects of CIPN, nurses must be aware of the risk factors, signs and symptoms, safety issues, and both pharmacologic and nonpharmacologic treatment options and educate the patient accordingly. Nurses should instruct the patient to report both symptoms and functional deficits promptly.30 Although a patient’s self-report is an important part of the history, symptoms

may be confounded by other side effects. Thus, it is also important to frequently assess and monitor the patient for early signs of CIPN.32 Several instruments are available to measure the severity of peripheral neuropathy grading severity based on symptoms and/or diminished functional status; however, these are not often used, and awareness and education are critical. It is important that the nurse educates the patient on personal safety. Because of lack of sensation, extra attention must be paid during ambulation to prevent falls. The patient should be advised to remove throw rugs, create clear walkways, and ensure adequate lighting around the house. The patient must be instructed to take special care of feet and be especially aware of temperature extremes in both the natural elements and in the home. The nurse should encourage the use of stool softeners, high-fiber diet, adequate fluid intake, frequent voiding, and slow position changes to combat the autonomic effect on the bowels and the bladder, and postural hypotension.30 Currently, there is no standard treatment for CIPN; however, some nonpharmacologic treatment options show promise in reducing symptoms. Unfortunately, most options have not been studied in oncology patients. Acupuncture has been shown to improve gait, decrease the amount of pain medicine used and, specifically in gynecologic oncology patients, increase sensation.30 Light exercise may help to increase muscle mass that can be lost due to activity limitations associated with neuropathy.30 A physical therapy consult may be helpful to provide safe, effective exercise options. Techniques that have demonstrated benefit in diabetic neuropathy include the following: pulsed infrared light therapy, which has shown positive results in sensation and pain reduction, and transcutaneous nerve stimulation, which blocks the conduction of nerve signals to the brain through electrical impulses and has been shown to improve numbness, pain, and prickling sensation.30 Relaxation techniques including yoga, meditation, and guided imagery may reduce stress and pain, may improve mood, and provide benefit for patients with CIPN.33 By providing the patient with strategies to manage the effects of CIPN, the oncology nurse can have a positive effect on quality of life. Conclusion Both the extent of surgical effort and selection of chemotherapy agents can impact survival in ovarian cancer. Treatment of this patient consisted of a bilateral salpingo-oophorectomy, rectosigmoid resection, omentectomy,

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www.JOMCC.com diaphragm peritonectomy, and resection of tumor implants followed by treatment with a combination of intravenous and intraperitoneal cisplatin and paclitaxel. With this regimen chosen, preventing or minimizing toxicities became our secondary focus. When patients experienced CIPN, docetaxel was substituted for paclitaxel and supportive care measures were implemented. When the disease recurred, her platinum-sensitive status led to treatment with a platinum drug (carboplatin) and liposomal doxorubicin, which was favored over paclitaxel because of her history of CIPN. This patient continues to do well. l

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References 1. American Cancer Society. Cancer Facts & Figures 2009. Atlanta, GA: American Cancer Society; 2009. 2. Goff BA, Mandel LS, Melancon CH, Muntz HG. Frequency of symptoms of ovarian cancer in women presenting to primary care clinics. JAMA. 2004; 291:2705-2712. 3. Goff BA, Mandel LS, Drescher CW, et al. Development of an ovarian cancer symptom index. Cancer. 2007;109:221-227. 4. Bristow RE, Tomacruz RS, Armstrong DK, et al. Survival effect of maximal cytoreductive surgery for advanced ovarian carcinoma during the platinum era: a meta-analysis. J Clin Oncol. 2002;20:12481259. 5. Eisenhauer EL, Abu-Rustum NR, Sonoda Y, et al. The effect of maximal surgical cytoreduction on sensitivity to platinum-taxane chemotherapy and

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subsequent survival in patients with advanced ovarian cancer. Gynecol Oncol. 2008;108:276-281. Aletti GD, Dowdy SC, Podratz KC, Cliby WA. Relationship among surgical complexity, short-term morbidity, and overall survival in primary surgery for advanced ovarian cancer. Am J Obstet Gynecol. 2007;197:676.e1-e7. Leitao MM Jr, Chi DS. Operative management of primary epithelial ovarian cancer. Curr Oncol Rep. 2007;9:478-484. Aletti GD, Dowdy SC, Gostout BS, et al. Aggressive surgical effort and improved survival in advanced stage ovarian cancer. Obstet Gynecol. 2006;107:77-85. Ozols RF, Bundy BN, Greer BE, et al. Phase III trial of carboplatin and paclitaxel compared with cisplatin and paclitaxel in patients with optimally resected stage III ovarian xancer: a Gynecologic Oncology Group Study. J Clin Oncol. 2003;21:3194-3200. McGuire WP, Hoskins WJ, Brady MF, et al. Cyclophosphamide and cisplatin compared with paclitaxel and cisplatin in patients with stage III and stage IV ovarian cancer. N Engl J Med. 1996;334:1-6. Armstrong DK, Bundy B, Wenzel L, et al; for the Gynecologic Oncology Group. Intraperitoneal cisplatin and paclitaxel in ovarian cancer. N Engl J Med. 2006;354:34-43. Vasey PA, Jayson GC, Gordon A, et al; for the Scottish Gynaecological Cancer Trials Group. Phase III randomized trial of docetaxel-carboplatin versus paclitaxel-carboplatin as first-line chemotherapy for ovarian carcinoma. J Natl Cancer Inst. 2004;96:1682-1691. Diaz-Montes TP, Bristow RE. Secondary cytoreduction for patients with recurrent ovarian cancer. Curr Oncol Rep. 2005;7:451-458. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Ovarian Cancer. V.2.2010. www.nccn.org/professionals/physi cian _gls/PDF/ovarian.pdf. Accessed April 18, 2010. Pujade-Lauraine E, Mahner S, Kaern J, et al. A randomized, phase III study of carboplatin and pegylat-

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ed liposomal doxorubicin versus carboplatin and paclitaxel in relapsed platinum-sensitive ovarian cancer (OC): CALYPSO study of the Gynecologic Cancer Intergroup (GCIG). J Clin Oncol. 2009; 27(18S):Abstract LBA5509. Herzog TJ. The current treatment of recurrent ovarian cancer. Curr Oncol Rep. 2006;8:448-454. Wolf S, Barton D, Kottschade L, et al. Chemotherapy-induced peripheral neuropathy: prevention and treatment strategies. Euro J Cancer. 2008;44: 1507-1515. Ocean AJ, Vahdat LT. Chemotherapy-induced peripheral neuropathy: pathogenesis and emerging therapies. Support Care Cancer. 2004;12:619-625. Gamelin L, Boisdron-Celle M, Delva R, et al. Prevention of oxaliplatin-related neurotoxicity by calcium and magnesium infusions: a retrospective study of 161 patients receiving oxaliplatin combined with 5-fluorouracil and leucovorin for advanced colorectal cancer. Clin Cancer Res. 2004; 10(12 pt 1):4055-4061. Nikcevich DA, Grothey A, Sloan JA, et al. A phase III randomized, placebo controlled, double-blind study of intravenous calcium/magnesium to prevent oxaliplatin-induced sensory neurotoxicity, N04C7. J Clin Oncol. 2008;26(May 20 suppl):Abstract 4009. Armstrong CM, Cota G. Calcium block of Na+ channels and its effect on closing rate. Proc Natl Acad Sci U S A. 1999;96:4154-4157. Pace A, Savarese A, Picardo M, et al. Neuroprotective effect of vitamin E supplementation in patients treated with cisplatin chemotherapy. J Clin Oncol. 2003;5:927-931. Argyriou AA, Chroni E, Koutras A, et al. Vitamin E for prophylaxis against chemotherapy-induced neuropathy: a randomized controlled trial. Neurology. 2005;64:26-31. Cascinu S, Cordella L, Del Ferro E, et al. Neuroprotective effect of reduced glutathione on cisplatin-based chemotherapy in advanced gastric cancer: a randomized double-blind placebo-controlled trial. J Clin Oncol. 1995;13:26-32. Smyth JF, Bowman A, Perren T, et al. Glutathione

26. 27.

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reduces the toxicity and improves quality of life of women diagnosed with ovarian cancer treated with cisplatin: results of a double blind, randomised trial. Ann Oncol. 1997;8:569-573. Ethyol (amifostine) [package insert]. Nijmegen, the Netherlands: MedImmune; 2009. Hilpert F, Stahle A, Tome O, et al; for the Arbeitsgemeinschaft Gynäkologische Onkologoie (AGO) Ovarian Cancer Study. Neuroprotection with amifostine in the first-line treatment of advanced ovarian cancer with carboplatin/paclitaxel-based chemotherapy—a double-blind, placebocontrolled, randomized phase II study from the Arbeitsgemeinschaft Gynakologische Onkologoie (AGO) Ovarian Cancer Study Group. Support Care Cancer. 2005;13:797-805. Leong SS, Tan EH, Fong KW, et al. Randomized double blind trial of combined modality treatment with or without amifostine in unresectable stage III non-small cell lung cancer. J Clin Oncol. 2003;21: 1767-1774. Schuchter LM, Hensley ML, Meropol NJ, Winer EP; for the American Society of Clinical Oncology Chemotherapy and Radiotherapy Expert Panel. 2002 update of recommendations for the use of chemotherapy and radiotherapy protectants: clinical practice guidelines of the American Society of Clinical Oncology. J Clin Oncol. 2002;20:2895-2903. Visovsky C, Collins M, Abbott L, et al. Putting evidence into practice: evidence-based interventions for chemotherapy-induced peripheral neuropathy. Clin J Oncol Nurs. 2007;11:901-913. Wickham R. Chemotherapy-induced peripheral neuropathy: a review and implications for oncology nursing practice. Clin J Oncol Nurs. 2007;11:361376. Stubblefield MD, Burstein HJ, Burton AW, et al. NCCN Task Force Report: management of neuropathy in cancer. J Natl Compr Canc Netw. 2009; 7(suppl 5):S1-S28. Paice J. Clinical challenges: chemotherapy-induced peripheral neuropathy. Semin Oncol Nurs. 2009;25 (2 suppl 1):S8-S19.

Operational and Financial Benchmarking... Continued from page 17 poor measure of actual oncology patient volume, which is largely outpatient; or because local program administrators find it difficult to secure valid and reliable outpatient or analytic case market share data for their institution and certainly for competitors. In 2010, this theory was supported, with respondents saying things such as “our hospital uses state-wide data for market share, but it is MS-DRG–based, which is not useful for the cancer program.” Others are utilizing cancer registry data for market share, but realize the limitation of timing for this measurement. Time to treatment used rarely One key patient dis-satisfier is often time to treatment, defined as the time from diagnosis to definitive treatment. Two (12%) respondents indicated that they used a time to treatment benchmark as part of their operational evaluations in 2007; no respondent reported using this metric in 2010. Remaining benchmarks Respondents identified many other measurements they used in developing business cases or requests for resources. These included: • Technology assessment based on the advisory board • Number of individuals attending community events

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• Grant or contract funding available for particular program elements. An interesting finding seen in 2010 but not seen in 2007 was the number of respondents who stated that they measured the use of drug replacement programs to show money saved to justify support for that program. Just over one third (3) of the respondents reported measuring this metric. Conclusions and discussion These survey results, although informal and limited in their general use, do show that cancer program administrators use a vast array of indicators to support their requests for continued or increased funding. As working oncology program administrators recognize (but which fewer hospital administrators may know), cancer care often represents 10% to 15% of a general hospital’s revenue. Furthermore, cancer patients often provide the majority of vaunted patient volume for at least three key hospital departments—the operating room, diagnostic radiology, and laboratory/pathology. Moreover, as reimbursement continues to be “rationalized,” an increasing number of supportive care or ancillary services targeted to cancer patients remain unfunded by the Centers for Medicare & Medicaid Services and other major insurers. These unreim-

bursed items include program elements such as patient navigation, nutrition counseling, financial counseling, support programs (support groups), and education. All these factors make it clear to program administrators that it is incumbent on them to continue to procure the funds necessary to care for individuals diagnosed with cancer who come to their institution for all, or most, of their care.

Procuring these funds typically requires the program administrator to “frame the cancer experience from the view of senior management,” as Catherine Harvey, RN, DrPH, AOCN, a leading cancer business consultant, puts it. This means coming to budget meetings armed with the facts that will tell your institution’s cancer care story in a compelling manner that covers both margin and mission. l

Breast MRI Accreditation Program In May 2010, the American College of Radiology (ACR) Committee on Breast Magnetic Resonance Imaging (MRI) Accreditation launched its Breast MRI Accreditation Program (BMRAP). This program enables facilities to improve and maintain the quality of their breast MRI services through a peer-reviewed assessment of their processes, equipment, and the quality of their images. BMRAP sets quality standards for providers and will help them continuously improve their patient care by evaluating the qualifications of personnel, equipment performance, effectiveness of quality control measures, and image quality. For facilities that solely offer breast MRI services, BMRAP fulfills the accreditation requirements under the Medicare Improvements for Patients and Providers Act. The ACR has accredited more than 20,000 facilities nationwide and has added to its staff of certified radiologic technologists to help providers through all stages of the accreditation process. The ACR does not require a fee to access the application nor an annual fee. l

JUNE 2010 I VOL 3, NO 4

Prostate Cancer

Hypofractionated Salvage Radiotherapy May Be Beneficial for Postprostatectomy Biochemical Recurrence By John Schieszer

SAN FRANCISCO—Hypofractionated radiotherapy (65 Gy in 2.5-Gy fractions) appears to be a convenient, safe,

and efficacious approach to salvage therapy after radical prostatectomy, according to researchers from the University of

Wisconsin. Looking at 108 men, investigators found that biochemical failure (increasing prostate-specific antigen lev-

with new enhanced online services There is A place you can go for user-friendly online tools and reimbursement forms… …where your coverage questions can be Answered …where online Access to forms is simple …where you can talk to A reimbursement specialist directly

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For insurance verification…prior authorization…patient assistance program information…and billing and claims processing support. Amgen Assist™ and Amgen Inc. do not guarantee success in obtaining reimbursement. Third party payment for medical products and services is affected by numerous factors, not all of which can be anticipated or resolved by our Amgen Assist™ staff. ©Amgen. All rights reserved. MC48319 11/09

JUNE 2010 I VOL 3, NO 4

Making Access easier.

els) compared favorably with other studies. They presented their findings at the 2010 Genitourinary Cancers Symposium. Approximately 25% of men experience biochemical failure following prostatectomy, so early salvage therapy may be a suitable alternative to the adjuvant treatment of patients at higher risk for failure. Other studies have suggested that hypofractionation is well-tolerated and efficacious in the definitive setting but experience in the salvage setting has been limited. It is theorized that hypofractionation may improve efficiency, reduce costs, and provide patient benefits in this population. For the current study, researchers conducted a retrospective analysis of 108 men (mean age, 63 years) treated to the prostatic fossa with 65 Gy in 26 fractions of 2.5 Gy. The median follow-up was 32.4 months (range, 5.8-70.5). A total of 18 (17%) patients had androgen-deprivation therapy following surgery or concurrently with radiation (maximum duration of 2 months after salvage). The researchers found that the actuarial freedom from biochemical failure at 4 years was 67%. They also found that only two biochemical failures occurred later than 24 months. The investigators found only one acute grade 3 genitourinary toxicity (obstruction) in a patient previously treated for bladder neck contracture. “We found it is very safe, and the level of side effects was very low. The level of side effects is consistent with or lower than what people have found with more standard and longer course radiation therapy. Secondly, it also appears to be very effective. We found that almost 70% of the patients longterm have reestablished control of their tumors,” said study investigator Mark Ritter, MD, who is a professor of human oncology at the University of Wisconsin School of Medicine and Public Health, Madison in an interview with the Journal of Multidisciplinary Cancer Care. He said that approach is much more convenient for the patients and a more efficient use of equipment. He said it could prove to be a boon to patients and medical facilities if they adopted this regimen on a wide scale. Lead study investigator Tim Kruser, MD, an oncology resident at the University of Wisconsin, said these findings are very good news for men who have radical prostatectomies. He said patients would like to have their treatment in a quicker fashion. “It means fewer patient visits, it would be cheaper overall, and the side effects are similar to more traditional regimens,” said Kruser. l

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ONCOLOGY DRUG CODES Supplied by: RJ Health Systems

Medications Used for the Treatment of Lung Cancer Lung cancer forms in tissues of the lung, usually in the cells lining the air passages. The two main types are small-cell lung cancer and non– small-cell lung cancer. The following section will assist healthcare professionals and payers by providing appropriate coding, billing, and reimbursement information associated with the management of lung cancer. The following sections include: • Associated ICD-9-CM codes used for the classification of lung cancer • Drugs that have been FDA-approved in the treatment of lung cancer • Drugs that are compendia listed for off-label use for lung cancer based on clinical studies that suggest beneficial use in some cases. Please note: if a check mark appears in the FDA column, it will NOT appear in the compendia off-label use column • Corresponding HCPCS/CPT codes and code descriptions • Current Code Price (AWP-based pricing) • Most recent ASP plus 6% (Medicare allowable), if applicable • Possible CPT Administration Codes for each medication

generic (Brand) name

HCPCS code: code description

amifostine (Ethyol) bevacizumab (Avastin) carboplatin (Paraplatin) cetuximab (Erbitux) cisplatin (Platinol AQ) cisplatin (Platinol AQ) cyclophosphamide (Cytoxan) cyclophosphamide (Cytoxan)

J0207: injection, amifostine, 500mg J9035: injection, bevacizumab, 10 mg J9045: injection, carboplatin, 50 mg J9055: injection, cetuximab, 10 mg J9060: cisplatin, powder or solution, per 10 mg J9062: cisplatin, 50 mg

cyclophosphamide (Cytoxan)

J8530: cyclophosphamide, oral, 25 mg J9070: cyclophosphamide, 100 mg (All 100 mg NDCs inactive—500 mg NDCs used to calculate code price) J9080: cyclophosphamide, 200 mg (All 200 mg NDCs inactive—500 mg NDCs used to calculate code price) J9090: cyclophosphamide, 500 mg

Associated ICD-9-CM Codes Used for Lung Cancer 162 Malignant neoplasm of trachea, bronchus, and lung 162.0 Trachea Cartilage of trachea Mucosa of trachea 162.2 Main bronchus Carina Hilus of lung 162.3 Upper lobe, bronchus or lung 162.4 Middle lobe, bronchus or lung 162.5 Lower lobe, bronchus or lung 162.8 Other parts of bronchus or lung Malignant neoplasm of contiguous or overlapping sites of bronchus or lung whose point of origin cannot be determined 162.9 Bronchus and lung, unspecified

FDAapproved for lung cancer

Compendia listed off-label use for lung cancera

Current code price (AWP-based pricing), effective 6/1/10

Medicare allowable (ASP + 6%), effective 4/1/10-6/30/10

CPT administration codes

$564.95

$327.96

$66.99

$57.57

✓

$48.55

$5.31

✓

$57.60

$49.73

✓

$4.33

$1.98

96409, 96413, 96415

✓

$21.66

$9.91

96409, 96413, 96415

✓

$2.09

$0.84

✓

$10.57

$4.35

96409, 96413, 96415

✓

$21.15

$8.69

96409, 96413, 96415

✓

$52.87

$21.73

96409, 96413, 96415

✓

96374 96413, 96415 96409, 96413, 96415 96413, 96415

N/A

Continued on page 24 www.JOmcc.com

JUNE 2010 I VOL 3, NO 4

ONCOLOGY DRUG CODES Supplied by: RJ Health Systems Continued from page 23

generic (Brand) name

HCPCS code: code description

cyclophosphamide (Cytoxan) cyclophosphamide (Cytoxan) docetaxel (Taxotere) doxorubicin HCl (Adriamycin) erlotinib (Tarceva)

J9091: cyclophosphamide, 1.0 gram J9092: cyclophosphamide, 2.0 gram J9171: injection, docetaxel, 1 mg J9000: injection, doxorubicin hydrochloride, 10 mg J8999b: prescription drug, oral, chemotherapeutic, not otherwise specified J8560: etoposide, oral, 50 mg J9181: injection, etoposide, 10 mg J8565: gefitinib, oral, 250 mg J9201: injection, gemcitabine hydrochloride, 200 mg J8999b: prescription drug, oral, chemotherapeutic, not otherwise specified S0176: hydroxyurea, oral, 500 mg

etoposide (Vepesid) etoposide (Toposar) gefitinib (Iressa) gemcitabine (Gemzar) hydroxyurea (Hydrea) hydroxyurea (Hydrea) ifosfamide (Ifex) irinotecan (Camptosar) mechlorethamine HCl (Mustargen)

J9208: injection, ifosfamide, 1 gram J9206: injection, irinotecan, 20 mg J9230: injection, mechlorethamine hydrochloride (nitrogen mustard), 10 mg methotrexate J8610: methotrexate, oral, 2.5 mg methotrexate sodium J9250: methotrexate sodium, 5 mg methotrexate sodium J9260: methotrexate sodium, 50 mg mitomycin J9280: mitomycin, (Mutamycin) 5 mg mitomycin J9290: mitomycin, (Mutamycin) 20 mg mitomycin J9291: mitomycin, (Mutamycin) 40 mg paclitaxel J9265: injection, (Taxol) paclitaxel, 30 mg paclitaxel J9264: injection, protein-bound paclitaxel protein-bound particles particles, 1 mg (Abraxane) panitumumab J9303: injection, (Vectibix) panitumumab, 10 mg

JUNE 2010 I VOL 3, NO 4

FDAapproved for lung cancer

Compendia listed off-label use for lung cancera

Current code price (AWP-based pricing), effective 6/1/10

Medicare allowable (ASP + 6%), effective 4/1/10-6/30/10

CPT administration codes

✓

$95.21

$43.46

96409, 96413, 96415

✓

$171.35

$86.92

96409, 96413, 96415

✓

$23.87

$17.85

96413

✓

$13.20

$3.04

96409

✓

N/A

✓

NDC level pricing $47.64

$28.26

N/A

✓

$0.53

$0.49

✓

$68.08

✓

$173.83

none reported $145.10

96413, 96415 N/A 96413

✓

NDC level pricing $1.28

✓

$56.40

NDC level pricing S0176 not payable by Medicare $30.76

✓

$31.50

$9.15

✓

$178.71

$154.50

96409

✓

$3.61

$0.16

N/A

✓

$0.29

$0.21

✓

$2.86

$2.10

✓

$67.20

$20.36

96372, 96374, 96401, 96409, 96450 96372, 96374, 96401, 96409, 96450 96409

✓

$218.40

$81.43

96409

✓

$300.00

$162.87

96409

$16.50

$11.46

✓

$11.20

$9.43

✓

$101.85

$87.23

✓

N/A

96413, 96415 96413, 96415

96413, 96415 96413

96413, 96415

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ONCOLOGY DRUG CODES Supplied by: RJ Health Systems

generic (Brand) name

HCPCS code: code description

pemetrexed (Alimta) porfimer sodium (Photofrin) procarbazine (Matulane)

J9305: injection, pemetrexed, 10 mg J9600: injection, porfimer sodium, 75 mg J8999b: prescription drug, oral, chemotherapeutic, not otherwise specified S0182: procarbazine HCl, oral, 50 mg

procarbazine (Matulane) tamoxifen (Nolvadex) tamoxifen (Nolvadex) teniposide (Vumon) topotecan (Hycamtin) topotecan (Hycamtin) trastuzumab (Herceptin) vinBLAStine vinCRIStine (Vincasar) vinCRIStine (Vincasar) vinCRIStine (Vincasar) vinorelbine tartrate (Navelbine) a

FDAapproved for lung cancer

Compendia listed off-label use for lung cancera

Current code price (AWP-based pricing), effective 6/1/10

Medicare allowable (ASP + 6%), effective 4/1/10-6/30/10

CPT administration codes

✓

$60.67

$50.63

96409

✓

$3,317.04

$2,934.28

96409 N/A

J8999b: prescription drug, oral, chemotherapeutic, not otherwise specified S0187: tamoxifen citrate, oral, 10 mg

✓

NDC level pricing $1.89

Q2017: injection, teniposide, 50 mg J8705: topotecan, oral, 0.25 mg J9350: injection topotecan, 4 mg J9355: injection, trastuzumab, 10 mg J9360: injection, vinblastine sulfate, 1 mg J9370: vincristine sulfate, 1 mg J9375: vincristine sulfate, 2 mg J9380: vincristine sulfate, 5 mg J9390: injection, vinorelbine tartrate, per 10 mg

✓

$376.55

NDC level pricing S0182 not payable by Medicare NDC level pricing S0187 not payable by Medicare $324.55

✓

$89.73

$74.66

N/A

✓

$1,306.10

$1,058.90

96413

✓

$78.26

$66.42

✓

$3.18

$1.02

96409

✓

$7.22

$4.31

96409

✓

$14.44

$8.62

96409

✓

$36.10

$21.54

96409

$42.60

$10.05

96409

✓

NDC level pricing $55.68

N/A

96413, 96415

Compendia references available upon request.

When billing a non-classified medication using a CMS 1500 claim form you must include both the HCPCS code (ie, J8999 for Tarceva) in Column 24D and the drug name, strength, and National Drug Code (NDC) in Box 19 in order to ensure appropriate reimbursement.

References HCPCS Level II Expert 2010 • Current Procedural Terminology (CPT) 2010 • ICD-9-CM for Professionals Volumes 1 & 2 2010 • The Drug Reimbursement Coding and Pricing Guide by RJ Health Systems International, LLC, Volume 7, Number 2, 2nd Quarter 2010 • FDA-approved indication (from product’s prescribing information) • National Cancer Institute® • www.ReimbursementCodes.com powered by RJ Health Systems International, LLC, Wethersfield, Connecticut • CMS (Centers for Medicare and Medicaid Services)—Medicare Allowable 2nd Quarter 2010 (effective dates 4/1/106/30/10). Prices listed herein are effective as of June 1, 2010. ASP indicates average sales price; AWP, average wholesale price; CMS, Centers for Medicare & Medicaid Services; CPT, Current Procedural Terminology; FDA, US Food and Drug Administration; HCPCS, Healthcare Common Procedure Coding System; NDC, National Drug Code.

This information was supplied by:

PO BOX 290616, Wethersfield, CT 06109 T: (860) 563-1223 • F: (860) 563-1650 www.RJHealthSystems.com

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JUNE 2010 I VOL 3, NO 4

Cancer Center–Physician Alignment Establishing Relationships... Continued from cover ing for a way to structure what we could provide to physicians who were participatory, those who were giving their time and expertise in a voluntary capacity. We wanted to structure it in a way that made it clear that what we offered would set these physicians apart. We looked for what we could give them back. In crafting the conditions, what incentives do you offer physicians? We offer them support for research. Our staff puts new studies through the institutional review board, our staff does all the data management, and our staff does all the contracting. In addition, we have a budget for when the physicians take histories and perform physicals; when they do work related to the research they are reimbursed. This gives our physicians the advantage of being able to offer their patients national studies without incurring the overhead and the work. We also involve the physicians in decision making when it comes to technology and equipment. For example, we just selected a new cancer electronic health record (EHR) system. The physicians were very much a part of the decision making and requirement setting for what capabilities needed to be included in the EHR. That was significant, not only in the respect that it was selecting what would go on in the cancer center but also in the respect that full participants would have priority in gaining access to that EHR in their offices. In addition, we are negotiating a very favorable financial arrangement so that it is easy for them to implement the EHR and meet the meaningful use requirement in the American Recovery and Reinvestment Act. Physicians who are full participants are featured on our website. We found that our physicians like being connected with the center. Because we promote our website quite a bit, they see it as an opportunity to be highlighted. We also offer physicians opportunities to participate in community events and physician education events. Plus, we support all the cancer conferences— more than 20 per month. Our staff reports all of our physicians’ cancer cases to our cancer registry. Our staff also takes care of the state-mandated requirement for cancer reporting. In addition, we track and manage many of the outcomes through our American College of Surgeon’s Commission on Cancer registry. Many have some special outcomes that they want to track in addition to survival, and we keep those up. The other thing that we do is we pro-

JUNE 2010 I VOL 3, NO 4

vide some nurse support. The center has nurse navigators who support these physicians as well as act as a safety net or additional coordinator for patients. For example, perhaps a patient had a clinical consultation and didn’t quite understand it. That patient will go to the navigator and ask what it all means or to put it into perspective. The nurse navigators work directly for the center, not any one physician. What do you expect the physicians to give back to the center? Our physicians are expected to be present at at least half of the cancer conferences. Our program is structured into site-specific teams. We have a breast team, a colorectal team, a urologic oncology team, a melanoma team, a head and neck team, and a liver tumor team. For some of the sitespecific teams, there is a core set of expectations on the hospital side as well as on the physician side, and there are some team-designed additions. For example, the lung team wants to see suspicious nodules within 48 hours. The genetics team has asked for a specific requirement regarding training for their members. A variety of things can be added to make the conditions of participation unique to each site-specific team. Physicians also need to be timely in terms of when they see referred patients. We expect that they will see these patients within 1 week, that they will provide verbal consults with the referring physicians within the same business day, that they will provide second opinions, and that they will maintain communication with the primary care or referring physician. We also expect the physicians to participate in a very active way with our nurse navigators. In addition, we started a breast clinic for underserved women, at which physicians are expected to provide care on a rotational basis, knowing full well that the reimbursement will not be very good. Physicians need to be board-certified and maintain their medical staff membership. They must participate in local, regional, and national organizations to maintain professional expertise. Physicians also must support us in publications and presentations at regional and national conferences. One of the biggest things we expect from our physicians is data. Physicians have to share their data so that we can generate outcomes, track outcomes, and publish outcomes. We also use these data to determine where we stand and where there are opportunities for improvement, and to know where we do very well, which we like to make

known. This includes things like participation in the American Society for Clinical Oncology’s Quality Oncology Practice Initiative, registry data, and, if we are doing a special study, the outcomes. We have done numerous special studies and have found that the physicians truly get engaged in the outcomes. They are as interested as we are in producing them. Physicians also participate in patient-satisfaction activities. We use those data to ensure that not only are we doing all the clinical things but also the satisfiers that are important to our patients and their families. We also require that the physicians participate in research. Part of this is going through the organizational mandate of city training. They cannot become a subinvestigator until they complete that training.

using a stick or anything. It is “here are our expectations, can you meet them or not; is this of interest?”

In developing your business model, did the center approach physicians or did physicians approach the center? The decision to design a new business model began when some of our physicians noticed the difference between the care some physicians gave compared with others. Because community physicians chose their referral patterns and because hospital-participating physicians had access to hospital resources, those who participated heavily wanted there to be a recognizable distinction. At the same time, the hospital wanted to structure something for recognition purposes. The hospital wanted to create those boundaries that are recognized legally as these individuals are giving and we are returning support in like quantities, that is, fair market value.

Were there any significant challenges you had to overcome? The biggest challenge is actually the tracking. Also, medical oncologists often view themselves as generalists, that is, they can do all cancers. The fact of the matter is that for the level of participation we are looking for as well as for just keeping up with all the data that are generated, it was very hard for some, because they want to do everything and they overwork themselves going to all the conferences to meet the participation requirements. We now are asking them to choose their passion. We want them to choose the conferences that appeal to them because when they come to the conferences, the expectation is that they will contribute, they will be an active member of the team with respect to research, presentations, and outcomes. We expect them to generate referrals among their colleagues who see them doing all this participation and sharing knowledge.

What research did you perform when developing your conditions of participation? We did some searches, both formally and informally, and some networking among colleagues. I spoke with Pat Grusenmeyer, past president of the Association of Cancer Executives and senior vice president of Christiana Care Health System, about conditions of participation. Christiana Care had just taken that step and published an article on it. We accessed that information, and then vetted it through a number of our physician leaders to see their responses. The key was to look at things that were sustainable, and doable, and had value for both parties. Another important component was that we invited the whole medical staff to choose whether they were going to opt in or out. Someone was not choosing for them. It was them making that choice for themselves. With that, it is not the hospital

What follow-up measures did you build into the system to ensure both parties meet expectations? We always track who is at cancer conferences. The registry is also tracked as far as who shares data. We have not met resistance. Sometimes it is cumbersome, sometimes it is time-consuming. It turns out that for the physicians were so participatory in the selection of our cancer EHR, it is not a matter of will they participate or will they share their data. It is a matter of how fast can they get it done. When they are part of the solution and they are part of making the center better and they truly have roles, there is a very different feel. It is truly much more of a partnership.

Is there anything you would recommend to physicians who wish to get involved in a program like yours? If they are looking to find common ground and quality is of concern and if they want to do outcomes work and they want research support, I think this mechanism is one that truly supports private practice physicians and creates a nonlegal relationship with a cancer center where expectations are clear. For the centers that chose to go down this path and the physicians who chose to participate at this level, I think this is how they can get the harmony and the quality patient care. Everyone is on the same page as far as this is the best for patient outcomes and this is the best as far as the clinical outcomes. It is agreement on that vision. l

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value-focused www.ValueBasedCancer.com www.ValueBasedCancer.com

New NewTools ToolsArriving ArrivingtotoMeasure Measureand and NCCN NCCNRoundtable: Roundtable:Clinical Clinicaland and Manage Economic ManageChemotherapy ChemotherapyCare Care EconomicIssues IssuesImpacting Impacting Business, Cancer Business,clinical clinicalconcerns concernsnow nowconnected connectedinin CancerCare CareDelivery Delivery value-focused value-focusedapproach approach ByBy Daniel Denvir Daniel Denvir

payers

Baltimore, MD—A long-held business Baltimore, MD—A long-held business truism is is that “if“if you can’t measure it, it, truism that you can’t measure you it.”it.” The application youcan’t can’tmanage manage The application ofofthis thisbelief beliefto tothetheoncology oncologysetting setting was demonstrated at a session of the was demonstrated at a session of the Association AssociationofofCommunity CommunityCancer Cancer Cen ters’ 36th Annual National Cen ters’(ACCC) (ACCC) 36th Annual National Meeting. Kimberly Bergstrom, PharmD, Meeting. Kimberly Bergstrom, PharmD, chief clinical officer for McKesson chief clinical officer for McKesson Specialty Care Solutions, told attendees Specialty Care Solutions, told attendees ofof thethe growing importance of of developing growing importance developing and andusing usingstandardized standardizedchemotherapy chemotherapy treatment regimens, and of of thethe tools that treatment regimens, and tools that

cost control

clinical practice guidelines

“Collision “Collisioncourse” course”ininsight sight cancan benchmark performance andand foster benchmark performance foster compliance with treatment guidelines. Dr DrGoodman Audrey Andrews Goodman compliance with treatment guidelines. By By Audrey Andrews Public and private payers areare movalluded to atolevel Public and private payers movalluded a level ingingto tocontrol exploding healthcare thatthat of frustration control exploding healthcare Hollywood, Hollywood,FL—Clinical FL—Clinicalpractice practice of frustration never been costs, told attendees, issued by by thethe National costs,DrDrBergstrom Bergstrom told attendees, guidelines guidelines issued National hashas never been and control in in cancer andbecause becauseincreased increasedcost cost control Comprehensive ComprehensiveCancer CancerNetwork Network higher higher cancer was areare followed by by conscien“Too many wasinevitable, inevitable,it itis isin inproviders’ providers’ (NCCN) (NCCN) followed conscien- care. care. “Too many interest to to getget a seat at at thethe table. tious oncologists in in their everyday areare stillstill interest a seat table. tious oncologists their everyday patients patients “It“It is is anan important topic, because areare developed young. WeWe important topic, because practice, practice,butbutthey they developed dying dying young. this is one of of those things, if we don’t on on clinical efficacy andand without innovations andand a cure,” he said. this is one those things, if we don’t based based clinical efficacy without need need innovations a cure,” he said. getget a handle on it, it’s going to happen regard to costs. At a roundtable held But the inadequacy of current treatof current treata handle on it, it’s going to happen regard to costs. At a roundtable held But the inadequacy to to us,” sheshe said. “People and groups NCCN’s 15th Annual for for cancer is no the the main us,” said. “People and groups during duringthethe NCCN’s 15th Annual ments ments cancer is longer no longer main Equally challenging, he sugand organizations areare going to to start and organizations going start Conference, Conference, moderator moderator Clifford Clifford problem. problem. Equally challenging, he sugdictating how we provide cancer care, Goodman, PhD, Senior Vice President gested, is finding a means to pay for dictating how we provide cancer care, Goodman, PhD, Senior Vice President gested, is finding a means to pay for and wewe can’t letlet that happen.” at The Lewin Group, predicted, “The ever-costlier carecare thatthat threatens to to and can’t that happen.” at The Lewin Group, predicted, “The thethe ever-costlier threatens appropriate use of evidence-based bankrupt the healthcare system. Continued on page 8 appropriate use of evidence-based bankrupt the healthcare system. Continued on page 8 guidelines is on a collision course As society struggles to find soluAs society struggles to find soluguidelines is on a collision course with the financial nonsustainability of tions, “the ground is shaking beneath with the financial nonsustainability of tions, “the ground is shaking beneath the healthcare system.” us,” Dr Goodman commented. the healthcare system.” us,” Dr Goodman commented.

Value-Based Value-BasedCancer CancerCare Care will willbebeatatthe theASCO ASCOAnnual Annual Meeting, June 4-8, in Chicago. Meeting, June 4-8, in Chicago.

Continued on page 19 Continued on page 19

Please visit usus atat booth 18121 Please visit booth 18121

SEER-Medicare SEER-MedicareDatabase DatabaseAnalysis Analysis Confirms Expensive Prostate Confirms Expensive Prostate Breast BreastCancer CancerSurvival SurvivalImproves, Improves, Cancers CancersGaining GainingSupremacy Supremacy Photo by © ASCO/Todd Buchanan 2009 Photo by © ASCO/Todd Buchanan 2009

Thanks ThankstotoNew NewTherapies Therapies

efficacy

cost effectiveness

But remains to to Butcost-effectiveness cost-effectivenessofofthis thismove move remains bebedetermined determined

Breast Cancer Conference (EBCC7). Breast Cancer Conference (EBCC7). This improvement, the researchers By Rosemary Frei, MSc This improvement, the researchers By Rosemary Frei, MSc Barcelona—Survival for patients with suggest, is due to increased use of The 2010 Genitourinary Cancers Barcelona—Survival for patients with suggest, is due to rise increased use of San Francisco, CA—The popularity of The 2010 Progress Genitourinary Cancers metastatic breast cancer has improved anthracyclines and the of targeted Symposium: in Multi San Francisco, CA—The metastatic breast has improved anthracyclines and the rise of targeted minimally Symposium: Progresswas in held Multidramatically in the cancer last 20 years, espe- therapies. Management invasive radical popularity prostatec- of disciplinary minimally radical prostatec- March dramatically in the last 20 years,with espe- “There therapies. disciplinary Management cially in the subgroup of patients is no doubt that trastuzu- tomy 5-7 in San Francisco. Allwas ses-held (MIRP),invasive intensity-modulated tomy (MIRP), intensity-modulated cially in the subgroup of patients with “There is no doubt that trastuzu March 5-7 in San Francisco. All HER2-positive tumors, according to mab (Herceptin), which targets the radiation therapy (IMRT), and of sions emphasized a multidisciplinarysesradiation therapy (IMRT), and of approach HER2-positive mab gene, (Herceptin), which important targets the brachytherapy sions emphasized a multidisciplinary research presentedtumors, at the 7thaccording European to HER2 is the most to care; a number of them combined with IMRT research presented at the 7th European HER2 gene, is the most important forbrachytherapy approach to cost care;and a number of them brought out the value issues prostate cancercombined started towith take IMRT off Continued on page 27 for 2002, prostate cancer started analysis to take off associated broughtwith out the cost for andgenitourivalue issues Continued on page 27 after caring a new database after 2002, a new database analysis associated with caring for genitourinary cancers. has confirmed. hasthe confirmed. nary cancers. At American Society of Clinical At the American Society of Can Clinical Oncology’s 2010 Genitourinary - and Women’s Hospital, Harvard Oncology’s 2010Paul Genitourinary Can- Medical and Women’s Hospital, Harvard School, Boston, and his cocers Symposium, L. Nguyen, cerspresented Symposium, Nguyen, Medical School, his coMD, the Paul resultsL. of his investigators foundBoston, MIRP and jumped investigators found MIRP jumped MD, analysis presentedof the team’s dataresults from of thehis from 1.5% of radical prostatectomies team’s analysis of dataand from from of 28.7% radicalinprostatectomies Surveillance, Epidemiology Endthe (RPs) in 1.5% 2002 to 2005. They Surveillance, Epidemiology and End also(RPs) in 2002 28.7% in 2005. They Results (SEER)-Medicare database. found that to IMRT soared from also found that IMRT treatments soared from Results (SEER)-Medicare Dr Nguyen, director of database. Prostate 8.7% of external radiation Dr Nguyen, director of Prostate for 8.7% of external radiation treatments prostate cancer to 81.7%. In addiBrachytherapy, Dana-Farber/Brigham Brachytherapy, Dana-Farber/Brigham for prostate cancer to 81.7%. In 24 addiContinued on page

By Colin Gittens By Colin Gittens

targeted therapies

Continued on page 24

A new publication for your new vocabulary

www.ValueBasedCancer.com

Viewpoint

No, You Can’t Keep Your Health Plan Insurers and doctors are already consolidating their businesses in the wake of ObamaCare’s passage. By Scott Gottlieb, MD

resident Obama guarbreast cancer patients, smaller “networks” of physicians that anteed Americans that though the facts don’t bear they will contract with so they can after health reform that out. manage doctors more closely. That became law they could keep Restrictions on how in- means even fewer choices for beneficitheir insurance plans and surers can spend money are aries. Insurers hope that owning their doctors. It’s clear that compounded by simultane- providers will enable health policies to this promise cannot be ous constraints on how they offset the cost of the new regulations. kept. Insurers and physican manage their costs. Doctors, meanwhile, are selling their cians are already reshaping Beginning in 2014, a new practices to local hospitals. In 2005, their businesses as a result federal agency will stan- doctors owned more than two-thirds of of Mr. Obama’s plan. dardize insurance benefits, all medical practices. By next year, more Scott Gottlieb, MD The health-reform law placing minimum actuarial than 60% of physicians will be salaried caps how much insurers can spend on values on medical policies. There are employees. About a third of those will expenses and take for profits. Starting also mandates forcing insurers to cover a be working for hospitals, according to next year, health plans will have a regu- lot of expensive primary-care services in the American Medical Association. A lated “floor” on their medical-loss full. At the same time, insurers are review of the open job searches held by ratios, which is the amount of revenue being blocked from raising premiums— one of the country’s largest physicianthey spend on medical claims. Insurers for now by political jawboning, but the recruiting firms shows that nearly 50% can only spend 20% of their premiums threat of legislative restrictions looms. are for jobs in hospitals, up from about on running their plans if they offer policies directly to consumers or to small employers. The spending cap is 15% for Insurers can only spend 20% of their premiums on policies sold to large employers. running their plans if they offer policies directly to This regulation is going to have its biggest impact on insurance sold direct- consumers or to small employers. The spending cap ly to consumers—what’s referred to as is 15% for policies sold to large employers. the “individual market.” These policies cost more to market. They also have higher medical costs, owing partly to One of the few remaining ways to 25% five years ago. selection by less healthy consumers. manage expenses is to reduce the actual Last month, a hospital I’m affiliated Finally, individual policies have high cost of the products. In health care, this with outside of Manhattan sent a note start-up costs. If insurers cannot spend means pushing providers to accept to its physicians announcing a new submore of their revenue getting plans on lower fees and reduce their use of costly sidiary it’s forming to buy up local medtrack, fewer new policies will be offered. services like radiology or other diagnos- ical practices. Nearby physicians are linThis will hit WellPoint, one of the tic testing. ing up to sell—and not just primarybiggest players in the individual market, To implement this strategy, compa- care doctors, but highly paid specialists particularly hard. The insurance com- nies need to be able to exert more con- like orthopedic surgeons and neurolopany already has a strained relationship trol over doctors. So insurers are trying gists. Similar developments are unfoldwith the White House: Earlier this to buy up medical clinics and doctor ing nationwide. month Mr. Obama accused WellPoint practices. Where they can’t own Consolidated practices and salaried of systemically denying coverage to providers outright, they’ll maintain doctors will leave fewer options for

Going for Gold... Continued from page 11 of pancreatic cancer and carries the worst prognosis of any cancer, even when diagnosed early. In 2009, it was estimated that more than 42,000 individuals, typically over the age of 60, were diagnosed with pancreatic cancer, making it the fourth leading cause of cancer death in the United States. A major reason that current pancreatic cancer treatments do not work is that scar tissue develops around the cancer. The scar tissue blocks cancerkilling drugs from entering the tumor. Omary and his colleagues are using a catheter to deliver the gold nanoparticles directly to the tumor. The catheter

JUNE 2010 I VOL 3, NO 4

is placed into an artery near the groin and navigated through blood vessels to the site of the tumor, all without surgery. The direct catheter injections have the potential to reduce side effects, such as vomiting and hair loss, that may be seen with traditional chemotherapy. “Researchers have been using the same toolbox for a long time without any benefit. It’s time for us to apply some high-tech tools to treat pancreatic cancer,” said Omary. Clinical trials are already under way using nanoparticles for other types of cancer. Omary told the Journal of Multidisciplinary Cancer Care that it may be 24 to 36 months

before pancreatic cancer patients can be referred for clinical trials. However, he said research is going well, and preclinical and animal trials have been very promising. Omary said now for the first time oncology team members have some positive news they can give patients with pancreatic cancer. Although this approach is not yet readily available, it does offer hope for the future. Omary said only approximately 5% of patients diagnosed with pancreatic ductal adenocarcinoma survive for 5 years. l

patients and longer waiting times for routine appointments. Like the insurers, physicians are responding to the economic burdens of the President’s plan in one of the few ways they’re permitted to. For physicians, the strains include higher operating costs. The Obama health plan puts expensive new mandates on doctors, such as a requirement to purchase IT systems and keep more records. Overhead costs already consume more than 60% of the revenue generated by an average medical practice, according to a 2007 survey by the Medical Group Management Association. At the same time, reimbursement under Medicare is falling. Some specialists, such as radiologists and cardiologists, will see their Medicare payments fall by more than 10% next year. Then there’s the fact that medical malpractice premiums have risen by 10%20% annually for specialists like surgeons, particularly in states that haven’t passed liability reform. The bottom line: Defensive business arrangements designed to blunt ObamaCare’s economic impacts will mean less patient choice. l Dr. Gottlieb, a former official at the Centers for Medicare and Medicaid Services, is a fellow at the American Enterprise Institute and a practicing internist. He’s partner to a firm that invests in health-care companies. Reprinted with permission. ©Scott Gottlieb. Originally printed in Opinion Journal. The Wall Street Journal. May 18, 2010.

Updates to the NCCN Guidelines for Prostate Cancer The National Comprehensive Cancer Network (NCCN) Prostate Panel has added sipuleucel-T as a category 1 treatment recommendation for patients with castration-recurrent prostate cancer. Sipuleucel-T is appropriate for asymptomatic or minimally symptomatic patients with Eastern Cooperative Oncology Group performance status 0 to 1. It is not recommended for patients with visceral disease and a life expectancy less than 6 months.

—JS

www.JOmcc.com

Chronic Lymphocytic Leukemia The Essentials of Patient Care LOG ON TODAY TO PARTICIPATE www.coexm.com/ace02.asp Release Date: April 29, 2010 Expiration Date: April 28, 2011

TARGET AUDIENCE This activity is intended for hematologists, oncologists and others who are involved with the care of patients with Chronic Lymphocytic Leukemia (CLL).

STATEMENT OF NEED CLL is the most common type of leukemia in the United States, with over 15,000 new cases per year, characterized by the accumulation of monoclonal B cells in the bone marrow, peripheral blood, and lymphoid tissue. Primarily a disease of the elderly, the median survival for CLL varies substantially: many patients survive more than 10 years after diagnosis, but a subset of symptomatic patients have shorter life expectancies—in the range of 1.5 to 6 years. The clinical/research body of knowledge in CLL is rapidly changing and represents a challenge for the whole treatment team.

FACULTY Neil E. Kay, MD Professor Department of Medicine Mayo Clinic Rochester, Minnesota

Michael Keating, MD Course Chair Professor of Medicine Deputy Department Chairman Department of Leukemia M.D. Anderson Cancer Center Houston, Texas

EDUCATIONAL OBJECTIVES On completion of this activity, participants should be able to: • List the essential steps in diagnosis and treatment planning of the CLL patient • Select CLL treatment regimens based on patient characteristics • Define data supporting the benefit/risk ratio of upfront, relapsed, and refractory CLL setting • Define strategies to manage fludarabine-resistant CLL • Describe emerging therapies in CLL

This activity is supported by an educational grant from Genentech BioOncology and Biogen Idec.

This activity has been approved for 1.5 AMA PRA Category 1 Credits™. For further information and to participate, please go to: www.coexm.com/ace02.asp

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