Potential Ripple Effects

In Canada, there are already a few instances of regionalization of cancer care, such as a move in Ontario to centralize treatment for head and neck cancers to high-volume centers, according to the JOP editorial. But if regionalization became more common in Canada, Dr Raphael noted, one question is whether those centers could handle a sudden influx of patients. An abundance of demand at select cancer centers could delay the timely initiation of drug treatment regimens for some patients.

Research shows that the postponement of therapeutic intervention in cancer is associated with inferior survival outcomes, Dr Raphael noted. “So [patients] may lose any benefit they might have accrued by going to that [high-volume] center.”

Since the United States operates on a fee-for-service model, patients couldn’t be mandated to use certain cancer centers, but rather, would have to choose them, Dr Boffa said. Even if that were achievable, he echoed Dr Raphael’s point that there could be health system ripple effects. “The small hospitals would shut down,” Dr Boffa predicted, which would impact local access to health care far beyond cancer treatment.

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Instead, Dr Boffa envisions moving toward a better-coordinated approach, in which a community cancer center would work with a specialized high-volume center to develop an optimal drug treatment plan. “But the treatment doesn’t have to happen at that [high-volume] facility,” he added.

Dr Nichols agrees with that approach conceptually, but said that it flies in the face of the current health care business model in the US. Oncologists typically don’t like to relinquish their patients to larger centers, he said.

“We think we can remediate that to some degree by keeping [patients] at home and having their local oncologist deliver care,” Dr Nichols said. “The problem there is the ego of the local oncologist, which is not insubstantial.”

Dr Nichols acknowledged that this shift in care won’t happen organically. Insurers and/or regulatory entities will need to allow and encourage more consultations, including by telemedicine, with high-volume cancer centers

In the future, Dr Nichols predicted that this need for more consultation with high-volume centers won’t be limited to uncommon malignancies, as genomic advances continue to reshape oncology. Already, he said, a common malignancy like lung cancer can be broken into different treatment subgroups based on the presence of molecular drivers of disease, depending on whether testing identifies actionable gene mutations.

Dr Nichols explained that tapping into the drug-treatment expertise of high-volume centers will become increasingly important as surgery starts taking the backseat. “We’re moving away from big complex surgeries, with better biomarkers and better systemic therapies.”

References

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