June 2010, Vol 3, No 4

Fostering a Dialogue to Improve Patient Care & Outcomes

Submit your cases online today at

www.myelomacases.com

JUNE 2010 www.JOMCC.com VOL 3, NO 4

InsideOncology DrugCodesMedications used forthe treatment of lungcancer

page 23

CE CreditGynecologic oncologic management of widely metastaticserous carcinoma of the ovary

page 18

COMPLIMENTARY

Al B. Benson III, MD, FACP, took the helm as pres-ident of the Association of Community CancerCenters (ACCC) at its 36th annual meeting,

held March 19, 2010, in Baltimore, Maryland. Dr Benson,a member of the ACCC board since 2003, is a professor ofmedicine in the Division of Hematology/Oncology atNorthwestern University Feinberg School of Medicine, Chicago. He is an advocateof comparative effectiveness research (CER) and evidence-based medicine, and

ONCOLOGY ADVOCACY

ACCC President Focuses onEvidence-based Medicineand the Impact of Healthcare ReformAn Interview with Al B. Benson III, MD, FACP

By Daniel Denvir

Continued on page 8

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

Continued on page 12

CANCER CENTER PROFILE

Steeplechase Cancer CenterProvides Patient-centeredCare in Community SettingBy Karen Rosenberg

Steeplechase Cancer Center at Somerset Medical Center in Som -erville, New Jersey, was established in 2007 in response to commu-nity needs for easily accessible high-quality cancer care. The center

is named for the steeplechase horse race, held each October in the neigh-boring community of Far Hills, New Jersey. Proceeds from the race aredonated 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 andtreatment of cancer in one place,” notes Joan Perrone, RPh, one of fourpharmacists who service the infusion center at Steeplechase. SomersetMedical Center is the only full-service hospital in the county, and “it’s anintegral part of the community,” she says. “We do community fundraisersand are well supported by the community.”

CANCER CENTER–PHYSICIAN ALIGNMENT

Establishing Relationshipsbetween a Cancer Center andPrivate Practice PhysiciansAn Interview with Nancy Harris

By Dawn Lagrosa


©2010 Green Hill Healthcare Communications, LLC

Al B. Benson III, MD,FACP

Many community cancer centers desire to offer prospective multidiscipli-nary case conferences for their patients. However, various business mod-els can be set up to achieve this goal. In this interview, Nancy Harris,

administrator of St. Joseph Hospital, The Center for Cancer Prevention andTreatment in Orange, California, discusses how her community center establishedrelationships 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 similarpractice model.

What type of practice model does The Center for Cancer Prevention andTreatment use?It is very much a cooperative relationship. We call the structure to this relation-

ship “conditions of participation.” This terminology came up when we were look-

BenchmarkingOperational and financialbenchmarking for oncologyBy Marsha Fountain, RN,MSN; and Karen Gilden

page 16

ReimbursementSmart money. Part 2:protecting oncologyreimbursementBy Cindy C. Parman,CPC, CPC-H, RCCpage 10

Copyright © 2010 US Oncology, Inc. All rights reserved.

Introducing the United Network of US Oncology. We are America’s largest network of

community-based oncologists. We work together to advance the science of cancer care and

realign reimbursement policies to reward quality care. And with our flexible options, there

are more ways than ever to join us and stand strong together.

To learn more about joining the United Network of US Oncology, visit usoncology.com/MCC

1,300 COLLABORATING ONCOLOGISTS. JOIN US.

EDITOR-IN-CHIEFMark J. Krasna, MDSt. Joseph Cancer InstituteTowson, MDSurgical Oncology

John F. Aforismo,BSc Pharm, RPh, FASCPRJ Health SystemsInternationalWethersfield, CTOncology Pharmacy

Elizabeth Bilotti,RN, MSN, APNcJohn Theuer CancerCenterHackensack UniversityMedical CenterHackensack, NJOncology Nursing

Nicole A.Bradshaw, MS,CICMountain States TumorInstituteNampa, IDOncologyAdministration

Anna M.Butturini, MDChildren’s Hospital Los AngelesLos Angeles, CAMedical Oncology

Minsig Choi, MDG. V. Montgomery VA Medical CenterJackson, MSMedical Oncology

Steven L. D’Amato,RPh, BCOPMaine Center for CancerMedicine Scarborough, MEOncology Pharmacy

Scott E. Eggener,MDUniversity of ChicagoChicago, ILSurgical Oncology

Beth Faiman, RN,MSN, APRN,BC, AOCNCleveland Clinic TaussigCancer InstituteMayfield Heights, OHOncology Nursing

Mehra Golshan,MDDana-Farber CancerInstituteBoston, MASurgical Oncology

Patrick A.Grusenmeyer,ScD, FACHEChristiana Care HealthSystemNewark, DEOncologyAdministration

Marilyn Haas,PhD, CNS, ANP-BCCarePartnersAsheville, NC Oncology Nursing

Dawn Holcombe,MBA, FACMPE,ACHEDGH ConsultingSouth Windsor, CTOncologyAdministration

Patricia Hughes,RN, MSN, BSN,OCNPiedmont HealthcareAtlanta, GAOncology Nursing

Arun Kumar, MDVA Medical CenterHuntington, WVMedical Oncology

Shaji K. Kumar,MDMayo ClinicRochester, MNHematology-Oncology

Terry Macarol,RT(R)(M)(QM)Advocate Health CareOak Brook, ILRadiological Technology

Patrick Medina,PharmD, BCOPOklahoma UniversityCollege of PharmacyTulsa, OKOncology Pharmacy

Patricia Molinelli,MS, RN, APN-C,AOCNSSomerset Medical CenterSomerville, NJOncology Nursing

Judy A. Olson,RT(R), RDMSSt. Luke’s MountainStates Tumor InstituteBoise, IDOncologyAdministration

Nicholas Petrelli,MDHelen F. Graham Cancer CenterChristiana Care Health SystemNewark, DESurgical Oncology

Greg Pilat, MBAAdvocate Health CareOak Brook, ILOncologyAdministration

Cristi Radford,MS, CGCSarasota MemorialHospitalSarasota, FLGenetic Counseling

Ritu Salani, MDOhio State UniversityMedical CenterColumbus, OHMedical Oncology

Andrew Salner,MDHartford RadiationOncologists AssociationHartford, CTRadiation Oncology

Timothy G. Tyler,PharmD, FCSHPComprehensive CancerCenter Desert RegionalMedical CenterPalm Springs, CAOncology Pharmacy

Gary C. Yee,PharmD, FCCP,BCOPUniversity of NebraskaMedical CenterOmaha, NEOncology Pharmacy

Burt Zweigenhaft,BSBioPharma Partners LLCNew York, NYManaged Care

Editorial Board

www.JOmcc.com JUNE 2010 I VOL 3, NO 4 1

JUNE 2010 • VOL 3, NO 4

PUBLISHING STAFFPublisherPhilip [email protected] DirectorKaren [email protected] EditorDawn [email protected], Client ServicesJohn W. [email protected]

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EDITORIAL CORRESPONDENCE should beaddressed to EDITORIAL DIRECTOR, Journal ofMultidisciplinary Cancer Care®, 241 Forsgate Drive, Suite205C, Monroe Twp, NJ 08831. E-mail: [email protected] YEARLY SUBSCRIPTION RATES: UnitedStates and possessions: individuals, $105.00; institutions,$135.00; single issues $17.00. Orders will be billed at indi-vidual rate until proof of status is confirmed. Prices aresubject to change without notice. Correspondence regard-ing permission to reprint all or part of any article publishedin this journal should be addressed to REPRINT PER-MISSIONS DEPARTMENT, Green Hill HealthcareCommunications, LLC, 241 Forsgate Drive, Suite 205C,Monroe Twp, NJ 08831. The ideas and opinions expressedin Journal of Multidisciplinary Cancer Care® do not neces-sarily reflect those of the Editorial Board, the EditorialDirector, or the Publisher. Publication of an advertisementor other product mentioned in Journal of MultidisciplinaryCancer Care® should not be construed as an endorsementof the product or the manufacturer’s claims. Readers areencouraged to contact the manufacturer with questionsabout the features or limitations of the products men-tioned. Neither the Editorial Board nor the Publisherassumes any responsibility for any injury and/or damage topersons or property arising out of or related to any use ofthe material contained in this periodical. The reader isadvised to check the appropriate medical literature and theproduct information currently provided by the manufac-turer of each drug to be administered to verify the dosage,the method and duration of administration, or contraindi-cations. It is the responsibility of the treating physician orother healthcare professional, relying on independentexperience and knowledge of the patient, to determinedrug dosages and the best treatment for the patient. Everyeffort has been made to check generic and trade names,and to verify dosages. The ultimate responsibility, howev-er, lies with the prescribing physician. Please convey anyerrors to the Editorial Director. ISSN # 1949-0321.

Journal of Multidisciplinary Cancer Care® is published 8 timesa 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 HealthcareCommunications, LLC. No part of this publication may bereproduced or transmitted in any form or by any meansnow or hereafter known, electronic or mechanical, includ-ing photocopy, recording, or any informational storage andretrieval system, without written permission from thePublisher. Printed in the United States of America.

CONTENTS

The Patient Protectionand Affordable CareAct will add an estimat-

ed 15.9 million Americans tothe Medicaid rolls by 2019,according to a new KaiserFamily Foundation report. Inaddition, the report estimatesthat 11 million low-incomeAmericans will no longer beuninsured. The Urban In -stitute, which prepared thereport for the Kaiser FamilyFoundation, projected enroll-ment at two levels of participa-tion. The “enhanced outreach

scenario” increases those numbers to 22.8 million peopleadded 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 thefederal government; state governments will need to pay theremainder. Under the enhanced scenario, the cost rises to$575 billion, with $532 billion paid by the federal govern-ment. For providers, this expansion of coverage will proba-bly allot less payment on a per unit service, likely exacer-bating the debt problem for providers that care for theunderinsured. As you may know, my facility, St. Joseph Cancer Institute

is a participating site with the National Cancer InstituteCommunity Cancer Centers Program (NCCCP). Using$40 million in funds from the American Recovery andReinvestment Act of 2009, the NCCCP has added 14 newsites to its existing 16. Even with this new funding, how are community cancer

centers going to continue to deliver high-quality care tothese new patients? This is not a question with simpleanswers. Various methods exist, and each method has mul-tiple components. As a strong proponent of multidisciplinary care, I am

pleased that more cancer centers will be implementingprospective case discussion for each patient focused ondeveloping the best evidence-based care plan for that indi-vidual. But even this comes in a variety of designs. Thisissue highlights two centers in which the oncology nurseand the oncology pharmacist are active participants. If yourcenter does not currently include them in prospective dis-cussions, it is one method you may wish to try. As our mul-tidisciplinary tumor board case study demonstrates, theexpertise of these team members can contribute valuableinformation and improve our patients’ quality of life.However, as Al Benson points out, these team members arein short supply.As always, I hope this issue of the Journal of

Multidisciplinary Cancer Care benefits your practice and pro-vides ideas on how to move it forward. We look forward toyour feedback.

FEATURE ARTICLES

4 AccreditationIs Commission on Cancer accreditation right for you?

10 ReimbursementSmart money. Part 2: protecting oncology reimbursement

11 Conference News: SIRNew approach may freeze out breast cancer

Going for gold with a novel treatment for pancreatic cancer

12 Breast CancerCEP17 breast cancer tumors are more likely to respond to anthracyclines

16 BenchmarkingOperational and financial benchmarking for oncology

18 Continuing EducationGynecologic oncologic management of widely metastatic serous carcinomaof the ovary

22 Prostate Cancer

Hypofractionated salvage radiotherapy may be beneficial for postprostatectomy biochemical recurrence

28 ViewpointNo, you can’t keep your health plan

DEPARTMENTS

8 Recent FDA Approval

23 Oncology Drug CodesMedications used for the treatment of lung cancer

Mark J. Krasna, MDST. JOSEPH CANCER

INSTITUTE

Editor-in-Chief

Green Hill Healthcare Communications LLCGreen Hill Healthcare Communications, LLC HGYour Innovative Partners in Medical Media™

™

241 Forsgate Drive, Suite 205CMonroe Twp, NJ 08831

INTRODUCTION

2 JUNE 2010 I VOL 3, NO 4 www.JOmcc.com

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

The American Col lege of Sur -geons’ Com mission on Cancer(CoC) is a consortium of profes-

sional organizations working to improvesurvival and quality of life for cancerpatients. Through the CoC Accred -itation Program, cancer programsachieve benefits for themselves and forthe patients they serve. To help ourreaders determine if accreditation isright for them, the Journal of Multi -disciplinary Cancer Care recently spokewith Robert Flanigan, MD, FACS, vicechair of the accreditation committeeand chair of the recruitment and reten-tion subcommittee of the CoC, aboutthe steps involved in the accreditationprocess.At present, approximately 72% of

newly diagnosed cancer patients aretreated in CoC-accredited centers, andthe number of accredited centers is justshort of 1500 throughout the UnitedStates and Puerto Rico, which repre-sents between 25% and 30% of hospitalfacilities. “I think we accumulated thisexpanse of attachment to these newlydiagnosed cancer patients becausemany of our facilities are dominant intheir areas in their communities, notspeaking of the National CancerInstitute facilities and the academicmedical institutions that are accredit-ed,” Flanigan said. “We accredit institu-tions that attract medical oncologists,radiation oncologists, and other special-ists, and they bring their cancer patientsto these facilities, perhaps from otherinstitutions or other outlying areas.”In short, CoC-accredited institutions

have something to offer. “The CoC’sgoal is to provide the best quality of careto the patients, which begins with acomprehensive multidisciplinary teamapproach to their care.” As Flaniganexplained: “Some cancers can be dealtwith by one board-certified individual.For example, a stage I melanoma doesnot require evaluation by a medicaloncologist or radiation oncologist, anyreasonably trained general surgeon canhandle that particular case. However,the vast majority of cancers (lung,colon, breast, etc) require a multidisci-plinary approach. The CoC has adiverse membership; it represents 47organizations. Those disciplines addressevery potential facet of cancer care thata patient could require.”There are five key elements to the

success of a CoC-accredited cancer pro-gram1:1. The clinical services provide state-of-the-art pretreatment evalua-tion, staging, treatment, and clini-cal follow-up for cancer patientsseen at the facility for primary, sec-

ondary, tertiary, or quaternary care.2. The cancer committee leads theprogram through setting goals,monitoring activity, evaluatingpatient outcomes, and improvingcare.

3. The cancer conferences provide aforum for patient consultation andcontribute to physician education.

4. The quality-improvement programis the mechanism for evaluatingand improving patient outcomes.

5. The cancer registry and database isthe basis for monitoring the quali-ty of care.

“For a physician to want a programwith these attributes, he/she needs to bededicated to the thought of providingthe best possible care for that patient.And for a program to succeed, it needsa number of individuals with a passionfor doing that and for wanting to followthrough with the effort,” Flaniganexplained. “It is a teamwork phenome-non, it cannot be just one individual,

that individual needs to seek others thatwant to be involved likewise and pro-ceed with this effort.”

Designing a programThere is no one design model for

CoC-accredited institutions. Each cen-ter develops its own approach to com-pliance with the CoC’s 36 standards.The standards provide a framework fordeveloping a program up to the point ofaccreditation. They cover all the basicsfrom the leadership model needed tothe necessary diagnostics, therapeutics,support services, quality studies, activi-ties, and registry management, accord-ing to Flanigan.“The path to accreditation is never

exactly the same,” he said. Many pro-grams that express an interest in becom-ing accredited already have a number ofthe required elements. It may be just amatter of making sure all the clinicalservices are available, and then coordi-

nating the interested surgical specialistsas well as medical and radiation oncol-ogists. A center does not necessarilyneed to provide all the clinical serviceson its campus; these services can be provided by referral, according toFlanigan. “For instance, I just surveyeda hospital and the radiation facility wasprivately owned and located across thestreet. That setup is fine. As long as theservices are available to the patients inthat community, that is an acceptableapproach.”In addition, most cancer programs

already have a cancer committee or agroup of individuals who are concernedabout the delivery of cancer care topatients at that institution. Accordingto Flanigan, “this is a major start point,as this is the leadership group who willdevelop the program and begin toaddress the 36 standards.”Developing a cancer conference is

usually not a complicated issue, nor isdeveloping a quality-improvement pro-

gram, Flanigan said. Most hospitalsalready have a manager to address qual-ity-improvement concerns.Developing a cancer registry, howev-

er, is “probably one of the major hurdleswhen developing a program with thegoal of accreditation because, thoughevery state requires reporting of cancerincidence data, having a dedicated reg-istry is a little bit different from havingan individual in the medical recordsdepartment assigned to accumulate thatinformation.” Registry activity must besupervised by a certified tumor registrar,and certified individuals are limited.However, according to Flanigan, cen-ters can enlist a consulting service thatprovides registrar services by contract.For accreditation, the CoC also

requires programs to have a certainstream of reliable data from their estab-lished registry that has been reported to the National Cancer Database(NCDB) before a program can be sur-

veyed and accredited. Another impor-tant step is for the programs to be eval-uated by a consultant, with a mock sur-vey performed. This will give theprograms a sense of whether they are incompliance with the 36 standards,Flanigan explained. “For new programs,the pass/fail bar is very high, with theCoC expecting them to be compli-ant on all 36 standards. They are givenonly one standard for noncompliance.Other wise, they have to go back andstart again.”Help is available, however. If a pro-

gram is making progress but needs helpwith some remaining challenges, it canrequest a visit by a CoC ambassador.“This no-charge to the facility visit by asurveyor or state liaison chair consists ofa site visit to meet with the cancer com-mittee and administration. The ambas-sador first reviews the benefits of beingan accredited program and then func-tions like a consultant, discussing someof the issues and problems that the cen-ter may be having in moving forward,”said Flanigan. The ambassador tries toprovide the center help in reaching thepoint of accreditation.

The timetableDeveloping a program requires lead-

ership from within the facility, and ittakes a number of physicians who havea passion to proceed with accreditationand who believe accreditation will ben-efit the patients, the community, andthe institution. Depending on a center’scurrent operating procedures, theaccreditation process may take 2 to 3years, according to Flanigan.After a center has been cleared for a

survey by a consultant, it is just a matterof getting the survey scheduled. AsFlanigan described, “the survey processmust include the surveyor attending acancer conference as well as meetingwith the cancer committee, having atour of the facility, and reviewing somecases via medical records case reviews.The surveyors also meet separately withthe administration.” Therefore, the sur-vey process takes between 6 and 7hours. Then, the turnaround time forreceiving the performance report can beas short as 2 weeks.

Benefits of accreditationThis year the CoC is refocusing on

one of the major benefits of accredita-tion. “I think everybody in the countryis certainly aware of the fact that weneed to be upfront with the quality ofwork that we are doing,” Flanigan said.“In particular, payers and the federalgovernment are very concerned about

“For a physician to want a programwith these attributes, he/she needsto be dedicated to the thought ofproviding the best possible care forthat patient. And for a program tosucceed, it needs a number ofindividuals with a passion for doingthat and for wanting to follow through with the effort.”

——Robert Flanigan, MD, FACS

Continued on page 7

Accreditation


Current activities at www.COEXM.com include:

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www.JOmcc.com6 JUNE 2010 I VOL 3, NO 4

Bayonne, New Jersey—Asdemand for their servicesgrew and it became increas-ingly clear that their prac-tice was becoming a region-al center for patients battlingcancer, the medical staff atColanta Hematology &Oncology Center made thedecision to build and openan outpatient infusion cen-ter that could adequatelyand comfortably serve theirpatients.The result was a state-of-

the-art infusion center with 20 reclinersin a patient-focused environment that isopen to serve patients 7 days a week. Themedical staff of three physicians and fournurses, led by practice administratorRomel Colanta, MD, now delivers abroad array of out patient oncology servic-es, including chemotherapy, albumin,anti emetic, and iron therapy infusions.Additionally, the infusion center staffprovides supportive cancer care services,including therapeutic phlebotomy, anti -biotic infusion, and electrolyte replace -ment. They also provide multidiscipli-nary infusion services for patientsreferred to the center by gastroenterolo-gists, neurologists, and infectious diseasespecialists.With the high volume of oncology

drugs required to treat their patientpanel, the medical staff at Colanta had tomake the decision as to how they wouldsupply their patients with oncology med-

ications. If they followed thetraditional practice of hema-tology and oncology pro -viders, they would “buy andbill” the medications, mean-ing they would have theresponsibility of sourcing andpurchasing the medications,storing them, preparing andsometimes compounding themfor patients, managing theinventory on an ongoing basis,and dealing with a bevy ofinsurance prior authorizationand reimbursement procedures

and requirements in order to get paid.Although buy and bill traditionally

had its benefits, including a substantialmargin paid by Medicare and other com-

mercial payers, changes that resultedfrom the Medicare Modernization Actlowered a margin that sometimes paidphysicians 40% over the cost of the drugto just 6%.The Colanta team decided there was a

better way. They knew they could out-

source the pharmacy func-tion to a pharmacy that washighly specialized in oncolo-gy medications. This phar-macy would prepare thedrugs under the highest clin-ical standards, deliver themjust in time for treatmentday (thereby eliminatingwaste), handle all the hasslesof insurance prior authoriza-tion and reimbursement,and free the center from thechallenges of safely storing and dispens-ing the drugs and the huge, capital-intensive “carry costs” that maintainingsuch an inventory requires.Dr Colanta and his colleagues

researched their options and chose

OncoMed—The Oncology Pharmacy.OncoMed is an oncology pharmacy,meaning that its sole business is oncolo-gy medications. Its specially trained andcertified oncology pharmacists work in atechnologically advanced pharmacy builtexclusively for oncology pharmaceuticalprescription processing and dispensing,including a USP <797>-compliant class5 clean room. To protect the supplychain and ensure a complete and fulldrug pedigree, all inventories are pur-chased directly from pharmaceuticalmanufacturers. The company’s “just-in-time treatment-day” service means thatoncologists and hematologists in anystate in the nation are guaranteed deliv-ery of medications and all therapy-specific administration supplies within24 hours of placing the order. Given theColanta Hematology & OncologyCenter’s close proximity to one ofOncoMed’s regional oncology pharmacysites, they were eligible to get same dayand even emergency stat dose deliverywhen needed.But what also set OncoMed apart from

specialty pharmacies thatconcentrate on more thanone class of pharmaceuticalsis the OncoMed care man-agement support team’s abil-ity to work with insurers toget the authorizations thatthe Colanta Hematology &Oncology Center’s pa tientsneed. OncoMed’s team in -cludes patient care naviga-tors and patient reimburse-ment specialists who have

extensive experience working with in -surers, oncology drug manufacturers, andmedical foundations. These specialistsalways know where to go to search forneeded funding for patients who arebanking on that expertise for theirrecovery.OncoMed has become a pivotal part-

ner to the Colanta Hematology & On -cology Center by owning the pharma-ceutical worry and letting the physiciansfocus solely on guiding their patients toremission.We sat down with Dr Colanta and

asked him about the new center and itspartnership with OncoMed.

Why did your infusion center chooseto partner with OncoMed?The buy-and-bill model that oncolo-

gists have always worked under is nolonger viable. Physicians can’t make anoffice run on a 6% margin. Under buyand bill, the average sales price (ASP) +6% methodology can very quickly go toASP + 4%, +2%, or -2% if we run intoany obstacles in getting reimbursed. Andwith expensive drugs like chemotherapy,we cannot take that risk. Plus, OncoMedhelps patients get funding for medicationeven after the patient’s insurer hasdenied coverage.

In addition to this new center, younow have two additional sites in NewJersey. How has the partnership withOncoMed enabled you to successfullylaunch and grow the center?When we opened, 90% of what we

infused in the clinic was oncolytics. As wehave grown, we infuse a far broader arrayof medications. The backbone of our prac-tice is still chemotherapy, but we haveincreased our nononcolytic infusions. For

New Jersey Hematology and Oncology Center Partners with OncoMed

Continued on page 7

Evolution inOncology Practice Management

PART2OF A SERIES

OncoMed providedfunding and

editorial support for this article

www.OncoMed.net

ADVERTORIAL

“The partnership with OncoMed has enabledus to make better use of our capital.”

——Romel Colanta, MDPractice Administrator

Colanta Hematology & Oncology Center

The outpatient infusion center at Colanta Hematology & Oncology Center comfortably servespatients.

Kevin Askari, RPhPresident and Chief Clinical PharmacistOncoMed

Burt ZweigenhaftCEO, OncoMed

JUNE 2010 I VOL 3, NO 4 7www.JOmcc.com

Accreditation

the quality of care that we are giving.”Accredited institutions have access to

the NCDB. The database, a joint projectof the CoC and the American CancerSociety developed in 1989, is currentlythe largest cancer database in the world.It contains nearly 25 million recordsfrom hospital cancer registries across theUnited States and Puerto Rico. Withtheir web-based, password-protectedaccess, accredited cancer programs canuse the database to access almost 8.3 mil-lion case reports of patients diagnosedbetween 2000 and 2007. The institutioncan generate reports showing datareported to the NCDB from the user’scancer registry; aggregated data by hospi-tal system, state, or region or at thenational level; or a comparison of thecases submitted to the NCDB by theuser’s cancer program and all the otherprograms identified by the user in thecomparative group.2Survival data are available on 51 can-

cer sites; supportive care; and detection,prevention, and risk reduction interven-tions. “Institutions can run their survivaldata and compare it with other institu-tions in the same accrediting category(there are 12 categories), so they can getan apples-to-apples comparison of theirsurvival data,” explained Flanigan.Benchmarking is also available

through the NCDB; again it is web-based, password-protected, and accessi-

ble only by accredited programs.Flanigan, a former breast surgeon,described how this feature can be used:“A breast surgeon can look at the stageof disease for his/her breast cancerpatients at diagnosis. One interestingphenomenon is the ability to look atstage 0, which is in situ disease that isonly detectable mammographically, andto compare the percentage of his/herstage 0 patients against other communi-ty hospital or teaching institutions.That percentage against peers will givethe surgeon an idea as to whetherhe/she is screening for breast cancerwell in the community or not. This is agreat example of how members can useNCDB data at a keystroke to demon-strate how effective they are in theircommunity at screening for breast can-cer.” In addition, “in a matter of sec-onds, surgeons can look at the percent-age of surgical procedures and the typesof surgical procedures performed fortheir breast cancer patients and seewhat percentage are having breast con-servation surgery versus mastectomy.This can then be compared with out-comes at other institutions in the samecategory,” Flanigan continued.Another use of the NCDB deals with

treatment guidelines. National Compre -hensive Cancer Network (NCCN)clinical practice guidelines correlatewith the 51 cancer sites and interven-

tions in the NCDB, which allowsaccredited programs to determinewhether they are in compliance.According to Flanigan, the NCDB cur-rently offers three breast measures andthree colorectal measures, with theadditional cancer measures being devel-oped soon. “With the federal govern-ment and payers believing that guide-line compliance is a better measure forquality of care than survival data alone,an institution can easily look at esti-mated performance rates in terms ofhow well it is following NCCN guide-lines and get feedback on this quality ofcare measure and, just as importantly,the quality of the data coming out of itscancer registry,” Flanigan said.In addition to the NCDB, the CoC’s

relationship with the American CancerSociety provides members a marketingboost. Flanigan provided this example:“On the American Cancer Society web-site, if a patient navigates through theweb site looking for a treatment center,the site links these inquiries for cancertreatment centers to the CoC, which al -low the patient to search in his/her zipcode. The treatment center identified willbe a CoC-accredited cancer program.”

So, is accreditation right for you?Each cancer program must make this

decision for itself. For programs dedicat-ed to the best patient care and a multi-

disciplinary approach, CoC-accredita-tion may be a good fit. Start by assessingwhere your program is in compliancewith the CoC’s five elements to success.Follow that with developing an actionplan to fulfill any currently unmet crite-ria. If you are willing to proceed withaccreditation, accreditation can benefityour patients, your community, andyour institution. l

References1. Commission on Cancer. Cancer program accredita-tion. October 12, 2009. www.facs.org/cancer/coc/whatis.html. Accessed March 15, 2010.

2. Commission on Cancer. National Cancer DataBase (NCDB). December 18, 2009. www.facs.org/cancer/ncdb/index.html. Accessed March 15, 2010.

Commission on Cancer... Continued from page 4

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

patients referred by gastro -intestinal practitioners, we in -fuse infliximab, and for thosereferred by infectious diseasephysicians, we provide antibi-otic infusions. Some of thosedrugs are still viable [underbuy and bill], but not all. Wehave been able to devotemoney that has traditionallygone to purchasing medica-tion and instead ex pand ourservices. The partnership withOncoMed has enabled us tomake better use of our capital.

How does the medication orderingand fulfillment process work withOncoMed?Having an efficient and focused

process in place is very important. Wehave been able to institute a processwhere we have someone devoted tobeing our liaison with OncoMed. When

a patient comes in and his orher benefits are precertified,we send the person’s caseinformation to OncoMed,and the drugs are sent to usdirectly, along with all theadministration supplies. Weget them on a next-daybasis, or sooner if needed,and everything is clearlylabeled with patient-specificinformation. That makes ahuge difference to us whendealing with Onco Med ver-

sus some specialty pharmacies that someinsurers have imposed upon us to use,which get the drugs wrong, ship themlate, and have no idea of the correctadministration supplies.

How does the relationship withOncoMed allow you and your team tofocus on what is important?I will give you a “before-and-after”

example. Before weworked with Onco -Med, 50% or more ofour time was spent onmanaging drug costsand reimbursement.We had five peoplemanaging pharmacyat the three loca-tions; we have beenable to reduce thatnumber of employeesto one. Before, wehad to continuallymake sure that wewere not underwateron drugs, as reim-bursement rates and times fluctuated.OncoMed has made it possible to notdevote time and effort on that.

Based on your experience, whatwould you say about OncoMed to he -matologists and oncologists considering

such a move?It is definitely a relationship that every

infusion center or oncologist has toexplore. When dealing with narrowingreimbursement margins and delayedreimbursement, ultimately it will be ben-eficial to switch to OncoMed. �

Continued from page 6

EVOLUTION IN ONCOLOGY PRACTICE MANAGEMENT™

Pharmacists filling orders at the OncoMed facility.

Ellen Scharaga, RPhSenior Vice PresidentOncoMed

Did You Know?Demand for large buildings on hos-

pital and other medical sites isincreasing as real estate investors seekstable investments. According todata presented at the 2010 MedicalOffice Buildings & HealthcareFacilities Conference in Chicago, inthe first quarter of 2010, medicaloffice buildings sold for an average of$230 per square foot, a 1% increasefrom 2009. In contrast, other officessold for $165 per square foot, a 39%decrease in value.


Oncology Advocacy

says that oncology must take an activerole in its implementation. Dr Bensonhas participated in organizations, includ-ing serving on a number of committeesat the American Society of ClinicalOncology (ASCO) and as the immedi-ate past-chair of the National Compre -hensive Cancer Network board of direc-tors. The Journal of Multi disciplinaryCancer Care spoke with Dr Benson abouthis plans for his upcoming year as presi-dent of the ACCC.

What are your goals for the ACCC?What are the biggest issues for com-munity oncology in the coming years?There are a lot of issues that will

require continuing effort, and thatincludes understanding the impact ofhealthcare reform on the oncologycommunity. I think continuing thetheme from Luana Lamkin’s presiden-tial year in terms of workforce issuesmust be an ongoing discussion. I thinkglobally we need to make sure that theadvances and innovations in oncologyare maintained, and continuing pressurescould greatly affect our ability to do that.That includes not only the workforceissue, but ongoing reimbursement issues,as well as the movement of oncology andpractices to the hospital setting and whatthat might mean for access to care andthe type of care that’s delivered.

What challenges does CER pose forcommunity oncology?We should begin to focus on the issue

of evidence-based practice and the dataacquisition requirements that we thinkwe will face increasingly over time. Someof this is also related to the concept ofCER, with pressure to make sure thatoncologists who are participating in thesedatabases have the necessary infrastruc-ture to transmit data for these databases.As these pressures mount, what im -

pact will that have on other activitiesand on the outpatient office, includingclinical research? The pressure to in -crease accrual to clinical trials will beheightened the more we are encouragedto practice evidence-based medicine.This will also require the integration ofguidelines into practice and the moni-toring of practice in terms of the qualityof care that is being delivered.I think much of this is driven by eco-

nomics and the increased cost of deliv-ering medical care. But my own bias isthat the more we can practice evidence-based medicine, the more likely we willbe able to use the dollars available forhealthcare appropriately—it’s the con-cept of delivering the right care to theright patient at the right time.

What led you to your current posi-tion?

That started with the creation of theIllinois Medical Oncology Society(IMOS). I started out as vice presidentand eventually became president. Earlyon, we fostered ties with ACCC as wellas ASCO, so through the years I got toknow ACCC people very well. I waspartly involved because ACCC helpedour state society in passing legislation in the state of Illinois on both off-labeldrug use and clinical trials. Eventually, Iwas asked to run for the board and justcontinued to be active within ACCCeven after I completed my term of officeon the IMOS board.

Healthcare reform is now law. Whatsort of changes should community on -cology practices expect?I think that one extremely critical

change is going to be the coverage ofindividuals with preexisting condi-tions—that is, insurance cannot bedenied for preexisting conditions. Thathas been a major concern for cancerpatients...even extending to the con-cerns about screening for cancer andgenetic testing with the fear that therewill be inability to obtain adequateinsurance, as well as other issues such asjob discrimination.The clinical improvements in can-

cer care have resulted in many morepeople either having been cured of

their cancer or living productivelywith their cancer. With these steps inthe right direction, in terms ofimproved lives of cancer patients, wehave to make sure there are not factorsthat will adversely affect their lives.These include the ability to havehealth insurance as well as the abilityto be gainfully employed.

What sort of changes do you foreseefor radiation oncology?This actually gets us back to the dis-

cussion of evidence-based medicine.One of the discussion points that we’rehearing more and more is the very highcost of imaging. One of these particularareas of imaging that requires tremen-dous attention is positron-emissiontomography scanning. Because of itsextensive use, and many say overuse,and because it is quite expensive, it hasreally had an impact on healthcareexpenditures.One of the problems with imaging is

that unlike drug therapies, we don’t rou-tinely conduct clinical trials, so thereare far less data as to optimal imagingstrategies. You also see huge variation inthe use of imaging. One example is sur-veillance for patients who have com-pleted cancer therapy. In my area ofcolon cancer, there have been trialsconducted to look at surveillance strate-gies. But that is the exception ratherthan the rule.

How significant is the mandate thatpayers cover the patient-care costs ofclinical trials?It’s obviously something a number of

members of the oncology communityhave strongly supported. We need to seehow that plays out in terms of possibleoutcomes and in terms of increasingnumbers of patients who are part of clin-ical trials. One of our concerns is that wereally have not improved the numbers ofpatients who go on cancer clinical trialssignificantly over a number a years. We’regoing to have to carefully look at strate-gies to improve our numbers of accruedpatients.

Given the workforce shortage, arethere currently enough oncologists tomeet the needs of the millions of newlyinsured patients?I think this is an extremely critical

component of the workforce discussion.Multidisciplinary oncology groups foryears have emphasized the importanceof patient access to quality oncologycare. There are also concerns that manypatients did not have such access andthat issues such as reimbursement mightaffect patients’ access to care. We’ve also known that we have a

growing crisis brewing in a projectedshortage of oncologists as well as highlytrained oncology nurses and othermembers of the healthcare team. Wehave a real potential threat to deliver-ing adequate oncology care. It’s notonly the fact that there may be morepeople with insurance benefits who willnow have access, but if you look at thedemographics of an aging population,we would expect our number of oncolo-gy patients to also increase. A goodthing is that cancer survivorship isimproving, but we have to have skilledprofessionals available to monitor sur-vivors over time.

What got left out of healthcarereform?I think the huge issue is that the

reform law does not adequately controlthe cost of healthcare. Many of usbelieve that this has to be the next step.It’s why I think the oncology communi-ty needs to emphasize evidence-basedmedicine. This is a concept of multiplecomponents: it includes increasing ourclinical research enterprise, being en -gaged in discussion of CER, and in dis-cussion of where such a strategy might beappropriately integrated. It involveslooking carefully at guidelines to try tomake sure that people practice the verybest based on the oncology principlesavailable. It means we have to start pay-ing attention to imaging.Getting back to clinical research, we

need more investment in understandinghuman cancer biology so that we canbetter select patients for appropriateinterventions. It also means to makesure that appropriate people arescreened, so we can try to limit thenumber of patients who present withadvanced cancers.It will also include having discus-

sions, and these will really be societaldiscussions, about what may be moreappropriate strategies for end-of-lifecare. There’s concern about how muchis spent in delivering cancer therapeu-tics for patients who will have no bene-fit. In addition, we need to make surethat patients have access to appropriatehospice programs, so that they receivethe very best in terms of end-of-life care.Of great concern is that most peoplewho enter hospice programs do so with-in, literally, days of their deaths. l

My own bias is that the more we can practiceevidence-based medicine, the more likely we will beable to use the dollars available for healthcareappropriately—it’s the concept of delivering the rightcare to the right patient at the right time.

ACCC President...Continued from cover

Trelstar Available in Twice-yearly FormulationThe FDA has approved Trelstar

(Watson Pharmaceuticals) 22.5mg for injectable suspension, anew 6-month formulation of theintramuscular GnRH agonist forpalliative treatment of advancedprostate cancer. This formulationcan be stored at room temperature.Approval was based on a 12-month phase 3 study in patientswith advanced prostate cancerthat showed >98% of patientswere below castrate level at 6 and12 months. In addition, prostate-specific antigen was reduced by96.4% at the end of the study. l

Recent FDAApproval


Reimbursement

Smart Money. Part 2: Protecting OncologyReimbursementBy Cindy C. Parman, CPC, CPC-H, RCCPrincipal, Coding Strategies, Inc, Powder Springs, Georgia

The days of plenti-ful al lowances fromhealth insurers, time-

ly pa tient payments, andminimal medical necessityrequirements are a fondmemory. In Part 1 of thisarticle (April 2010), wereviewed patient paymentsincluding coinsurance, de -ductibles, advanced benefi-ciary notices, and waivers ofliability. In addition to pa -tient payments, practices can streamlineprocesses to protect oncology reimburse-ment.

Payment postingProviders should audit their remit-

tance advices and explanation of bene-fit documents every quarter. In doing so,many groups find and decipher theirpayment problems, and often discoverhundreds of thousands of dollars ofunderpayments. In addition, providersshould review payments posted on aregular basis to ensure that contractualadjustments are not applied in error forinsurers where there is no contract orparticipation agreement.1Although each facility or practice

may encounter different nonpaymentsituations, two common reasons chargesare inappropriately reduced include theincorrect application of bundling guide-lines and services that are downcoded.Bundling occurs when a practice or

facility submits a claim for two or moreprocedure codes for a single patient on asingle date of service, but the payer con-siders these multiple procedures to berepresented by one procedure code.According to the American MedicalAssociation (AMA): “Bundling hasbecome more widespread, becausehealth insurers have increased their useof code-editing software. Health insur-ers not only integrate these code-edit-ing software programs into their claimsreview cycle, but also add another layerof confusion by modifying the program’sstandard code-pair edits to fit their ownmedical payment policies.”2Another potential problem is down-

coding, which can occur when a healthinsurer unilaterally reduces the level ofcomplexity of a patient-visit service or aprocedure. For example: code 99204(level 4 new patient visit) was billed,but code 99203 (level 3 new patientvisit) was paid by the insurer. Thehealth insurer may base the downcod-ing on the diagnosis code(s) reported

with the procedure code, orit may have specific docu-mentation re quirements forpatient visits in addition tothe AMA or Centers forMedicare & Medicaid Ser -vices guidelines.Tracking denials for

bundling, and ensuring thata modifier is applied whenrequired, may improvepractice reimbursement. Inaddition, monitoring pay-

ments to verify that insurer discountswere correctly applied and codes werenot altered can also guarantee appropri-ate revenue.

CollectionsLimit your patient statements to a

maximum of two or three; sending moreincreases the practice’s cost and dragsout the collection/bad debt cycle.History shows that more mailings won’tlead to better collections. In addition,make certain that the statementincludes a due date for the payment, notjust the date the bill was sent. Last,when the patient cannot pay the entireamount, avoid questions such as “Whencan you pay?” Instead, request that thepatient provide full payment by a spe-cific date or before the next treatment isprovided.E-mailing patient statements is

known as “electronic presentment”; thetelephone and credit card companies

have been doing it for years. Thepatient will appreciate the cost reduc-tion, and it may help further cementyour patient relationships.1Also watch for “rubber checks.”

During a tough financial time patientsmay bounce checks for copayments anddeductibles. In addition to not receiv-ing the money due, the bank maycharge the practice a fee (such as $25)per bounced check. The medical prac-tice may want to consider a policy thatappends an extra charge to the patientaccount when checks are returned bythe bank. According to the AMA,medical practices may also have anincreased risk of receiving bad checkswhen there are high deductibles andhealthcare savings accounts and whentreating uninsured patients.3

Denials and appealsEven when a practice codes claims

correctly, health insurers may still inap-propriately deny, delay, or significantlyreduce payments.2 Many practices loserevenue every day due to partially paid,delayed, and denied health insuranceclaims that the practice does not chal-lenge or may not even notice. Whenthe practice or facility receives a denialor rejection:• It should not be processed as a write-off unless it has been completelyinvestigated.u If the claim is denied because thepatient is not enrolled in theinsurance plan, investigate.

u Review for data entry errors, suchas transposed digits in the groupnumber or patient identificationnumber. If the insurance card hasbeen scanned or copied, ensurethat all information is legible.

u Review the application of modi-fiers, procedure codes, and diagno-sis codes, and compare with payerprocessing guidelines.

u Review for medical necessitydenials.

When responding to a medicalnecessity denial, make certain that theappeal letter includes specifics relatingto the individual patient. Consider doc-umentation that supports the patient’scurrent medical condition, chief com-plaint(s), physical examination find-ings, and any correlating diagnostic test

results. Also include documentation ofmedical management options that werepreviously tried, but failed to adequate-ly treat the patient’s medical condition.

Operational reviewNow is the best time to evaluate

overhead expenses, staffing levels, mar-keting practices, and the superbill.Evaluate current expenditures, includ-ing office supplies, kitchen supplies, andother routine purchases, and look fornew ways to trim costs. It may also beprudent to consider outsourcing certainsegments of the practice, such as humanresource functions and benefit plans.The silver lining to a cloudy econom-

ic forecast is the fact that there are plen-ty of new opportunities on the horizon.Although the superbill or charge cap-

ture document should be reviewedwhen diagnosis and procedure codes areupdated, this is an excellent time toreview all services performed by thepractice. Are there services performedthat are not being captured and billed?Are there services that the practiceconsidered in the past that it shouldoffer now? For example, tobacco cessa-tion counseling (procedure codes 99406and 99407) may be performed by thephysician or a qualified nonphysicianhealthcare professional, but the practicemay not have reviewed these codes tosee if there is an opportunity to bill forthis service.Consider offering cash-only services

that will benefit the patient populationin your location. For oncology practices,this may mean installing a massagetherapist in an empty examinationroom. This may provide an activity thatpatients and/or caregivers would enjoy(for a small charge) and could lead toother services such as the sale of spaproducts for skin care. The massagetherapist need not be a practice employ-ee, but can lease space on a daily orhourly basis.Last, know your market today and be

able to estimate tomorrow’s market.Assess your competition, determinewhat makes your practice different, anduse that information to launch orredesign a marketing campaign. Workclosely with referring physicians toensure that they understand your com-mitment to patient care in addition tothe services offered at your oncologypractice. Position your practice to betheir “partner” through an open house,fast and accurate updates on theirpatients, etc.

Reimbursement realizedIt seems that we have already

changed priorities, tightened our belts,stretched our budgets, and delayedimplementing new technology. How -ever, the current economic environ-ment demands that we continue tobecome more efficient, even in areaswhere it seems impossible, and that wehonestly address what we need andwhat we want for our practice. l

References1. 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 cloggingrevenue flow. January 26, 2009. www.ama-assn.org/amednews/2009/01/26/bica0126.htm. AccessedMarch 10, 2010.

Cindy C. Parman, CPC,CPC-H, RCC

The health insurer may base the downcoding on thediagnosis code(s) reported with the procedure code.


Conference News

SIR 2010

The following articles are based on presentations at the Society of Interventional Radiology’s35th Annual Scientific Meeting in Tampa, Florida.

New Approach May Freeze Out Breast CancerBy John Schieszer

TAMPA, FL—In the first reported study,researchers in Detroit have found thatimage-guided, multiprobe cryo therapymay be able to successfully freeze breastcancer in women who do not undergosurgery. They presented data that showthis approach appears to be highly effec-tive with minimal discomfort for thepatient.Researchers conducted 13 cryotherapy

sessions in which they treated 25 breastcancer foci in 13 patients. What makesthis series unique is that it used multiple2.4-mm cryoprobes. Using only localanesthesia with mild sedation, ultra-sound guidance alone was used in six ofthe patients; seven patients requiredboth computed tomography (CT) andultrasound to better define ice margins.The researchers used saline injections toprotect the skin and/or chest wall. Breastmagnetic resonance (MR) imagingand/or clinical follow-up were availablefor up to 65 months after cryotherapy.The researchers found no significant

complications. All the patients reportedminimal discomfort and satisfactionwith the cosmetic results. The investi-gators found that biopsies at the marginsof the cryotherapy sites immediatelyafter the procedure and at the cryother-apy sites in follow-up were all negative.No local recurrences have been notedat 18-month average follow-up.“Minimally invasive cryo therapy

opens the door for a potential new treat-ment for breast cancer and needs to befurther tested. When used for local con-trol and/or potential cure of breast can-cer, it provided safe and effective breast

conservation with minimal discomfortfor a group of women who refused inva-sive surgery or had a local recurrenceand needed additional management,”said study investigator Peter Littrup,MD, who is an interventional radiolo-gist at Karmanos Cancer Insti tute,Detroit, Michigan. “This is the firstreported study of successfully freezingbreast cancer without having to under-go surgery afterward to prove that it was

completely treated.”With this cryotherapy treatment,

researchers used several needle-like cryo -probes that were evenly spaced and theninserted through the skin to deliverextremely cold gas directly to the tumorto freeze it. This technique has been usedfor many years by surgeons in the operat-ing room. However, in the past few yearsthe needles have become small enoughto be used by interventional radiologiststhrough a small nick in the skin, withoutthe need for an operation.The “ice ball” that is created around

the needle grows in size and destroys thefrozen tumor cells. The major benefits

of cryotherapy are its superb visualiza-tion of the ice treatment zone duringthe procedure. It also provides a lowpain profile in an outpatient setting andhas been shown to have excellent heal-ing with minimal scarring, according toLittrup, who is also a professor of radiol-ogy, urology, and radiation oncology atWayne State University.He said this approach is very attractive

because of the dramatic improvements in

imaging that have occurred over the past2 years. Breast imaging has markedlyadvanced through accurate improve-ments in breast MR imaging. This haspaved the way for excellent treatmentplanning, because of clear determinationof tumor size and extent within thebreast. It also allows the clinician to seezones of destruction thoroughly coveringthe tumor after cryotherapy.Littrup said this current study con-

firmed sufficiently deadly temperatureswhen using two or more cryo probes. Priorbreast cryotherapy studies had “inexplic-ably” used only a single cryo probe andsuggested 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 morethan six probes in order to generatewell-defined sufficiently deadly temper-atures throughout the whole gland. Wesimply translated this concept to breastcancer to assure deadly temperatureswell beyond all apparent tumor marginsin order to generate successful use ofcryotherapy in women,” said Littrup.He said more studies are now needed

with larger numbers of breast cancerpatients at multiple centers. Littrup saidcryotechnology is now offering thepromise of being more MR-compatible.This may allow for more accurate target-ing of more difficult-to-see breast tumors.“With recent developments of powerfulnew cryotechnology, multiple directionsfor breast cryotherapy can be pursued,including translating the current, some-what challenging procedure done withultrasound and/or CT guidance to amore consistent and reproducible MR-guided approach,” said Littrup.He noted this may turn out to be a

cost-effective approach for some womenpresenting with breast cancer. Littrupsaid oncologists can now counsel theirpatients that this new approach maybecome much more widely available inthe not too distant future.“In the future, I think there could be

a broad utilization,” said Littrup in aninterview with the Journal of Multi -disciplinary Cancer Care. “Patients whohave very few other options may becandidates.” l

Going for Gold with a Novel Treatment forPancreatic CancerTAMPA, FL—Pancreaticcancer, ac knowl edged as themost fatal cancer with noknown effective treatment,requires a radical new therapy.Now, researchers at North -western University in Chi -cago think they have come upwith one. They presented forthe first time a promising newap proach in the form of goldnanoparticles.Traditional attempts to treat this

cancer include some combination of

chemo therapy, radiationtherapy, and/or surgery.However, none of thesemethods result in effectivetreatment. “This cancer isthe kiss of death,” said ReedA. Omary, MD, who is aprofessor of radiology andbiomedical engineering atNorth western Uni versityFeinberg School of Med -icine, Chicago. “The median

survival is less than 6 months, and thepatients die on schedule.”

So, he and his colleagues have comeup with a new treatment they call “nano - embolization.” It involves extremely tinyparticles made out of gold with cancer-killing agents attached to them. Thesenanoparticles, which measure only 13nanometers in diameter, are so smallthat 8000 of them could be strungtogether and still occupy less than thewidth of a single human hair.“As the current treatments for pan-

creatic cancer offer minimal benefit,entirely new approaches are needed.We’ve developed a radically different

approach that might be able to over-come some of the obstacles that havehampered previous therapies for pan -cre-atic cancer,” said Omary. “Using nano -embolization, we dramatically increasedthe concentration of the nano particles inthe tumor by 55 times over traditionalmethods that use a vein (such as at theelbow). That’s a massive improvementand a promising discovery for thisdreadful disease.”He noted that pancreatic ductal ade-

nocarcinoma is the most common type

Reed A. Omary, MD


“This is the first reported study ofsuccessfully freezing breast cancerwithout having to undergo surgeryafterward to prove that it wascompletely treated.”

——Peter Littrup, MD


Cancer Center Profile

Kathleen Toomey, MD,medical director of the can-cer center, notes that pa -tients are not only able to gettheir care close to home butare able to continue to seetheir own doctors. “The doc-tors who know the patientsbest are here and can helpcoordinate their care withthe many specialists.”In addition to medical,

radiation, and surgical oncology, Steep -lechase’s services include plastic surgery,a breast care center, genetic counseling,a cancer registry, clinical trials, rehabil-itation medicine, palliative care andpain management, and nutrition coun-seling. “Besides the clinical trials thatare available to patients, there are fourmultidisciplinary groups [breast, pro -

state, colorectal, and lung] that discusscases. In the case of breast and coloncancer, all new cases are discussed in amultidisciplinary forum,” Toomey says.The Tobacco Quitcenter, one of eightin New Jersey, is available to helppatients stop smoking using a compre-hensive approach. Somerset Medical Center is a clinical

research affiliate of The Cancer Instituteof New Jersey, allowing patients accessto clinical trials. Currently, patients areenrolled in treatment trials for breast,prostate, renal, bladder, and colorectalcancers as well as chemo therapy-

induced peripheral neuropa-thy. There are also industryregistry trials in multiplemyeloma and chronic lym-phocytic leu kemia and alarge annual screening trialfor prostate cancer. “Weaccrued 92 patients to trialslast year, 23 on treatmenttrials and 69 on the screen-ing trial,” Toomey notes. A complementary medi-

cine suite provides a variety of servicesincluding yoga, meditation, and mas-sage. Other resources include a patientlibrary, an onsite wellness boutique, asurvivorship program, a healing garden,and educational and support groups forpatients and their families. Toomeynotes that “it is a beautiful facility andpatients appreciate that if they have to

have a terrible illness; the surroundingscan help lift their spirits.”The Steeplechase Cancer Center

earned its 3-year Community Com -prehensive Cancer Program accredita-tion from the American College ofSurgeons in 2008, and it ranks in the99th percentile for patient satisfactionscores in New Jersey.Inpatient services are provided at the

35-bed Paul R. Nardoni OncologyPavilion. In recognition of the impor-tance of involving families in patients’care, patient rooms have sofa beds forvisitors wishing to stay overnight in

addition to amenities such as blanketwarmers, lounge chairs, showers, refrig-erators, flat-screen televisions, andDVD/VHS players. Patricia Molinelli, MS, RN, APN-C,

AOCNS, is nurse managerof the inpatient and outpa-tient oncology units. Shecame to the center fromlarge academic medical cen-ters in New York and valuesthe intimacy afforded byworking in a smaller setting“I try to know one thing thatis important to every pa -tient,” she says. Her ownfather was treated at thecenter, and she takes pride inproviding the same quality of care for allpatients. Care at the cen ter is patient-centered. As Molinelli describes it, “Iam the gatekeeper, the coordinator of allthese orbits. The patient is the sun.” Sheviews family members and other care-

givers as “an extension of the patient”and takes care to provide for their com-fort with a well-stocked pantry, games,and DVDs for visitor use. “We try totake a lot of the burden off the family,”

she explains. She alsopoints to the latest technol-ogy in evidence throughoutthe center. “We rush to getwhatever is available toreduce medical errors andincrease patient safety.” Hercurrent goal is to incorpo-rate genetics into the can-cer program.Other plans include a

new interdisciplinary groupfor lymphoma, myeloma,

and leukemias, and a head and neckgroup as well as gynecology-oncologyand palliative care programs, and amen’s cancer support group. A Day ofHope is planned for cancer survivormonth. l

Steeplechase Cancer Center... Continued from cover

Joan Perrone, RPh

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

In the Frimmer Healing Gardens at Steeplechase Cancer Center. Backrow 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; BozenaOwsieniuk, RN; Erica Schermer; Kathy Wagle, PCT.“Besides the clinical trials that are

available to patients, there are fourmultidisciplinary groups [breast,prostate, colorectal, and lung] thatdiscuss cases.”

——Kathleen Toomey, MD

BREAST CANCER

CEP17 Breast Cancer Tumors Are More Likely toRespond to AnthracyclinesBy Jill Stein

BARCELONA—Breast cancer patientswith the chromosome enumerationprobe 17 (CEP17) alpha satellite abnor-mality are more likely to have good out-comes from chemotherapy involvinganthracycline antibiotics than womenwithout the abnormality, according tonew data released at the SeventhEuropean Breast Cancer Conference.John Bartlett, MD, with the Uni -

versity of Edinburgh in Scotland pre-sented the results of a meta-analysis offour adjuvant breast cancer trials thatenrolled a total of nearly 3000 women.Women with CEP17 tumors that

were treated with anthracyclines wereroughly two thirds more likely to sur-vive without recurrent cancer thanthose who did not receive anthracy-clines. Recurrence-free survival was

67%, and overall survival was 63%.Prior research by the same investiga-

tors had shown that duplication ofCEP17 predicts sensitivity to anthracy-clines. “CEP17 can be readily assessed influorescent in situ hybridization analysisof human epidermal growth factor recep-tor type 2 [HER2] status and may repre-sent a clinically useful biomarker for theselection of patients likely to benefit

from anthracycline-containing thera-pies,” Bartlett pointed out.He added that the research is impor-

tant because there has been conflictingevidence on the best way to predictresponse to anthracyclines and becauseit has not been clear whether any of theknown biomarkers like HER2 andtopoisomerase 2 alpha were accurateindicators of response to these drugs. l

A Newsletter Series for Cancer Care Professionals

Center of Excellence Media, along with Editor-in-ChiefSagar Lonial, MD, of Emory University, are pleased tooffer your multidisciplinary cancer team this series ofnewsletters focusing on the challenges of treatingpatients with multiple myeloma.

SAGAR LONIAL, MDAssociate Professor of

Hematology and Oncology Emory University School of Medicine

� Earn Continuing Education Credits �

Each newsletter will feature:

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

• Front-line therapy• Maintenance Settings• Transplant Settings• Retreatment Settings

• Non-Transplant Patients• Cytogenetics• Side Effect Management• Bone Health

• Contributions from thought-leadingphysicians, nurses, and pharmacists

• Continuing Education credits availableto physicians, nurses, and pharmacists

Presents the Third Annual Curriculum for CONSIDERATIONS IN MULTIPLE MYELOMA

PARTICIPATE TODAY at www.COEXM.com

8-part newsletter series

CASE STUDY DISCUSSIONS:

For complete learning objectives and accreditation information, please refer to each activity.

Target AudienceThese activities were developed for physicians, nurses, and pharmacists.

These activities are jointly sponsored by


Benchmarking

Operational and Financial Benchmarking forOncology By Marsha Fountain, RN, MSNPresident, The Oncology Group, Waco, Texas

Karen GildenExecutive Vice President, The Oncology Group, Alpharetta, Georgia

As healthcare con-sumes a significantportion of the US

budget, oncology servicessimilarly consume a signifi-cant portion of any hospi-tal’s budget. The need torecruit qualified and well-paid clinicians, the continu-ing medical arms race toensure the hospital remainscompetitive by providingphysicians and staff with the latest tech-nical equipment, as well as the desire tosatisfy increasing consumer demands fora reasonable clinical experience (eg,physician office wait times, navigationto traverse the physical confines of hos-pitals and their many facility add-ons,nontraditional treat ment-hour exten-sions to enable individuals to continueworking) all converge to ensure anactive cancer program administrator isoften in the position of requesting yetadditional dollars to improve cancercare services, upgrade oncology equip-ment, or recruit new or additional spe-cialized staff.Although the term “benchmarking”

is ubiquitous in quality-of-care litera-ture, of immediate importance to can-cer program administrators is theirongoing challenge with internal hospi-tal competition for acquiring access toscarce or limited resources (eg, equip-ment dollars, capital budget funds).Because it is a highly technical field(often coupled with intense consumer/patient/media scrutiny) without ade-quate funding, cancer programs mayquickly fall behind and begin to bleedpatient volume to competitors.Program leaders often ask for accept-

ed standards or benchmarksto establish a baseline needas they prepare a com-pelling (and successful)business case for whateverservice extension, facilityimprovement, or staff re -cruitment challenge theprogram currently faces.Whereas certain bench-marks are well established,such as profitability, The

Oncology Group queried participantson the Association of Cancer Exec -utives (ACE) listserve regarding whatother oncology-specific benchmarks ormetrics experienced administratorsfound useful. An original survey wasconducted in Novem ber 2007, and asimilar survey was conducted in early2010. Differences between the 2 yearswill be shown.

The surveyThe survey asked respondents (the

ACE listserve) to answer this series ofopen-ended questions.As you work to position your cancer

center within the confines of the largerhospital:•What are the three to five mostimportant benchmarks that you useto make your case for resources andsupport from senior administration;or which benchmarks does youradministration require?

• What information/metrics/numbersdo you need to sell the importanceof oncology to your senior team?

• What metrics or resources do youuse? Also, what has been successful?

• What metrics do you track andreport on your oncology dashboard?

• And most importantly, what met-rics have proven most useful to yourteam?

• If the hospital uses a balanced score-card, what specific measures doesyour team use to track oncologyservices (eg, productivity standardsfor radiation therapy, department-based profit margin, cost-per-case,etc).

Survey findingsSeventeen experienced hospital can-

cer program administrators responded tothe survey in 2007. Fourteen (82%) ofthe respondents represented large com-munity hospital cancer programs. Theremaining respondents (3; 18%) repre-sented academic center cancer programs.In 2010, eight administrators responded,all from community hospitals.

Primacy of financial metricsAs expected, when reporting to se-

nior administration, most respondentsfocused on financial metrics. Seventy-six percent (13) in 2007 and 85% (7) in2010 of the program administrators usedsome type of financial metric for report-ing. Whereas some used a full serviceline financial metric, others used depart-mental measures as a surrogate. This isnot uncommon, as many hospitals findit difficult to roll up the total financialimpact cancer has on a hospital/health

system (especially outpatient down-stream revenue in pharmacy, radiology,surgery, and laboratory). In 2010, thetrend was to use hospital-wide finan-cials, which, in some cases, the respon-dents said “were not useful.” For exam-ple, financials were based on Medicareseverity diagnosis-related groups (MSDRGs) and not ICD-9-CM codes orwere for hospital inpatient only.Table 1 lists financial measurements

oncology program administrators re -ported they use and find useful toachieve their objectives with senioradministration.

Patient volume also used by mostThe next most common metric,

patient volume, is relatively easy tomeasure and was used by 65% (11) ofthe respondents in 2007 and 100% ofthe 2010 respondents. However, it mustbe cautioned that using volume onlymay not provide an accurate picture ofprogram growth. If the market is grow-ing and your institution’s or cancer pro-gram’s volume is not keeping pace withthat growth, the hospital (or the pro-gram) may be losing market share. Table2 lists typical patient volume measuresrespondents reported using.An interesting difference seen in

2010 was that half (4) of the hospitalsmonitored volume per physician (suchas cases per medical oncologist; referrals

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

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

Marsha Fountain, RN, MSN


Benchmarking

to breast surgeon). This indicates that agrowing number of cancer programshave closer alignment models (includ-ing employment) for cancer physiciansthan were evident in 2007. Volume andproductivity measures are listed inTables 3.

More than half report using clinicalquality guidelinesJust over half (53%; 9) of the respon-

dents in 2007 and 25% (2) in 2010reported using some clinical qualityguidelines when preparing a businesscase. A number of programs used specif-ic clinical quality guidelines and reliedon numerous pages of quality measuresand benchmarks, based on theAmerican Society of Clinical On -cology’s Quality Oncology PracticeInitiative, the National ComprehensiveCancer Network Clinical PracticeGuidelines in Oncology series, andother groups. Other programs reportedusing very few (ie, 1-5) clinical qualitymeasures. Table 5 lists a sample of clin-ical quality metrics that several programleaders noted are of value to them andto their senior administrators.

Productivity benchmarks seen as valuableMore than one third (35%; 6) of

respondents in 2007 and up to 62% ofthe 2010 respondents indicated report-ing operational productivity statisticscarried weight with hospital administra-tors. These metrics appeared most oftento be monitored for radiation therapydepartments. Table 4 lists examples ofthese benchmarks.

Patient satisfaction metricsimportant to some More than one third (35%) of

respondents in each year also noted thatthey used measurements of patient sat-isfaction to make their cases for addi-tional resources. Most respondents didnot list specific patient satisfactionmeasurements, though some noted theycompared themselves with local resultsfrom Press Ganey data. A few respon-dents also noted that they used depart-ment-specific patient satisfaction scoresas opposed to hospital-wide or cancerpatient–specific surveys. Survey ana-lysts assume these were tailored to thespecific business case being made, or

perhaps to what patient satisfactiontools or outcomes data were available inthe institution.

Treatment volumes spell revenue Surprisingly, less than one third (29%;

5) of respondents noted that they rou-tinely used treatments per visit or typesof treatment metrics in their operationalor planning work in 2007. In 2010, thatnumber 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 tomarket share. Only three (18%) respon-dents noted that they used market shareas an ongoing tracked metric in 2007.Analysts surmised this may be becauseinpatient market share data (althoughalmost universally available) is such a

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

Operational and FinancialBenchmarkingRecommendations1. Know your institution’s leaders

• Lead with data that address their priorities• Educate as you go—gradually introduce new information to enable themto 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 impacton 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 efforts6. 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


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

ESTIMATED TIME TO COMPLETE: 1.0 HOUR

CONTINUING MEDICAL EDUCATION ACCREDITATION AND DESIGNATION OF CREDIT STATEMENTVeritas Institute for Medical Education, Inc. is accredited by the Accreditation Councilfor Continuing Medical Education to provide continuing medical education forphysicians.Veritas Institute for Medical Education, Inc. designates this educational activity for amaximum of 1.0 AMA PRA Category 1 Credits™. Physicians should only claim creditcommensurate with the extent of their participation in the activity.

METHOD OF PARTICIPATION1. Read the article in its entirety2. Log on to www.JOMCC.com3. Click on “CE Credits”4. Click on “Click here to complete the posttest and obtain a CME certificate online”5. Register to participate6. Enter program number MCC37. Complete and submit the CME posttest and CME Activity Evaluation and Request

for Credit Form online8. Print your Certificate of CreditThis activity is provided free of charge to participants.

FINANCIAL DISCLOSURESVeritas Institute for Medical Education, Inc. is required to disclose to the activity audi-ence the relevant financial relationships of the planners and faculty involved in the

development of CME/CE content. An individual has a rele-vant financial relationship if he or she has a financial rela-tionship in any amount occurring in the last 12 monthswith a commercial interest whose products or services are

discussed in the CME/CE activity content over which the individual has control. Inaddition, all faculty are expected to openly disclose any unlabeled/unapproved/investi-gational 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 HealthcareCommunications, LLC have nothing to disclose.

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

EDITORIAL BOARDFloor Backes, MDDivision of GynecologicOncologyDepartment of Obstetrics &GynecologyArthur G. James CancerHospital and SoloveResearch InstituteThe Ohio State UniversityCollege of MedicineM210 Starling Loving320 West 10th AvenueColumbus, OH 43210

Ritu Salani, MD, MBAAssistant ProfessorDivision of GynecologicOncologyDepartment of Obstetrics &GynecologyArthur G. James CancerHospital and SoloveResearch InstituteThe Ohio State UniversityCollege of MedicineM210 Starling Loving320 West 10th AvenueColumbus, OH 43210

Greg Samijlenko, PharmD,BCPSClinical GeneralistPharmacistArthur G. James CancerHospital and SoloveResearch InstituteThe Ohio State UniversityCollege of MedicineM210 Starling Loving320 West 10th AvenueColumbus, OH 43210

Andrea Easley, MS, RN,WHNP-BCNurse PractitionerDivision of GynecologicOncologyDepartment of Obstetrics &GynecologyArthur G. James CancerHospital and SoloveResearch InstituteThe Ohio State UniversityCollege of MedicineM210 Starling Loving320 West 10th AvenueColumbus, OH 43210

Chief complaint: Abdominal bloating anddiscomfort.

History of present illness: A 67-year-oldCaucasian woman presented to her primarycare physician complaining of bloating,abdominal discomfort, and some mild nau-sea. Because of her history of diverticulosis,

she was treated with antibiotics for a pre-sumed episode of diverticulitis. The patient’ssymptoms did not improve, but when asked,she would answer that she felt somewhat bet-ter, believing that the antibiotics shouldwork. When the symptoms persisted, thepatient was evaluated with a colonoscopyand computed tomography (CT) scan. The

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

STATEMENT OF NEEDOnly two controllable factors can impact survival in metastatic ovarian cancer: extentof surgical effort and selection of chemotherapy agents. The choice of chemotherapyagents is complicated by the high rates of chemotherapy-induced peripheral neuropa-thy in patients receiving cisplatin and paclitaxel. This program will enhance compre-hension of the thought processes involved in applying personalized medicine in ovari-an cancer by elucidating the one team’s prospective discussion in their treatmentdecisions for a 67-year-old Caucasian woman with stage IIIC high-grade serous carci-noma of the ovary.

TARGET AUDIENCEMedical, surgical, and radiation oncologists, and other interested healthcare profes-sionals, especially those caring for cancer patients.

LEARNING OBJECTIVESAfter 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. Althoughits 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 foradvanced ovarian cancer consists of surgical resection followed by chemotherapy. In these cases, only two controllable factors can impact survival: extentof surgical effort and selection of chemotherapy agents. The following article presents the thought processes behind the treatment of a patient with wide-ly metastatic serous carcinoma of the ovary. This patient, like many who receive cisplatin and paclitaxel, also developed chemotherapy-induced peripher-al neuropathy (CIPN). Supportive therapies were also discussed and implemented by the team.

Case Presentation

CONTINUING EDUCATION

PLANNING COMMITTEEGloria MuiMedical DirectorVeritas Institute for MedicalEducation, Inc.611 Route 46 West Hasbrouck Heights, NJ 07604

Julie Ann TagliareniCME DirectorVeritas Institute for MedicalEducation, Inc.611 Route 46 West Hasbrouck Heights, NJ 07604

Anne L. FingerPresidentVeritas Institute for MedicalEducation, Inc.611 Route 46 West Hasbrouck Heights, NJ 07604

Dawn LagrosaManaging EditorGreen Hill HealthcareCommunications, LLC241 Forsgate DriveMonroe Twp, NJ 08831

Karen RosenbergEditorial DirectorGreen Hill HealthcareCommunications, LLC241 Forsgate DriveMonroe Twp, NJ 08831

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


www.JOMCC.com

A 67-year-old Caucasian woman wasreferred to the gynecologic oncologydepartment and underwent tumor-reductive surgery. Prior to her referral,the patient experienced persistentsymptoms of what she believed wasdiverticulitis. Her primary care physi-cian evaluated her with a colonoscopyand CT scan. The CT image showedbilateral 4-cm pelvic masses, omentalthickening, and peritoneal nodularity.Because he suspected an ovarian malig-nancy, a CA125 level was obtained andnoted to be elevated at 1363 units/mL(normal, <35 units/mL). At the time of surgery she was found

to have extensive disease, involvingthe ovaries, rectosigmoid colon, andupper abdomen. She underwent a bilateral salpingo-oophorectomy, rec-tosigmoid resection, omentectomy,diaphragm peritonectomy, and resec-tion of tumor implants. Pathology find-ings revealed widely metastatic adeno-carcinoma of the ovary, resulting in afinal diagnosis of stage IIIC high-grade serous carcinoma of the ovary.Postoperatively, she was treated with acombination of intravenous andintraperitoneal cisplatin and paclitaxelfor six cycles. Overall, she toleratedtherapy well, with the exception ofmoderate neuropathy. In addition tosupportive care measures, docetaxelwas substituted for paclitaxel. Her neu-ropathy improved; however, she con-tinued to have mild numbness and tin-gling in her fingertips, which did notlimit her daily activities.After treatment, she had a complete

clinical response with a normal CA125level and negative imaging study. Shecontinued routine follow-up with apelvic examination and CA125 levelevery 3 months. At her 15-month visit,she complained of urinary frequency,changing bowel habits, and new lowerabdominal pain. Her CA125 level hadalso increased to 98 units/mL. A CTscan of the abdomen and pelvis con-firmed recurrent disease, consistentwith platinum-sensitive disease. Be -cause of persistent neuropathy, paclitax-el was avoided, and she began second-line treatment with carboplatin andliposomal doxorubicin for six cycles.

She is almost 1 year out from comple-tion of therapy and remains withoutevidence of disease.

Physicians’ perspective In a typical presentation, this patient

presented with the vague symptomatol-ogy of ovariancancer, includ-ing abdominaldiscomfort andbloating, uri-nary urgency,and pelvic pain.A study byGoff and col-leagues foundthat 89% ofpatients withstage I/II and 97% of patients withadvanced ovarian cancer presentedwith the aforementioned symptomsprior to diagnosis.2,3 Symptoms occurredmore frequent-ly and with in -creased severi-ty in pa tientswith o variancancer whencompared withpa tients withbe nign ovari-an masses andwith healthycon trols. Whenpatients present for evaluation of thesesymptoms, however, they are oftenattributed to other conditions, such asdiverticulitis. This, in conjunction witha lack of a reliable screening method forovarian cancer, results in most patientsbeing diagnosed in advanced stages.The mainstay of treatment for ad -

vanced ovarian cancer consists of surgi-cal resection followed by chemotherapy.Factors affecting survival include stage,grade, and performance status; however,there are only two controllable factorsthat impact survival.One factor is the extent of surgical

effort. Specifically, patients who under-go optimal cytoreductive surgery, de -fined as ≤1 cm of residual disease following surgical resection, have sig nif-icantly improved disease-free survivaland overall survival.4-8

The other factor is the selection ofchemotherapy agents. For the past sev-eral decades, the use of platinum with ataxane has been shown to have superiorresults and/or toxicity profiles whencompared with other agents, thus mak-ing this combination the standardfrontline regimen.9,10 Recently, theGynecologic Oncology Group evaluat-ed the route of chemotherapy adminis-tration, comparing cisplatin and pacli-taxel given intraperitoneally versusintravenously. The results demonstrateda significant survival benefit of 16months favoring the intraperitonealgroup; however, only 42% of patientswere able to complete the scheduled sixcycles of this regimen.11 Patients oftendiscontinued therapy secondary to toxi-cities, namely grade 3/4 neurotoxicity,which occurred in one fifth of thepatients.

The development of CIPN can havea great impact on quality of life.Typically, most patients experiencingCIPN recover after the completion oftherapy. In the aforementioned study, al -though more patients experienced neu-ropathy in the intraperitoneal arm, bothgroups had a similar quality of life at the12-month follow-up. In addition, alter-native treatment regimens are availablefor those patients who develop signifi-cant CIPN. The Scottish RandomizedTrial in Ovarian Cancer (SCOTROC)evaluated the use of carboplatin witheither paclitaxel or docetaxel in pa -tients with advanced ovarian cancer.12Those in the docetaxel arm were foundto a have similar progression-free sur-vival as those in the paclitaxel arm;however, patients reported significantlyless CIPN with this regimen.Unfortunately, similar to our case, at

least 60% of patients with ovarian can-cer will have a recurrence.13 Therefore,

close observation with pelvic examina-tion, with or without CA125 levels, isrecommended.14 When recurrence isdetected, the treatment is impacted bythe time between clinical response anddisease recurrence. If disease recurs ≥6months after a complete clinicalresponse, patients are classified as hav-ing platinum-sensitive disease. Thesepatients generally have a better progno-sis than those who are platinum-refrac-tory or -resistant, defined as patientswho have progressive disease or recur-rence within 6 months after primarytreatment. In the platinum-sensitivegroup, surgery and/or chemotherapymay be applicable. In regard tochemotherapy, the favored regimenconsists of treatment with a platinumagent, which may be used as a singleagent or combined with agents such aspaclitaxel or gem cit abine.14 Recently,

the CALYPSO trial demonstrated thatthe combination of carboplatin andliposomal doxorubicin had similar sur-vival outcomes in the recurrent settingand a lower rate of severe neuropathywhen compared with carboplatin andpaclitaxel.15 Generally, response ratesfor second-line treatment in this grouprange from 30% to 64%,16 and selec-tion, of the specific regimen is oftenbased on the toxicity profile.After primary treatment, our patient

was without evidence of disease for 15months, indicating that her disease wasplatinum-sensitive. She was offeredretreatment with a platinum drug (car-boplatin) and liposomal doxorubicin,which was favored over paclitaxel dueto her history of CIPN. She continuesto be monitored closely for recurrentdisease but is currently enjoying lifewithout chemotherapy.

Medical history: Hypertension and type 2 diabetesmellitus.

Surgical history:Hysterectomy (leiomyomas) in 1974.

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

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

Medications:Metformin 500 mg twice daily and meto-prolol extended release 50 mg daily.

Allergies: No known drug allergies.

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

Heart: Regular rate and rhythm, no murmurs or gal-lops.Chest:Normal excursions, lungs clear to auscultationbilaterally.Abdomen: Softly distended with a mild fluid waveand 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; CA125level, 1363 units/mL.

Floor Backes, MD

Ritu Salani, MD, MBA



Recently, the CALYPSO trial demonstrated that thecombination of carboplatin and liposomal doxorubicinhad similar survival outcomes in the recurrent settingand a lower rate of severe neuropathy whencompared with carboplatin and paclitaxel.

CONTINUING EDUCATIONContinued from page 19

Pharmacist’s perspective When selecting a regimen for the

treatment of ovarian cancer, a patient’sbaseline healthstatus and con-current med-ical conditionsshould be as -sessed. This isparticularly im -portant, as thepotential toxic-ity from chemo -therapy maymake symptomsworse. For in-

stance, patients with diabetes may havea preexisting neuropathy, which couldimpact the regimen administered.14Although this patient did not have anybarriers to receiving intraperitonealtreatment with cisplatin and paclitaxel,preventing/minimizing toxicities, alongwith curative treatment, was our mainfocus.Both cisplatin and paclitaxel are

known to cause painful and disablingneurotoxicity.17,18 Paclitaxel causes largesensory fiber lesions leading to polyneu-ropathy, which consists of loss of vibra-tion sense, proprioception, and muscleweakness.18 Cisplatin reduces fast ax o -nal transport and induces apoptosis indorsal root ganglion, resulting in pares-thesias, sensory ataxia, loss of vibration,and loss of deep tendon reflexes.18

These symptoms may continue longterm after therapy. Unfortunately, anefficacious agent for the treatment ofCIPN has not been found. However,there have been some promising resultsin the prevention of neurotoxicity.17,18Calcium and magnesium infusions havebeen shown to be effective in prevent-ing neuropathy associated with oxali-platin.18-20 Oxaliplatin increases thehyperexcitability of peripheral neuronsand forms a neurotoxic metabolite ox -alate.21 Increasing extracellular calciumis thought to help reduce hyper -excitability of peripheral neurons, and calcium and magnesium chelateoxalate.17,19,21 Because cisplatin andpaclitaxel do not cause neurotoxicity bythese mechanisms, calcium and magne-sium infusions would not be helpful inthis setting.Vitamin E has shown some promise

in the prevention of CIPN, particularlyin patients receiving cisplatin- andpaclitaxel-containing regimens.17,22,23Vitamin E is a fat-soluble antioxidant

vitamin that may reduce the incidenceor severity of peripheral neuropathy.Pace and colleagues randomized 47patients to receive cisplatin with andwithout vitamin E 300 mg/day. Only31% of patients in the vitamin E groupdeveloped CIPN compared with 86% ofpatients in the control group.22 Anotherstudy randomized patients who werereceiving cisplatin, paclitaxel, or bothto vitamin E 300 mg twice daily or nointervention. One fourth of patients inthe vitamin E group developed CIPNcompared with 73% in the no-interven-tion group.23 Although these results arepromising, there is a concern that theantioxidant properties of vitamin E mayreduce the effectiveness of chemothera-py, as seen in radiation therapy, and fur-ther studies are warranted.17Glutathione has also been shown to

help reduce peripheral neuropathy bypreventing the accumulation of plat-inum in the dorsal root ganglia.17 Twostudies, both placebo-controlled, dou-ble-blind trials, showed that the addi-tion of glutathione resulted in a reduc-tion of CIPN in patients receivingplatinum therapy.24,25 In addition to glu-tathione, the use of N-acetyl-cysteine,which increases the whole blood con-centration of glutathione, is of interest.However, to date, there are no studiesevaluating its role with cisplatin-basedregimens.17Another agent that is theoretically

promising for the prevention/treatmentof CIPN is amifostine. Amifostine is aprodrug that is dephosphorylated intofree thiol, which binds and deactivatesactive metabolites of cisplatin and scav-enges free radicals.26 However, two ran-domized controlled trials combiningamifostine with paclitaxel and carbo-platin regimens have not found signifi-cant effectiveness.27,28 The AmericanSociety of Clinical Oncology has re -leased clinical practice guidelines thatdo not support the use of amifostine forprevention of CIPN.29Despite the efforts being made to find

appropriate agents to prevent CIPN,more data are needed before recom-mending any particular treatment. It iscrucial to provide counseling to patientson all toxicities associated withchemotherapy and the rationale forrelated treatments to ensure optimalefficacy. This education allows patientsto recognize toxicities early on and toreport them to the clinical team foreffective management. This form of

counseling empowers patients to beactive participants in their disease andits management, ideally resulting in thebest outcome.

Nurse’s perspective CIPN is a common side effect of ther-

apies used to treat patients with gyneco-logic malig-nancies. CIPNcan affect sen-sory, autonom-ic, and motorsystem func-tion. Sensorysymptoms in -clude dimin-ished sensa-tion, pain, andnumbness ortingling, which

often begins in the toes and fingers thenspreads proximally in a stocking-and-glove pattern. Autonomic symptomsinclude constipation, urinary retention,and sexual dysfunction. Motor symp-toms include weakness, gait distur-bance, balance disturbance, and diffi-culty with fine motor skills.17,30,31Because of a lack of a standardizedmeasurement, the exact prevalence isdifficult to determine, but CIPN is esti-mated to affect about 30% to 40% ofpatients.17,30 The symptoms can bedebilitating, with a significant negativeeffect on quality of life. Although symp-toms often resolve either partially orcompletely within 6 months to 2 yearsafter completion of treatment, they canbe permanent.32The nurse plays a key role in provid-

ing care for patients with CIPN. With afocus on patient education, assessment,and monitoring, the nurse is instrumen-tal in helping the patient identify earlysigns and symptoms of peripheral neu-ropathy leading to earlier diagnosis.Early identification is essential forappropriate adjustments/interventionsto limit the progression of symptoms.Because of the potentially debilitatingeffects, CIPN may be a dose-limitingside effect, meaning the chemotherapydose is reduced, the cycle is delayed, orthe treatment is discontinued orchanged entirely. There is currently nostandard treatment that is both safe andproven to either prevent or reverseCIPN.30 Currently, the treatmentoptions being used have varying rates ofeffectiveness.To limit the effects of CIPN, nurses

must be aware of the risk factors, signsand symptoms, safety issues, and bothpharmacologic and nonpharmacologictreatment options and educate thepatient accordingly. Nurses shouldinstruct the patient to report both symp-toms and functional deficits promptly.30Although a patient’s self-report is animportant part of the history, symptoms

may be confounded by other side effects.Thus, it is also important to frequentlyassess and monitor the patient for earlysigns of CIPN.32 Several instruments areavailable to measure the severity ofperipheral neuropathy grading severitybased on symptoms and/or diminishedfunctional status; however, these are notoften used, and awareness and educationare critical.It is important that the nurse edu-

cates the patient on personal safety.Because of lack of sensation, extraattention must be paid during ambula-tion to prevent falls. The patient shouldbe advised to remove throw rugs, createclear walkways, and ensure adequatelighting around the house. The patientmust be instructed to take special careof feet and be especially aware of tem-perature extremes in both the naturalelements and in the home. The nurseshould encourage the use of stool sof-teners, high-fiber diet, adequate fluidintake, frequent voiding, and slow posi-tion changes to combat the autonomiceffect on the bowels and the bladder,and postural hypotension.30Currently, there is no standard treat-

ment for CIPN; however, some non-pharmacologic treatment options showpromise in reducing symptoms. Unfor -tunately, most options have not beenstudied in oncology patients. Acu -puncture has been shown to improvegait, decrease the amount of pain medi-cine used and, specifically in gynecolog-ic oncology patients, increase sensa-tion.30 Light exercise may help toincrease muscle mass that can be lostdue to activity limitations associatedwith neuropathy.30 A physical therapyconsult may be helpful to provide safe,effective exercise options. Techniquesthat have demonstrated benefit in dia-betic neuropathy include the following:pulsed infrared light therapy, which hasshown positive results in sensation andpain reduction, and transcutaneousnerve stimulation, which blocks theconduction of nerve signals to the brainthrough electrical impulses and hasbeen shown to improve numbness,pain, and prickling sensation.30 Relax -ation techniques including yoga, medi-tation, and guided imagery may reducestress and pain, may improve mood, andprovide benefit for patients withCIPN.33By providing the patient with strate-

gies to manage the effects of CIPN, theoncology nurse can have a positive effecton quality of life.

ConclusionBoth the extent of surgical effort and

selection of chemotherapy agents canimpact survival in ovarian cancer.Treat ment of this patient consisted of abilateral salpingo-oophorectomy, rec-tosigmoid resection, omentectomy,

Andrea Easley, MS, RN,WHNP-BC


Although a patient’s self-report is an important part ofthe history, symptoms may be confounded by otherside effects. Thus, it is also important to frequentlyassess and monitor the patient for early signs of CIPN.

Greg Samijlenko,PharmD, BCPS

www.JOMCC.com

diaphragm peritonectomy, and resec-tion of tumor implants followed bytreatment with a combination of intra-venous and intraperitoneal cisplatinand paclitaxel. With this regimen cho-sen, preventing or minimizing toxicitiesbecame our secondary focus. Whenpatients experienced CIPN, docetaxelwas substituted for paclitaxel and sup-portive care measures were implement-ed. When the disease recurred, her plat-inum-sensitive status led to treatmentwith a platinum drug (carboplatin) andliposomal doxorubicin, which wasfavored over paclitaxel because of herhistory of CIPN. This patient continuesto do well. l

References1. 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 womenpresenting 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 foradvanced ovarian carcinoma during the platinumera: a meta-analysis. J Clin Oncol. 2002;20:1248-1259.

5. Eisenhauer EL, Abu-Rustum NR, Sonoda Y, et al.The effect of maximal surgical cytoreduction onsensitivity to platinum-taxane chemotherapy and

subsequent survival in patients with advanced ovar-ian cancer. Gynecol Oncol. 2008;108:276-281.

6. Aletti GD, Dowdy SC, Podratz KC, Cliby WA.Relationship among surgical complexity, short-termmorbidity, and overall survival in primary surgeryfor advanced ovarian cancer. Am J Obstet Gynecol.2007;197:676.e1-e7.

7. Leitao MM Jr, Chi DS. Operative management ofprimary epithelial ovarian cancer. Curr Oncol Rep.2007;9:478-484.

8. Aletti GD, Dowdy SC, Gostout BS, et al.Aggressive surgical effort and improved survival inadvanced stage ovarian cancer. Obstet Gynecol.2006;107:77-85.

9. Ozols RF, Bundy BN, Greer BE, et al. Phase III trialof carboplatin and paclitaxel compared with cisplatinand paclitaxel in patients with optimally resectedstage III ovarian xancer: a Gynecologic OncologyGroup Study. J Clin Oncol. 2003;21:3194-3200.

10. McGuire WP, Hoskins WJ, Brady MF, et al.Cyclophosphamide and cisplatin compared withpaclitaxel and cisplatin in patients with stage IIIand stage IV ovarian cancer. N Engl J Med.1996;334:1-6.

11. Armstrong DK, Bundy B, Wenzel L, et al; for theGynecologic Oncology Group. Intraperitoneal cis-platin and paclitaxel in ovarian cancer. N Engl JMed. 2006;354:34-43.

12. Vasey PA, Jayson GC, Gordon A, et al; for theScottish Gynaecological Cancer Trials Group.Phase III randomized trial of docetaxel-carboplatinversus paclitaxel-carboplatin as first-line chemo -therapy for ovarian carcinoma. J Natl Cancer Inst.2004;96:1682-1691.

13. Diaz-Montes TP, Bristow RE. Secondary cytoreduc-tion for patients with recurrent ovarian cancer.CurrOncol Rep. 2005;7:451-458.

14. National Comprehensive Cancer Network. NCCNClinical Practice Guidelines in Oncology: OvarianCancer. V.2.2010. www.nccn.org/professionals/physician _gls/PDF/ovarian.pdf. Accessed April 18, 2010.

15. Pujade-Lauraine E, Mahner S, Kaern J, et al. A ran-domized, phase III study of carboplatin and pegylat-

ed liposomal doxorubicin versus carboplatin andpaclitaxel in relapsed platinum-sensitive ovariancancer (OC): CALYPSO study of the GynecologicCancer Intergroup (GCIG). J Clin Oncol. 2009;27(18S):Abstract LBA5509.

16. Herzog TJ. The current treatment of recurrent ovar-ian cancer. Curr Oncol Rep. 2006;8:448-454.

17. Wolf S, Barton D, Kottschade L, et al. Chemo -therapy-induced peripheral neuropathy: preventionand treatment strategies. Euro J Cancer. 2008;44:1507-1515.

18. Ocean AJ, Vahdat LT. Chemotherapy-inducedperipheral neuropathy: pathogenesis and emergingtherapies. Support Care Cancer. 2004;12:619-625.

19. Gamelin L, Boisdron-Celle M, Delva R, et al.Prevention of oxaliplatin-related neurotoxicity bycalcium and magnesium infusions: a retrospectivestudy of 161 patients receiving oxaliplatin com-bined with 5-fluorouracil and leucovorin foradvanced colorectal cancer. Clin Cancer Res. 2004;10(12 pt 1):4055-4061.

20. Nikcevich DA, Grothey A, Sloan JA, et al. A phaseIII randomized, placebo controlled, double-blindstudy of intravenous calcium/magnesium to preventoxaliplatin-induced sensory neurotoxicity, N04C7.J Clin Oncol. 2008;26(May 20 suppl):Abstract 4009.

21. Armstrong CM, Cota G. Calcium block of Na+channels and its effect on closing rate. Proc NatlAcad Sci U S A. 1999;96:4154-4157.

22. Pace A, Savarese A, Picardo M, et al. Neuro -protective effect of vitamin E supplementation inpatients treated with cisplatin chemotherapy. J ClinOncol. 2003;5:927-931.

23. Argyriou AA, Chroni E, Koutras A, et al. Vitamin Efor prophylaxis against chemotherapy-induced neu-ropathy: a randomized controlled trial. Neurology.2005;64:26-31.

24. Cascinu S, Cordella L, Del Ferro E, et al.Neuroprotective effect of reduced glutathione oncisplatin-based chemotherapy in advanced gastriccancer: a randomized double-blind placebo-con-trolled trial. J Clin Oncol. 1995;13:26-32.

25. Smyth JF, Bowman A, Perren T, et al. Glutathione

reduces the toxicity and improves quality of life ofwomen diagnosed with ovarian cancer treated withcisplatin: results of a double blind, randomised trial.Ann Oncol. 1997;8:569-573.

26. Ethyol (amifostine) [package insert]. Nijmegen, theNetherlands: MedImmune; 2009.

27. Hilpert F, Stahle A, Tome O, et al; for theArbeitsgemeinschaft Gynäkologische Onkologoie(AGO) Ovarian Cancer Study. Neuroprotectionwith amifostine in the first-line treatment ofadvanced ovarian cancer with carboplatin/paclitax-el-based chemotherapy—a double-blind, placebo-controlled, randomized phase II study from theArbeitsgemeinschaft Gynakologische Onkologoie(AGO) Ovarian Cancer Study Group. Support CareCancer. 2005;13:797-805.

28. Leong SS, Tan EH, Fong KW, et al. Randomizeddouble blind trial of combined modality treatmentwith or without amifostine in unresectable stage IIInon-small cell lung cancer. J Clin Oncol. 2003;21:1767-1774.

29. Schuchter LM, Hensley ML, Meropol NJ, Winer EP;for the American Society of Clinical OncologyChemotherapy and Radiotherapy Expert Panel. 2002update of recommendations for the use of chemo -therapy and radiotherapy protectants: clinical prac-tice guidelines of the American Society of ClinicalOncology. J Clin Oncol. 2002;20:2895-2903.

30. Visovsky C, Collins M, Abbott L, et al. Putting evi-dence into practice: evidence-based interventionsfor chemotherapy-induced peripheral neuropathy.Clin J Oncol Nurs. 2007;11:901-913.

31. Wickham R. Chemotherapy-induced peripheralneuropathy: a review and implications for oncologynursing practice. Clin J Oncol Nurs. 2007;11:361-376.

32. Stubblefield MD, Burstein HJ, Burton AW, et al.NCCN Task Force Report: management of neu-ropathy in cancer. J Natl Compr Canc Netw. 2009;7(suppl 5):S1-S28.

33. Paice J. Clinical challenges: chemotherapy-inducedperipheral neuropathy. Semin Oncol Nurs. 2009;25(2 suppl 1):S8-S19.

poor measure of actual oncology patientvolume, which is largely outpatient; orbecause local program administratorsfind it difficult to secure valid and reli-able outpatient or analytic case marketshare data for their institution and cer-tainly for competitors.In 2010, this theory was supported,

with respondents saying things such as“our hospital uses state-wide data for mar-ket share, but it is MS-DRG–based,which is not useful for the cancer pro-gram.” Others are utilizing cancer registrydata for market share, but realize the lim-itation of timing for this measurement.

Time to treatment used rarely One key patient dis-satisfier is often

time to treatment, defined as the timefrom diagnosis to definitive treatment.Two (12%) respondents indicated thatthey used a time to treatment bench-mark as part of their operational evalu-ations in 2007; no respondent reportedusing this metric in 2010.

Remaining benchmarksRespondents identified many other

measurements they used in developingbusiness cases or requests for resources.These included:• Technology assessment based on theadvisory board

• Number of individuals attending community events

• Grant or contract funding availablefor particular program elements.An interesting finding seen in 2010

but not seen in 2007 was the number ofrespondents who stated that they mea -sured the use of drug replacement pro-grams to show money saved to justifysupport for that program. Just over onethird (3) of the respondents reportedmeasuring this metric.

Conclusions and discussionThese survey results, although infor-

mal and limited in their general use, doshow that cancer program administra-tors use a vast array of indicators to sup-port their requests for continued orincreased funding. As working oncolo-gy program administrators recognize(but which fewer hospital administra-tors may know), cancer care often rep-resents 10% to 15% of a general hospi-tal’s revenue. Furthermore, cancerpatients often provide the majority ofvaunted patient volume for at leastthree key hospital departments—theoperating room, diagnostic radiology,and laboratory/pathology.Moreover, as reimbursement contin-

ues to be “rationalized,” an increasingnumber of supportive care or ancillaryservices targeted to cancer patientsremain unfunded by the Centers forMedicare & Medicaid Services andother major insurers. These unreim-

bursed items include program elementssuch as patient navigation, nutritioncounseling, financial counseling, sup-port programs (support groups), andeducation. All these factors make itclear to program administrators that it isincumbent on them to continue to pro-cure the funds necessary to care for indi-viduals diagnosed with cancer whocome to their institution for all, ormost, of their care.

Procuring these funds typically re -quires the program administrator to“frame the cancer experience from theview of senior management,” asCatherine Harvey, RN, DrPH, AOCN,a leading cancer business consultant,puts it. This means coming to budgetmeetings armed with the facts that willtell your institution’s cancer care storyin a compelling manner that coversboth margin and mission. l

Operational and Financial Benchmarking... Continued from page 17


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

Breast MRI AccreditationProgram

SAN FRANCISCO—Hypofract ion -ated radiotherapy (65 Gy in 2.5-Gy frac-tions) appears to be a convenient, safe,

and efficacious approach to salvage ther-apy after radical prostatectomy, accord-ing to researchers from the University of

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

els) compared favorably with other stud-ies. They presented their findings at the2010 Genitourinary Cancers Symposium.Approximately 25% of men experi-

ence biochemical failure followingprostatectomy, so early salvage therapymay be a suitable alternative to the adju-vant treatment of patients at higher riskfor failure. Other studies have suggestedthat hypofractionation is well-toleratedand efficacious in the definitive settingbut experience in the salvage setting hasbeen limited. It is theorized thathypofractionation may improve efficien-cy, reduce costs, and provide patient ben-efits in this population.For the current study, researchers con-

ducted a retrospective analysis of 108men (mean age, 63 years) treated to theprostatic fossa with 65 Gy in 26 fractionsof 2.5 Gy. The median follow-up was 32.4months (range, 5.8-70.5). A total of 18(17%) patients had androgen-depriva-tion therapy following surgery or concur-rently with radiation (maximum dura-tion of 2 months after salvage).The researchers found that the actuar-

ial freedom from biochemical failure at 4years was 67%. They also found that onlytwo biochemical failures occurred laterthan 24 months. The investigators foundonly one acute grade 3 genitourinary tox-icity (obstruction) in a patient previouslytreated for bladder neck contracture.“We found it is very safe, and the

level of side effects was very low. Thelevel of side effects is consistent with orlower than what people have foundwith more standard and longer courseradiation therapy. Secondly, it alsoappears to be very effective. We foundthat almost 70% of the patients long-term have reestablished control of theirtumors,” said study investigator MarkRitter, MD, who is a professor of humanoncology at the University of Wiscon sinSchool of Med icine and Public He alth,Madison in an interview with theJournal of Multidisciplinary Cancer Care. He said that approach is much more

convenient for the patients and a moreefficient use of equipment. He said itcould prove to be a boon to patients andmedical facilities if they adopted thisregimen on a wide scale. Lead studyinvestigator Tim Kruser, MD, an oncol-ogy resident at the University ofWisconsin, said these findings are verygood news for men who have radicalprostatectomies. He said patients wouldlike to have their treatment in a quick-er fashion. “It means fewer patient vis-its, it would be cheaper overall, and theside effects are similar to more tradi-tional regimens,” said Kruser. l


Prostate Cancer

There is A place you can go for user-friendly online tools and reimbursement forms…

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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

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Hypofractionated Salvage Radiotherapy May Be Beneficialfor Postprostatectomy Biochemical RecurrenceBy John Schieszer


Medications Used for the Treatment of Lung Cancer

Current MedicareFDA- code price allowableapproved Compendia listed (AWP-based (ASP + 6%), CPT

generic (Brand) HCPCS code: for off-label use for pricing), effective effective administrationname code description lung cancer lung cancera 6/1/10 4/1/10-6/30/10 codes

amifostine J0207: injection, ✓ $564.95 $327.96 96374(Ethyol) amifostine, 500mgbevacizumab J9035: injection, ✓ $66.99 $57.57 96413, 96415(Avastin) bevacizumab, 10 mgcarboplatin J9045: injection, ✓ $48.55 $5.31 96409, 96413, 96415(Paraplatin) carboplatin, 50 mgcetuximab J9055: injection, ✓ $57.60 $49.73 96413, 96415(Erbitux) cetuximab, 10 mgcisplatin J9060: cisplatin, powder ✓ $4.33 $1.98 96409, 96413, 96415(Platinol AQ) or solution, per 10 mgcisplatin J9062: cisplatin, 50 mg ✓ $21.66 $9.91 96409, 96413, 96415(Platinol AQ)cyclophosphamide J8530: cyclophosphamide, ✓ $2.09 $0.84 N/A(Cytoxan) oral, 25 mgcyclophosphamide J9070: cyclophosphamide, ✓ $10.57 $4.35 96409, 96413, 96415(Cytoxan) 100 mg (All 100 mg NDCs

inactive—500 mg NDCs used to calculate code price)

cyclophosphamide J9080: cyclophosphamide, ✓ $21.15 $8.69 96409, 96413, 96415(Cytoxan) 200 mg (All 200 mg NDCs

inactive—500 mg NDCs used to calculate code price)

cyclophosphamide J9090: cyclophosphamide, ✓ $52.87 $21.73 96409, 96413, 96415(Cytoxan) 500 mg

O N C O L O G Y D R U G C O D E SSupplied by: RJ Health Systems

Lung cancer forms in tissues of the lung, usuallyin the cells lining the air passages. The twomain types are small-cell lung cancer and non–small-cell lung cancer. The following sectionwill assist healthcare professionals and payers byproviding appropriate coding, billing, and reim-bursement information associated with themanagement of lung cancer.The following sections include:• Associated ICD-9-CM codes used for theclassification of lung cancer

• Drugs that have been FDA-approved in thetreatment of lung cancer

• Drugs that are compendia listed for off-labeluse for lung cancer based on clinical studiesthat suggest beneficial use in some cases.Please note: if a check mark appears in theFDA column, it will NOT appear in thecompendia off-label use column

• Corresponding HCPCS/CPT codes and codedescriptions

• Current Code Price (AWP-based pricing)• Most recent ASP plus 6% (Medicare allow-able), if applicable

• Possible CPT Administration Codes for eachmedication

Associated ICD-9-CM Codes Used for Lung Cancer

162 Malignant neoplasm of trachea, bronchus, and lung162.0 Trachea

Cartilage of tracheaMucosa of trachea

162.2 Main bronchusCarinaHilus of lung

162.3 Upper lobe, bronchus or lung162.4 Middle lobe, bronchus or lung162.5 Lower lobe, bronchus or lung162.8 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






cyclophosphamide J9091: cyclophosphamide, ✓ $95.21 $43.46 96409, 96413, 96415(Cytoxan) 1.0 gramcyclophosphamide J9092: cyclophosphamide, ✓ $171.35 $86.92 96409, 96413, 96415(Cytoxan) 2.0 gramdocetaxel J9171: injection, ✓ $23.87 $17.85 96413(Taxotere) docetaxel, 1 mgdoxorubicin HCl J9000: injection, doxorubicin ✓ $13.20 $3.04 96409(Adriamycin) hydrochloride, 10 mgerlotinib J8999b: prescription drug, ✓ NDC N/A N/A(Tarceva) oral, chemotherapeutic, not level

otherwise specified pricingetoposide J8560: etoposide, ✓ $47.64 $28.26 N/A(Vepesid) oral, 50 mgetoposide J9181: injection, etoposide, ✓ $0.53 $0.49 96413, 96415(Toposar) 10 mggefitinib J8565: gefitinib, ✓ $68.08 none N/A(Iressa) oral, 250 mg reportedgemcitabine J9201: injection, gemcitabine ✓ $173.83 $145.10 96413(Gemzar) hydrochloride, 200 mghydroxyurea J8999b: prescription drug, ✓ NDC NDC N/A(Hydrea) oral, chemotherapeutic, level level

not otherwise specified pricing pricinghydroxyurea S0176: hydroxyurea, ✓ $1.28 S0176 not N/A(Hydrea) oral, 500 mg payable by

Medicareifosfamide J9208: injection, ✓ $56.40 $30.76 96413, 96415(Ifex) ifosfamide, 1 gramirinotecan J9206: injection, ✓ $31.50 $9.15 96413, 96415(Camptosar) irinotecan, 20 mgmechlorethamine HCl J9230: injection, ✓ $178.71 $154.50 96409(Mustargen) mechlorethamine hydrochloride

(nitrogen mustard), 10 mgmethotrexate J8610: methotrexate, ✓ $3.61 $0.16 N/A

oral, 2.5 mgmethotrexate sodium J9250: methotrexate sodium, ✓ $0.29 $0.21 96372, 96374, 96401,

5 mg 96409, 96450methotrexate sodium J9260: methotrexate sodium, ✓ $2.86 $2.10 96372, 96374, 96401,

50 mg 96409, 96450mitomycin J9280: mitomycin, ✓ $67.20 $20.36 96409(Mutamycin) 5 mgmitomycin J9290: mitomycin, ✓ $218.40 $81.43 96409(Mutamycin) 20 mgmitomycin J9291: mitomycin, ✓ $300.00 $162.87 96409(Mutamycin) 40 mgpaclitaxel J9265: injection, ✓ $16.50 $11.46 96413, 96415(Taxol) paclitaxel, 30 mgpaclitaxel J9264: injection, ✓ $11.20 $9.43 96413protein-bound paclitaxel protein-boundparticles particles, 1 mg(Abraxane)panitumumab J9303: injection, ✓ $101.85 $87.23 96413, 96415(Vectibix) panitumumab, 10 mg

Continued from page 23





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

www.RJHealthSystems.com

This information was supplied by:

pemetrexed J9305: injection, ✓ $60.67 $50.63 96409(Alimta) pemetrexed, 10 mgporfimer sodium J9600: injection, porfimer ✓ $3,317.04 $2,934.28 96409(Photofrin) sodium, 75 mgprocarbazine J8999b: prescription drug, ✓ NDC NDC N/A(Matulane) oral, chemotherapeutic, level level

not otherwise specified pricing pricingprocarbazine S0182: procarbazine HCl, ✓ $55.68 S0182 not N/A(Matulane) oral, 50 mg payable by

Medicaretamoxifen J8999b: prescription drug, ✓ NDC NDC N/A(Nolvadex) oral, chemotherapeutic, level level

not otherwise specified pricing pricingtamoxifen S0187: tamoxifen citrate, ✓ $1.89 S0187 not N/A(Nolvadex) oral, 10 mg payable by

Medicareteniposide Q2017: injection, teniposide, ✓ $376.55 $324.55 96413, 96415(Vumon) 50 mgtopotecan J8705: topotecan, ✓ $89.73 $74.66 N/A (Hycamtin) oral, 0.25 mgtopotecan J9350: injection topotecan, ✓ $1,306.10 $1,058.90 96413(Hycamtin) 4 mgtrastuzumab J9355: injection, ✓ $78.26 $66.42 96413, 96415(Herceptin) trastuzumab, 10 mgvinBLAStine J9360: injection, ✓ $3.18 $1.02 96409

vinblastine sulfate, 1 mgvinCRIStine J9370: vincristine sulfate, ✓ $7.22 $4.31 96409(Vincasar) 1 mgvinCRIStine J9375: vincristine sulfate, ✓ $14.44 $8.62 96409(Vincasar) 2 mgvinCRIStine J9380: vincristine sulfate, ✓ $36.10 $21.54 96409(Vincasar) 5 mgvinorelbine tartrate J9390: injection, ✓ $42.60 $10.05 96409(Navelbine) vinorelbine tartrate, per 10 mg

aCompendia references available upon request.

bWhen 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 DrugCode (NDC) in Box 19 in order to ensure appropriate reimbursement.

ReferencesHCPCS 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 HealthSystems International, LLC, Volume 7, Number 2, 2nd Quarter 2010 • FDA-approved indication (from product’s prescribing information) • National Cancer Institute® • www.ReimbursementCodes.compowered by RJ Health Systems International, LLC, Wethersfield, Connecticut • CMS (Centers for Medicare and Medicaid Services)—Medicare Allowable 2nd Quarter 2010 (effective dates 4/1/10-6/30/10).

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.


Cancer Center–Physician Alignment

Establishing Relationships... Continued from cover

ing for a way to structure what we couldprovide to physicians who were partic-ipatory, those who were giving theirtime and expertise in a voluntarycapacity. We wanted to structure it in away that made it clear that what weoffered would set these physiciansapart. We looked for what we couldgive them back.

In crafting the conditions, what in -centives do you offer physicians?We offer them support for research.

Our staff puts new studies through theinstitutional review board, our staff doesall the data management, and our staffdoes all the contracting. In addition, wehave a budget for when the physicianstake histories and perform physicals;when they do work related to theresearch they are reimbursed. This givesour physicians the advantage of beingable to offer their patients nationalstudies without incurring the overheadand the work. We also involve the physicians in

decision making when it comes to tech-nology and equipment. For example, wejust selected a new cancer electronichealth record (EHR) system. The physi-cians were very much a part of the deci-sion making and requirement setting forwhat capabilities needed to be includedin the EHR. That was significant, not only in the

respect that it was selecting whatwould go on in the cancer center butalso in the respect that full participantswould have priority in gaining accessto that EHR in their offices. In addi-tion, we are negotiating a very favor-able financial arrangement so that it iseasy for them to implement the EHRand meet the meaningful use require-ment in the American Recovery andReinvestment Act.Physicians who are full participants

are featured on our website. We foundthat our physicians like being connect-ed with the center. Because we promoteour website quite a bit, they see it as anopportunity to be highlighted.We also offer physicians opportuni-

ties to participate in community eventsand 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. Ourstaff also takes care of the state-man-dated requirement for cancer reporting.In addition, we track and manage manyof the outcomes through our AmericanCollege of Surgeon’s Commission onCancer registry. Many have some spe-cial outcomes that they want to trackin addition to survival, and we keepthose up.The other thing that we do is we pro-

vide some nurse support. The center hasnurse navigators who support thesephysicians as well as act as a safety netor additional co ordinator for patients.For example, perhaps a patient had aclinical consultation and didn’t quiteunderstand it. That patient will go tothe navigator and ask what it all meansor to put it into perspective. The nursenavigators work directly for the center,not any one physician.

What do you expect the physiciansto give back to the center?Our physicians are expected to be

present at at least half of the cancerconferences. Our program is structuredinto site-specific teams. We have abreast team, a colorectal team, a uro-logic oncology team, a melanomateam, a head and neck team, and aliver tumor team. For some of the site-specific teams, there is a core set ofexpectations on the hospital side aswell as on the physician side, and thereare some team-designed additions. Forexample, the lung team wants to seesuspicious nodules within 48 hours.The genetics team has asked for a spe-cific requirement regarding training fortheir members. A variety of things canbe added to make the conditions ofparticipation unique to each site-spe-cific team. Physicians also need to be timely in

terms of when they see referred pa -tients. We expect that they will seethese patients within 1 week, that theywill provide verbal consults with thereferring physicians within the samebusiness day, that they will provide sec-ond opinions, and that they will main-tain communication with the primarycare or referring physician. We alsoexpect the physicians to participate in a very active way with our nurse navi-gators. In addition, we started a breastclinic for underserved women, at whichphysicians are expected to provide careon a rotational basis, knowing full wellthat the reimbursement will not be very good.Physicians need to be board-certified

and maintain their medical staff mem-bership. They must participate in local,regional, and national organizations to maintain professional expertise.Physicians also must support us in pub-lications and presentations at regionaland national conferences.One of the biggest things we expect

from our physicians is data. Physicianshave to share their data so that we cangenerate outcomes, track outcomes,and publish outcomes. We also usethese data to determine where we standand where there are opportunities forimprovement, and to know where wedo very well, which we like to make

known. This includes things like par-ticipation in the American Society forClinical Oncology’s Quality OncologyPractice Initiative, registry data, and, ifwe are doing a special study, the out-comes. We have done numerous specialstudies and have found that the physi-cians truly get engaged in the out-comes. They are as interested as we arein producing them. Physicians also par-ticipate in patient-satisfaction activi-ties. We use those data to ensure thatnot only are we doing all the clinicalthings but also the satisfiers that areimportant to our patients and theirfamilies.We also require that the physicians

participate in research. Part of this isgoing through the organizational man-date of city training. They cannotbecome a subinvestigator until they complete that training.

In developing your business model,did the center approach physicians ordid physicians approach the center?The decision to design a new business

model began when some of our physi-cians noticed the difference between thecare some physicians gave comparedwith others. Because community physi-cians chose their referral patterns andbecause hospital-participating physicianshad access to hospital resources, thosewho participated heavily wanted thereto be a recognizable distinction. At thesame time, the hospital wanted to struc-ture something for recognition purposes.The hospital wanted to create thoseboundaries that are recognized legally asthese individuals are giving and we arereturning support in like quantities, thatis, fair market value.

What research did you performwhen developing your conditions ofparticipation?We did some searches, both formally

and informally, and some networkingamong colleagues. I spoke with PatGrusenmeyer, past president of theAssoc iation of Cancer Executives andsenior vice president of Christiana CareHealth System, about conditions of par-ticipation. Christiana Care had justtaken that step and published an articleon it. We accessed that information,and then vetted it through a number ofour physician leaders to see theirresponses.The key was to look at things that

were sustainable, and doable, and hadvalue for both parties. Another impor-tant component was that we invited thewhole medical staff to choose whetherthey were going to opt in or out.Someone was not choosing for them. Itwas them making that choice for them-selves. With that, it is not the hospital

using a stick or anything. It is “here areour expectations, can you meet them ornot; is this of interest?”

What follow-up measures did youbuild into the system to ensure bothparties meet expectations?We always track who is at cancer

conferences. The registry is also trackedas far as who shares data. We have notmet resistance. Sometimes it is cumber-some, sometimes it is time-consuming.It turns out that for the physicians wereso participatory in the selection of ourcancer EHR, it is not a matter of willthey participate or will they share theirdata. It is a matter of how fast can theyget it done. When they are part of thesolution and they are part of making thecenter better and they truly have roles,there is a very different feel. It is trulymuch more of a partnership.

Were there any significant chal-lenges you had to overcome?The biggest challenge is actually the

tracking. Also, medical oncologistsoften view themselves as generalists,that is, they can do all cancers. The factof the matter is that for the level of par-ticipation we are looking for as well asfor just keeping up with all the data thatare generated, it was very hard for some,because they want to do everything andthey overwork themselves going to allthe conferences to meet the participa-tion requirements. We now are askingthem to choose their passion. We wantthem to choose the conferences thatappeal to them because when they cometo the conferences, the expectation isthat they will contribute, they will be anactive member of the team with respectto research, presentations, and out-comes. We expect them to generatereferrals among their colleagues who seethem doing all this participation andsharing knowledge.

Is there anything you would recom-mend to physicians who wish to getinvolved in a program like yours?If they are looking to find common

ground and quality is of concern and ifthey want to do outcomes work andthey want research support, I think thismechanism is one that truly supportsprivate practice physicians and creates anonlegal relationship with a cancercenter where expectations are clear. Forthe centers that chose to go down thispath and the physicians who chose toparticipate at this level, I think this ishow they can get the harmony and thequality patient care. Everyone is on thesame page as far as this is the best forpatient outcomes and this is the best asfar as the clinical outcomes. It is agree-ment on that vision. l

www.ValueBasedCancer.com

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A new publication for your new vocabulary

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NCCN Roundtable: Clinical andEconomic Issues Impacting Cancer Care Delivery “Collision course” in sight

©2010 Engage Healthcare Communications, LLCContinued on page 24

Baltimore, MD—A long-held businesstruism is that “if you can’t measure it,you can’t manage it.” The application of this belief to the oncology setting was demonstrated at a session of theAssociation of Community Cancer Cen ters’ (ACCC) 36th Annual NationalMeeting. Kimberly Bergstrom, PharmD,chief clinical officer for McKessonSpecialty Care Solutions, told attendeesof the growing importance of developingand using standardized chemotherapytreatment regimens, and of the tools that

can benchmark performance and fostercompliance with treatment guidelines.Public and private payers are mov-

ing to control exploding healthcarecosts, Dr Bergstrom told attendees,and because increased cost controlwas inevitable, it is in providers’interest to get a seat at the table. “It is an important topic, because

this is one of those things, if we don’tget a handle on it, it’s going to happento us,” she said. “People and groupsand organizations are going to startdictating how we provide cancer care,and we can’t let that happen.”

Hollywood, FL—Clinical practiceguidelines issued by the NationalComprehensive Cancer Network(NCCN) are followed by conscien-tious oncologists in their everydaypractice, but they are developedbased on clinical efficacy and withoutregard to costs. At a roundtable heldduring the NCCN’s 15th AnnualConference, moderator CliffordGoodman, PhD, Senior Vice Presidentat The Lewin Group, predicted, “Theappropriate use of evidence-basedguidelines is on a collision coursewith the financial nonsustainability ofthe healthcare system.”

Dr Goodmanalluded to a levelof frustration thathas never beenhigher in cancercare. “Too manypatients are stilldying young. Weneed innovations and a cure,” he said.But the inadequacy of current treat-ments for cancer is no longer the mainproblem. Equally challenging, he sug-gested, is finding a means to pay forthe ever-costlier care that threatens tobankrupt the healthcare system. As society struggles to find solu-

tions, “the ground is shaking beneathus,” Dr Goodman commented.

Continued on page 8



By Audrey Andrews

SEER-Medicare Database AnalysisConfirms Expensive ProstateCancers Gaining SupremacyBut cost-effectiveness of this move remains to be determined

San Francisco, CA—The popularity ofminimally invasive radical prostatec-tomy (MIRP), intensity-modulatedradiation therapy (IMRT), and ofbrachytherapy combined with IMRTfor prostate cancer started to take offafter 2002, a new database analysishas confirmed.At the American Society of Clinical

Oncology’s 2010 Genitourinary Can -cers Symposium, Paul L. Nguyen,MD, presented the results of histeam’s analysis of data from theSurveillance, Epidemiology and EndResults (SEER)-Medicare database.Dr Nguyen, director of Prostate

Brachytherapy, Dana-Farber/Brigham

and Women’s Hospital, HarvardMedical School, Boston, and his co-investigators found MIRP jumpedfrom 1.5% of radical prostatectomies(RPs) in 2002 to 28.7% in 2005. Theyalso found that IMRT soared from8.7% of external radiation treatmentsfor prostate cancer to 81.7%. In addi-

By Rosemary Frei, MSc

New Tools Arriving to Measure andManage Chemotherapy CareBusiness, clinical concerns now connected in value-focused approach By Daniel Denvir

Breast Cancer Survival Improves,Thanks to New Therapies

The 2010 Genitourinary CancersSymposium: Progress in Multi -disciplinary Management was heldMarch 5-7 in San Francisco. All ses-sions emphasized a multidisciplinaryap proach to care; a number of thembrought out the cost and value issuesassociated with caring for genitouri-nary cancers.

Value-Based Cancer Carewill be at the ASCO Annual Meeting, June 4-8, in Chicago. Please visit us at booth 18121

Barcelona—Survival for patients withmetastatic breast cancer has improveddramatically in the last 20 years, espe-cially in the subgroup of patients withHER2-positive tumors, according toresearch presented at the 7th European

Breast Cancer Confer ence (EBCC7).This improvement, the researcherssuggest, is due to in creased use ofanthracyclines and the rise of targetedtherapies.“There is no doubt that trastuzu -

mab (Herceptin), which targets theHER2 gene, is the most important

By Colin Gittens


��

Photo by © ASCO/Todd Buchanan 2009

value-focused

payers

cost control

clinical practiceguidelines

cost effectiveness

efficacy

NCCN Roundtable: Clinical andEconomic Issues Impacting Cancer Care Delivery “Collision course” in sight

©2010 Engage Healthcare Communications, LLCContinued on page 24

Baltimore, MD—A long-held businesstruism is that “if you can’t measure it,you can’t manage it.” The application of this belief to the oncology setting was demonstrated at a session of theAssociation of Community Cancer Cen ters’ (ACCC) 36th Annual NationalMeeting. Kimberly Bergstrom, PharmD,chief clinical officer for McKessonSpecialty Care Solutions, told attendeesof the growing importance of developingand using standardized chemotherapytreatment regimens, and of the tools that

can benchmark performance and fostercompliance with treatment guidelines.Public and private payers are mov-

ing to control exploding healthcarecosts, Dr Bergstrom told attendees,and because increased cost controlwas inevitable, it is in providers’interest to get a seat at the table. “It is an important topic, because

this is one of those things, if we don’tget a handle on it, it’s going to happento us,” she said. “People and groupsand organizations are going to startdictating how we provide cancer care,and we can’t let that happen.”

Hollywood, FL—Clinical practiceguidelines issued by the NationalComprehensive Cancer Network(NCCN) are followed by conscien-tious oncologists in their everydaypractice, but they are developedbased on clinical efficacy and withoutregard to costs. At a roundtable heldduring the NCCN’s 15th AnnualConference, moderator CliffordGoodman, PhD, Senior Vice Presidentat The Lewin Group, predicted, “Theappropriate use of evidence-basedguidelines is on a collision coursewith the financial nonsustainability ofthe healthcare system.”

Dr Goodmanalluded to a levelof frustration thathas never beenhigher in cancercare. “Too manypatients are stilldying young. Weneed innovations and a cure,” he said.But the inadequacy of current treat-ments for cancer is no longer the mainproblem. Equally challenging, he sug-gested, is finding a means to pay forthe ever-costlier care that threatens tobankrupt the healthcare system. As society struggles to find solu-

tions, “the ground is shaking beneathus,” Dr Goodman commented.

Continued on page 8



By Audrey Andrews

SEER-Medicare Database AnalysisConfirms Expensive ProstateCancers Gaining SupremacyBut cost-effectiveness of this move remains to be determined

San Francisco, CA—The popularity ofminimally invasive radical prostatec-tomy (MIRP), intensity-modulatedradiation therapy (IMRT), and ofbrachytherapy combined with IMRTfor prostate cancer started to take offafter 2002, a new database analysishas confirmed.At the American Society of Clinical

Oncology’s 2010 Genitourinary Can -cers Symposium, Paul L. Nguyen,MD, presented the results of histeam’s analysis of data from theSurveillance, Epidemiology and EndResults (SEER)-Medicare database.Dr Nguyen, director of Prostate

Brachytherapy, Dana-Farber/Brigham

and Women’s Hospital, HarvardMedical School, Boston, and his co-investigators found MIRP jumpedfrom 1.5% of radical prostatectomies(RPs) in 2002 to 28.7% in 2005. Theyalso found that IMRT soared from8.7% of external radiation treatmentsfor prostate cancer to 81.7%. In addi-

By Rosemary Frei, MSc

New Tools Arriving to Measure andManage Chemotherapy CareBusiness, clinical concerns now connected in value-focused approach By Daniel Denvir

Breast Cancer Survival Improves,Thanks to New Therapies

The 2010 Genitourinary CancersSymposium: Progress in Multi -disciplinary Management was heldMarch 5-7 in San Francisco. All ses-sions emphasized a multidisciplinaryap proach to care; a number of thembrought out the cost and value issuesassociated with caring for genitouri-nary cancers.

Value-Based Cancer Carewill be at the ASCO Annual Meeting, June 4-8, in Chicago. Please visit us at booth 18121

Barcelona—Survival for patients withmetastatic breast cancer has improveddramatically in the last 20 years, espe-cially in the subgroup of patients withHER2-positive tumors, according toresearch presented at the 7th European

Breast Cancer Confer ence (EBCC7).This improvement, the researcherssuggest, is due to in creased use ofanthracyclines and the rise of targetedtherapies.“There is no doubt that trastuzu -

mab (Herceptin), which targets theHER2 gene, is the most important

By Colin Gittens


��

Photo by © ASCO/Todd Buchanan 2009

targeted therapies

Viewpoint


President Obama guar-anteed Americans thatafter health reform

became law they could keeptheir insurance plans andtheir doctors. It’s clear thatthis promise cannot bekept. Insurers and physi-cians are already reshapingtheir businesses as a resultof Mr. Obama’s plan.The health-reform law

caps how much insurers can spend onexpenses and take for profits. Startingnext year, health plans will have a regu-lated “floor” on their medical-lossratios, which is the amount of revenuethey spend on medical claims. Insurerscan only spend 20% of their premiumson running their plans if they offer poli-cies directly to consumers or to smallemployers. The spending cap is 15% forpolicies sold to large employers.This regulation is going to have its

biggest impact on insurance sold direct-ly to consumers—what’s referred to asthe “individual market.” These policiescost more to market. They also havehigher medical costs, owing partly toselection by less healthy consumers.Finally, individual policies have high

start-up costs. If insurers cannot spendmore of their revenue getting plans ontrack, fewer new policies will be offered.This will hit WellPoint, one of the

biggest players in the individual market,particularly hard. The insurance com-pany already has a strained relationshipwith the White House: Earlier thismonth Mr. Obama accused WellPointof systemically denying coverage to

breast cancer patients,though the facts don’t bearthat out.Restrictions on how in -

surers can spend money arecompounded by simultane-ous constraints on how theycan manage their costs.Beginning in 2014, a newfederal agency will stan-dardize insurance benefits,placing minimum actuarial

values on medical policies. There arealso mandates forcing insurers to cover alot of expensive primary-care services infull. At the same time, insurers arebeing blocked from raising premiums—for now by political jawboning, but thethreat of legislative restrictions looms.

One of the few remaining ways tomanage expenses is to reduce the actualcost of the products. In health care, thismeans pushing providers to acceptlower fees and reduce their use of costlyservices like radiology or other diagnos-tic testing.To implement this strategy, compa-

nies need to be able to exert more con-trol over doctors. So insurers are tryingto buy up medical clinics and doctorpractices. Where they can’t ownproviders outright, they’ll maintain

smaller “networks” of physicians thatthey will contract with so they canmanage doctors more closely. Thatmeans even fewer choices for benefici-aries. Insurers hope that owningproviders will enable health policies tooffset the cost of the new regulations.Doctors, meanwhile, are selling their

practices to local hospitals. In 2005,doctors owned more than two-thirds ofall medical practices. By next year, morethan 60% of physicians will be salariedemployees. About a third of those willbe working for hospitals, according tothe American Medical Association. Areview of the open job searches held byone of the country’s largest physician-recruiting firms shows that nearly 50%are for jobs in hospitals, up from about

25% five years ago.Last month, a hospital I’m affiliated

with outside of Manhattan sent a noteto its physicians announcing a new sub-sidiary it’s forming to buy up local med-ical practices. Nearby physicians are lin-ing up to sell—and not just primary-care doctors, but highly paid specialistslike orthopedic surgeons and neurolo-gists. Similar developments are unfold-ing nationwide.Consolidated practices and salaried

doctors will leave fewer options for

patients and longer waiting times forroutine appointments. Like the insurers,physicians are responding to the eco-nomic burdens of the President’s plan inone of the few ways they’re permitted to.For physicians, the strains include

higher operating costs. The Obamahealth plan puts expensive new man-dates on doctors, such as a requirementto purchase IT systems and keep morerecords. Overhead costs already con-sume more than 60% of the revenuegenerated by an average medical prac-tice, according to a 2007 survey by theMedical Group Management Asso -ciation. At the same time, reimburse-ment under Medicare is falling. Somespecialists, such as radiologists and car-diologists, will see their Medicare pay-ments fall by more than 10% next year.Then there’s the fact that medical mal-practice premiums have risen by 10%-20% annually for specialists like sur-geons, particularly in states that haven’tpassed liability reform.The bottom line: Defensive business

arrangements designed to blunt Obama -Care’s economic impacts will mean lesspatient choice. l

Dr. Gottlieb, a former official at theCenters for Medicare and MedicaidServices, is a fellow at the AmericanEnterprise Institute and a practicinginternist. He’s partner to a firm thatinvests in health-care companies.

Reprinted with permission. ©ScottGottlieb. Originally printed in OpinionJournal. The Wall Street Journal. May18, 2010.

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

Scott Gottlieb, MD

Going for Gold... Continued from page 11

of pancreatic cancer and carries theworst prognosis of any cancer, evenwhen diagnosed early. In 2009, it wasestimated that more than 42,000 indi-viduals, typically over the age of 60,were diagnosed with pancreatic cancer,making it the fourth leading cause ofcancer death in the United States.A major reason that current pancre-

atic cancer treatments do not work isthat scar tissue develops around thecancer. The scar tissue blocks cancer-killing drugs from entering the tumor.Omary and his colleagues are using acatheter to deliver the gold nanoparti-cles directly to the tumor. The catheter

is placed into an artery near the groinand navigated through blood vessels tothe site of the tumor, all without sur-gery. The direct catheter injectionshave the potential to reduce side effects,such as vomiting and hair loss, that maybe seen with traditional chemotherapy.“Researchers have been using the

same toolbox for a long time withoutany benefit. It’s time for us to applysome high-tech tools to treat pancreaticcancer,” said Omary. Clinical trials arealready under way using nanoparticlesfor other types of cancer. Omary toldthe Journal of Multi disciplinary CancerCare that it may be 24 to 36 months

before pancreatic cancer patients can bereferred for clinical trials. However, hesaid research is going well, and preclini-cal and animal trials have been verypromising. Omary said now for the firsttime oncology team members havesome positive news they can givepatients with pancreatic cancer.Although this approach is not yet read-ily available, it does offer hope for thefuture. Omary said only approximately5% of patients diagnosed with pancreat-ic ductal adenocarcinoma survive for 5years. l

—JS

Insurers can only spend 20% of their premiums onrunning their plans if they offer policies directly toconsumers or to small employers. The spending capis 15% for policies sold to large employers.

Updates to theNCCN Guidelinesfor Prostate CancerThe National Comprehensive Can -

cer Network (NCCN) Prostate Panelhas added sipuleucel-T as a category 1treatment recommendation for pa tientswith castration-recurrent pro state can-cer. Sipuleucel-T is appropriate forasymptomatic or minimally sympto-matic patients with Eastern Coopera -tive Oncology Group performance status 0 to 1. It is not recommended forpatients with visceral disease and a lifeexpectancy less than 6 months.

TARGET AUDIENCEThis activity is intended for hematologists, oncologists and others whoare involved with the care of patients with Chronic LymphocyticLeukemia (CLL).

STATEMENT OF NEEDCLL is the most common type of leukemia in the United States, withover 15,000 new cases per year, characterized by the accumulation ofmonoclonal B cells in the bone marrow, peripheral blood, and lymphoidtissue. Primarily a disease of the elderly, the median survival for CLLvaries substantially: many patients survive more than 10 years after diagnosis, but a subset of symptomatic patients have shorter lifeexpectancies—in the range of 1.5 to 6 years. The clinical/research bodyof knowledge in CLL is rapidly changing and represents a challenge forthe whole treatment team.

EDUCATIONAL OBJECTIVESOn completion of this activity, participants should be able to:

• List the essential steps in diagnosis and treatment planning of theCLL 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

www.coexm.com/ace02.aspLOG ON TODAY TO PARTICIPATE

Release Date: April 29, 2010Expiration Date: April 28, 2011

In collaboration with

FACULTYNeil E. Kay, MD Professor Department of Medicine Mayo ClinicRochester, Minnesota

Michael Keating, MDCourse ChairProfessor of Medicine �Deputy Department Chairman�Department of Leukemia�M.D. Anderson Cancer Center�Houston, Texas

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

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

Chronic Lymphocytic LeukemiaThe Essentials of Patient Care

Today, he got the cancer treatment he needed.Along with a healthy dose of peace of mind.

A cancer diagnosis gives a patient a lot to worry about. The truth is, it can also cause treatment concerns for physicians as well as reimbursement and coverage issues for practice administrators and insurers. Call us or visit our Web site to learn how we can partner with you to simplify it all. It’s the kind of support you need, while patients receive the treatment they need. For more information, visit www.LillyPatientOne.com or call 1-866-4PatOne (1-866-472-8663).

Lilly Oncology

Patient Assistance Insurance Expertise Claim Appeals

1-866-4PatOne

MQ43286 0807 PRINTED IN USA © 2009, Lilly USA, LLC. ALL RIGHTS RESERVED.

Documents

June 2010, Vol 3, No 4