Making Their Own Way

When Patricia Hardenbergh, MD, left the academic environment of Duke University Medical Center in North Carolina to become director of radiation oncology in a mountain town in Colorado about 10 years ago, it was more than simply an 1800-mile change of scenery. She suddenly found herself in entirely different and unfamiliar clinical territory.

“We’re the only cancer center within about a 2 1/2-hour driving radius,” said Hardenbergh, referring to Shaw Regional Cancer Center in Edwards (population 8257). “I was trained in the world of high-powered academics. Now I had to figure out how community doctors practiced.”

Hardenbergh soon learned that necessity is indeed the mother of invention. She played a leading role in establishing the Shaw Center’s multidisciplinary approach to cancer care and is now developing a virtual networking service that aims to link radiation oncologists with specialists, state-of-the-art research, and educational resources far beyond their offices.

While the growth of technology has placed the telemedi- cine trend in the limelight, the concept is often interpreted as a high-tech lifeline that major research centers extend to isolated community practices. In contrast to that notion,Hardenbergh and other community oncologists are working from their offices to develop technological solutions to the real-world challenges they face.

Statistics indicate their efforts to provide quality care have a major impact on cancer patients overall; community oncologists handle twice as many patient visits per week as their academic peers who are spending more time on research and teaching, according to a 2007 study by the Association of American Medical Colleges.1

Making Connections in Person and Online

After Hardenbergh moved to Colorado, she found herself on a journey to deliver the same kind of care that she provided at Duke. She began to develop relationships with colleagues who specialized in treating prostate cancer, or breast cancer, or head and neck cancer, and spoke with them about her cases. But soon she realized that “they didn’t have that much time for me.”

She developed a schematic to pay them for their time, and to have them look at her radiation plans through the Internet. She was trying to solve the issue of delivering the level of care that patients in the community deserve, and that she was used to delivering, without the layers of backup that clini- cians have at a large university or academic center.

“You can’t just go to the journals and say how do the ex- perts do this, because it takes years and years to develop that evidence-based medicine,” Hardenbergh said. “Out in the community you might see 20 cases a year of a certain type of problem, as opposed to when I was at Duke and I would see 10 to 15 cases a week. Without any evidence to back you up in the community on how to make decisions, we really have to rely on the people who are seeing the most cases to talk to the community physician, and bridge that gap.”

Bridging that gap will be a little easier now that Harden- bergh was recently awarded a $1.35 million grant from the ASCO Cancer Foundation and Susan G. Komen for the Cure to improve cancer treatment for those living in rural areas. Hardenbergh’s project is called Chartrounds, and it focuses on using the Internet for a Web-based radiation oncology treatment planning review program. Radiation oncologists will collaborate virtually with experts, similar to in-person patient chart reviews. A computer connection will allow direct, live, visual illustration of the planned radiation treatment in the context of the overall treatment plan.

“It’s a great way to connect the community to academia,” Hardenbergh said. “In the grant, the academicians are re- imbursed for their time. The only other time they get reim- bursed for their value is when they’re invited speakers at different conferences. What Chartrounds allows them to do is get a stipend without ever leaving their office. It’s good for them, and it’s good for the community.”

Chartrounds recently launched the service for breast cancer information; there are plans to roll out disease sites on head and neck, lung, central nervous system, prostate, gastrointestinal, and gynecologic cancers during the second half of 2011 and in 2012. The first Chartrounds session earlier this month featured a ratio of 3 to 1 as community oncologists from Texas, North Carolina, and Arkansas reviewed their cases with a department chair from the Dana-Farber Cancer Institute in Boston, Massachusetts. More than a dozen ses- sions with experts are scheduled through February.

Hardenbergh said that having lived on both sides of the street, and having learned “so much since coming out into the community,” she expects the Chartrounds experience will provide ample benefits to both community and academic on- cologists.

“I think having the opportunity to see what the community docs are facing on a day-to-day basis, and what the challenges are, will be great for the experts in terms of training the next group of doctors that are coming out,” Hardenbergh said. “We’re not trained, really, to be community physicians. At least in the radiation oncology world, our training is specifically an academic training. And all of the residency training programs are in large academic centers. They don’t get exposure to the community during training. But the truth is, most of our trainees go back out into the community, and then there’s this lack of understanding before they get out there. Having an insight into what the challenges are out in the community would

be really good for the experts.” The community physician, in turn, will benefit from having the interactions with an expert, and hearing how that expert would be treating the community doctor’s patient.

“They are very different, but very good lessons to be learned on both sides,” Hardenbergh said.

Chairing a Tumor Board

Robert Kilbourn, MD, is director of the San Juan Regional Cancer Center in Montrose, Colorado. A former University of Texas professor at MD Anderson Cancer Center in Houston, he calls himself a hybrid physician, having spent half his ca- reer in private practice and half in academia.

The San Juan Center is affiliated with the University of Colorado as an outreach clinic. Prior to Kilbourn’s arrival, university physicians would fly some 300 miles into Montrose (population 18,000) to see patients, and then attempt to manage care from afar between trips. Kilbourn, in addi- tion to serving full time in Montrose, began spending time at the university, strengthening ties and developing a group of common patients—local patients who were referred to the university because their care was too complex. With 4 other outreach clinics joining the fold, Kilbourn soon took the lead in organizing and running a quarterly statewide tumor board via teleconference hook-up.

“The venue,” Kilbourn explained, “is for a particular out- reach clinic to present a case, one of its more interesting cases, and the idea is not just to present for the purpose of a second opinion from the university, but to present the case, talk about management, and then teach the fellows who are participating at the university, which I think is probably one of the most important aspects.”

Kilbourn said that it is important for oncology fellows to understand the reality of what a more rural setting is like. He said fellows often believe that the pace is slow in a com- munity practice, and that the clinical issues might be rela- tively uninteresting compared with a day’s worth of unusual patients in an academic setting. Kilbourn said that perception is far from accurate; usually, his days are quite complicated.

“The complexity of patients and the variety is something I think the fellows can miss when they’re in a clinic setting where all day long they’re just seeing patients with breast cancer,” Kilbourn said. “I think that experience is extremely important because they get the depth of what they need by going to a specialty clinic, but they don’t get the breadth of what they can see if they were out on their own, or with a small practice in the community.”

That’s a philosophy Kilbourn hopes to build on going forward.

“I’d like to see the opportunity for university-trained physi- cians to come and participate in a rural setting; have a rota- tion for one of the fellows for a period of time to get an experience, and then to have them participate and present a case in tumor board from the outreach clinic to the university,” Kilbourn said. “In that case, it’s almost as if they were at the university. They get the experience here, and they can participate with their colleagues and attendings at the university at the same time.”

Counseling Patients in Video Sessions

During the past 2 years, the American College of Obstetricians and Gynecologists, and the American Society of Clinical Oncology have been encouraging physicians to conduct assessment and testing for hereditary cancers as part of their standard of care. What that means, said Keith Vrbicky, MD, a practicing obstetrician/gynecologist in Norfolk, Nebraska (population 23,577), and founder of American Educational Telecommunications, is that clinicians in the field need to gather detailed information from patients regarding their family history for certain cancers.

“From a clinician’s standpoint, that’s very cumbersome, and a lot of information needs to be discussed with these patients,” Vrbicky said. What he and his colleagues at Midwest Health Partners, PC have done is provide patients with a 1-page questionnaire about their family history of cancers. The information obtained clearly identifies the patients with a strong family history of these hereditary cancers, and determines whether or not these patients should be offered counseling by the professional genetic counselors who work in this field day in and day out.

“If [patients] desire that counseling, then we schedule that appointment from our offices to the genetic counselors at the University of Nebraska Medical Center by video conferencing,” said Vrbicky, referring to the Omaha in- stitution. “Those patients and their families can be in our office and a couple of hundred miles away at the university, the experts in the field are able to take a more extensive interview, family history, assess the patient’s risk, then offer them testing. And if they choose to have the testing, they can then come back and again visit with them to discuss what the test results mean, and what their options are as to proper treatment and potential prevention of getting cancer. So the emphasis is now in trying to identify those at risk and preventing them from getting some of these hereditary cancers.”

Vrbicky recalls a new patient who recently completed a he- reditary cancer questionnaire. It turned out that her mother had breast cancer at age 32, her sister was diagnosed at age 46, and on her father’s side, there was a history of an aunt having breast cancer. The new patient, who was 52 years old, had been getting regular mammograms and everything had been fine. But based on the statistics, Vrbicky says, “she has up to a 70 percent chance if she has a mutation in her BRCA gene of getting breast cancer in the next 5 to 10 years. And so if she chooses to have that testing done, and it is identi- fied, then there are things to do to potentially prevent these patients from getting breast cancer or ovarian cancer.”

Vrbicky noted that there’s tremendous value in being able to offer patients these services via teleconferencing. “When you get patients who are 50, 100, or 200 miles from us, being able to offer them these highly expert services from not only our [practice] but from university research academic centers that might be part of clinical trials that are having better results—that collaboration, that’s what it’s all about, in terms of improving outcomes.”

Sharing Evidence-based Standards

Abraham Schwarzberg, MD, is a medical oncologist and pro- gram director for clinical trials at the Cancer Center of South Florida in Lake Worth (population 32,559). A few months ago, he began using a point-of-care tool—the Proventys CDS Oncology system—that features guidance on lab and imaging tests, the latest information on treatment regimens, and real-time alerts of critical updates to National Comprehensive Cancer Network (NCCN) guidelines as part of a pilot program.

Although it has only been a short time, Schwarzberg is impressed with the benefits and features of the Web-based tool. “The beauty of the program in my mind as a practicing clinician is the ability to integrate the unbelievably enriched academic knowledge and scientific knowledge that NCCN provides by pooling together the best and brightest minds in specialties that deal with different aspects of cancer, and different subtypes,” Schwarzberg said. “And then translating that into a tool that a clinician can use in a room with a patient in real time to help make decisions, help order the ap- propriate testing, and pick the right chemotherapy, the right dosing, and the right scheduling, as if the expert was sitting in the room with you.

“It’s an active, living machine that allows it to be up to date, highly accurate, and I think really provide cutting-edge care to your patients in a way where you otherwise would have to go out of your way to make phone calls and track people down, and trying to obtain the same information which you can get in almost a seamless fashion,” he said.

The tool will initially include NCCN guidelines for breast, colon, and non-small cell lung cancers, as well as Hodgkin lymphoma. Those four diseases cover a substantial portion of all the cancer patients diagnosed in the United States, said Ephraim Hochberg, MD, a senior oncologist for Proventys CDS who practices at Massachusetts General Hospital in Bos- ton. Plans call for launching 4 additional disease sites during the second quarter of 2011.

“The goal,” said Hochberg, “is to allow the oncologist at the point of care to reference the guideline in an active fashion. It should make providing care dramatically more efficient.”

And, added Schwarzberg, it likely will prove to be a major benefit in terms of improving accuracy, quality control, and safety for community oncologists anywhere in the country.