Professor of Medicine and Associate Director for Clinical Investigations, Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL
Q: How would you define the concept of best practices, and what makes an oncology center, such as the Northwestern University Robert H. Lurie Comprehensive Cancer Center, be among the best oncology practices in the country?
Dr Benson: “Best practices” is a critical area for Northwestern and, in particular, is an important area of responsibility for our cancer center as a member of the National Comprehensive Cancer Network (NCCN). The NCCN has a very productive Best Practices Committee that has been active formany years. The committee members do surveys of NCCN practices and have very focused discussions on the quality and effectiveness of care, with the goal of improving the care for patients with cancer.
Among the areas of high interest for the Best Practices Committee is quality assurance. The goal is to ensure that NCCN’s institutions, such as our Northwestern Robert H. Lurie Comprehensive Cancer Center, are following clinical guidelines for patient management, and that we verify how concordant our institutions are in following clinical guidelines and quality indicators that are based on the guidelines.
Another very important aspect of best practices is the integration of practice models to enhance comprehensive cancer care delivery. Practice models include defining the role of different providers of care, such as the role of nurse practitioners in the oncology practice. This is a multifaceted concept that encompasses the overall goal of providing the best comprehensive services possible for each individual patient. It can also include other areas, such as looking at reimbursement patterns.
The way patient services are delivered can vary significantly, depending on the type of practice and practice location, for example.
Q: What are some of the unique features offered at your Northwestern center, and what makes it one of the leading cancer centers in the country? Dr Benson: One significant advantage we have is a centralized clinical cancer center, which enables us to provide broad-based services. We have had to divide our clinical cancer center into 2 different buildings, principally because of our patient volume and space limitations. The bulk of the clinical cancer center is on one floor of our ambulatory care tower (the Galter Pavillion), where we provide a full range of services, including full infusion services.
Our clinical nurse specialists, who provide treatment to patients, also work closely with individual tumor type. For example, I have been working with the same nurse clinician for 15 years, and she knows gastrointestinal oncology inside out, which is also my area of expertise. She is an enormous resource for patients undergoing treatment.
The same floor houses our surgical oncologists, hematologists, medical oncologists, the transplant team, neuro-oncology, urologic oncology, interventional radiology, psychologists, dieticians, financial counselors, and social workers. Such proximity offers a great advantage that allows us to offer services in one place that cannot always be provided by smaller centers.
Our second clinical cancer center is located in PrenticeWomen’s Hospital. The gynecologic oncology service clinicians have moved from our original clinical cancer center to our Women’s Hospital. Patients with breast cancer are also seen in this location by the breast cancer oncologists, including the surgeons and the medical oncologists. Prentice Women’s Hospital also has a radiation unit, so patients undergoing radiation treatments can conveniently take one elevator from the oncology service down to radiation oncology.
We have full laboratory services in both clinical cancer center locations, as well as radiology services in both buildings. Therefore,most patients have consolidated services all in one location.
To further support patients, we try to coordinate multidisciplinary appointments, although with some exceptions—we do not have multidisciplinary clinics as is the case in some centers.We try to set up various appointments for a patient so different providers end up seeing the patient on the same day.
In addition, we have weekly multidisciplinary tumor conferences for the different diseases.Many of our patients are presented at these conferences that result in a multidisciplinary opinion; we then take that recommendation to our patients and schedule the appropriate follow-up visits and interventions based on these conferences.
This centralization and ready availability of the various disciplines are important for patient care, as are our financial counselors, social workers, psychologists, dieticians, and other important services that are integrated within the same location.
We emphasize palliative care through our supportive oncology care team, which is a critical component of our comprehensive approach to cancer care.
Q: You have a huge advantage being in a big city, and you likely have good funding as well. Is this typical for most cancer centers? Dr Benson: Large cities often offer a number of different cancer programs. There are hospital-based cancer center programs that may not be National Cancer Institute (NCI) comprehensive cancer centers, as our center is, but they are in large hospitals that also try to offer comprehensive cancer care services. Regardless, there can be many differences in how the care is delivered.
Overall, there are many permutations as to the structure of cancer programs and a multitude of challenges. For example, when there is not one center location, where people may have to go to the medical oncologist’s office or to a separate infusion center, and they may even have to go to a separate center for imaging, and maybe yet another location for radiation oncology, coordination of care can become very complicated and challenging.
Another advantage we have at Northwestern is our complete electronic medical records (EMRs) system; we do not use paper records at all. An EMR system enhances care coordination, because the records are computer-based and readily available to all the medical staff at the center. Scheduling among specialists can also be more readily coordinated, for example.
At Northwestern, we receive many outside referrals, so we have many outside medical records, which in turn are scanned into our own EMR system. For example, today I was referred a new patient whom I scheduled to see tomorrow. The records and scans were sent to me on a disk and have been downloaded into our system. I have already called the interventional radiology specialist and asked him to look at this patient’s liver CT [computed tomography], to see what we might have to offer for this individual patient. All of this was coordinated before I am seeing the patient (tomorrow), thanks to our EMR system.
Q: Clearly your EMR system helps care coordination for a patient with cancer. But what if that patient was also diabetic— would you have access to medical records not related to the cancer?
Dr Benson: In addition to our cancer center, we have immediate access to electronic patient records from Northwestern Memorial Hospital, as well as to the outpatient records through the Northwestern Medical Faculty Foundation. Our faculty members use the same EMR; therefore, if I am referring a dia-betic patient (with cancer) to an endocrinologist, the endocrinologist has total access to our EMR, and vice versa.
The exception would be one that involved our private physicians, who are on the medical staff of the hospital, who many have offices that are off site. Their record system may therefore be totally different from ours and may not be directly linked to the outpatient system, although the off-site physicians may have access to the hospital EMR system through their office computers.
As faculty members, we have the advantage of being able to go online to access the Northwestern EMR system, do charting at home, and if a patient calls when the faculty member is off site, we have immediate access to that patient’s records.
Q: Disparities of care is an important issue in cancer care. Does your centralized care help to reduce disparities in care?
Dr Benson: Not exactly. No matter what system we have, we are going to face disparities for many reasons—some are very obvious, such as lack of insurance and limited financial resources—and a truly big area is the underinsured. With complex cancer services, there is a risk that all the required services may not be fully reimbursed.
In addition, high copayments may make it difficult for some patients to receive all the medications they need.
Our social and financial services try to assist patients, including trying to arrange transportation or to find other assistance programs, but often there are obstacles that make it difficult for patients to receive the comprehensive care they require.
We have a big urban environment that covers a very large referral area, which, in addition to Chicago, encompasses Indiana, Michigan, Wiscon - sin, and even Iowa, as well as the entire state of Illinois. With such a geographically diverse population, some complex issues come up, and many of our patients, because of their geographic distance, also need services closer to their home.
They may have oncologists closer to home, or they may get some testing done closer to home; when that happens, it can result in disjointed care, which may not necessarily be health disparities, but it does fragment the care. In addition, many patients have very limited resources, and it becomes a challenge how to orchestrate a comprehensive program for these individuals to ensure that they can receive the care they need.
Q: Many oncologists today are urging other oncologists to refer patients to clinical trials, especially those who have few or no therapeutic options. As one who is heavily involved in clinical research, where does clinical research fit within best practices in oncology?
Dr Benson: The philosophy is that clinical trials represent a standard of care and are directly integrated into the decision process in terms of therapeutic options, and this is also part of the best practices concept of using evidence-based medicine.
In gastrointestinal oncology, where we have a very vigorous clinical trials program,we actively discuss clinical trialswith our patients, and we get referrals requesting us to consider a patient for our clinical trials. We certainly buy into this philosophy of clinical research and integrated cancer care and try to promote such an approach by our involvement with the NCCN guidelines, which actively promote clinical research. As an NCI comprehensive cancer center, clinical research is an integral part of our mission.
Q: Does being an NCI cancer center imply participation in clinical trials?
Dr Benson: Absolutely. An NCI comprehensive cancer center must show significant funding and activity in 3 big areas of research—clinical research, laboratory research, and what we often call “cancer control,” which is a very broad area that can encompass everything from screening, prevention, symptom management, and quality-of-life measures.
Q: Finally, what do you see as some of the major challenges today for oncology practices?
Dr Benson: There is a laundry list ofmassive challenges that revolve around the growing workforce shortage. It is clear that we are going to have insufficient numbers of oncologists, including medical and radiation oncologists, and in particular a shortage of oncology nurses and nurse practitioners.
When we project a growing population of individuals who will be faced with a cancer diagnosis, there are very significant issues that willmagnify our challenges, including reimbursement of cancer care, the ongoing struggle to deliver comprehensive care, and the ability to afford these services.
Patients having access to treatment financially is going to continue to be a big problem. In addition, if we are going to more readily advance cancer care and take advantage of rapidly emerging technologies as well as rapid development of new agents, we simply have to have a far greater percentage of patients who are participating in clinical trials, particularly trials that include tissue acquisition, so we can continue to learn more about and develop a strategy centered around tumor biology.
This is where the concept of personalized medicine comes into play. We need to look at personalized medicine in providing overall comprehensive cancer services to the individual patient, and to be able to select appropriate treatment based on the host and the tumor biology profiles. To be able to do this is going to take a concerted investment not only in the science of cancer but also in supporting the infrastructure of clinical trials work.
So much of what we do now represents tremendously underfunded clinical trials and a dependence on a voluntary effort, as well as institutional financial support to conduct these trials. With the economic pressures on institutions, and with the workforce shortage pressures, we have a mix of challenges that could directly impede our efforts to advance cancer research and, subsequently, cancer care.
We require a much more integrated comprehensive program in this country that will merge together all the components of what it takes to deliver oncology care in a cooperative venture, as well as to maximally promote research. Advancements in research will require enhanced government support not only from the NCI but also from our regulatory agencies in the government, reimbursement branches of government, and for drug development, the pharmaceutical industry.
It is going to require integration of imaging, diagnostics companies, and third-party carriers to at least help support the standard care costs for patients on clinical research trials; future research endeavors will mandate interdisciplinary collaboration including other critical people, such as surgeons, radiologists, and pathologists who have not been routinely awarded appropriately for their clinical trials efforts and are too often underfunded and underrecognized for their work.
A societal commitment to the notion that scientific innovation is of critical importance—and worth the investment in capital and people—is necessary if we are to improve cancer care and expected outcomes. Participation in these research programs by clinicians and patients alike in far greater numbers will need to become the norm rather than the exception.
