Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

We're really honored to have Doctor Jason join us again and uh we're really um grateful for your time. Uh Thank you so much for joining us. We're gonna talk in this session about planning for clinical implementation of treatment regimens. And as we like to do, we like to frame things around a patient. We like to take this discussion and to give you a, a case vignette to really think about how we take this discussion and implement it into clinical practice. And we've got a little bit of a case scenario that we've written to kind of frame our conversation here today and it's about Samuel. Samuel is a 72 year old retired farmer living in a rural community and he was diagnosed with advanced prostate cancer and his local healthcare facility lacked the resources and specialized expertise available in urban centers, presenting some unique challenges in managing his condition. So recognizing the need for comprehensive care, Samuel's primary care physician referred him to doctor Da uh who was renowned for his innovative approach to implementing new treatment regimens across diverse health care settings. And that case vignette really is a bit of a springboard for our conversation today and how we implement changes and how we overcome barriers and how we use a multidisciplinary team to navigate some of the barriers in, in health care and make sure that that patients receive um the most critical therapies for their advanced prostate cancer. So doctor Leason, you've highlighted previously the importance of recognizing the diversity in healthcare settings and identifying some of the barriers that might exist. I really wanted to ask if you could share some potential strategies that you've employed to try to overcome some of these barriers. Yeah, um you know, this, this is a really important topic that resonates closely with me because I feel like it in the vignette and in the description of what's going on is clearly a reflection of our patient population here in Central Ohio. Um You know, I'm located in a metropolitan area with about 2 to 3 million people in about a 45 minute radius, but we geographically cover um patients, you know, 2 to 3 hours south, 2 to 3 hours west. Um in, in a sense East also where they're coming from both a large distance, as well as a large gap in access to any other kind of ancillary services as well as sometimes also socioeconomic disparities that can exist in these rural settings. And so I see these challenges, I guess on a very regular basis and I'm always um working on how we can kind of figure out maybe the best care for the patient in, in light of these challenges. So, um yeah, strategies to work on this. Well, I think one huge, huge strategy has been telehealth. Um you know, before the COVID pandemic, um we very rarely did telehealth. In fact, I would say that there was essentially no telehealth as part of our practice. Um There are a few reasons for this. I think one of it really is cultural. Um It just wasn't part of the way that we practice medicine, you know, pre COVID. Uh The second really relating to reimbursement, um There was no financially viable way to do that in our healthcare system, um without the telehealth kind of being written off. And so, um that I guess shifted markedly with COVID. And so I think that was a really big step forward in cancer care that originated from, you know, a challenging situation, of course. And so, um now I feel like it is the routine that, you know, a quarter of our clinics are done via telehealth at least a quarter. Um And so for patients without the ability to take the day off work and make the two-hour round trip, which means it's, you know, at least half the day traveling, um you know, to come into town to see us for a routine visit, this has really allowed um us to kind of deliver that care quite effectively at home. Now, um, of course, that doesn't apply to every situation, but it can often be quite effective in the patient with prostate cancer where it's just a routine visit. They might need to just complete some labs locally and check in with you. Um This would allow for um real kind of uh access there in these rural settings. Now, not just that, but it also promotes a little bit the centralization of care because for the patient who is hesitant to pursue care um at a setting like ours where, you know, we do have access to some of the greatest and latest and greatest um options. Um The idea that they would have to travel very, very regularly. Um For that care is often a a big turn off while the knowledge that hey, some of it could be delivered by telehealth where appropriate is a is a huge potential benefit to this patient population that is hesitant on the travel. Um The other strategy that I think works really well is partnership with local healthcare providers. So it is very uncommon for a patient in a rural setting to have no healthcare provider um that can address their need. I think the bigger challenge that we see at least is that the healthcare provider locally may just not have the same familiarity, expertise and comfort with the advanced cancer setting that they may be experiencing. Um But of course, these are still often excellent healthcare providers located in a place that's much more convenient for the patient. And so I think that a partnership in some fashion is really the key to delivering the best care in these rural settings. Um as an example, um patients in our rural settings, um will often have access to a local urologist or a local oncologist that might be, you know, two or three hours closer to them than coming to our center. But that local urologist, local oncologist may not be familiar um with some of the latest treatment, indications with some of the latest testing and maybe what the best first steps are. So what's very routine is for a patient to come to see us for an initial consultation. Um Often a multidisciplinary consultation, um myself on the surgical end, um a colleague on the medical oncology and a colleague on the radiation oncology and um for recommendations and they may or may not then actually receive all of their care at our center depending on what they might have access to locally. So I feel like on the surgical end because it's often a one and done thing um once they've recovered and a lot of the time depending on the surgery being proposed in the cancer setting, the local urologist may be less able to deliver that locally. Um The surgery will often say happen at our center, but then let's say they then need um postoperative systemic therapy or some other, you know, thing that pops up down the line while the consultations and recommendations may originate from, you know, a one time visit or uh back and forth a little bit after a bit of testing. Um They could often then follow up with a local medical oncologist um for receiving that ongoing treatment and perhaps revisit at the time of progression or revisit at the time of significant toxicity to figure out maybe how we can move forwards um in these selected settings. Sure. Um I guess the other, the other barrier that we've kind of discussed is resource allocation to um be able to afford some of these life prolonging treatments. Um How do we, how do we go about achieving that kind of long term sustainability? So that actually some of these life prolonging treatments for people with advanced prostate cancer are widely available. Um What can we do within our healthcare systems to begin to achieve that? Yeah, I mean, that's a real, real um big can of worms and it's a challenge because it's something that we see on a day to day level in the oncology setting. Um At this point in time, you know, most patients that are receiving cancer care will have some form of insurance. Um whether that's Medicare, Medicaid, private insurance, some sort of other governmental payer like the veterans system. Um And so the I mean insurance um availability has markedly gone up in the past 10 years with shifts in the healthcare system, those that are uninsured are certainly a target population. But the good thing is that with Medicaid expansion and with other options, at least that we have at our Center for Charity Care and grants, um, that is increasingly a shrinking population which is at least one positive light for progress being made in access to cancer care. The challenge is that even with insurance, the sticker price on medications on other treatments is so high that a 10 or 15% coinsurance is a significant financial burden for people. And you know, many Americans um especially in rural settings and settings where um job access to high paying jobs is lower, et cetera, uh live paycheck to paycheck. And with uh cancer treatment, it wouldn't be uncommon for there to be an out of pocket cost of 5 to $10,000 a year for patients to receive the best care. Um, and that might be a low end estimate with reasonable insurance. And so if you think about it, you know, that is a marked financial burden for the average patient. Um Yes, there are gonna be some people that will not have financial stress, but there are gonna be many people for which that is a dealbreaker and they actually will then have to choose to prioritize that their spending be placed elsewhere and that they not receive the best standard of care because it's just too expensive even with insurance. And so I think that that's really an avenue for where we can make big inroads. Um You know, there are often granting or costing programs that companies have um where the drug cost will be reduced and the copay and the coinsurance cost will be reduced through a special application. Um But the problem is that those are not universally accessible. Um You know, it requires a little bit of insight, a little bit of navigating the system if you will to be able to access some of these things. Uh Additionally, there are other financial assistance programs and I'm fortunate to work in a center where, you know, we have good um facilitation of access to some of these things. But um that's uh again, it's a, a sense of navigating the system which can be quite difficult to navigate at times. And so I think it would ideally be, you know, if we had a um magic system where we could just fix it so that pe people don't have to navigate how to access financial assistance. So they don't have to navigate how to access cost reductions. That would be great. But um II just don't know what the perfect solution is and I don't think we're anywhere close to figuring that out, especially with the increasing costs of the treatments in general. Um It's gonna be passed down in some fashion to patients and it's not like, you know, patients are having any easier time in affording these. So, um uh I think it's gotta be multifaceted. We're gonna need legislative work. We're gonna need medical system work. We're gonna need, you know, insurance system work. Um, to really help with this issue, I guess. I mean, we've, we've chatted previously about the role of academia and clinical trials in prostate cancer and this is an interesting area, right? Um Where do you see the role of academic research particularly in influencing practical clinical approaches in treating advanced prostate cancer, particularly in diverse settings. Should do we need to do some trials in this space? Yeah, I mean, I think that a lot of our trials are focusing on the latest and greatest agent they're focusing on, you know, we talked about earlier parp inhibition and T cell directed therapies and these medical advances are clearly remarkable. Um and they're clearly getting the press and the buy in that they should. But on a practical level, prostate cancer, it's the most common cancer in men. It's afflicting a lot of men across diverse settings. We're seeing an elevated risk of diagnosis and death amongst black men. We're seeing a access challenges in rural areas. We're seeing all sorts of disparities in care and that definitely does not get the press that it needs and definitely does not get the clinical trial attention that it needs. Um And we really don't know the answers to some of the questions that you've been asking me in that. How do we best care for patients in rural settings? How do we best minimize the financial toxicity and burdens that people have so that they can get the best access to care. How can we afford this all as a healthcare system? Um And I think that those are probably the best areas for us to conduct clinical trials and then for us to do future research in because they're really the most practical questions that need answering, you know, in advanced prostate cancer today. Because if every single advanced prostate cancer patient is on treatment with an A DT with something novel hormonal active agent and DOCEtaxel. And they're getting tumor and genetic uh germline testing, you know, a and then they're going on to get PS ma pet scan and then they're gonna go on to get, you know, luteum ps ma pet um agents and then they're gonna get maybe a parp inhibitor and this and that and you know, this is a marked advance for prostate cancer care from a scientific level in that we've got all these options for patients. But yes, how do people access it? How do people afford it? We can come up with these kind of back of the napkin ideas, but we really do need clinical trials in these settings. And kind of final, final kind of topic from my side is thinking about standardization and um variability and variability variability exists in how we all approach our patients, right? And how we approach treatment. And I guess how can we be leveraging some of the recent clinical trial data or should we be doing so to develop standardized protocols that maybe allow a little bit of flexibility for patient needs but ensuring that we are delivering evidence based care for advanced prostate cancer, particularly across those diverse settings. Should we be trying to put a push more on standardization or do you think we're about right in terms of the amount of flexibility that we uh facilitate, I guess, as a multidisciplinary team. Yeah, I mean, I think it's hard to say because on the one hand, flexibility is key because you know, patients at the center of their cancer journey and you really need to focus on making sure that all of your care is patient centric and within what they would wish for their goals and their quality of life. And you know, et cetera. On the other hand, we're probably seeing marked heterogeneity in how patients are cared for just because of limitations in knowledge, limitations in the dissemination of the latest research, limitations in access to, you know, to therapies that are not exactly the kind of flexibility that we want that guideline discordance per se. So the right, I guess ideal way that we would deliver care would be that it's patient centric and that there's flexibility to deviate from the guidelines, you know, when it's appropriate um to maximize the patient uh quality of life and experience, but also minimizes um these other aspects that are not the kind of variability and flexibility that we want. And in all honesty, I mean, I think that this is where A I in the next few years is really going to, um allow for this because, you know, if you look at the latest NCCN prostate cancer guidelines, um, and you weren't up to date, uh, let's just say you were a prostate cancer specialist from four or five years ago, you wouldn't recognize them. You wouldn't have any idea what's going on because the field has just changed. It's so different now. Um The way that one approaches anything is totally different, turned on its head than, you know, five or 10 years ago. Um, you know, when I was in training in castration resistant prostate cancer, there was one, you know, chemotherapy option, DOCEtaxel and, you know, two clinical trials we have to know about and, you know, that that single option extended life by three months or so. And that was it for castration resistant prostate cancer. And otherwise it was just a DT and, you know, it, it, it's now, um you can fill books with what has been developed since. Um And so I think that that's where we can see these um a i options of really figuring out what's best for people, at least from a standard of care standpoint. And then the humanistic aspect of medicine will then be figuring out how to apply some of these things just because as we were talking about earlier in the rural setting, in the nonspecialist setting, you know, keeping up to date with all of the latest clinical trial data and even how to read your National Comprehensive Cancer Network guidelines and put a patient into the right algorithm is very difficult. And once you've got them into the right algorithm, a and you've, you know, figured out which of the 20 algorithms to follow. Um You now have four or five or eight drug options. Um uh You know, and some of them may be drug options uh with or without radiation added to it or, you know, so, so it's very difficult as a nonspecialist that might see a few cases of advanced prostate cancer a year to figure out how to properly um figure out the best options per clinical trial and standard of care for a particular patient. But I think this is actually a very easy A I task. Um Now a lot of the commercially available A is that you can go on when you go and check GPT. I'm not gonna give you these medical answers yet um because they're kinda told not to or they haven't been fed the right data to be able to do this, but the capabilities are clearly there. Um And in some of the custom A I work that I've seen, um it, it's, it's certainly a very feasible thing to say. This is a patient's chart, these are the patient's standard of care options. Um And I think that once you get down to having access to that easy knowledge, you can then figure out, you know, what is, is within their goals and their interests and what they would like for their day to day life. And there's probably the potential for A I to help there too in that, you know, you could put some of these details in and understand how the treatments can affect that particular aspect of things, which doesn't then require the same level of expertise on the part of the clinician, which again, um if we're talking about delivering care for the most common cancer in men um across a vast um you know, geographic area, you're gonna have to have the nonspecialist oncologist treating prostate cancer. It can't be that only prostate cancer oncologist treat prostate cancer because it just isn't feasible. And so that's where, you know, some sort of assistance could really make it much more practical. And I think that making it much more practical is going to make it much better for patients. I think you've stimulated the future debate in uh advanced prostate cancer. And it's, it's really great to begin to touch on where we're gonna go with A I and, and how that's gonna change all of our lives. Um uh So really great to kind of see another potential application of it. Doctor Da Thank you so much for your time today and it's been great to kind of discuss with you how we begin to practically implement some of the latest, uh, research. We're, we're really grateful. Yeah, it was my pleasure. Always enjoyed talking with you.