JCO Oncology Practice Podcast

Dr. Chino welcomes Dr. Jennifer Miller and breast cancer survivor Megan-Claire Chase to discuss Dr. Miller's recent OP article, "Representation of Women, Older Adults, and Racial and Ethnic Minoritized Patients in Pivotal Trials for U.S. Food and Drug Administration Novel Oncology Therapeutic Approvals, 2012-2021: Bright Spot Trials and Trends Over Time," highlighting new research about how we are doing with diversity in key cancer clinical trials TRANSCRIPT Dr. Fumiko Chino: Hello and welcome to Put into Practice, the podcast for the JCO Oncology Practice. I'm Dr. Fumiko Chino, an associate professor in Radiation Oncology at MD Anderson Cancer Center with a research focus on access, affordability, and equity. There are known problems in enrolling a representative sample on cancer clinical trials, with stark disparities within certain demographic groups, including age, sex, and race and ethnicity. Patients who are female, non-White, and at the age extremes, either younger or older, are known to be less likely to participate. With skewed patient participation, the validity of randomized data may be questioned, with some asking whether clinical trial results based on a charmed enrollment sample can truly be applied in routine practice. I'm happy to welcome two guests today to discuss new research highlighting how we are doing with diversity in key cancer clinical trials. Dr. Jennifer Miller, is Co-Director of the Program for Biomedical Ethics and an associate professor at Yale School of Medicine. Her research focuses on ethics, equity, and governance in research, development, and accessibility, as well as in the ethics of healthcare data sharing. She is the first author of the manuscript, "Representation of Women, Older Adults, and Racial and Ethnic Minoritized Patients in Pivotal Trials for US Food and Drug Administration Novel Oncology Therapeutic Approvals, 2012 to 2021: Bright Spot Trials and Trends Over Time," which is featured in JCO OP's March print issue. Megan-Claire Chase is a 10-year breast cancer survivor, patient advocate, and a current program director at SHARE Cancer Support, a national nonprofit that provides free education, assistance, and navigation services for people with breast and gynecological cancers. Since her treatment for stage 2A lobular cancer, she has worked to fill the gap of knowledge and advocacy for young patients with cancer, including through her blog, Life on the Cancer Train, and through the podcast, Our BC Life. Our full disclosures are available in the transcript of this episode, and we've already agreed to go by our first names for the podcast today. Jen and Megan-Claire, it's really nice to speak to you today. Dr. Jennifer Miller: Thank you for having us. Megan-Claire Chase: Thank you. Dr. Fumiko Chino: Jen, before we dig into the specific research, do you mind giving us a little bit of background about your work in bioethics and what led you to start this specific work on clinical trial diversity? Dr. Jennifer Miller: Yes, thank you so much. So, as you mentioned, I'm the Director of Bioethics for Yale School of Medicine and a professor of internal medicine at Yale. And then also in 2005, I co-founded a nonprofit called Bioethics International and direct a project called the Good Pharma Scorecard. In all of those roles, I'm focused on one big question: How can we help the 7 billion people around the world live a good life, a flourishing life? And in order to even talk about that bigger concept, we need to think about some basic things: access to clean water, housing, food, education, among other things, and a level of health. And there are so many determinants of health, but one of them is access to medicines and vaccines. And when you think about access to medicines, you have to think about the role of the pharmaceutical industry, given that it sponsors 75 to 90% conservatively of the clinical research supporting FDA approval of our new medical products. What's interesting...

Dr. Chino welcomes Hari Raman, MD, MBA, author of "End-of-Life Care for Older Adults With Blood Cancers With Medicare Advantage Versus Medicare Fee-For-Service Insurance," to discuss new research highlighting how insurance type may affect receipt of quality end-of-life care for patients with blood cancers. TRANSCRIPT Dr. Fumiko Chino: Hello, and welcome to Put into Practice, the podcast for the JCO Oncology Practice. I am Dr. Fumiko Chino, an associate professor in radiation oncology at MD Anderson Cancer Center with a research focus on access, affordability, and equity. People with blood cancers may have prolonged clinical courses lasting years or decades and requiring specialty care. Prior research has shown that end-of-life care in this population may be suboptimal with higher hospitalization and lower hospice enrollment. Capacity for receiving appropriate specialty care has been a known concern with Medicare Advantage plans, but paradoxically, there may be unique advantages for those at the end of life. I am excited to welcome a guest today to discuss new research highlighting how insurance type may affect quality of end-of-life care for patients with blood cancer. Dr. Hari Raman, MD, MBA, is a clinical fellow in hematology-oncology at Dana-Farber Cancer Institute. He got his MBA from Harvard Business School in 2023 while doing his internal medicine residency at Brigham and Women's. His research focuses on quality care delivery and value in healthcare with a focus on hematological malignancies. He is the first author of the manuscript, "End-of-Life Care for Older Adults With Blood Cancer With Medicare Advantage Versus Medicare Fee-for-Service Insurance," which was featured in JCO OP's February print issue. Our full disclosures are available in the transcript of this episode, and we have already agreed to go by our first names for the podcast today. Hari, it is really wonderful to speak to you today. Dr. Hari Raman: Thank you so much, and I really appreciate this opportunity to join you. Dr. Fumiko Chino: I have been hosting this podcast for over a year, and I think you are actually our first guest who is still in their training. So, I love this, I am excited to have you here. Do you mind giving us an overview of kind of where you are in your career and what got you interested in this topic? Dr. Hari Raman: Yeah, no, of course. And again, I am really grateful to be here in training. I knew I wanted to care for patients, but as I continued training, particularly in my residency, I came to realize how many considerations around care delivery and the administration of healthcare actually exerts a significant influence on the patient care itself. And so while I was in training, I was really fortunate enough to receive an MBA while in residency to gain kind of a foundational understanding of how the business and financing of healthcare in the US, particularly, impacts care delivery and access. And as a clinical fellow at Dana-Farber, I have just been incredibly grateful to join Dr. Oreofe Odejide's lab here at Dana-Farber. She is actually the senior author of this study, where we have been able to examine care delivery and outcomes research for patients with blood cancers. This is really the intersection of both my clinical and academic interests given that my clinical focus will be caring for patients with lymphomas. Dr. Fumiko Chino: And you are at the tail end of your training, right? So, you are, you know, out the door, correct? Or maybe you are not out the door. Dr. Hari Raman: No, exactly. You hit it right on the head. I will actually be staying on as faculty here at Dana-Farber next year, and I am really excited to continue our research and also be able to care for patients with lymphoma starting quite soon, actually. Dr. Fumiko Chino: That is so exciting. So, within this calendar year, you will be setting up shop on your own. Dr. Hari Raman: That is the plan. Dr. Fumiko Chino: Wonderful. And it is amazing...

Dr. Chino welcomes Dr. Erika Moen and Dr. Dan Zuckerman to discuss new research highlighting how specialist scarcity is felt by oncologists practicing in rural environments. Dr. Moen is the first author on "Rural Oncologists' Perceptions of Specialty Scarcity and Repercussions for Care Delivery: A Qualitative Study," which is featured in JCO OP's January 2026 issue. TRANSCRIPT Dr. Fumiko Chino: Hello, and welcome to Put Into Practice, the podcast for the JCO Oncology Practice. I'm Dr. Fumiko Chino, an Associate Professor in Radiation Oncology at MD Anderson Cancer Center, with a research focus on access, affordability, and equity. Rural oncology care has many challenges, including travel distance, limited specialty care, sparse clinical trial infrastructure, and financial barriers leading to worse outcomes and access for patients from diagnosis through survivorship care. Oncologists practicing in rural areas often have difficulties coordinating care with geographically distant providers and limited availability. This is made worse by known workforce gaps. I'm happy to welcome two guests today to discuss new research highlighting how specialist scarcity is felt by oncologists practicing in rural environments. Dr. Erika Moen, MS, PhD, is an Assistant Professor of Biomedical Data Science at Dartmouth. She is a health services researcher and leads a multidisciplinary team working to leverage network analysis to optimize cancer care delivery and patient outcomes. The long-term goal of Dr. Moen's lab is to improve equitable access to coordinated cancer care with a particular focus on rural populations. She is the first author of the manuscript, "Rural Oncologists' Perceptions of Specialty Scarcity and Repercussions for Care Delivery: A Qualitative Study," which was featured in JCO OP's first issue of 2026. Dr. Dan Zuckerman, MD, FASCO, is the director of GI oncology and staff medical oncologist at St. Luke's Cancer Institute in Boise, Idaho. The center encompasses eight locations and is the region's largest provider of cancer care, treating a catchment area of over 20 counties. He is past president of the Idaho Society of Clinical Oncology and has been active in ASCO, including past chair of the Clinical Practice and Innovation Committee. Our full disclosures are available in the transcript of this episode, and we've already agreed to go by our first names for the podcast today. Erika and Dan, it's really wonderful to speak to you today. Dr. Erika Moen: Hi, Fumiko and Dan. It's great to meet you both, and I'm looking forward to this discussion. Dr. Dan Zuckerman: Me as well. Thanks, Fumiko. Nice to meet you, Erika. Dr. Fumiko Chino: Erika, do you mind starting us off on how you got interested on how to try to optimize multidisciplinary care and why your focus is specifically in rural populations? Dr. Erika Moen: Yes, absolutely. When I was a new assistant professor, I knew I wanted to focus my research program on bringing together my methods expertise in patient-sharing network analysis, which involves using healthcare administrative data to identify networks of physicians who share the same patients, with my research interest in cancer care delivery. I remember reading an oncology workforce report published by JCO OP, and in that paper, there was a map visualizing county-level metrics of the number of oncologists per capita. And one of the things that immediately struck me was what I was seeing in rural areas. There would often be one county that had a relatively high density of oncologists, and it would be surrounded by counties with none. I wondered what the multidisciplinary referral networks of those physicians looked like and how physician departures or retirements would impact those patients and care teams. And because rural areas have known workforce shortages, and the delivery of high-quality cancer care depends on relationships between multidisciplinary specialists, these networks of physicians seemed critical...

Dr. Chino talks with Dr. Talya Salz, the first author of the JCO OP manuscript "Impact of an Electronic Patient-Reported Outcome–Informed Clinical Decision Support Tool on Clinical Discussions With Head and Neck Cancer Survivors: Findings From the HN-STAR Randomized Controlled Trial (WF-1805CD)" which was published earlier this year simultaneous to the ASCO Quality Care Symposium. Jeff White, the Director of PR and Strategic Communications for the American Society for Radiation Oncology, also joins the conversation to provide the patient advocate perspective. TRANSCRIPT Dr. Fumiko Chino: Hello, and welcome to Put into Practice, the podcast for the JCO Oncology Practice. I'm Dr. Fumiko Chino, an Associate Professor in Radiation Oncology at MD Anderson Cancer Center with a research focus on access, affordability, and equity. Incidence of head and neck cancers is rising, primarily driven by HPV-positive oropharynx cancers, which are commonly diagnosed in younger people with overall excellent disease outcomes. Patient-centered cancer survivorship is a key evolving area of study, with the goal of improving quality of life after cancer treatment. This is particularly important for people in head and neck survivorship given large post-treatment symptom burden, including speech and swallowing problems, dry mouth and dental concerns, neck fibrosis, and pain. I'm happy to welcome two guests today to discuss new research on how to improve communication in cancer survivorship. Dr. Talya Salz, PhD, is an Associated Attending Outcomes Research Scientist at Memorial Sloan Kettering. Her research aims to improve the quality of life for cancer survivors, focusing primarily on late effects after cancer treatment. She is the first author of the JCO OP manuscript "Impact of an Electronic Patient-Reported Outcome-Informed Clinical Decision Support Tool on Clinical Discussions With Head and Neck Cancer Survivors: Findings From the HN-STAR Randomized Control Trial." This publication was simultaneously presented with the 2025 ASCO Quality Care Symposium. Mr. Jeff White is the Director of PR and Strategic Communications for ASTRO, the American Society for Radiation Oncology. He focuses on media outreach and manages ASTRO's social media channels in a way to expand knowledge and awareness about radiation oncology and its critical role in curing cancer. He was diagnosed and treated for an HPV-positive tonsillar cancer in 2023 and shared his story on RT Answers to help other patients understand the role of radiation, surgery, and chemotherapy in head and neck cancers. Our full disclosures are available in the transcript of this episode, and we've already agreed to go by our first names for the podcast today. Talya and Jeff, it's really great to speak to you. Dr. Talya Salz: Thank you for having me. Jeff White: Great to be here. Dr. Fumiko Chino: Talya, do you mind starting us off on how you got interested in trying to improve survivorship care, and specifically what gaps your research can fill? Dr. Talya Salz: My research is really shaped by my experiences trying to navigate the health care system. I had some health issues in my 20s, and as a recent college graduate in a new job with my brand new health insurance, I was really shocked at how hard it was for me to find doctors that I trusted. It was hard to communicate what I needed and to get insurance to cover my care. That experience really steered me toward a career that addressed reasons why patients, and we're all patients at some points in our lives, have difficulty getting care that's appropriate, that's needed, and that's patient-centered. So when I started doing health services research in cancer almost 20 years ago now, there was a growing consensus that after cancer treatment is over, after patients are told there's no evidence of disease, that they're cured, there are so many more health issues that can arise that had historically been neglected. And late effects of cancer...

Dr. Chino talks with Dr. Navneet Majhail and patient advocate Laurie Adami about CAR-T therapy, an advance cancer treatment that biologically engineers a patient's own T-cells to recognize and kill cancer cells. This discussion will be based off the JCO OP article, "Outpatient Administration of Chimeric Antigen Receptor T-Cell Therapy Using Remote Patient Monitoring," on which Dr. Majhail served as lead author. TRANSCRIPT Dr. Fumiko Chino: Hello, and welcome to Put into Practice, the podcast for the JCO Oncology Practice. I'm Dr. Fumiko Chino, an associate professor in radiation oncology at MD Anderson Cancer Center with a research focus on access, affordability, and equity. CAR T-therapy is an advanced cancer treatment that biologically engineers a patient's own T cells to recognize and kill cancer cells. It has shown remarkable benefits, leading to long-term remission or even cure for select patients with hematological cancers that have not responded to other treatments. Primary trials were exclusively conducted in the inpatient setting due to high risk of quick onset and life-threatening toxicities requiring close monitoring and immediate treatment. Advances in symptom monitoring and care delivery have allowed the introduction of outpatient CAR T, which is cost saving and more patient centered. I'm happy to welcome two guests today to discuss this promising operational shift. Dr. Navneet Majhail, MD, MS, serves as the Physician-in-Chief of Blood Cancers at the Sarah Cannon Cancer Network, where he oversees 10 transplant and cellular therapy programs that collectively perform over 1500 transplants and cellular therapies each year. He is the first author of the JCO OP manuscript, "Outpatient Administration of Chimeric Antigen Receptor T-Cell Therapy Using Remote Patient Monitoring," which was published earlier this year. Ms. Laurie Adami was President of the LA-based Interactive Data's Fixed Income Analytics Division when she was diagnosed with stage four follicular lymphoma at age 46. From 2006 to 2018, she was in continuous treatment and received multiple lines of therapy, including three clinical trials. In 2018, she received treatment number seven, a clinical trial of Kite CAR T-therapy. Thirty days later, she was in complete remission, where she remains today. She is an active patient advocate and legislative policy advocate for several not-for-profits. Our full disclosures are available in the transcript of this episode, and we have already agreed to go by our first names for the podcast today. Navneet and Laurie, it's so wonderful to speak to you today. Dr. Navneet Majhail: Thank you. Looking forward to this conversation. Laurie Adami: Thank you, Dr. Chino. I guess I'm supposed to call you Fumiko. Great to be here today. Great to be alive, first of all, and great to be here on this call. Thank you for having me. Dr. Fumiko Chino: I think with everything you've gone through, Laurie, we all go on a first name basis. Now, Navneet, do you mind starting us out with a short history of CAR T in the US, including the side effects and the precise care delivery needs that were the initial reasons why care was limited to the hospital? Dr. Navneet Majhail: So, Fumiko, you laid an excellent background as to why these therapies are done in the inpatient side and what they are. I mean, it's really exciting, right? These are what we call transformative therapies in oncology or medicine as a whole. You're taking patients with very, very advanced diseases who traditionally would have gone on to hospice, where you can potentially put around half of these patients into very deep remissions, and maybe some of them might be cured of their underlying malignancies. Now, having said that, as you alluded to in the introductions, most of the trials early on were focused entirely on the inpatient space for a few reasons. One was the unknowns. These were early therapies, unknown side effects, you needed to have that monitoring. The...

Dr. Chino welcomes Dr. Vivek Patel and Dr. Eleonora Teplinsky to discuss a recent article in JCO OP that reported a podcast-based curriculum could improve knowledge and comfort with common education topics for oncology fellows. TRANSCRIPT Dr. Fumiko Chino: Hello, and welcome to Put Into Practice, the podcast for JCO Oncology Practice. I am Dr. Fumiko Chino, an assistant professor in Radiation Oncology at MD Anderson Cancer Center with a research focus on access, affordability, and equity. There are over 450 million podcasts available today, and online audio consumption continues to rise year after year. In the US alone, over 200 million people have listened to online audio in the last month, and health and fitness remains one of the most popular categories. Podcast audiences range from the lay public to patients with cancer to providers, with the dual goal to both entertain and inform. A recent randomized control trial published in JCO OP reported that a podcast-based curriculum could improve knowledge and comfort with common education topics for oncology fellows. I am happy to welcome two guests today to discuss the role of podcasts to improve information sharing. They are both podcast hosts, making this ASCO’s first podcast about podcasts. Dr. Vivek Patel, MD, is an assistant professor and APD at Vanderbilt University with a treatment focus on blood cancers. He co-founded the Fellow on Call podcast in 2021 to fill a perceived gap in high quality, free, online medical education content in Hem-Onc. The podcast provides the fundamentals, core concepts, and important management approaches in an easily accessible, asynchronous learning platform. He is the first author of the JCO OP manuscript, “Education Impact of a Podcast Curriculum for Hematology-Oncology Fellows,” which was simultaneously published with his oral presentation at the 2025 ASCO Annual Meeting. Dr. Eleonora Teplinsky, MD, FASCO, is the Head of Breast and Gynecological Medical Oncology at Valley Health System and a clinical assistant professor at Mount Sinai. She is the host of the Interlude podcast, founded in 2018 with the goal to promote support, inspiration, knowledge, and hope to listeners via patient and provider interviews. She is also active on social media, providing real time expert commentary on active new stories from emerging research to celebrity diagnosis and treatment. Our full disclosures are available in the transcript of this episode, and we have already agreed to go by our first names for the episode today. Vivek and Eleonora, it’s so wonderful to speak to you. Dr. Eleonora Teplinsky: Thanks for having us. Dr. Vivek Patel: Glad to be here. Dr. Fumiko Chino: Our specific topic today is podcasts as an avenue for knowledge transfer for both patients and providers. This conversation is loosely based on a manuscript that Vivek and team published on the findings of a randomized control trial of an education intervention. Vivek, do you mind sharing with us how you got interested in podcasting and then briefly discussing what your study team did and the findings? Dr. Vivek Patel: Yeah, yeah. So getting interested in podcasting really started when I finished residency and was starting Hem-Onc fellowship. There is a popular podcast, The Curbsiders, and I always listened to it when I was a resident to learn core concepts in internal medicine. When I got to Hem-Onc fellowship, there was a gap. And after my first year of fellowship, I met with a couple of my co-fellows and we just decided, “Hey, let’s just make a podcast. Maybe it will just be for our program.” It ended up being this bigger thing that we created with The Fellow on Call. So that that is really what the start of the journey was, was just, "Hey, there is nothing here. Let us just do something for fun," and then it just kind of took off from there. For the study that we did though, what we really focused on was, there’s been so many studies out there now that have looked at using...

Dr. Chino welcomes Dr. Yael Schenker to discuss a new clinical trial testing the best way of engaging patients with Advance Care Planning (ACP), the process of understanding personal values, life goals, and medical care preferences so that patient wishes are honored at end-of-life. TRANSCRIPT Dr. Fumiko Chino: Hello, and welcome to Put Into Practice, the podcast for the JCO Oncology Practice. I am Dr. Fumiko Chino, an Associate Professor in Radiation Oncology at MD Anderson Cancer Center with a research focus on access, affordability, and equity. Care delivery goals for the critically ill, including those with cancer, have shifted towards a patient-centered framework. Advance care planning (ACP) is the process of understanding and sharing personal values, life goals, and medical care preferences so that patient wishes are honored at the end of life. Despite growing evidence of the benefits of these discussions, documentation of advance directives remains low, with some studies showing less than half of people with advanced cancer have a living will or health care power of attorney. I am happy to welcome a guest today to discuss a new clinical trial evaluating the best way of engaging patients with advance care planning. Dr. Yael Schenker, MD, MAS, FAAHPM, is a Professor of Medicine with tenure and the Director of the Palliative Research Center at the University of Pittsburgh and the UPMC Hillman Cancer Center. She is also a practicing Palliative Medicine Physician at UPMC. Her research focuses on improving quality of life in serious illness with a particular focus on palliative care delivery models. She is the first author of the JCO OP manuscript, "Facilitated Versus Patient-Directed Advance Care Planning Among Patients With Advanced Cancer: A Randomized Clinical Trial," which was published earlier this year. Our full disclosures are available in the transcript of this episode, and we have already agreed to go by our first names for the podcast. Yael, it's wonderful to speak to you today. Dr. Yael Schenker: Thank you so much for having me, Fumiko. I am such an admirer of you and your work. It's really an honor to be here. Dr. Fumiko Chino: I am excited for our discussion. Do you mind starting us off with just a little history about how you got interested in palliative care and what the field looked like when you were in training and your early career? For example, the term "death panels" from 2009 still really haunts many of us interested in advance care planning. Dr. Yael Schenker: Yes, that is actually when I started in the field, and I remember those days well. I had a windy path to medicine, and by the time I got to medical school, I was really drawn to taking care of the sickest, most complicated patients. I loved all of the life stuff, the stuff that was not on the diagnosis list but had such an impact on how people navigated a serious illness and what was important to them. I remember going to a funeral in the Western Addition in San Francisco for one of my first primary care patients when I was a resident and just being blown away by this incredible community, this church filled with people, this vibrant life that I had only caught tiny glimpses of in our 15 minute clinic appointments. I caught the research bug during residency, and I started really thinking about how we were communicating with patients and how we figured out what was important to them. At that time, I was headed towards a career as a primary care doc, but I stayed at UCSF to do a general medicine research fellowship, and I wrote my first grant about serious illness communication to the National Palliative Care Research Center. I got that grant, and I figured if I was going to be a palliative care researcher, I should really be a palliative care physician also. Amazingly, back then, and this was 2010, you could grandfather in and take the palliative care boards without doing a palliative care fellowship. So I did that. I started practicing...

Dr. Chino welcomes Dr. Emily Mackler, PharmD, BCOP, the Co-founder and Chief Medical Officer of the YesRx program and an Adjunct Clinical Associate Professor at the University of Michigan. The YesRx program has saved patients in Michigan more than 17 million dollars in the past 2 years. Dr. Mackler's article, "Creating a Statewide Cancer Drug Repository Network to Improve Cancer Drug Access and Affordability," presented at the ASCO Quality Care Symposium. TRANSCRIPT Dr. Fumiko Chino: Hello and welcome to Put into Practice, the podcast for the JCO Oncology Practice. I'm Dr. Fumiko Chino, an Associate Professor in Radiation Oncology at MD Anderson Cancer Center with a research focus on access, affordability, and equity. Our listeners know that financial toxicity is a growing issue which limits access to high quality cancer care. Cancer drug repository programs offer a unique solution to the affordability crisis, connecting patients to free medications while reducing medical waste. Cancer drug repositories collect unused, unexpired, manufacturer sealed cancer medications and redistribute them to those in need. I'm happy to welcome a guest today to discuss the YesRx program that has saved patients in Michigan over 17 million dollars in the past 2 years. Dr. Emily Mackler, PharmD, BCOP, is the Co-founder and Chief Medical Officer of the YesRx and an Adjunct Clinical Associate Professor at the University of Michigan. Go Blue! She has led the development and implementation of quality improvement programs across the state of Michigan to improve the care of patients with cancer. She is the first author of the JCOP manuscript "Transforming Cancer Drug Access: Insights on Utilization and Clinician Satisfaction in a Statewide Cancer Drug Repository Network," which was simultaneously published with her oral presentation at the 2025 ASCO Quality Care Symposium. Our full disclosures are available in the transcript of this episode, and we have already agreed to go by our first names for the podcast today. Emily, it's wonderful to speak to you. Dr. Emily Mackler: Thank you. It's an honor to be here, and I appreciate the "Go Blue." Dr. Fumiko Chino: I spent some time in Ann Arbor and have some great love of Michigan. So, and the Mitten State in general. Dr. Emily Mackler: Wonderful. Dr. Fumiko Chino: Absolutely. I'm a Midwesterner at heart, so there's deep love. I love the YesRx program. I think it just makes sense. Do you mind outlining for me just how the program started, what you found in the last two years helping lead it? Dr. Emily Mackler: I actually love our initiation story to this program in that our legislation in Michigan took effect actually in 2006, and our program, the first repository went live in 2021 in a small community practice in Michigan where the community oncologist came into the pharmacist's office, put a bottle of medication on her desk and said, "This is a Honda Civic. Can you do something with it?" That was really our impetus or kind of the starting point. We started the network in 2023 because the first three sites in the state that developed their own internal cancer drug repository programs were done as most things are because a need was identified and there was passion about providing this care and resource to patients. And it became more and more evident that the sustainability for those sites was becoming challenged as there was growth. And I think the most important component that brought us together as a network was that not every practice had the resources to house their own repository, therefore further limiting access to those who probably already had it limited. Dr. Fumiko Chino: I got you. Do you mind just running through some numbers? Because I know, for example, you've had really incredible growth over the last 2 years, starting at 9 participating sites, going to over 100 now, and I know you've helped over 1000 people in Michigan. Dr. Emily Mackler: We did start with 9 sites, and those...

Germline genetic testing can play an essential role in identifying cancer risk, guiding treatment decisions, and informing screening and/or preventive strategies for both patients and patient family members. Access to timely and convenient genetic testing can be challenging based on increased indications for testing, larger gene panels, and high numbers of positive tests which are overloading a limited genetics workforce. This is leading to long wait times and widening disparities in access to genetic testing. Dr. Chino welcomes Dr. Trevor Hoffman to discuss an intervention he helped pilot using non-genetics providers to increase access while maintaining quality. TRANSCRIPT Dr. Fumiko Chino: Hello and welcome to Put Into Practice, the podcast from the JCO Oncology Practice. I'm Dr. Fumiko Chino, an assistant professor in radiation oncology at MD Anderson Cancer Center with a research focus on access, affordability, and equity. Germline genetic testing can play an essential role to identify cancer risk, guide treatment directions, and inform screening or preventative strategies for both patients and patient family members. Access to timely and convenient genetic testing can be challenging based on increased indications for testing, larger gene panels, and high numbers of positive tests that are overloading a limited genetics workforce. This is leading to long wait times and widening disparities in access to genetic testing. I'm happy to welcome a guest today to discuss an intervention he helped pilot using non-genetics providers to increase access while maintaining quality. Dr. Trevor Hoffman, MD, PhD, is an associate professor in clinical medicine at the Kaiser Permanente Bernard J. Tyson School of Medicine and the Regional Chief of Medical Genetics in the Southern California Kaiser Permanente Medical Group. He leads a department of 10 medical geneticists and approximately 40 genetic counselors, serving 5 million Kaiser members in Southern California. He is the first author of a JCO OP manuscript, "Expanding Germline Hereditary Cancer Gene Panel Testing by Non-Genetics Providers," which was published earlier this year. Our full disclosures are available in the transcript of this episode, and we've already agreed to go by our first names for the podcast today. Trevor, it's wonderful to speak to you today. Dr. Trevor Hoffman: Thank you so much for inviting me on the pod. I'm really psyched about it. Dr. Fumiko Chino: Our specific topic today is something that I know you know a lot about, germline genetic testing. Despite broadened eligibility, only a small percentage of people diagnosed with cancer will undergo germline genetic testing, and I'd love your thoughts on the changes in genetic testing over your 20+ year career, and particularly, obviously for our respects, within the cancer patient population. The who, what, when, where, how, and wherefores of genetic testing and how this has evolved as our scientific knowledge has really improved over time. Dr. Trevor Hoffman: Yeah, it's been a wild ride considering everything I've seen happen in my own field. Back when I started in practice, we were doing like standard karyotypes and maybe sequencing a gene here or there by Sanger sequencing, and testing was cost prohibitive, thousands of dollars. You know, there were gene patents. You know, we were this little hidden department, like in the basement, that hardly anybody knew about, and we liked our little place in anonymity, and it was all good. Come the genomics revolution and next-generation sequencing, and, you know, all of a sudden you can, in one machine, sequence, you know, billions of letters of genetic code for hundreds of dollars. It was like a paradigm shift caused by technology. So that and the removal of gene patents, we've come, you know, in the ensuing years to hereditary cancer gene tests that's, you name it, depending on whether it's done 20, 30, 40, 70 genes for under $500 in most cases and can be done...

An estimated 85k adolescents and young adults (AYAs) between the ages of 15 to 39 will be diagnosed with cancer in the United States this year. AYAs with advanced cancer face care gaps for psychosocial support and communication. A recent paper published in JCO OP titled “Promoting Resilience in Stress Management: A Randomized Controlled Trial of a Novel Psychosocial Intervention for Adolescents and Young Adults With Advanced Cancer” detailed the findings of a clinical trial testing a skills-based coaching program with the goal of decreasing psychological distress and improving quality of life. TRANSCRIPT Dr. Fumiko Chino: Hello, and welcome to Put into Practice, the podcast from the JCO Oncology Practice. I'm Dr. Fumiko Chino, an Assistant Professor in Radiation Oncology at MD Anderson Cancer Center, with a research focus on access, affordability, and equity. An estimated 85,000 adolescents and young adults (AYAs) between the age of 15 and 39 will be diagnosed with cancer in the United States this year. Although this accounts for less than 5% of all cancers, AYA cancers have been rising over the past decade, and AYA survivors have unique survivorship needs, including physical, emotional, social, and spiritual communication. A recent paper published in JCO OP titled "Promoting Resilience and Stress Management: A Randomized Control Trial of a Novel Psychosocial Intervention for Adolescents and Young Adults With Advanced Cancer" detailed the findings of a clinical trial testing a skills-based coaching program with the goal of decreasing psychological distress and improving quality of life. I'm excited to welcome two guests to the podcast today to discuss optimal care for the AYA population. Dr. Abby Rosenberg, MD, MS, MA, is the Chief of Pediatric Palliative Care at the Dana-Farber Cancer Institute, Director of Pediatric Palliative Care, Boston Children's Hospital, and an Associate Professor of Pediatrics, Harvard Medical School. She is also the current designated pediatric oncologist at the ASCO Board of Directors. Both Dr. Rosenberg's clinical approach and her research focus on helping patients facing critical illness live their best lives and for as long as possible. Specifically, she and her team develop programs that help patients and families build resilience and optimize quality of life. She is the first author of the published trial we will be discussing today. Dr. Lauren Ghazal, PhD, FNP-BC, is an Assistant Professor and researcher at the University of Rochester School of Nursing. As an AYA cancer survivor herself and a family nurse practitioner with a background in economics, she brings a unique perspective to cancer care delivery research. Dr. Ghazal completed a postdoctoral research fellowship at the University of Michigan on an NCI T32 in cancer care delivery after earning her PhD at NYU, where her dissertation focused on work-related challenges and financial toxicity in AYAs. Our full disclosures are available in the transcript of this episode, and we've already agreed to go by our first names for the podcast today. Abby and Lauren, it's wonderful to speak to you. Dr. Abby Rosenberg: Thanks for having us. We're so happy to be here. Dr. Lauren Ghazal: Yes, thank you for having us. Dr. Fumiko Chino: Our specific topic today is: improving outcomes for the AYA population. Abby, do you mind starting us off by sharing some background on this trial and giving us a brief overview of the study and your findings? Dr. Abby Rosenberg: Yeah, I'm happy to. And thanks again for having us. You mentioned, Fumiko, the prevalence and problems that adolescents and young adults with cancer often have. One of the things that I like to point out is we know that if you're diagnosed with cancer as an adolescent or a young adult, you have higher risks of poor psychosocial outcomes forevermore compared to younger pediatric or older adult counterparts. With that in mind, we have been thinking for a long time about: how do you...

There is often a disconnect in toxicity assessment between what is reported on clinical trials as being “well tolerated” and the lived experience of taking a treatment for patients. Toxicity minimizing language including “safe” and “tolerable” are subjective and can downplay quality of life limiting side effects from treatment. A recent paper published in JCO OP reported that less than half of phase 3 clinical trials had “complete” toxicity reporting including total adverse events, deaths, and discontinuation due of toxicity. Dr. Chino welcomes two guests to discuss patient-centered clinical trial design with a focus on side effect profiles of treatment. TRANSCRIPT Dr. Fumiko Chino: Hello, and welcome to Put into Practice, the podcast for JCO Oncology Practice. I'm Dr. Fumiko Chino, an Assistant Professor in Radiation Oncology at MD Anderson Cancer Center with a research focus on access, affordability, and equity. There is often a disconnect in toxicity assessment between what is reported on clinical trials as being, quote-unquote, "well tolerated" and the lived experience of taking a treatment for patients. Toxicity-minimizing language includes words like "safe" and "tolerable." They are subjective and can downplay quality of life–limiting side effects from treatment. A recent paper published in JCO OP reported that less than half of phase 3 clinical trials had complete toxicity reporting, including total adverse events, deaths, and discontinuations due to side effects. I'm overjoyed to welcome two guests to the podcast today to discuss patient-centered clinical trial design with a focus on side effects from treatment. Dr. Ethan Ludmir is an Assistant Professor at MD Anderson Cancer Center with a primary appointment in GI radiation oncology. He is a prolific researcher on topics encompassing clinical trials, cancer outcomes, and the integration of biostatistics in oncology. He has a specific interest in improving clinical trial design, including designing patient-centered endpoints and complete reporting. He led collaborators in the manuscript that will frame our discussion today called, "Incomplete Toxicity Reporting and the Use of Toxicity-Minimizing Language in Phase III Oncology Trials," which was published earlier this year in JCO OP. Stacey Tinianov is the executive director and co-founder of Advocates for Collaborative Education, a global advocacy organization uniting patient, research, and policy advocates through pan-cancer collaborations, basic and advanced advocacy education, and the sharing of leading practices to change the narrative in cancer outcomes. Following her diagnosis and treatment for early-stage breast cancer 12 years ago, Stacey has become a leading national voice for patient advocacy and empowerment via collaborative education, community building, shared decision-making, health data access, and person-centered design. Our full disclosures are available in the transcript of this episode, and we've already all agreed to go by our first names for the episode today. Ethan and Stacey , it's wonderful to speak to you. Dr. Ethan Ludmir: Terrific. Thank you so much for having us, Fumiko. It's a pleasure to be here with friends and colleagues of many years to be able to talk about this important topic. Stacey Tinianov: Yes, thank you. Delighted to be invited, delighted to be part of the conversation. Dr. Fumiko Chino: Our specific topic today is toxicity minimization, either by underreporting or by language and framing that downplays the lived experience of treatment. Ethan, do you mind starting us off by telling us how you got interested in toxicity reporting and then briefly discussing what your study team did and the findings? Dr. Ethan Ludmir: Absolutely. Thank you, Fumiko. I have the privilege and luxury of being able to present research that is 100% the brainchild and terrific work of colleagues and friends, including the first author, a terrific graduate student named Avi Miller;...

Frustrations regarding the costs and difficulties with parking at hospitals is a common concern voiced by patients, families, and healthcare providers. Transportation barriers to receiving cancer care are incredibly common despite what appears to be relatively straightforward solutions. Dr. Chino welcomes two patient-centered health policy experts to discuss this: Dr. Arjun Gupta, MBBS, an Assistant Professor at the University of Minnesota; and Dr. Shakira Grant, MBBS, MSCR, the Founder & CEO of CROSS Global Research & Strategy. Transcript Dr. Fumiko Chino: Hello, and welcome to Put Into Practice, the podcast for JCO Oncology Practice. I'm Dr. Fumiko Chino, an assistant professor in radiation oncology at MD Anderson Cancer Center with a research focus on access, affordability, and equity. Frustrations regarding the costs and difficulties with parking at hospitals are some of the most common concerns voiced by patients, families, and healthcare providers online. There is nary a topic where you'll find a more unified level of outrage. Transportation barriers to receiving cancer care are incredibly common, despite what appears to be a relatively straightforward solution—to parking costs, at least. To discuss this, I'm excited to welcome two patient-centered health policy experts as guests today. Both have published work in JCO OP about transportation barriers. Dr. Arjun Gupta, MBBS, is an assistant professor at the University of Minnesota. He is a gastrointestinal oncologist, a symptom management enthusiast, and a health services researcher. His research examines cancer care access and delivery, the cost of cancer care, and the hidden burdens imposed on and faced by people with cancer and their caregivers while receiving this care. His 2020 editorial, "Park the Parking," documented parking costs at the top US hospitals as a source of financial toxicity. Dr. Shakira Grant, MBBS, MSCR, is the founder and CEO of CROSS Global Research and Strategy, a boutique consultancy focused on advancing equity-centered strategic solutions to complex healthcare challenges at the local, national, and global levels. She is the former health policy advisor to the US House of Representatives Ways and Means Health Subcommittee. Prior to that, she was an assistant professor at the University of North Carolina. Her qualitative analysis was published earlier this year and is called "Paying to Be a Patient in the Hospital and the Parking Lot: Patient-Caregiver Dyad Perspectives on Health-Related Transportation Access in Multiple Myeloma." Our full disclosures are available in the transcript of this episode, and we've already agreed to go by our first names for the podcast today. Arjun and Shakira, it's exciting to speak with you today. Dr. Arjun Gupta: Thank you. It's a joy to be here, Fumiko. Dr. Shakira Grant: Thank you so much for having me also. Dr. Fumiko Chino: Our specific topic today is transportation barriers to receiving optimal cancer care. This concern fits within the larger focus of addressing the social determinants of health, with the goal of improving access to high-quality cancer care for all. Research on health-related social risks and needs has proliferated in the last decade, and recent evaluations of food, housing, and transportation insecurity have expanded our knowledge on the barriers that some people face to receive care. Arjun, do you mind starting us off with just a bit of background about why these issues matter for patients? Dr. Arjun Gupta: Sure. So, just some background on social determinants of health. These are non-medical factors that are often at the community level that can have direct impacts on both health and health outcomes. So, these are all the issues that are associated with living and our daily lives: where we live, where we work, do we play, and what we play. All of these issues can, of course, impact what sort of medical conditions one might develop, but also the medical care that one might be...

Dr. Chino talks with Dr. Erin Roesch and patient advocate Julia Maues about pregnancy associated cancer with a focus on breast cancer, the most common cancer diagnosed during pregnancy. This discussion is based off an JCO OP review article published in late 2024 called “Multidisciplinary Management of Pregnancy-Associated Breast Cancer.” Transcript Dr. Fumiko Chino: Hello and welcome to Put Into Practice, the podcast for the JCO Oncology Practice. I'm Dr. Fumiko Chino, an assistant professor in radiation oncology at MD Anderson Cancer Center with a research focus on access, affordability, and equity. The incidence of early-onset cancer—new cancers in adults under the age of 50—is rising by 1% to 2% annually. Young women appear to be at particular risk, with cancer incident rates over 80% higher than similarly aged male counterparts. Collectively, that means that more patients are being diagnosed with cancer during their childbearing years. Pregnancy-associated cancer occurs in 1 in every 1,000 to 3,000 pregnancies and refers to cancer that is diagnosed either during pregnancy or within 1 year of delivery. On today's episode, we'll be talking about pregnancy-associated cancer, with a focus on breast cancer, as it is the most common cancer diagnosed during pregnancy. This discussion will be based off of a JCO OP article published in late 2024 called “Multidisciplinary Management of Pregnancy-Associated Breast Cancer.” I'm excited to welcome both the first author of this review article and a patient advocate to the podcast today. They are both passionate about improving outcomes for people with breast cancer. Dr. Erin Roesch is an assistant professor of medicine at Cleveland Clinic Lerner College of Medicine and a medical oncologist at the Cleveland Clinic Taussig Cancer Institute specializing in the treatment of breast cancer. She is involved in clinical trials research, and some of her specific interests include the care of young women diagnosed with breast cancer, fertility in oncology patients, and women's health and survivorship. Julia Maues is a patient advocate working with researchers, clinicians, and other stakeholders to ensure research is patient-centered, innovative, accessible, and inclusive. She was working as an economist when she was diagnosed with breast cancer while pregnant in 2013. After delivering her son, she found out that cancer had already spread to her bones, liver, and brain. Julia co-founded GRASP (Guiding Researchers and Advocates to Scientific Partnerships), an organization that connects and fosters collaborations between researchers and patient advocates. She is also active within the Metastatic Breast Cancer Alliance and helped write the ASCO guideline for brain metastasis. Our full disclosures are available in the transcript of this episode, and we've already all agreed to go by our first names for the podcast today. Erin and Julia, it's really wonderful to speak to you today. Dr. Erin Roesch: Thank you. I appreciate the opportunity to be here and discuss this really important topic. Julia Maues: Thank you for having me. It's very important to include the patient voice on this topic, and unfortunately, I have a personal experience with this. Dr. Fumiko Chino: Our topic today is pregnancy-associated cancer. Erin, can you give us a quick overview of the background for pregnancy and breast cancer? I know in the recent era, breast cancer rates for those under the age of 50 have been rising faster than for other cancers, up to 1.4% per year since the mid-2000s. I'd always thought that pregnancy-associated cancer was pretty rare, and so I was really shocked to read in your paper that for women younger than 35, 1 in 6 with breast cancer are diagnosed around pregnancy. Dr. Erin Roesch: Yes. So, a cancer diagnosis during pregnancy is rare, with the incidence, as mentioned, of about 1 in 3,000 pregnancies, with pregnancy-associated breast cancer, or PABC, representing about 7% of all...

Dr. Chino talks with Dr. Atif Khan and Dr. Lola Fayanju about the shift in breast cancer management from reducing locoregional recurrence and improving breast cancer mortality to deintensification, shared decision making, and improved quality of life. This discussion will be based off a JCO OP editorial published in late 2024 called “Contextual Framework for Understanding Treatment De-Escalation in Patients With Breast Cancer.” Transcript Dr. Fumiko Chino: Hello, and welcome to Put into Practice, the podcast for JCO Oncology Practice. I'm Dr. Fumiko Chino, an Assistant Professor in Radiation Oncology at MD Anderson Cancer Center with a research focus on access, affordability, and equity. Breast cancer treatment has made significant strides in the past century, with the five-year survival rate rising from less than 5% in the early 20th century to around 90% in the present day. In today's episode, we'll be discussing the shift in breast cancer management from reducing local-regional recurrence and improving breast cancer mortality to deintensification, shared decision-making, and improved quality of life. This discussion will be based off of a JCO OP editorial published in late 2024 called "Contextual Framework for Understanding Treatment De-escalation in Patients with Breast Cancer." I'm excited to welcome two breast cancer experts as guests today: the first author of this editorial and radiation oncologist, as well as a health services researcher and breast surgeon. They're both engaged in research to improve outcomes for breast cancer, including treatment optimization. Dr. Atif Khan, MD, MS, is a full attending breast cancer disease site leader and Service Chief in the Department of Radiation Oncology at Memorial Sloan Kettering Cancer Center. He is also on the steering committee of the Clinical Research Innovation Consortium, as well as on the Research Council at MSK. Dr. Khan is the chair of the breast section of oral examiners for the American Board of Radiology and is active in NRG, helping develop and lead key clinical trials to optimize radiation delivery for breast cancer. Dr. Khan is also a translational science investigator of novel radiosensitizers. Dr. Oluwadamilola "Lola" Fayanju, MD, MA, MPHS, is the Helen O. Dickens Presidential Associate Professor and Chief of the Division of Breast Surgery at the Perelman School of Medicine at the University of Pennsylvania. She is also Surgical Director of the Rena Rowan Breast Center at the Abramson Cancer Center, Program Director for Implementation Innovation at the Penn Center for Cancer Care Innovation, and a Senior Fellow at the Leonard Davis Institute of Health Economics at Penn. Our full disclosures are available in the transcript of this episode, and we've already agreed to go by our first names for the podcast today. Atif and Lola, it's wonderful to speak to you today. Dr. Atif Khan: It's a pleasure to be here. Thank you for inviting me, Fumiko. Dr. Lola Fayanju: Yeah, thanks for having me. Dr. Fumiko Chino: The topic today is treatment de-escalation for breast cancer, loosely based on the editorial that Atif wrote in JCO OP outlining a conceptual framework, which is primarily focused on local-regional therapies, i.e., radiation and surgery for breast cancer. The concept of rightsizing treatment has really been developing over the past three decades, spearheaded by surgical de-escalation. Lola, do you mind giving me a brief overview of surgical de-escalation as you have seen it throughout history and as currently realized in your practice? Dr. Lola Fayanju: Happy to. So, you know, it's one of those things where I think increasingly we recognize that breast cancer is a heterogeneous condition that shares an anatomical space. And with that refined understanding of treating breast cancer, we're no longer using a very blunt and large hammer to deal with what is actually a constellation of nails. So originally, when people used to treat breast cancer, the...

Dr. Chino discusses the past, present, and future of prior authorization in cancer care with Dr. Michael Anne Kyle, a health policy expert with a research focus on utilization management and patient burdens from prior auth. TRANSCRIPT Dr. Fumiko Chino: Hello and welcome to Put Into Practice, the podcast for the JCO Oncology Practice. I'm Dr. Fumiko Chino, an Assistant Professor in Radiation Oncology at MD Anderson Cancer Center with a research focus on access, affordability and equity. On today's episode we'll be discussing prior authorization in cancer care. Prior auth has been a recent focus of healthcare policy and reform, given rising demands seen by both providers and patients. I'm excited to welcome an expert on prior authorization to the podcast today. Dr. Michael Anne Kyle is an Assistant Professor in the Department of Medical Ethics and Health Policy at the Perelman School of Medicine at UPenn. Her work focuses on defining and measuring patient administrative burden in cancer care delivery with a focus on prior authorization and how it impacts cancer care delivery, including patient wellbeing and outcomes. She holds a Ph.D. from the Harvard Business School, an MPH from the Harvard T.H. Chan School of Public Health, and a Master's in Nursing from the UPenn. Our full disclosures are available in the transcript of this episode, and we've all already agreed to go by our first names for the podcast today. Michael Anne, it's so great to speak with you today. Dr. Michael Anne Kyle: It is so great to speak with you too, Fumiko. I'm really excited about this conversation and our shared interest in improving prior authorization. Dr. Fumiko Chino: I love it that you've taken time out of your day to talk to me. To start us off, can you tell us a little bit about yourself and your career? How did you transition from being a nurse into a health policy researcher? Did you always plan on a career in research or was there some specific event or transition that put you on this path? Dr. Michael Anne Kyle: There was not. And so for anyone who's listening, who isn't sure what they want to do, I guess I have a good story to show that you actually don't need to know in advance. I started out as a critical care nurse and I still actually work as a critical care nurse. But as I think anyone who is a clinician who's listening to this knows, when you work in the healthcare system you just see so many things that could be different, that could be better. You notice the ways that the systems like really aren't set up for us to do our work or to take great care of our patients some of the time. And so that's really what sparked my interest in policy and in research. So I had really no background. After working in a hospital, high acuity critical care, a lot of oncology, I spent several years working in community-based programs in New Jersey and this is before the Affordable Care Act. We were focused on access to medication, trying to get people more access to Medicaid, and did work around the initial rollout of the Affordable Care Act. And that experience where I spent a lot of time helping people enroll in social programs really gave me like some of the first insights into how much paperwork and how much time and how tedious it is to figure a lot of this out, even if you had someone helping you it’s still challenging. And that sort of stayed in the back of my mind as I went to grad school. And really what got me interested in like all the non-medical side of patient care is just like my friends and my family talking to me about it. And I think it's something we all just experience in our lives, but there just wasn't a ton of research. And so I've really been motivated to try to put some, like, numbers and evidence beside all these experiences that we know very deeply. Dr. Fumiko Chino: So what I'm hearing is that you learned yourself by doing the work, how difficult the work was to actually obtain services for your patients, and so...

Dr. Fumiko Chino talks with Dr. Aditi Singh and patient advocate Liz Salmi about how this essential tool for documentation could be optimized to be more patient-centered. This discussion will be based off the JCO OP article published in late 2024, “Re-Envisioning the Electronic Health Records to Optimize Patient-Centered Cancer Care, Quality, Surveillance, and Research,” on which Dr. Singh served as the lead author. TRANSCRIPT Dr. Fumiko Chino: Hello and welcome to Put into Practice, the podcast for JCO Oncology Practice. I'm Dr. Fumiko Chino, an Assistant Professor in Radiation Oncology at MD Anderson Cancer Center with a research focus on access, affordability and equity. On today's episode we'll be discussing our friend, the Electronic Medical Record and how this essential tool for documentation could be re-envisioned to be more patient centered. This discussion will be based off of a JCO OP article published in late 2024 called, “Re-Envisioning the Electronic Health Records to Optimize Patient-Centered Cancer Care, Quality, Surveillance, and Research.” I'm excited to welcome two guests, the first author, as well as a patient researcher advocate, to the podcast today. Both are passionate about improving how we use the EMR to communicate and provide care. Dr. Aditi Singh is an Assistant Professor in Clinical Medicine and Hematology Oncology with a focus on thoracic malignancies, particularly neuroendocrine tumors of the lung. She also serves as the Director of Clinical Informatics for the Abramson Cancer Center at the University of Pennsylvania. Her work focuses on optimizing the EHR to enhance provider efficiency and provide high quality cancer care. She also serves on the NCCN Guidelines Committee for non-small cell lung cancer, thymic malignancies and mesothelioma. Liz Salmi is the Communications Inpatient Initiatives Director for OpenNotes. In this role, she helps clinicians, hospitals and the health system understand the changing nature of patient-clinician communication in an era of growing transparency. As a person living with a malignant brain tumor, she is active in research and advocacy to ensure that the patient voice and patient-centered care is prioritized. Our full disclosures are available in the transcript of this episode. And we've all already agreed to go by our first names for this podcast today. Aditi and Liz, it's so great to speak with you today. I hope you guys are both staying warm. Dr. Aditi Singh: Hi. I'm very happy to be here. Liz Salmi: Thanks for having me back. Dr. Fumiko Chino: Our topic today is about how we make the electronic medical record more patient-centered. To start it off, I'd love to actually ask a hopefully non-controversial question to both of you. What is patient-centered care? How do you personally define it? Are there key characteristics or is it something that it's commonly mistaken for? Or is it like the Supreme Court's definition of pornography - ‘I know it when I see it’? Liz, do you want to take that first? Liz Salmi: Sure. Yeah. So, I've been living with a malignant brain tumor or a grade 2 astrocytoma for 17 years. And when I first got into this space, I'm a person with a communications background originally, so when I would hear that term, I'm like, “Yeah, of course, patient-centered care - like what were you doing before that?” And then in the last 11 years I've been working in healthcare and the last eight years specifically with the OpenNotes team at Beth Israel Deaconess Medical Center. So, when I would hear that term, I was like, “What were they doing before that?” Like still even more frustrated. So, it to me sounds like jargon, like a bad form of jargon. And I think that there's new words we could be evolving into over the next, say, decade, maybe sooner. Dr. Fumiko Chino What are those words, actually, just out of curiosity? Liz Salmi: I want to co-design that with patients. Dr. Fumiko Chino: I love it. So that's still a work in progress. I love...

Host Dr. Fumiko Chino sits down with co-editor and health outcomes researcher Dr. Ryan Nipp, and contributing author Dr. Kelly who is living with metastatic breast cancer to have a candid conversation about financial toxicity, the lived experience for patients, and what we can do to move the needle on affordability in cancer care. TRANSCRIPT The disclosures for guests on this podcast can be found in the show notes. Dr. Fumiko Chino: Hello and welcome to the inaugural episode of Put into Practice, the podcast for JCO Oncology Practice. I'm Dr. Fumiko Chino, an Assistant Professor in Radiation Oncology at MD Anderson Cancer Center with a research focus on access, affordability, and equity. In today's episode, we'll be highlighting the special issue of JCO OP focused on financial toxicity. I'm delighted to serve as an editor for this special issue, and I'm overjoyed to welcome two guests who were instrumental in creating the issue. The first is my co-editor, Dr. Ryan Nipp. He's a Medical Oncologist focused on GI cancers at the University of Oklahoma Stephenson Cancer Center, where he also does cancer outcomes research. I'm also pleased to welcome Dr. Kelly Shanahan, who is an author of a narrative piece for this issue. Dr. Shanahan was a practicing OB/GYN in Lake Tahoe, California when she was diagnosed with stage 2B breast cancer in 2008. She has now been living with metastatic breast cancer since 2013 and serves as a patient advocate and research advisor. Our full disclosures are available in the transcript for this episode and we're all already agreed to call ourselves by our first names for the podcast today. Kelly and Ryan, so great to speak with you today. Dr. Kelly Shanahan: Likewise, Fumiko. Dr. Ryan Nipp: Thank you so much. Dr. Fumiko Chino: To start us off, I'd love to just set the scene about financial toxicity, our topic. Ryan, do you mind sharing an overview of financial toxicity, what it is, what it isn't, and how you got involved in this type of research? Dr. Ryan Nipp: Absolutely. Thank you. So I always start with the idea that the NCI website, I remember when this came out a few years ago, they provide some helpful information on this topic. The definition that they provide I think works nicely. It states that financial toxicity describes the issues patients may have related to the cost of medical care. The high cost of medical care, in addition to the cost for missed work, loss of employment and travel and lodging for care, can cause financial problems and may lead to debt and bankruptcy. Financial toxicity can also affect a patient's quality of life and access to medical care. For example, a patient may not take a prescription medicine or may avoid going to the doctor to save money. Research also suggests that patients with cancer are at risk for experiencing financial toxicity potentially greater than people without cancer or other medical issues. Financial toxicity is also sometimes called financial burden, financial hardship, financial distress, financial stress, economic burden, and economic hardship. So it goes by a lot of different names. Throughout my career and my research to date, I developed an interest in financial toxicity as I'm particularly interested in improving care delivery and outcomes for patients impacted by cancer and this continually became an issue as I was growing and training in oncology, noticing that the financial toll of having a cancer diagnosis can be remarkably problematic and concerning for our patients. Thus, I wanted to find ways to study this issue and ultimately develop strategies to address the problem. So just to give a little bit of background on the current JCO OP special issue, we wanted to do this special issue for numerous reasons. We're fortunate to work at JCO OP or work with JCO OP, JCO Oncology Practice which has a unique interest in this topic. We've been working to address this issue of financial toxicity throughout our careers, I say me and Fumiko,...

Dr. Pennell and Dr. James Hammock discuss the provision of oncologic services by Project Access safety net care coordination programs. NATHAN PENNELL: Hello, and welcome to the latest JCO Oncology Practice podcast, brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content, and offering enriching insight into the world of cancer care. You can find all recordings, including this one, at podcast.asco.org. My name is Dr. Nate Pennell, medical oncologist at the Cleveland Clinic and consulting editor for the JCO OP. I have no conflicts of interest related to this podcast. And a complete list of disclosures is available at the end of the podcast. Today, I'd like to talk a little bit about the complexities of providing cancer care for patients who are uninsured or underinsured, which is a relatively large percentage of patients in the US. How do patients without insurance receive cancer care? One way is through community programs, including a program called Project Access, a care coordination program connecting patients to specialty medical care at no or reduced cost, including, in some instances, oncology care. But how does it work? Who does it help? And how impactful are this and other programs designed to obtain cancer care for low-income, uninsured, and underserved patients? With me today to discuss this topic is Dr. Jamey Hammock, a resident in internal medicine at the University of Alabama Birmingham. We'll be discussing the paper from he and his colleagues titled, Oncologic Services Through Project Access and Other Safety Net Care Coordination Programs, which was published online July 31, 2020 in the JCO OP. Welcome, Jamey, and thank you for joining me on the podcast. JAMEY HAMMOCK: Hey. Thank you, very excited to be here. I did want to say too that I do not have any conflicts of interest or disclosures for this particular study. NATHAN PENNELL: Why don't we start out by talking a little bit about how big a problem it is for providing cancer care in uninsured and underinsured patients in the US. JAMEY HAMMOCK: It's an enormous problem. If you look at previous studies, they've looked at patients who are underserved, underinsured, or even uninsured with cancer. And these patients actually typically present with later stage disease, they experience delays in treatment, and ultimately have worse overall survival compared to well-insured patients. So just that alone tells you how big of a problem that this is. I think that when you look at cancer care for underinsured and uninsured, you have to break those things up. And you can't really talk about it without talking about the Affordable Care Act. So let's take uninsured patients, for example. If you look at pre-Affordable Care Act and post-Affordable Care Act, there's a great study in 2017 that really broke down these two groups, pre and post. And what they found is with the Affordable Care Act, if you are uninsured across any income level and you lived in a Medicaid expansion state, the percentage of patients who were uninsured decreased from about 5% to 2 and 1/2%. So it really cut that percentage in half, which is pretty impressive. And then if you look at low-income uninsured patients, because they broke that down in the study, the percentage actually dropped from around 10% to 3 and 1/2%. So It just shows you when you talk about absolute numbers and then those percentages, how many individuals are really affected that have a diagnosis of cancer and are uninsured. And it gives you a little bit of insight of what Medicaid expansion has done for that group. And then I want to touch really quickly too on underinsured. So basically underinsured patients, they don't have the means to get the care that they need, even if they have insurance. That's important. And patients with Medicaid, for example, they have insurance, but they have their own challenges. For example,...

Dr. Pennell and Dr. Friedman discuss the variety of ethical dilemmas for health care providers brought on by COVID-19. NATE PENNELL: Hello, and welcome to the latest JCO Oncology Practice Podcast, brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content, and offering enriching insight into the world of cancer care. You can find all recordings, including this one, at podcast.asco.org My name is Dr. Nate Pennell, Medical Oncologist at the Cleveland Clinic, and consultant editor for the JCOOP. I have no conflicts of interest related to this podcast, and a complete list of disclosures is available at the end of the podcast. Today I want to talk about a very serious topic that all of us who care for cancer patients really had at the front of our minds back in the spring of 2020. While it may already seem like a long time ago, when the COVID pandemic was at its peak in the United States, New York City was being inundated with of COVID. And for a while there was quite a bit of uncertainty about whether they might run out of personal protective equipment or ventilators. And there were very serious discussions happening about allocation of resources. I personally remember patients asking me, even here in Ohio, if they might not be offered a ventilator if they became sick, because of their cancer diagnosis. And while this certainly never came close to happening in Ohio, I think it actually came closer than we'd like to admit in places like New York. With me today to discuss this really fascinating topic is Liz Blackler, who is the program manager for the Ethics Committee and Consult Service at Memorial Sloan Kettering Cancer Center in New York City. We'll be discussing the upcoming manuscript from her and her colleagues titles, "COVID-19-related Ethics Consultations at a Cancer Center in New York City-- a Content Review of Ethics Consultations During the Early Stages of the Pandemic," which was published online August 27, 2020 in the JCOOP. Welcome Liz, and thank you for joining me on the podcast. LIZ BLACKLER: Thank you so much for having me here today. I'm definitely looking forward to discussing our manuscripts with you. Just to note, I do not have any relationships or disclosures related to this study. NATE PENNELL: Thank you. So what was it like to be really in the epicenter of the COVID pandemic back in the spring? LIZ BLACKLER: There was a lot of uncertainty. We were all just trying to find our way, to figure it all out. Staff was just reconciling what was happening in real time in the city and the world, and then looking into our own hallways, seeing what was happening there. I would say it was both chaotic and eerily quiet. Our ethics consultation service, as with many ethics consultation services in the hospital, went virtual. So only those people who needed to be on site were there. And the rest of us were working from home. And so I think as a staff, we were adjusting to doing our jobs remotely, and also watching and feeling the enormity of what was happening at the hospital with patients, and feeling just a little bit far away. NATE PENNELL: So you are in charge of the ethics consult service. I think anyone who's ever been involved in a case that needs to involve the ethics consult service knows how incredibly interesting a job that must be, and complicated. Can you just, before we get into the COVID thing, explain what an inpatient ethics consult team does, and who is on that team? LIZ BLACKLER: Sure. So ethics consultations are most frequently requested to help analyze and resolve complex value-laden concerns that arise between or among clinicians, and patients, and/or families. Anyone-- clinicians, non-clinician staff, patients, family members, health care agents, surrogate decision makers can request an ethics consultation. And depending on the situation, the consultant may facilitate communication between the...

Dr. Pennell and Dr. Jennifer Tsui discuss the processes that lead to suboptimal EOL care within Medicaid populations and among racial/ethnic minority groups. Hello, and welcome to the latest JCO Oncology Practice podcast, brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content and offering enriching insight into the world of cancer care. You can find all recordings, including this one, at podcast.asco.org. My name is Dr. Nate Pennell, medical oncologist at the Cleveland Clinic and consultant editor for the JCO OP. I have no conflicts of interest related to this podcast, and a complete list of disclosures is available at the end of the podcast. Aggressive care at the end of life for cancer patients is widely recognized as poor-quality care. And by aggressive care, I don't mean aggressive supportive care or hospice, but rather inappropriate interventions, like chemotherapy or hospital and ICU admissions, near the end of life that rarely improve outcomes and often actually worsen quality of life. Efforts are being made to educate physicians and cancer patients to try to minimize aggressive treatments near the end of life and to help as many patients as possible benefit from things like hospice benefits and appropriate end-of-life care. However, not all patients receive high-quality end-of-life care, and there may be differences in end-of-life care in various populations. For example, how do race and things like Medicaid status impact aggressive care at the end of life? With me today to discuss this topic is Dr. Jennifer Tsui, Assistant Professor in the Division of Population Science at Rutgers Cancer Institute of New Jersey. We'll be discussing her paper "Racial Disparities in Health Care Utilization at the End of Life Among New Jersey Medicaid Beneficiaries With Advanced Cancer," currently in press for the JCO OP. Welcome, Dr. Tsui, and thank you for joining me on the podcast. Thanks so much. Thanks for having me. I have no conflicts of interest with this study whatsoever. Dr. Tsui, can you please tell me a little bit about what exactly constitutes high or low-quality end-of-life care? Sure. I mean, I think that, in this study in particular, we wanted to focus on guideline-related end-of-life care. So we wanted to see if it was possible to take a look at patterns at the end of life for breast and colorectal cancer and stage cancer cases and see sort of what the patterns were in relation to adherence to guideline adherence and what they should be receiving at the end of life. And so that included a set of measures around aggressive care related to hospitalization in the last 30 days, emergency department visits in the last 30 days of life, an ICU admission in the last 30 days of life, and chemotherapy in the last 14 days of life. These are guidelines that have been discussed and published by national organizations. And we also looked at hospice enrollment. So we looked at whether there was any hospice enrollment and whether there was hospice enrollment in the last 30 days of life, I'm sorry. Are there already data existing for various disparities in end-of-life care among different racial groups or patients of different socioeconomic status? There are. So there have been a few prior publications before our study that have shown that Medicaid patients frequently-- not just for end-of-life care, but cancer care in general-- that Medicaid patients receive lower quality of care. And there were studies done prior to ours that did show, I think, in New York, for example, that Medicaid patients had lower-quality end-of-life care compared to Medicaid and privately insured patients. We have seen other studies also mentioning disparities by race in terms of quality of end-of-life care. However, I don't think-- some of these studies have focused on different populations and cancer sites. So some of the studies I mentioned looked...