Advances in treatment and new drugs are pushing cancer care even farther away from hospital campuses into outpatient settings and, soon, right into patients' homes.
It's part of an ongoing evolution of care that started 30 years ago with new types of anti-nausea drugs — and more recently, novel immunotherapies — that is changing how and where patients are treated, turning the private practice model for providers on its head.
The result affects not just patients and their families, but also physicians, private practices and hospitals themselves, all of which are making significant investments to remain viable and competitive in the midst of ongoing change.
“Generally things have moved to the outpatient ambulatory setting and this is true no matter what illness you’re treating: It’s true for orthopedics and chronic conditions, too and it has to do with the cost of care,” said Dr. Sai Yendamuri, chief strategy officer and chair of the department of thoracic surgery at Roswell Park Comprehensive Cancer Center. “It’s true with cancer as well.”
The ongoing migration is also changing where and for whom oncologists work. Like for many other medical specialties, the costs of providing care, and the way payers reimburse for that care, has led to fewer and fewer independent oncology practices, with the majority of cancer doctors now employed by hospitals or large multi-specialty groups.
Most cancer care now off-campus
About 80% of all cancer care is now delivered in outpatient settings, a change that’s sped up over the past decade as radiation and chemotherapy have become safer to administer and surgery has shifted toward more minimally invasive procedures, Yendamuri said.
Among the outpatient projects in Western New York in recent years:
- Roswell Park last year opened the $23 million outpatient Rowell Park Scott Bieler Amherst Center on Park Club Lane in Amherst.
- Buffalo Medical Group added a new infusion center and specialty care as part of the 19,000 square-foot hub it opened earlier this year at 6950 S. Transit Road in Lockport, where it also houses primary care, X-rays and a laboratory.
- Kaleida Health and its Western New York Urology Associates affiliate recently completed a $5 million ambulatory surgery center expansion at Harlem Road Professional Park in Cheektowaga, adding eight rooms for urological and prostate cancer surgery.
“We’re embedded in the community now,” said Dr. Roberto Pili, associate dean for cancer research and integrative oncology and chief of the division of hematology/oncology in the University at Buffalo’s department of medicine at the Jacobs School of Medicine & Biomedical Sciences. “Cancer care is meant to be decentralized from a historical perspective, more than just in a hospital or established cancer center."
With ongoing shortages in the workforce and increasing incidence rates linked at least in part to the aging population, cancer providers and patients are looking for solutions. Telemedicine and remote monitoring are among the answers, but so too are new therapies and technology that make it easier for patients to get quality treatment closer to home or, in some cases, without actually leaving the house.
Pili also serves as vice president for oncology services with the Great Lakes Cancer Care Collaborative, a joint initiative between 11 organizations that include Kaleida, Erie County Medical Center, UBMD Physicians’ Group and Cancer Care of Western New York.
Pili said the evolution likely will go a step further as soon as a year from now, as patients diagnosed with some forms of cancer might be able to avoid leaving the house and dealing with the hassles of parking and waiting rooms as more convenient types of therapies become available.
He pointed to the advent of oral immunotherapy drugs as well as subcutaneous therapies that can be delivered under the skin in non-hospital settings under the guidance of home-care nurses.
“The implementation of telemedicine and subcutaneous administration of these commonly used drugs will allow patients to stay at home and be monitored at home,” he said. “This will have impact on saving costs for the payers, saving costs for the practice and also saving time for the patients.”
What’s driving changes?
For patients, the shift has been all about convenience and easing the treatment process: Who wants to endure a longer than necessary drive when they know they will feel awful after chemo?
“We are continuing to see most of our oncology care provided in an outpatient setting,” said Amy Craib, senior vice president of service lines for Kaleida Health. “They very much want to be close to home, to easily park and have access to treatment and have their families easily join them. That kind of convenient, easy access is important to patients as they navigate their care.”
The same is true more and more for physicians and surgeons, who find it easier to travel to ambulatory surgery centers and suburban outpatient care sites than going into the city, said Dr. Mike Mineo, chief medical officer for Kaleida.
Bigger thoracic surgeries for lung cancer and the esophagus as well as more complex colorectal surgeries must still be provided in a hospital setting. But more and more, robotic surgery cases are moving away from multi-day stays inside the hospital to same day, laparoscopic procedures.
“I think we’re going to start to see more home-based infusions and more of a shift to oral oncolytics and more and more minimally invasive surgery to help patients manage the continuum,” Mineo said.
That will be important as an aging population leads to more cancer diagnoses, Craib said. The region’s providers are also dealing with higher rates of later-stage cancer following delays in screenings during the pandemic.
Changing models
Dr. Robert Zielinski has seen a lot of changes in his 40-year career in oncology. He remembers when nearly all cancer care took place inside hospitals. Then, as anti-nausea medications became more accessible, the viability of outpatient therapy led to the launch of community-based practices.
Today, the majority of cancer therapies are provided with commercially available agents and standardized therapies that can be delivered by any qualified oncologist in the community, including Buffalo Medical Group's infusion centers at its sites in Orchard Park, Williamsville and Lockport.
“Cancer therapies are much more manageable than they used to be partly because of the nausea drugs and because of the shift away from traditional chemotherapy and more immunotherapy and biologics, which don’t have as much of those effects that keep people tied to IVs and hospitals, so the vast majority of care is done in outpatient settings, which is much better for patients," said Zielinski, BMG's associate director and chair of the hematology/oncology division.
Roswell Park is also continuing to expand its network outside the region through the Roswell Park Care Network, now stretching across the state from Buffalo and Niagara Falls to Utica, Syracuse and Oneida down to Long Island.
“This has rapidly expanded, particularly over the last two to three years,” Yendamuri said. “We’ve onboarded almost five new sites in the last 12 months, so we’ve really embraced the model of delivering cancer care as much as possible as close as possible to the patient.”
Roswell Park is in talks to bring more sites into the care network, both in New York and also possibly outside the state, including the possibility of three facilities in India for affiliations that could include clinical trials development and consulting.
“Sort of the next step of the network is looking at new technology to enhance this care coordination, so we are going to be conducing pilot initiatives to explore different technology to make this happen like remote patient monitoring, more telehealth and more AI-based strategies to coordinate care,” Yendamuri said. “That’s what we will really need to operationalize and figure out what works in our community for our patients.”
City services growing, too
Suburban sites aren't the only places patients are going for care. Investments continue at hospitals as well, though on a much smaller scale. ECMC is working to convert the former emergency department into a $2 million breast health center for women that includes mammography; Buffalo General Medical Center is spending $1.35 million to renovate and expand infusion services; and Roswell Park will spend $3 million to grow its theranostics infusion program at the downtown hospital on Carlton Street.
At ECMC, the focus is on providing care for city residents who should be able to get services close to their homes as well, said Cassie Davis, senior vice president of operations. The breast health center will join a growing oncology service line that includes thoracic/lung cancer, head and neck cancer as well as plastics and reconstructive breast surgery.
The center — expected to open early next year — will expand screening and diagnosis, as well as access to treatments. That should lead to better survival rates: Right now, the mortality rate for Black women is 42% higher than for white women, despite a five-year survival rate for breast cancer that is 99%.
“Access to mammography should be like primary care – you just have it available to you,” she said. “The way that care is now for women if they have breast cancer and how it’s diagnosed and treated is very fragmented in the community. Screening is in one place, and they may have to try to figure out transportation to get to Williamsville for follow up. This is going to bring everything under one roof and one place, and again, in the community that people live in.”
ECMC is also exploring opportunities for outpatient and off-site care, but creating services in the city is the priority to complement screenings offered at community-based outreach events, as well as services from a mobile mammography bus.
“Yes, there’s a push to outpatient and a push to off-site, and you see some places popping up in the suburbs and for us that’s still part of our future vision,” Davis said. “The East Side continues to be heavily impacted by lack of services, so our commitment is building that outpatient capacity at 462 Grider, building services on our campus.”
Private practice sites disappear
Changing payment models and higher costs of new immunotherapies in more recent years have also led to the demise of private, community-based practices, Zielinski said.
The changes in how and where cancer care is delivered is having a major impact on community providers: With the exception of BMG, all of the region’s privately owned, independent oncology practices have either been sold or merged into area hospitals like Roswell Park.
That drives up pricing, he said, leading to higher premiums for employers, even though patients might not notice if their co-pays remain flat. And on the provider side, it leads to less competition and fewer providers.
“We’re the last one standing in Western New York, and if you look across the country, they’ve been folding at a regular rate into largely institutional umbrellas,” Zielinski said. “There used to be a bunch of smaller medical oncologists in the community … all of those are gone. They’re either retired or folded into these institutional settings.”