Cancer: Written in the Stars?

Cancer: Written in the Stars?

Among other things the summer equinox means

(besides the sunlight fracturing my sleep at 5:30 in the freaking morning), star-gazers know that the sun’s most northerly position on the day of the equinox is in Taurus – though it wasn’t always so. In ancient Greece, the sun would’ve ridden to its equinox peak in a different constellation: specifically, Cancer. When I stumbled on that tidbit in the paper yesterday, I was reminded how long that name’s been with us.

Cancer’s new prominence in the modern age – in incidence, and in awareness – often fools us into thinking it’s a new illness; but in fact, the disease is as old as our species. It was first named in the fifth century B.C.E. by Greek physicians in the Hippocratic tradition who, frustrated in their attempts to pry tumors free of their patients, called them karkinos (“the crab”) because of the tumors’ claw-like grip.

Greek knowledge formed the basis of much of Roman learning. As Hellenic power waned and Roman influence dominated the world, the Greek word for the disease was eventually replaced by the Latin synonym for crab: cancer.

There may even be another reason these tumors reminded Greek physicians of a crab, though I’ve no proof of this. In mythology, the goddess Hera tried to foil Hercules at every turn – and during his battle with the Hydra (when he needed all his wits and strength) she sent a large crab to bite at his feet during the battle, hoping it would affect his footing enough to cause his defeat. When Hercules instead crushed the crab, myth says Hera memorialized it in the heavens as one of the signs of the Zodiac.

In Hippocrates’ time lifespans were much shorter so cancer would’ve been rare, and would’ve affected the young and otherwise healthy. It would’ve seemed a random calamity of cosmically cruel proportions, biting at the heels of otherwise vibrant youth – like the one Hera sent to torment Hercules – and just like pediatric cancer still seems to us today.

U.S. Oncologists are Working Shorthanded

U.S. Oncologists are Working Shorthanded

The relationship between cancer patients and their oncologists is an intense one.

The stakes are high for everyone involved, and cancer patients especially have very high expectations of their doctors (more info here). There are approximately 15 million cancer survivors in the U.S. right now, and as our population ages and cancer treatments become more and more effective, the number of cancer survivors needing precious time with their oncologist keeps increasing. That number is expected to reach 20 million by 2026.

But the demand for cancer doctors is outrunning supply: in 2016, there were 12,100 practicing oncologists in the U.S., approximately one-fifth of whom are due to retire within the next five years. At present, graduate programs can only supply about 600 new oncologists per year – and with increasing financial pressures on educational programs, there’s almost no potential to increase that output within the next decade (more info here).

And it isn’t simply a matter of current oncologists stepping it up, either: the average oncologist is already working 63 hours per week.

It was hoped that widespread implementation of computerized medical records would yield a boon of efficiency, but unfortunately that hasn’t materialized either. It’s currently estimated that oncologists now spend 50% or more of their time on computer work, leaving less (rather than more) time for patients. Maybe physicians haven’t yet climbed the steep computer learning curve to gain new efficiencies, or maybe current technologies (as implemented) aren’t designed to make physician work easier, but either way it’s been more burden than benefit so far.

So if the work’s hard, getting harder, and there’s more of it than ever before, who in their right mind would go into medical oncology in the first place?

Good question; I’ll try to answer it in my next blog.

For more information about the author of this blog: click here

 

GBM Treatment: One Small Step at a Time

GBM Treatment: One Small Step at a Time

Brain Cancer.

The term strikes fear in even the strongest of us and for good reason. In the past 5-10 years, treatment’s progressed by leaps and bounds in a great many cancers, while in others progress lags. Unfortunately  glioblastoma (GBM), the most common of adult brain cancers, is one of the latter. GBM remains an aggressive disease with a median survival of just over a year in the strongest of patients (and only half that in the more infirm).

In 2005, we took a baby step forward with glioblastoma. The EORTC / NCIC trial showed the addition of temozolomide to standard surgery and radiotherapy extended median survival from 12.1 months to 14.6 months, and improved patients’ chances of being alive at 2 years from 10.4% to 26.5%2.  While not a home run, it was good enough to become the standard of care for the next decade.  But there progress stalled, and would probably still be stalled if it hadn’t been for some unconventional thinking.

The conventional approach to cancer treatment is to eradicate every single cancer cell, achieving cure. But because GBM cells are extremely hard to kill, all of these approaches ultimately failed.

All right then, so we can’t kill it – but what if we could hold it to a stalemate?

Enter Tumor Treating Fields (TTF): a little bit science fiction, a little bit science fact. I have to admit I was very skeptical when I first heard of the technology, and was even less enthused when I saw what a nuisance it is for patients – but it works. In 2015, investigator Roger Stupp (who developed temozolomide treatment in the first place) showed that adding TTF to standard treatment improved median overall survival from 16.6 to 19.6 months, and improved a patients’ chances of surviving 2 years from 29% to 43%3 – that’s as big a step forward as adding temozolomide was in 2005.

What’s the magic? TTF subjects tumor cells to rapidly alternating electrical fields, disrupting cell division. And since it’s uncontrolled cell division that makes a cell cancerous in the first place, the TTF approach hits the cancer right where it hurts.

TTF doesn’t cause nausea, or fatigue, or infections, or low blood counts. It doesn’t even require patients come into the office for treatment– but there is a down side. Patients have to wear an electrode array affixed attached to their bare scalps (meaning they have to shave their heads), and powered by a backpack-sized battery pack. – and they have to wear it for 18 hours a day. Apart from the obvious inconvenience, the worst side effect most patients experience is some mild scalp irritation.

In America we like to imagine beating cancer all at once, a sudden stunning breakthrough that solves the problem once and for all. We’re a culture that prefers football to soccer – touchdowns, home runs, and blowout victories to gradual wins of 2-1 – but in reality cancer treatments have almost always improved gradually, one small step at a time. I’m not sure we will ever see a home run in GBM…but I do believe that slow and steady will eventually win the game.

  1. Stupp R, Mason W, van den Bent MJ, et al. Radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma. NEJM, 2005 Mar 10; 352(10): 987-96.
  2. Stupp R, Hegi ME, Mason WP, et al. Effects of radiotherapy with concomitant and adjuvant temozolomide versus radiotherapy alone on survival in glioblastoma in a randomized phase III study: 5-year analysis of the EORTC-NCIC trial. Lancet Oncol. 2009 May; 10(5): 450-66.
  3. Stupp R, Taillibert S, Kanner AA, et al. Maintenance therapy With Tumor-Treating Fields Plus Temozolomide vs Temozolomide Alone for Glioblastoma: A Randomized Clinical Trial. JAMA. 2015 Dec 15; 314(23): 2535-43.

Melanoma Deserves Your Attention

Melanoma Deserves Your Attention

Our skin is the body’s largest organ, so maybe it’s no coincidence that skin cancer is the most common type of cancer.

Though there are exceptions, they usually form on skin that had heavy sun exposure – so unlike most cancers that hide inside the body, we can actually see these cancers with our naked eyes.

Most types of skin cancer aren’t terribly dangerous, but malignant melanoma’s the exception. Though it’s the least common type of skin cancer, it’s by far the most aggressive. Melanoma’s easy to cure – but only if we can catch it before it starts to spread. It can invade nearby tissues and spread to other body sites much earlier in its lifespan than most other cancers – while it’s still just millimeters in size. That’s what makes it so dangerous, and why early detection is so crucial.

Recognizing melanoma’s signature features are the key to early diagnosis, treatment and cure.

Just remember “ABCDE”:

Asymmetry: One part of a mole or birthmark doesn’t match the other.

Border: The edges are irregular, ragged, notched, or blurred.

Color: the color is not the same all over and may include shades of brown or black, sometimes with patches of pink, red, white or blue.

Diameter: The spot is larger than ¼ inch across – about the size of a pencil eraser.

Evolving: The mole is changing in size, shape, or color over a few weeks or months.

If you’re in doubt about a spot on your own skin, please don’t hesitate and see your primary care provider. It might save your life.

FLT3 mutations in AML: From Trivia to Triumph

FLT3 mutations in AML: From Trivia to Triumph

Here’s an aggravating fact about medical education – a large chunk of what’s taught in medical school is useless trivia:

  • The muscle that elevates your palate is called the tensor veli palatini…
  • Here’s the best way to treat leprosy…
  • Adults whose acute leukemia cells carry an internal tandem mutation of the FLT3 surface tyrosine kinase have a worse prognosis…

I and other cancer specialists have known that last little nugget for about ten years, but haven’t been able to do squat with it:

“So should I use a different induction chemotherapy for FLT3-mutants?” (No)

“Should all FLT3 mutants get a stem cell transplant?” (Not necessarily)

“Is there anything I can do differently for these patients?” (Silence)

Thanks. Thanks a fricken’ lot.

It’s a little unfair to rant, I know. There’s a long lag time between discovery and new treatments for cancer -but the wait is hard, especially with new leukemia patients coming in the door every month.

But last week finally – finally – a drug targeting this specific molecular defect was approved by the FDA.

See, FLT3 is like an “on” switch for cell division. It’s supposed to only be on when it gets a particular environmental signal, and not every cell even carries the switch. But about 35% of acute myeloid leukemia patients have FLT3 abnormally expressed in their cancers – and the switch is stuck in the “on” position, driving cancer cell growth.

Happily, the new FLT3-inhibiting drug midostaurin (given as a twice-daily pill) markedly improved response and survival rates in AML when added to the standard chemotherapy cocktail. The benefits seemed most pronounced among people who ultimately went on to receive a stem cell transplant – but a higher percentage of patients were able to achieve the remission usually required as a first step before transplant.

So now I can re-categorize the FLT3 information from “trivia” to “critical information” in my brain, as I impatiently wait for more breakthroughs.

FDA Press Release 4/28/17: click here

My Hero

My Hero

Oprah’s guest pointed to the place above her collarbone where the tumors first appeared. It’d been a hard fight, with one particularly close call, but she’d made it and now she was a survivor – even a hero. Cue tears from the audience.

Normally I’d have been moved, crying along with the show and applauding the brave woman on Oprah’s couch. I loved stories about women who faced their fears and came out stronger. I wanted to be one of those women.

But the thing was, I had a lump, too. It was in almost the exact same spot as hers. It’d been there for a few weeks now. They’d told me in the clinic that lymph nodes come and go all the time, that I shouldn’t worry if it went away in a week or so, but that I needed to call them back if it didn’t.

But it hadn’t gone away. The thing was getting bigger – a lot bigger. And now there was a new one starting on the other side of my neck. And I wasn’t up to facing it. I was twenty-three years old, about to start a new job as a real estate agent, and the brave woman on Oprah’s couch was mocking me.

I wasn’t feeling any braver when I drug myself back to the clinic. And brave wasn’t on the menu when I had the biopsy, either.  And when I finally heard someone say aloud what I already knew – “cancer” – brave had skipped town.

When you’re in a situation that threatens your future, you can’t know at the time that everything’s going to work out all right. All you know is fear. You’re afraid of the lymphoma, you’re afraid of the chemotherapy that’s supposed to save you, and you’re afraid every next test will tell you something you don’t want to hear.

They must’ve smelled it on me because it seemed that every nurse, every receptionist, practically every person I saw at GBO put in something extra to help me feel less afraid. And they were calm. They’d been there and done that, and their calm reassured me.  I will never forget those wonderful people. They’ll always be a special part of my life.

But there’s just something about Dr. Jaslowski.

Ever met him? He’s soft-spoken and a little shy. He’s so casual that you can almost forget how much information he’s got in his head, and how brilliantly he can use it. He’s gentle and reserved. But then when you most need and least expect it, he wraps you in this huge kindness and you realize he’s the best person on earth.

There was this one day late in my course, and I’m in clinic for treatment. It was almost routine by then, but for some reason fear had gotten out of the barn and was galloping off with me. My chest was tight, and my mind couldn’t fix on anything to ground me. It felt like trying to catch hold of a branch while falling from a very tall tree. I was a mess.

I’m sure Dr. J had a million other things to do right then. I know it would’ve passed eventually and I’d have been fine eventually. But he came to me in that dark place, and helped walk me out of it. I can’t even recall everything he did or said. I just remember feeling unhinged before he came, and somehow afterwards I could remember where I’d started from and how far and how well things had come.

How do you say thank you for something like that?

All I could think to say, remembering the day I’d seen the brave woman on TV and finally admitted to myself I had a problem was, “Dr. J, you’re my hero.”

He looked a little confused for a second, a bit uncomfortable before replying, “But…you’re the hero. You’re the one doing all the fighting.”

Now how do you not love a guy like that?

Henrietta’s Still With Us

Henrietta’s Still With Us

HBO’s newest movie “The Immortal Life of Henrietta Lacks” (seen here)  tells how one woman’s death from cervical cancer in the segregated South of 1951 helped fuel generations of scientific discovery – though she never gave permission for her specimens to be used in this way.

 Here’re a few things to know:

  • Most cancer cells can’t survive outside the human body. Cancer cells are more fragile than most people realize, and can’t survive the harsh conditions in the test tube for very long. The vast majority of cancer cells harvested from patients die after only a few hours, but Lack’s cells (dubbed HeLa cells) survived indefinitely. This allowed researchers to observe multiple generations of cell division, and begin to understand that cancers evolve over time similar to the way species do. That’s what made the HeLa cells so unusually valuable.
  • In 1951, researchers didn’t need permission to obtain tissue specimens for research. When Dr. George Gey, a researcher at Johns’ Hopkins, realized the potential of Lacks’ uniquely aggressive cancer, he sent his lab technician down to the morgue to retrieve more specimens. It never occurred to either of them to ask for her family’s permission – and as distasteful as that seems to us today, informed consent wasn’t required for medical research until the the National Research Act passed in 1974.
  • Henrietta Lacks’ story wasn’t known outside of scientific circles until 2000. The story gained general notoriety with the publication of Rebecca Skloot’s book The Immortal Life of Henrietta Lacks (available here: https://www.amazon.com/Immortal-Life-Henrietta-Lacks/dp/1400052181/ref=sr_1_1?ie=UTF8&qid=1493146609&sr=8-1&keywords=the+immortal+life+of+henrietta+lacks).
  • The scientific community failed to protect the Lacks family’s privacy. Science can work very efficiently when information is openly shared. But since the genetic information about an individual or family can potentially lead to insurance discrimination, such data must be treated carefully. Unfortunately, details of Henrietta Lacks’ genetic information were widely circulated  on the internet before the need for this kind of discretion was generally appreciated – and it wasn’t secured until 2013.

Henrietta Lacks’ story holds special interest to me for a couple of reasons: first, I worked with the HeLa cell lines (among others) while a postdoctoral fellow at the Mayo Clinic; and second, a college friend of mine served as Johns Hopkins Medical Center’s official liaison to the Lacks family, and wrote a book about their reminiscences of Henrietta (which you can get here: purchase book).

I hope that Henrietta Lacks is somewhere, somehow aware of her rich scientific legacy – that her tragic and premature death from cancer has taught us how to save others – and that she’s managed to forgive science for its sins against her.

 

What More Can I Do? World Cancer Day 2017

What More Can I Do? World Cancer Day 2017

After a certain point awareness just wears us down.

Like comedian Doug Stanhope, when I see the ribbons and vigils and observances I sometimes think “could we be doing anything with less impact?”

In the last ten years I haven’t met anyone over the age of five who isn’t aware of cancer, so – check – mission accomplished.

But World Cancer Day asks for more than just awareness. It asks us to take actual steps to reduce the impact of cancer for ourselves, our communities – hell, our whole species. So as a part-time cancer caregiver (and a full-time mortal with a high probability of being an eventual cancer patient) I’ve come up with three areas to focus on:

Don’t tempt the gods 

We can’t be rid of cancer entirely, since it’s one of the ways our body naturally unravels, but too many of us are dying too young because of avoidable risks.

  • Obesity: we’re only beginning to understand how this works, but the link is beyond all doubt – and that’s bad news since obesity’s now a worldwide epidemic. The good news is this one’s still firmly in our control, if we can muster the will and discipline.
  • Alcohol: like many fellow cheeseheads, I sometimes overdo it. It’s not as much fun as it used to be, and it increases my risk of throat, liver, esophagus, and colon cancer 2-3 fold. Is it really worth all that?
  • Tobacco: I’m an ex-smoker who still misses it, so I get it, I really do. But there’s just no safe level of tobacco use. We can and should retain the right to make our own choices – but quitting is among those choices, and newer therapies make quitting more achievable than ever.

Stop pretending resources are unlimited 

Conservative estimates predict that by 2020 we’ll spend 39% more on cancer care in the United States than we did in 2010, to the tune of $173 billion dollars. (full article: click here) And though I’m no economist, I get the distinct impression that we just don’t have that kind of money to throw around anymore.

Yet every day I see unnecessary waste: labs drawn daily on hospital patients out of habit, PET and CT scans ordered when there’s no probability they’ll change our understanding, and expensive tumor genetics testing ordered when it can have little impact on choosing proper treatment.

So from now on I’m going to start each day by remembering what one of my medical school mentors used to say: “if you can’t explain in one sentence how a particular test could change your decision, you don’t need it.”

Earn back medicine’s credibility 

Medical professionals do not and have never deserved reverence or obedience.

In the Hippocratic tradition physicians were humble servants. But somewhere down the years we got a little too enamored of our growing knowledge, a little too excited by new tools and techniques, and a little too stuck on the idea of being saviors. Today, patients rightly fault us for communicating poorly, keeping them uninformed, and ignoring their priorities. Is it any wonder that most cancer patients use some form of (largely untested and unproven) complementary treatment?  Or that clinical trials participation is at an all-time low? Or that long-proven measures like vaccination are increasingly abandoned?

I need – we all need – to remember our place as physicians. We’re supposed to serve patients’ goals and priorities, not our own. We’re supposed to give ear to patient’s stories of their illnesses, and the meaning they make of them.

Though science does indeed have a powerful story to tell about cancer, physicians must earn back the right to tell it by relearning how to listen.

Financial Counselors: A Must Have in Oncology

Financial Counselors: A Must Have in Oncology

As an innovator in the oncology field, Green Bay Oncology

has created a solid financial counseling program to ensure that no patients have to carry the financial burden that may accompany a cancer diagnosis by themselves. By sharing our story, the financial counseling team hopes other cancer programs can benefit from our experiences to either develop their own financial counseling services or to enhance existing services.

Our Story

The financial counseling position at Green Bay Oncology began as a 1 person team 10 years ago when our group consisted of 7 physicians and 6 clinic locations.  At a time when prior authorizations for IV chemotherapy were still unheard of, the financial counselor’s basic responsibilities consisted of meeting with uninsured patients who needed to start treatment and working with the pharmaceutical companies to get free drug, if available. Over the next few years, however, the financial counselor position continued to grow along with patient demand and began to include assistance for oral anti-cancer agents as well.

Given the growing complexity of cancer care, along with the increase in the number and cost of oral anticancer therapies, it is no surprise that the financial counselor program quickly became an important part of Green Bay Oncology. In 2015, Green Bay Oncology aligned with Hospital Sisters Health System St. Vincent Hospital, becoming part of the regional cancer center and making us the largest oncology group in northeast Wisconsin.

Today, we have a team of 6 counselors assisting 9 medical oncologists, 3 pediatric oncologists, 3 radiation oncologists, 1 gynecology oncologist, 8 nurse practitioners, and 3 physician assistants across 6 cancer center locations in northeast Wisconsin and the Upper Peninsula of Michigan.
In our comprehensive cancer program, financial counselors follow patients from the start to the completion of their treatment journey and are an integral part of the patient’s experience. We act as a liaison between the patient, the provider, and other clinic departments, as well as the patient’s insurance carrier. Efficient communication between all of these individuals and departments is the core of our program’s success. Jerry WinklerWe are also fortunate to have providers who understand the key message concerning financial toxicity and its potential to impact patient outcomes.

“Medicine in general, and oncology in particular, used to believe that money shouldn’t be a consideration in treatment,” said Green Bay Oncology provider Mitch Winkler, MD. “This led us to act as if ‘money was no object’ where cancer treatment was concerned. We feared that considering financial factors would harm our patients or impede their care. But by neglecting financial factors in cancer treatment, we’ve exposed our patients to terrible harm.”

Our Process

The financial counselor’s job begins before the patient steps foot in our clinic. Acting as an advocate for patients, our benefits specialist will first verify their insurance benefits to ensure patients are in-network with our physicians.

Once treatment is prescribed, whether IV, oral, or radiation therapy, the financial counselor will immediately verify that the treatment is indicated for the patient’s diagnosis, checking the National Comprehensive Cancer Network (NCCN) Compendium and/or the Medicare Compendium.

Next, we verify whether the patient’s insurance requires prior authorization. If so, we initiate the authorization process immediately to ensure that treatment can start within three to five days.

Once we’ve obtained the authorization approval, we continue to follow the patient to ensure that if treatment continues longer than anticipated, the approval does not lapse. We are able to generate a notification in our electronic health record (EHR) that will alert us of an expiring authorization two weeks before the expiration date. We can then go into the patient’s chart and determine if re-authorization is needed.

For patients treated with oral therapies, our financial counselors initiate the first prescription fill with specialty pharmacy to verify insurance approval and make sure the medication is affordable for the patient. The financial counselors first meet with patients while they are in the clinic, explain how specialty/mail-order pharmacies operate and—depending on their insurance—discuss co-pay assistance.

After meeting with the patient, we fax the prescription along with the patient’s demographics, current medication list, and copies of insurance cards to our single point of contact at the specialty pharmacy. Because we have a pre-existing relationship with this point of contact, communication is often quick and easy, helping to ensure that the medication gets to the patient in a timely manner.

Our pharmacy contact will notify us if an authorization is required. Once we receive that notification we then submit to the insurance company for the approval. When approval has been obtained, we notify the pharmacy and the financial counselor is then given a date when the patient is scheduled to receive his or her medication. We then verify that the patient has an appointment scheduled for a toxicity evaluation within 10 days from the date the medication is received.

Financial Assistance for IV & Oral Therapy

If the physician is ordering a treatment that is not yet FDA approved for the patient’s diagnosis, or not indicated (i.e., off-label), we will always try to get approval through the insurance company first. If we receive a denial from the insurance company, we then go straight to the pharmaceutical company and apply to the patient assistance program in hopes to receive free drug assistance for our patients. We do not ask patients to fill out any patient assistance forms; all forms are completed and sent in by the financial counselor. All that is needed from patients is their signature and, if required, income documentation to ensure eligibility.

When patients are first diagnosed and prescribed treatment, one of their first concerns is usually “How am I going to afford this?” Most will have insurance to assist them with their treatments and appointments but, as we all know, the out-of-pocket maximums on insurance plans just keep getting larger. It is important to meet with patients before they start treatment and discuss cost and options to help alleviate any financial burdens of cancer treatment.

Depending on the type of treatment, we will go over options, such as foundation assistance on the national level (Patient Advocate Foundation, Patient Access Network Foundation, CancerCare, etc.) or on the local level. For example, in northeast Wisconsin we have some great local foundations, such as Ribbon of Hope and the Ovarian Cancer Community Outreach (OCCO), to help reduce not only treatment costs, but everyday living costs as well.

Once approved, we will add these foundations to the patient’s EHR and take care of all submissions for payment. Claims are sent to the foundation before patients receive a bill. This process is in place to alleviate as much of the financial burden as we can from patients in hopes of reducing any anxiety caused by additional bills and/or collection phone calls.

For commercially-insured patients who do not qualify for foundation assistance and/or for whom there are no funds available for their diagnosis, we will turn to pharmaceutical company co-pay cards. These drug-specific cards can be a great option for reducing out-of-pocket costs. There is no income limitation for these cards so long as patients give us their consent to enroll them; financial counselors can take care of everything, including submitting charges on their behalf.

In 2015 alone, we saved our patients $573,328.50 on their oral chemotherapy co-pays. This amount is only from three of the main specialty pharmacies we use: Accredo, Diplomat, and Community Pharmacies. Recently, in 2016, the financial counseling team worked closely with the hospital’s charity foundation and reached out to donors to create a specific fund for our patients on oral therapy that could be used when all other foundation funds were exhausted.

With the constant increase of insurance plans’ yearly out-of-pocket maximums, the amount of money our program saves our patients each year continues to grow. Figure 1, page 7, illustrates exactly what was paid to our clinic from foundations and pharmaceutical co-pay cards. This does not reflect the full grant amount that was issued to patients. In 2015, between IV and oral chemotherapy assistance, the financial counselors at Green Bay Oncology saved patients more than 1 million dollars!

 Financial Assistance for Radiation Oncology

Unfortunately the radiation oncology world is a little bit different in terms of financial assistance. There is very limited access to patient assistance for radiation oncology patients when it comes to treatment; for that reason we like to meet with these patients before they start radiation therapy.

Our financial counselors provide patients with an overview of their insurance coverage, including their out-of-pocket responsibility, what they’ve met, and how much they have remaining. Also, specific forms (see page 5) are given to each patient, depending on their type of coverage, i.e., commercial, Medicare Advantage, or Medicare and a supplement. This information helps give patients an idea of how much they may be responsible for.

We also talk to these patients upfront regarding payment plans, as well as Community Care/Charity Care if they feel this is something they would be eligible for. Patients are also made aware that a financial counselor will be given their treatment plan in order to verify that everything is indicated and authorized prior to their beginning therapy.

Due to the success of these forms in our radiation oncology department, our goal is to meet with and provide these same benefits to all patients in the medical oncology clinic by 2017.

At Green Bay Oncology, our financial counselors do not just handle the above-mentioned duties. Financial counselors are constantly involved in projects, creating new processes and building teams within other departments to continue driving our cancer program forward.

Financial counselors work closely with social workers and nurse navigators to make sure patients are taken care of both inside and outside of the clinic, including ensuring patients have all the necessary appointments scheduled, transportation to and from the clinic, or assistance to help with everyday bills that seem to take a backseat when medical bills start accumulating.

Our team also works with outside resources to enroll eligible patients in Medicaid. Financial counselors can also refer underinsured patients to the proper resources to gain the additional coverage they need going forward, such as Medicare supplemental plans and/or prescription coverage (Medicare Part D). The open communication between departments is a prime example of how our cancer program strives to always put patients first. Financial counselors work closely with physicians to develop and continually update clinical pathways. These disease-specific pathways help standardize our approach to how we treat our patients while showing payers that we are consistent in our treatment plans. Counselors verify that all treatments are listed in the NCCN Compendium while taking into consideration the cost of the therapy—not only for the patient, but also for the clinic.

The financial counselors are the patient’s direct point of contact for any and all billing concerns. Patients are instructed to call their financial counselor with any questions or concerns they may have once they start receiving bills. We work with patients to set up payment plans tailored to their comfort level.

Community Care applications are also given to patients once all other assistance options have been exhausted. Some factors taken into consideration while processing Community Care applications include annual household income, household size, assets and debt information, and the past three months of bank statements. Once the signed application and all required financial documentation are returned, financial counselors process these and inform patients of the amount of assistance for which they have been approved.

On top of all medication authorizations, including chemotherapy and retail prescriptions, our team also authorizes any radiology imaging that is ordered by providers, as well as molecular lab testing such as chromosome analysis, BCR/ABL, and JAK2 orders. It’s very important to verify coverage for any testing ordered by physicians to prevent that financial burden from falling into our patients’ laps.

When our clinic does receive a denial from a payer on any physician-ordered treatment, it is our financial counseling team’s responsibility to appeal. We will draft a letter to send to the payer along with all supporting documentation, such as compendium listings, FDA indications, insurance policies, etc. Our team is proud to say it’s not very often that the denials are upheld once our appeals are submitted.

Working for a hospital system that understands the need for financial counselors is imperative. We hear far too often while attending conferences around the region that cancer programs are trying to “prove” to their leadership that a financial counselor position is feasible. We think to ourselves, “What? You have to prove it?” Don’t the numbers speak for themselves? Institutions that do not think they need financial counselors should answer these questions:

• What does your Patient A/R (Accounts Receivable) stand at?

• How are your patients affording their treatments?

• How much are you writing off as charity?

• How many patients are you sending to collections?

Financial counseling is not only a service to assist the patients; it also guarantees the clinic is going to get paid. It’s 2017 and the cost of care is going to continue to climb. Committing as a practice or program to be financially responsible to patients has to be at the forefront.

By attending multiple ACCC meetings (the Financial Advocacy Network [FAN] Meetings, Oncology Reimbursement Meetings [ORMs], and the National Oncology Conference) our financial counselors have experienced ample opportunity for networking with other clinics across the country who have continually expressed their desire to learn more about our comprehensive financial counseling program. We have provided consulting services to several other cancer programs in Wisconsin and Michigan, helping them replicate our financial counselor position within their own program. ACCC meetings have opened our eyes to the fact that there are far too many cancer programs that are unaware of how they can help mitigate financial toxicity for their patients. It is vital for us to educate the cancer community on the importance of financial toxicity prevention. Won’t you join us?

Gretchen Van Dyck is a financial counselor, Green Bay Oncology at HSHS St. Vincent Hospital Regional Cancer Center in Green Bay, Wisconsin

To view the complete ACCC Patient Assistance & Reimbursement Guide 2017: click here

Dear Cancer Patient – Finishing Up

Dear Cancer Patient – Finishing Up

Dear Cancer Patient,

You probably thought this day would never come, but you’re finally finishing treatment. Well done!

You probably expected to feel only relief, but don’t be surprised if it’s mixed with a little anxiety. Treatment can become a kind of security blanket, a trusted shield against the cancer – and now it’s going away. Being on treatment made you feel safe, and now you feel unsafe.

But your treatment was meant to mop up the last traces of the cancer – nothing more, nothing less. You’re not really losing ongoing protection, you’re just losing the illusion of protection, just as you’ve been stripped of many illusions by this experience.

You’ll also probably want to ask me if it’s all really gone forever, if you’re “cancer free”, and what tests we’re going to do to find out. And I must tell you there is no possible way for us to know right now if you’re cured, or if you’re not. I wish there were. We can only know that we’ve done everything possible to cure you, and to secure your future cancer-free state. But we can’t know that future until it arrives. We’ll find out what that future is together, over time.

Can you still remember when you believed that cancer could never happen to you? It never entered your thoughts that those normal aches, pains, or energy lulls could be cancer – and of course they weren’t. But now, when those aches and pains come, cancer will cross your mind. Because you know now that such things are possible. You’ve lost the sense of safety you had before the cancer came, but that’s only because the idea of safety itself is an illusion – and it’s only the illusion that you’ve lost.

This is nothing to grieve, but it does take some getting used to. Living without illusions takes courage. Living without illusions is also known as wisdom, or so I’m told. I don’t know personally, because I’ve not had your experience yet. The only things I know about wisdom I’ve learned from you, and those who came before you.

It’s almost time for you to go, and I’d like to send you off with some impossible advice: take this experience and make it part of your identity, let it be written into your lines and verses; and also try to forget about it as soon as possible – it looms too large in your mind right now, and after all it’s only a few verses in a very long song.

I’ll be here if ever and whenever you need me. But right now I’m going to walk you to the door because it’s time.

Go now, and live.

Affectionately,

Your Devoted Oncologist