Miscellaneous
Dr. Pennell and Dr. Jan Franko discuss Dr. Franko’s article, “Effect of surgical oncologist turnover on hospital volume and treatment outcomes among patients with upper gastrointestinal malignancies” 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. Today, I'd like to talk a little bit about the impact that physician shortages can have on cancer care in the United States. While there are some parts of the country, for example Boston or New York, where you can't turn around without tripping over a specialist in some field or another of medicine, for much of the vast geographic expanse of the United States, especially outside of larger cities, there's areas that lack adequate specialty physician coverage, perhaps having either small numbers or even a single practitioner covering large areas. Now, this is very important for patient care because most cancer patients get their treatment in community settings closer to their home and not at large academic centers. But how does this impact care when, for example, specialized surgical services are needed, and no one's available close to home? With me today to discuss this topic is Dr. Jan Franko. With me today to discuss this topic is Dr. Jan Franko, Chief of the Division of Surgical Oncology at Mercy One Medical Center in Des Moines, Iowa. We'll be discussing his paper "Effect of Surgical Oncologist Turnover" on hospital volume and treatment outcomes among patients with upper gastrointestinal malignancies, which is currently in press at the JCO OP. Welcome, Dr. Franko. And thank you for joining me on this podcast. Thank you for this opportunity, Dr. Pennell. It's my pleasure. I do not have any conflicts of interest with this work. Thank you for that. So we hear in the media about shortages of physicians, especially in underserved areas. How common would it be that a larger community hospital would lack access to, say, a surgical oncologist? Well, I did not really research that. But just to give you an example, the city where I practice currently has about 750,000 people with surrounding suburbs. And we had a shortage of surgical oncologists for about two years. But I can recall that one of the large hospital systems lost an entire radiation oncology department. So for nearly two years until they hired three new radiation oncologists, they actually could not do any radiation. We, ourselves, have been a flagship for many decades for gynecology oncologists. We lost one about three or four years ago. And since then, we can't hire. And on top of that, I recall that about three years ago, we had one year when 90% of urologists left the town. After 12 urologists, about eight or nine had to leave. And they came back for a different practice within the same locality, but it was about a year plus without adequate urology work. So these things do happen. No, I can imagine, especially for specialties that are relatively small to begin with. And just to put this in perspective, can you explain a little bit about what exactly is a surgical oncologist? And how does that differ from, say, a general surgeon who may also do some cancer surgeries? So, thank you for this question. I, myself, am a surgical oncologist. And I suspect there will be a lot of different definitions. For me, it would be a general surgeon who is focused on a cancer treatment. General surgeons do treat both cancers but also trauma and general surgical conditions, [INAUDIBLE] gall bladders, hernia. But a subset of surgeons have focused on cancer. And the majority of those have accredited fellowship. These surgeons, in my opinion, should maintain a broad spectrum of practice, for example, not only liver and pancreas, but liver, pancreas, and stomach and esophagus and other organs. And what's also very important for them is to cultivate a multi-specialty understanding of how to transition the care between an operation's systemic therapies and radiation oncology so they can maintain that momentum of cancer control and smart means of surgery or avoid an operation, and when it comes to the question, be able to execute even complex operations. And given the complexity of cancer care these days and how multidisciplinary it is, I would imagine that most surgical oncologists are centered around academic university hospitals as opposed to working out in perhaps more rural areas or community hospitals. Is that the case, or are they pretty much available everywhere? So, indeed, you are right. It, in fact, was published in the Annals of Surgical Oncology around 2018 and 2019 that an absolute majority of surgical oncologists are centered at the university hospitals or NCI-designated cancer centers. The number varies. But, for example, in Iowa, more than 80% of such a workforce is concentrated in the single university center, which is outside of our town. And that number ranges from approximately 65% up to 90% of surgical oncologists working from the university, not a community hospital. That makes sense. And so if you were a patient who needed specialty surgical care for, say, pancreas cancer or esophageal cancer and you didn't have a hospital with a surgical oncologist nearby, what do they usually do? Is this something that's handled by a local surgeon, or do they travel to academic centers to get that care? So this is subject of lots of research. And I think that is a dramatic geographical variation. And also, there is a variation depending on the patients and their socioeconomic status and understanding of the situation. Plus another question which is not discussed, how long is it reasonable to travel? How far? So I do think that complex surgical therapy should be done by people who do have experience in that. And what is experience that can be defined by a number of cases? But does doing 10 pancreases improve you operating on the stomach as well, I would believe there is some degree of cross-fertilization. Is it reasonable for people to travel for an operation 100 miles, 150, 200? It's probably not reasonable as long as they get quality care closer to home. Yeah, it certainly would put a burden on them. And you could think that their follow-up care might be compromised by being so far away as well. Yeah, I agree with that. One has to understand that the discharge from a hospital after operation by far doesn't mean end of the surgical care, or at least it should not. Patients are these days discharged from operations very quickly. There are various tricks. Sometimes surgeons let them stay in a town in the hotel, which I don't know how good a discharge that is. But then coming back for unexpected postoperative, whether complications or troubles, which do not amount to major complications, that has to be readily available. So there are mechanisms how people can do that. But can you really do it on a distance of 100 miles? That remains to be proven. And we will have to ask the patients who do that and what resources they have. Do they have family members who can actually travel with them? Not everybody does. And, of course, as you mentioned before, this is a very multidisciplinary field. And so you also need to have your GI physicians doing the EOS. You've got your radiation and medical oncologists giving neoadjuvant or adjuvant treatment that you would want to coordinate with. So I can imagine that would also be difficult for patients coming from another state, for example. Yeah. Indeed, this must be difficult why it could be organized for very defined, this acute element of care, either before the operation, during operation, or at a time of very intense neoadjuvant therapy. It's hard to imagine that all of the issues would be able to be solved locally. And we do know that whether it is related to the operation latency [INAUDIBLE] or [INAUDIBLE] of chemotherapy or radiation, there's still becomes some troubles in survivorship of these patients. And it's best that the qualified surgeons are relatively close. Obviously, the question is, what is relatively close? 20 miles travel for most people is not a big deal. But it has been described that for some people it is a big deal. Well, 20 miles in Boston is different than 20 miles in Iowa. And 20 miles is not considered distance in Iowa. And probably 100 miles is not considered a distance in Texas. But it still puts a burden. No, absolutely. Well, with that in mind, can you take us through your study? What were you trying to show? So, thank you. This was almost a classical before-and-after study. But it was not only before and after, it was before we lost surgical oncologists, and the short period of time that we did have it, and the latter period of time when we actually regained surgical oncologists, which is how I came to the local practice. And I'm still practicing here for about 12 years. So the whole study spanned over about 15 years between 2001 to 2015 and looked at the patients who are typically taken care of by a surgical oncologist and not focusing on the technically rather simpler procedures like the skin cancer. So we focused here because of complexity and inherent risk on esophageal cancer, gastric cancer, and pancreatic cancer. For the ease of this study, we looked at carcinomas only and excluding neuroendocrine tumor, benign conditions, gastrointestinal stromal tumors and others. And we only focused on those conditions which could be potentially resectable because otherwise there is no particular influence of surgical oncologists for a majority of therapy. So, for example, if it was a gastric cancer, but looked at stage I through III, and for pancreatic cancer, on stage I through II because stage III, in general, historically was never really considered for an operation. It might be changing currently, but it was not in the past. So in 2006 our prior and very excellent surgical oncologists simply retired. And over the next two years, very clearly there was no surgical oncologists in the hospital. And they observed a proportion of these diagnoses. And they observed that during the time there was no identifiable surgical oncologist responsible for advising and executing surgical care on those patients, the number of referred cases dropped dramatically down. So it went down from about 12.2% of these cancers diagnosed within this hospital as compared to the state to down to only about 6.7% of all stage cancers being diagnosed in that particular hospital, which at that time was missing surgical oncologists. Once the new surgical oncologist, which was myself coming back, were able to [INAUDIBLE] work of services or perhaps the confidence of referring physicians in the society at large better, and they returned back to these prior numbers, again, diagnosing and treating approximately 12% of the state volume of these neoplasms. We also wanted to see that it could not compare that to a SEER database within the State of Iowa, that the-- well, we asked the question, did the number of these cancer for those two years somehow decrease in the State of Iowa? And it did not. So at the state level, there was a maintaining-- maintaining of the trend of the annual diagnoses. But in the particular hospital, they were not apparent there. So we assumed that they out-migrated to other institutions. And empirically and by discussion by other physicians who were here understand they clearly outlined credit to different systems and out of town, but they were simply not present at this hospital. We looked at the overall survival as perhaps the most important measure of efficacy of therapy. And we were able to restore the surgical oncology quality to the point that survival after that new surgical oncologist came close not worse, perhaps it improved in some situations. And there also was a higher proportion of patients undergoing multidisciplinary therapy. Now, that means either chemotherapy or radiation or combination of those in addition to surgery. That would be an expected trend over the last 15 or 20 years. But it was very reassuring we could actually see it to be restored back once the surgical oncologist services became available. So that's probably the main conclusion, services could be restored. I think that's a great way to illustrate what happened there. So I'm curious about what happened to those patients in that two-year period. Now, you say that anecdotally, they were referred out. There were some patients who still got their surgical care, though? Was there any change in outcomes for the people who continued to get care, I guess, through some of the other-- perhaps the other surgeons that were not specialists in cancer care? So this is a very enticing question. And I chose after considering not to look very deep into there because while it is an enticing question, there were just simply not enough patients to make a reasonable conclusion. Now, we pulled in here esophagus, and gastric, and pancreatic cancer together. It was only a two-year period of time. So we got down to about less than 40 cases treated in here. So if we divided by stages by different disease sites, I don't think it could make a justifiably reasonable valid data. So very enticing, but I chose not to look in there without good data. Yeah, fair enough. And there's probably no other way to really look to see what the outcomes were for all of the patients that normally would have gotten their care there. I don't know if there was any change in the overall state outcomes during that two-year period. You certainly have a sizable chunk of the total state cases treated at your center. Well, interestingly, and we have to discuss, but on figure 1 within the article itself, there is a proportion of annual cases diagnosed in the state and also operated in the state. And that's a fairly steady, very minor increase over the years. But a very steady line, there was no drop within the annual cases referred to the SEER database in Iowa state. So really this is one of the, which I would consider, the strength of the study, the proper selection of one or more controls. And in here, the have the ability by a SEER state database to compare the outcomes to geographically similar patients and also contemporary at that particular time. So when we took to patients from our hospital, let's say between 2001 to 2007, we also compared those to patients in the State of Iowa where this hospital resides. So a geographically similar population in the same time period are very important to compare for the trends. It did not compare it to populations which are geographically or time very different, which would introduce bias. And how well do you think the overall state SEER numbers reflect the real results that you would see in your patient population there? I think it reflects very tightly a very valid reality. SEER has been demonstrated on a nationwide level to be-- to be very effective and very precise with a very low rates of the errors. Interestingly, and many don't know that Iowa was one of the original states where the SEER database has been established and participated in the program since 1973. And to some degree, it, could be given by the fact that there is not too many hospitals which actually have cancer registries. So in reality, you don't have to train that many registrars. But those registrars and individual cancer centers actually support both the SEER database and other databases, including the National Cancer database. So there is historically for perhaps some nearly 50 years of consistent reporting of the data. So I have a lot of trust into data reported, especially from Iowa SEER segment. No, it sounds like that in your case in particular is a reliable-- reliable database to compare your outcomes to. In the paper, I noted that you, over time, as we get closer to the modern time, that the outcomes seemed to improve. Is that-- or at least compared to the time before the previous surgical oncologist was there. Is that because the new surgeon was more skilled, or is it that outcomes just overall are improving as we-- as we move on and have new treatments? I think it's completely explained by the overall improvement of care over the years, a multidisciplinary statement. I had a distinct pleasure to, for about two or three operations, operate with that surgeon who continues to work now, in his mid 70s, on the minor procedures. And that's an excellent surgeon that definitely could observe it. So while many like to think that it is because of one person or one surgeon, it is not one surgeon. It is really the whole system maintained adequacy compared to improvements, which we experienced over the last 15 years in the care overall. So I think it's the whole team, as would be expected to get better over time. So I think you did a very nice job of illustrating the major impact that losing a surgical oncologist has on a health system, dramatic changes in the numbers of patients treated and over time. So is there a message that health systems who maybe have only one or a couple specialists in various fields can take from this? How should they be addressing potential loss of their relatively small numbers of crucial specialists? I think this is a great point. And all of that kind of advice would be consideration and planning. And while I do think that some specialties with low frequency of practitioners, like surgical oncology, are at risk, but there are many other specialties. And in fact, every single specialty could be at some degree of risk because I'm a medical oncologist. The level of the knowledge which is required to practice with evolving molecular studies and immunotherapies is enhancing, essentially doubling every year or two. So sub-specialization within even medical or radiation oncology is also ongoing. So I think every health system is at the risk of losing some portion of its common skill if the key individuals do leave. So surprisingly, as I mentioned at the early part of our podcast, we actually lost in, not in our hospital, but another large hospital, an entire group of radiation oncologists, which is hard to believe that it occurs in a city of 750,000, but it did happen. So I think that planning and perhaps more research and attention into who delivers care, not only how, but who delivers care, into how do we cultivate our pattern of nurses, physicians, nurse practitioners, or extenders becomes extremely important, and perhaps at least as important as the buildings because it's really the professionals who create the program. And those gaps-- I definitely experienced this gap as I came. And I thought I would take over a working practice. There was no practice. That is not necessarily important about me, but what about the community which actually experienced this decline? And I would, though, submit that every health care system in some form or another, whether large or small, is in some degree of a risk if they do not address the planning and the career transition of the services which are often perceived as granted and available until they also do them if you're not present, so planning purposes. Well, I guess it's reassuring, at least, that you found that there wasn't clear evidence of harm to the patients during that period, that they were able to find care elsewhere. Although, as we discussed, it probably was somewhat of a burden and perhaps less than ideal. Yeah. I think, though-- yeah, on a second thought, I really do think the ability to restart the program exists. Now, obviously, can the program be restarted after two years, after one year, or after five years? Well, what does it take to restart the program? And perhaps there could be a bias. Let's say that myself and the colleagues are not successful to restart this program appropriately, we probably would not be able to publish it. So there might be a publication bias to the programs which we just don't hear about, and it fades into dark history, and again, to the detriment of the community if those programs have occurred. Well, I do think-- I'm not an expert in this area, but consolidations of health systems and physician practices, and, of course, there's lots of things in the press about smaller community hospitals going out of business because they're not as profitable. And so, I think it would-- this kind of research being able to study that it's possible to have an effective program and to build it from scratch when it's missing is an important thing to illustrate. Yeah, I agree with that. I really do think that looking into bibliography and what has been published about it, there's surprisingly very little understanding about the staffing. But the staffing is an issue. We empirically perceive it in many hospitals. With talking to colleagues at the congresses, it becomes very clear that there is some staffing problem almost at every place more or less intense. So to really maintain the skill, a lot of a specialty, it takes a lot of effort. And I think this responsibility has to be shared between the professional physician leadership and the administration leadership because it really can have consequences both for the cancer center and the hospital decreased presentation of the patients, that have substantial downstream revenue. And, who knows, there could be easily programs which were successful and they aren't any longer here with resulting detriment to the community where they have existed before, which is hard to replace with a very long travel. So while travel is desired for high quality care, the question is, how much of a travel? And what conditions is reasonable? Is 100 miles reasonable to travel for chemotherapy every week? Is 100 miles one time reasonable to travel for a big operation? I think those questions may be different from geography to geography, from disease to disease, and perhaps even from a patient to patient. Other patients who come to see me travel for two and 1/2 hours. In the State of Iowa, we don't live in a rural town, but we are surrounded by a rural area. And they travel two and 1/2 hours. That has to be taken into account of how to take care of them and how to deliver the care, including with any troubles after operations or chemotherapy. So it's a different set of complexities, though probably less than perfectly recognized in the literature. No. When you say it, it seems very obvious. But you're right, I bet that's not something that people have published a lot on. Well, I think we've certainly talked for enough to fill our podcast. Is there anything that we didn't get a chance to talk about that you wanted to make sure we addressed? No. I just got these questions. So thank you for emailing so I run in here, I'm ready for them. And I prepared myself about as good as I could, which I'm sure-- and thank you for the time. As you know, this is nothing what I typically do. I have to take care of the patients, or I love to publish something, but this is my first podcast. Now, there's one more thing to perhaps discuss, Dr. Pennell. I have a little note in here. When we discussed what does it-- I think this is a great question. Who is it, and what is a surgical oncologist versus a general surgeon? The one additional element which is often not appreciated is that surgeons and/or surgical oncologists are now faced not only with what used to be open operation and how to integrate with the multi-modality therapy, but there is a completely different type of operating, including laparoscopy robotic operations, which are complete different platforms. So for me to perform laparoscopy versus robot versus open operation, this is three different things. And that's probably too much to discuss, I would say, in general oncology practice. This is more of surgical aspect that it is amazing to see that a burden would needed to take care of the broad spectrum of the cancer from breast to thyroid to esophagus to pancreas to [INAUDIBLE]-- I do cytoreductions. And I actually do those both laproscopically open and robotically. I mean, where does it end? It probably doesn't end. But I don't think that this component of-- so yeah, I don't know. No, but I think what you're describing is a phenomenon. Certainly we see that in medical oncology. There's just too much now. You can't-- I realize that lots of people still are general oncologists, but even in private practices, people tend to segregate towards treating just a couple of different diseases because it's so hard to know how to do everything now. And I'm sure that that's true in surgery as well. Yeah, it is-- I just can't believe how much is coming out. I do read a little bit about the immunotherapy, systemic therapies. I do have to have some degree of knowledge of that. But what happened in the last three years is absolutely astonishing. I had no idea how people can keep it together. And they have similar challenges. I mean-- I have operated open operation and then robotically. And how to choose or not to choose one, it's completely different approaches. Wisconsin is very different. But I guess that what we have to do. No, it is. So we'll do that. So if it's OK with you, I'm just going to wrap up. Dr. Franko, thanks so much for joining me on the podcast today. Thank you very much, Dr. Pennell. It was my pleasure. And for the listeners out there, until next time, thank you for listening to this JCO Oncology Practice podcast. If you enjoyed what you heard today, don't forget to give us a rating or review on Apple podcasts or wherever you listen. While you're there, be sure to subscribe so you never miss an episode. JCO OP podcasts are just one of ASCO's many podcast programs. You can find all recordings at podcast.asco.org. The full text of this paper will be available online at asco.org/journal/op. This is Dr. Nate Pennell for the JCO Oncology Practice signing off. OK, that's it. Thank you very much. I think you did great. Nope, thank you very much. I will miss it. Thank you. Have a great day, and stay safe. You, too. Bye bye. Yeah, bye.