KUCC Delivers Cutting-Edge Care for Urban and Rural Populations

Providing cancer care in Kansas means treating both urban and rural populations, and each has unique challenges, explained the speakers at an Institute for Value-Based Medicine (IVBM) event cohosted by The American Journal of Managed Care and The University of Kansas Cancer Center (KUCC).

KUCC is not only the sole National Cancer Institute (NCI)–designated cancer center in the state, but it is also the only NCI-designated cancer center within a 3 1/2-hour plane ride of 90% of the individuals living in the continental United States, according to Roy Jensen, MD. Jensen is a professor of pathology and laboratory medicine; professor of cancer biology; the William R. Jewell, MD, Distinguished Kansas Masonic Professor of Cancer Research; director of the Kansas Masonic Cancer Research Institute; and director of KUCC.

KUCC is one of the newer NCI-designated cancer centers, earning the status in July 2022.¹ With more than 6000 institutions in the United States delivering cancer care, the 56 NCI-designed comprehensive cancer centers represent the top 1% of cancer care facilities, Jensen noted. Research has shown that, on average, patients have up to a 25% improved survival rate if they’re treated at one of the NCI-designated cancer centers, he added.²

“That is a stunning difference,” Jensen said. “Most people are taken aback by what a huge difference there is.”

The reason there is such a difference is that new treatments are being developed at NCI-designated comprehensive cancer centers. Cancer is no longer a “set science,” Jensen explained. Although there is still a long way to go before there is a possible cure for every patient with cancer, he said, these NCI-designated centers are “on the cutting edge” of cancer treatment development.

Offering cutting-edge care and research is not enough, Jensen said, because 1 out of 2 men and 1 out of 3 women will develop cancer, and those numbers are on target to increase significantly by 2050.³

The population of individuals 65 years or older is increasing, which contributes to the growing prevalence of cancer, Jensen said. In addition, he noted, approximately 3 of 10 patients who receive cancer treatment will die within 5 years.⁴

“If anybody thinks that we’ve got this cancer problem solved, it couldn’t be further from the truth,” he said. “We have a long, long way to go. So what does that mean? Well, I think it means this is the time to change our approach. We’re not going to cure…all of these diseases without a new approach and new thinking.”

Obtaining the NCI designation was about serving the region in a practical way, since not everyone lives in Kansas City or even within a 25- to 50-mile radius of the city, said Gary Doolittle, MD, the Capitol Federal Masonic Professor of Medicine in the Division of Oncology at the University of Kansas Medical Center. Doolittle also is the medical director of the Masonic Cancer Alliance (MCA); vice-chair of education in the Department of Internal Medicine; and assistant dean for the Office of Medical Education.

“Just because you live in the rural sector doesn’t mean you don’t want excellence in your cancer care, right? And it doesn’t mean you don’t want access to the kinds of care you can get at a comprehensive cancer center. So part of our goal was to make sure that we build strong relationships in the region,” he said.

When practical and possible, the best care is delivered close to home for patients. Someone receiving standard therapy shouldn’t have to travel to Kansas City for chemotherapy or immunotherapy. As a result, KUCC created the MCA, an outreach network of the cancer center that strives to enhance care in the region by partnering with health care providers.

KUCC is based in an urban area and cares for an urban underserved population with diversity and inclusion issues, but its staff also cares for patients in the western half of the state who live in frontier counties with a population of 6 or fewer individuals per square mile.

The MCA helps KUCC take care of the rest of the state away from the main campus. When MCA was getting started and there was a listening tour through the state, one thing that came through loud and clear was that there are patients in rural Kansas with incurable cancer for whom standard therapy isn’t the right treatment, and they need access to clinical trials.

Through MCA, KUCC also offers a second opinion for member sites. Doolittle will consult at member sites for challenging melanoma cases, but he said he’s “always impressed with what our partner physicians and advanced practice practitioners know about the care of a [patient with] melanoma.”

In addition, there are also consultations going on between cancer surgeons, genetic counselors, and psychosocial support. “I don’t think you can overstate the importance of the collaboration that goes on,” Doolittle said. “It is challenging to practice medicine in the rural sector. It is not an easy job.”

Joaquina Baranda, MD, professor of medical oncology and medical director of the Early Phase Program at KUCC, discussed bringing early phase 1 and phase 2 trials evaluating new drugs or new combinations of drugs to underrepresented populations. These early trials aim to determine safety and recommended dosing of drugs, but they can be complicated and put too heavy of a burden on patients who need to make more frequent and longer clinic visits.

“Many of these trials are actually performed only in larger cancer centers that are located in the metro area,” Baranda explained. “So these kinds of clinical trial practices actually perpetuate that burden that we give these already disadvantaged, underrepresented populations, and also, it puts into question the generalizability of some of the results of these trials if we are not including the patients from underrepresented populations.”
She outlined the program created by the NCI called Create Access to Targeted Cancer Therapy for Underserved Populations (CATCH-UP.2020), which was designed to “enhance access to targeted cancer therapy for minority/underserved populations” through grants to 8 NCI-designated cancer centers.⁵

The cancer centers that received the grants had to enroll a minimum of 24 patients each year to trials in the NCI Experimental Therapeutics Clinical Trials Network, and at least half of these patients had to be from an underserved population.

Continuing the theme of working with the local community, Hope Krebill, MSW, BSN, RN, assistant director of community outreach and engagement at KUCC, discussed Patient and Investigator Voices Organizing Together: Engaging Community and Patient Research Partners (PIVOT), a patient research advocacy program.

PIVOT has a community advisory board that meets 4 times a year to meet with KUCC leadership regarding research priorities, community outreach activities, and community concerns. The advocates involved with PIVOT include cancer survivors and family members, partners, and friends of survivors.

Within PIVOT there are teams to engage with researchers and allow the researchers to bounce ideas off the advocates prior to a research proposal being sent out. These meetings allow researchers to get a better understanding of a collective experience.

“This really allows the researchers to prioritize their topics, hone the research questions, really look at the patient burden that comes up a lot with the study procedures, or even the patient burden after…treatment,” as well as improve recruitment and retention in trials, Krebill said.

Once treatment is complete, there are considerations for survivorship for individuals living in rural counties, noted Jennifer Klemp, PhD, MPH, MA, professor of medicine in the Division of Medical Oncology, director of Cancer Survivorship, co–program leader for Cancer Prevention and Control, and coleader of the Cancer Care Delivery and Health Equity Disease Working Group at KUCC.

With precision medicine allowing for a more targeted treatment of cancer, a similar model needs to be created to treat those patients, whether they are cured of their disease or will go on to receive treatment for the rest of their life.

For rural patients, access is just one issue to deal with in survivorship. Social determinants of health are unique in rural areas and sometimes worse. Financial toxicity is a big problem. Rural patients also are less likely to get preventive care, Klemp noted.

“Another thing that we tend to see is that patients may choose more aggressive therapies, where a patient who could have a lumpectomy may opt for a mastectomy, because driving for radiation therapy may be a barrier in regard to not only time away but also the distance from that care,” Klemp said.

It can also be very difficult for rural primary care to identify patients with a history of cancer if they don’t have sophisticated electronic health records that include that information.

Utilizing Project ECHO, KUCC was able to create a virtual community of practices to go over issues, increase access, and improve care. Project ECHO was launched in 2003 by Sanjeev Arora, MD, FACG, MACP, and it provides telementoring with specialists consulting with primary care physicians to share knowledge.⁶

KUCC focused on the 4 most common cancers in the state (breast, colon, lung, and prostate cancer) during Project ECHO, using local subject matter experts and real-life case studies for teachable moments and to show primary care physicians what they can implement in everyday practice.

The IVBM event ended with a panel discussion of cancer treatment advances at KUCC with Mazin F. Al-Kasspooles, MD, FACS, professor of surgery in the Division of Oncologic Surgery; Anurag K. Singh, MD, associate professor of hematologic malignancies and cellular therapeutics; and Ronny Rotondo, MDCM, FRCPC, associate professor of radiation oncology and medical director of proton therapy.

Although cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) have both been around for a long time, mainly used for certain low-stage appendiceal cancers, the indications have broadened significantly, said Al-Kasspooles, who treats patients with peritoneal carcinomatosis.

Approximately 20% of patients with colorectal adenocarcinoma are candidates for HIPEC, and HIPEC has been shown effective in ovarian cancer, he noted. There is also a clear benefit when HIPEC is added to cytoreductive surgery. However, cytoreductive surgery is very difficult because it requires going in to get all the cancer out, even in instances where there are hundreds of tiny tumors. These procedures can take as long as 18 hours, he noted.

Proton therapy more effectively concentrates or targets radiation to significantly reduce the amount of radiation delivered to surrounding healthy tissue, Rotondo explained. Proton therapy, he said, marries the 3 missions of KUCC: delivering the most advanced and cutting-edge cancer treatment, conducting research to advance the field of cancer treatment, and training the next generation of cancer doctors with the latest technology and innovations.

Since KUCC began treating patients with proton therapy nearly 2 years ago, more than 250 patients have received the therapy, and one-third of those were younger than 35 years.

KUCC also is using chimeric antigen receptor (CAR) T-cell therapies to treat patients. The first patients treated with CAR T-cell therapy were in clinical trials in 2015, with patients coming from Australia, Belgium, and Canada, Singh said.

More trials are looking to not only move approved CAR T-cell therapies into earlier lines of therapy but also to expand their indications, he said. There is research into using CAR T-cell therapies for patients with solid tumors and even diseases other than cancer, such as neurology and autoimmune diseases. Singh recently saw a patient being treated for myasthenia gravis.

“We’re scratching the surface of these T-cell [therapies],”
Singh said.

But there remain important challenges, particularly for KUCC and its rural populations, because patients have to travel to Kansas City, which could be as much as 7 hours away. In addition, physicians in the community might not know all the adverse effects to watch for with CAR T-cell therapies.

The big problem, though, is late referral to CAR T-cell therapy, Singh said. “We have been working with the community and our colleagues throughout the state to address some of these issues,” he said. 

References
1. Hawes K. The University of Kansas Cancer Center earns National Cancer Institute’s most prestigious status — comprehensive. The University of Kansas Cancer Center. July 7, 2022. Accessed January 27, 2024. https://bit.ly/47YFDco
2. Onega T, Duell EJ, Shi X, Demidenko E, Gottlieb D, Goodman DC. Influence of NCI cancer center attendance on mortality in lung, breast, colorectal, and prostate cancer patients. Med Care Res Rev. 2009;66(5):542-560. doi:10.1177/1077558709335536
3. Hayat MJ, Howlader N, Reichman ME, Edwards BK. Cancer statistics, trends, and multiple primary cancer analyses from the Surveillance, Epidemiology, and End Results (SEER) Program. Oncologist. 2007;12(1):20-37. doi:10.1634/theoncologist.12-1-20
4. Cancer stat facts: cancer of any site. National Cancer Institute. Accessed January 29, 2024. https://seer.cancer.gov/statfacts/html/all.html
5. Create Access to Targeted Cancer Therapy for Underserved Populations (CATCH-UP.2020). National Cancer Institute. Updated November 1, 2022. Accessed January 30, 2024.
https://ctep.cancer.gov/initiativesPrograms/etctn_catch-up2020.htm
6. Dr Sanjeev Arora explains the origins of Project ECHO and improving access to care. AJMC. November 2, 2018. Accessed January 30, 2024. https://bit.ly/3udFy72