Quality and Outcomes Research in Head and Neck Cancer: From Bench to Bedside with Yale Leading the Charge

Transcript

• 00:00Hi. Welcome everybody.
• 00:01I'm Barbara burtness. I'm a.
• 00:03Medical oncologist and work on
• 00:05head and neck cancer and I'm
• 00:07really like I could not be more
• 00:10extraordinarily delighted than I
• 00:12am to be today presenting Dr Saral
• 00:15Mera as our grand round speaker.
• 00:17Doctor Mehra is an associate professor
• 00:19of surgery in otolaryngology and
• 00:21Section chief of head and neck surgery.
• 00:23He received his medical degree from
• 00:25Columbia University College of
• 00:27Physicians and Surgeons in New York,
• 00:29also obtained an MBA there and went
• 00:31on to residency in Otolaryngology
• 00:33Head neck surgery at New York
• 00:35Presbyterian Memorial Sloan Kettering,
• 00:37and then completed his training with
• 00:40a extremely coveted fellowship in
• 00:42head and neck and thyroid cancer
• 00:44surgery at Mount Sinai,
• 00:46including Subspecialization in
• 00:48complex reconstruction.
• 00:50His clinical practice focuses on
• 00:52treating patients with head and
• 00:54neck salivary and thyroid diseases,
• 00:56particularly those patients who
• 00:58need a very advanced resection
• 00:59or advanced reconstruction.
• 01:01And I've been privileged to share
• 01:03many hundreds of patients with him.
• 01:04And I can like very personally say
• 01:07his oncologic and reconstructive
• 01:09outcomes are exceptional.
• 01:11And so his primary research
• 01:12interest ties in this very nicely
• 01:14because he focuses on measuring and
• 01:16improving quality in the treatment
• 01:17of head neck cancers and I think
• 01:19one of the central conundrum.
• 01:21Our field is how do we take exceptional
• 01:24care and and broaden its accessibility
• 01:27and broaden its applicability.
• 01:28So he's going to be talking about
• 01:30quality and outcomes research and
• 01:32head neck cancer from bench to
• 01:34bedside with Yale leading the charge,
• 01:35Cyril.
• 01:41Thank you so much for that
• 01:43introduction Barbara and thank
• 01:44you everybody for logging in and
• 01:46and and listening to this talk.
• 01:48I know it's a diverse group of basic
• 01:51scientist clinical researchers
• 01:52and hopefully some outcomes
• 01:54researchers out there as well.
• 01:56So that's my topic.
• 01:59It's been discussed.
• 02:00Just make sure this is working.
• 02:14OK, so I have no I have
• 02:16no financial disclosures,
• 02:17so I couldn't do a head and neck
• 02:19research talk without mentioning 2
• 02:22important studies recently published,
• 02:24ECOG 3311 and keynote O48,
• 02:25of which Yale specifically Doctor
• 02:27Burtness was lead author on both of
• 02:29these very different types of studies.
• 02:31But these are practice changing
• 02:33studies recently published.
• 02:35Um ECOG 3311 looked at T1 and T2
• 02:38resectable HPV positive oropharynx
• 02:41squamous cell carcinoma and
• 02:44keynote O48 looked at locally
• 02:45the opposite end of the spectrum,
• 02:48locally incurable recurrent or metastatic
• 02:50head neck squamous cell carcinoma.
• 02:52What I've put up here,
• 02:54I'm not going into details of these studies,
• 02:56but what I've put up here are
• 02:59survival curves from these huge.
• 03:01Hugely important recent practice
• 03:03changing studies, OK,
• 03:04I'm not going to get into details
• 03:07about these over the next 45 minutes.
• 03:08What I really want to do though is
• 03:10convince you of two things and I think
• 03:12I may have already done the first one
• 03:14because it doesn't take much convincing.
• 03:16Large scale multi institutional
• 03:18randomized control trials are important
• 03:20and they can lead to practice changing
• 03:23innovations in the care of cancer patients.
• 03:26Any cancer, I'm going to put a
• 03:29check mark beside that already.
• 03:31Based on that first slide and
• 03:32which you probably already know,
• 03:33but really what I want to do
• 03:35is tell you that the quality,
• 03:37that quality of care research
• 03:39or call it what you will,
• 03:41patient reported outcomes reaches
• 03:44patient centered outcomes research.
• 03:47Comparative effectiveness research goes
• 03:48by different names at different times.
• 03:51But when you can take this from
• 03:53the bench to the bedside,
• 03:55we can have a remarkable impact
• 03:57on patient outcomes.
• 03:58And not only that but this type
• 04:00of research is actually necessary.
• 04:02For I'll put in quotes the real
• 04:04science to mean anything.
• 04:06That's the basic scientist,
• 04:08the clinical trials.
• 04:10That's what I want to convince you of.
• 04:11By the end of this talk,
• 04:13I'm going to start with a case.
• 04:15This is a 52 year old man.
• 04:16This is actually very recent.
• 04:20And within our system,
• 04:21OK, the very recent case,
• 04:2352 year old man never smoker 2.9
• 04:26centimeter right neck mass and a
• 04:28right tonsil mass was seen in our
• 04:31system and had a right tonsil mass.
• 04:33Biopsy showed poorly differentiated
• 04:35squamous cell carcinoma and the P-16
• 04:38stain was strongly and diffusely positive.
• 04:41The patient went for surgery.
• 04:45And what the pathology identified with
• 04:47the tonsillectomy and a neck mass
• 04:49excision was a P-16 positive cancer,
• 04:523 centimeters extending to the
• 04:54margins of resection and a 2.7
• 04:57centimeter node with no ENE.
• 05:01And a few other nodes also that
• 05:03that came with the specimen.
• 05:04So this patient was then referred
• 05:06for radiation and chemotherapy.
• 05:07There's a positive margin.
• 05:10The guidelines say radiation
• 05:12chemotherapy was then re referred
• 05:15to but by care center physician
• 05:18to the head neck disease team at
• 05:20the at at the Big House.
• 05:22And this was interesting because
• 05:24a few things first of all was
• 05:26staging completed prior to treatment
• 05:27was one of
• 05:28the questions that came up
• 05:30when they were discussed.
• 05:31And the answer was no.
• 05:32And then more important was the
• 05:35latest science applied to this patient
• 05:38ECOG 3311 had already come out.
• 05:39I told you this is a very
• 05:42recent case and preoperatively
• 05:43pre surgery this patient will
• 05:44be in the low risk category of
• 05:48T1N1 cancer where we
• 05:52could potentially operate.
• 05:54And go to observation, no radiation,
• 05:56no chemotherapy and this patient
• 05:58have a 94% progression free survival
• 06:00based on the data from ECOG 3311.
• 06:03But now this patient has a positive margin.
• 06:06Now he's in the high risk category
• 06:08and now he technically should go
• 06:11on to chemotherapy and radiation.
• 06:13Nothing about this tumor change,
• 06:15nothing about the patient changed,
• 06:16about the biology changed,
• 06:18but now the treatment recommendation
• 06:21could be different.
• 06:22So we had a long discussion in tumor board.
• 06:25And what we decided to do after
• 06:27multidisciplinary team care was complete,
• 06:29the staging taken for transoral
• 06:32robotic surgery to clear that margin
• 06:34and do a formal neck dissection.
• 06:37Unfortunately,
• 06:37this patient did have to escalate
• 06:39after a discussion,
• 06:40we did decide to escalate his therapy
• 06:43to radiation because of the original
• 06:45positive margin and discussing the
• 06:47risks and benefits with the patient.
• 06:50Controversial,
• 06:50but that's what we decided to do.
• 06:53OK. So that's my case.
• 06:55Some kind of frames,
• 06:56this discussion,
• 06:57so some background and definitions.
• 06:59What is quality in cancer care?
• 07:01I'm not going to read all these,
• 07:03but if you look at some of the literature
• 07:06on quality and cancer care nationally,
• 07:09they have all these fancy definitions.
• 07:11But this is what I think is just,
• 07:13it's so simple,
• 07:13so simple and you all know this already,
• 07:15I know, but it's just getting the
• 07:17right care to the right patient at
• 07:20the right time and doing it every time.
• 07:22That's it, that's quality.
• 07:24In healthcare,
• 07:25especially cancer care.
• 07:26So what went wrong with this patient?
• 07:29This patient is going to do fine.
• 07:30The survival rate still 90% plus,
• 07:33you know,
• 07:33it wasn't technically harmed other
• 07:35than treatment and functionally
• 07:37and maybe some side effects,
• 07:39but he's going to live,
• 07:40he's going to have a good outcome.
• 07:42But,
• 07:42but I would argue this wasn't the
• 07:45highest quality of care and it
• 07:47wasn't applying the latest science.
• 07:49So if anyone here has been
• 07:51to Business School,
• 07:53you would have read a lot
• 07:55about Edward Edwards Deming,
• 07:57who created basically the Toyota,
• 08:00Toyota Quality Improvement
• 08:01process and brought you know,
• 08:04car production to the
• 08:05highest quality in Japan.
• 08:07And I think he said it best and
• 08:09it really applies to cancer care.
• 08:12What the fault in the interpretation
• 08:14of observations seen everywhere
• 08:16is just suppose that every event,
• 08:18any defective mistake and accident
• 08:20is attributable to someone,
• 08:22usually whoever's closest at hand or
• 08:25some special extraordinary event.
• 08:28But the fact is,
• 08:28it's not the people that are the issues,
• 08:30it's the system that doesn't work
• 08:32when there's errors and mistakes.
• 08:34The Institute of Medicine,
• 08:36in their crossing the Quality Chasm report,
• 08:39said it well that poor quality care
• 08:41occurs not because of a failure of
• 08:44goodwill or knowledge or effort or resources,
• 08:47but because of fundamental shortcomings
• 08:48in the way cancer care is organized.
• 08:51There's no there's no bad doctor,
• 08:53there's no one who wants to harm a patient.
• 08:55That I know of at least.
• 08:57But the system can be the problem.
• 09:01So how do we measure quality?
• 09:02There's really three ways what a
• 09:04lot of us do, and what was done
• 09:07all the time, many years ago,
• 09:10was implicit or expert review.
• 09:13I'm in an ivory tower.
• 09:14I say it's high quality.
• 09:15I'm. I'm great.
• 09:16And so it is. That's it.
• 09:18But there are scientific
• 09:19ways to measure quality,
• 09:21specifically structure and process metrics.
• 09:26So why is structure so important?
• 09:29Take a moment to talk about this.
• 09:31So right now,
• 09:32I'm sure you can all recognize the
• 09:34organization of cancer care most of the US,
• 09:36the patient at least in the middle,
• 09:39and then doctors all around them
• 09:41and communication can be very,
• 09:42very challenging.
• 09:43This happens to be from a publication.
• 09:44And regarding thyroid cancer cares,
• 09:46we've got nuclear medicine specialists,
• 09:48we've got radiologists,
• 09:49we've got endocrinologist,
• 09:50medical oncologists and the patients.
• 09:54Left in the middle and can be quite confused.
• 09:58This is the structure of hospital
• 10:00care in the United States.
• 10:02There's about 6000 hospitals
• 10:04registered in the United States.
• 10:06About 1500 of them are registered by
• 10:09the ACS Commission on Cancer and about
• 10:1371% are treated at ACS Commission
• 10:16on cancer accredited hospitals.
• 10:20And I'm sure you've heard of SEER,
• 10:21which is a representative national database
• 10:24and that captures about 14% of cancer cases,
• 10:27but is supposed to be and probably
• 10:30is representative of cancer care
• 10:32within the country.
• 10:33So you can get incidence rates from Seer,
• 10:35where you can't get that from NCDB,
• 10:37which is a,
• 10:38which is the Commission on cancer data set.
• 10:42There's a number of
• 10:43comprehensive cancer centers,
• 10:44there's cancer centers,
• 10:46there's community cancer centers,
• 10:47all designated by the NCI.
• 10:49And I tried to find how many surgeons
• 10:51or medical oncologist radiation
• 10:53oncologists treat head and neck cancer.
• 10:55As you could guess,
• 10:57it's pretty much impossible to find that.
• 10:59So the organization of US cancer
• 11:02cases so diffuse diverse that
• 11:04providers have not you as a provider,
• 11:06if you are a doctor,
• 11:07have not had to provide accountability
• 11:10for specific processes or outcomes for
• 11:13you specifically or at your center.
• 11:16OK, so now let's get into some research,
• 11:18research and cancer quality
• 11:20that that's my background.
• 11:21So my research journey at Yale
• 11:25really is about quality of care,
• 11:28patient centers, out centered outcomes.
• 11:30And what I'm trying to do now is
• 11:33my version of bench to bedside.
• 11:35So how do we take the science in outcomes
• 11:38research and apply it to patients?
• 11:40It's really not just fluff.
• 11:41I know there's real quote real
• 11:44scientists out there, basic scientists.
• 11:46Huge randomized control types
• 11:49of signs is out there.
• 11:50I think this is real and going
• 11:52to try and convince you of that.
• 11:54So my foray into patient centered
• 11:56outcomes research started in fellowship
• 11:58and these republished in my first
• 12:00year being here some pretty large
• 12:02reviews on thyroid cancer care and
• 12:04how can we measure and improve thyroid
• 12:06cancer care across the country.
• 12:08And I reviewed all the databases
• 12:11for thyroid cancer and
• 12:12published these in thyroid with
• 12:14a nice team of colleagues.
• 12:16Um, kind of around the country
• 12:18and thyroid cancer care.
• 12:19When I got to Yale, I saw,
• 12:21Oh my God, there's actually a
• 12:22lot of people doing this stuff.
• 12:23People like Dan BofA and Ben Judson,
• 12:26who and and Kerry Gross,
• 12:28who were really nationally known
• 12:30in quality of cancer care research,
• 12:32two of them being surgeons through
• 12:34basic and head and neck surgeons.
• 12:37So what I wanted to do first was,
• 12:38well, how are we doing it, Yale?
• 12:40I mean, are we delivering quality
• 12:43care at Yale? I had no idea.
• 12:45Nobody had any idea. Yes.
• 12:46Many of these are even Dan and Ben.
• 12:48And you asked them,
• 12:49hey, how's your quality,
• 12:50how's your divisions quality,
• 12:51what's your margin rate,
• 12:53survival rates for different cancers,
• 12:55nobody had any idea.
• 12:57So I tried,
• 12:58I tried to figure this out and I
• 12:59created a head neck scorecard using
• 13:01some of the science and outcomes research.
• 13:03We had structural metrics.
• 13:05We had process metrics, pretreatment,
• 13:07treatment post treatment and then
• 13:08of course outcomes, oncologic,
• 13:10functional and patient reported
• 13:12outcome metrics.
• 13:13We created this big scorecard,
• 13:14reviewed all the registry data over.
• 13:16A few years divided things into
• 13:19surgical outcomes, medical outcomes.
• 13:21I'm not going into the details of this,
• 13:23and what I found was that it was
• 13:26actually hard to get the data.
• 13:30And 2nd,
• 13:31we didn't really have national
• 13:32benchmarks upon which to compare our
• 13:35data with the country as a whole.
• 13:37We were sort of in the realm of expert
• 13:40opinion to say how we were doing.
• 13:45So it was under that idea that I began
• 13:47the first stage of research in measuring
• 13:50quality and head and neck cancer.
• 13:53So these were some of the
• 13:55areas of interest that I had.
• 13:57I started first with volumes and outcomes,
• 14:00a structural metric. I didn't spend
• 14:02much too much time here because.
• 14:06It's been published and researched
• 14:07and sort of known to death.
• 14:09Higher volumes lead to better outcomes.
• 14:12It's been known for years and every aspect,
• 14:15probably of medicine definitely surges,
• 14:18definitely surgery.
• 14:19Here's a few studies published 2009, 2010.
• 14:23And I was surprised to see even
• 14:24in this last studies, 2022,
• 14:26people are still publishing the
• 14:28volume outcomes relationship studies.
• 14:30That was pretty well known,
• 14:31but I didn't want to be left in the lurch.
• 14:34So I looked at this as well.
• 14:35I said well, how about.
• 14:36I tried to look at Connecticut.
• 14:38Turns out the NCDB won't give you
• 14:39the data for Connecticut because
• 14:40there's not that many hospitals
• 14:42and you could probably identify
• 14:43which hospital is which one of you
• 14:45were trying to do the research.
• 14:47For example,
• 14:47I don't think there's too many
• 14:49hospitals in Connecticut that do 200.
• 14:51Analytic head and neck cancer cases,
• 14:54but I was able to get New England data
• 14:56and so we looked at data for upper
• 15:00aerodigestive tract cancers and we
• 15:02looked at average case volume by hospital,
• 15:04which was about 26 cases per year with a
• 15:09range of 1 case to 213 cases per year.
• 15:12And we did our standard multivariate
• 15:14analysis controlling for age,
• 15:16stage grade,
• 15:17comorbidity,
• 15:18insurance status and we found that
• 15:20worse survival was associated with.
• 15:23Treatments at a facility seeing
• 15:25less than 50 cases per year compared
• 15:27to greater than 50 cases,
• 15:28a pretty pretty impressive hazard ratio.
• 15:32Not new, not novel. But I wanted to know.
• 15:35I'm Canadian. I'm in New England.
• 15:36How are we doing?
• 15:38And that that gave me the the answer.
• 15:41So then I went on to a series of studies
• 15:43looking at timeliness in cancer care.
• 15:44So why is timeliness important?
• 15:46Well,
• 15:47timely diagnosis and treatment is
• 15:49associated with improved perceived quality
• 15:52of care and lower patient anxiety.
• 15:54So that's important.
• 15:55And then one could say that
• 15:58assuming the disease progresses
• 16:00while waiting for treatment,
• 16:02delays may result in more extensive
• 16:04treatment and possibly increased costs.
• 16:07And 3rd,
• 16:07the impact of treatment
• 16:09timeliness for cancer on true.
• 16:11Health outcomes like patient
• 16:13reported outcomes,
• 16:14functional outcomes,
• 16:15even survival a little bit less clear
• 16:17and this is going back you know 10 or 15,
• 16:19about 10 years when I was
• 16:21doing this research originally.
• 16:22So we started a number of studies.
• 16:24First we looked at treatment
• 16:26delays in oral cavity,
• 16:27squamous cell cancer across the country.
• 16:30We had three objectives in this
• 16:32study and this study was presented
• 16:33at the American Head Neck Society
• 16:35meeting as one of the best papers
• 16:37at the meeting and we looked at
• 16:39national trends in treatment time.
• 16:41Tables in patients with oral cavity cancer.
• 16:43So just get some benchmarks.
• 16:45How is the country doing?
• 16:47How can we know how we're doing at
• 16:48Yale or you're doing wherever you are?
• 16:50If we don't know what a benchmark is,
• 16:53then we wanted to identify factors
• 16:55associated with extended treatment
• 16:57time intervals and then to determine
• 16:59if delays in treatment intervals
• 17:01were associated with survival.
• 17:02These last two were more secondary outcomes.
• 17:04Really my main purpose of this was
• 17:06just to see how is the country doing.
• 17:09So we went through our standard.
• 17:11Inclusion exclusion criteria of
• 17:13oral cavity squamous cell carcinoma
• 17:15treated over a 14 year period using
• 17:17the National Cancer database and
• 17:19ended with about 6000 patients in the
• 17:21final cohort with oral cavity cancer.
• 17:23These are the time intervals that
• 17:26we measured diagnosis to surgery was
• 17:29diagnosis to treatment initiation.
• 17:31Surgery to RT start was what it says
• 17:33and then RT start to RT radiation
• 17:36start to radiation end was was at
• 17:38its was as it says and then we had
• 17:40total treatment package which is
• 17:42from when you started treatment to
• 17:44ending treatment and then diagnosis
• 17:46to treatment ends.
• 17:47So these are these are the intervals
• 17:49that we used and this is what we found.
• 17:53These are box plots you can hear
• 17:55you see huge variation across the
• 17:57country in every single one of
• 18:00these treatment intervals.
• 18:02As a quality researcher,
• 18:03if you are when you'll know,
• 18:04or any researcher really would know,
• 18:06that the wider these box plots,
• 18:09the greater variation and a huge
• 18:11opportunity for quality improvement
• 18:13is to shrink these box plots.
• 18:16We looked at survival.
• 18:18Again, secondary outcome,
• 18:20probably not the best database
• 18:22to look at survival.
• 18:23Plus we only had overall survival.
• 18:26What we found was that radiation
• 18:28duration if you were in the median
• 18:30or below versus the 4th quartile was
• 18:32significantly associated with worse survival,
• 18:35meaning treatment breaks during radiation.
• 18:37Not new,
• 18:38not novel but but that's what we found.
• 18:40And look at this survival curve.
• 18:42This is RT duration.
• 18:44You compare this to the ECOG 3311
• 18:47and the keynote O48 survival curves,
• 18:49which I flashed up there.
• 18:50I think this is a little bit more impressive.
• 18:53Not as great a study but so many
• 18:56more problems with it but I just do
• 18:59that for a visualization and these
• 19:01were this is what I thought was more
• 19:03more interesting though was the now
• 19:06finally we had time intervals across
• 19:08the country at NCNC DBCC accredited
• 19:11hospitals for for median times to
• 19:14treatment and and this is what we're at.
• 19:17We did this a lot and we did
• 19:19it for oral cavity.
• 19:20We did it for oral pharynx
• 19:22treated with surgery.
• 19:23We did it with oropharynx
• 19:27treated nonsurgically.
• 19:28We did it for hypopharynx cancer.
• 19:31Did it for salivary cancer and
• 19:34we established benchmarks.
• 19:35We we had box plots for all of these.
• 19:37We looked at survival outcomes
• 19:39for all of these.
• 19:40So I told you about oral cavity already.
• 19:42Here's oral pharynx,
• 19:43look at the the wide variety in
• 19:45the whole huge variation in treatment for
• 19:48oral fairness cancer treated surgically.
• 19:50Here's a survival curve.
• 19:52This was diagnosis to treatment end.
• 19:54We're seeing big differences if you were
• 19:57delayed versus not delayed and this was
• 19:59the same for oral pharynx cancer treated.
• 20:01Nonsurgically multivariate analysis
• 20:03controlling for all the standard factors
• 20:06that we always control for hypopharynx,
• 20:09cancer, salivary cancer, it goes on.
• 20:11So my point here is that analysis of
• 20:14variation in treatment time intervals really
• 20:17can identify opportunities for us to improve.
• 20:212nd, we found that there's a number
• 20:23of factors associated with delays.
• 20:24I didn't show you that that data here,
• 20:27but these can also are are often related
• 20:31to access and coordination of care.
• 20:33And so the third finding here was that
• 20:36every effort should be made to prevent
• 20:38prevent radiation treatment breaks,
• 20:40because in every single one of those
• 20:42there was a significant association
• 20:44with overall survival,
• 20:45meaning worse if you had treatment
• 20:48breaks or extended radiation.
• 20:49And this matters to patients, too.
• 20:51Here's a patient with an oral cavity cancer
• 20:54diagnosed elsewhere delayed getting in,
• 20:57starting with an oral cavity cancer,
• 20:59but eventually,
• 20:59when he came to treatment,
• 21:01extending through his skin,
• 21:04through the mandible.
• 21:06Original CT scan,
• 21:07no mandible invasion and here we are
• 21:10taking this cancer out mandibulectomy
• 21:13composite SO4 mouth mandible skin,
• 21:16using the fibula to reconstruct
• 21:18with a plate and using the skin
• 21:21on the outside to reconstruct so.
• 21:24Cancer is out, but at what cost?
• 21:26Because of delay in diagnosis,
• 21:29delay in treatment,
• 21:29delay in diagnosis is a whole
• 21:31other discussion,
• 21:32which I don't talk about and
• 21:35I don't really study.
• 21:39The Commission on cancer has
• 21:41just in March of this year,
• 21:44very recently finally put in their
• 21:45first head and neck oncology quality
• 21:48metric that's going to be measured at
• 21:50every single ACS accredited hospital
• 21:52across the country and that's time to
• 21:55initiation of post operative radiation.
• 21:57This my study didn't really
• 21:59show much of an association.
• 22:01There's tons of studies focused using
• 22:03that as their primary outcome that
• 22:05have shown that 42 weeks, 42 days.
• 22:07Is a big cut off to affect survival to start
• 22:10radiation after head and neck cancer surgery.
• 22:13So this is a new quality metric
• 22:15that we're all being measured on,
• 22:16just so you know. OK.
• 22:19So then did volume outcomes,
• 22:22did timeliness.
• 22:23So then I wanted to look at surgical quality.
• 22:25How do we measure that?
• 22:26How do we benchmark this?
• 22:27How do I know if I'm doing a good job?
• 22:29And so we started looking
• 22:31at a number of things.
• 22:32So this was Ben Judson
• 22:33was a lead author on this,
• 22:34but our whole team was involved
• 22:36where we look, tried to identify.
• 22:39Thresholds for lymph node yields.
• 22:42For oral cavity cancer,
• 22:43so our objective in this study was to
• 22:46determine lymph node yield threshold
• 22:48and oral cavity squamous cell
• 22:49cancer that might impact survival.
• 22:51This was a very interesting study because
• 22:55we used the NCDB to establish those
• 22:58yields and then validated it in SEER.
• 23:01And.
• 23:02To find the threshold,
• 23:04we looked at the clinically end zero oral
• 23:07cavity cancers versus the clinically
• 23:10and positive oral cavity cancers.
• 23:12And.
• 23:15Looked at different.
• 23:18Hazard ratios based on number of
• 23:20the lymph node yield basically and
• 23:23after regressive statistical models,
• 23:25we basically eventually found
• 23:27that there was a difference at
• 23:2916 lymph nodes for N0 neck N,
• 23:310 lymph node yields and 26
• 23:34for and positive lymph nodes.
• 23:36And after adjusting for all sorts of factors,
• 23:39we found a survival benefit,
• 23:41overall survival and cause specific
• 23:42survival based on lymph node yields.
• 23:45This is using SEER data so
• 23:46we finally had disease.
• 23:48Specific survival,
• 23:48which we don't have in NCDB.
• 23:50So again,
• 23:51if you look at these survival curves,
• 23:53I think they're quite.
• 23:56Not provoking.
• 23:58This study came out at the exact
• 24:00same maybe like a three months
• 24:02after our study and this looked
• 24:04at all of head neck cancer and it
• 24:06looked at used 18 lymph nodes,
• 24:08so kind of an arbitrary number they picked.
• 24:10To be honest based on some other
• 24:12single institution studies they
• 24:14didn't use the same statistical
• 24:15rigor that we use in oral cavity
• 24:17but it applied to all head neck
• 24:18cancer and so it was more applicable
• 24:20in 18 has become the big number
• 24:22for head and neck cancer partly
• 24:24based on this study but again.
• 24:26Think what you will just have a #18
• 24:29lymph nodes. Big survival difference.
• 24:32So that's lymph node yield.
• 24:33Then we wanted to look at positive
• 24:35margin rates and this is another
• 24:37study that we did trying to
• 24:38again figure out positive margin
• 24:40rates in this country for oral
• 24:41cavity, squamous cell cancer,
• 24:43what is the baseline?
• 24:45And again we found incidence of
• 24:47positive margins based on this study
• 24:49and we did look at the volume outcomes
• 24:52relationship and the facility setting.
• 24:54And if you were to academic center,
• 24:55your risk of having positive
• 24:57margins was significantly less.
• 24:5920 cases seem to be a good threshold,
• 25:01but again you see a lot of variety.
• 25:03Variation across the country.
• 25:05We also looked at transoral robotic surgery.
• 25:09So the transoral robotic surgery is FDA
• 25:12approved for T1T2 oropharynx cancers.
• 25:14And what I wanted to know was well
• 25:18what is the positive margin rate
• 25:21nationally and then what factors are
• 25:23associated with positive margin.
• 25:24So we did our standard inclusion
• 25:26exclusion criteria.
• 25:27We found about 2600 patients who
• 25:29had a transoral robotic surgery for
• 25:31oropharynx squamous cell carcinoma
• 25:33and what did we find overall.
• 25:36A 17% positive margin rate in this
• 25:38country and it varied by T stage
• 25:43T1T2T3T4. You can see that all here.
• 25:47We also found factors
• 25:48associated with positive margin,
• 25:49specifically Lymphovascular invasion,
• 25:51T classification and again facility
• 25:54volume of patients treated at high
• 25:56volume centers were less likely to have.
• 25:59Positive margin,
• 26:00you can see academic centers versus
• 26:03non academic and high volume versus
• 26:06high volume versus low volume.
• 26:08So in the, this is interesting because
• 26:11in the year since FDA approval,
• 26:13what we found is that the positive
• 26:15margin rate for towards the 17%.
• 26:16But if you look at the ECOG 3311 trial,
• 26:20the positive margin rate of
• 26:22credentials academic surgeons was 3.3%.
• 26:25And if you look at pooled data
• 26:28from 3 clinical trials looking at
• 26:31academic single institution studies
• 26:32or even a systematic reviews,
• 26:34we're looking at significantly
• 26:36less than the real world.
• 26:38Positive margin rate,
• 26:39so there is and then this study
• 26:42also showed a linear association
• 26:45between positive margins with T32
• 26:47and T4 tumors greater than 28%.
• 26:50So these patients are the ones that
• 26:52are going on to chemotherapy and
• 26:54radiation and probably had no benefit
• 26:57from transoral robotic surgery based
• 26:59on their current treatment paradigms.
• 27:01We did this for parotid cancer,
• 27:03I won't get into those details.
• 27:05And then this is a interesting
• 27:07study that combined margin rates
• 27:09nationally and lymph node yields and
• 27:12what they looked at was treatment at
• 27:15the try identify that the treatment
• 27:17at hospitals that attain a high
• 27:19rate of negative margins.
• 27:20So if you're if you have if you're
• 27:22a hospital that's that's high rate
• 27:24of negative margins and lymph
• 27:25node yields of more than 18.
• 27:27They found that there is a
• 27:29significant association with
• 27:30improved survival if you did.
• 27:31Both of those and these predicted
• 27:33outcomes independent of those generally
• 27:35modifiable characteristics including
• 27:37the volume outcomes relationship.
• 27:40These were independents of volume of
• 27:43the hospital but only 105 hospitals
• 27:46out of 1000 in in the country achieve
• 27:50negative margins in 90% or more patients and.
• 27:57If you look at lymph node yields
• 27:58of greater than 18,
• 27:59only 199 hospitals out of 1000 consistently
• 28:05achieved lymph node yields of 18 or more,
• 28:08meaning in an 80% or more of that's the case.
• 28:10We're not looking for 100%,
• 28:11you know,
• 28:1280% of cases having 18 or more lymph nodes.
• 28:16So in contrast to the traditional emphasis
• 28:18on the volume outcomes relationship,
• 28:20this showed that negative margins
• 28:22and lymph node yields can actually
• 28:24neutralize the effect of hospital volume.
• 28:29OK. So then another area that I want
• 28:31to look into was guideline adherence
• 28:33and this it came up because of a study
• 28:36published in 2009 from MD Anderson.
• 28:39They looked at 107 patients who came
• 28:42to them for second opinions with
• 28:44persistent or recurrent disease.
• 28:46So they've been treated elsewhere.
• 28:47They had persistent or recurrent disease and
• 28:50they wanted to look at well what's going on.
• 28:52What they found was that 43% of
• 28:54patients had NCCN guideline non
• 28:56compliance is the term that they used.
• 28:59And they try to find some
• 29:00factor associated with it,
• 29:02even the specific referring physician,
• 29:04the type of physician,
• 29:05the subset of disease,
• 29:06insurance status, age, sex.
• 29:07And there was nothing that was
• 29:10significantly associated with why someone
• 29:12would get NCCN noncompliant treatment.
• 29:15So I'm in the same vein.
• 29:18As you can see my theme here is,
• 29:20well, how's the country doing?
• 29:21You know we know how single institutions
• 29:23are doing, but how about the country?
• 29:24What's the benchmark?
• 29:25What are we aiming for?
• 29:27So we undertook a study to look
• 29:30at national NCCN guideline,
• 29:32not non adherence rates.
• 29:33That was the main objective.
• 29:35We also wanted to look at associations
• 29:38between non adherence and survival.
• 29:40In head neck cancer,
• 29:41we wanted to look at reasons,
• 29:43reasons for non non adherence
• 29:45and then factors associated with
• 29:47non adherence as secondary aims.
• 29:49So this is our we started with 375,000
• 29:54patients treated from 2004 to 2013.
• 29:58And we tried to figure out which ones
• 30:00were not adhering and which ones
• 30:02were adherent to NCCN guidelines
• 30:04and not going into the details.
• 30:06This is how we define non adherence by site.
• 30:09It's just look at the NCCN guidelines.
• 30:11It's actually pretty easy and they
• 30:14were surprisingly consistent in
• 30:15all these areas throughout the
• 30:17entire years of the study.
• 30:19We've got the guidelines going back to when
• 30:22this study started actually from the NCCN.
• 30:25And these are the numbers.
• 30:26So if you go to 2004 non adherence
• 30:28rates throughout this country,
• 30:30it was 30% for head and neck
• 30:32squamous cell carcinoma by 2013,
• 30:34we're still looking at almost
• 30:361/4 of patients are getting non
• 30:39adherent guideline non adherent
• 30:41care within this country.
• 30:43We looked at his by sub site
• 30:46for oral cavity cancer,
• 30:4746% of patients are getting non
• 30:50adherent care and oral pharynx,
• 30:52much lower hypopharynx,
• 30:54larynx and sinuses here.
• 30:57And then we looked at survival.
• 30:59So if you have non adherent care
• 31:01versus adherent care to NCCN
• 31:03guidelines we found a significant
• 31:05association with overall survival.
• 31:07Again a multivariate analysis
• 31:10controlling for all the typical factors.
• 31:13And then we looked at factors associated
• 31:15with guideline not adherence,
• 31:17black race, age over 65,
• 31:19comorbidity, non private insurance,
• 31:21higher T stage and then being
• 31:24treated and non academic facility.
• 31:27So I like this quote because it
• 31:30really talks about highlights why
• 31:32this is so important when clinicians,
• 31:34clinicians already know the information
• 31:36contained in guidelines and this
• 31:38was years ago, this was 1999,
• 31:40now they're so accessible.
• 31:41So I'm going to extend this to
• 31:42say when physical clinicians.
• 31:43Know how to get the guidelines
• 31:45within minutes at their fingertips.
• 31:47Those clinicians who want to improve
• 31:50quality need to redirect their
• 31:52efforts to identify the barriers.
• 31:54It's not knowledge that stand
• 31:55in the way of behavior change.
• 31:57So by addressing the barriers that
• 32:00prevent adherence to NCCN guidelines
• 32:03and their treatment protocols,
• 32:05I think there is a great opportunity
• 32:08for us to improve survival.
• 32:10I would even say a responsibility.
• 32:12Final area of research I wanted to look
• 32:15at and I haven't done much in this yet.
• 32:17So I'm going to quote a a different
• 32:20study by Bevin you who's the chair
• 32:23at Minnesota University of Minnesota
• 32:25and he was actually a Robert Wood
• 32:28Johnson scholar here at Yale and very
• 32:30well known and outcomes research.
• 32:32And that cancer he just wanted,
• 32:34this was a spoke to him about his
• 32:35very controversial study when he
• 32:37published this because it was within
• 32:38his own network of patients that
• 32:40he was seeing looking at patients
• 32:41who were treated with radiation.
• 32:43Therapy at the academic center versus
• 32:45the non academic center and found
• 32:47significant differences in five
• 32:48year survival on there were similar
• 32:50rates of treatment completion,
• 32:52similar rates of treatment breaks,
• 32:54more advanced cancers at the academic center.
• 32:57Multivariate analysis really you
• 32:59know statistically rigorous study
• 33:02couldn't say why but there was.
• 33:05OK.
• 33:06So the last thing I want to talk
• 33:08about is really this concept of bench
• 33:11to bedside for the patient centered
• 33:13outcomes researcher and that's what
• 33:15I've been doing over the last year or so.
• 33:19What I wanted to do now is take all
• 33:21this national benchmark data we had.
• 33:23We knew what good quality was or
• 33:24at least what the standard of care
• 33:26was across the country.
• 33:27I said, hey, how,
• 33:28how is Yale New Haven Health system doing?
• 33:31And so this is what we did, we looked.
• 33:36At tumor registry data from Yale,
• 33:39New Haven Hospital, Bridgeport Hospital,
• 33:41Greenwich Hospital, L&M and Westerly.
• 33:43So our entire network and we got
• 33:45all the analytic oral cavity cases
• 33:47from 2012 to 2018.
• 33:48And we looked at a number of
• 33:50these quality metrics for which we
• 33:52now had national benchmarks.
• 33:54And we looked at the positive margin rate.
• 33:55We looked at lymph node yields
• 33:58greater than or equal to 16 adherence
• 34:00rates to NCCN guidelines and time to
• 34:03adjuvant therapy within six weeks.
• 34:05So we started with 500 patients
• 34:07and these were the three groups of
• 34:09patients that were treated academical
• 34:11surgery and radiation or all their
• 34:13treatment if there was no radiation
• 34:15at the academic only center,
• 34:16Community Center being the opposite
• 34:18end and then the combined group.
• 34:20So they had in this combined group,
• 34:22it was always surgery at the main
• 34:24center and radiation elsewhere.
• 34:25For some reason it didn't go the other way.
• 34:28And these were our key findings.
• 34:31There was a higher positive surgical
• 34:34margin rate within our health
• 34:36system at the Community hospitals,
• 34:3812% versus 2.5%.
• 34:39There was a lower likelihood to
• 34:41meet that bottom lymph node yield
• 34:43threshold of 16 lymph nodes and a
• 34:46neck dissection at the community,
• 34:4859% versus 90%.
• 34:49There were decreased rates of
• 34:51adherence to NCC and guidelines in
• 34:53other hospitals within our Network,
• 34:5576 versus 86% and adjuvant radiation
• 34:58therapy within six weeks it was the same.
• 35:01If you were all academic or all community,
• 35:03but if you fragmented your care,
• 35:05it was significantly less.
• 35:0722% of patients, when fragmenting their care,
• 35:10received radiation therapy within six weeks.
• 35:14So it sounded negative originally,
• 35:15but then we said, hey, well,
• 35:16we have national benchmarks.
• 35:18How are we doing?
• 35:18It turns out that we're actually
• 35:19doing pretty good within the system.
• 35:21The, our numbers are on par with the nation.
• 35:23We're not any worse than the national
• 35:26benchmarks in our community hospitals.
• 35:28If you look at the national positive
• 35:29margin rates based on our studies,
• 35:31oral cavity cancer is almost 13%.
• 35:33Our community partners are 12%.
• 35:37I mean our academic center is 2.5%.
• 35:39So that's a significant difference,
• 35:40but but the system is.
• 35:44Not doing horrible.
• 35:46There's a lot of reasons that there could,
• 35:48you know, there could be differences.
• 35:50For example, availability of frozen section,
• 35:52access to advanced reconstructive surgery,
• 35:54we can get more aggressive on the resection,
• 35:58constant communication between
• 35:59pathologists and surgeons,
• 36:01presence of trainees,
• 36:02perhaps higher case volumes,
• 36:04how margins are taken by surgeons or
• 36:06how they're assessed by pathologists.
• 36:08Countless reasons this for this,
• 36:11all theoretical.
• 36:13The other point about positive margins
• 36:15other than affecting survival is
• 36:18that it can often lead to unnecessary
• 36:20escalation of cares like that oropharynx
• 36:22cancer case that I showed you.
• 36:24But in this cohort of patients
• 36:26within our system,
• 36:27two patients in the Community only
• 36:30group received adjuvant chemotherapy
• 36:32plus radiation for early stage disease.
• 36:34So stage 1/2 cancer positive margin
• 36:36went on to chemotherapy and radiation.
• 36:38There's no LINOP and I in those cases.
• 36:41And when you look at non adherence rates.
• 36:44Again nationally for all of cancer,
• 36:4726% of patients for head neck
• 36:48cancer nationally are non adherence
• 36:50with guidelines for oral cancer.
• 36:52If you'll recall based on our
• 36:54previous studies,
• 36:5546% of patients are non adherent
• 36:57in our community.
• 36:59Yale New Haven Health System is doing
• 37:00pretty good when you look at national data,
• 37:02much better than than the
• 37:04country for oral cavity cancer.
• 37:05But if you look at the academic center,
• 37:07we see a significant difference
• 37:09and again no one looking for
• 37:11100% adherence to guidelines,
• 37:13that's not possible, a lot of reasons,
• 37:15sometimes you can't.
• 37:15Adherence to guidelines,
• 37:17but we're looking to benchmark against
• 37:19the country and against each other.
• 37:22So.
• 37:22We looked at lymph node yields
• 37:24and this is where things got a
• 37:26little bit more interesting.
• 37:27Nationally,
• 37:27greater than or equal to 16 lymph nodes,
• 37:3070, we used 18.
• 37:32That's what we have for national data.
• 37:3470% of patients have more than 18
• 37:36lymph nodes in their neck dissections.
• 37:39In our community,
• 37:4059% and in the academic center,
• 37:4290%. And you can see the huge
• 37:45variation as well everywhere really.
• 37:48Again, there's multiple reasons for this.
• 37:49How pathologists count limp,
• 37:51it's not all surgical related,
• 37:52how pathologists count lymph nodes,
• 37:54but maybe also the quality of the
• 37:56neck dissection and this these
• 37:58can sell a lot of these can be
• 38:00modifiable treatment factors.
• 38:01So in this study,
• 38:02we found that treatment of oral
• 38:04cavity cancer at Community facilities
• 38:06within our system may increase the
• 38:08likelihood of positive margins,
• 38:09lower likelihood of adequate lymph
• 38:11node yields and decrease adherence.
• 38:12NCCN guidelines.
• 38:13Not only that, but if you fragment your care,
• 38:16you can have a lower likelihood
• 38:19of achieving radiation initiation
• 38:21within six weeks.
• 38:22A lot of problems with this study.
• 38:24I think it's still very informative
• 38:26and very useful to make us better,
• 38:28but you know,
• 38:30data were collected retrospectively.
• 38:32We found a lot of differences in process
• 38:34related metrics and other studies
• 38:36have shown association with survival.
• 38:39This study in and of itself
• 38:40did not show that there was
• 38:41any difference in survival,
• 38:42definitely not powered for this.
• 38:44It was not the main outcome and
• 38:46of course there are socio.
• 38:47I recognize there are socioeconomic and
• 38:49other factors that can impact patient
• 38:52care delivery and confound the results.
• 38:54For example,
• 38:55patients who are willing to
• 38:56travel to the academic centers may
• 38:58differ systematically from those
• 38:59who seek care closer to home.
• 39:04Since then, I'm not going to read all
• 39:06this and tell you this is historic
• 39:08data going back to 2012 to 2018.
• 39:11Smilo has, I think, been aware of this.
• 39:13The leadership has been aware of
• 39:15this and there's been a lot of
• 39:17things that have changed to improve
• 39:18quality even in the last five years.
• 39:20And I'd love to do this study and I
• 39:21will do the study a few years from now
• 39:23as well and see how much better we are.
• 39:25For example, oncology care pathways
• 39:27have been initiated.
• 39:28Community hospitals and disease teams
• 39:31have been better integrated at SMILOW.
• 39:34We are creating local disease teams,
• 39:36experts at community hospitals primarily
• 39:39dedicated to head and neck cancer care.
• 39:42Physicians at the academic Center have
• 39:45established clinics in surrounding
• 39:46care centers.
• 39:47We're trying to bring culture from
• 39:50one place to another as well and
• 39:53better integrating and aligning
• 39:54culture across our care centers.
• 39:57Of course,
• 39:57advancement in ER has helped a lot.
• 39:59This is going back to 2012
• 40:01when the ER was first.
• 40:03Initiated in the health system,
• 40:06we have more clinical trials and
• 40:08they're offered at care centers
• 40:09and there's a lot of other
• 40:11improvements that are ongoing.
• 40:13And I think delivering high quality
• 40:15care across the system for head and
• 40:17neck cancer is an important part of
• 40:20our systems growth and integration.
• 40:24So really what I think is that integrated
• 40:26health systems can leverage the strength
• 40:28of the academic center to figure out
• 40:31a way to disseminate best practices,
• 40:33to break those structural barriers
• 40:35within our network, to improve patient
• 40:37care and bring high quality care,
• 40:38whether it's closer to home
• 40:40or bring the patients here.
• 40:41But we can do this and dare I say
• 40:43we have a responsibility to do this,
• 40:45but how are we going to overcome
• 40:48these structural barriers?
• 40:49So bringing it back to the patient.
• 40:52You know, processing,
• 40:53quality care improves survival.
• 40:54I told you that.
• 40:56But quality care.
• 40:57It means more than just the
• 41:00process of care and survival.
• 41:02It means more than just being cancer free.
• 41:07Say
• 41:091234512345. Left and right.
• 41:13Just to the outside.
• 41:17Hi, this is **** Morris.
• 41:19You may have seen me on some of
• 41:21my Facebook or Internet posts.
• 41:23I had tongue cancer and doctor Mayer.
• 41:27Doctor Mehra operated and after
• 41:29the portion of the tongue that was
• 41:33cancerous was removed, he replaced
• 41:35it with a skin graft from my forearm.
• 41:39I'm now speaking to you 5 weeks to
• 41:41the day after surgery and I no longer
• 41:44feel like I have marbles in my mouth.
• 41:47I can speak clearly and
• 41:50it's entirely due to him.
• 41:52Yeah, Mike, partial Larry.
• 41:54Mack Larnax, see perfect was four months ago.
• 42:00And.
• 42:02I'm amazed that I have this voice.
• 42:06Go
• 42:101234567. Do you have a feeding tube?
• 42:13No. Do you have a tracheotomy? No.
• 42:18Ohh, I had my surgery three months ago.
• 42:25Free **** pie,
• 42:27I had my surgery
• 42:29on May 2nd by Doctor Merritt.
• 42:31So you can see these are patients
• 42:33who where function is important.
• 42:35It's not just that they're alive
• 42:37and they're cancer free and they
• 42:39had guideline compliant care,
• 42:40but you have a laryngectomy patient
• 42:42speaking hands free thanks to our
• 42:44speech and language pathologist.
• 42:45You've got patients who are in the
• 42:47public speaking after having significant
• 42:49portions of their tongue removed,
• 42:52but high quality reconstructions.
• 42:54Partial laryngectomy is for
• 42:56salvage which are not done at,
• 42:59certainly not at in low volume places,
• 43:01saving saving the larynx.
• 43:05So I hope what I've done now is
• 43:07you already knew that randomized
• 43:09control trials are great.
• 43:10They lead to practice changing innovations
• 43:12in the care of cancer patients.
• 43:14But I hope you can have a better.
• 43:17Respect maybe for quality
• 43:19of care research as well.
• 43:21We can have a remarkable impact
• 43:23on patient outcomes and I think
• 43:25it's necessary for the quote real
• 43:27science to mean anything to patients.
• 43:29You have basic science researchers who
• 43:31feed the clinical researchers within
• 43:33clinical researchers feed the patient
• 43:35centered outcomes researchers and that's
• 43:38what leads to better patient care.
• 43:40So Healthcare is remember this is
• 43:42getting the right care to the right
• 43:43patient at the right time every time.
• 43:45That's quality cancer care.
• 43:47Thank you.
• 43:56Thank you so much for both for the
• 43:58wonderful talk and the wonderful work.
• 43:59Are there any questions either
• 44:01here in the room or I know people
• 44:05are also potentially posting?
• 44:10Through the webinar.
• 44:14Yeah, Tommy.
• 44:18Open.
• 44:21COVID-19.
• 44:27I don't know yet is a short answer.
• 44:30I think that's it's an area of active study.
• 44:32There are some small scale
• 44:34publications on that,
• 44:35but I think we're going to know.
• 44:37Pretty soon, I can tell you our experience,
• 44:39but that's not based on the data.
• 44:40Maybe Doctor Burtness has
• 44:41more information about that,
• 44:43but I think we're going to
• 44:44know better soon enough.
• 44:48I mean I I think we saw a number of,
• 44:51I don't know that we have stats on it,
• 44:53but we saw a number of patients with
• 44:57considerable delays in diagnosis.
• 44:59So I have a I have a question.
• 45:02When we participate in,
• 45:03so dragging you back to the
• 45:05clinical trial side for a moment,
• 45:07but a really important consideration for
• 45:11surgically based trials is how do we set
• 45:15what the benchmark is for the right surgery.
• 45:19And I know you're participating in
• 45:21the Sentinel lymph node trial now,
• 45:24sort of how does that credentialing process?
• 45:28Sit with our own quality enhancement efforts.
• 45:34It's a good question.
• 45:35I think you're right.
• 45:36It's just exciting now to have
• 45:38surgeons involved in randomized
• 45:39control trials like ECOG 3311,
• 45:41the Sentinel node trial.
• 45:42It's actually great because it hasn't
• 45:44happened a lot in head neck cancer.
• 45:47You know, I think that for clinical
• 45:49trials it's different than patient these,
• 45:50these comparative effectiveness
• 45:52researchers because you need to know if
• 45:55the intervention is effective or not.
• 45:57You need high quality surgeons every
• 45:59time they need to be credentialed
• 46:01and the surgical quality metrics
• 46:03are being monitored constantly and
• 46:04I think you need that for clinical
• 46:06research and I'm glad it's there.
• 46:08But how you apply that to the
• 46:10real world I think is,
• 46:12you know at the second
• 46:13area of research interest.
• 46:14But I'm glad they're credentialed
• 46:16high quality surgeons during
• 46:18the clinical trials.
• 46:20We
• 46:20have a a question from Doctor
• 46:22Robinson in radiation oncology.
• 46:24How do you disseminate the
• 46:29these quality insights to?
• 46:32The lower volume centers and are there
• 46:35specific guidelines for which patients
• 46:37should be referred for high volume?
• 46:40Is it practical to refer everyone
• 46:43with less common cancers like head,
• 46:45neck cancer? And if not,
• 46:48how do you feed these?
• 46:52These care care approaches
• 46:54to the lower volume centers.
• 46:57That's a great question.
• 46:58I think it's $1,000,000 question.
• 47:00If we could do that honestly I
• 47:02think we could improve survival more
• 47:04than the next billion dollar drug
• 47:06basically and I think that's that's our
• 47:08challenge that's what we need to do.
• 47:10I don't know I think every system
• 47:12has it has a different approach.
• 47:14I think Yale New Haven Health System
• 47:15is going to be different than
• 47:17memorial is going to be different
• 47:18than pen is going to be different
• 47:20than any health system but.
• 47:21I don't know what the right answer is,
• 47:23but we need to figure it out.
• 47:28I guess I have a follow up question
• 47:31to that and and that is some of
• 47:34the hypothesis you had about what
• 47:37controlled let's say the rate of
• 47:40margin positivity had to do with.
• 47:45Frozen margin evaluation communication.
• 47:52Are are there components of that that
• 47:55could be enabled by telemedicine?
• 47:57So you know you referred to digital
• 47:59pathology once or twice in your talk,
• 48:01but are there ways that expert disease
• 48:06focused let's say pathology evaluation?
• 48:10Could be extended through telemedicine.
• 48:14Yeah, I think that would be,
• 48:16I think that's one way to bring expert
• 48:20level care across the system with
• 48:22telemedicine and I think pathology
• 48:25would be a great way to start actually.