Enhancing Patient Care with Cancer Programming

Podcast Transcript

Dale Shepard, MD, PhD: Cancer Advances, a Cleveland Clinic podcast for medical professionals, exploring the latest innovative research and clinical advances in the field of oncology. Thank you for joining us for another episode of Cancer Advances. I'm your host, Dr. Dale Shephard, a medical oncologist here at Cleveland Clinic, Directing the Taussig Early Cancer Therapeutics Program and Co-Directing the Cleveland Clinic Sarcoma Program. Today, I'm happy to be joined by Alison Ibsen, Senior Director for Cancer Programming. She's here today to talk to us about optimizing the care for patients with cancer through cancer programming. Welcome, Allison.

Alison Ibsen: Thank you. Thanks for having me.

Dale Shepard, MD, PhD: So Director of Cancer Programming, give us a little idea what do you do here at the Cleveland Clinic?

Alison Ibsen: Sure. So essentially, our team is responsible for being the administrative partners to our clinical teams who take care of cancer patients, and essentially, we have responsibility for really driving the work that happens around a specific cancer patient population. So if you think about a breast cancer patient, the vast majority of our breast cancer patients will see a breast surgeon first, so that breast surgery lives in the Integrated Surgical Institute. Perhaps that patient will see a medical oncologist who is out of the Taussig Cancer Institute. Maybe radiation oncology will get involved also out of Taussig. Perhaps plastic surgery will be consulted, and ultimately, in survivorship, the patient would be handed back to primary care. So the idea is our team is responsible for bringing together all of those providers and practitioners and team members that I just mentioned around that patient population of breast cancer patients.

Dale Shepard, MD, PhD: Excellent. So more an ability to get unified care.

Alison Ibsen: Exactly, and so really helping to promote multidisciplinary care in the interest of optimizing the outcomes as you said earlier, so that's really about driving highest quality, highest value care for our patients.

Dale Shepard, MD, PhD: And so when we think about cancer programming, give us a little bit of an idea, this is not something that happens in lots of places.

Alison Ibsen: Indeed.

Dale Shepard, MD, PhD: So how did this come about?

Alison Ibsen: So essentially, as you stated, Dr. Shephard, it's not something that would necessarily exist in many other hospitals, and really, it was born out of just how incredibly sub-specialized we are here at Cleveland Clinic. So we have our institute model, which is of course geared towards that integrated, vertically integrated model to support patient care. However, if you think about cancer care, it's really sort of a horizontal, so cancer care doesn't just occur within the Cancer Institute here at Cleveland Clinic, and the Cancer Institute really houses medical radiation, oncology, palliative care, psychosocial support, other supportive care services, but any of the diagnostic services, imaging, pathology and lab medicine, the surgical services, those all live outside of our cancer institute. So cancer programming came about back in 2014 in the interest of building an infrastructure that sits across the natural organizational structure, the institute org structure.

Dale Shepard, MD, PhD: And so lots of moving parts and pieces. How have we managed to pull it together as one unified group?

Alison Ibsen: From a clinical perspective of course, and you know this well as a cancer practitioner yourself, our clinical teams have of course always worked together to care for their patients in the best manner possible. What cancer programming brings is really to help to facilitate and provide a venue for further collaboration and further multidisciplinary care. So our team is responsible for helping to build on the administrative side, be that administrative partner to our clinical colleagues, so helping to build and optimize multidisciplinary clinics for example, doing the actual work to design care pathways. So our physicians of course know how to care for cancer patients. The idea is how do we as a cancer programming team help to document that, circulate, socialize those documents also across the Cleveland Clinic enterprise, and then also do the administrative legwork responsible for making sure that those care pathways are documented, codified and posted in places where they're visible for people across the enterprise.

Dale Shepard, MD, PhD: So a lot of different people might be listening in different backgrounds. Let's use care paths as an example. What exactly is a care path and how do we utilize that in terms of our care?

Alison Ibsen: So the way that we use care paths in practice is really to provide a standard guide that enables anyone who's taking care of, let's use the breast cancer example, anyone who's providing care to a breast cancer patient of a particular stage of disease, a Cleveland Clinic guide as to how they should care for that patient. So following with that example, in breast cancer, in the Breast Cancer Tumor Board, during the Tumor Board review where multidisciplinary cases are reviewed, when a case is presented, within the tumor board, that team will actually bring up the care pathway just to ground the entire team in the standard of care. The idea is certainly not a cookbook medicine type of thing. The idea is 80% of the time, there's a standard pathway that should be followed based upon those national guidelines, and then perhaps there is some sort of multidisciplinary nuanced approach that Cleveland Clinic uses, and that's where we get to the Cleveland Clinic secret sauce, so to speak.

Dale Shepard, MD, PhD: But then by utilizing cancer programming, as a sarcoma doc for instance, you guys are great at helping us disseminate that information to everyone else in terms of how we need to be thinking about sarcoma.

Alison Ibsen: Right, indeed. And so for an individual who, to your point, perhaps doesn't care for sarcoma patients every day of their life, an oncologist or a surgeon who perhaps is more of a generalist in terms of the cancers that they treat and the patients they care for, the idea with a care path is to help to guide that practitioner in how they should take care of a sarcoma patient who presents with X stage of disease, et cetera.

Dale Shepard, MD, PhD: Really big place, lots of issues that come around in management of any particular disease. How do you set priorities? How do you decide what's the next thing to work on?

Alison Ibsen: Great question, because if everything's a priority, nothing's a priority, right?

Dale Shepard, MD, PhD: Correct.

Alison Ibsen: So it's really, I will say it's more art than science. It's kind of a top down meets bottom up approach and we try to negotiate in the middle. When I first started this job, I went into a disease program meeting, and I will not name names. It was not Dr. Shephard I'll say for the audience, and I was, I will say a lowercase A, accused of, I'm using air quotes right now, of trying to bring a particular top-down agenda to that disease program team. And the response from the program leader was, "We know what we need to do in our disease program to advance cancer care. We know the clinical work that we need to do. We know the administrative work. Basically, no, thank you."

And that program leader and I did negotiate and we got to a much better place over time, but what I explained was the intent here is not to only bring top-down Enterprise Institute priorities to your disease program. It's to figure out where do we have enterprise and institute priorities that align and actually could help to bring some horsepower, resources, visibility to the work you're doing? And how do we marry that with the things that as a program leader are really, really important for your disease team? So it's really kind of a melding of the two and meeting in the middle. We always want to be in a position to help to provide that advocacy and resources wherever needed to help to advance the priority agenda for all of our 13 disease programs.

Dale Shepard, MD, PhD: And then of course, that extends not only to patient care directly but also to things like marketing and philanthropy and research and things like that in terms of integration of programs.

Alison Ibsen: It does. It does. And so an example of this is, you mentioned a couple of great examples, Dr. Shephard, and I think one that relates to the marketing piece is related to an expectation from institute leadership and from the Cleveland Clinic Enterprise that we continue to grow, and so how do we do that? Well, the starting point is having data to understand, for instance, how many patients did we see last year in the comprehensive sarcoma program? Not just in medical oncology, not just in radiation oncology, not just in surgery, but across the board. And from a comprehensive perspective, how many patients did we see? Because how can I come into the sarcoma program and ask you and your colleagues to grow through specific marketing initiatives, et cetera, if you don't even have a good handle on that comprehensive view of what your volume looks like currently?

And so in that particular example, one thing that our team worked towards a number of years ago when we were asked to work with the disease programs to grow and see more patients and to accommodate that was to work with our finance colleagues, not just within the Cancer Institute but within the surgery institutes and all of the relevant players across the organization to get to that data so that we could then bring it forward to our program leaders and say, "Okay, here's where you currently stand, and now let's have a realistic conversation about how much you'd like to grow and how we think and what interventions we could put in place from a marketing perspective, et cetera, to actually grow."

Dale Shepard, MD, PhD: And then, so not only are we... We have lots of projects going on, so not only are we growing but we're trying to optimize care of the people that we're seeing, and particularly new patients. So one thing where cancer programming seems to have had success is what we were focusing on, time to treat as an example. Tell us a little bit about how cancer programming put people together in a way that made us really leaders in the ability to get people treated quickly.

Alison Ibsen: So again, it starts with the data. So initially, we had to understand, how long is it taking us to get patients into treatment? So that's from the time they have a positive biopsy that shows that they have cancer until their initial treatment, whatever that would be, whether that's administration of chemotherapy, radiation therapy, surgical intervention. And so that was step one, understanding how we are doing in that regard. And we wanted to look at that not only in the aggregate in cancer care at Cleveland Clinic, but also at a disease program level because there are going to be specific nuances for the sarcoma team and that pathway versus the breast team versus the lung cancer team, et cetera. So that was step number one. And then not just looking at that data once, but keeping it front and center for everyone, all of the players all the time became very, very important, socializing it and making it really a north star, a guiding star.

And you ask about this initiative. It's one that of course you and I are both quite familiar with, and it came about really at the start of cancer programming. And I think that that was so critical at that time because not only is time to treatment a measure, it's also a proxy for teamwork. And so if we're able to get our patients in as quickly as possible to treatment, to that first treatment to alleviate any anxiety, try, do our best to try to alleviate unnecessary anxiety for that patient, if we're able to help to alleviate unnecessary anxiety associated with an extended timeline, then that is of course the optimal situation for the patient in their cancer care, in their experience, potentially in their outcome, in their trajectory. It's also a proxy for how well the team is working together.

So within our group, what we've been responsible for over these many years since we've put that initiative in place and since time to treatment became such an important guide for us and guiding light is to look at where do we have trends? So do we have an opportunity on the front end of when a patient is initially diagnosed? Do we have an opportunity to improve that timeline from when the biopsy results to the time when the patient is actually notified of their diagnosis? And in looking at some of those intervals, I'll say, we've been able to pinpoint opportunities for improvement within specific disease programs and then also across disease programs as well. All of what I'm describing is in partnership with our clinical colleagues. Cancer programming is a partner and a supplement, and our responsibility is to help to provide that venue to get some of this additional work done that our clinical partners would never have the opportunity or time to be able to do.

Dale Shepard, MD, PhD: Or even the access to the information.

Alison Ibsen: Exactly.

Dale Shepard, MD, PhD: Because as a medical oncologist, I don't have that same perspective on my colleagues in other areas, so it kind of ties that all together. I guess speaking of tying all together, we are a large organization. We have our main campus, we have our regional sites, we have sites in Florida and London and Abu Dhabi. Tell us a little bit about how we're changing our view in terms of trying to have cancer programs that are across disciplines, but also across locations. So ideally, if you walk in and you seek breast cancer care and there's Cleveland Clinic on the building, you're going to get the same level of cancer care. How are we trying to accommodate that?

Alison Ibsen: Yeah, that's a really important question, especially as our enterprise continues to expand. So this is definitely top of mind now and it's something that we're focused on this year and into the future, is how do we do exactly what you just described? And so we like to start with what we know, foundational elements that are familiar. So we talked about care pathways earlier. We know that care paths are a way for us to export our standard approach to cancer care at a disease program level, at a stage of disease level. So our thought is we have our care pathways, we have them as a tool. We've used them here in Northeast Ohio, certainly beyond our main campus, to perpetuate that Cleveland Clinic standard of cancer care. We've used them with affiliates. Why not use those to help standardize cancer care and start the journey that you just described across the Cleveland Clinic enterprise? So that's one step.

The other step, it goes back to another foundational element of cancer programming and multidisciplinary care is our tumor boards. So we have these tumor boards that our clinical colleagues run and manage and consider such a foundational and critical element to highest quality multidisciplinary cancer care, so we're looking to ensure that all of our colleagues from across the Cleveland Clinic Enterprise across the globe now, including our colleagues at Cleveland Clinic Abu Dhabi, and in the future Cleveland Clinic London, are able to have access to those tumor boards and have the ability to participate, whether that's to listen in from an educational perspective or to present their own complex cancer patients to our disease program experts.

So those are some of the things that we're thinking about, at least as a starting point, and while basic in many ways, we think that those kinds of simple steps are actually going to take us a long way in terms of collaboration and building that network and that integration.

Dale Shepard, MD, PhD: You've been at this for a little while. You've put together a great system. What are you most proud of?

Alison Ibsen: Oh, that's a great question. The relationships. I'm an organizational animal, I'm an organizational beast. People often say, "How do you do this job where you have this very broad scope and a lot of responsibility, and yet your direct operational responsibility, your direct authority, is actually quite limited?" I never take offense to that because it's the truth. I have the lowercase A authority and it's all about influence, leading through influence. I get very, very charged up by that, so I would say I'm most proud of the relationships that have been built, the trust that has been forged.

And building relationships with clinical colleagues like yourself, Dr. Shephard, and so many others across all of our disease programs within disease programs across our Cleveland Clinic enterprise is very gratifying, but being able to sustain them and to coalesce large, diverse groups of people around a common vision, a common set of objectives, and to be able to achieve anything at all in that environment, I'm very, very proud of. We have a great team and they work really, really hard. They're ready to take on anything. That also makes me really, really proud. I think it's the sustainment of what we've done and what we've built and an open-mindedness to the future that really make me most proud.

Dale Shepard, MD, PhD: But you're in a great position. Because you have that lowercase A authority, you get to lead instead of manage.

Alison Ibsen: Yes, yes. It's true. It's true, and it's part of what charges me up. If I go into a meeting knowing that there are people in the room who are on all different pages so to speak about whatever it is that we're talking about - a particular project, an initiative, even just a philosophical discussion - the greatest thing that I can get out of that is helping to unify that group. Because I don't have that capital A a piece, the skin in the game is really just doing the right thing for our patients. And so that is, as you point out, it's a great advantage because I walk into the room with that sole agenda, which is essentially no agenda. It's a patient facing, patient focused agenda, and I think that perspective always wins. That's what we're all here for.

Dale Shepard, MD, PhD: Fantastic. So if people are listening in and they go, "Well, why aren't we doing that?" What advice would you give?

Alison Ibsen: I would say start small, right? Study, learn it, start small. That's what we did here. Certainly before, when cancer programming was started, that was the idea, was let's just see what this thing is and let's not get ahead of ourselves. Let's just feel things out. Because so much of it is about the people, so my advice would be study the environment, understand what's needed, and just set realistic goalposts. And sometimes those goalposts need to be about intangible things like assessing the buy-in from your key players, from your providers. Do they feel the need to have care pathways for instance? I think that's the most important piece, assessing and understanding, who are the players? I call it the coalition of the willing. Who are the players who are most apt prepared and open-minded to try something new? And start with them.

Dale Shepard, MD, PhD: Fantastic. You're leading a great group that's doing big things to help our patients. I appreciate your insights.

Alison Ibsen: Thank you so much. Thanks for having me.

Dale Shepard, MD, PhD: To make a direct online referral to our Cancer Institute, complete our online cancer patient referral form by visiting clevelandclinic.org/cancerpatientreferrals. You'll receive confirmation once the appointment is scheduled.

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