Improving the Quality of Care for Cervical Cancer Patients

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 Shepard, 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 very happy to be joined by Dr. Sudha Amarnath, Co-Director of Gynecologic Cancer Program and Assistant Professor of radiation oncology. She's here today to talk to us about improving the quality of care for patients with cervical cancer. So welcome.

Sudha Amarnath, MD: Thank you. Thanks for having me.

Dale Shepard, MD, PhD: Absolutely. So cervical cancer, you talked about some data you presented at the recent ASTRO meeting, is that right?

Sudha Amarnath, MD: Yeah. So cervical cancer is such a devastating disease to so many women, and in this era it should a hundred percent be preventable. We have HPV vaccination that we know reduces the risks of dysplasia and then the subsequent development of cancer. We have PAP screens and HPV testing, and with early detection we should be able to catch dysplasia and early cancers. If we catch it early, patients do quite well with high survival rates, but unfortunately, a lot of women still don't get access to those things and ultimately, end up with this devastating diagnosis with ultimately a potentially very poor prognosis.

Dale Shepard, MD, PhD: What are the biggest barriers? This is frustrating, because it's something that really is much more preventable than virtually any cancer we treat.

Sudha Amarnath, MD: Absolutely.

Dale Shepard, MD, PhD: So certainly, there's socioeconomic barriers. Are there other things in play that people just don't come and get screened, and they don't get vaccines? What drives this?

Sudha Amarnath, MD: I think the vaccine question is a little bit tricky in places where there's been really a lot of national attention paid to this issue. Like Australia, actually, I think the first Lady of Australia had an early-stage cervical cancer and ultimately pushed for high rates of HPV vaccination in younger people. Over the last decade or so, they've seen their dysplasia rates decrease dramatically. We haven't really had that attention to the HPV vaccination, I think, in the United States. So, I think that there is a little bit of a lack of overall education.

I think that sometimes parents are concerned that an HPV vaccination means that their child will somehow be more sexually promiscuous in the future, so just a lot of disinformation in that space. Then I think what happens on the screening side is a lot of women, after they go through childbearing, their life gets really busy and they start to focus a lot of their attention on their children, their partners. So, a lot of people are missing out on the routine screening that's recommended. So often we see patients who haven't had a PAP test in five years, 10 years, whatever it is, and so I think a lot of barriers there.

Dale Shepard, MD, PhD: It looks like you've done some interesting work trying to figure out how to improve overall care for these patients. Tell us a little bit about that.

Sudha Amarnath, MD: Yeah. So, this is going to be, I think, a longstanding and ongoing project because over the continuum of care for patients from the prevention side all the way through treatment, there are certainly, I think, a number of places where we can better intervene. But after taking care of cervical cancer patients essentially over the last 10 years here at the Cleveland Clinic, I've seen just too many young women who had late diagnoses, misdiagnoses because providers just weren't well equipped to look for the right diagnosis or they missed things, radiologists, whatnot. So ultimately, the idea here was can we just optimize the treatment paradigm for the patients who are coming through our system? If you look at the data nationally, if patients have locally advanced cervical cancer, only about 30 percent of patients actually receive standard of care treatment, which is shocking because treatment hasn't really changed over the last 20 years.

Dale Shepard, MD, PhD: I'm going to say more than a little shocking. That's really shocking.

Sudha Amarnath, MD: It's really shocking, and so I assumed that our numbers would be much better than that, but again, over that continuum of care, we're the Cleveland Clinic and we aim to be the best. So, I wanted to figure out what are the things that we can do along that continuum of care to really make sure that our cervical cancer patients are getting the care that they need to optimize their outcomes.

Dale Shepard, MD, PhD: Makes sense. What were some of the metrics you looked at?

Sudha Amarnath, MD: So, a lot of this emerged from some of the metrics that have come from some of the national accreditation programs in cancer. So, there are two major ones that are run by the American College of Surgeons and Commission on Cancer, the National Accreditation Program in rectal cancer and breast cancer. So, in the other hat that I wear, which is to take care of patients with colorectal cancer, we've seen that multidisciplinary care, and that team approach can really improve patient outcomes long term. So some of the things that they have done in that space is making sure that all patients are presented at tumor boards, all patients have pathology reviewed at the center that they're getting treated at, making sure that all patients are getting their imaging, the correct imaging prior to the initiation of treatment, using things like synoptic reports by our radiologists and our pathologists to make sure that all of the important and vital information that's necessary to make diagnostic and management decisions is there.

So those were some of the metrics that we thought about, but then also specific to this population, you mentioned that there are a number of socioeconomic barriers that exist in this population, and so making sure that all of our patients were being seen by a social worker or talking to a social worker very, very early on in their diagnosis so that if they had transportation or other needs that we could help alleviate that early. Then making sure that they were really getting standard of care treatments to ensure that on the treatment side of things, we were really optimizing the care that they were receiving. So, we ultimately ended up with essentially 10 metrics to start out with.

In the midst of creating this program, we developed what we call a cervical cancer huddle, which is an interprofessional team of people. So that includes typically a physician, a nurse practitioner. We have social workers from our many different regional sites. We have some research folks who join us as well. Every Friday morning for about 10 to 30 minutes, depending on the number of patients we get together virtually and essentially talk about every new patient who is diagnosed with cervical cancer at the Cleveland Clinic all the way through when they're starting their treatment with the goal of making sure that their imaging is correctly being ordered and scheduled, that they're seeing social work and all of these other metrics that we've talked about.

Dale Shepard, MD, PhD: Excellent. So, as we are starting to think of cancer programs at the Cleveland Clinic being across all institutes and all locations, you mentioned regional sites. So regional site diagnosis gets included in this as well?

Sudha Amarnath, MD: Absolutely. So, the guide program is unique in this way at the clinic because our GYN oncologists aren't based not only out of the main campus, but they're the same providers who are at our regional hospitals as well. So, we really are a disease team that reaches across the entire Northeast Ohio Cleveland Clinic system. So that part of the challenge is we're seeing patients at these different locations. We're working with different radiologists, pathologists, all of these various team members, social workers at different sites. So, we wanted to make sure that care was really being optimized at all of our locations and not just here at the main campus.

Dale Shepard, MD, PhD: Excellent. You mentioned pathology a couple of times. Certainly, within sarcoma, pathology is massively important. Cervical cancer, again, you have different levels of dysplasia. How important did you find so far that path review here is important and changes diagnosis or changes approach? Seems like that's something that could really commonly out in the community where people are reading lots and lots of things instead of just cervical cancer, how big a role has that played?

Sudha Amarnath, MD: It certainly plays a very large role. Sometimes there's confusion about whether it's cervical cancer versus endometrial cancer, especially because we're seeing higher rates of cervical adenocarcinomas. So, differentiating between those two because they have very different management paradigms can be really important. Then essentially, management is based off of many things that we get at the time of biopsy like, is there lymphovascular space invasion? How deep is this cancer? So, all of those things ultimately can help affect the management options of, is this patient a good candidate for a radical hysterectomy versus needing to go through chemoradiation? So, it's vitally important.

Dale Shepard, MD, PhD: When you think about imaging, what are the most common things that you see are missteps? Again, we have a lot of different people that might be listening in from different areas. Just from an instructional standpoint, what do people need to be doing that you oftentimes see gets missed?

Sudha Amarnath, MD: Yeah, so I think this is where the synoptic reports really make a big difference because in the synoptic report, you essentially lay out all of the important pieces of information. So that's things like not only how big is a tumor and where is it located, but are the parametrial tissues involved? Is vaginal tissue involved? How much of that vaginal tissue is involved? How deep does it go into the wall of the cervix? Are there lymph nodes that are involved? All of these different parameters affect our treatment decision making. So if any one of those things are missed that can make the difference between a patient undergoing a radical hysterectomy and then requiring radiation or chemoradiation after the fact, which we know leads to increased toxicity and side effects compared to maybe just getting chemoradiation alone. So it's really, really important. That's probably the number one thing that we see is a lot of the radiologists in the community will say, "Oh, there's this size tumor in the cervix," but a lot of these other pieces are missing.

Dale Shepard, MD, PhD: I guess it goes back to pathology as well. I think back to bladder cancer and a diagnosis of whether it's muscle invasive or not, when there's no muscle in the sample, I can imagine that standardizing pathology and biopsies and things are important.

Sudha Amarnath, MD: Absolutely. I think ultimately standardizing these things helps us. Physicians are busy, and having a template that's there to help remind you of what you need to include and what's going to be important for the providers who are treating patients when you're on the diagnostic side, I think can be so helpful.

Dale Shepard, MD, PhD: From a patient standpoint, what kind of patient factors in terms of patient satisfaction knowing, "Hey, look, I have a whole team looking over things," do you get good feedback from patients in terms of changes in care based on this multidisciplinary approach?

Sudha Amarnath, MD: We have gotten a lot of really positive feedback. We haven't studied that kind of question directly, but I think our patients are really happy that social work is reaching out so early. We certainly have had a number of patients who would've had major delays in getting their diagnostic imaging to even get to treatment if a social worker hadn't called them and said, "Hey, we can help arrange transportation for you to get to that appointment." Or "Hey, we have some financial resources that are available that are going to allow you to undergo this treatment." So, I think having that early intervention as well as just having a whole care team that is taking care of them, patients, they see that, they feel that, and it's certainly very impactful to their care.

Dale Shepard, MD, PhD: I guess when we're thinking about a lot of these patients needing social work support and things, with the current program, what's involvement or maybe proposed involvement of patient navigators or outreach programs, things like that?

Sudha Amarnath, MD: Yeah, that's a great question. I was actually really heartened to hear at ASTRO this year that patient navigators will likely be paid for in the next iteration of Medicare. So non-clinicians who can really help patients walk through this process are so important. It's confusing to people who are in medicine, let alone to someone who is newly diagnosed, anxious, overwhelmed, and then you have 15 different appointments. I think at the Cleveland Clinic, we're able to do multidisciplinary visits. So, patients are seeing a number of providers often on the same visit, but a lot of patients, of course, are taken care of in the community. They're seeing multiple providers at different locations over a long period of time. So patient navigators in our hospitals as well as in community hospitals, I think, are just going to be so key to helping patients get the care that they need.

Dale Shepard, MD, PhD: Yeah, that's encouraging considering that if people don't have the right navigation and they miss important parts of their therapy, they're not going to do as well. So, it's an important recognition that if you pay a little bit for navigation and have people get treated the right way, that can only help.

Sudha Amarnath, MD: I think certainly Medicare seems to be recognizing that piece of things, which is why it's going to be part of insurance coverage in the future. I think that will hopefully drive insurance coverage for a lot of the other payers as well and will allow us as well as other hospitals to deliver better care overall.

Dale Shepard, MD, PhD: So, when you think about care for cervical cancer, what do you think would remain the biggest barriers?

Sudha Amarnath, MD: We mentioned the prevention piece. Certainly, I would love to be put out of a job 10 years from now, 15 years from now because everyone is getting vaccinated and getting screened appropriately. That would be ideal. But the other sad part that I didn't mention with cervical cancer is that treatment really hasn't changed in the last two decades, and survival hasn't really changed in the last two decades compared to most other cancers where we've seen these more dramatic improvements with newer therapies. So certainly, especially for our locally advanced and metastatic patients who have unfortunately poor five-year survival rates, really seeing more funding and attention paid to implementing new treatment paradigms that can hopefully help improve upon the care that we're delivering.

Dale Shepard, MD, PhD: Is there anything that you see as being particularly promising in terms of newer therapies?

Sudha Amarnath, MD: In the metastatic and recurrence setting, we've seen some major improvements with the use now of immunotherapy that hasn't played out in the locally advanced setting for some reason, but I think there are more trials that are underway that potentially look promising as well. So, we've had a lot of negative trials. Cervical cancer is due for a win sometime soon.

Dale Shepard, MD, PhD: There you go. When we think about specifically on the radiation side, are there any newer techniques or ways to deliver radiation that seem particularly promising?

Sudha Amarnath, MD: Yeah, so for a very long time, we have done these five weeks of radiation with chemotherapy weekly followed by brachytherapy, which is the internal radiation piece of things. One of the things that I'm excited about is the idea of using more hypofractionated or shorter courses of radiation, which have been very successful in many other sites like rectal cancer sarcoma, to see if we can decrease the amount of time that patients have to spend on treatment, which again, with a patient population that has a lot of barriers to care in the first place and a lot of young women who often have children at home, taking off eight weeks to be able to do treatment is challenging. So, I think that's probably the next thing on the radiation side, on the horizon, which will be exciting to see.

Dale Shepard, MD, PhD: Well, it looks like you have a great group of people that are being very mindful of what it takes to deliver quality care to these patients, and you're doing good work. Thanks for being with us.

Sudha Amarnath, MD: Thanks so much for having us. It's awesome to be part of such a wonderful team.

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

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