MONICA BERNER: I'm Doctor Berner, a family physician who cared for patients for over a decade and now chief clinical officer. In this podcast series, we take on key health challenges facing workforces today and what we can do together to address them for employers and their employees. The field of cancer is changing quickly and becoming more and more complex. Cancer is America's second leading cause of death, and cancer rates are rising in younger adults. For employers, it's now the top driver of health costs. But even though cancer is so common, those who are struggling need to know they're not alone in facing it. I want to welcome my guest today, Doctor Joseph Alvarnas, who I am honored to get to talk with about all this. Doctor Alvarnas, please introduce yourself and tell us a little bit about your experience as an oncologist.
JOSEPH ALVARNAS: Doctor Berner, it's a pleasure to be here with you this morning. I am a professor of Hematology at the City of Hope. I've worked there for about 28 years, and most of my work has been focused either in the care of patients with acute leukemia. I spent a lot of that time working as a blood and marrow transplant physician. And I also worked in the care of patients with HIV related malignancies. One of the things that's been really striking over the course of my career is how much care has changed, and how patients today can now enjoy outcomes and opportunities for survival that couldn't have imagined being possible 28 years ago. It's a pleasure being here with you.
MONICA BERNER: Thank you. So as we mentioned earlier, cancer rates have been steadily increasing. And especially among younger adults. It's estimated that we'll have over 22 million people living with cancer by the year 2030, and over half of them could still be considered part of the workforce, given the typical retirement age is going up. Help us understand the root cause of increasing rates and how this is affecting employers and their workforces now.
JOSEPH ALVARNAS: There's a series of phenomena going on here. One is on the earlier diagnosis side. There are probably a multitude of factors, including behavioral factors. The epidemic of obesity in the United States, continued smoking rates, and other health challenges that are finding their way towards increased cancer diagnoses in young individuals. The other factor here, though, is that our delivery system, our ability to serve patients throughout the country, has become increasingly challenged both by the portfolio of new treatments as well as gaps in care to oncology care, especially for patients in rural areas, which are significantly underserved.
MONICA BERNER: And it's also been said that medical knowledge used to double every 50 years. And today it doubles every 73 days. And this is especially true in the field of oncology where there is much research going on. What does this mean for patients, their families? And what does it mean for oncologists who are trying to practice the best way they can and care for their patients?
JOSEPH ALVARNAS: For patients and families, the challenges are numerous. In part, those challenges lie in having to work with the physicians and making increasingly complex decisions regarding types of therapies and approaches to care that they're not familiar with. Many patients, through the experience of family members in the past, are familiar with surgery, radiation therapy, chemotherapy. But as we move into a new domain of targeted therapeutics and immuno-oncological drugs, the number of choices and the complexities of what patients face in moving forward and understanding their journey and their choices has grown exponentially. For oncologists, it means that the complexity of care has also grown exponentially, and the idea that previously a lot of our approaches to therapy, again, were driven by that classic triad of treatment modalities. But now based upon genomic information, which has expanded what we're expected to know on a daily basis, the treating patients with lung cancer or leukemia and lymphoma bears no resemblance to what it looked like 10 years ago. It bears little resemblance to what it looked like five years ago, and it's changed significantly over the last year.
MONICA BERNER: Let's back up a little bit and go upstream and talk about the importance of early identification. There are a handful of types of cancer that have evidence based screening guidelines. And of course, there are those that don't. But visit with us a little bit about those types of cancers that we should be screening for, what those recommendations are, and how we can encourage our patients to go ahead with those tests.
JOSEPH ALVARNAS: I love the way you framed this question, because this isn't about deploying tests. It's about establishing relationships with patients or members within an organization so that they understand the value of early diagnosis. We have a portfolio of preventative, diagnostic testing, screening tests, that continues to grow. We not only have technologies which go back decades, like mammography and pap smears and blood tests like a PSA, but also increasingly important technologies like low dose CT scans for early detection of lung cancer. They all have one thing in common. They're profoundly underutilized. One of the estimates that I saw come out of the COVID-19 pandemic is that delays in screening were-- and these were data based from both the United States and also from the United Kingdom's national health service-- which estimated that delays in the use of preventative screening tests were going to increase cancer mortality by significant percentages. Because people were going to be diagnosed at more advanced stages, where cancer was less curable. So the important message for patients and families here is that you have the power to survive cancer within your hands, and with your behaviors, by getting screened early and consistently. And in doing so, cure rates can rise significantly, as well as the toxic effects of therapy, or the types of therapy needed to cure cancers can be minimized and the risks reduced by having patients engaged much earlier in the process.
MONICA BERNER: Thank you. And you must know that that topic in particular is near and dear to my heart as a primary care physician. And this is where patients and their PCPs and their oncologists can all partner together. Because really, it starts out with that relationship with your PCP. Getting that early screening and then hopefully we won't even have to have a relationship with an oncologist. But if we do, we hope that we've identified the cancer early enough that it gives you a number of options to offer those patients. So secondly, then once a person is diagnosed unfortunately, we think it's often important for them to get a second opinion, both to ensure that they're getting the correct diagnosis, and for the creation of a treatment plan. But oftentimes, just like the screening, these second opinions don't happen. Can you talk to us a little bit about the importance of a second opinion, and the barriers that people encounter when doing so?
JOSEPH ALVARNAS: This is such an important topic. Once cancer is diagnosed, there's a whole inertia about people moving forward to treatment. And given the emotionally devastating nature of hearing those words, you have cancer, a lot of patients and families don't pause for a moment to consider how they should think about what happens next. Very few patients, a very small percentage of patients actually get a second opinion. And the value of a second opinion, especially as the complexity of cancer care has grown, is that there may be new options that have evolved as a result of advances in treatment technologies or advances in risk stratifying diagnostic technologies. And in fact, there are patients today who can do very well without chemotherapy, who a year ago or five years ago would have been treated standardly with chemotherapy. Unless patients and families take the moment to get the full breadth of information that they need to make the best choices possible, you could miss out on one of those opportunities to find not only more effective treatments, but treatments that have less toxicity, greater convenience, greater life sustainability in moving forward.
MONICA BERNER: I've often heard from my patients that they have a belief that chemotherapy is just a singular cocktail of poisons that they're being administered. But clearly that's not the case. When a person is diagnosed accurately and staged accurately, oftentimes there are a handful of options for them to select from. How do patients know what's the right choice for them?
JOSEPH ALVARNAS: One of the important things to consider here is outside of a couple of malignancies that grow at a breathtaking pace, acute leukemia being one of them, patients actually oftentimes have enough time to think through their options. And that involves, was the diagnosis correct? And by diagnosis that also means was certain genomic testing done or genetic testing to let you know what's the risk. What's the biological behavior of that cancer? And then the other thing you raised, which is really important is adequate staging. Because sometimes we think cancer is more extensive than what it is. Sometimes cancer is more advanced than what we think. And if you don't have a clear vision of where you're going, you may move forward with treatments that don't match your need. The other part, though, is, and I love it because it's so true throughout the course of my training, back when I was a resident in the early Mesozoic era of the 1980s, we literally had a recipe book of chemotherapy. And you would turn to the page for breast cancer, and there were one or two combinations. We don't do that anymore. The idea is that there's an extraordinary breadth of therapeutic options for patients, and the way to move forward is to find a physician who helps work with you in shared decision making. The second thing is, to get the aid of expertise that might be as current as possible, and understanding what these new technologies mean for you as an individual, and then to make sure you have clarity as to what is the plan and why is that the best approach for me. Patients oftentimes are too afraid to ask questions, and my best advice to them is be provocative. Ask questions. Put a hard stop there before moving forward, because some of your best options might not be self-evident at first glance.
MONICA BERNER: I love that. And that of course, is incredibly important when you develop a relationship with a trusted oncologist or primary care provider, or honestly, any specialist, if you will. It's really important that they know you as a person and that you as a person feel comfortable asking these questions. Because this clearly is important to your well-being in the end. Unfortunately, many of us don't live in urban settings where we have options for second opinions nearby. So how do we bridge that gap for our patients that are living in rural areas, or small towns?
JOSEPH ALVARNAS: There are a number of challenges for patients, particularly those who live outside of major urban centers, to get access to care. The first is there is a nationwide shortage of oncologists, which means that many patients living in the more rural, the 3,000 counties in the United States may not even have an oncologist close by. The second thing is that oncologist might not necessarily be an expert in your specific type of cancer. What makes the path towards great care, optimal care, with phenomenal outcomes possible is the idea that information is portable. So the best way to move forward is to find ways in which clinicians in these communities that are underserved, based upon the limited number of oncologists and the extraordinary burden placed upon those oncologists to be all things, to all patients, to find better ways for them to work in partnerships with clinical experts at centers like the National Cancer Institute designated Comprehensive Cancer Centers, which are our nation's designated centers for top cancer technology. They're clusters of knowledge and expertise.
MONICA BERNER: So we've talked about screening. We've talked about the importance of getting a second opinion, so you have an accurate diagnosis. And you have a great understanding of the options available to you for treatment, once you have the accurate diagnosis. What about the role of palliative care?
JOSEPH ALVARNAS: So important. So I'll start by saying I think palliative care needs a rebranding. We've seen this before, to some good effect. We've seen it with some bad effect with the New Coke. But I think the idea is when we call palliative care, palliative care patients and families have a reflexive reaction, which this is something about helping patients transition at the time of death. And nothing could be further from the truth. Palliative care, in its full fruition, represents a series of supportive care technologies, support tools, and clinicians who work to help humanize the cancer journey. The first and most important step in supportive care is determining what are the goals of care. Are you moving forward in a cancer care journey that's focused upon hearing that cancer? Is this focused upon palliation and quality of life? What are the values of your family? What are the values that you seek? What are the things that you fear? And supportive care medicine physicians and their ancillary colleagues create an ecosystem around a patient to help not only identify where are we going with this, but also finding ways to avert distress, insomnia, the fact that food can taste awful when people are getting treated. The fact that they're not sleeping well. Even challenges of talking to their children and family members about what this cancer diagnosis means. There is a powerful portfolio of ways to support patients and families and humanize the cancer journey that for far too many patients are untapped and unrealized, which is why people fear that cancer journey. So I think if we could integrate supportive care medicine from the time of diagnosis through the time of survivorship, then you can really not only enhance the value of care, but transition from something that patients dread to something that represents a path towards wholeness and restoration to wholeness.
MONICA BERNER: Thank you. I absolutely love that approach. So I think what I've heard today really resonates in that the pace of discovery in oncology is stunning, and it really does offer great hope to many patients. Unfortunately, there are a lot of oncologists who use former paradigms to treat patients, and a lot of times patients, because they're so devastated and they're uncomfortable in a clinical setting, don't necessarily have the courage to speak up and ask the right questions. So we want to avoid the old fashioned oncology, using a hammer, right? When you should be perhaps using a wrench or even something more fine tuned. And also want to make sure that we're following clinical evidence. And that is effectuated through getting that second opinion and making sure that we're all doing the right thing, because we do have better therapies that have increasingly humanistic ways to consider the side effects, consider the desires and the future plans of the patient, which can be less costly in the end as well. Even though that's not our primary goal, our primary goal is to think of the patient first, always. But when we look at the variety of cancers and the new hope around the survival expectations, I think we should all be very optimistic about the future and what we can expect within the 10, 15, 20 year realm. Whereas perhaps in the past people did think of cancer as a death sentence, it's not necessarily so any longer. So given all of these things that we've talked about, what would you say are the top three things that employers can do to best support their workforce in the face of cancer, either upstream, midstream, or downstream?
JOSEPH ALVARNAS: The first is that employers need to work with their employees to try to get patients and families diagnosed earlier in the process. This includes not only helping them to form better relationships with their primary care doctors, and get existing screening tests, but as new screening technologies become available, helping employees to get access to those would be very important. The second component here is to help provide them with assistance and ensuring that the diagnosis is correct, and to provide resources in terms of being able to reality check their care, to make sure that they're receiving the right care for the right diagnosis, delivered with the right level of expertise. A third way that employers can help is to realize that cancer care doesn't end with chemotherapy, or with immunotherapy. That there's a whole phase called survivorship in which people may have unmet needs, and finding ways to support employees during that period of time, when they've gone from people under active treatment to those receiving survivorship care, represents an untapped area where employees could benefit significantly from the current state.
MONICA BERNER: I think those are all really important points. Because in fact, when we think about cancer, it is not a singular point in time, right? It is those things that you do ahead of time, whether it is lifestyle modification or screening. It is what you do when you receive that diagnosis to make sure that it's accurate and you're receiving the best care. And then it's also understanding that your social support system, your employer, your family, your friends, your coworkers, can all be part of that recovery and the aftermath of a cancer survivor. So I really appreciate all that you do, and we appreciate everything that our employers do as well. On behalf of their employees. Thank you for your time today, Dr. Alvarnas.
JOSEPH ALVARNAS: Thank you so much for the opportunity to speak with you. It's been a pleasure.
MONICA BERNER: At the end of the day, the cancer journey is a human journey. Dealing with cancer is incredibly stressful and sometimes the paths that lead to the best outcomes feel overwhelming or out of reach. That's why we need to work together, doing everything we can as health care providers, specialists and insurers, and as employers to alleviate that journey for our employees. Because when it comes to cancer care, one less thing can mean everything.
