Bringing Surgical Oncology Services On Board

Increasing the number of subspecialists (e.g., breast surgeons, gynecologic oncologists) was identified as the top opportunity to realize cancer program ROI by respondents to ACCC's 2019 Trending Now in Cancer Care survey. On March 4, the Surgical Oncology Pre-Conference to the ACCC 46th Annual Meeting & Cancer Center Business Summit explored what achieving that ROI may entail, with sessions on effective models for integration of surgical oncology services into freestanding practices and hospital-based cancer programs.  

Loren Rourke, MD, MHCM, FACS, and Lawrence D. Wagman, MD, FACS, FPCS (hon), level-set the discussion by delineating the commonalities and differences between surgical oncology and medical oncology services. Dr. Rourke is Chief Surgical Officer, US Oncology, and Dr. Wagman is surgical oncologist, City of Hope, Upland, and regional medical director for the Inland Empire.

Among the considerations regardless of care setting:

• Program/practice marketplace: What is needed in your community? Where are there gaps in care or expertise?
• Physician champion: Do you have physician leadership buy in?
• Recruitment: What are the oncologic surgeon skillsets needed and what care gaps will you fill?
• Infrastructure: Understand the needs of surgical oncology services and assess whether your program is adequately resourced.
• Marketing: How will you spread the word about your surgical oncology services?

As a first step, Dr. Wagman advised “See what you need, see what your resources are, and see what you can do with what you have.”

Pre-conference presentations demonstrated that ROI will come, but integrating surgical oncology services is not a simple or fast process and requires multifactorial assessment. The investment yields multiple benefits. “Bringing services together is beneficial from the patient quality perspective. It's good for patients and for physicians," Dr. Wagman said, citing the benefits of streamlined access to care and multidisciplinary collaboration.

The process of bringing these specialties together is much easier when physicians are employed than in the community, noted Dr. Rourke. Areas of overlap between specialties can be a prickly issue. In sorting this out, “there is no right or wrong answer,” however, she emphasized, “these conversations have to take place upfront.”

Lucy Langer, MD, President, Compass Oncology, a 40-physician practice, shared steps for effective integration of surgical oncology services into an independent freestanding practice. In the today's turbulent healthcare landscape, top-of-mind concerns, Dr. Langer said, are how to survive the multiple pressures exerted on practices and ensuring the practice’s future viability.

Diversifying the practice's portfolio by bringing surgeons on board is one strategy for addressing viability, Dr. Langer said. Cancer clinics considering this option need to proceed with carefully to mitigate risk. This includes assessing patient volumes, practice infrastructure, surgical oncologists’ practice needs, and learning to “speak the same language,” she said. When a surgeon says, “I need a scheduler, it [means something] very different from a medical oncology scheduler." Just one example of the challenges of effectively integrating specialties with diverse processes and workflows. 

When integration is done well, bringing surgeons into the practice offers the opportunity to partner with gynecologic oncologists and surgeons who are upstream, while also more effectively partnering with referral sources, she said.

Compass Oncology’s secret to successful integration? Dr. Langer shared the following tips:

• Bring surgeons into the practice as equals
• Acknowledge the differences between medical and surgical oncology
• Learn what your surgeons need and work to adapt quickly
• Provide leadership opportunities for surgeons, including involvement in governance (e.g., a guaranteed seat on board)
• Acknowledge the challenges to getting the compensation formula "right" and have the flexibility to adjust

Integrating Surgical Oncology Services into a Hospital-based Cancer Program 
Joseph J. Bennett, MD, FACS, Chief of Surgical Oncology, Helen F. Graham Cancer Center & Research Institute, presented lessons learned through development of a highly successful surgical oncology program within a hospital cancer center. 

As in the practice setting, the process begins with assessment, he said. "Do you need a surgical oncology program? What disease site will be your focus?"

Next, consider what your surgical oncologists want to do. These highly trained physicians want opportunities to use their specialized skillsets. At the same time, oncologic surgeons want to work in cancer multidisciplinary care, Dr. Bennett said.  “Surgical oncology is a team sport.”  

Among the considerations and challenges that have to be resolved along the path to developing a successful surgical oncology service are the following: 

• Employment model—Hospital-employed? Private practice? Hybrid?
• Infrastructure to support surgical oncology?
• Culture change for surgical oncologists—providers may feel threatened by the start of a surgical oncology program and a new model of integrated services 
• Referral patterns—navigating changes
• Performance expectations—setting and maintaining these
• Need to evolve
• Recruitment of surgical oncologists

Pre-conference presentations on integration of services across care settings demonstrated that ROI can be realized, but building a successful program takes time and commitment. Equally important to success in all settings: physician champions, supportive leadership, and patience.

Rounding out the pre-conference discussion, Dr. Rourke focused the discussion on the role of surgical oncology in breast cancer  on the patient. Referencing the surgical, medical, and radiation oncology pillars of cancer care and the need for coordination and integration of care delivery, she said, "The patient is sitting on a three-legged stool. If one leg isn’t working well, the patient falls off the stool.”

There is no one-size-fits-all solution to integration of breast surgeons into the cancer program, she said. “It depends on where you live, the market you’re in." However, breast surgeon integration into the multidisciplinary cancer team is the new standard of care, Dr. Rourke emphasized.

"It’s less about owns what in terms of continuum of care and more about can we get all these resources around the table [to benefit the patient]," she said. 

“It takes a village to bring breast surgery into any environment—hospital-based or community cancer center. Breast surgeons are comfortable being part of the team. Not any one person makes this work, it’s administrators, clinicians, staff all working together for the benefit of patients.”

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Stay tuned to ACCCBuzz blog for more takeaways from the ACCC 46th Annual Meeting & Cancer Center Business Summit. On Twitter follow @ACCCBuzz and use the #AMCCBS hashtag.