NEW YORK – Duke Cancer Institute is undertaking a project to expand its molecular tumor board to community practices and support the use of precision oncology in these settings.
The initial expansion will focus on patients with lung and thyroid cancers, which are likely to have molecular aberrations targetable by multiple US Food and Drug Administration-approved or off-label treatments. The cancer center aims to expand the molecular tumor board, or MTB, to several counties in North Carolina that have a high proportion of underserved populations, including African Americans, Native Americans, and low-income patients, said John Strickler, an associate professor of medicine at Duke University School of Medicine and co-leader of Duke Cancer Institute's MTB.
The project has support from the National Comprehensive Cancer Network's Oncology Research Program, which this month funded this project and several other research efforts focused on improving care for lung and thyroid cancer patients by optimizing the workflow for providers. The project at Duke received $300,000 in grant funding from the NCCN.
Currently, the MTB meets weekly to discuss cases, which mostly are patients seen at Duke Cancer Institute's main campus in Durham, North Carolina. However, community care sites affiliated with the Duke Cancer Network across North Carolina don't necessarily have the same access to molecular profiling and subsequent MTB support.
"Prior research has found that molecular profiling of cancers is less likely to occur when physicians are lacking support from an institutional molecular tumor board," Strickler said. "The overall goal of our proposal is to expand our Duke molecular tumor board support to our Duke Cancer Network sites, which are generally located in places with higher populations of underrepresented minorities and in rural communities where there are fewer research capabilities and patients don't have the same access to care."
Previous studies have shown that patients have improved access to precision cancer care when community oncologists engage with programs to increase molecular profiling rates and follow an MTB's treatment recommendations. A study from Sanford Health, which serves a rural population in North and South Dakota, found nearly half the patients in community clinics who received molecular profiling through such a program either joined clinical trials or were matched with a targeted therapy.
Another study tracked how readily oncologists at the West Cancer Center, a community-based oncology practice in Tennessee, took up the recommendations of the MTB and found that when expert reviewers pointed to standard treatments, 78 percent of doctors took up their advice; 57 percent of doctors enrolled patients in recommended clinical trials; and 37 percent gave patients recommended off-label treatments.
By focusing on expanding MTB access for individuals with lung and thyroid cancers at Duke Cancer Network affiliate sites, Strickler is hoping to mitigate precision oncology access barriers for a significant number of patients. Non-small cell lung cancer, for example, is more common within groups that this project is targeting, including Black patients, low-income patients, and patients living in rural areas, he added.
"Molecular profiling for those two cancers is particularly valuable," Strickler noted. "The availability of therapies that could potentially spare patients chemotherapy and the toxicity of less effective treatments, and improve survival outcomes long term is why those two particular cancers were selected."
Duke's MTB includes experts from various fields, including pathologists, oncologists, research scientists, hereditary cancer geneticists, and clinical trial coordinators, who review patients' genomic tumor profiling reports and recommend the best treatment options. When determining therapy opportunities, the MTB will also consider germline mutations associated with an inherited cancer predisposition syndrome that patients may have and help their families get tested to assess their cancer risks.
At Duke, most doctors order large next-generation sequencing panels, typically for patients with metastatic disease, though patients may be tested earlier depending on the kind of cancer they have. The cancer institute has partnered with several "preferred diagnostic vendors" for NGS profiling, according to Strickler, including Foundation Medicine, Guardant Health, Caris, and Invitae. His group selected Foundation Medicine as a partner for this project. After patients are tested, the MTB typically discusses their cases within a week.
One aspect of the project is to collect data on current molecular profiling usage among Duke Cancer Network affiliates. Strickler noted that there isn't a good understanding of how many patients in rural, community settings receive testing because "it's highly provider specific." Once researchers have baseline data on NGS testing patterns among community oncologists in the network, they will continue tracking testing rates at community sites to see if greater access to Duke's MTB and other services is improving access.
With greater insights into the testing needs and access gaps among network affiliates, the project will build an internal workflow for the community oncologists to order NGS profiling through the Duke Department of Pathology and receive support from the MTB.
In the past, the Duke Cancer Institute has had difficulty reviewing patients' records and molecularly profiling results from affiliate clinics, according to Strickler, because the format of the test results is difficult to upload in the electronic medical records system. Moreover, legal barriers prevent patient data from moving easily between institutions.
To address this, Duke is developing a bioinformatics workflow to ensure patient records and molecular profiling results are accessible and can move seamlessly between the community sites and its cancer institute. With this workflow, the MTB will have full access to a patient's records, and they will be able to review cases and provide decision-making support to doctors at an affiliate site as easily as they would a colleague at the main Duke Health campus.
Since the MTB access project will focus on communities with high levels of poverty, the cancer institute will also support and advocate for patients who receive bills for the molecular testing they receive. Specifically, Duke's relationships with preferred diagnostic vendors can prevent patients getting bills in the first place. A condition of being a preferred vendor, according to Strickler, is that patients won't receive surprise or excessively high bills. If patients receive a bill, the MTB will reach out to the test vendor to resolve the issue, he added.
Strickler believes Duke's program will be able to provide community doctors better end-to-end support, from guiding testing and treatment decisions to financial support. "It's a much deeper level of support than they would have otherwise received either locally or by relying exclusively on a commercial vendor's workflow," Strickler said. "Before this grant, there was no way for a patient from one of these rural community settings to have all of their information, clinical and molecular data, flow to our molecular tumor board in a compliant way."
The project has kicked off with two Duke Cancer Network sites in Robeson and Scotland counties in North Carolina. In these two counties, about a third of the population is low-income, Strickler said. That, along with the counties' distance from an academic medical center, makes accessing precision oncology care more difficult.
While the project has just begun, Strickler is optimistic that by giving greater access to simpler testing workflows and MTB expertise — or "concierge support" as he calls it — doctors will be able to identify more lung and thyroid cancer patients in the community with actionable biomarkers, increase their opportunities for precision oncology care, and improve outcomes. Such support can also give patients who typically don't have the chance to partake in research more opportunities to enroll in clinical trials.
"One of the aspects of this project that I'm particularly enthusiastic about is that it will allow for our research to be more inclusive of patient populations that have typically been excluded," Strickler said. "And it will allow us to generate scientific insights that are more broadly applicable to a real-world population."