When physician Claire Raab, MD, sat down to read the latest cancer catchment data from Fox Chase Cancer Center in Philadelphia, she was floored.
"We all understand health inequities and disparities, but seeing that data really hit us like a ton of bricks," she said. "It made us realize just how much patients in our community are struggling."
Dr. Raab is president and CEO of Temple Faculty Physicians, Philadelphia-based Temple University Health System's academic practice plan. Fox Chase Cancer Center is also part of Temple University Health System.
Besides the obvious geographic differences — Fox Chase is in a more suburban area compared to the urban setting of Temple University Hospital — Dr. Raab saw that Fox Chase patients were presenting at a much earlier stage: about 1.6, when cancer is still largely treatable.
At Temple University Hospital, less than an hour's drive from Fox Chase, the average stage of cancer presentation is about 2.2, Dr. Raab said, at which point it is much harder to treat.
"We see it on an individual basis, but the data amplified the reality of the challenge," she said. "That realization became our call to action."
The reality of cancer care disparities
Dr. Raab, alongside colleagues Dharmini Shah Pandya, MD, and Rachel Rubin, MD, endeavored to address the circumstances and care needs of North Philadelphians with cancer.
Their work led to the formation of Temple Health's Trauma-Informed Oncology Evaluation Clinic. The team recently shared more about the clinic, also known as MVP-CAN, with Becker's.
Patients come to the clinic through multiple pathways, though the pilot phase focused on incidental findings. These findings can occur when a patient visits the emergency department with a new late-stage stage cancer diagnosis or when a physician uncovers signs of cancer during non-cancer-related ED care.
Dr. Rubin is section chief of hospital medicine at Temple University Hospital and an associate professor of clinical medicine at the University's Lewis Katz School of Medicine.
"The goal of an acute inpatient hospitalization is to address immediately life-threatening conditions," she said. "The workup for cancer, however, can take a few weeks and is really better completed in an outpatient setting where we have more tools available to us."
Dr. Rubin sees these cases as patients she wishes she could have evaluated earlier. A large portion of Temple University Hospital's patient population is uninsured or underinsured. If they have been assigned a primary care physician, they may not have the resources to establish care.
Dr. Shah Pandya is an associate professor of clinical medicine and associate program director of the internal medicine residency program at the Lewis Katz School of Medicine. She said the clinic can close this care gap for patients and physicians.
"We've worked on addressing both of these angles," she said. "Recognizing the lack of accessible primary care physicians for patients, [while ensuring physicians] can prioritize and support patients effectively."
A fresh take on cancer navigation
One way the clinic does this is by taking on care coordination at an individual level, beyond simply telling patients what they should do next.
"Health literacy can be a significant challenge. The logistics of getting a diagnosis can be overwhelming," Dr. Raab said. "Navigating all the providers you need to see, the imaging you need to undergo and potentially needing a procedure can be incredibly difficult for someone without a medical background."
This is where the MVP-CAN clinic's trauma-informed navigator steps in.
"Unlike traditional programs that rely heavily on medical teams, we start by focusing on the social and emotional barriers to care," Dr. Shah said.
The clinic can schedule appointments and even arrange transportation, but some patients still may not understand or receive messages explaining their care plans. While physicians coordinate clinical care, the navigator takes on the role of supporting patients and guiding them toward the healthcare system.
"Rather than relying solely on nurse oncology navigators, we hired a navigator with a trauma-informed lens," Dr. Shah said. "This individual isn't an RN but is skilled in engaging patients who may show resistance."
Optimizing physician performance
The clinic's navigator role enables physicians and care teams to perform at the top of their license, Dr. Rubin said, in what she called a "critical component" of the program.
"The goal is to leverage our physicians' time and skills," she said. "My navigator can spend significant time talking to a patient about what an endobronchial biopsy entails, but only the physician can perform the biopsy itself."
Many primary care physicians are now requesting to send their patients to the clinic after seeing its success. These requests have come so frequently that the clinic is moving beyond incidental findings to helping patients with positive screening results fully transition to oncologic care.
"Our goal is to take patients from that positive test to entering care as quickly as possible, ideally as quickly as patients who don't face those social challenges, if not faster," Dr. Rubin said.
The clinic team brings in the necessary specialists for a virtual consultation, collectively reviewing the patients' imaging or screening results and determining next steps.
With streamlined care, diagnostic work up is often completed before a patient sees their specialist. Not only does this lead to more productive patient-provider interaction, it alleviates the cognitive and logistical burden typically experienced by cancer patients balancing multiple appointments and providers.
"The program has gained significant traction in this second phase," Dr. Raab said. "We have a robust mechanism for wraparound services and the ability to expedite all the necessary work. Primary care physicians have recognized that this is a great way to organize care because we have the resources to do so and we're embedded within the health system."
A key factor in the program's success was the systemwide informatics infrastructure build-out. This includes an e-consultation system, a navigator dashboard and electronic health records that support clinical collaboration.
"This infrastructure has been a vital part of building a massive, multi-specialty program," Dr. Shah said. "Unlike traditional approaches that might start with a specific body part or condition, we adopted an inclusive approach: Anything you find, send it in and we'll figure it out. This level of collaboration has been essential to the program's success. Cancer care is never a single-specialty process; it always involves a team."
What's on the horizon
The clinic is planning to expand its services for primary care offices and federally qualified health centers outside of Temple Health's network, as requests are already being submitted.
"This issue isn't unique to Temple, it's reflective of the challenges patients nationwide face in accessing timely care. This program has the potential for a very wide reach," Dr. Raab said. "I suspect that in a few years, we'll be sitting here with a much larger clinic."
Cancer centers across the U.S. — and, in Temple's case, even across town — are acutely aware of care disparities. The team at Temple Health's Trauma-Informed Oncology Evaluation Clinic has worked to address those inequities for its community.
"It's not easy; this program has required effort and flexibility from all sides to make it successful. Dr. Rubin said. "[When discussing health equity], the analogy often used is patients standing on different-sized stools to see over the fence. I think of this program as building the stool for our patients — ensuring they can get over the fence and into care."