Al B. Benson III, MD, FACP, took the helm as president of the Association of Community Cancer Centers (ACCC) at its 36th annual meeting, held March 19, 2010, in Baltimore, Maryland. Dr Benson, a member of the ACCC board since 2003, is a professor of medicine in the Division of Hematology/Oncology at Northwestern University Feinberg School of Medicine, Chicago. He is an advocate of comparative effectiveness research (CER) and evidence-based medicine, and says that oncology must take an active role in its implementation. Dr Benson has participated in organizations, including serving on a number of committees at the American Society of Clinical Oncology (ASCO) and as the immediate past-chair of the National Comprehensive Cancer Network board of directors. The Journal of Multi disciplinary Cancer Care spoke with Dr Benson about his plans for his upcoming year as president of the ACCC.

What are your goals for the ACCC? What are the biggest issues for community oncology in the coming years?

There are a lot of issues that will require continuing effort, and that includes understanding the impact of healthcare reform on the oncology community. I think continuing the theme from Luana Lamkin’s presidential year in terms of workforce issues must be an ongoing discussion. I think globally we need to make sure that the advances and innovations in oncology are maintained, and continuing pressures could greatly affect our ability to do that. That includes not only the workforce issue, but ongoing reimbursement issues, as well as the movement of oncology and practices to the hospital setting and what that might mean for access to care and the type of care that’s delivered.

What challenges does CER pose for community oncology?

We should begin to focus on the issue of evidence-based practice and the data acquisition requirements that we think we will face increasingly over time. Some of this is also related to the concept of CER, with pressure to make sure that oncologists who are participating in these databases have the necessary infrastructure to transmit data for these databases.

As these pressures mount, what impact will that have on other activities and on the outpatient office, including clinical research? The pressure to increase accrual to clinical trials will be heightened the more we are encouraged to practice evidence-based medicine. This will also require the integration of guidelines into practice and the monitoring of practice in terms of the quality of care that is being delivered.

I think much of this is driven by economics and the increased cost of delivering medical care. But my own bias is that the more we can practice evidencebased medicine, the more likely we will be able to use the dollars available for healthcare appropriately—it’s the concept of delivering the right care to the right patient at the right time.

What led you to your current position?

That started with the creation of the Illinois Medical Oncology Society (IMOS). I started out as vice president and eventually became president. Early on, we fostered ties with ACCC as well as ASCO, so through the years I got to know ACCC people very well. I was partly involved because ACCC helped our state society in passing legislation in the state of Illinois on both off-label drug use and clinical trials. Eventually, I was asked to run for the board and just continued to be active within ACCC even after I completed my term of office on the IMOS board.

Healthcare reform is now law. What sort of changes should community oncology practices expect?

I think that one extremely critical change is going to be the coverage of individuals with preexisting conditions— that is, insurance cannot be denied for preexisting conditions. That has been a major concern for cancer patients...even extending to the concerns about screening for cancer and genetic testing with the fear that there will be inability to obtain adequate insurance, as well as other issues such as job discrimination.

The clinical improvements in cancer care have resulted in many more people either having been cured of their cancer or living productively with their cancer. With these steps in the right direction, in terms of improved lives of cancer patients, we have to make sure there are not factors that will adversely affect their lives. These include the ability to have health insurance as well as the ability to be gainfully employed.

What sort of changes do you foresee for radiation oncology?

This actually gets us back to the discussion of evidence-based medicine. One of the discussion points that we’re hearing more and more is the very high cost of imaging. One of these particular areas of imaging that requires tremendous attention is positron-emission tomography scanning. Because of its extensive use, and many say overuse, and because it is quite expensive, it has really had an impact on healthcare expenditures.

One of the problems with imaging is that unlike drug therapies, we don’t routinely conduct clinical trials, so there are far less data as to optimal imaging strategies. You also see huge variation in the use of imaging. One example is surveillance for patients who have completed cancer therapy. In my area of colon cancer, there have been trials conducted to look at surveillance strategies. But that is the exception rather than the rule.

How significant is the mandate that payers cover the patient-care costs of clinical trials?

It’s obviously something a number of members of the oncology community have strongly supported. We need to see how that plays out in terms of possible outcomes and in terms of increasing numbers of patients who are part of clinical trials. One of our concerns is that we really have not improved the numbers of patients who go on cancer clinical trials significantly over a number a years. We’re going to have to carefully look at strategies to improve our numbers of accrued patients.

Given the workforce shortage, are there currently enough oncologists to meet the needs of the millions of newly insured patients?

I think this is an extremely critical component of the workforce discussion. Multidisciplinary oncology groups for years have emphasized the importance of patient access to quality oncology care. There are also concerns that many patients did not have such access and that issues such as reimbursement might affect patients’ access to care.

We’ve also known that we have a growing crisis brewing in a projected shortage of oncologists as well as highly trained oncology nurses and other members of the healthcare team. We have a real potential threat to delivering adequate oncology care. It’s not only the fact that there may be more people with insurance benefits who will now have access, but if you look at the demographics of an aging population, we would expect our number of oncology patients to also increase. A good thing is that cancer survivorship is improving, but we have to have skilled professionals available to monitor survivors over time.

What got left out of healthcare reform?

I think the huge issue is that the reform law does not adequately control the cost of healthcare. Many of us believe that this has to be the next step. It’s why I think the oncology community needs to emphasize evidence-based medicine. This is a concept of multiple components: it includes increasing our clinical research enterprise, being engaged in discussion of CER, and in discussion of where such a strategy might be appropriately integrated. It involves looking carefully at guidelines to try to make sure that people practice the very best based on the oncology principles available. It means we have to start paying attention to imaging.

Getting back to clinical research, we need more investment in understanding human cancer biology so that we can better select patients for appropriate interventions. It also means to make sure that appropriate people are screened, so we can try to limit the number of patients who present with advanced cancers.

It will also include having discussions, and these will really be societal discussions, about what may be more appropriate strategies for end-of-life care. There’s concern about how much is spent in delivering cancer therapeutics for patients who will have no benefit. In addition, we need to make sure that patients have access to appropriate hospice programs, so that they receive the very best in terms of end-of-life care. Of great concern is that most people who enter hospice programs do so within, literally, days of their deaths.