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New ASCO president: Society must help oncologists thrive while focusing on patients’ best interests
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Daniel F. Hayes, MD, FASCO, will begin a 1-year term as ASCO president in June.
Hayes — professor of internal medicine, Stuart B. Padnos professor of breast cancer research and clinical director of the breast oncology program at University of Michigan Comprehensive Cancer Center — has been an ASCO member since 1986.
He has served on several of the society’s expert panels and, in 2009, he chaired the scientific program committee for the ASCO Annual Meeting. He also served on the society’s board of directors from 2011 through 2014.
HemOnc Today spoke with Hayes about how oncology has evolved during his career, what he hopes to accomplish during his term as president, and the ways ASCO’s membership can help him and his colleagues succeed and maximize the society’s potential.
Question: What was your reaction upon being selected ASCO president?
Answer: I was, of course, excited and honored. I never thought I would be in a situation where I would become president of an organization as far-reaching and impactful as ASCO, following in the footsteps of so many incredibly talented giants in our field. I have been amazed by ASCO’s broad constituency, representing so many people both in the United States and internationally, and by its stunning portfolio of activities. Perhaps most importantly, I have been struck by how both ASCO staff and volunteers are all are headed in the same direction.
Q: What excites you most about the opportunity?
A: My role as scientific program chair led me to seek membership on the ASCO board of directors, and I was fortunate to be elected in 2011 for a 3-year term. That experience reinforced that everything ASCO does is based upon the question, ‘Is this what is best for the patient?’ That is ASCO’s mission, and that is what excites me.
Q: What did you do as president-elect to prepare for your term as president?
A: Despite being on the board of directors for 4 years and having the other experiences mentioned above, I did not really understand the depth of this organization. So, working with ASCO staff, I have done my homework. I have learned how the various ASCO departments function and how they interact with volunteer committees. However, ASCO does so much, I still cannot get my hands around all of it. To mix metaphors, the last several months have been like drinking data out of a firehose. There is so much to know. For example, I have been a clinician at an academic center throughout my career. Although I have paid attention to health care and reimbursement issues and reform, the concerns of an academic clinician are different from the 50% or so of our members in community practice in a nonacademic setting. I have had a crash course on these issues. I also have had little experience in international medicine and global oncology, especially in low- or middle-income countries. This has become a major priority for ASCO for the past 10 years or so. I have spent a lot of time speaking to ASCO volunteers who have worked in this area, and we are now trying to link with sister societies — such as the College of American Pathologists — that have similar initiatives to be sure we are all rowing in the same direction. As for practice reform issues, I have been on a steep learning curve, figuring out how I can support this already expanding initiative within ASCO so it works out for everybody.
Q: What specific priorities do you hope to address during your term as president?
A: This is an overwhelming question. There are so many facets to ASCO’s programs, and it is hard to say that one is more important than the other. However, one of the most important initiatives ASCO has going right now is CancerLinQ. ASCO has a huge stake in improving the quality of cancer care for our patients afflicted with this disease. We believe CancerLinQ is going to be enormously valuable. Once fully operational, we will be able to access CancerLinQ to help physicians monitor quality of care, interact smoothly with new reimbursement models, improve their practices’ organizational systems, and even place the patient in front of them in a context of thousands of other patients with a similar condition to help guide care. CancerLinQ will be the largest and most granular cancer outcomes database in the world. It will be available to researchers for things that we do not normally pick up in prospective clinical trials, such as postmarketing toxicity surveillance. ASCO has made — and will continue to make — an enormous investment, both financially and emotionally, in CancerLinQ during the next few years.
On the practice front, I am very focused on making sure ASCO does everything possible to help practicing oncologists thrive in this rapidly changing environment. New Medicare payment rules, a wave of demonstration projects, tremendous financial pressures, growing administrative burden, and a huge amount of new diagnostic and treatment information to assimilate have all put unprecedented pressure on all of us who provide cancer care delivery. We all need to be confident that ASCO is the go-to source to deal with these issues so we can concentrate on what we do best — taking care of our patients.
I am very concerned about the clinical workforce. Many of us who came into the field decades ago are getting older. We need to remain relevant to the new generation of doctors — and specifically oncologists — and we need to get young people in the medical schools and training programs to get excited about coming into the field. Another concern is that we may not have enough doctors to take care of everyone with cancer, and that there are health care professionals who provide aspects of care that complement and even exceed what physicians may be able to deliver on their own. We are very anxious to help train and to bring in nonphysician practitioners so we are all working together for patients. Moreover, we believe ASCO should not just be a society for medical oncologists, but also for pediatric, surgical and radiation oncologists, as well as those in the diagnostic specialties. We would like to increase representation in our membership for all of these diverse constituencies, and that means being relevant to their needs and desires.
Q: What do you consider the greatest challenge in cancer care, and how can ASCO help meet that challenge?
A: The greatest challenge in cancer care is that we do not cure everyone. Why not? Several reasons. We need to better understand the biology of cancers and develop better ways to treat abnormal biologies in a manner that is acceptable to the patient — in other words, better efficacy and lower toxicity. Understanding the biology will let us develop better tumor biomarker tests that tell us who does not need therapy or, if needed, which one will not work for certain patients. Overdiagnosis and overtreatment is a critical issue, especially coupled with screening that is life-saving for so many people but results in a substantial number getting therapy they actually do not need. We need to get it right, and we need more and better research to do so. That is what ‘precision medicine’ is all about — getting the right therapy to the right patient at the right time and, if it is a drug, at the right schedule and dose.
What this really spells, if laid out, is research. We need to be sure that people who want to do research feel valued and will be financially supported to do it. Otherwise, we are going to be stuck in 2015 medicine. This year’s proclamation by Congress to increase the NIH budget is a great start. Hopefully the new national cancer moonshot initiative will keep momentum going.
The second challenge is delivery of care. The best drug in the world does no good in the bottle. It has to get to the patient. There are a number of factors related to this concern. For example, oncologic caregiver availability. We need to ensure that reimbursement for physicians is sufficient so our profession is one that people will want to join and stay in, and that they are in geographic and economic areas where oncologists are needed. I am in favor of the new approach to paying doctors for doing things for patients instead of doing things to patients, but this needs to be done thoughtfully and carefully to avoid unintended consequences.
We also need to address the cost of care — which is spiraling out of control — and disparities in cancer care delivery, which is an enormous concern. You should not get good care only because you have money. This is a fundamental right for all.
Q: With so much attention focused on the cost of cancer care, what is ASCO’s responsibility to ensure value?
A: The ASCO Value Framework, published in Journal of Clinical Oncology in June 2015, is the first generation of what we believe will be a major opportunity to help patients and their caregivers decide if a selected therapy is worth it for that patient based on benefits and toxicities, as well as economic cost. The concept has been open for public discussion during the last few months and ASCO is now considering the submitted comments and revising the framework accordingly. The aim is to evaluate the efficacy and toxicity of a new drug — defined as the net health benefit — along with its cost, as compared with the standard of care or older regimen, and work with the patient to decide on the most appropriate treatment for that patient.
Value is in the eyes of the beholder, but we all are going to have to grapple with this. I am very excited about this project, and I think we can work in tumor biomarker tests. A good tumor biomarker test has as much value as a good drug by focusing our therapies on those who need and will benefit from them. It is going to evolve enormously, but we have to walk before we can run, and I think that we have taken a first major step.
Q: Much has been made about the projected shortage of oncologists, as well as the potential for burnout in the field. How can ASCO help ensure a viable and satisfied workforce?
A: I talked previously about encouraging and enticing people into the field. Doing so is a huge challenge, but we are already starting to work on this. ASCO is providing grants to medical schools. These grants are designed so students can have cancer focus groups with dinners with oncology-based faculty. We hope this program will get medical students excited about taking care of patients with cancer.
When I trained, oncology treatment was done in the inpatient setting because, in those days, cancer drugs were so hard to administer. It is amazing what we do now compared with what we did 30 years ago. Most of the really exciting dynamics — the fun of being an oncologist, if you will — are out in clinics, yet we are still teaching medical students on the inpatient service. For solid tumor oncology, especially, the inpatient services in most hospitals have become palliative care wards. I am absolutely aware of the importance of teaching our young doctors how to provide palliative care for patients who are not doing well, but the real excitement is in the outpatient clinics. We need to set up opportunities like medical student oncology interest groups and help work with the house-staff training directors in our hospitals and academic centers so young people can really see why they should go into oncology.
The third component of my concern about the oncology workforce is burnout. We have to be aware that it can and does happen, as well as why it happens. Sometimes it occurs because doctors are seeing too many patients, and sometimes doctors are discouraged because the patients they are seeing are not doing so well. In addition, the bureaucracy of medicine has added to this feeling of frustration. ASCO’s department of education, science and professional development and the newly created department of clinical affairs are addressing these issues. It would be a shame to have people burning out and leaving during a time when we are once again starting to make enormous gains. This is not the time to allow physicians to burn out. It is a time to re-engage them, get them excited and have them understand these new therapies and know how they work.
Q: Is there a specific area of practice or policy in which you would like to see ASCO become more involved?
A: It is important to build more quality control into standard practice. Our diagnostic and surgical colleagues have done an excellent job doing so, but in part because procedures are a bit easier to measure than cognitive services and systemic therapies. Although ASCO’s Quality Oncology Practice Initiative has been a first attempt for such measures, we are optimistic that two important strategies will improve our ability to do so — CancerLinQ, and better standardization of practice pathways and guidelines. Coupled with our value framework, ASCO is clearly taking a leading role that we believe our clinical constituency can trust and embrace.
Q: How can ASCO’s membership help you and the society’s other officers succeed and maximize the association’s potential?
A: This is one of the reasons why I wanted to be ASCO president. It is gratifying to see the number of members of ASCO who want to volunteer their time, expertise and services to the society. During the past 12 months, I have received anywhere from five to 10 emails per week from people asking how they can become involved in ASCO. I would urge people to visit the ASCO website and see the different things we do and the different initiatives we are part of. Determine what excites you. Send an email to me or to the chair of the relevant committee and let us know you would like to help. We are anxious to do what the membership wants us to do.
The membership also needs to remember that ASCO has the Conquer Cancer Foundation. The mission is to conquer cancer worldwide by funding breakthrough research and sharing cutting-edge knowledge, and the vision is a world free from the fear of cancer. ASCO leans heavily upon the generous philanthropic support we receive. The grants we provide to young investigators, many of our educational initiatives, even CancerLinQ are all a direct result of gifts to the Conquer Cancer Foundation. That money does not grow on trees, so if people are thinking about gifting to support cancer research, education and care, I say give it to the Conquer Cancer Foundation.
Q: What is your opinion on the state of government funding for cancer research, and what is ASCO’s role in the effort to ensure adequate funding?
A: As a lifelong academic researcher, I am obligated to say ‘not enough.’ There is considerable concern about long-term, dependable funding to support cancer research. In this regard, ASCO is enthusiastic about Vice President Biden’s commitment to cancer research, as am I. But we do not want to build a bubble that goes away in a few years.
I have been distressed during the past 30 years as I have watched NIH cancer funding follow a sine wave pattern of ups and downs. Although we all hope for ‘big bangs’ and ‘Eureka’ moments in our research, the truth is that cancer research is tough, it can be frustrating and it usually takes long periods of time to pan out. We need to have dependable support to avoid boom and bust circumstances. Our investigators should not have to face a situation in which no more than 10% of grant submissions are funded for periods of time, as was the case during the last several years. We need to be certain we are funding all levels of research at an adequate level. We need to be willing to let investigators approach problems with novel ideas and fail.
Failure to obtain funding after spending countless hours over several months is a recipe for driving young and old researchers out of our field. ASCO has and will continue to advocate for steady, dependable and adequate support. Too many Americans will die of cancer this year. We need to continue to state this problem emphatically. We need to point out that we have made substantial progress through federal funding so that cancer treatment is better and safer, and that cancer mortality is dropping. We need to make the public understand the imperative to keep those statistics improving.
Q: What are the consequences if funding levels are not adequate?
A: I am amazed at the progress we have made in my 30-plus years as an oncologist. I am also amazed at the lack of progress we have made due to lack of adequate funding to extend these advances to areas in which we have not made the progress we’d like. I am convinced that, had we been able to support laboratory and clinical cancer investigators at a much higher level than we have, we would already be far ahead of where we are now.
I am also concerned about losing a generation of clinical investigators in the United States. Young doctors are coming out of medical school with enormous debt — sometimes approaching $250,000 or more. Becoming involved in research — whether it is laboratory, translational or clinical — requires delaying immediate gratification for long-term satisfaction. So, we are asking a young man or woman who has just spent 4 years in medical school to now spend 6 or more years in clinical training to become a clinical oncologist, and to then stay in a research-related field at a much lower salary than one might make in community practice. And, by the way, you only have a 10% chance of getting a grant to support your salary and research. I can do that math pretty quickly, and it is frightening to me.
We need to have more debt forgiveness-type grants, which are available but relatively difficult to obtain, to keep these bright young people in our field. We need to convince Congress that this is a great investment, with a huge return on the dollar in the long run.
Finally, it is not all about academics. The vast majority of accrual to cooperative group trials comes from community oncologists, who contribute their time and, frankly, extra income to participate because it is the right thing to do. Funding for these collaborating practices needs to increase to keep them in the game. No one’s getting rich by doing so, but we should not be asking them to lose money by participating in life-saving research. Advances do no good if they cannot be applied. This goes back to payment reform and government policy, but we need to be sure that all patients with cancer have free and equal access to proper care and therapy. The research around cancer care disparities is frightening, and it needs to be addressed quickly.
Q: So much progress has been made in cancer diagnosis and treatment in the past decade. What are your expectations for the field for the next 5 and 10 years?
A: I wish I was 30 years old again. This is one of the most exciting times in cancer research and therapy in the past 60 years. The advances we have made from the time our predecessors started giving cytotoxic drugs to patients with leukemias and lymphomas — and then when my old boss, Emil “Tom” Frei III, MD, and his partner, Emil Freireich, MD, began to cure cancers by combining agents — are what led many of us to become oncologists. We hit a plateau in the late 1980s, and many of us wondered if perhaps we had seen all we were going to see. Obviously, during the past 10 years, the field has taken off again, taking advantage of the incredible revolution in technology.
In this regard, I am very supportive of clinical trials such as Lung MAP and MATCH, led by the cooperative groups with NCI support. Led by our chief medical officer, Richard Schilsky, MD, FASCO, ASCO has started the TAPUR trial. TAPUR aims to match genetic abnormalities in cancers with drugs approved for one type of cancer, but not for another. TAPUR will be a very pragmatic trial. Patients whose tumors have been genetically profiled using any one of a number of assays, as long as the assay was performed in a CLIA–approved, CAP–accredited laboratory, are eligible. If the tumor has an abnormality that those drugs hit in another disease, then the patient will be enrolled in a phase 2 segment of the study to receive that drug, which would otherwise be given off label.
To me, these trials are really exciting. They are not the future, they are now. They give clinical investigators in academic and community hospitals many options to treat patients using the new genomics as drivers, but in settings in which we can determine if this approach really provides benefit to the patients.
On a different front, immune tolerance has been the fundamental obstruction to effective immunotherapy. Some, but not all, of the mechanisms of immune tolerance have now been discovered, leading to the exciting results we have seen with immune checkpoint inhibitors. I can only see this field expanding, providing us with even more therapies for our patients — especially those for whom genomic analysis fails to identify a druggable target.
To me, the current era is as exciting as it could possibly be, but I am more excited about the unknown. I am sure something is going to happen within the next year that I would have never thought of. That is the fun part of science and medicine. – by Jennifer Southall
For more information:
Daniel F. Hayes, MD, FASCO, can be reached at The University of Michigan Comprehensive Cancer Care Center, 1500 E. Medical Center Drive, Ann Arbor, MI 48109; email: hayesdf@med.umich.edu.
Disclosure: Hayes reports stock and other ownership interests in Inbiomotion and OncoImmune; honoraria from Lilly; consultant or advisory roles with Pfizer; and research funding to his institution from AstraZeneca, Janssen, Lilly, Merrimack Pharmaceuticals/Parexel International Corporation, Pfizer and Puma Biotechnology.