The Cancer Letter ran an in-depth interview with José Baselga, Memorial Hospital’s Physician-in-Chief, about the Memorial Sloan Kettering Alliance, in its September 27, 2013, issue.
The interview — conducted by Cancer Letter editor Paul Goldberg and reprinted below — outlines Memorial Sloan Kettering’s plans for pursuing collaborations with other institutions and describes the MSK Alliance as a “mission-oriented” initiative.
Paul Goldberg: Why does Memorial need an outreach network?
José Baselga: I think [there are] a number of reasons why Memorial Sloan Kettering is launching its outreach program. I think that the most important thing is that this is a mission-oriented objective.
The vast majority of cancer care in the US today is delivered in the community, and we feel strongly that we need to be present there. We are aware that it may take years to have some of the key advances be developed in the community, so that’s something we want to be present.
We are worried we are just providing our care in one isolated location, so I think to be in the community is important; is one component to that.
The other component to the whole thing is that clinical trials are going to be increasingly complex, and we are seeing totally unprecedented fragmentation of the tumor subtypes that we’ve had until now.
With the new set of clinical trials based on mutation-driven tumor classification, we just don’t have the numbers to be able to ask the questions that we want to face. So I think that’s also an important component.
And then the third one: We feel strongly and we have had a lot of discussions within Memorial Sloan Kettering that we need to learn from the community. We see this as a bidirectional experience in many ways.
We also need to learn how care is delivered efficiently out there, and maybe we can bring that to our main campus as well.
PG: There is a sort of overwhelming scientific rationale for doing this, and that might just be the numbers of patients available to conduct relevant trials.
JB: Yes. I think that’s very, very clear. So one of the things that’s happening is that with the availability of sequencing — doing deep sequencing with every single tumor — we are seeing is that there are a number of driving mutations that are present in a very small proportion of tumors.
And one of the things that we are launching is a whole set of what we call basket trials, in which we are testing specific therapies against oncogenes or mutant genes, that go across platforms.
And some of these genes are mutant in only 1 to 2 percent of our patient population, so we need to expand. One of the major focuses of this alliance is to be able to genetically annotate all the tumors in the community, and to be able to identify patients that may benefit from our clinical trials.
PG: Of course Memorial sees about 12,000 to 13,000 new patients per year, and Hartford, which isn’t one of the largest health systems, sees about 6,000. Is that a good beginning or is this good enough?
JB: It’s a good beginning. I think that, just by this initial alliance, we are increasing our potential number of catchment areas — if you wish, in terms of patients — by 50 percent. So it’s a substantial number of patients.
This is a good, healthy network. I think it’s a very good starting point.
If we are successful, if we are satisfied in the way this process moves, and if we feel that we provide value and that we can achieve some of the objectives, then we are in place to expand to other networks.
We are thinking that we could, down the line, have a number of alliances, that could expand to between six and ten networks down the line. And that would then increase the number of patients even more.
But it’s more than a numbers game. I think what we are focused on right now is on making this a successful enterprise. It’s going to be a process.
PG: So you are really thinking 40,000, 50,000 patients? Somewhere in there? That’s huge.
JB: That is huge, but I think that’s what this field needs.
And, again, we are going to be seeing such a fragmentation of the tumor subtypes that we are going to have not hundreds of tumor types, but thousands of tumor types. So we are going need large numbers if we are going to address some of these questions.
PG: That’s the way to stay scientifically relevant?
PG: What’s the business rationale for doing this? Is it a cost, or is it a revenue generating activity? Or is it an investment?
JB: Well, you know, I think we’ve made clear through the whole process that this is not, for us, a revenue [issue]—or at least we are not doing this for the business, to create revenue. This is a mission-oriented project.
It could be that it’s costing us. I don’t know; we will see.
But clearly the objective is not just a business proposition; it is rather a mission one.
PG: I guess that sort of leads into the next question, which is: how is this outreach network different from other outreach networks?
JB: We have spent a lot of time trying to decide on what is the content of our outreach network, and we want to make sure that we have decided to do it, that we need to make sure that we would provide content to it — that it would be deep and meaningful.
Our process, our network, will have two components that are important:
One is the clinical program part to it, and with that, what we are doing is we are providing access to our expertise and our standards of care, and we have put a lot of resources into that cause.
Physicians in the network are going to be embedded into our disease management teams. They are going to be an integral part of our teams. So that’s going to be powerful and useful, I hope.
We are going to be developing a bidirectional communications process in which we are making sure that we both learn from each other. We are going to be sharing with them our practices, our standards. Our templates, in many occasions, our order sets.
It’s going to be sharing all of our own internal processes: access to grand rounds, to our CME. We are going to be able to provide on-site observerships that are going to be designed based on their needs.
And something that is very exciting to us — we still need to work on it — we are going to be tracking outcomes. We want to be able to track the outcomes of patients being treated in the community. That is a critical part of the experience. It relates to the clinical program part.
Then the other thing about the clinical trial sites is that it’s a full integration. We are going to be opening our clinical trials [at Hartford]. We will have our personnel — it will be our [clinical research associates], our data managers, our coordinators — they are going to be Memorial Sloan Kettering employees.
It will be a centralized IRB, so there is going to be no difference from one of our own operative networks.
They, of course, have a number of clinical trials — and they don’t have to do all the clinical trials under the Memorial clinical trials umbrella. But for those trials that are part of our agreement, they are going to be Memorial clinical trials.
I think that if you are going to put together both the clinical program and the clinical trial part of it, this becomes a very unique alliance.
JB: Well, a number of things. Proximity is important. We can visualize clearly that once we know how to do this, we could build partnerships that would be more distant, once we figure it all out. But for this early time, Hartford is still within driving range, so we can still go back and forth.
And, further, we were very impressed by their quality. This is a high-quality network. They are superb in delivery, in training, and in some of the initiatives they are taking. They are very avant garde.
As we were talking to them, we felt they were fulfilling all our pre-specified criteria that we would seek in a partner.
PG: How will the informatics piece of it function? What are the goals?
JB: The goals — at this point the informatics should support some of the objectives that we want to achieve.
A very obvious one is that we are going to be sharing the genotyping of our tumors. So the investigators at both sites of the alliance are going to be able to check and identify all of the data that relates to tumor genotyping. That’s something that would be easy to incorporate.
And the same applies to the clinical trials and to all the other things that we already have online such as our standards of care and access to disease management contents.
The thing we need to still work on is that we need to make sure that we will be able to obtain outcomes, data from our IT support. Also to share, find a way that our electronic medical record systems will talk to each other.
So, ideally, you would like to see a seamless integration between the two systems. I think that’s something we are going to be working on intensively in the next six months.
We just announced the alliance, but I think before it comes alive and fully operational, it’s going to be a process, and especially on the IT part.
We are working with Wendy [Perchick, Memorial Sloan Kettering chief of strategic planning and innovation] and with Peter Bach [director of the Memorial Sloan Kettering Center for Health Policy and Outcomes], and we will see what shape that takes.
PG: What can you say about health services research? How will you know you are succeeding? What are the metrics?
JB: Remember the expert here, the visionary, is Peter Bach, who has a very clear mind on what kind of metrics can be applied.
We are concerned about delivering high-quality care at an appropriate cost. The ratio between the quality of care and patient outcomes and the cost is going to be important. We would be extremely satisfied — and it would be like mission accomplished — if we can see that over time the outcomes that this alliance brings to the community improves.
If we could show an improvement in patient-based outcomes, such as improved survival, such as improved number of quality metrics — which I think we could do, because we have these in-house at Memorial Sloan Kettering, and we have our own benchmarks — I think that we could compare benchmarks and identify ways to improve.
I think that would be, to us, a tremendous success. So that’s what we are going to be focusing on.
PG: So you’d look at something fairly narrow, such as a specific disease site? Or would you look globally?
JB: Well, it could be disease site, that’s one issue; it could be based on certain procedures, such as surgical outcomes. It could be based on specific metrics, such as many infections and readmissions.
Basically, since we have our own quality and safety program here at our main campus, there is a lot of metrics and parameters that we can use as the basis for comparison.
PG: Peter Bach says it’s a work in progress.
PG: What’s the next step? Will this be a regional network? National? Worldwide? What’s the timeframe?
JB: We are going to take it one step at a time.
We want to be sure that we feel comfortable in what we do. And we are facing right now, two components to this.
We have, on one side, a significant expansion of our own network. We are going to be opening two new network sites in the next couple of years. So these are Memorial-owned and operated sites. That’s keeping us busy.
And then we want to make sure that [the alliance] is working.
If this is working, the next step would be to expand to between six and ten additional alliances. I would imagine that the majority at this point would be regional.
Maybe, if we feel satisfied and confident, maybe we want to be exploring another alliance nationwide.
Worldwide? These are bigger words. It’s difficult, very difficult, to export the Memorial Sloan Kettering experience and reality to a setting that is different than ours, so we are going to be very prudent when it comes to international initiatives.
PG: I guess the last question is, are you the architect of this, or is Dr. Thompson?
JB: It’s a joint [project]. We both share the blame.
I think it’s something that we discussed. We have all these leadership meetings.
We all agree that this is something we need to be in the community. I have been deeply involved in shaping the precise vision on how to implement that. And I did spend a lot of time doing that.
But I think the whole leadership, [including] Craig, shares this vision.
PG: It also seems to be very similar to what NCI is doing with the cooperative groups, at least in part.
JB: Yes. I think what is happening is that that’s where the science is taking us.
We all see the direction that our research is taking — that’s clear. I think the issue is going to be the implementation.
How/what will be the best way to implement this? And maybe there is not a joint recipe, and the NCI is doing something similar, which is to provide the testing of tumors to identify these mutations. I’m able to think other major networks should be doing the same, because that’s the way cancer care will go.