I recently spent two days at the Patient-Centered Oncology Care (PCOC) conference in Nashville, TN. I left thinking a lot about the distance between breakthrough therapies and the point of care, and how much of our field is now focused on closing that gap.
You could hear it on multiple panels, where leaders from community practices and academic medical centers discussed what it takes to bring CAR-T and bispecific therapies closer to home for patients. And you could hear it in multiple conversations about integrating remote monitoring and symptom management to ensure safety and efficacy as new treatment modalities are adopted.
Oncology practices are building the operational models to deliver increasingly complex therapies to their communities. And there is a groundswell of collaboration behind this, as clinicians, practice leaders, diagnostics companies, academics, payers, and support teams work to accelerate the systems that bring the most cutting-edge options to patients wherever they are treated.
As the pace of innovation accelerates, we need to stay focused on the question of access—who really has access to the newest therapies, clinical trials, and the testing that determines whether a patient is a candidate at all?
That was the center of the panel I joined on Thursday, "Is Precision Medicine Making Cancer Care More or Less Equitable?" moderated by Chris Prakash, MD, Medical Director of Precision Medicine at US Oncology, alongside William Oh, MD, Director of Precision Medicine at Yale Cancer Center; Kyle Kitchen, PharmD, MBA, Chief Clinical Officer at Utah Cancer Specialists; and Lori Brisbin, MS, MLS, SVP of Precision Medicine at Texas Oncology.
Dr. Prakash opened by saying, "This is probably the most exciting topic of the whole conference, right?" I may be biased, but I agree. I’d like to share a few themes that have stayed with me since our discussion.
Precision medicine works as a system
Dr. Oh traced the field back more than two decades to the sequencing of the human genome. He reflected on how we are always catching up, because new technologies keep arriving with new opportunities attached. What decides the outcome is the system built around them—and systems must be designed to bring the latest innovations to the right patients at the right time.
I think about this as a chain. You have to know who to test, place the test, get the results back, and use those results in an actionable way. Every link has to hold for the patient to benefit, and the infrastructure supporting that chain varies widely across practices. Some have notifications that remind clinicians to test, patient education included in the workflow, or financial counselors who address cost barriers upfront. Many smaller practices are working toward all of this with a fraction of the staff.
Kyle reminded us of the geography factor. Community practices often draw patients from across rural counties and state lines, and testing penetration typically drops the farther you get from a population center. As precision medicine evolves toward serial ctDNA and MRD monitoring, the requirements on patients grow with it: each round of testing is another appointment to schedule, another trip to make, and another set of results to understand. For a patient that lives hours from the nearest clinic, that turns into a serious logistics problem.
Technology should enable the system
At Flatiron, we ran a pilot in a key disease area looking for evidence of on-guideline biomarker testing. Where we couldn't find it, we surfaced a non-blocking notification in the EMR, where the clinician is already seeing that patient, with the details one click away—making it easy to place the order right from there. That single notification produced a double-digit improvement in on-guideline testing rates against baseline.
This worked because the system helped carry the cognitive load for the clinician. Clinicians are attempting to carry a volume of new information that has outgrown what any individual can hold in memory, and their workflow and technology should help absorb that load. Kyle described FDA approvals arriving weekly, sometimes several times a week, many carrying new testing requirements. All of that volume of new information eventually needs to be synthesized to one decision about the patient in front of you.
Dr. Oh showed what that complexity feels like in the moment. He is a prostate cancer specialist, and described a challenging treatment scenario with a patient in his 60s with new metastatic disease, who could be a candidate for any of three biomarker-driven regimens given his multiple driver mutations. If that choice is hard for a specialist who treats a single disease, it can be even harder for a generalist oncologist treating a broad array of diseases. He expects technology to help, with an important caveat about AI: "The problem with AI is that it's not a human being. How do we look at the person in front of us and help make the best decision for that person?"
The lead domino is testing
The panel closed on genomic databases, which remain heavily skewed toward patients of European ancestry.
Data, and the volume of data available, are imperative to understand the impact of genomic alterations. Variations of unknown significance are unknown due to insufficient evidence to make a determination either way. The solution to this volume issue is more testing, and specifically more testing of under represented populations to understand variability across our patient population.
Lori offered another side of the challenge. Her team used their molecular database to screen for patients with a certain alteration for a lung cancer trial, and the patients they identified included a higher percentage of African American and Hispanic patients than expected. But when it came to treatment, fewer of these patients ended up enrolled in the clinical trial. Somewhere along the way between screening, eligibility and enrollment there was a drop-off; and understanding that drop-off is what her research team wants to dig into next.
Moving forward together
The most encouraging moments in our conversation were examples of groups collaborating across boundaries, often improvising. Dr. Prakash noted that 25 states have now passed biomarker coverage legislation, which, in Texas, has improved payment patterns and reduced denials. Lori described leaning on diagnostic labs until those labs began sending phlebotomists out to patients living hours from the facilities where they had been seen. That same spirit showed up in payer pilots that waive prior authorization when ordering runs through a decision support tool, which has meant faster results for patients on Medicaid.
Increasing equity in precision medicine requires collaboration across organizations, with technology vendors, academic centers, and community practices each contributing something. The more we share our experiences and learn from each other, the better the solutions we'll build for patient care and outcomes. I left the stage inspired, and grateful for the collaborators we get to work with along the way.
My thanks to Dr. Prakash for moderating, to Dr. Oh, Kyle, and Lori for a thoughtful exchange, and to PCOC for hosting us!
.png)