Kurbegov, MD, Dax

Westgate, DO, MPH, FACOG, Candace

Jefferson Digital Commons

C O L L E G E  O F  P O P U L AT I O N  H E A LT HInnovation in Personalized Medicine and Population Health Speaker SeriesMulti-Cancer Early Detection: Supporting Patients and Providers in Navigating the New ParadigmDecember 14, 2021Today's PresentersCandace Westgate, DO, MPH, FACOGDirector, AHEAD programsSt. Helena Hospital Adventist HealthDax Kurbegov, MD, FASCOVice President, Physician in ChiefSarah CannonAlexis Skoufalos, EdD (Moderator) Associate Dean for Strategic DevelopmentProgram Director, Doctor of Health Science in Population HealthJefferson College of Population HealthCONFIDENTIAL – Contains proprietary information.Not intended for external distribution.Multi-Cancer Early Detection:Supporting Patients and Providers in Navigating the New ParadigmDax Kurbegov, MD, FASCOVice President, Physician in Chief of Clinical Programs4CONFIDENTIAL – Contains proprietary information.Not intended for external distribution.• I  have no personal conflicts of interest to disclose.• Dr. Kurbegov is employed by HCA Healthcare/Sarah Cannon (stock ownership).• Sarah Cannon, the Institution that employs Dr. Kurbegov, has been paid for consulting/advisory roles from the following companies: FORMA Therapeutics. Daiichi Sankyo, Pfizer, Bayer, GRAIL, Novartis, Vincerx, AstraZeneca, Boehringer Ingelheim and Incyte (non-compensated).• Sarah Cannon, the Institution that employs Dr. Kurbegov, has conducted research projects funded by the following companies: Agios, Arch, ARMO Biosciences, Array BioPharma, Arvinas, AstraZeneca, Bayer, BIND Therapeutics, BioAtla, BioMed Valley, BioTheryx,  Boehringer Ingelheim, Bristol-Myers Squibb, CALGB, CicloMed, Coordination Pharmaceuticals, CytomX, eFFECTOR Therapeutics, EMD Serono, Foundation Medicine, Gossamer Bio, Lilly, Roche/Genentech, Gilead Sciences, GlaxoSmithKline, Harpoon Therapeutics, Hengrui Therapeutics,  Incyte, Infinity Pharmaceuticals, Janssen, Jounce Therapeutics, Kymab, MacroGenics, MedImmune, Merck, Millennium/Takeda Pharmaceuticals, miRNA Therapeutics, Moderna, NGM Biopharmaceuticals, Novartis, Pfizer, Revolution Medicine, Ryvu Therapeutics, Seattle Genetics, Tesaro, TG Therapeutics, Verastem, Vertex Pharmaceuticals, Xbiotech, Zymeworks.Disclosures5CONFIDENTIAL – Contains proprietary information.Not intended for external distribution.The Staggering Human and Economic Toll From Cancer“Preventing cancer in the first place or detecting it early is the best way to reduce many costs associated with cancer treatment—patient out-of-pocket costs, healthcare payer costs, and indirect costs.”   — AMERICAN CANCER SOCIETY CANCER ACTION NETWORK6UNITED STATES ESTIMATES8.7MYears of lost life1One of the leading causes of death in the US2 with more than 600,000 deaths expected in 20203; $94.4B in lost earnings associated with cancer mortality$1.3TEconomic burden1,5The majority is due to cancers without recommended screening programs$201BAnnual cost of cancer4Total estimated US direct healthcare costs in 2020US, United States.1Islami F et al. JAMA Oncol. 2019;5:e191460. 2https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm. 3https://seer.cancer.gov/statfacts/html/all.html. 4Mariotto et al. (2020) Cancer Epi Biom Prev. 29:1304. 5Based on willingness to pay of $150,000. 6American Cancer Society Cancer Action Network, “The Costs of Cancer: Addressing Patient Costs” 6CONFIDENTIAL – Contains proprietary information.Not intended for external distribution.Benefits of Early Cancer Diagnosis 8CONFIDENTIAL – Contains proprietary information.Not intended for external distribution.Additional Cancers Detected w/ MCED Added to Current ScreeningBreastColonLung (unscreened)Head and Neck (7)Lymphoma (2)Lung (screened)PancreasProstateLiver (2)BladderStomachOther Cancers (22)OvarianUterineEsophagusKidneyCervical0                   20,000             40,000             60,000              80,000              100,000           120,000  140,000           160,000Cancers DetectedDetected by USPSTFAdditionally detected by an MCED among cancers with no current screening guidelinesAdditionally detected by an MCED among cancers with current screening guidelinesHackshaw A, Cohen SS, Reichert H, Kansal AR, Chung KC, Ofman JJ. Estimating the population health impact of a multi-cancer early detection genomic blood test to complement existing screening in the US and UK. Br J Cancer. 2021 Nov;125(10):1432-1442. doi: 10.1038/s41416-021-01498-4. Epub 2021 Aug 23. PMID: 34426664; PMCID: PMC8575970.9CONFIDENTIAL – Contains proprietary information.Not intended for external distribution.Multi-cancer Early Detection test has the potential to identify more cancers more efficiently1 Based on SEER incidence of population ≥50 years. Data on file.Assumes nationally representative adherence to USPSTF recommended screening (breast, colorectal, lung, prostate and cervical cancer) and 100% screening with GRAIL test in the USPSTF screened group.*These costs include downstream workup costs after initial screening test• $25B spent annually in US on diagnostic workup services* for single cancer screenings • Single cancer screening alone estimated: ~$89,000 in diagnostic work-up services* per cancer diagnosed• Galleri could contribute to fractional increase in false positives• Galleri + single cancer screening estimated: ~$32,000 in diagnostic work-up services* per cancer diagnosed8.7M0.74M021345678910206K447K01002003004005006007008009001,000True positives(in 000’s)False positives(in millions)MCED testSingle cancer screening329K cancer types which lack screening guidelinesModeled diagnostic workup cost* per cancer diagnosed could be reduced by 65% when combined with single cancer screening10CONFIDENTIAL – Contains proprietary information.Not intended for external distribution.Areas of Vulnerability with MCED Testing • Education• Access/ Coverage• Patient Selection• Telemedicine• PCP Role• Equity Issues• Gold Standard?• Impact of Phase Duration• Provider Comfort/ Competence• Subspecialty Preparedness• Patient Satisfaction/ Distress• Patient Education• Timeliness/Delays• “False” Positives• Absence of Standards• USPSTF Compliance• Outcomes Reporting• Patient/ Provider• Satisfaction• RegistriesInitiation Testing Diagnostic Odyssey Long Term Follow-up11CONFIDENTIAL – Contains proprietary information.Not intended for external distribution.HCA Healthcare is one of the nation’s leading providers of healthcare services, comprised of more than 2,000 locally managed sites of care including 183 hospitals in 20 states and the United Kingdom.Other sites of care: Our affiliated services:^ Approximate                                                                                                                *As of June 2021                                                                                                       All information is as of Sept. 30, 2021 unless otherwise stated. 275Kcolleagues93K+registered nurses47Kactive and affiliated physicians^By the numbersLeveraging Scale and Experience12CONFIDENTIAL – Contains proprietary information.Not intended for external distribution.Key HCA Programs Relevant to MCED Preparation• Oncology Nurse Navigation• High Risk Programs/Lung Nodule Program13CONFIDENTIAL – Contains proprietary information.Not intended for external distribution.Sarah Cannon Navigation – A Model for HCA200oncology navigators1110+HCA Healthcare hospitalsHCA Healthcare Hospital Locations (180+ hospitals in 20 states)Far WestContinentalMidAmericaNorth TexasSan AntonioCentral West Texas Gulf CoastNorth FloridaWest FloridaEast FloridaSouth AtlanticMissionCapitalTriStar1 Director10 Navigators1 Director20 Navigators1 Sr Navigator1 Director16.5 Navigators1 Director14.5 Navigators1 Director12 Navigators1 Director13 Navigators1 Director11.5 Navigators1 Director14 Navigators1 Director11 Navigators1 Director9 Navigators1 Director15 Navigators1 Sr Navigator1 Director8 Navigators1 Director17 Navigators13 Navigators1 Program Manager4 Virtual NavigatorsMountainVirtual Navigation1 Director9 Navigatorscancer patients navigated since 2016123,000+ ¹Includes virtual navigators and senior navigatorsVirtual & In-Person NavigationaskSARAH Resource Line + Web Chat14CONFIDENTIAL – Contains proprietary information.Not intended for external distribution.Oncology Navigation WorkflowSARAH CANNON NAVIGATION Touch PointsBMT = bone marrow transplantCARE = Clinical Alignment and Resource Effectivenesschemo = chemotherapyMDC = multidisciplinary caremed onc = medical oncologymgmt = managementPCP = primary care physicianPatient Care ContinuumBegins at diagnosisEnds atSurvivorship15CONFIDENTIAL – Contains proprietary information.Not intended for external distribution.Sarah Cannon Model of Virtual MCED NavigationAreas of ImpactPre-test• Patient/Provider EngagementPost-test• Patient Experience• Patient Understanding• Patient/Provider Satisfaction• Timeliness of Care• Diagnostic Pathway Compliance• Outcomes TrackingProviderCommunicationCancer Care Warm Hand-OffInitiationIntroductions& AssessmentsEducationCare Coordination:Imaging/Procedures Support & Barrier RemovalData CollectionMCED Signal Detected WorkflowSubspecialistReferrals16CONFIDENTIAL – Contains proprietary information.Not intended for external distribution.High Risk Program Development Case Study:Incidental Lung Nodule• Low dose CT screening has been demonstrated to save lives, but less than 6% of eligible patients are screened• Thousands of CT scans performed annually demonstrate a nodule requiring following • The rate of follow through for nodule evaluation is very low17CONFIDENTIAL – Contains proprietary information.Not intended for external distribution.• Program pilot completed• Build guided by a multi-disciplinary steering committee• Standardized criteria and workflows utilized across the enterprise• Program “qualification” criteria established• Primary Care communication templates implementedKey Steps in the Programmatic Build18CONFIDENTIAL – Contains proprietary information.Not intended for external distribution.Sarah Cannon/HCA Lung Nodule Program• Evidence-based algorithms for at-risk patient populations• Queries structured and non-structed data• Identifies critical nodules that are “incidental” to visit• Follows evidence-based clinical guidelines• Coordinate with medical teams• Personalized education and navigation• Streamlined scheduling• Improves patient adherence and satisfaction19CONFIDENTIAL – Contains proprietary information.Not intended for external distribution.839KCT’s Processed         (>50 Facilities)14K (1.7 %) Confirmed Nodules687 Lung Cancers DiagnosedLung Nodule Program Impact 202120CONFIDENTIAL – Contains proprietary information.Not intended for external distribution.• Substantive preparation is required for successful MCED test introduction• Produce educational content for patients/providers on the new paradigm• Develop standardized assessments pre-implantation to assess readiness• Consider navigation/coordination models to support patients• Define a scalable “easy button” for participating providers• Engage the multidisciplinary community well in advance• Define key metrics and plan for data collection from the outset• Ensure organizational “buy-in”Summary of Strategies to Support Patients & Providers in an MCED21CONFIDENTIAL – Contains proprietary information.Not intended for external distribution.NFIDENTIAL – Contai s proprietary information.i t ded for external distribution.THANK YOU22CONFIDENTIAL – Contains proprietary information.Not intended for external distribution.© Adventist Health 2017Precision Cancer Risk Assessment and Early Detection  Candace Westgate DO MPH FACOGDirector of AHEAD programsSt. Helena Hospital Adventist Health23CONFIDENTIAL – Contains proprietary information.Not intended for external distribution.Disclosures: • Consultant:  Myriad Genetics Laboratories • Speaker Bureau: Grail, Myriad Genetics Laboratories 24CONFIDENTIAL – Contains proprietary information.Not intended for external distribution.AGENDA● Precision Cancer Prevention and Early Detection (AHEAD)● The Nuts and Bolts● Improving Early Detection (MCED)● Catching it when it counts ● Action Steps ● Build your toolbox. 25CONFIDENTIAL – Contains proprietary information.Not intended for external distribution.© Adventist Health 2017A.H.E.A.D PROGRAM’sCandace Westgate DO MPH FACOGDirector of AHEAD programsSt. Helena Hospital Adventist HealthHelping You And Your Patients Stay A.H.E.A.D Of Cancer –responsibly and sustainably 26CONFIDENTIAL – Contains proprietary information.Not intended for external distribution.27CONFIDENTIAL – Contains proprietary information.Not intended for external distribution.INTENSITY OF MEDICAL MANAGEMENTHigh RiskModerate RiskLow RiskCancer Risk Assessment = Personalized Management to Improve Patient Outcomes28CONFIDENTIAL – Contains proprietary information.Not intended for external distribution.BMP. Grandma Breast Cancer at 75P. Aunt Ovarian Cancer at 52 and diedMarch 6, 2014:• 33 yo G2 P2, saw me for the first time: Annual Exam• Had an IUD since 2010 – very happy with it.• BRCA test collected in the officeWhat are her risks for breast and ovarian cancer?What medical and/or surgical recommendations should I be making for her?29CONFIDENTIAL – Contains proprietary information.Not intended for external distribution.BMP. Grandma Breast Cancer at 75P. Aunt Ovarian Cancer at 52 and diedUp to 87%Up to 63%[ADVENTISTHEALTH:INTERNAL]30The Foundation for Cancer Risk AssessmentPRIMARY CARE and BREAST IMAGINGAdministration Nurse NavigatorBehavioral HealthPatient Ambassadors Genetic Specialist31CONFIDENTIAL – Contains proprietary information.Not intended for external distribution.31The AHEAD Program at Adventist Health47 Clinics already enrolled in AHEAD2 Breast AHEAD3 Women’s health1 Primary care2 Specialty clinic5 Primary care,1 Specialty clinic1 Breast AHEAD2 Women’s Health1 Primary care1 Breast AHEAD1 Cancer Center2 Primary care1 Specialty clinic3 Primary care2 Women’s health1 Specialty clinic1 Specialty clinic1 Breast AHEAD1 Specialty clinic21 Clinics in the queue for 20221 Women’s health2 Specialty clinics1 Primary care2 Women’s health1 Breast AHEAD2 Women’s Health1 Primary care3 Specialty clinics1 Breast AHEAD,1 Specialty clinic32CONFIDENTIAL – Contains proprietary information.Not intended for external distribution.48,241 Patients Screened13,934 High Risk (29%)5,725 Tests Ordered (41% of Eligible)4,525 Eligible for Annual Breast MRI16,990 Care Plans Selected for 2,530 Patients351 Pathogenic MutationsAHEAD PROGRAM: All Time Summary (10/23/2017 – 11/12/2021)33CONFIDENTIAL – Contains proprietary information.Not intended for external distribution.AHEAD program Goals: • Prevent Cancer• Early detection• Improve survival and decrease suffering. INTENSITY OF MEDICAL MANAGEMENTFocus on high-risk individuals34CONFIDENTIAL – Contains proprietary information.Not intended for external distribution.© Adventist Health 2017Ripple Affect:[ADVENTISTHEALTH:INTERNAL]Breast Cancer and Colon Cancer Surveillance Compliance74859051 52686443704870650102030405060708090100Breast CA Cervical CA Colorectal CA%tile RankNCR CA Screening ComplianceJuly 20 - Rolling 12 MonthsAHSH AHCL AHUV AHHM[ADVENTISTHEALTH:INTERNAL]35.00%40.00%45.00%50.00%55.00%60.00%65.00%70.00%75.00%80.00%2015 2016 2017 2018 2019NCR Breast CA Screening Compliance2015-2019AHSH AHCL AHUV AHHMLaunch of AHEAD Program • 25% increase in Breast Cancer screening compliance.• No all Markets saw the same increase with the AHEAD program• Rural Health clinics needed:• Significantly more resources• Different “play book” [ADVENTISTHEALTH:INTERNAL]“Swiss Cheese” Prevention ModelInterview StyleEHR AlertsPatient ScreenPOC Alerts for Follow-UpFamily HistoryScreening History[ADVENTISTHEALTH:INTERNAL]© Adventist Health 2017Expanding to a Population Based Cancer Screening:[ADVENTISTHEALTH:INTERNAL]The Opportunity75% NORMAL Personal/ Family History of CancerGENERAL POPULATION~750,00025% ABNORMAL Personal / Family History of Cancer1~ 250,000~90% FAMILIAL RISK ~225,000~10% HEREDITARY RISK2~ 25,000 Low Risk Moderate Risk High Risk1. Hughes K, et al. Rate of Abnormal is defined by cancer family history meeting red flags. The Breast Journal. (2003) 9(1):19-25. 2. Rosenthal, E. et al. Outcomes of Clinical Testing for 76,000 Patients Utilizing a Panel of 25 Genes Associated with Increased Risk for Breast, Ovarian, Colorectal, Endometrial, Gastric Pancreatic, Melanoma and Prostate Cancers. Abstract #1515 presented at ASCO June 1, 2015. https://myriad-web.s3.amazonaws.com/ASCO2015_myRisk%20Series_Presented_Rosenthal_01JUNE2015.pdf.Unique lives touched by Adventist Health annually: 1,000,000~1/3 of these patients qualify for annual breast MRI (67,500)[ADVENTISTHEALTH:INTERNAL]INTENSITY OF MEDICAL MANAGEMENTBUT what about the general population[ADVENTISTHEALTH:INTERNAL]Cancer Awareness months:Jan: CervicalFeb: Cancer Prevention MonthMarch: ColonApril: TesticularMay: Skin and MelanomaJune: Cancer SurvivorJuly: BladderAugust:September: Ovarian and ProstateOctober: Breast CancerNovember: Pancreatic and Lungcancer Hereditary Cancer December: 41Adventist Health Cancers screen program: [ADVENTISTHEALTH:INTERNAL]Cancer screening and related Dealths. 5 Cancers we can currently screen for • Breast à mammogram • Cervical à PAP smear/HPV testing • Colon à Colonoscopy/FIT/ Cologuard etc. • Prostate à PSA • Lung à Low dose CT scan• HCRA à Genetic testing6th cancer we can test for: Hereditary Cancers. [ADVENTISTHEALTH:INTERNAL]© Adventist Health 2017How can we do better?How can we move the dial?[ADVENTISTHEALTH:INTERNAL]INTENSITY OF MEDICAL MANAGEMENTBUT what about the general populationAHEAD + MCEDAHEAD + MCED[ADVENTISTHEALTH:INTERNAL][ADVENTISTHEALTH:INTERNAL]Building your Tool box[ADVENTISTHEALTH:INTERNAL]Work flow?47[ADVENTISTHEALTH:INTERNAL]WHOHow[ADVENTISTHEALTH:INTERNAL]Adventist Health Physician working group: • Who • Who should we screen and when• Cancer Signal Detected à NOW WHAT?• Imaging• Biopsy• Need a workflow per cancer type• Challenges for us physicians• Manage expectations• Diagnostic dilemmas• Patient anxiety• COST – no insurance coverage yet. • Oncologists• OBGYN• Genetics• Primary Care• Administration [ADVENTISTHEALTH:INTERNAL]Adventist Health AHEAD program Proposed Implementation tracks• AHEAD workflow Track 1• High risk patients à gene positive• AHEAD workflow Track 4• Age >50 (at time of annual)• AHEAD workflow Track 3• AH Employees • AHEAD workflow Track 2• High risk patients à gene Negative • AHEAD workflow Track 5• Cancer SurvivorsWHO[ADVENTISTHEALTH:INTERNAL]51AHEAD MARKET INFRASTRUCTUREPRIMARY CARE AdministrationNurse NavigatorBehavioral HealthPatient Ambassadors Genetic SpecialistHowCancer Signal specific Play book with Central Navigation[ADVENTISTHEALTH:INTERNAL]The Enemy of Good is Better• Start some where – Don’t wait for perfection • Importance of stakeholder by in• Physicians • Primary care • Specialists• Oncology • Administration• Support services and Navigation • Warm handoffs to decrease patient anxiety and improve patient satisfaction • Understand limitations of the test and have guardrails. [ADVENTISTHEALTH:INTERNAL]Questions?53Please fill out our survey:https://www.surveymonkey.com/r/MCED_Dec14THANK YOU

Multi-Cancer Early Detection: Supporting Patients & Providers in Navigating the New Paradigm

https://jdc.jefferson.edu/cgi/viewcontent.cgi?filename=0&article=1002&context=mcedspeakerseries&type=additional

Multi-Cancer Early Detection: Supporting Patients & Providers in Navigating the New Paradigm

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