Development of a Multidisciplinary Los Angeles CountyBased Brain Cancer Program
Being diagnosed with a brain tumor is a life-changing and potentially harrowing experience that greatly affects patients and families alike. The treatment of brain tumors is inherently complex, and requires streamlined management by a variety of healthcare practitioners (physicians, nurses, rehabilitation specialists, social workers, hospice workers, etc.) Patients diagnosed with brain tumors are often young and otherwise healthy and productive members of society that may suddenly transition to requiring frequent and chronic care, resulting in reduced workforce participation and mandating a variety of additional support services. The physical, financial, and emotional burdens on patients diagnosed with brain cancer, as well as their families, are further exacerbated when they are constrained by complex socioeconomic factors. Numerous studies have identified significant healthcare disparities with regard to access to care and treatment outcomes in brain tumor patients with lower socioeconomic or minority status, less education, and no insurance (Curry WT, Neurosurgery, 2010 and Mukherjee D, J Clin Neurosci, 2013). For brain tumor patients with such disadvantages, following complex treatment regimens (such as chemotherapy, daily radiation therapy, or clinical trials) and navigating a complex healthcare system composed of fragmented clinics and/or hospitals or non-native languages can be especially disheartening. These factors, coupled with the neurological deficits often caused by these tumors (such as paralysis or language/memory deficits) makes adherence to complex medical regimens even more of a struggle. It is therefore no surprise that many patients with socioeconomic disadvantages receiving brain tumor care have a difficult time making all their appointments (often several per week), or adhering to physician recommendations, sometimes resulting in delays in time-sensitive care. The LA County+USC Medical Center is the largest public hospital in Southern California, serving as a safety net institution and providing quality healthcare to millions of underserved and indigent Angelenos and other U.S. and world citizens. In January 2013, a group of Norris Comprehensive Cancer Center and Keck School of Medicine of USC physicians decided to form a multidisciplinary Brain Tumor/ Neuro-Oncology Clinic at LAC+USC in an attempt to streamline care for patients with complex primary brain tumors being treated at all LA County facilities. The weekly LAC+USC Brain Tumor Clinic staffed by these physicians receives patient referrals from any LA County-DHS sites AND OTHER LA HOSPITALS, thus serving as the ONLY centralized multidisciplinary Neuro-Oncology clinic for LA county residents. Patients have access to neurologists, neuro-oncologists, neurosurgeons, and radiation-oncologists during the SAME clinic visit, allowing the panel of physicians to discuss best-practice treatment options as a team, rather than fragmenting this care over several visits and potentially weeks or months. Furthermore, the clinic allows ALL patients to access the same therapeutic clinical trials as first-rate private academic institutions and cancer centers, which is a factor that has independently been associated with prolonged survival in patients with brain cancer (Shahar T, J Clin Neurosci, 2012). Although the Brain Tumor Clinic at LAC+USC was designed to accommodate a maximum of 12 patients per day, it is already overbooked to 15-18 patients per clinic for the next 3 months, demonstrating the dire need for this integral service in LA County. Our primary aim is to develop a world-class multi-disciplinary Brain Tumor/Neuro-Oncology Center of Excellence that will provide all LA County patients, regardless of insurance status, race, or education level with the same access to quality care for years to come. The development of a formal program at LAC+USC will ensure that this service is centralized at the County’s primary safety-net institution for decades. Support from the LA2050 grant will be used to develop a LA County Neuro-Oncology Center of Excellence, support a clinical nursing navigator/coordinator, manage a prospective patient database, create a program website and referral system, and provide seed money for researching brain tumor genomics and healthcare disparities in patients with brain tumors. By 2050, the potential for healthcare delivery in complex medical problems such as brain tumors to become even more disparate is a sad but sobering reality. Most indigent LA County patients with brain tumors do not have the luxury of visiting several practitioners or “shopping around” for their care. The potential to establish a Brain Tumor Center of Excellence embedded in our County’s largest public medical center is likely to at least partially offset this disparity, and help ensure that all patients with brain tumors in LA have access to the same basic care, clinical trials, and rapidly-evolving therapies.
What are some of your organization’s most important achievements to date?
The multidisciplinary Neuro-Oncology program at LAC+USC is one of the few in all of Southern California to provide multidisciplinary care to complex brain tumor patients, and the only designated Los Angeles County facility to do the same. The establishment of this clinic has streamlined care for chronically ill patients with brain cancer, and the demands placed on accommodating patients within this clinic highlights the need for this integral service to the population of LA County as a whole. Over the past decade, we have treated thousands of patients with complex benign and malignant brain and spine tumors using various combinations of surgery, radiation, and chemotherapy, and have always strived to maintain the highest comparable standards with regard to quality of care as we have done for patients at our affiliated USC Norris Cancer Center (one of three National Cancer Institute-designated Cancer Centers in Southern California). Perhaps most importantly, we have maintained an open door policy in treating all-comer patients with brain cancer referred from dozens of hospitals all over Southern California, and have never turned a patient with the diagnosis of a brain tumor away based on insurance or socioeconomic status. We have enrolled hundreds of patients in some of the latest and most promising clinical trials available worldwide. Our program has been the major site of the Los Angeles County Cancer Surveillance Program, and chronicles information on all new cancer cases in LA County (approximately 30,000 patients per year). The LA County Cancer Surveillance Program is now the largest contributing registry to the NCI-funded Surveillance, Epidemiology, and End Results (SEER) program. Many of our Brain Tumor Center physicians are internationally recognized for their contributions to patient care and clinical-translational research, and have won numerous awards in recognition of their research contributions. Finally, clinician-scientists in our group have published numerous peer-reviewed research articles pertaining to novel treatments for brain tumors (such as inhaled therapies and vaccine trials), healthcare disparities and trends relating to brain tumors, and brain tumor genomics studies.
Please identify any partners or collaborators who will work with you on this project.
Gabriel Zada, MD (Neurosurgery)
Naveed Wagle, MD (Neuro-Oncology)
Rose Lai, MD (Neuro-Oncology)
Eric Chang, MD (Radiation-Oncology)
Thomas Chen, MD, PhD (Neurosurgery)
Other memebrs of LAC+USC and the USC Norris Cancer Center Brain Tumor Center
Please explain how you will evaluate your project. How will you measure success?
The specific aims of the project are to: 1) Develop a centralized, multidisciplinary center of excellence for brain tumor patients throughout Southern California at LAC+USC Medical Center, 2) Accommodate the increasing number of patient referrals to this program, 3) Increase clinical trial enrollment for patients with brain tumors, 4) Increase research output from this program.
Success in these terms will be measured using very specific benchmarks according to each of these aims:
1) Within 1 year of funding, we aim to have an organized program consisting of a clinical program director, website with referral information and clinical trial information, and clinical outcomes database for prospective patient data entry.
2) During the first year following funding, we will monitor and compare specific clinical outcomes in patients before and after implementation of the clinical program. These will include: Time from diagnosis to initiation of treatment, time to completion of chemotherapy and radiation treatment, progression-free survival, and overall survival. In addition, the referral volume and overall clinical volume will be monitored.
3) Patient Satisfaction: We will provide questionnaires to patients and allow them to rate their experience with the new multi-disciplinary program as compared to prior to initiation of the program.
4) During the first 2 years following funding, we will monitor the number of patients enrolled in clinical trials, as well as the number of newly established clinical trials based out of this program.
5) During the first 2 years following funding, we will monitor the number of research papers published and new grants obtained from LA2050 seed funds.
How will your project benefit Los Angeles?
This project will benefit Los Angeles in several ways. First and foremost, it will improve direct care to the thousands of Angelenos who already have existing benign and malignant brain tumors by developing the multidisciplinary Neuro-Oncology program at LAC+USC. LAC+USC Medical Center is one of the busiest public hospitals in the western United States and the largest single provider of health care in Los Angeles County. LAC+USC records nearly 39,000 inpatient discharges, 150,000 emergency department visits, and 1 million ambulatory care visits each year. Secondly, it will help ensure that all residents of LA County have future access to a specialized Neuro-Oncology care, physicians, clinical trials, and emerging therapies for years to come, so that care provided to LAC+USC patients is on par with any National Cancer Center. When new therapies for brain cancer do emerge, having the infrastructure in place to efficiently deliver care to patients with brain cancer will be critical; The proposed clinic will help with streamlined care delivery. Thirdly, it will help develop a Center of Excellence in LA County for many years to come, serving as a structural model and network for additional specialty centers to develop. Finally, research that emerges from this program may have indirect benefits for LA residents with brain tumors for years to come. Although complete elimination of healthcare disparities in Los Angeles by 2050 is a daunting task, we aim to serve as a model program for how a group of practitioners/providers with converging goals for patients can be a Center of Excellence despite limited resources, and reduce healthcare disparities within our treatment focus area.
What would success look like in the year 2050 regarding your indicator?
True success regarding health in malignant brain tumors will mean finding a CURE for this disease by 2050. This can only be achieved through high-quality RESEARCH AND CLINICAL STUDIES. In addition, finding risk factors for brain tumors (such as genes, environmental factors, social factors, etc.) may help in preventing brain cancer or identifying individuals who are at particular risk for developing these tumors, and thereby increasing surveillance and providing earlier treatment.
Realistically, however, if a promising clinical trial, emerging therapy, or even cure was to be developed for malignant brain tumors today, the time to dissemination into public county-based hospitals may lag behind some private institutions. Development of a Neuro-Oncology Center of Excellence in the LA County system would provide an INFRASTRUCTURE FOR DELIVERING EQUAL ACCESS TO THE LATEST THERAPIES, cure or not, within the LA County referral network. Based on national healthcare trends and prior research studies, it has been shown that centralized/specialized care sites for complex diseases such as brain tumors provide the best outcomes for patients possible. By 2050, prespecified Centers of Excellence may very well be the referral sites for a majority of patients with newly diagnosed conditions. As such, a major parameter of success over the next several decades would be to become such a Center of Excellence and to minimize or eliminate healthcare disparity as it relates to availability of brain cancer treatment in LA. By 2050, we aim to be a first-rate national and international Center of Excellence in Neuro-Oncology housed within a public county institution, ensuring that the latest therapies, such as vaccines, stem cell treatments, and drugs are delivered in a timely fashion to patients without regard to socioeconomic status, race, or neighborhood.