We’ve all been touched by cancer in some way, whether through a personal experience or a loved one’s experience, and we all know how terrifying a diagnosis can be. I’ve spent more than 20 years in oncology, both as a neuro-oncologist treating patients with brain tumors and in the industry, so I know how heavy the burden of cancer is.
People may find comfort in knowing that they or their loved ones will have access to care at well-known institutions, often called “centers of excellence.” You’re likely familiar with some of the highly renowned centers in the United States, such as Memorial Sloan Kettering Cancer Center, Dana-Farber Cancer Institute, and MD Anderson Cancer Center – and their reputation for providing exceptional care. Yet, when faced with a cancer diagnosis, traveling in person to one of these institutions is not necessarily the best option for every patient.
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What are cancer centers of excellence?
Cancer centers of excellence (COEs), like my own alma mater, Dana-Farber Cancer Institute, are large institutions that offer cutting-edge, high-quality cancer treatment. Most are academic centers that are involved in teaching, training, and basic and clinical research in addition to care. They are typically organized around specialty centers for certain types or subtypes of cancer and often have robust clinical trial programs to offer patients the latest innovations in treatment.
A large and growing number of employers offer COE approaches to give employees with cancer comfort and reassurance, guide them to high-quality care, and ideally improve outcomes. In fact, 53% of employers plan to offer a cancer-focused COE approach in 2024, and an additional 23% plan to consider it by 2026.
When an employer offers a COE approach, it often means they partner with a third-party company that can connect employees with care at National Cancer Institute-Designated Cancer Centers (NCICCs), such as those listed above. While the specific offerings and costs vary, some of these programs encourage employees to travel for care at academic centers as opposed to receiving care in their own communities.
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The programs can be extremely valuable for some patients, but they also have potential downsides. When an employer offers a COE approach, it can create an expectation that, if an employee is diagnosed with cancer, they must go to these centers for care, even if it may not be the best option for them given their particular diagnosis, geographic location, or financial situation.
The value of a community approach to cancer care
People tend to trust “brand name” institutions, and they may assume that the care at these facilities is better. However, community cancer centers are often more accessible to patients and can provide high-quality and cost-effective care, especially for common types of cancer. Even if a COE is available, patients must not overlook the fact that effective cancer care is often available in their backyards. Community-based oncologists have extensive experience treating patients with common types of cancers including breast, colon, prostate, lung, and more, and many offer a limited set of clinical trials.
There are many advantages to receiving care in one’s community, including avoiding the need to travel and find accommodations in a new location, which can be logistically challenging, expensive and stressful. Academic centers are often located in major cities or urban areas, which may be inaccessible for patients in rural or underserved areas.
Receiving treatment at a COE can present a serious financial obstacle. At COEs, patients typically receive care from specialized oncologists or multidisciplinary teams. While these teams have deep expertise, they may charge higher fees for their services than general oncologists in a patient’s community. In addition, COEs often offer advanced diagnostic tests, cutting-edge treatments, and experimental therapies that may be more expensive than standard therapies offered in local settings.
Even for standard therapies, academic centers tend to mark up the prices of drugs significantly more than community centers – sometimes 4x or more. For example, according to a recent AHIP report, the average price of a single treatment of Keytruda, a common cancer therapy, is $2,309 when administered at a local physician office but $10,582 at an academic center hospital. Our own data shows that the average reimbursement for pertuzumab/trastuzumab/hyaluronidase, an injectable drug for a common subtype of breast cancer, at community infusion centers is $6,680, but the same treatment when administered at one of the NCICCs referenced above is $26,718 on average. In either case, the treatment is injected under the skin by an oncology nurse over 5-10 minutes.
Are there advantages to receiving care at centers of excellence?
There are certain cases in which patients are best served at a COE. If a patient has a rare type of cancer, an unusually complex case, a poor or uncertain prognosis, or a complicated multidisciplinary treatment plan, they may benefit from the unique expertise available at academic centers. Patients whose treatment options are limited or wish to participate in clinical trials will often find that the number and variety of clinical trials available are greater in the COE setting.
Some studies have suggested better outcomes at academic centers, but this evidence is controversial. A study published in 2022 found that patients with cervical cancer who received care at NCICCs had a greater survival rate compared to those who received care elsewhere. This study acknowledges that the findings may be due to “structural, organizational, or provider characteristics and differences in patients receiving care at centers with and without NCI designation” – implying that the groups of patients who choose care at COEs are not the same as the patients who choose care in community settings.
Studies have found that Medicaid-eligible individuals, older patients, and certain marginalized groups are significantly less likely to seek care at NCICCs. Ultimately, the outcomes at COEs may appear to be better not because they are more effective at treating common types of cancer, but because the patients who go there are different – and may be more likely to have better outcomes to begin with.
What should patients do?
While academic centers have real advantages in terms of specialized expertise and multidisciplinary care, the outcomes of cancer are influenced by numerous factors, and going to a COE does not guarantee any certain result. For those who believe that the higher cost of care will be worth it, unfortunately, cost does not correlate to outcomes. A review published in 2020 of studies of the relationship between spending and outcomes in cancer found little or no association between higher spending and better outcomes in the United States.
Ultimately, there is no one-size-fits-all approach. The choice between going to an academic center or staying in one’s community should be based on the patient’s individual needs, preferences, and cancer case, and it should involve discussions with healthcare professionals to determine the most appropriate course of treatment. From my years working at Dana-Farber Cancer Institute, I can tell you with full certainty that COEs offer outstanding care and can change patients’ lives. I also know it can be a burden to travel to a major city such as Boston, and I believe many patients could be served just as well in the comfort of their own communities.
The notion that patients are always better off receiving treatment at academic centers is flawed, and when an employer offers a COE approach, it can mislead patients to choose that option when care in their local community may be more sensible. Some of the best COE programs available today are increasingly focused on providing remote second opinions without encouraging travel for care. These approaches may help bring together the advantages of both community care and subspecialized expertise, meaning that it’s not necessarily all or none and patients do not have to commit entirely to just one care setting.
In my own clinical practice, many patients were effectively treated in a collaborative manner in which I played a role in setting the treatment strategy for a rare brain tumor type, while the actual treatment was administered and monitored by a medical oncologist near the patient’s home. Let’s listen to our oncologists, trust our communities, and make informed decisions in order to achieve the outcomes cancer patients deserve.
oncology
Andrew Norden, MD, MPH, MBA, is a neuro-oncologist and physician executive who serves as Chief Medical Officer of OncoHealth, the leading oncology specialist dedicated to helping health plans, employers, oncologists, and patients navigate the physical, mental, and financial complexities of cancer, where he leads clinical affairs and strategy. Dr. Norden previously served as Chief Medical Officer of COTA and Deputy Chief Health Officer and lead physician for oncology and genomics at IBM Watson Health. He is the author of more than 65 peer-reviewed papers, an Associate Editor of JCO-Clinical Cancer Informatics, and an active member of ASCO and the Society for Neuro-Oncology.
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