Philippa Cheetham, MD: We hear about so many breakthroughs in medicine with these targeted therapies, all the molecular testing that we can do, and these very sophisticated scans. How often do you know exactly what the patient needs, whether it be imaging, whether it be radiation treatments, or whether it be immunotherapy or chemotherapy? How often are you in a situation where you know exactly what you want to do with that patient and yet, there are financial constraints with getting the right imaging approved by insurance; with getting medication that may be FDA approved, but the insurance company doesn’t want to pay for it; or where patients may be eligible for clinical trials, but it’s not necessarily available at your institution? How common is it for the medicine choice to be clear, but the financial, logistical obstacles come in to impair patient management? Dr. Sandler, what about imaging? Is it fairly easy to get the scans that you want to do approved in a timely manner, so the patient is not exposed to delay?
Kim L. Sandler, MD: I think, unfortunately, it often depends on the patient’s insurance provider and what sort of information we can give them. Screening for lung cancer is covered in full by Medicare and private insurers, but often, the necessary follow-up testing will not be. So, if a patient comes in and has a screening study and the recommendation is to come back in a year, we feel very comfortable that will be covered. If the patient needs a study done in 3 or 6 months, or needs another diagnostic study or even a tissue diagnosis and a biopsy, that can become very expensive very quickly, even prohibitively expensive for a patient in some circumstances. And it’s frustrating to come in for a screening exam that you’re being told is free, and then need additional testing that may really cause a financial hardship. So, we always try to have those discussions with the other specialists and with the patient to make sure we’re making the best decision, not only what would we love to have in every patient every time, but also what the best decision is at this time for this patient.
Philippa Cheetham, MD: Do you find a lot of your time is spent fighting to get scans approved and authorized by insurance companies? How much of your day is spent on the phone having to convince someone they need to pay for this?
Kim L. Sandler, MD: I am incredibly fortunate to have a nurse practitioner whose sole job is to run the lung screening program. She is exceptional, and she has those conversations on a daily basis. I’d say the more difficult conversation is with the patient, to say, “This is going to be a challenge. We are here to work with you, and we are going to give you all of the information and all of the help we can.” But that can be a very, very difficult conversation to have with the patient, and I’ve been part of those conversations as well. We never want a patient to come back to us and say, “I had no idea this was going to be so expensive, and, if I did, I would have made a different decision.”
Philippa Cheetham, MD: In centers of excellence where you’re following national guidelines, hopefully it’s easier to get things pushed through if you’ve got the data to support your argument on the phone with insurance companies. We know that radiation therapy comes in many different forms with external beam radiation, IMRT [intensity-modulated radiation therapy], CyberKnife, different protocols, accelerated protocols, and high-dose protocols. How do you navigate the treatment protocol for patients who receive radiation therapy? Is it a 1-size-fits-all if you have lung cancer, where everybody gets the same protocol? Where do the financial restraints come in with that for treating patients?
Evan C. Osmundson, MD, PhD: That’s an excellent question. It certainly is not a 1-size-fits-all. Each patient is fitted with individualized radiation therapy, so to speak. We use different modalities depending upon the stage of disease. For example, in patients with early-stage node-negative lung cancer who are not operation candidates, we will use SBRT [stereotactic body radiation therapy] or SABR, which is stereotactic ablative radiotherapy. In patients who have a high burden of disease, where irradiation of the thorax is going to lead to a lot of normal tissue getting irradiated, we will push for a fancier type of radiation called IMRT, intensity modulated radiation therapy, or VMAT, which is volumetric modulated arc therapy.
The advantage of those types of modalities are that they allow us to really sculpt a radiation dose around tumors, within millimeters of precision, and minimize normal tissue toxicity, which is very, very important. There are some cancers that are in locations where we can irradiate with standard techniques, and there are others that are in very tricky locations with very sensitive normal structures where we really need to use this more advanced technique. At times, because the fancier technique is unfortunately costlier, we get pushback from insurance companies. But there are a lot of data-driven guidelines in terms of normal tissue tolerance that we can use and present to insurance companies and say, “Well, if I irradiate this patient in this particular way, I really think this patient is going to have a lot of toxicity.” We’re usually able to get it approved.
Philippa Cheetham, MD: Dr. Horn mentioned earlier that patients with localized disease go for surgery. Is it always surgery for localized disease, or are some patients eligible for radiation, to radiate the tumor instead of surgery?
Evan C. Osmundson, MD, PhD: That’s an excellent question. Currently, the standard of care for early-stage node-negative lung cancer is lobectomy. Because of the comorbidities, many of these patients who were smokers have COPD [chronic obstructive pulmonary disease] and are not operation candidates. In those patients, stereotactic ablative radiotherapy is an excellent choice providing excellent local control. In terms of the decision between SBRT or SABR and lobectomy, this is where I think the relationship between your other multidisciplinary care providers is very important, because a patient may be referred to me for stereotactic ablative radiotherapy and I’ll say, “Hey, this patient could be an operation candidate.” I’ll get on the phone and talk with my colleagues in surgery, and vice versa. So, clear communication and trust between care providers is very important, but certainly, SBRT can be potentially curative for early-stage lung cancer.
Philippa Cheetham, MD: Going back to some of the newer medications, these drugs are extremely expensive. Do you find that’s a big issue: getting coverage for some of these newer, more expensive immunotherapies for patients? Or are they usually covered by insurance when the patient needs them?
Leora Horn, MD, MSc: It’s interesting. It’s often harder to get coverage for oral therapies than the targeted therapies and immunotherapies, because you’re giving an infusion in the hospital versus sending a different prescription that’s a different part of a patient’s insurance plan. But, luckily for the majority of patients, once the drugs are approved we can get them on. Having the wrong insurance or not enough insurance is never a reason not to give the drug. There are compassionate access protocols. There is help through companies. There are many, many different ways. We have social workers and financial counselors who help us figure out how to get the drug for the patient, so that our patients get the right treatment.