10 Developments Driving the Fundamental Shift in Cancer Centre Design
What's Next for Cancer Centre Design?
Cancer care is changing dramatically around the world due to the efficacy of new novel therapies. Traditional treatments such as radiotherapy, chemotherapy and surgical extractions that indiscriminately affect both malignant and healthy cells through “blunt force treatment” are being superseded by Precision Medicine, which is the overarching term for new therapies that target only cancer cells. Many of these therapies use advanced technologies supported by machine learning to educate a patient’s own immune system to eradicate and cure cancer. These radically innovative treatments are fundamentally altering the arc of care and — equally important — the facilities that support it.
For the past 20 years, the number of drugs approved each year was around five. Now, that annual average is about 20 with around 4,000 new drugs still in the approval pipeline. Further, artificial intelligence’s rapid movement into both research and clinical care is evident. A recent study from the Massachusetts Institute of Technology and Massachusetts General Hospital provides outcome data from all mammograms taken at Mass General over the past 20 years. They found that an artificial intelligence algorithm could spot a breast cancer forming five years before trained humans could — and this is one example among many. AI-guided decisions and diagnosis is emerging as an important part of cancer care.
This shift will inform the cancer care facilities we design — from overarching, big-picture changes in the network to smaller, but equally critical changes to accommodate personalised medicine. The complexity of cancer care will only increase, and so the facilities that support it must evolve.
Here are 10 ways that cancer care is changing that will have a significant impact on how we plan and design facilities and operations in the future:
1. A Wider Safety Net
With so many new treatments and therapies, there will be a greater variety of facility types, systems, and networks — connected electronically — to support the new continuum of care. This is a perfect opportunity to create health equity. According to a report by the Advisory Board, one in three cancer deaths can be attributed to a social disparity in care. Federally funded community health centres and independent community providers and hospitals will start to be better integrated into larger cancer-care networks through affiliations with academic medical centres. This will result in more statewide and national healthcare networks — depending in part on whether reimbursement is government-based or through private insurance.
There will be a big push for getting underserved populations into trials to discover therapeutics that may work better for them. Finding ways to get trials into these underserved communities will be an important part of cancer research and treatment in the next five to 10 years.
More and more space will be needed for larger numbers of patients in clinical trials. There may be a need to expand the health system network outpatient centres for this purpose. Utilising the effective concepts of universal care, all people will be provided with remote monitoring irrespective of their ability to pay for the technology.
2. The Return of the House Call
As we transition from Fee for Service to a Value Based “bundled payment” reimbursement system, our health toolset will include telemedicine, virtual visits and even the return of the house call. For example, with a novel immunotherapy, telemedicine can monitor the metabolic changes. If something “trips,” rather than have the patient go to the emergency department, the better option may be to treat the patient where they are — in their own home thus avoiding a costly disruptive trip to the ED through an investment in trained EMT’s guided virtually by clinical specialists remotely.
Telemedicine will have a huge impact on care going forward, minimising the need for patients to go to a facility — and reducing associated exam space. Pre-assessment will also promote triage to the lowest acuity setting convenient to the patient, meaning a trip to the primary clinic rather than the cancer centre or ED. This will change the utilization of the hospital and also increase the demand for a robust command centre required to monitor CRS and neurologic toxicities associated with novel treatments.
3. Where’s the Front Door?
Novel therapies are already disrupting evidenced-based patient pathway protocols. As treatment plans continue to become more complex and less predictable, with more options depending on how a patient is responding; and as we transition from large, cohort-based oral pharmacological clinical trials to personalized in-vivo cell therapies, possible treatments are exponentially expanding. These treatments have a greater variability in patient health. For most, there is a rapid return to wellness, but some experience a dreaded episodic cytokine reaction that requires immediate treatment.
Telehealth, virtual monitoring, command centres, and discrete novel therapy patient portals — all components of precision medicine — will change access points throughout the continuum of care. Currently, portals of entry for cancer patients are not consistent across academic medical centres, community cancer centres, and hospitals. We need to determine, through evidence, which portals are most effective.
4. Transforming the Point of Care, CAM it!
For over a half century the NCI has successful pushed to integrate clinical care, research, and education in one large comprehensive centre. This objective has been challenged by the concept of continuum of care that promotes moving care to the patient rather than moving the patient to the point of care. Maintaining collaboration among clinicians, researchers and educators will require virtual rather than in person. CAM, Complementary and Alternative Medicine, is an increasingly valuable option as we progress from simply treating cancer symptoms to substantial remission or actually curing the disease. CAM is about maintaining a good life balance promoting wellness through nutrition, exercise and good mental health.
Many of these visits will occur in small community clinic settings, but some in the patient’s home with virtual access. This will challenge where and how care is delivered, particularly in large comprehensive cancer centres. While care sites may be disbursed, the need to accommodate technologically advanced equipment will remain with the hub CCC.
5. Space for Translation: Change It or Perfect It?
Genomics has spurred a transformational change in pharmacological care. With the number of cancer drugs in the pipeline increasing exponentially, more and more drugs will require testing and the need for clinical trial subjects will increase. And competition for these subjects will increase. The challenge for our healthcare system is that while cancer accounts for only one percent of all cases, it accounts for over 12 percent of cost, a percentage that will likely increase with the advent of novel therapies. Private pharmaceutical and biomedical device companies partnering with academic medical cancer centres can generate substantial income for a healthcare system.
Space to accrue, manage, and work with subjects for the increasing amount of clinical research required by new therapies and combinations of therapies will run the gamut of treatment spaces — related to all treatment types. Healthcare facility space could be shared with pharmaceutical and biomedical device companies in partnership.
6. New Kinds of Labs
Validating cancer through surgical extraction with cell malignancy confirmed at a lab has been the norm for decades. However, as target therapies become exponentially more specific, diagnostics are becoming more complicated, involving both in vivo and ex vivo science at a molecular and nano scale. Combined with new methods to determine a person’s susceptibility to specific therapies makes personalized cancer care a sophisticated and complex process. With a plethora of new, widely available, improved tools (mass spectrometry, flow cytometry, and genome sequencing, to name a few), including some that are moving to the point of care, diagnostics laboratories are also changing.
The traditional pathology reading that happens ex-vivo in a central lab or stat lab adjacent to the surgical suite, will more often be conducted in real-time in-vivo, for more precise tumour resection. Additionally, many new therapies employ technologies that manipulate extracted cells that are put back into the body. This takes weeks to process and requires ongoing monitoring. Further, new techniques are being developed to determine malignancy of a cell within the body, foretelling the promise of real-time diagnostics and treatment
These new technologies and techniques will change the nature of supporting diagnostic and pathology labs as well as procedure space. The hybrid operating room that provides the surgeon with image guidance will morph towards AI supported targeted therapy emphasising the benefit of universal specialty operating rooms.
7. Imaging and More Imaging
Identifying cancer cells has progressed from the haptic detection of a hard lump. Diagnostic and therapeutic imaging is transitioning from imaging organs and tissue to cells and molecules. All are essential to new therapies and targeted diagnostics. In addition to anatomical imaging, which registers where the cancer is within the body, tumour size, etc., these new therapies also employ metabolic imaging to identify changes at the cellular and even molecular levels — an essential part of precision medicine. Treatment is transitioning from relying solely on anatomical imaging, to using both anatomical and metabolic imaging. Targeted therapies that use short-life radioisotopes, in-vivo triggered immunotherapies, and other novel agents will increase the use of concurrent imaging during treatment.
In the future, dosimetry, required for all solid tumour cases, will require less pre-planned imaging, and more real-time imaging during treatment. New proton and heavy-ion therapies that promise significantly reduced tumour margins will impact how cancer centres are designed as will the need for cyclotrons to generate short half-life radioisotopes.
Moving forward, the sheer quantity of data will make aligning the best treatment with a patient’s diagnosis much more complex — and sometimes beyond the capability of human beings. AI or machine learning will help determine the best alignment but getting that information into the correct “clinical pathways” to more effectively incorporate precision medicine with social determinants of health will likely require a new group dedicated to knowledge transfer decision support.
Essentially, this Decision Support Centre would be the current “Tumor Board” on steroids. The tipping point will be getting beyond “meaningful use” to a secure, but fully transparent and compatible, electronic medical record across health systems. However, many believe that the importance of creating these genomic registries combined with the expansion of telemedicine will break the geographic connection between the patient and provider leading to supersystems not unlike what Amazon has done to the retail market.
Command centres are going to become a necessity. Investment in robust IT, data warehousing, telemedicine and biorepositories will provide the resources for confirming the Next Gen diagnostics and treatment methodologies.
9. Knowledge Is Not Cheap
With research identifying more and more biomarkers for genetic familial cancers, and with machine learning able to track specific markers in thousands of specimens to find matches way beyond the capacity of the human mind, more patients will be able to receive early treatment, and some may be able to avoid cancer altogether. To date, screening has been general and based on broad-based risk analysis; diagnosis based on biomarkers and conditions; and treatment personalised.
Now, we’re broadening the concept of screening because we can identify genomic variability that predetermines susceptibility to specific cancers and move closer to population health and pre-emptive interventions to lower the risk of future cancer. However, white-bagging or the requirement to source drugs from specific specialty pharmacies has put significant pressure on the cost of care.
Going forward, it will be imperative for clinical providers to collaborate with commercial vendors to improve the supply chain conundrum of supply and demand. Whether it’s deferring routine care to the neighbourhood CVS or providing space in our clinic design for Norvartis.
10. Who Has the Key?
When there’s a new discovery — a gene, a biomarker — that is determined to affect health, there is the potential to review existing medical records to identify patient susceptibility, but the questions are: Who has the key to unlock this data? And how will the chain of custody of relevant, though personal, information be handled?
Personal medical records create easy access to patients’ history for decades. As our ability to screen for more and more cancers continues to increase, how to screen, who to screen, and where to screen will become a more complex proposition, as will determining who will be the keeper of medical records. As more and more information is more easily accessed, we will see increased pressure on health systems to create “meaningful use” of this newfound data.
There are several paths that the transformation of cancer care can take but one certainty is that the singular stand-alone cancer centre staffed by clinicians utilising their decades old training to diagnose and treat cancer will morph into an umbrella of health providers working under one network or through collaborative arrangements to provide precise and personalised diagnosis and treatment in locations convenient to the patient with continued screening and monitoring to ensure the health and wellness of the population.