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Physician executive Shamar Young discusses his article, “Geographic disparities in advanced cancer care: a call for innovation,” highlighting the uneven access to emerging cancer treatments across different health care systems. Shamar explores the impact of geography on advanced therapies like theragnostics and transarterial radioembolization (TARE), emphasizing how disparities in expertise, technology, and resources limit patient options. He discusses how specialized third-party services, such as TeleDaaS, can bridge these gaps by centralizing expertise and improving care accessibility. The conversation examines potential solutions for ensuring that all patients receive optimal cancer treatment, regardless of their location. Listeners will gain insights into how innovation in care delivery can reduce health disparities and improve patient outcomes.
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Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Shamar Young. He is a physician executive. Today’s KevinMD article is “Geographic disparities in advanced cancer care, a call for innovation.” Shamar, welcome to the show.
Shamar Young: Thank you for having me. It is a pleasure to be here.
Kevin Pho: All right, let us start by briefly sharing your story and journey.
Shamar Young: Yeah, so I am an interventional radiologist, and some people may not be familiar with the fact that interventional radiologists commonly treat cancer, especially liver cancer. One thing that we have seen as interventional oncology, as we like to call it, has evolved is that there are a lot of disparities between how patients are treated depending on where they happen to show up to clinic. So patients who are treated in New Hampshire, where you are at, may be treated very differently in Tucson, and a lot of that has to do with the resources that various systems have. That is really what our article talks about and explores.
Kevin Pho: All right, so talk about the article itself for those who did not get a chance to read it.
Shamar Young: The article really explores how an individual patient’s journey can be very heterogeneous depending on where they happen to present with whatever problem they may have. Our focus was definitely on cancer therapy; however, this can be true in many different aspects of modern medical therapy. It is easy for people just to have knee-jerk treatment reactions of, “Oh, that doctor is bad,” or “Oh, that system is bad,” but that is not actually what is happening in most of the cases. There are a lot of complex things that happen in the modern American health care system that affect how people are treated, what kind of care they get, what level of care they get. There are a lot of challenges for us, and we just kind of explore the various challenges that medical systems and individual physicians have, and some options to try to overcome those.
Kevin Pho: So what would be some examples of these geographical disparities where patients who need interventional radiology procedures for cancer care would differ based on where they live? What would be some examples of conditions and procedures we are talking about here?
Shamar Young: Yeah, so for instance, if somebody presents with hepatocellular carcinoma, which of course is the most common primary liver cancer, if they present to a large center with a strong IR presence, many of those patients—if not most—will be treated up front with something we call local regional therapy, which, of course, just means we are going to try to treat the cancer there in the liver. If they happen to present to a low-population system, then they may not even hear the word “interventional radiology” at any point; they may just hear systemic therapy, maybe a surgical therapy if they are a candidate (unfortunately very few patients are), and then maybe transplant if they are lucky. Even if they hear the word “interventional radiology,” one of the most common treatment methods at this time is something called transarterial radioembolization. It sounds like a very standard thing, but as we all know in the medical field, the devil is in the details. So how the radiation that is used to treat the hepatocellular carcinoma is prescribed can vary greatly between providers and between systems and whether or not the system has the software they need to do advanced dosimetry and try to optimize outcomes for those patients. It is very heterogeneous across the country.
Kevin Pho: So give us a sense of the impact on patient outcomes if you have patients in different geographic locations undergoing different treatment algorithms. How does that impact outcomes?
Shamar Young: Yeah, and so, you know, one of the trials that we will often look at in interventional oncology—and again, it is a radioembolization trial—was called DOSISPHERE. Really what it showed is that if we use these advanced dosimetry techniques, the benefit can be over a year in survival benefit, the overall survival benefit can be over a year, and many more of these patients can be what we call “downstaged” to curative-intent surgery if they do have the advanced dosimetry. But while it is hard to get a feel for how much advanced dosimetry is really being used, one of the markers we can sometimes look at is Medicare data and who is billing for advanced dosimetry. We see that less than 1 percent of all are billing for it. So this leads us to believe that there is quite a bit of heterogeneity between them. Of course, many interventional radiologists may be performing advanced dosimetry and not billing for it, but we would say that is probably going to be a minority of physicians.
Kevin Pho: You alluded to this earlier, but in terms of the reasons why there is such heterogeneity, is it because of cost, because of training, and you cannot get interventional radiologists in rural areas? What are some of the factors that lead to these disparities?
Shamar Young: Yeah, it is a great question. I think there are really two reasons, exactly as you are alluding to. Interventional radiologists are a small subspecialty, and there are just not enough of them to go around, so they tend to be clustered in larger hospital systems and larger population centers. Many of these rural hospitals can simply not hire anybody because the demand is too high, and those locations may be considered less desirable by some physicians who are leaving residency and looking for jobs. Another factor is just the resources that an individual interventional radiologist and system may have available to them. It is easy to say, “Hey, just get that software,” but we all know that all systems face a lot of demands with very limited resources. So if, perhaps, you are only treating one patient every other month with this treatment, it may not make sense for your hospital system to invest in a software, and so that can lead to some differences in treatment patterns.
Kevin Pho: In your article, you talk about some of the lessons that the U.S. health care system can learn from European models of centralized, specialized care. Talk about that contrast.
Shamar Young: Yeah, in Europe, as I am sure many of your listeners are aware, they tend to have centers of excellence. They will send everybody with HCC to one or two centers within a particular European country, and that is an excellent model for Europe because it really does allow patients to get a more homogeneous treatment algorithm. It concentrates patients of a certain diagnosis within a center, allowing that center to then optimize the resources and really invest for that disease, all the special bells and whistles—for lack of a better term—for that disease. The problem we have in the U.S. is that we are so large geographically that it is really tough. I mean, just frankly speaking, nobody in Tucson wants to hear, “Hey, you need to go to New Hampshire to receive treatment; that is where the center of excellence is.” It is a financial impossibility for many of my patients and a huge burden even for those who have the economic means to do it.
Kevin Pho: All right, so what are some paths forward to address some of these disparities in the United States?
Shamar Young: I think a lot of people are looking at third-party vendors to try to close some of the disparities when you have the physicians available. There are third-party vendors where you can concentrate certain steps of various treatment algorithms. The dosing, for instance, in radioembolization can be concentrated with a third-party vendor, and it reduces the entrance cost and the overall cost to a system if you are not doing so many. In terms of physician availability, it is a real challenge for a number of reasons. One, there is just not enough, and frankly speaking, the statistics tell us that the shortage of interventional radiology—just because I am an interventional radiologist, it is of great interest to me—is going to increase rather than decrease over the coming decade; we are not training enough right now. We can hope to increase our residency spots, but those are really long-term issues. The other factor many systems are facing is that, again, interventional radiologists are a small subspecialty, so if you are a small community hospital in a small population center, then it may be difficult to justify having an interventional radiologist because there may not be enough work for them to do on a day-to-day basis. I think those are the challenges that are going to be harder to crack, but we will continue to move forward. Various models—such as interventional radiologists showing up at a certain small, low-volume center hospital once a week or twice a week—have been explored, and hopefully will provide some benefit.
Kevin Pho: I hope you understand that role of third-party services. Give us a case study, story, or scenario where a third-party service can address some of these expertise shortages. What would that look like?
Shamar Young: Yeah, so in the case of radioembolization, we have been talking a lot about dosimetry because it is a personal passion of mine. Advanced dosimetry requires time and requires a software program, and it is one of those situations where, again, if you are not treating tons of patients—if you are not using that software every day—the time that it takes for you to do the dosimetry aspects increases quite a bit compared to somebody who is using it every day. That is something that can be offloaded to a third-party vendor. The third-party vendor can use the program, return the case with segmentation and all the details that are required to be inputted into the program, and then the physician can work with that and relatively quickly choose a dose or optimize the dose for that patient. That can lower your barrier in a number of ways. It can reduce physician time, and it can reduce the hospital’s cost because they do not have to purchase that software upfront, which can be expensive.
Kevin Pho: Anything from a systemic or policy standpoint that can decrease these disparities?
Shamar Young: It is really challenging, to be honest. I think all of us are hoping for and looking for a magic wand, and to the best of my abilities, I have not personally come up with one. Of course, we can incentivize physicians by increasing revenue for those who are doing certain things like advanced dosimetry, but to be frank, many of these physicians have a lot of relatively—quote, unquote—”high RVU” activities that they could be doing at any one moment, so it only goes so far. In terms of trying to increase the number of specific specialty physicians who are trained—interventional radiology is just one example of many, as you and your listeners are well aware, where we could probably benefit from an increased number of those physicians—that, too, is challenging. It is hard sometimes to just increase the publicity, so to speak, of that specific subspecialty; it is even harder to train people quickly. Residency is at least six years, and so, of course, everything takes time. But these are things that we could look to. That said, I honestly wish I had some great idea that was a magic wand, but I think it would be disingenuous to say I do.
Kevin Pho: We are talking to Shamar Young. He is a physician executive. Today’s KevinMD article is “Geographic disparities in advanced cancer care, a call for innovation.” Shamar, let us end with some take-home messages that you want to leave with the KevinMD audience.
Shamar Young: The things I would like to say are really twofold. One, I think that in modern American society, it is very easy to demonize certain entities, but many of these issues are very, very complex. So again, it is not necessarily that any physician is bad; it is not that any system is bad; it is that they are facing real challenges, and we should at least try to understand those. The other thing I would like to say is that there are many people aware of these problems and working to find creative solutions. We could always use more people trying to find creative solutions, so we would love to have anybody out there who has a passion for this to jump in. Creative solutions are needed.
Kevin Pho: Shamar, thank you so much for sharing your perspective and insight. Thanks again for coming on the show.
Shamar Young: Thank you for having me.
