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Ruchika Talwar: Hi everyone. Welcome back to UroToday's Health Policy Center of Excellence. As always, my name is Ruchika Talwar, and today I'm joined by Dr. Raj Bhanvadia, who's a urologic oncology fellow at UT Southwestern.

Dr. Bhanvadia is here with us today discussing some recent work he's done on how partnerships between cancer centers and safety net hospitals can potentially affect the care of GU cancer patients. Thanks so much for being here with us today.

Raj Bhanvadia: Thanks for the introduction, Dr. Talwar. Really excited and looking forward to our discussion on this topic. So again, we're examining cancer center partnerships, improving outcomes for genitourinary urinary cancers at safety net hospitals.

So to cover a little bit of background. So we know that safety net hospitals care for the medically vulnerable and have a policy or ambition to take care of all patients regardless of their ability to pay. And so are often considered the backbone of healthcare access for medically vulnerable populations.

This includes patients with un-insurance or no insurance, underinsurance, patients living in high levels of poverty, and patients of racial and ethnic minorities. Despite this increased access, historically, studies have shown that safety net hospitals have been associated with worse health outcomes. This includes perioperative outcomes and oncologic outcomes. But one of the flaws I think with the literature is that they've often treated safety net hospitals as a single large homogenous group.

And so what we wanted to ask was, are all safety net hospitals the same? Specifically, are there safety net hospitals that deliver high-quality urologic cancer care to vulnerable populations? And so what we hypothesized was that safety net hospitals that have academic or teaching partnerships with NCI-affiliated cancer centers will be associated with improved outcomes for genitourinary urinary cancers compared to unaffiliated safety net hospitals.

And the rationale here was that we long consider NCI cancer centers to be considered the gold standard for cancer care across America. And having access to the resources of these cancer centers and the physicians and personnel of these cancer centers may improve care for medically vulnerable patients receiving their care at safety net hospitals.

So to answer this question and look at this hypothesis, we used the Texas Cancer Registry. Which is a unique database in that through Texas law, has over 98% cancer cases ascertainment of all cancers diagnosed in the state of Texas, and resulted in over a million cases captured. Uniquely, the Texas Cancer Registry allows for hospital-level identification, which is important for our research approach because it allowed for sub-stratification of safety net hospitals into separate groups for analysis.

And so what we did was first identify all Texas cancer centers based on publicly available data. We then used a top quartile of DSH index payments to identify all safety net hospitals in the state of Texas. We then stratified out safety net hospitals that have longstanding teaching or academic partnerships with NCI cancer centers as a separate group. And then finally, all other hospitals in Texas, which were neither safety net hospitals nor cancer centers, made up the final group for analysis. Our outcomes of interest were overall survival, and again, we were trying to do a comprehensive analysis of genitourinary urinary cancers. And so we looked at patients receiving radical cystectomy, patients with metastatic prostate, metastatic kidney, and metastatic urothelial cancers.

And then our secondary outcomes related to treatment data and so we looked at rates of systemic therapy for the patients with metastatic cancer by hospital designation, and we looked at rates of neoadjuvant chemotherapy and lymph node dissection for the cystectomy population. So jumping into the data. We analyzed 18,200 patients with genitourinary urinary cancers over 155 unique hospitals in Texas. What we found was that about 50% of genitourinary urinary cancer care was performed at a hospital identified as a safety net hospital.

You can see that the proportion of the breakdown by hospital designation that NCI cancer centers and NCI-affiliated safety nets only took care of about 14% of all patients with genitourinary urinary cancers in the state of Texas. And that unaffiliated safety net hospitals took care of 43% of all genitourinary urinary cancer cases in the state of Texas.

Looking at the breakdown of patient demographics, what we found and what I thought was really unique was that NCI-affiliated safety net hospitals, again, those safety net hospitals affiliated with NCI cancer centers, took care of the most vulnerable patient populations. This included the highest percentage of racial minorities, the highest percentage of patients with Medicaid or no insurance, those living in the highest levels of neighborhood poverty.

And then when you aggregate these definitions of medically vulnerable populations, you see that about 90% of patients treated at NCI-affiliated safety net hospitals would've met the definition of medically vulnerable. So again, these are small unique health systems that are taking care of patients that are considered the highest risk for having the worst oncologic outcomes.

Despite taking care of patients that they were the highest risk of worse oncologic outcomes, NCI-affiliated safety net hospitals had superior overall survival for metastatic prostate cancer compared to unaffiliated safety net hospitals. And then this trend held for metastatic kidney cancer, metastatic urothelial cancer, and for the cystectomy population.

I'm showing the univariate Kaplan-Meier analysis here, but the results held on multivariable COX regression analysis as well. Looking at data as to trying to understand what's driving these outcomes and differences in survival, what we found was that patients treated at safety net hospitals not affiliated with cancer centers had 40 to 60% lower odds of receiving systemic therapy compared to NCI-affiliated safety net hospitals for metastatic prostate cancer, metastatic kidney cancer, and metastatic urothelial cancer on multivariate logistic regression analysis.

We see a similar trend for the cystectomy population in that patients who were undergoing cystectomy and treated at unaffiliated safety net hospitals, those not affiliated with NCI cancer centers had 40 to 60% lower odds of receiving neoadjuvant chemotherapy and lymph node dissection at the time of cystectomy compared to safety net hospitals affiliated with NCI cancer centers.

So when you take this data together and you aggregate it, what we would summarize with, would say is that 50% of genitourinary urinary cancer care in Texas was at a safety net hospital. Overall similar to prior research, safety net hospitals are associated with worse oncologic outcomes, but we were able to identify a subset of high performing safety net hospitals for genitourinary urinary oncologic outcomes.

These are those safety net hospitals affiliated with cancer centers. These had increased adherence to quality measures and increased odds of delivering systemic therapy to metastatic patients and this was in a primarily medically vulnerable patient population.

So I think naturally next steps of what we're trying to work towards is understanding and identifying what factors at these NCI-affiliated safety net hospitals are most influential on oncologic outcomes and which of these are most portable so that they can potentially be implemented at other safety net hospitals to improve care.

Ruchika Talwar: Thank you. Really, really interesting study. And I think most importantly, you suggest a potential solution there in that it sounds like at these NCI-designated safety net hospitals, patients are more likely to get systemic therapy.

So for example, neoadjuvant chemotherapy in bladder cancer comes to mind. And that may be one thing that can be implemented at safety net hospitals that are not NCI designated and potentially improve outcomes there. But I'm just curious to hear your thoughts if you think that linkage potentially could be driving some of this or other potential solutions.

Raj Bhanvadia: Certainly. Yeah, I think part of this is probably access to the right personnel and right physician staff. I think when you have NCI cancer center physicians who are delivering cutting edge care and are up-to-date with the latest guidelines, you're getting a high fidelity of guideline-based care at these centers.

I think when you translate those personnel to safety net hospitals, which is what we see with these academic partnerships, you are getting the same decision making.
Additionally, I think if you talk to some of our medical oncologists, there are many tips and tricks to get patients through chemotherapy, to get patients through a lot of these systemic therapies and things that they desperately need.

And so I think part of it is a knowledge gap that puts some of these centers. And then part of it is probably resource related, which we didn't answer here with this dataset. And so I think the natural next step is to say... basically, identify a running list of, "Here are the things that are of highest impact on cancer outcomes for these patients, and then which of these are most easily transferable?"

Is it just knowledge? Is it having quality metrics that we need to assess at the state level periodically at these centers? And saying, "Which centers don't stack up?" Things like that. Or is it getting more resources to these centers? Because it may be that these centers don't have enough infusion centers. We just don't know that yet.

Ruchika Talwar: Yeah, absolutely. I think your study is a great start, but there are certainly more questions that need to be answered. But I'm curious, what is your advice out there to people who deliver urologic care at some of the safety net hospitals that are not affiliated with NCI cancer centers?

Raj Bhanvadia: Certainly. I think at these centers, it's tough. Obviously, if you're a limited resources, you're a patient population of limitations it may be hard. But I think at the very basic level, you really relying on your NCCN and NUA guidelines to make sure you're delivering at the very least guideline-based care.

And there are mechanisms amongst other cancer types for transferring these patients due to the complexity of care to other centers. And so I think part of it is just having that recognition that maybe you're a little bit in over your head and you may need to be able to transfer that patient to these other centers.

I mean, I think a lot of these cancer centers have funding available to treat a lot of patients through grants and things like that that increase their access, and so it's a matter of getting the patients to the right center.

But at the very least, I think we have to, as physicians, say that our knowledge is correct and our short baseline level of decision making is correct. And I think that's really relying on those guidelines, which I think based on the data we see on the multivariable analysis, is even when you adjusted for insurance status and race and things like that, these unaffiliated safety net hospitals who were still delivering a lower rate of systemic therapy for these patients.

And that's a little bit troubling to me because you think that those are all related to patient factors that on the multivariable analysis, it should have washed out and then it didn't.

Ruchika Talwar: Yeah. Just to go back to what you started with regarding the ability to transfer patients to a center that is potentially NCI-affiliated with an NCI designated cancer center, I think it's important that we just acknowledge though putting the burden on the patient can sometimes be tough.

Especially in a state like Texas where patients may be driving several hours, need to take time off from work, there's a certain degree of caregiver burden. So I think another take home point here would also be at the policy level encouraging some of these NCI-designated cancer centers to potentially build community partnerships with safety net hospitals that may not be close in proximity.

And that onus needs to be more on, I think, the government that funds these safety net hospitals. We should be able to encourage those alliances. And instead of relying on NCI funding, potentially even build safety net hospital funding that would allow for those sorts of programs. I think it'll just, it helps alleviate some of that burden. Any other thoughts on high-level policy solutions that we haven't covered?

Raj Bhanvadia: That's a great question. I think there's so many ways you can go with this. But I think I hundred percent agree with you. I think that the biggest point is it really can't be a patient-centric solution in that you can't force to put the onus on the patient to get the right access to care.

We as health systems need to say that as health systems, we're delivering equitable care. And I think this data is at least showing that at a health system level, there's huge variations in care across health systems. And that's something that I think that we can at least track at a quality level and say, "This is..." establish some sort of baseline for saying, "This is what we expect of our health systems, are you below that or not?"

And if you're below that, there needs to be some sort of mechanism to allow for improvement. Whether that's partnership with cancer centers or funding changes in funding structure to allow for systems to put the onus on themselves to improve.

So I agree with you. I think it's got to be at a systems level because I think at a systems level, we can modify these things. It's hard to modify upstream patient factors like where they live, their poverty level, rural access to care. Those things are relatively rigid and hard to change. But at a health systems level, we should be able to say we're delivering the same level of care across systems.

Ruchika Talwar: Yeah, couldn't agree more. Congratulations on this really important work. I think that we're not seeing enough of this stuff. And so really we're happy to have you on, sharing your insights and looking forward to seeing what future work you have in store.

Raj Bhanvadia: Awesome, thank you.

Ruchika Talwar: And to our audience, thanks again for joining us. We'll see you next time.