Sam Chang: Hello. My name is Sam Chang, and we are quite fortunate today to have Dr. Dan Joyce, who's currently a fellow at the Mayo Clinic in Rochester, Minnesota. Dr. Joyce will actually be coming to Vanderbilt and joining us as an assistant professor. And today, Dan, I think you're going to be speaking on the abstract that was presented to ASCO looking at the impact of actually advanced urothelial carcinoma on costs to patients as well as quality metrics that you guys were looking at. Tell us a little bit about that abstract.

Daniel Joyce: Thanks so much for having me. Urothelial cancer, of all the cases that present, about 10% are upper tract urothelial cancer, so that's cancer of the ureter and renal pelvis. Of those, only about half will have metastatic disease. So we're talking about a very small, rare disease space that is poorly studied. Often it's included within bladder cancer research. And so our goal was really to understand what were oncologic outcomes and costs different, and how were they better described in a complete metastatic urothelial upper tract cancer cohort. We also developed a three-item quality metric that was very rudimentary to better assess how care was being done in this space and try to figure out a way to improve quality of care in this space as well.

Sam Chang: Okay. So those quality metrics for advanced disease were-

Daniel Joyce: Very simple. So you either could get systemic treatment if you had metastatic disease where you're getting systemic treatment. If not, then what was the reason for that? And we thought, well, if you're not getting systemic treatment, then there must be some assumption that these patients will live longer than a year, and so a watch-while-waiting period, and so the second metric was cancer-specific survival greater than 12 months. And then the third is, well, maybe you didn't get systemic treatment, you weren't having a good life expectancy predicted, and so then palliative care, hospice care should be engaged at that time, so receipt of palliative care was the third metric.

Sam Chang: Some assumptions were built in, very broad, general assumptions regarding, were patients at least advised somewhere along the pathway to receive some type of care? And if not... Supportive care, pain control, palliative care, et cetera. And if not, you're assuming that for some reason they didn't get systemic care, but still were doing okay, and then they went on to live.

Daniel Joyce: Yep.

Sam Chang: So what were your findings?

Daniel Joyce: It's disappointing, truthfully. Of those three metrics, only 40% of patients met at least one of them. And when we look at-

Sam Chang: So one out of three. That's it.

Daniel Joyce: Yeah, any one of them. Less than half. So obviously wide variation in care and a lot of patients not receiving care. Also, when we look at patients who had synchronous versus metachronous disease, so patients who presented with metastatic disease versus got localized treatment and then progressed to metastatic disease, the synchronous patients, those that presented upfront, had worse overall survival than metachronous patients. So the idea being that there may be some access to care that those patients don't have and presenting with later disease, and therefore their outcomes are worse, whereas patients who are plugged into the system have had localized treatment, have access to care, do better and have better quality care.

Sam Chang: That's interesting. So presenting with higher volume perhaps actually pushes you down the road to actually get more care earlier, or at least some quality metric that you all measured. And then what about the cost impact?

Daniel Joyce: So the cost on average was about $30,000 more per patient if you had one of those quality measures. So yes, it costs more to get better care, but the survival at two years for those patients who had at least one quality metric was double that of those who didn't.

Sam Chang: So all they needed was one.

Daniel Joyce: Yeah.

Sam Chang: They could have even gotten palliative care and received some type of quality improvement.

Daniel Joyce: Yep.

Sam Chang: So in looking at that, give me an idea, and perhaps... You definitely know better than me. Well, you know a lot of things better than me. But what about the... In terms of cost and impact, in terms of preservation of life, give me an idea of what $30,000 per patient means. Is that a drop in the bucket? Is that a significant amount?

Daniel Joyce: I mean, ultimately it's very hard to compare, 'cause it's not really apples to apples. But $30,000 per patient is not outrageous, especially when you look at the survival benefit. Some of the work we've done, not in upper tract space, but is using cost-effectiveness analyses, which has some caveats in and of itself. But the idea there being is, can we measure extended life, the quality of that life, and the cost it takes to get that extended quality of life? And that gives you a nice metric of value in the form of an incremental cost-effectiveness ratio to understand and compare different treatment and management options and the value of those options.

Sam Chang: For that individual disease process, to have an idea. I mean, clearly as practicing physicians, I think we underestimate what's actually happening. We don't really know. We don't have that scale to understand. So where is this research going to go next? Are you guys going to focus more on quality, on cost-effectiveness? What's next?

Daniel Joyce: Yeah, certainly there's a lot of work to be done in the upper tract space, in that we need to understand, well, what are the barriers to care in these patients, and why are we seeing only 40% of patients meeting at least one of these quality metrics? There are numerous efforts that could be pursued in the cost side of things as well. Deescalation of treatment duration is one proposed mechanism for decreasing cost, especially in the systemic disease setting. And then also this quality metric, we feel, is really widely applicable, especially applicable to rare diseases. So these are very basic metrics that can be applied to, say, penile cancer, things where we have a harder time capturing that cohort in our studies, and really evaluate, are they getting good care? And how can we improve that?

Sam Chang: Yeah, clearly the less common cancers, there must be an increase in variation in terms of knowledge base, treatment choices, treatment choices that can actually be achieved wherever that patient may be. It clearly complicates the situation. And clearly they're underserved, because they're not large numbers, there's no big advocacy groups, et cetera.

Well, Dan, thank you so much for spending some time with us. I think that your studies in obviously the quality metrics we just talked about, but also the impact on cost, will be really important as we try to temper down this spiraling cost increase in terms of healthcare and problems with quality metrics. So thanks again.

Daniel Joyce: Thanks for having me.