Welcome to Yale Cancer Center Answers with Dr. Francine Foss and Dr. Lynn Wilson.  Dr. Foss is a Professor of Medical Oncology and Dermatology, specializing in the treatment of lymphomas.  Dr. Wilson is a Professor of Therapeutic Radiology and an expert in the use of radiation to treat lung cancers and cutaneous lymphomas.  If you would like to join the conversation, you can contact the doctors directly.  The address is canceranswers@yale.edu and the phone number is 1-888-234-4YCC.  This week, Dr. Francine Foss is joined by Dr. Anne Chiang.  Dr. Chiang is Assistant Professor of Medical Oncology and Chief Medical Officer for the Smilow Center Hospital Network.  Here is Francine Foss.
Foss              Could we start off by having you tell us a little bit about yourself?  Where you came from, how long you have been here at the Smilow Cancer Hospital and what your major areas of interest are?
Chiang          I have been here since October 2011 and I originally started out as a scientist, so I got my PhD in fruit fly molecular biology and then I decided to go into medicine, and I trained in New York and I did my fellowship at Sloan Kettering and I got very interested in cancer.  I actually did a lot of bench research and translational research in the area of lung cancer and metastases.  At that time, I trained in lung and stayed on and I did some work in the gynecological malignancies and then decided that I had always wanted to practice general oncology.  So, then I took a turn and when into private practice, a community practice for three years and saw all sorts of cancers, liquid tumor, solid tumors and I had a lot of fun in North Western Connecticut which is where our practice was.  At that time, I met Tom Lynch and Yale was thinking about expanding into the communities and extending the clinical footprint for Smilow Cancer Hospital across the State of Connecticut and he asked me if I was interested in helping with that, and I said absolutely.  So, that is sort of why I ended up here.
Foss              You have had a lot of experience in different settings, can you contrast your experience in the private practice setting to what you are now doing at Yale?
Chiang          Absolutely, recently we have had some very exciting developments, as of January 2012, Smilow Cancer Hospital acquired Medical Oncology and Hematology, which is one of the largest oncology practices in the State of Connecticut and 18 doctors joined the Yale faculty and 120 of their employees joined Yale-New Haven Hospital staff, and so this practice is in six different locations and offers patients the ability to access all of the advantages of being part of an academic hospital like Smilow and the research that Yale has to offer and at the same time offer patients that local care, which is something that I experienced as a community oncologist for the past three years.  So for folks who do not live near New Haven or even do live in New Haven, but prefer to go to a smaller setting than a large academic hospital, they are able to continue to do that and yet have many of the privileges and access to research and different expertise that Smilow has to offer too.
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Foss              You had the unique prospective of being one of those community practice doctors before you came here.  Can you talk with us about the advantages for those doctors out in the community to have this alliance with Smilow Cancer Hospital?
Chiang          I think that for practitioners in the community, you are forced to be a generalist because you see everybody, you see everybody's family, and so to be able to have access to, for example, services or experts in T-cell lymphoma, which is your field, and to be able to consult those experts and still be able to care for the patient in the local setting, I think that really provides an advantage for the patients.
Foss              Can you talk a little bit about the nuts and bolts of this collaboration, how are those doctors actually tied into what is going on at the Cancer Center?
Chiang          These doctors are actually Yale faculty.  That is a bit of a different model than in other places in the country where they are affiliated and that means that we really consider them a direct part of the family here at Yale to that extent that they are Yale faculty, they have access to all the tumor boards, all the services here at the main campus at Yale and that means that we need be able to facilitate those tumor boards or those interactions, and those are things were are working out right now in those relationships.  Another big part of it is access to research.  At some sites, we have been very active in community research already but what we are trying to do is be able to tie them again to the main campus so that anything that is offered here eventually patients would be able to access locally and not necessarily have to travel back and forth.
Foss              For our patients, for instance you mentioned tumor boards, which are really important, a patient could be seen say in one of the satellite offices and their case could actually get reviewed in the main tumor board at Yale.  Could you just talk about the advantages of that for the patient?
Chiang          I will use an example, one of our doctors out in Derby had a patient with a liver tumor and it was a relatively rare tumor and he was able to present that patient and their films were reviewed, the pathology, with the liver tumor board here at the main campus.  He was able to attend by phone, audio conference in, and as well as look at all of the films and the slides that were being projected on the screen, he was able to participate in full with a discussion about his experience, what the situation was, and was able to talk to all the liver experts in the room, the surgeons, the pathologist, etc., and come up with a plan for that patient.
Foss              And also from the patient’s point of view, obviously they did not need to necessarily travel to Smilow Cancer Hospital to get that opinion?
Chiang          That is correct.  In that particular case, there was no traveling involved, and I think that is one of real advantages of having this community and academic hybrid system in that we will be able to expand services in the local settings.
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Foss              Are those tumor boards being conducted for all the different disease indications at this point?
Chiang          As you know, Smilow has tumor boards in all of the different diseases, breast, lung, GI, lymphoma etc.  We are in the process of getting that set up so that folks in the community can access those easily.  It is not yet set up completely, I did have that example of the liver patient, but that is something that we are shooting for absolutely.
Foss              So Ann, as this project is just getting underway now, could you reduce some of the major issues that you are currently dealing with?
Chiang          Absolutely, when you are talking about six different sites, in this particular case, for the former MOH practice, each site has their paper record and their individual ways of doing things and so what has happened since the go live is we have had to standardize across all sites, the forms that need to be Yale forms as well as have all the sites comply with a lot of regulations, as they now provide a base clinic. For example, we have placed a pharmacist in pharmacist services throughout those locations, so its been a lot of work and I think there has been a lot of change there, but overall the transitions have gone extremely well and the patients have been relatively happy with the transition.
Foss              What are the various committees that you have set up to help you facilitate this process?
Chiang          There is a physician advisory counsel that consists of the physicians who serve as an advisory body.  One aspect of care that we are very interested in is providing clinical research opportunities, so there are folks who are specifically interested in clinical research.  Finally, clinical practice and quality is a real interest of mine, if you are delivering care in 6 or 7 or 8 or eventually more sites, then how do we know that the cancer care being delivered in one site is the same is the other and that quality cancer care is being delivered across all sites? This kind of mirrors a national conversation which is how do you measure quality in ambulatory cancer care? And I think it is a very exciting thing.  We are actually starting to measure that using a program through ASCO called QOPI or Quality Oncology Practice Initiative which is basically a set of quality measures that have been agreed on and involves looking at charts from each different site to look at those measures.
Foss              For the patients who are listening to this, could you talk specifically about what some of those outcomes are that you think are important as you look across these different practices?
Chiang          I think that it is hard for different patients with different cancers, obviously the cancer that you
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have is going to affect you and your outcome, so a lung cancer patient may do better or worse than a breast cancer patient.  The things that we are interested in are often process, so if you are a new
patient, is your pathology in the chart by a certain time? Has your staging been completed, has your pain been assessed by the second visit? Very basic process measures that people have agreed upon that are important in delivering cancer care.  Those are the things that we are looking at.
Foss              I know that at Smilow Cancer Hospital patients will oftentimes get a questionnaire in the mail after their visit, just to assess how they thought the visit ran and what their care was like and I am wondering if you are going to implement that across the practices as well to get the patient's input as far as how this is going.
Chiang          Absolutely.  There are several ways of measuring patient’s satisfaction and getting the patient's input.  One of them is through Press Ganey which is a national survey and that is being initiated in May. The other way of getting patient’s information which I think is really interesting, is through potentially collecting outcomes, the patient reported outcomes through a patient's portal, so in about a year we should be going live with electronic medical records across all systems which is called EPIC.  A part of EPIC has a patient portal which is a way that the patient can interact with their own record called ‘My Chart’, and I think that it will be really interesting if patients are able to talk to their providers through e-mail to schedule appointments and to tell them how they are doing after chemotherapy, for example.
Foss              That sounds really exciting I would like to talk a little bit more about that after the break.  We have to break now for a medical minute.  Please stay tuned to learn more information about the Smilow Cancer Hospital Community Cancer Network with Dr. Anne Chiang.
Minute          There are over 12 million cancer survivors in the United States right now, and the numbers keep growing.  Completing treatment for cancer is a very exciting milestone, but cancer and its treatment can be a life changing experience.  The return to normal activities and relationships may be difficult and cancer survivors face other long term side effects of cancer including heart problems, osteoporosis, fertility issues and an increased risk of second cancers.  Resources for cancer survivors are available at federally designated comprehensive cancer centers such as the one at Yale Cancer Center to keep cancer survivors well and focused on healthy living.  This has been a medical minute brought to as a public service by Yale Cancer Center.  More information is available at yalecancercenter.org. You are listening to the WNPR Health Forum on the Connecticut Public Broadcasting Network.
Foss              This is Dr. Francine Foss and I am joined today by my guest Dr. Anne Chiang, and we are here discussing the Smilow Cancer Hospital Community Cancer Network.  Prior to the break you were
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getting into this new computer system that is going to have a patient portal, and basically you were
saying that a patient can actually get into that and get feedback from their doctors and find out about their appointments, could you just elaborate a little bit more on what that is going to look like from the patient’s point of view?
Chiang          I think it will be something that patients will really like.  It will be an opportunity to be able to look at when your scheduled appointments are, to get some of your lab results directly sent to you, and be able to access your provider and, for example, if you are on chemotherapy, there may be an opportunity to tell your provider via e-mail how you are feeling several days after chemotherapy, when you are not in the office and you might not normally give them that input.
Foss              Are there other cancer networks around the country that have a similar type of a system?
Chiang          Yes, EPIC is one of the most common electronic medical records, or integrated health systems, used. It is one that we put a great deal of investment into, currently the Yale Medical Group and many of the digestive diseases, neurology, were the ones that most recently went live in February and are on this same medical system.  What it will allow us is to be able to access all your providers across the system, whether it be your primary medical doctor or your oncologist, or your cardiologist.  They will be able to actually look at each other’s reports and know what is going on with you.  In the past, you were always playing faxing and telephone tag with different offices to make sure you are up-to-date with what happened with the patient.  In this case, you will be able to login to the computer and see what the most recent visit with the cardiologist showed rather than trying to chase those results done.
Foss              Anne, some patients feel that too much information is too much to handle.  Other patients want more information.  How do you approach a patient in the office, when you are presenting this to them?  And is this something that is going to be good for everybody?
Chiang          I think that some patients will love it and other patients who will never even use it and that is their prerogative.  I think it is really a tool to use if patients wish to, but there is absolutely nobody saying that you have to do this.
Foss              In our earlier discussions, one of the key points with this network was to bring clinical trials into the community setting and I wonder if you could talk a little bit about what you have been doing in that regard and what you project the future is going to look like?
Chiang          I should add that the cancer network as it stands includes both those care centers, which are the former community practice MOH as well as Greenwich Hospital and the center there. We recently had a research summit in which we had about 50 people here on the main campus including around
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20 to 25 of our care centers in Greenwich faculty intermingling with about the same number of disease team leaders, yourself included, and we had sort of a speed dating format where we had different people go from table to table to hear about the most recent trials in the pipeline and developments in research going on at the main campus as well as what was interesting to focus in the community sites, what kind of trials would be important to have out there?  So, I think that was a very productive conversation and definitely a start to developing a clinical research network.
Foss              I would agree with you Anne, the thing that I got out of that was really hearing from the community physicians what is important to them in the practices that they have and some of the things that we may do say at the tertiary care center, may or may not be helpful to what they are doing in the community, but also it was really interesting to hear how interested they were and trying to get involved with some of these new drugs, some of these cutting edge clinical trials, where we can offer patients drugs that are not commercially available and this would be a great way to do that.
Chiang          Absolutely, the fact of the matter is by establishing this network we have already increased our number of patients significantly and so any kind of new cutting edge treatments that we would like to be able to provide now have an expanded clinical population in which to offer that.
Foss              We have talked primarily about medical oncology, but I am wondering, if in radiation oncology and surgical oncology the same kind of paradigm is being built with the community centers.
Chiang          Actually radiation oncology has a history of working in a network and providing a lot of services along the shoreline in Guilford in various different communities.  So they have actually been at this a little bit longer than medical oncology and have been doing quite well.  In terms of surgical oncology, that is basically the same story, I mean there are gynecologic oncologists here who go to four or five different hospitals in the state of Connecticut and I think that what we would like to do ideally is be able to provide a service line or multidisciplinary effort that will allow people again to stay where they are to have quality of care locally, but with access to expertise and the latest therapies.
Foss              Would you say that there might be some specific kinds or treatment or some specific protocols for instance that might be done say at Smilow Cancer Hospital that would not be done in the community setting?
Chiang          Yes, I mean there are earlier stage trials that are very complicated protocols, which require a lot of blood draws or perhaps biopsies.  Those are more appropriate for the main campus.  There are also other trials where typically you may not have enough patients in the community because they are
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so rare, T-cell lymphoma may be an example, or certain melanomas that have traditionally and probably will remain refereed to the main campus for their care.
Foss              I think that touches another point I wanted to ask you about which is that you obviously have a background in translational research having come from the research lab originally.  Can you talk about how translational research is going to be integrated in the network and also into the clinical trials at Smilow moving forward?
Chiang          I think that translational research, which is basically applied research, is going to be very important in all of clinical research nationally. And the idea is that as we learn more about the actual tissue, the genetics, and the molecular alterations in tumor tissue. The bottom line is that we are learning that the cancer is very heterogeneous and that we would like to move towards a personalized medicine where depending on the kind of tumor that you have and perhaps this is the presence of a certain mutation, you might be eligible for receiving a certain treatment targeted to that tumor that perhaps has less side effects than the traditional chemotherapy, and one of the things that we are working on, on the main campus, is developing this kind of phase I personalized medicine clinic that Dr. Herbst is working on very-very strongly and that is something where you need to have tissue and you need to have clinical information, basically translational research.
Foss              Within this network, will patient’s tissues all be analyzed, say if they present at one of the satellite facilities with lung cancer, for instance, will they have the opportunity to have those tissues analyzed within our institution to see whether they are eligible for some of these new targeted therapies?
Chiang          Yeah, at the research summit, one of our molecular pathologists was there and talking to folks about the opportunities to do this kind of genetic testing on tumor tissue that we could certainly do at the main campus and to some extent can be done commercially, but certainly that would help to guide targeted therapy or personalized medicine.
Foss              So, the concept is that cutting edge cancer care is occurring throughout the entire system?
Chiang          Yeah, I like that, definitely.
Foss              In terms of your other hats, you certainly wear many other hats, you do practice oncology within our center.  Can you talk about your membership in the thoracic oncology group and what your role is there?
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Chiang          I recently joined the thoracic oncology group, and it is a great group to practice in, we see a lot of patient’s with obviously lung malignancies.  There are a number of different protocols, again a lot of these targeted therapies that we are trying to utilize that often have less toxicities than the regular therapies.  I have had experience treating lung malignancies in the past and as I said have done research on lung metastasis and would love to get involved with that here as well, although as you said, I do not have a lot of time, so we will see what happens with that.
Foss              In terms of the Thoracic Oncology Program, is that a multidisciplinary clinic?
Chiang          Yes, TOP has a pulmonologist, thoracic surgeons, medical oncologists, and includes a pathologist.  We recently had a Thoracic Oncology Program retreat and there were probably about 100 people there on a Saturday and we talked about the developments and achievements over the past five years, which have been considerable.
Foss              And you have also had a background in gynecologic oncology, are you practicing that at all at the Smilow Cancer Hospital?
Chiang          No, actually I am not focusing on gynecologic malignancies now, although I do like the patient population.  Right now I am focusing on the thoracic patients.
Foss              Are there any new developments that you are really excited about?  It sounds like you are involved in a number of different areas in terms of research, but are there any things that are particularly exciting for you right now?
Chiang          Our efforts at looking at quality are really exciting and I think that this is an area that again with all of this publicity around healthcare, health care reform, and the legislature looking at health care legislation, I think that it is really important for us to work in a very proactive fashion as physicians to look and see what kind of care we are delivering and make sure that it is really quality care and that we are being very careful about that and not having that mandated by other folks but for us to work in a proactive fashion on that.
Dr. Anne Chiang is Assistance Professor of Medical Oncology and Chief Medical Officer for the Smilow Cancer Hospital Network.  If you have questions or would like to add your comments, visit yalecancercenter.org, where you can also get the podcast and find written transcripts of past programs. You are listening to the WNPR Health Forum on the Connecticut Public Broadcasting Network.