I am not sure how many docs continue to do this, but I still read the actual hard copy of my NEJM, and that means I flip past ad pages with smiling grandfathers playing with grandchildren thanks to supercalifragilistic products on my way to scholarly papers with tables and figures. But this time, I stopped in puzzlement when I came across exhibit 1; Intermountain is a health system based in Utah, very highly respected for its sound approach to quality and cost control, but not broadly well known for cancer care in the way of centers like Dana Farber or Sloan Kettering.
Digging further by going to the website uncovers the actual offering which is a streamlined 5 step process:
- Send tumor sample
- Deep sequencing of 96 key cancer genes
- Genomic data analysis
- Tumor board makes a treatment recommendation
- Facilitated procurement of the relevant cancer drugs
Turn-around time is about two weeks, fast enough to wait for the information before starting a regimen.
Let’s dissect these steps a bit more. The first is standard pathology, with the sample put in the mail just as it would be for a second opinion. The sequencing step relies on what appears to be an internal custom-built screen of 96 actionable genes called ICG100 itself based on an Illumina Next Generation Sequencing platform. This will almost certainly evolve rapidly as full sequencing becomes the norm, as well as transcriptional expression analysis through RNAseq. The data is then analyzed for meaningful mutations and the results are transmitted to an Intermountain tumor board to arrive to a treatment recommendation. It is not clear what the exact claim of expertise of the tumor board is (although some members are well published) but a reassuring feature is that referring physicians are welcome to participate in the discussion by dialing-in from wherever they may have their office. Finally, the process optionally includes ordering of the relevant drugs to be delivered to the requesting oncologist and pre-authorization with the patient’s insurance. Given that chemotherapy buy and bill is still a core source of income for oncology practices, it will certainly catch the eye of practitioners contemplating the use of such a service.
So what does this mean? It means that from a scientific/clinical capabilities perspective, smaller independent practices may not be doomed, because they should be able to very conveniently leverage delocalized best in class capabilities to plan treatment for their patients. At the same time, it means that at the national level, there will likely be in the end only a few winners providing this type of service (which may or may not include Intermountain), and could ultimately be driven by machine-based algorithms like Watson Health – after all would you want anything else than the top expertise to plan your cancer treatment? This could be a major threat to the middle layer of major brick-and-mortar cancer centers that lose the race for national recognition of expertise as they might end up bypassed by their local community oncologists unless they find a way to tie them up through other arrangements, possibly related to reimbursement.
This has also implications for the cancer drug supply chain as facilitated procurement is just a few steps away from the role of an outright purchasing group.
Funny how a single ad can evoke a whole brave new world of oncology.
 James, Brent C., and Lucy A. Savitz. “How Intermountain trimmed health care costs through robust quality improvement efforts.” Health Affairs 30.6 (2011): 1185-1191.