Harlan Levine of City of Hope talks about efforts to improve health equity and produce better outcomes for underserved communities.
Treating cancer requires a different approach and mindset than other diseases, Harlan Levine says.
Levine is the president of health innovation and policy at City of Hope. Based in Los Angeles, California, the system focuses on cancer care. City of Hope is focused on improving access to care and treatment of cancer in underserved communities, Levine says.
He talked about those themes in a presentation at the HLTH Conference in Las Vegas last month. He also shared his thoughts in an interview with Chief Healthcare Executive®.
“The most important thing for people to understand, the takeaway, is that cancer care is different,” Levine says. “And the system keeps wanting to treat it with the same tools that we use for other chronic diseases like diabetes, or back pain. And what separates cancer from the other fields is that it's just changing so quickly.”
In a wide-ranging interview, Levine talks about closing disparities in cancer care, improving research, better messaging to underserved communities, efforts to change health policy and expand access to cancer care.
A need for more subspecialties
City of Hope has been increasingly focused on health equity in recent years. Levine points to the expansion of the system’s footprint in southern California, moving from a handful of sites 10 years ago to 40 locations today. City of Hope has also expanded its footprint in other states, including the acquisition of the Cancer Treatment Centers of America in February 2022.
Too many patients in underserved communities don’t live near a National Cancer Institute-designated cancer center, Levine says. Nationwide, there are 72 NCI-designated cancer centers in 36 states. Even patients living in urban areas may not have easy access to high quality cancer care.
Part of why Levine says cancer treatment is different from other conditions is the acceleration of knowledge, and how quickly standards of care can change.
Cancer is no longer “just a handful of conditions,” Levine says. “It's hundreds of conditions, each one defined by its own DNA blueprint.”
Because of that fact, Levine says cancer care requires new thinking.
“The system doesn't want to hear this, but it actually requires more sub-specialization to understand the genomics and all the different combinations that can occur,” he says.
“Like in breast cancer alone, there's probably 20, 30 common manifestations given the genomics,” Levine adds. “It's just hard to keep up with all of it. And that's just the diagnostics, and then you have all the new therapeutics. So, you know, that's why cancer is different. And we need to have a system that understands that it's really impossible for any one general oncologist that’s seeing 30 patients a day to keep up.”
Levine points to advances in treatment of small cell lung cancer. A decade ago, many patients with small cell lung cancer would only live six to eight months.
For most patients at the time, the only way to survive for a longer period “was if you're on a clinical trial,” he says.
Now, better treatments are allowing some patients to live five years or longer. “The importance of having equal access to clinical trials should be really clear from that example,” he says.
Better messaging, diverse trials
Researchers have documented that members of minority communities, including Black Americans, are more likely to die of cancer than white patients.
Black women are slightly less likely than white women to develop breast cancer, but the mortality rate among Black women is 40% higher than white women, the American Cancer Society says. Black men also are twice as likely to die of prostate cancer than white men, Levine notes.
Levine acknowledges the role of social drivers of health, including the ability to pay for healthcare, as well as access to transportation, housing, and nutrition. He also says health systems need to consider their outreach efforts to underserved communities.
“I also think that there's a lack of culturally appropriate messaging that goes into these communities,” Levine says. “So patients aren't really aware of the importance of screening, they aren't aware of the importance of following up and symptoms. And then oftentimes because of the health product they're in, there's often a lack of access to specialization or just a delay in the system to get to the care that they need.”
Given the disturbing disparities among Black patients in cancer, Levine says it’s vitally important to expand clinical research trials to include more Black patients and patients of other underrepresented groups.
“There's no doubt that we have always been slow in the healthcare system to address the needs of the underrepresented communities,” Levine says. “You know, studies are typically done on white populations of men between the ages of 18 and 55. Now, we're moving away from that slowly, but there's a huge lag to catch up with that.”
Some changes to improve cancer care have required efforts at the policy level.
City of Hope formed a coalition called, “Cancer Care is Different”, that began work on influencing state policy in California. The coalition helped pass a resolution for a “patient bill of rights” for cancer patients in California, spelling out that patients had the right to see an expert for their specific clinical needs.
Eventually, California lawmakers went beyond a resolution, which lacked teeth, and moved to change state law. In 2022, the state’s lawmakers approved the California Cancer Care Equity Act.
The law gives patients the right to go outside their own health networks if they have a complex cancer, and their network doesn’t have expertise in treating that type of cancer. The law also requires health plans to make patients aware of that right, Levine notes.
Levine also notes another effort to expand access to care comes in the form of AccessHope, a company developed by City of Hope.
Working with other organizations such as Dana Farber Cancer Institute, Emory Healthcare, Johns Hopkins Medicine, and others, the company connects cancer experts with employers’ health plans, allowing patients to get better care while still seeing their own doctors. AccessHope offers the benefit to more than 150 employers and is now covering more than 5 million lives, Levine says.
"This is in such demand by employers, we've caught the attention now of large health plans,” Levine says. “So we're really excited. And what we're able to do is equalize the access to NCI-level expertise.”
“And so whether you're working in the boardroom for a company or you're working in the mailroom for a company, you get the same access to expertise, without having to travel. We know it's important to get care in your community,” he says.