S2E1 | Expanding value-based care, clinical trials, mental health support: A conversation with Dr. Atul Dhir
Pat: Hi, I'm Dr. Pat Basu, the President, CEO of Cancer Treatment Centers of America and the host of Focus on Cancer. It is my pleasure today to welcome Dr. Atul Dhir. Dr. Dhir has become a great friend and he has spent the last 30 years shaping and forwarding cancer care in so many ways as a physician, as a scientist, as an executive, as a leader. I'm really excited to get Dr. Dhir's perspectives today. So Atul, welcome to the show. Thanks for being here.
Atul: Thanks Pat. I'm really looking forward to this.
Pat: Yeah. Yeah. We've got a lot to talk about. As I mentioned, you've done so much in the field and we're going to get into a lot of those aspects from again, being a physician. You've led some very important organizations in the field of oncology, from a variety of sectors, as a scientist, as a CEO. But you were, I think the most important perspective of all, and I think you, and I would agree with that, and that is as a cancer patient. I think that's really been something that I know has motivated you. Your story has inspired me, and I know it well for our audience. So do you mind just maybe starting with, with sharing that journey?
Atul: It takes me back many years. So this is almost 19 years ago and I was the President of one of the major cancer organizations called US Oncology under 40 years old. We went for a general physical executive health checkup at Mayo Clinic in Florida. Lo and behold, completely asymptomatic, they found a lymph node that didn't look that great. As we pursued it I, to cut a long story short, ended up being diagnosed with stage four Hodgkin's disease, which it was later found, had progressed to a non- Hodgkin's lymphoma, completely asymptomatic. That began an interesting journey from not just being a physician and an executive, but actually going through the whole experience of chemotherapy, and everything that's involved in getting treated for this disease.
Pat: Wow. Well, as you and I both know that healthcare is one of those that in many ways, it is a bond between all of us as humanity, where we share its presence and when sadly it leaves us, it is one of those things where it doesn't matter whether you're a doctor or an executive or what you're doing, we can really sense that feeling, we have a mutual empathy for each other. But that being said, I think cancer is in such a league of its own. Often times, because exactly like you mentioned, there's that lack of the progression for most patients where it's lightening out of a blue sky, right? With certain conditions, certainly not all, but you might have your, these are all various serious conditions, but CLPD might get worse, or heart disease might get worse, but there's sort of a, you go from two to three to four, where basically in your case, as with so many of our patients it is, one day you're going along and the next day, your world changes physically, and emotionally and spiritually. So thank you for sharing that with us. How are you doing now? How has that journey changed you and changed your perspective?
Atul: One of the things that, Pat, this experience has shaped me in a very deep way is gratitude, right? I'm doing really well. As far as I know, and no symptoms, no residual. I was one of the lucky few that benefited from early diagnosis, appropriate treatment. So for all intents and purposes, while you don't use that term in cancer care, I feel cured. I'm in great health, from a health perspective, doing really well. It almost feels like it was in my distant past. The question of how it has shape me, is an evolving journey. In some ways it never completely recedes from your memory, even though there is not nothing that I do that is specifically related to being a cancer patient, or more appropriately a cancer survivor. But I feel I have a much better appreciation, as you said, and you know that from your experience. This particular illness has in addition to health implications, psychosocial implications, that it changes you, changes you in a much deeper way than you can even appreciate. One of the ways it influenced me was really in my professional way, in professional career to have a much deeper appreciation, and in some ways gave me a passion that was deeper than just a clinical and a scientific passion to see how I could contribute to this area in different ways that I've tried to in my professional life, and hopefully also help people in a personal capacity.
Pat: Yeah. But I love what you said. I loved that the first thing you started off with is gratitude. I think that's such a powerful place to be, but there is that sense on one hand that there is so much outside of our control, but at the same time being grateful for what we have, and particularly as it comes to health. You also mentioned so many things that I think resonated with me, you ended with this concept of, it's not just the clinical or the scientific dimension. Sometimes you and I share a passion for teaching medical students and residents, and I sometimes talk about the difference between learning something cerebrally, versus viscerally. What I mean, inaudible trying to have a second year medical student who you teach about the gene, or the mutation, or the pathophysiology of a cancer. But the difference between that student and the one who meets the patient with colorectal cancer or breast cancer, is very different. That visceral knowledge is a powerful sort of, its wisdom in addition to the knowledge. I think that the great privilege of working against this horrible disease and, and working with cancer patients is, we not only get to advance on the science and the clinical, but also on this visceral very human journey that you spoke of.
Atul: It's going to sound like a cliche, but cancer is a human. I don't even like using the word disease. It's almost an existential event that happens. Sometimes as physicians, we forget that. It doesn't just affect the patient or the individual. It affected my entire, geographically, internationally distributed family. We just don't take that into consideration because it is such an existential issue when you use the C word, that it makes you confront life issues. That in the heat of the clinical diagnosis and the treatment, as a patient, you don't even realize, and certainly as a physician, you don't fully appreciate. CTCA's distinctive brand is based on the appreciation of the whole person, and even sometimes beyond the person, the whole family unit. As they go through this journey of diagnosis treatment and post- treatment. I think that is going to become even more important as it evolves, as you know very well, from being what used to be a terminal disease to now something that you live with, it's like a chronic illness. I also want to share with you the excitement which I know we both share. The clinical excitement and the scientific excitement of how these new therapies and understanding of the biology of cancer. As you know, my PhD is in molecular biology. Cancer is a shining example of how these modern discoveries of genetics, of DNA, cell multiplication, and all of these incredible diagnostic tools of precision, medicine, and next gen sequencing, they are really impacting the experience and the biology of this disease. As a survivor of stage four lymphoma, I don't take any medicines than perhaps someone with diabetes has to do or with congestive heart failure. So I'm also in addition to the general gratitude of having had the benefit of early diagnosis and excellent treatment. I'm really grateful to the scientific and the medical community, for us to now have the privilege of thinking through a full life as a survivor.
Pat: The advancements in our ability to fight this disease are a testament to science, a testament to medicine, a testament to the resolve in which we fight cancer. So the targeted therapy is all of those things, and I share your optimism. I think in the years, and in the decade ahead, we are going to see even more of those advancements that are going to help patients all over the world in multiple cancer types. I know you've made it a big part of your mission to both advance the science, and going back to your molecular biology roots, as well as the journey. As well as even just the accessibility of cancer care. Maybe let's start there. You've done so many different things in your career that have, again, advanced medicine and in so many ways. Most recently value- based care, which is a term that gets used a lot more nowadays, and ultimately the question was always value to whom? You and I always believe that should be value to the patient. I like to think of value as a denominator. Quality service over whatever resources need to be consumed during that. But talk about value- based care, the journey that you've led in that space, what the opportunities are in value- based cancer for oncology. Because I know a lot of people hear about it, but it's still, in some ways it's still a relatively young concept.
Atul: Yeah. As you know, I had the privilege of leading New Century Health for almost eight years as the CEO and the Chairman, and by all accounts really feel privileged. New Century Health was and continues to be a leader in the delivery of value- based care or value health care in cancer specifically, but we also did that for cardiology. I have to say my understanding of the value- based care or VBC, as it's often referred to, has evolved as well. In candor, in the early days, value- based care was really a very polite term, often defined by the pear industry, by the insurance companies, that as you correctly said, value is quality over cost was more focused on the denominator of cost of care, than necessarily the appropriate focus required on quality as well. It was understandable because again, because of the advance in science, we are now in a position where we have a range of choices in both diagnosis, as well as treatment of patients, but they're not cheap. They have a price tag that is staggering sometimes. We have even therapies today, as you know well, and that can be almost half a million dollars for one course of treatment, particularly with CAR- T therapy, et cetera. We have to not only think about the cost of care, but also look at from a patient centric perspective, how are we enhancing the quality of care? Quality as you know, is not just treating the disease, how well we are shrinking the tumor or reducing some of the side effects that some of these tumors can cause in terms of just the spread of the cancer in different parts of the body. But quality also is about the kind of quality of life that the patient is experiencing, because some of the toxicities of these chemotherapies can be worse than the cancer itself. Therefore, how do you think about supportive care? Which we now have, thankfully, a lot more tools available as a physician than we had decades ago. How do you think about palliation? Not at the end of the cancer journey, but at the beginning of the cancer journey. Therefore, it's not about giving more therapy, sometimes we can be very aggressive as physicians in trying to get at that cancer, that tumor, that cell, but in the process lose the perspective, how is that affecting? What are the toxicities? And how is it affecting the quality of life of that patient? Then the second aspect is particularly what value- based care has helped us. I think America, as a healthcare delivery system leads the world there, is to start thinking about managing the overall care and costs of a population that you take responsibility for. Often, you don't have that many choices in terms of what to do with individual patients. But when we start looking at how do we care for this entire population of cancer patients, there are tools and capabilities that we can put in place, and how we work with the cancer delivery system, and the site of care, whether it's delivered in the emergency room or in the hospital, audit is provided in a community setting, and increasingly I think in patients home. These now give us a more systemic view, which allow us to not only provide better care, but also in a more cost effective way that is good for patients, good for the insurance companies, but overall, ultimately good for society, I believe.
Pat: That version of value- based care, the patient centered, quality driven version of value- based care has a real future in American healthcare and certainly a place in oncology. You and I have talked about it in our own efforts at CTCA with a platform we call Ora, to really find ways that find the areas in cancer care that deliver real quality and change the patient while squeezing out the areas that may be wasteful or harmful. So you and I could talk a great deal about that, but at the same time, you also have had a huge experience, not just in leading value- based care, but also in the biotech sector of advanced cancer care. Tell us what you did in oncology, and in biotech, and what have you learned from that experience?
Atul: Yeah. Pat, I have to say before I respond to your question, it is such a joy to talk to you because I marvel at your career. You have an incredibly systemic view and awareness of the healthcare system with your work at United, obviously as a physician yourself and now what you're doing with CTCA. I share that with you, I think we're really lucky to have in our professional lives, an experience of just one therapeutic area like cancer, and look at it from a systemic view that once you start understanding it, not just from the perspective of the physician, but also the patient, the insurance and all the other supportive services that go with it. You touched on something about the antiquated system, I think you called it. That's one thing that we may not have time to go through it, but as we started looking at value- based care, you begin to see the gaps, and as it was the fault lines in how the reimbursement systems are also haven't caught up with the way cancer is treated. Cancer is now often treated in the community. A lot of the reason why palliative care and supportive care is not often provided at the level it should be, is because, and there's no reimbursement for it, for very important services like cancer rehab, for instance. So there is a lot of catch- up we have to play, and it is fun. I just enjoy our conversations because it's few people who have such a wide lens on the entire healthcare delivery system beyond just the medical and the scientific side.
Pat: If I may, I just also wanted to just jump in there, because I agree with you and you. You look at so many examples in oncology care where, yeah, our financing mechanisms have not caught up with it. We already gave one example where the benefit may be five, 10 lifelong. But somebody's an employer, and insurance company is having to bear all those costs in a single year. That leads to let's just use the euphemism, suboptimal decisions rather than doing the right thing. But you also hit the nail on the head, palliative care or things that make the patient feel better, so many of the integrated services are oftentimes not covered. So one of the things I think collectively we have to do in oncology in particular is get the payments system to catch up to what is really best for patients. That's where the blend of medicine and science, but also policy, and even economic theory needs to come together. It's one thing I love about our conversations, it's one thing that I invite our audience to participate in is these tough grand challenges require team thinking, a multidisciplinary approach. It's not just going to be the physicians or the policymakers, but it needs to be, just like medicine needs to be patient centric with a team around the patient, I think health policy and healthcare delivery needs to have that same team based approach around the patient. So thank you for that comment, but really it's something I feel passionate about.
Atul: I think that's something Pat, going back to your earlier question, I hadn't quite appreciated until I went through the cancer journey as myself. Or as my wife put it that," I know you like hands- on experience, but this is too much, you don't have to get cancer to really appreciate what happens in cancer." What I began to really appreciate is it does take a village. It is such a complex illness if you truly take, which we were told and taught in medical school, if you truly take the patient centric view, there is an incredible number of people. Some of them who are never appreciated on the front line, the nurses, the pharmacist, the social worker, and we haven't even talked about clinical trials yet. There is a number of people that as a physician, frankly, I've not appreciated. They actually have more frequent contact and affect the quality of life of a patient. Sometimes more than just what we would attribute to a treating physician or a surgeon. That really has given me an appreciation of it's a team sport, and how do we not only recognize that? But how do you provide those services and make sure that these are compensated? The pressure on the physicians, because they're only paid for the actual consultation or the delivery of chemotherapy, or diagnostic tests, but what about the grief counseling? What about the conversation that the physician is having with the patient's family, which has nothing to do with the cancer, but the kind of issues that you're talking about? There's no reimbursement for, as you know and CTCA has really led that field in providing nutritional support and nutritional counseling. They do affect not only predisposition to some cancers, but also during treatment, in terms of managing some of the side effects, or exercise and addition to psychosocial sexual health conversations, there is no reimbursement for those. So I think we have a lot of work cut, from the policy side ahead of us as well. I'm so glad that people like, if physicians are taking that role in leadership for the work you're doing, because it brings a level of integration of not just the medical perspective, but also some of these other perspectives that have to be brought if we are to really enhance the entire delivery process and system.
Pat: Even cancer care, being a very important microcosm of the entire healthcare system, where health and wellness and prevention are oftentimes not as rewarded as things that both you and I, as physicians in our career have done. To be clear, it's not to diminish those things because those are critical, but it's to say, we also need to find ways to insent and pay for those other elements. Then the team sport concept I think, is right on. I just have to briefly share, because I was speaking with my team earlier today, there's a story I love. When John F. Kennedy said that we're going to the moon, he was touring NASA shortly thereafter with the NASA administrator at the time James Webb and a couple of other people, and walking through a hallway and he stops and speaks to the environmental services professional, the janitor and says," What are you doing?" And the janitor says," I'm helping put a man on the moon." I am just an ardent believer that everybody in the cancer care arena is fighting cancer, is helping save lives. That is exactly what you've said, that the nutritionist that we have here, the nurse, but also even the nonclinical folks who are really helping behind the scenes to ensure all of those things happen. If there's a silver lining, I think to 2020 Atul, it's that I think some of these previously unrecognized heroes, both clinicians and those who help clinicians, whether it's supplying them with things, but the healthcare supply chain I think has been raised at least in awareness and recognition. You did mention another important aspect that I think sometimes gets lost behind the scenes, which is what is clinical trials, without those clinical trials, many of the cutting edge therapies that we've talked about, let alone, many of those that are on the horizon would not be put into the place to save lives in the first place. You've been very close to the clinical trial world. I asked you earlier about the biotech experience, but will you just share your perspective on the biotechnology world itself and how clinical trials in particular are shaping the future of cancer care?
Atul: I feel in the spirit of a team sport, I want to also acknowledge the role of the pharmaceutical industry, which often doesn't get the credit that it deserves. So when I finished my role at US oncology and shaped by my experience of having cancer, I began to really appreciate how, while there are big gaps in how we can improve the delivery of care, and access to care, and reimbursement for care as we've talked about. But boy, having a good targeted chemotherapy that like Rituxan, which is a monoclonal antibody, that is like a missile going at the cancer specific B cells in lymphoma, and with minimum to no side effects was not lost on me. That was really powerful display of excellent science, and my deep appreciation for the scientists, and the industry, pharmaceutical and the biotech industry. At US Oncology, one of the things that I was passionate about that led to my move to the biotech industry or the pharmaceutical, working for them, was I had built and grown what is now one of the largest clinical trial organization, physician led in the country in US for doing cancer clinical trials, and that was the US Oncology Clinical Trial Organization. I was the president of that. In fact, we were involved in some of the pivotal clinical trials for some of these therapies, including Rituxan, and in breast cancer, or Herceptin, et cetera, and now obviously immunotherapies. So when I completed my role at US Oncology and took some time to accurately reflect on what mattered most to me and where I could have the most impact. Given my background in science, but also my experience of clinical trials, I was recruited to lead what was then regarded as one of the most exciting biotech companies called BiPar Sciences, which had recently been acquired by Sanofi, which is a multinational pharmaceutical company headquartered in France. I had a double mission. I had a mission to be able to take what was some really exciting targeted therapies, these were parp inhibitors, which are now mainstay of many cancers, including ovarian cancer. We had the best in class and at that point, the first in class in that area. So my goal was to be able to develop this drug, which had very early clinical trial results into large scale clinical trials, and obviously then commercialize it. But I had a second role also as you know, the innovation in cancer therapies has been lagging a little bit in large pharmaceutical companies. They hadn't been on the forefront of developing these targeted therapies, and was really led by these incredibly entrepreneurial scientifically intense and rich biotech companies. So my second role was in addition to being the CEO of BiPar, but also as a member of the Global Oncology Executive Committee for Sanofi, to be able to see how we could bring some of the entrepreneurial and scientifically very focused efficient processes of a biotech in the context of large pharma, which clearly has a tremendous role. So I was attracted to that, I had the privilege of working with both teams of this entrepreneurial team, which was based primarily out of South San Francisco, but also the team from the parent pharmaceutical Sanofi, which was in Cambridge, which is where I was based, and also in Paris. It was an incredible experience, began to really appreciate what it takes to develop a drug, the challenges of running global clinical trials. I'm sure it's not lost in both of us as these vaccines, in fact today, one of the vaccines is being reviewed for emergency authorization by FDA. Ironically, the Chief Medical Officer of Moderna now was my colleague at Sanofi, he's an oncologist by training. So fortunate that he's doing such wonderful things. But also the Pfizer drug is a good example where it was a combination of a niche biotech company that developed this inaudible vaccine, and the power and the strength of Pfizer that could manufacture and distributed in millions of doses overnight. That's what we were trying to build in early 2000. It's not easy. I can tell you what Pfizer has now accomplished with this vaccine is as much a miracle in terms of taking this incredible science, and then have the heft and the resources to be able to deliver it on time. In fact, ahead of time at such scale, it also highlights the risk these companies take when they develop innovative therapies. The lead drug that we were developing did not meet the clinical endpoints in a global phase three trial, which had shown survival advantage in phase two. Then we had to spend a lot of time trying to figure out why it didn't. So I've seen what you may call as a failure, but in science, we learn as much from failures as we learn from successes. So it was an incredible experience working for BiPar and Sanofi.
Pat: Well, Atul, there's just so much to talk about. This has just been such a fun episode. We could have gone into, I feel, a does another topics and maybe at some future point we should do that. But for now, I just, first of all, wanted to say, thank you, and second, any parting words of advice or wisdom for our audience, anything from the direction of cancer care or your own journey, things that you'd like to share?
Atul: My main message and what excites me really is we're lucky Pat, in our individual roles to be involved with an illness where we have the privilege of not only making a contribution in patient's life. But also it's one of those therapeutic areas in medicine, which is going to be transformed over the next decades. So there's incredible excitement on the therapies that are coming across, gratitude for the scientists and the pharmaceutical industry, and the biotech industry. For the diagnostic industry in terms of precision medicine, which CTCA has taken a leadership role in as you know well. But what I think we are both aware of is for it to have the kind of potential and impact we can have on patients, on families and fundamentally transform the experience that people go through with cancer over the next several decades is very much possible. But it's going to require the kind of integrated leadership that people like you are providing, which is, it's not just the science, it's not just a drug therapies, it's looking at the entire ecosystem. From the delivery side, from all the different professionals beyond just the physicians, the nurses, the social workers, the nutritionists, and the pharmacists. The reimbursement challenges that we are going to face, the access issues and inequity issues we are going to face. So I'm grateful for what you are doing. Excited for the privilege we both have of working in an industry where we can make a meaningful impact. It's going to require the kind of leadership that I know you are providing and others are. So overall, I have great excitement for this area and a great appreciation for all the people who contribute to making this disease manageable, and potentially something that's not as scary as it once used to be.
Pat: Well, thank you. Gratitude, optimism, a sense of the entire team or the village, as you said, I think is a great way to sum it up. Thank you for sharing your time. Thank you for all of the amazing things you've done and will continue to do in this journey ahead.
Atul: Thank you, and thank you for what you are doing, and thank you for this opportunity.