Relationships Between Hematology/Oncology Practices and Transplant Centers

In a two-part episode on Evidence for Shared Care in HCT, our expert guests discuss recent research supporting strong relationships between hematology/oncology and transplant center care teams.

Wendy Woods (formally Woods-Swafford), MD, MPH of Blank Children's Hospital, and Heather Stefanski, MD, PhD of NMDP, join Kelley Steffens, principal investigator and research manager at NMDP, to examine research findings and discuss best practices for shared or coordinated care to address access, barriers to care, and equity concerns in HCT.

• Part 1: The Impact of Sharing Care and Timing
• Part 2: Addressing Barriers and Equity with Shared Care

Listen to Part 1

In part one of this two-part episode, Kelley Steffens presents major findings from her recent abstract at the 2022 Tandem Meetings of the American Society of Transplantation and Cellular Therapy (ASTCT) and the CIBMTR^® (Center for International Blood and Marrow Transplant Research^®) showing support for shared care and strong relationships between hematology/oncology practices and transplant centers. Dr. Woods and Dr. Stefanski then add their perspective on the results, discussing the importance of shared care and timing in HCT...

Research supports strong provider relationships and shared care

Kelley opens the episode with the rationale for this research, recognizing that hematology/oncology physicians play a critical role at the beginning of a patient's disease course when HCT may be a treatment option. She emphasizes NMDP's commitment to early consultation for all patients who may need a transplant since patients who receive HCT earlier in their disease course have better outcomes. In this context, a survey was conducted among hematologists/oncologists who are independent of a transplant center focusing on the relationships between their practices to streamline the pathway for patients to transplant. Community hematologists/oncologists who identified having strong relationships with their nearest transplant center were ultimately more likely to be supportive of early treatment interventions and be more comfortable with post-transplant care. While no causal relationship can be inferred from the results, the association does support work that NMDP is doing to facilitate and examine best practices for shared care.

Dr. Woods agrees with the logical suggestion that relationships between community providers and the transplant team could impact treatment decisions for HCT. She stresses the importance of that initial comfort level between the care teams. According to Dr. Woods, without frequent communication, a lot can be missed, and decisions made can actually complicate a patient's care. Immediate and frequent real-time contact with transplant teams is essential, and that culture sets the stage for patients and their families when transitioning from one care team to the other and back. Dr. Stefanski agrees, citing the strength of the working relationship she had with Dr. Woods. According to Dr. Stefanski, Dr. Woods could have sent her patients to multiple transplant centers, but she often chose University of Minnesota likely due to the strength of their relationship. Dr. Stefanski also emphasizes the culture of collaboration needed to ensure that patients reach transplant and then get sent back to their hematologist/oncologist for post-transplant care as part of a joint extended care team.

Dr. Stefanski goes on to discuss the frequent meetings University of Minnesota would have including community hematologists/oncologists to discuss patients at different time points in their journey. Kelley corroborates this approach to shared chare with an example from the luncheon NMDP hosted at Tandem to discuss these research results with a panel of transplant physicians and other members of the care team. Monzr M. Al Malki, MD at City of Hope is used as an example of a physician who mentioned inviting hematology/oncology providers to tumor board meetings and visiting their practices in person to strengthen his relationship with surrounding practices. Dr. Stefanski agrees with the importance of building that trust between care teams, and also reiterates the importance of nurse coordinators and the entire care team to help keep those lines of communication open.

Dr. Stefanski asks Dr. Woods to elaborate on how she chooses a transplant center for her patient referrals, referencing the impact insurance can play on this decision. Dr. Woods states that in her fellowship training program, the importance of a strong relationship with your transplant team was emphasized as a key point to build into conversations with patients up front. While she does ask the patient if they have a preferred transplant center or if they have family or relatives near any transplant centers than might afford them a housing or caregiver opportunity, she stresses that it is often the relationship with the transplant center and her understanding of where the patient can get the best care that influences her choice. According to Dr. Woods, it is about a culture of communication being a part of the entire center and not just about close relationships with a single physician or touchpoint at that center. Distance is less of a factor, though insurance or financial support for patients can play a role.

Dr. Stefanski agrees with Dr. Woods that the insurance, financial and legal barriers make a huge difference. Working with the transplant team to help the patient get the best outcome means a culture of coordination to help deal with challenges across insurance, transportation, housing, financial limitations and even interpreters that are needed for international patients. Dr. Woods emphasizes that consistent coordination takes more work up front, but building those relationships helps the care team work through barriers to care and prevent complications.

Starting the conversation early and the importance of timing is then discussed, with Dr. Woods emphasizing the need for early HLA typing with programs like HLA Today. Without coordination and communication from the time of diagnosis, you can lose weeks and weeks that can make a big difference. Kelley brought up findings from the research study that 73% of hematologists/oncologists with strong relationships with transplant centers agreed with discussing transplant as a treatment option with acute myeloid leukemia (AML) patients at diagnosis, while only 40% of those without a strong relationship with a transplant center agreed. Dr. Woods and Dr. Stefanski agree that those conversations for AML especially should start right away. The NMDP partners with the ASTCT to publish HCT Consultation Timing Guidelines to help hematology/oncology providers know when it's the right time to contact a transplant center.

Listen to Part 1

Listen to Part 2

In part two of this episode, Kelley Steffens, Dr. Woods, and Dr. Stefanski dig deeper into barriers to care and health equity concerns for adult and pediatric patients in need of HCT. They go on to discuss how building relationships, connectivity, and shared care between hematology/oncology practices and transplant centers can help, and ways to apply these principles to clinical practice.

Barriers and equity – addressing access via shared care

Dr. Woods begins by discussing the differences in barriers to care for adult and pediatric patients. Given Dr. Woods specialty in adolescent and young adult care, she discusses the challenges of the young adult population with special care needs that aren't always met by adult programs.

With pediatric patients, insurance coverage is less of an issue, but there may be different standards for what constitutes a center of excellence for insurance authorization. This can limit where a patient goes for transplant.

Dr. Stefanski emphasizes that the family dynamics are much different for pediatric patients, with caregivers typically being parents or guardians compared to a spouse. When an adult and their spouse can't work during the transplant process, it leads to additional challenges and the need for financial assistance. This all makes early consultation, coordinated care and relationship building between providers essential to helping to overcome these barriers.

In terms of health equity, Dr. Stefanski specifically calls attention to the fact that social barriers are much more challenging now than HLA-related barriers. With advances in mismatched unrelated donor (MMUD) HCT and improved outcomes, NMDP is able to identify a MMUD for nearly 100% of patients in need of transplant.

Dr. Stefanski specifically mentions the currently enrolling ACCESS trial, a continuation of the NMDP-sponsored 15-MMUD study in which 48% of patients enrolled were ethnically diverse. This work validates the potential of MMUD to expand HCT access to patients who are racially and ethnically diverse. Dr. Stefanski calls attention to biases related to donor availability or social barriers that a patient may face in this context, stressing that this should not limit transplant consultation.

Kelley adds additional context with recent research from Vamsi Kota, MD, of Georgia Cancer Center, Augusta Health, who found targeted outreach to regional hematology/oncology practices greatly increased transplant utilization in the area, especially for African American/Black patients.

Dr. Woods agrees with the challenges in equity discussed, giving the example of transplant for sickle cell disease and its limited availability. She gives an example of a colleague who had success addressing barriers for African American patients by visiting churches and encouraging blood donation, marrow registration and screenings at local events. Dr. Woods stressed the importance of helping build trust between providers and the community by bringing awareness of transplant to diverse ethnicities and nationalities.

When asked about day-to-day tactics for clinical practice to implement shared care, Dr. Woods reiterates that it all comes back to building relationships and connectivity, thinking of transplant teams as an extension of your care team. Dr. Stefanski agrees and says that active outreach to hematology/oncology practices is essential as a transplant physician if you want to build trust, create genuine connections with your patients and ensure you get consultations.

All guests agree that these patients have a scary path to navigate, so having that connection across the care team is critical. Dr. Woods gives an example of the entire care team coming together to transfer a patient and deal with complications.

Kelley discusses ongoing patient research suggesting care teams with less coordination leave patients feeling more scared and less confident in their treatment. Dr. Woods agrees that especially when complications arise, having taken the time to build those relationships becomes so powerful. In fact, without communication throughout complications, patients can really suffer or even be lost, and that may close the door unnecessarily for future patients if a physician has a bad experience.

As final tips for shared care, Dr. Woods and Dr. Stefanski really emphasize the trust that they built as colleagues and the importance of taking the time to do so. The handoff process in the patient's path to transplant and back makes that coordination and trust especially important.

Dr. Stefanski recommends going the extra mile whenever possible, whether that be a transplant center site visit to hematology/oncology practices, or 15 minutes to write an extra note, email or phone call. Dr. Woods agrees, and says to not only visit each other's practices, but take the extra time with these patients and their families to help address barriers to care, taking advantage of all the resources at your transplant centers to help. That's how shared care can save lives.

Listen to Part 2

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