Ethan Basch’s ASCOQLTY24 Joseph Simone Quality Care Award lecture

ASCO (American Society of Clinical Oncology) shared a post on X:

”A recording of Dr. Ethan Basch’s ASCOQLTY24 Joseph Simone Quality Care Award lecture is now available in which he reflects on the evolution of quality improvement in cancer care. On the Brink of a Golden Age in Quality Cancer Care.”

Source: ASCO/X

The transcript of Ethan Basch’s speech

Thank you very so much for that kind introduction. And I’d like to thank you and the program committee for this honor. I’m truly humbled.

I’d also like to thank the phenomenal ASCO staff for once again organizing a superb meeting. I enjoyed this morning very much and I’m looking forward to these next two days. Today, I’d like to talk to you all about why it is my belief that we are on the verge of a golden age in quality cancer care.

And to help explain this, I’d like to start by discussing where we’ve come from, where we are today. I’ll take a brief interlude and talk a little bit about my own journey. And then I’ll finish up by describing some of the opportunities that I see towards the future.

Now, when I started my career as an oncologist and as a health services researcher more than 20 years ago, our focus was largely on asking why questions. For example, why should we make changes to operational processes? Why should we consider inequities? Why should we do advanced care planning? Why should we support patient navigation to our session earlier today? And researchers at that time were largely engaged in characterizing problems. But a substantial change has occurred during my career and we have shifted today largely to asking how questions.

How do we address these problems rather than why? And accordingly, our emphasis has also shifted more towards implementation, operations, sustainability, and reimbursement. So what happened to cause this shift? Well, this occurred thanks to several decades of intensely focused work by champions like Joe Simone, who understood that there were quality, safety, and equity problems in cancer care that needed to be addressed. Multiple high-profile reports from the Institute of Medicine’s National Cancer Policy Forum, like the one shown on the screen, highlighted these problems and brought them into the consciousness of the oncology and policy communities.

During this time, there was also prolific evidence generation that substantiated these assertions by describing problems like guideline discordance and in outcomes. And this research was financed by visionary funding programs from the NCI, from AHRQ, from the American Cancer Society, and ultimately, more recently, from PCORI. Now, ASCO itself has played a key role in this change over time, right, by elevating quality as one of its strategic pillars.

In the early 2000s, ASCO developed COPI, the Quality Oncology Practices, to support their quality improvement activities. And COPI, by the way, was a vision of Joe Simone’s. More recently, under the leadership of Steve Grubbs and his team, ASCO launched the ASCO Certified Program, which really updates these quality initiatives in ASCO.

It brings practices together into co-learning collaborative groups to work on key areas of value-based cancer care. ASCO has also provided avenues for the setting of two dedicated journals that are now widely familiar in our community, right, the JCO Oncology Practice and JCO Clinical Cancer Informatics. And ASCO has further enabled dissemination of this work through its many different meetings.

And I give credit to Jamie Von Roenn, who retired this past year, and her team for making sure that quality themes were always intercalated into the disease-focusing this meeting. Now, I’ll just take a moment to note that it has not always been quite this glamorous as today for our community. And those of us who have been going to the health services research and quality sessions for many years may remember back in the day of the ASCO annual meeting when the health services and quality session was in the last session on the last day, a little tiny conference room at the farthest reaches, changed over time, right? I mean, it’s really incrementally changed almost in pace with these changes I’ve described.

And for those of you who are at the annual meeting this year, you’ll note that the health services and quality sessions were in a pretty prime spot in an excellent conference room. So thank you very much to ASCO for that, but it’s gratifying to see that change. Now, this quality symposium itself now in its 13th year reflects the changes that started coming to this meeting.

It looked a little bit different from this. You know, back at the beginning, there were really two different constituencies at this meeting. On the one hand, you had health services research that was coming out of academia that made use of very rigorous methods, but it really wasn’t very deeply embedded into clinical practice.

And on the other hand, you had quality programs being presented coming out of the community that were really issues of the day, but didn’t necessarily capitalize on the methods from health services. But today we really see a convergence of these communities into what we have today. And if you walk the halls and look at the posters at the meeting this weekend, or if you listen to the presentations, you’ll see this convergence that’s happened.

You’ll see academic work from health services researchers, you know, coming out of academic institutions, their clinical practice, and you’ll see quality projects coming out of the community that’s making use of state-of-the-moment health services techniques. So it’s a really nice convergence and really gratifying to see here at the meeting. And much of this change over time has focused around one central concept, which is keeping the patient at the center of everything we do.

This theme kept coming up in the presentations earlier today, and this is really the ultimate why of why we do things. The patient experience is a powerful driver of alignment between many different stakeholders in the care delivery ecosystem, right? Between patients and caregivers, researchers, quality officers, clinicians, practice leaders, and even payers. And that’s because we can all come together and agree that it is terrible, it’s undesirable if a patient is unable to come to clinic to receive their cancer treatment, either because their symptoms are poorly controlled or because they could not arrange transportation to come into the office visit.

So our motivations may be different, but we are all aligned in our ultimate goal. And as such, there is a rising realization that patient-centered care, in fact, is good business. And this is a theme that actually came up earlier today in the navigation session.

Now, wait a minute, you might say, what are you talking about, Dr. Bash? Well, I’m not on the verge of a golden age in cancer care delivery. My organization’s culture is focused on margin, not on mission. And most of our focus these days is on staff vacancies and space and finance.

It is true, there are many competing priorities and practices these days. Moreover, doing quality work or doing health services research that’s embedded in health systems has become harder because cancer care delivery itself has become much more complex during this time. For example, team-based care has brought many benefits, but also fragmentation and communication challenges.

Information systems generate an enormous amount of data, but we still are inefficient at harnessing those data into dashboards to drive quality or health services projects. And most cost in oncology is still tied up in expensive drugs and is not specifically earmarked for care transformation in most cases. So how can we get past these challenges and capitalize on the opportunities of this moment to get to this golden age of which I speak? Well, to answer this question, I’d like to take a step back in the time capsule and talk about my own professional trajectory a little bit.

As Ray mentioned, I am an oncologist. And when I came out of my fellowship training, there were limited options for physicians to focus on a career in quality. And I was lucky at that time to be able to stay on the faculty at Sloan Kettering, where I had done my fellowship, seeing patients as an oncologist and doing health services research.

But not all of the leadership necessarily saw the value in that trajectory. And I remember at the graduation reception for my fellowship class, I was standing at the reception with some of my fellow fellows, some of the people shown on this slide and my wife-to-be, and up walked the chair of my department, who was a very famous oncologist and a very famous clinical trialist. And he put his arm around me and said, Ethan, you’ve done a great job as a fellow.

You would have been a great clinical trialist. You would have been a great clinical trialist. I don’t really understand this work that you plan to do or exactly why we hired you, but I’m sure it’ll all work out in the end.

Good luck. And I was a little bit speechless, but I was fortunate that there was somebody else standing by my side as well. And that person was my mentor, Deb Schreck.

And Deb was just a few years older than I was, but she had agreed to be my mentor. She herself is an oncologist and a health services researcher. She had been mentored by one of the giants in our field, Jane Weeks.

And Deb really insulated me from this kind of skepticism. And she had actually championed for me to get the job as an oncologist and health services researcher at Sloan Kettering. And this really underlines that having fellow travelers and champions is foundational to success.

And Deb and I would meet on a regular basis at Java Girl, a coffee house on 66th Street between First and Second Avenues. It’s still there today. It gets four and a half stars on TripAdvisor.

It makes a pretty good cup of coffee. And we would meet regularly to talk about research ideas and quality projects. And we had a small, but pretty resilient outcomes research group back in those days.

And we would sit down and trade research ideas. And I learned two really key tenets from those early days in those meetings, trading ideas. And the first is what we call the so what question, right? Some of you may hear about the so what question.

The so what question goes like this. You bring forward an idea for a research project or a quality project. And that first order query is, well, so what? What difference will it make? Will this idea really meaningfully change the experience or care processes? And the second key tenet that I took away was the importance of rigor and intellectual honesty.

And I carry these forward, I’d say, every day in my own career. And I try to instill these in my own mentees. Now, to find a research focus for myself, I turn to my own observations as a clinician.

I think many of us who do health services work or quality work, right? This is how we develop ideas. We see something in front of us that doesn’t exactly make sense and we scratch our heads and we dig a little deeper under the surface to see if there’s a there there, right? Something that we could change or intervene upon to improve. And for me, something that really bothered me was that patients would come into the clinic and they would have poorly controlled symptoms that they had been experiencing for weeks since their prior visit.

And we were completely unaware, completely unaware of this and therefore unable to do anything about it. And the patient shown on this slide was a wonderful gentleman, a patient of mine who had metastatic prostate cancer. And he came to clinic one day with terrible bone pain.

And I said to him, well, why didn’t you call us? Why didn’t you message the clinic to let us know we could have done something, right? It’s our job to help manage people’s symptoms and side effects. And he said, well, I thought it was normal to have pain when you have cancer. And in any case, I didn’t want to bother the team.

And I realized, you know, this is an opportunity for us to do better, to do better with communication, to do better with patient engagement, to do better with symptom management. And so I chose this as an area that I wanted to focus on. And I thought, maybe I’ll spend a year on this idea.

Thank you. I’ll take a year. I’ll dig in deep.

I’ll find a solution and publish it and that’ll be it. Well, I’ll be done and I can move on to the next idea. But of course, those of you here who do this kind of work know that it’s not so easy.

Changing even the simplest care process can take an enormous amount of time and effort. And here I am more than 20 years later, I am still working on this problem. But something that’s really gratifying about working on a problem over time is the ability to accrue fellow travelers, to have collaborators who you can work with over time, right, to be part of that journey.

And for me, I was able to continue working with Deb, who graciously transitioned from being my mentor to being my colleague. And we still work together today. And we’ve published more than 50 papers together over the years.

I also gained many other wonderful collaborators. A key collaborator for me has been Amy Ludueck, who’s a superb statistician at the Mayo Clinic. Another is Bryce Reeve, who was my program officer at the NCI, who then transitioned to being my colleague, who’s now at Duke.

Another was Claire Snyder, who I first met when we were both junior faculty members on the old ASCO Guidelines Committee, who became one of my longstanding collaborators and many more people. And we started by characterizing this problem. And we systematically demonstrated that we, as clinicians, miss more than half of our patients’ symptoms during cancer treatment, more than half of our patients’ symptoms.

And we published these results. They were picked up by the New York Times, right? And they got some coverage. I thought, oh, that’s great.

Okay, now I’m done, right? I’ve revealed this problem. Everyone’s going to notice this. Everyone’s going to change their care processes.

And now I can move on to the next idea. But of course, you all know that’s not the case. Really nothing changed at all.

And in fact, my skeptical clinical colleagues came to me and they said, well, Dr. Basch, it’s all well and good. You’ve shown that we miss a lot of our patients’ symptoms. But are those really the symptoms that matter? You know, the symptoms are really important.

They rise to the top. We find out about them. And in any case, it would be much too hard to change our processes.

There’s a reason that we do things the way that we do. It would be very challenging to change all of that. And so I tried to rise to the skeptics and so moved on next to developing an intervention to try to address this problem.

And the intervention that I envisioned was to create a computer system or computer surveys for patients to self-report their own symptoms and then to convey that information back to care teams in real time. What we today call patient reported outcomes, but we didn’t really have a term for it then. And we also didn’t have computer systems amenable to doing that because there were no, you know, iPhones or no iPads or no apps in those days.

There were no software developers on our teams. And so I searched out for some software engineers who could help to build a system. And the folks that I found were actually the programmers who created and maintained the billing system at Sloan Kettering.

And I found them in the basement of one of the buildings and I approached them and pitched this idea to them. And they were very excited to be involved in a program, right, in a project on the front line of care delivery. And they built a fantastic patient interface that we used for many, many years thereafter in many trials that I’ll describe in a moment.

And they became my colleagues. They became part of the team science and they were co-authors on many papers over the years. And then we conducted what we called feasibility studies, right? We implemented this electronic PRO system into practice, ultimately nationally through the co-author groups to the presentation by Joe Unger earlier.

I’ve done almost all of my work through the co-author groups, through the alliance and before that the CA LGB showing the value of publicly funded research infrastructure. And in these feasibility studies, we showed that the vast majority of patients are willing and able to self-report their own symptoms during cancer treatment. Even when they’re extremely ill and close to death, patients still are willing and able to do this.

In fact, most patients are quite enthusiastic to do this because it creates a feeling of involvement and engagement in care processes. And so we published these results and I thought, okay, well, great. Now I’m done, right? I’ve shown the problem.

I created an intervention. We showed that it’s feasible. We published this.

Everyone’s going to change what they do. I can move on, which of course, once again, did not happen. And my skeptical clinical colleagues continued to have comments on this work.

And in this case, while it’s all well and good, Dr. Vash, we see there’s this problem, we’ve developed this intervention, but does it really make a difference? Does it really change measurable, meaningful outcomes? So once again, trying to rise to the skepticism, we tested the intervention and we conducted randomized control trials, ultimately national randomized trials. And we showed that remote symptom monitoring using electronic patient reported outcomes and conveying the information about patient symptoms back to the care team during treatment leads to meaningful and significant benefits on multiple outcomes. We showed that it improved symptom control, it improved quality of life, it decreased emergency room visits, it decreased hospitalizations, and in some cases even lengthened overall survival.

Now, finally, this was an outcome that caught the interest of my clinical colleagues, overall survival, because overall survival is of course the coin of the realm in drug development in clinical trials. And so this was seen as being a meaningful finding. And in fact, this research was selected as one of the research projects for the 2017 plenary session at the ASCO annual meeting, and it got a fair amount of press coverage.

And I thought, okay, finally I’m done. Right now I’m done. We produced level one evidence showing that symptom monitoring improves outcomes.

Everyone’s going to change what they do. Every practice in the country is going to start monitoring patient reported outcomes, and I can finally move on to something else. But of course, you all know that it’s not quite so simple.

Because implementing a change in care processes like symptom monitoring with PROs requires changes in the roles and responsibilities of personnel, changes in information systems, changes in workflow, and in the case of PROs, engagement with patient populations. And all that costs money, and there was no reimbursement for PROs. There wasn’t a path for that.

It wasn’t like drug development when there’s a clearly demarcated pathway for reimbursement and distribution. So I had to shift my role a little bit. I had to take on a new role as more of an advocate, and I started to work with payers, including CMS, on the development of billing codes and incorporation into payment models of patient reported outcomes.

I worked with electronic health record companies and patient reported outcome software companies on developing these interfaces, and with professional societies to develop clinical practice guidelines. And in fact, just recently, ESMO’s PRO guideline was published, and ASCO is working on a guideline for PROs presently. And I realized that practices needed guidance on how to implement PROs.

Now this has led me to a current project I’m working on that I’m very excited about, that I think really is of the moment in quality work, and this is called OncoPRO. I’m leading this project in collaboration with two of my wonderful colleagues, Gabrielle Rock and Deborah Patton, and many practice leaders who are in this room. And OncoPRO is built upon a simple idea, which is for practices that are interested to onboard patient reported outcomes, we bring together clinical leaders, IT leaders, and quality or value-based care leaders into collaborative co-learning groups with an excellent coach from the ASCO certified program.

And in OncoPRO, we meet monthly. The practices are divided up by what type of EHR they use, and the practice leaders trade notes on what’s working, what’s not working, what are the barriers they’re facing, the facilitators. We’ve partnered with the EHR vendors and the PRO software companies to bring user guides forward, and we’re developing data dashboards with direct data feeds to help to guide implementation.

And I think that this is an exemplar for the future, and this is a foundation for the ASCO certified program in general, because we can’t keep reinventing the wheel, each of us, every time we take on some sort of new care innovation. We have much to learn from each other, and we should rise together. If there are any of you in the crowd that would like to join this, I’ll do a little pitch.

If you’d like to join this initiative, if you’re interested in implementing PROs, you can feel free to reach out to me, or Gabrielle, or Debra, or one of our wonderful project managers, Jennifer Jansen, is here, and one of the really terrific ASCO coaches, Katie Boyk, is here. I’d be glad to direct you to any of them. So, given some of the lessons that I’ve learned during my own journey, I’d like to return now to the question I posed earlier, what is needed now today to take advantage of the promise of the current moment? And my casual observation is that we’ve gotten so caught up in the day-to-day challenges of implementing programs that we sometimes lose sight of why we are doing this work.

I believe we need to consistently return to the why focus, right, with the patient at the center to keep us on track, and I’ve been trying to practice this myself. As Ray mentioned, over the years I’ve taken on organizational leadership roles, and I moved from Sloan Kettering to the University of North Carolina in 2012 to build a program to create a community of researchers and help train methodologists focused on improving quality. And again, I’ve had wonderful partners in doing this.

Eden Gifford is our legendary program manager, and my academic partner in doing this is Stephanie Wheeler, who’s been the chair of this meeting in the past. And every Tuesday morning, we get together with about 70 faculty and trainees for our outcomes research seminar. This is in quality.

We have a hot southern breakfast, including grits. We also have a really terrific pre-doctoral and post-doctoral training program. Many of our trainees are here today in the crowd, and glad to have you all here.

And in this endeavor, the why question continues to be interpreted. But I also find myself in another role as well, and that is as physician-in-chief of our North Carolina Cancer Hospital, trying to walk the talk of meaningful care transformation. And in this role, I’ve had to take on yet another new function, and that’s as a sort of, I guess you could say, implementer-in-chief, because I need to sit through many meetings fighting for staff or for space or for salaries.

And in all of these meetings, I need to always keep my mind focused on the why of it all, the mission, the patient-centeredness of what we’re doing. But again, here, I’m lucky to have wonderful colleagues who can kind of keep me on point. I think most notably at UNC, Hannah Sanoff, who is the leader of quality for cancer services, keeps me focused on the why of it.

And she also has been a leader in the program committee for this meeting. And I’m highly aligned. I’m fortunate to be highly aligned with our hospital operational leaders.

Now, in these roles, I’ve observed two key elements that I believe are essential to keeping us focused on this why of doing things amidst the many competing priorities and challenges that we face. And the first element, the first key element, is organizational culture. As a health system leader, building culture is what I put the most effort into.

Culture must have at its heart a mission, which I believe of delivering high-quality care and treating patients with respect, the patient at the center. Creating a positive culture is deliberate. It takes a lot of work.

It requires providing support and infrastructure for people to be successful in carrying out the mission. It requires constantly reminding people of why we do what we do, celebrating the successes of people who advance the mission, and creating incentives to do the right thing, including, conversely, getting rid of distorted incentives, which encourage people to do the wrong thing. The second key element to me is purposeful leadership.

Now, I happen to be a jazz bass player on the side. And as a jazz bass player, my job is to set the tempo and the chord structure and otherwise to stay invisible. In fact, if people notice me, right, I’m not doing much.

Every once in a while, rarely, every 10 or 15 tunes, maybe once every gig or two, I get to take a bass solo. And the funny thing about bass solos, when you take a bass solo, people in the audience kind of look at you and they scratch their heads and they think, I think that’s good. That’s good, right? Yeah, yeah, that bass solo, that’s all right.

But then before they know it, you know, I’m back to just doing, you know, doing my thing again. So here today, this is my bass solo for all of you today. And then doing my thing again.

A purposeful leader to me stays on mission and enables others to do the work necessary to carry out that mission. And the success of our field is really due to the purposeful leadership of many people in this room. And I’ll just speak for a moment about people who I came up with, who are part of my cohort, who have become inspiring leaders, who have almost universally stayed on mission since day one, right? Now the editor of JCO Oncology Practice, or Don Hirschman, who now leads a cooperative group, or Monica Krzyznowska, who now leads a cancer center, or Blaise Polite, who’s a leader in policy, or Neeraj Arora, who is an impactful program director at NCI, and now at PCORI, and many, many more people, too many to be able to mention now.

And I apologize to those who I haven’t mentioned. It’s pretty much anybody in our decade of life. I’m not going to say what decade that is.

You know who you are. If you have one of these little stickers that says 20-year member, you know, on your badge today, you know you’re in that group. Now while I’m talking about leadership, I’ll share an interesting epilogue to a story that I told earlier.

And you might remember I recounted the story of my department chair who came up and put his arm around me at my fellowship graduation. Well, I had one last encounter with him. It was when I was leaving Sloan Kettering to move to the University of North Carolina.

And it was many years later, and I was beckoned to his cavernous office, and I walked in, and there he was before his gigantic desk, and I sat down, and he looked at me and said, Ethan, you’ve done a great job on faculty. You’ve published papers, you’ve gotten grants, you’ve made an impact on our field. I always knew you’d be a success.

And I thought, wow, you know, I wonder if he remembers our encounter years ago. But you know, I think it’s kind of a nice bookend to the story. And the reason is because, you know, I think that his change of mind and all this is a testimonial to the collective success of our field, right? Over those intervening years, our entire field has shown its relevance in the cancer community.

And so his change in mindset, right, at the very beginning, right, when I was first being hired, he was scratching his head and asking that so what question, right? Like, why are we hiring this person? Is it really meaningful? And over time, I think we collectively have shown the salience of our work. And so I think that, you know, it’s sort of a nice way to have completed, you know, that my time at Sloan Kettering. So what next? I’ve talked about the key elements that I think can help us to stay focused on our mission at the current moment.

But what are the pragmatic steps that we can take to make quality work and health services research more feasible and successful in the next 20 years so that a young person out here in the crowd, when they’re standing up here at this podium 20 years from now, they can look back on my cohort, on my generation and say, okay, we did the things that needed to be done to set them up to be successful. I’d like to share four practical steps that I hope people in this room might pick up on in the next few years. The first is we need better data and analytics, right? We are now able to harness EHR and administrative claims data in a rudimentary way to support our quality work and our health services work.

But we need to be able to collect real-time data and to have real-time analytics and dashboards. The second is that we need playbooks and standards for key care delivery elements that we are all trying to implement in various ways so that we don’t continue to each reinvent the wheel each time we roll out a program. And I do think that co-learning collaboratives like in ASCO certified and in OncoPro that I mentioned are a route to this.

But, you know, having standards is very useful. Like for me, you know, within my own system, if I have standards that I can take forward to our system leadership and say, listen, you know, this is the staff to provide a ratio that is a national standard. This is the number of navigators that we need, right, to the presentation earlier.

That really is very useful. The third is that we need to advocate for reimbursement to pay for what matters. And we’re at the beginning of this.

We’re starting to see this. But we really need billing codes and greater participation of our practices and payers and payment models that reward meaningful activities of care teams. And I applaud the CMS Innovation Center team for focusing on care components that truly matter to patients in the OCM and now in the EOM payment models.

You know, just as a side note, last year we heard evidence at this meeting that the OCM might not have yielded short-term financial benefits. But I think many of us would argue that the reorganization of cancer services under the OCM were in many cases profound, right? Having financial incentives that are aligned with the tenets of patient-centered care, it has empowered quality leaders at OCM practices to advocate internally for resources to do things that really matter. And the fourth is that we need increased care delivery research that is deeply embedded in health systems.

And I feel that we as leaders need to support professional pathways for this. And mostly, we need more of this. I love this meeting.

I’ve always loved this meeting. It is a highlight of my year. And my hope is that 20 years from now there’ll be four times or six times the number of people in this room encompassing all of the stakeholders that I’ve mentioned today.

So here we are together, right, viewing a sunrise through a rainy window. Actually, it looks a lot out there in San Francisco like it does in this slide today. I hope that we can all see through this to our continued progress.

Thank you so much.

ASCO (American Society of Clinical Oncology) is a leading professional organization representing nearly 45,000 physicians and oncology specialists worldwide, dedicated to cancer care. Founded in 1964 by Fred Ansfield, Harry Bisel, Herman Freckman, Arnoldus Goudsmit, Robert Talley, William Wilson, and Jane C. Wright, ASCO is committed to advancing cancer research, education, prevention, and high-quality patient care.