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Practicing oncologist, adjunct professor at Duke University, and chief medical officer at AccessHope Yousuf Zafar discusses his article “Remote second opinions for equitable cancer care.” Yousuf explains how a patient’s zip code often dictates their survival odds despite biology showing that rural and urban patients have identical potential for recovery when given the same protocols. He details how the explosion of precision oncology has made cancer care vastly more complex, leaving community practices struggling to keep up with over 100 unique cancer subtypes. The conversation highlights how virtual reviews allow subspecialist expertise to flow from academic hubs to local clinics, changing treatment plans in over 52 percent of cases. Yousuf also emphasizes that this collaborative model supports rather than replaces local doctors by connecting them with just-in-time knowledge and clinical trial opportunities. Learn how technology is redrawing the map of medical expertise to ensure life-saving knowledge travels faster than the disease itself.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back Yousuf Zafar, oncology physician. Today’s KevinMD article is “Remote second opinions for equitable cancer care.” Yousuf, welcome back to the show.

Yousuf Zafar: My pleasure to be here. Thanks for having me, Kevin.

Kevin Pho: All right, so tell us what your latest article is about.

Yousuf Zafar: There is a great deal of evidence already that patients with cancer who live in rural areas or socioeconomically underprivileged areas have less access to cancer care, less access to quality cancer care, and as a result, have worse outcomes. So the question that we wanted to ask is, what do we know about how a remote second opinion might impact those patients?

We looked at over 5,000 remote opinions that we have delivered at AccessHope as a part of our services. What we found was that patients who live in non-urban or rural areas and socioeconomically underprivileged areas were most likely to benefit. Meaning those were the patients who were most likely to see changes in their treatment as a result of these remote second opinions. It just sort of highlights this idea that we have an existing disparity gap in cancer care in this country.

Kevin Pho: So give us a sense of some of the obstacles those in underprivileged areas or remote areas face as it relates to the accessibility to cancer care. Just give us some numbers and give us a picture of some of the difficulties cancer patients in these areas face.

Yousuf Zafar: You see it in the headlines it feels like almost every day regarding rural hospitals closing. It can start with something as simple as a geographic access issue where a patient who is living in my state in Western North Carolina might literally have to travel for hours to get to cancer care because some of these rural hospitals are closing. It could be something as simple as that.

We also know that in underrepresented areas, because there are fewer oncologists there, the oncologists who do practice in those areas are overwhelmed. They are seeing more patients than in many cases they can handle. They are doing their absolute best to keep up with care, but just do not have the time to keep up with that rapid pace of advancement of cancer care.

These and other factors really contribute. Other factors might be education, the ability to understand treatment, access to transportation, coverage, and the ability to pay for out-of-pocket costs for cancer care. All of these factors come together to really highlight this disparity gap that we see in cancer care.

Kevin Pho: And when you say that there is a disparity in outcomes, are we talking mortality rates? Specifically what kind of outcome disparities are we talking about?

Yousuf Zafar: It can start all the way from time to diagnosis where socioeconomically underprivileged patients have a later diagnosis of cancer. We all know that when you start with a late cancer diagnosis, outcomes get worse from there. There is evidence around access to treatments, to new treatments, and access to clinical trials. These are all proxies for quality care in cancer.

Kevin Pho: So for those living in these remote or rural areas, you of course bring up the topic of remote options. So what typical options are available for these patients?

Yousuf Zafar: We are seeing a growing toolbox of remote access options. Some actually have been around for years and haven’t gotten that much attention. The VA health system in the U.S. provides remote oncology care across the country and does it incredibly effectively. So we are seeing new models like that pop up around the country.

Many NCI-designated Comprehensive Cancer Centers will provide remote second opinions in certain instances. What we do at AccessHope is provide an employee health benefit. We provide remote second opinions where the patient does not have to travel to go to get that opinion. They get the opinion that is coming from an NCI-designated Comprehensive Cancer Center that might not be in their backyard.

In certain instances, we are seeing other aspects of cancer care that can also be provided in a remote manner, like supportive care and palliative care as well. All of which are really important for that holistic approach to the patient with cancer.

Kevin Pho: So as an oncologist, give us an idea of the spectrum of services that you can do remotely. What are some things that you can’t do remotely? What are some things that lend itself well to a remote scenario?

Yousuf Zafar: It depends on the resources that are available. Let’s take the VA example. In many cases, it is the ideal way that remote oncology can be delivered. For example, an oncologist who is sitting at the Durham VA Medical Center can provide oncology care for a patient in rural North Dakota. But in order to do so, that patient needs access to at least a nurse or a nurse practitioner who can physically administer the chemotherapy and manage some of the side effects that happen in real time.

That oncologist can see the patient, provide education, assess the patient, and determine what is happening remotely while the nurse practitioner or physician assistant who is in the room with the patient can conduct a physical exam and obtain labs. So what that does is scale the capabilities of the oncologist to physically provide care and provide anti-cancer therapy for the patient.

Now, from a consultative perspective, there is much more that you can do with much fewer resources. In many cases, you can obtain medical records remotely, review those medical records, and then provide a snapshot view of what could happen next in that patient’s care. That is much easier to scale with fewer resources than that direct care delivery component that we see, for example, in the VA.

Kevin Pho: So it sounds like there are two tracks, right? One for ongoing continuous care where you have to oversee chemotherapy and a more, perhaps one-time consultative role where you would give a remote second opinion.

Yousuf Zafar: Yeah, that is exactly right. But that gives a couple of different flavors of how you can impact cancer care. It is not just with the delivery of that anti-cancer drug. It is also potentially with that consultative opinion.

Kevin Pho: When you give that second consultative opinion, what happens if that opinion is in conflict with that patient’s original oncologist? So tell us some steps in terms of what happens next.

Yousuf Zafar: We see that often. We see that in actually the majority of the reviews that we do, where there is some aspect of the cancer care that our expert reviewer who is at an NCI-designated Comprehensive Cancer Center says: “I think I would adjust this.” Maybe it is the anti-cancer drug. Maybe it is the supportive care. Maybe it is the diagnostics that need to happen.

So what we are able to do is deliver that opinion, validate whether or not the opinion is adopted, but also provide that community oncologist the opportunity to have a discussion with us and understand why that recommendation might be made and how that might help the patient. So it is not just a one-way street. I think that is really important because these peer opinions have to happen in a collaborative setting because that is the practice of modern oncology today. It has to be collaborative.

Kevin Pho: And those community oncologists whose opinions that your team may be in conflict with, how receptive or open are they for that collaborative process?

Yousuf Zafar: They are incredibly receptive for a couple of reasons. One, we provide those opinions in a collaborative tone because again, that is the practice of medicine today. We do not say, “Oh, you are doing something wrong.” There isn’t often a clear right or wrong in cancer care. It is: “Here is something that you could do that might align care better with the evidence.”

Second, the opinion is coming not actually from AccessHope. It is not coming from me. It is coming from an NCI-designated comprehensive cancer subspecialist in that cancer type who spends all their day just treating patients with that cancer. So it is a respected opinion. Because of that, I think the oncologists who receive our opinion realize that this is an opportunity to impact the care of their patient and really impact their education as well.

Kevin Pho: Can you tell us a story, case study, or example where a remote second opinion changed the treatment trajectory of a remote cancer patient? What would that look like on a practical basis?

Yousuf Zafar: Kevin, I do not think we have enough time to give you all the examples I want to give you, so I will give you one. There was an opinion that we saw recently for a patient with kidney cancer who was being treated in a rural setting actually. That patient was getting care that was not aligned with the current standard of care.

A kidney cancer specialist at an NCI-designated Comprehensive Cancer Center reviewed that case for us and made recommendations not just to adjust the patient’s standard of care, but also found a clinical trial that was located geographically relatively close to the patient. So we sent that review to the community oncologist who was treating that patient. Because of that disparity in care, again, we had a communication with that oncologist. We talked to him and said: “Hey, look, we see there is a discrepancy here. Do you want to talk about it?”

That oncologist said: “This review could not have come at a better time. I wasn’t sure what to do next, and this review really guided me in the right direction. And my patient is very interested in looking for a trial. I didn’t realize that trial was available, so I am going to make that referral as well.”

I think that is a really great example of the collaborative nature of what we do. I think all of us as doctors need help now and again. If we can provide help in a way that helps the oncologist and helps the patient, that is a win-win.

Kevin Pho: How about in the future? Because as you know, rural medicine is only becoming more scarce from a resource setting. I do not see more oncologists moving to rural areas. So from a health care framework standpoint, what does it say about our health care system going forward that more and more of these rural patients may eventually need to depend on these remote second opinions just because they cannot have access to a local oncologist?

Yousuf Zafar: It says a lot about our health care system and where we need to spend the next health care dollar. But it also means that we need to work harder to improve some of these remote capabilities because in many cases it is just as good if not better care for the patient. If we can provide not just cancer care, but primary care in a remote fashion, we can again sort of scale the capabilities of our health care workforce today. That workforce, which in many specialties including oncology continues to shrink.

So I think it is twofold. One is yes, where can we reinvest to grow our health care infrastructure in rural areas? But two, where can we invest to grow our remote capabilities, whether that is in policy development or in reimbursement or in technology to make that remote experience more reliable and more accessible?

Kevin Pho: And in terms of the root causes, what are some of the reasons why there is such a shortage of in-person oncologists in remote or rural areas?

Yousuf Zafar: That is a tough question. I think a lot of it has to do with where people want to work. It has to do with reimbursement. And I think a lot of it has to do with, to be honest, a lot of the overwhelm that an oncologist practicing as the only oncologist in a county or in a region might face in terms of the volume of patients that that oncologist would need to care for. So it turns into this sort of chicken-and-egg problem where we have to find a way to break this cycle to ensure that we have more oncologists that are going to socioeconomically underprivileged and rural areas to meet that demand.

Kevin Pho: So if someone is a remote oncologist perhaps listening to you on this podcast and perhaps interested in more remote support, obviously you work for an entity, AccessHope. What are some of the other spectrum of resources remotely that are typically available for a rural oncologist?

Yousuf Zafar: I think the first step is to look at maybe the referral center or academic center or NCI-designated center nearby that might offer that option for the oncologist or patient. In some cases, those centers are also providing remote multidisciplinary conferences or remote tumor boards, which are becoming incredibly important for cancer care today. That is a great resource where the patient does not necessarily even need to be involved. But the oncologist could take the case to that remote tumor board. So I think that is an important resource.

And then third, check with the patient and the patient’s employee benefits to see if they have access to something like what we provide, where that patient could get that expert opinion and that oncologist could get that expert opinion at no charge to the patient or the oncologist for that matter. So those are a few resources to look into.

Kevin Pho: We are talking to Yousuf Zafar, oncology physician. Today’s KevinMD article is “Remote second opinions for equitable cancer care.” Yousuf, as always, let’s end with some take-home messages that you want to leave with the KevinMD audience.

Yousuf Zafar: I think one of the things that has surprised me over the past few months or past year, maybe it shouldn’t have been a surprise, is that now cancer care is complex for patients. It is complex for doctors. It is also complex for those who pay for the care. So it is complex for payers and it is complex for employers.

What that means is we need to do a better job to educate all the stakeholders in the cancer care delivery system. If payers do not understand the care, they are not going to have a clear vision into what should be covered. To determine and make sure our patients are getting the best care possible, we need to do more to work with payers and work with employers to really make sure they understand this rapidly evolving landscape of cancer care.

Kevin Pho: Yousuf, as always, thank you so much for sharing your perspective and insight. Thanks again for coming back on the show.

Yousuf Zafar: Thank you for having me, Kevin. Always a pleasure.