Resources such as facilities, equipment, medications, and trained healthcare professionals are essential to provide proper care. Yet, many areas in the US and around the globe have challenges providing some of such resources. This ASCO Education podcast will explore oncology practice in low resource settings. 
Dr. Thierry Alcindor, a medical oncologist at the Dana-Farber Cancer Institute and Brigham and Women's Hospital in Boston, Dr. Richard Ingram, a Medical Oncologist at Shenandoah Oncology in Winchester, Virginia, and Chair of the Appalachian Community Cancer Alliance and Dr. Sana Al Sukhun, an Adjunct Professor of Medical Oncology and Director of Oncology Practice at Al-Hayat Medical Center in Jordan will discuss the barriers they face providing cancer care in low resource areas in the US (1:48 ) and Jordan (11:52 ) and the one challenge that is key to solve in order for proper treatment to be administered in the US (29:07 ) and Jordan (31:42 ).

Speaker Disclosures
Dr. Sana A. Al-Sukhun: Honoraria – Novartis; Speakers' Bureau – Novartis, Roche, Pfizer; Travel, Accommodations, Expenses – Roche, BMS

Dr. Richard Ingram:  None

Dr. Thierry Alcindor: Consulting or Advisory – Merck, Bayer, BMS, Astra Zeneca, Astellas Scientific and Medical Affairs Inc.; Research Funding – Epizyme, EMD Serono, Karyopharm Therapeutics, Springworks, Astellas Pharma, Deciphera

Resources 
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TRANSCRIPT

Disclosures for this podcast are listed on the podcast page.

Dr. Thierry Alcindor: Hello, dear ASCO audience, welcome to this episode of the ASCO Education podcast. Today, we will examine practicing oncology in a low-resource setting. Managing cancer patients is a multifaceted challenge. Resources such as facilities, equipment, medications, and trained healthcare professionals are essential to provide proper care. Yet, many areas in the US and around the globe have challenges providing some of such resources.

I'm Dr. Thierry Alcindor. I'm a medical oncologist at the Dana-Farber Cancer Institute and Brigham and Women's Hospital in Boston. Joining us are Dr. Richard Ingram, a Medical Oncologist at Shenandoah Oncology in Winchester, Virginia, and Chair of the Appalachian Community Cancer Alliance. He is, as well, the current president of the Virginia State Oncology Society. We are also very pleased to be joined by Dr. Sana Al Sukhun. She is an Adjunct Professor of Medical Oncology and Director of Oncology Practice at Al-Hayat Medical Center in Jordan. She is also the past president of the Jordanian Oncology Society. 

So, I'll begin with Dr. Ingram. You have experience with patients in the Appalachian region of the US by practicing medical oncology in rural northwestern Virginia for the past 25 years. Can you describe this unique region for our listeners and detail some of the challenges you face when providing care there?

Dr. Richard Ingram: I have been practicing here in Northwestern Virginia for the past 25-ish years, and have seen over time barriers to care that I think could be applied anywhere. And, I think we'll hear some interesting stories today from our colleague from Jordan also, in that regard.

The main barriers I think are somewhat slightly stereotypical but real where I am. There is a diverse population here, meaning a big geographic area and a somewhat underpopulated area. So, resources are scattered and scarce sometimes and located in concentrated areas. So, patients have difficulty with access to cancer screening, imaging, and sometimes downstream or tertiary care where I am. I have patients that will travel an hour and a half to two hours one way i.e., a three to four-hour round trip - sometimes over some difficult terrain, meaning some difficult roads out our way, both with mountains and some geographic challenges just to get to us. You can imagine the difficulty that is with either coordination of care with a multidisciplinary patient having to see multiple providers or more practically, a patient receiving radiotherapy on a daily basis. And, this not only is time but money because you're trying to make a decision about follow-up appointments and missing work at an hourly wage versus working that week and paying your bills.

I have patients currently who are working around that. I have several concurrent chemo-radiotherapy patients - currently, actually two I saw this morning - in clinic, both of which live in a town called Petersburg, West Virginia, which is about an hour and 45 minutes one way. So, three and a half hours from us. And, we've had to connect them appropriately with resources around transportation to make sure they stay compliant with their care. 

You have this empathy and drive to care for patients and try to apply the same care you would across the continuum. That socioeconomic status is not unique to Appalachia but I think is somewhat emblematic in our area - lovely, hardworking people and diligent in their craft. But, when you have barriers such as cancer diagnosis and now superimposed strain and stress on your family life and work life, it can throw things out of balance. 

A similar patient of mine that I saw today actually in clinic, same area, same concurrent diagnosis, their big access issue is that they're also the primary caregiver for some grandchildren that are staying at home. They've taken in their grandchildren and, not unique to Appalachia, but somewhat in that we have a lot of multigenerational families living together. So, you're trying to help that person get through their therapy and still be the homemaker for grandchildren and try to battle their cancer diagnosis and at the same time not bankrupt them financially from a socioeconomic standpoint.

Dr. Thierry Alcindor: What's the insurance coverage pattern like?

Dr. Richard Ingram: In my area, about half to 60% of our patients are on either uninsured or they are on public insurance, whether that be Medicare or state Medicaid or exchange programs. From the private sector, there are private plans, but a lot of those are self-funded, meaning they are local municipalities, teachers' unions, first responders, and then a small pocket of what you and I would call traditional commercial insurance coverage.

And so, for us, we for a lot of our patients have built relationships, for instance, we know this gastrointestinal group will take that insurance of a Medicaid or uninsured patient and this one won't, or vice versa. So, there is some fragmentation of care if you're not very conscious and deliberate at the medical oncology and radiation oncology side, which is in my practice about making sure the patient can get access to care.

Dr. Thierry Alcindor: I understand. So you talked about the lack of adequate or complete primary care coverage. Do you have enough medical oncologists?

Dr. Richard Ingram: Excellent question. I appreciate that. Yes. So we do, in that my group does and my region does. So we are very strong, as I like to say, the end of the funnel. You know, I consider