While academic medical centers and hospital systems often dominate discussions about the settings of oncology care, a growing body of research suggests that local physician practices can deliver comparable outcomes to those larger institutions for certain patients with advanced cancer.

Community oncology practices’ rapid access to care, continuity of care, and proximity to home could contribute to some of their patients living longer and being satisfied with the quality of their care, according to experts interviewed by Medscape Medical News.

In a recent analysis from the Community Oncology Alliance (COA), patients with de novo metastatic breast cancer and metastatic non-small cell lung cancer (NSCLC) treated in community oncology practices experienced longer overall survival than patients treated across all care settings represented in the Surveillance, Epidemiology, and End Results (SEER) Program. While the comparator group came from a population-based US cancer registry that included patients with cancer seen in hospital outpatient departments and academic medical centers — and those who never receive specialty oncology care — it also included patients receiving care in community practices.

“What I think that you can draw from the COA study is that patients receive high-quality cancer care in community oncology practices,” said Debra Patt, MD, PhD, MBA, executive vice president of Texas Oncology and current COA president.

The authors of this analysis, which was published on the COA website, examined patients diagnosed with de novo stage IV breast cancer or NSCLC between 2013 and 2022.

Independent community oncology practices provide care to approximately 85% of patients with cancer in the US, according to the National Cancer Institute. At the same time, academic medical centers and large hospital systems are known for offering complex surgeries and highly specialized procedures in oncology. But for individuals with advanced cancers treated primarily with systemic therapy, community-based care matches — and in some cases exceeds — the quality and efficacy of care seen in hospital outpatient departments, other studies have shown.

A study published in The American Journal of Managed Care, for example, found that patients with advanced or metastatic breast cancer, NSCLC, and colorectal cancer treated in physician-office community oncology practices and hospital outpatient departments had comparable overall survival. Likewise, a study from JCO Oncology Practice reported that physician-office community oncology practices and hospital outpatient departments prescribed evidence-based, guideline-concordant anticancer regimens at nearly identical rates. The COA analysis extends the discussion on how the care received by patients with cancer in community practices compares with that received by these patients in other settings.

The community oncology cohort in the COA study came from the Flatiron Health Research Database, an electronic health record-derived database that includes data from more than 220 oncology practices across the US. Approximately 30% of the broader Flatiron network are academic medical centers and hospital-based programs, but data from these practices were excluded from the analysis.

The new research found that median overall survival for metastatic breast cancer was 46 months in the Flatiron community oncology cohort vs 29 months in SEER. For metastatic NSCLC, median survival was 12 vs 6 months. Restricting both the Flatiron and SEER cohorts to patients with documented treatment yielded smaller between-group differences — but still superiority of the Flatiron patients — in estimated survival (for metastatic breast cancer: 48 vs 40 months; for metastatic NSCLC: 15 vs 13 months).

The COA research could not establish that receiving care via community oncology accounted for the survival differences or that the setting delivers better care than academic medical centers. Seeking to determine potential drivers of the study findings, Medscape Medical News asked experts: What characteristics of community oncology might contribute to strong outcomes for patients living with metastatic cancer?

One frequently mentioned characteristic was location. According to experts interviewed for this piece, many who receive treatment in community practices are able to remain close to home throughout their cancer journey.

For patients with metastatic disease, treatment often continues for months or years, and sometimes patients have to travel far distances to receive their care.

“That can influence their ability to sleep in bed next to their spouse, sit at the dinner table with their families, and have the easy and daily support of their loved ones,” Pratt said.

Avoiding frequent travel can help patients maintain normal routines and preserve social support systems. That support may become more important because metastatic cancer increasingly resembles a chronic disease requiring long-term management rather than short episodes of treatment.

According to the experts interviewed, another strength of community oncology is speed.

Barbara McAneny, MD, founder of New Mexico Cancer Center and former president of the American Medical Association, described community oncology as a practice model designed around rapid response.

“If anyone calls with any version of ‘I’m sick’ or ‘I don’t feel good,’ that call is answered within an hour,” she said. “If that person needs to be seen today, we see them today.”

That responsiveness may reduce emergency department visits, hospitalizations, and treatment interruptions, experts said.

Community oncology practices may also offer a degree of continuity that can be difficult to quantify.

“Having someone who knows who you are and cares how you feel [which is commonly experienced by patients treated in this setting], really makes a difference for people,” McAneny said.

Mark G. Kris, MD, a thoracic oncologist at Memorial Sloan Kettering Cancer Center in New York City, made a similar observation.

“In a community setting, there’s a lot more personalized care,” he said. “The person giving you the infusion is likely to be one of your neighbors.”

Those relationships may not appear in survival curves, but they can shape how patients experience treatment and whether they remain engaged in care, Kris continued.

He also argued that survival alone may not be the best measure of quality for patients with advanced cancer.

“There are different metrics for quality,” he said. “When you have a very serious illness like this, where the survivals were very short and where sadly the ultimate outcome is identical, that folks do not survive, then how the care is delivered and the person’s perception of how that care is delivered is very important.”

For many patients, quality of life may matter as much as length of life, according to Kris.

Why Metastatic Disease Matters

Patt emphasized that the COA’ study’s focus on de novo metastatic disease is important.

“I would say that sometimes there can be differences in academic and community settings,” she said. “It may be that someone in Wyoming doesn’t have access to proton therapy, and they have a brain tumor where proton therapy may be useful, then traveling for their cancer care may make sense for them.”

Similarly, patients requiring highly specialized surgical procedures may benefit from referral to centers that perform those operations in large volumes.

But metastatic breast cancer and NSCLC — the patient populations in the recent COA analysis — are largely managed through systemic therapies and ongoing disease management.

They weren’t measuring surgical care, McAneny said.

Lessons for the Broader Oncology Community

One of the strengths Patt and McAneny attribute to positive community oncology outcomes — offering care closer to more patients’ homes — is increasingly becoming a priority for other cancer care models across the US. 

A 2021 review led by Linda Bosserman, MD, of City of Hope in Duarte, California, noted that although most cancer care in the US is delivered in community settings, oncology increasingly is being organized through networks that link academic centers with community practices.

The review describes how City of Hope and other organizations have developed regional networks that combine standardized treatment pathways, precision medicine, shared clinical expertise, supportive care, and coordinated care management across both academic and community sites. Rather than replacing community oncology, these networks seek to strengthen local care by making specialized resources available close to patients’ homes.

Jeffrey Crawford, MD, professor of medicine at Duke Cancer Institute in Durham, North Carolina, said many academic cancer centers are pursuing similar strategies, such as operating affiliated hospitals, regional networks, and satellite clinics that bring expertise closer to patients.

“Most centers are doing sort of what we’re doing,” Crawford said. “We have smaller hospitals that we manage within our region, and we have doctors there that are linked to us. The goal is for access to be the same for patients, regardless of where they live.”

Indeed, according to a paper published in the Journal of Clinical Medicine, “community oncology practices now deliver a significant portion of their oncology care in association with academic cancer centers.”

In many ways, the distinction between community and academic oncology may be narrowing as molecular testing, targeted therapies, immunotherapies, clinical trials, and subspecialty expertise become increasingly available outside major referral centers, such as community-based practices, experts said.

“Maybe this new COA study is a true observation that outcomes are improving now for community patients now that some of these barriers have diminished,” Crawford said.

Important Caveats

The study’s findings should be interpreted cautiously because it compared outcomes from two very different data sources rather than two comparable groups of patients, Kris said.

“This is a comparison of survival in two different databases. The devil is in the details of how those databases were collected and curated,” he continued.

The Flatiron Health Research Database included patients from dozens of participating physician-owned private practices, whom Pratt characterized as “representative of traditional community oncology practices.” In contrast, SEER is a population-based cancer registry that captures virtually all patients diagnosed with cancer within its geographic regions, regardless of where they receive care — or whether they receive specialty oncology care at all.

“The patients who are in the Flatiron database are also in the SEER database,” Crawford explained. “But there are additional patients in the SEER database that don’t get to the Flatiron database.”

The fact that both databases included community oncology practices is just one reason the COA study could not determine that better survival was attributed to being treated in a community oncology practice. Others were characteristics of individual patients affecting where they received care, Crawford and Kris said.

Some patients with metastatic lung cancer present so ill that they never receive systemic therapy, for example, Crawford said. This could lead to them being represented in SEER but not in the Flatiron community oncology cohort.

What the new research does suggest is that community oncology practices are achieving outcomes that compare favorably with national benchmarks.

Another positive of these settings, which was cited by experts, is that they often offer benefits that may improve a patient’s quality of life.

The physicians interviewed for this piece had no disclosures.