
I was a caregiver for a few years when my older brother was diagnosed with kidney cancer. One of the most annoying experiences in that journey involved the regular visits to the infusion center to receive treatment. The wait involved, the driving involved, just took a lot out of us at a time when we were working full-time. Could this not be done at home where he would be most comfortable?
So, when I came across what Mayo Clinic Florida was doing with its Cancer Care Beyond Walls program, I was intrigued. How is this even possible? I interviewed Dr. Roxana Dronca, the oncologist who thought up the idea and Dr. Jeremy Jones, another physician helping her to scale the program and even bring it to other hospitals.
This episode of the Pivot podcast is presented by Veradigm, a healthcare technology company.
Below, you will find the audio, video and transcript of the interview.
Here’s a video of our interview
Here is an AI-generated transcript of our recording:
Arundhati Parmar: Hello and welcome to the Med City Pivot Podcast. There are some interviews that get a little emotional for me, given my experience with my older brother who died of kidney cancer at the age of 44 back in 2017. This is one such episode. I was fascinated by the story of Dr. Roxana Dronca of the Mayo Clinic, who found purpose in the midst of tragedy.
After her young daughter passed away, she developed a program for cancer patients to receive cancer care at home. Thus was born the Cancer Care Beyond Wall’s program in Mayo Clinic for Florida. This episode features Dr. Dronca, as well as Dr. Jeremy Jones, also of the Mayo Clinic, who worked collaboratively to scale this program.
Before we view the episode, I wanted to thank our sponsor Paradigm, which is supporting this episode today. Here’s a message from Verdi.
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Arundhati Parmar: Welcome Dr. Dronca and Dr. Jones.
Dr. Jeremy: Hi.
Arundhati Parmar: So let’s start. This is the first time we have two uh, guests on our show. So I will, um, start with you. Dr. Dronca, can you introduce yourself to our audience?
Dr. Roxana: Sure. Thank you for having me today. My name is Roxana Bronca. I am a medical oncologist. I practice at Mayo Clinic in Florida.
I am the site director for our comprehensive cancer center in Florida, and um, I also am one of the physician leads for our Cancer Care Beyond Walls program.
Arundhati Parmar: Dr. Jones,
Dr. Jeremy: Yeah. Hi, I’m uh, Jeremy Jones. I’m a GI medical oncologist and I am also, uh, here, located here in Florida. And I’m, uh, also one of the, uh, physician leads for our Canto Care Beyond Walls program, uh, specifically focusing on Mayo Clinic platforms, um, uh, efforts.
Arundhati Parmar: Perfect. So, um, let me start with this. Um, I personally have dealt with cancer as a caregiver. Um, my older bro brother passed away, uh, from cancer, you know, it’ll be eight years in November, and I have made many trips, uh, to the Stanford, you know, cancer Center for infusion. So when this idea of Cancer Care Beyond Walls was sent to me, I was like, this is perfect.
I know exactly what it feels like and if you’re going alone, I can only imagine how difficult it must be, when to drive yourself to go by yourself and, and, and, and to, uh, deal with this situation. So the idea of getting cancer care and getting infusions beyond the hospital and the clinic was very fascinating.
Um, to me, Dr. Dronca, first of all, please accept my condolences. Um, just reading up on your background and what you went through. I choke up myself. I’ve seen my mom deal with the, the loss of a child, um, her first born, in fact. So, um, please, uh, accept my condolences. Um, let’s start there. The genesis of this, um, of this program.
Dr. Roxana: Thank you. And, um, yes, very emotional. I am so very sorry to hear, um, about your brother. And, um, I am sure that many people out there can relate to our stories, you know, one way or another. Unfortunately, cancer impacts a lot of us.
Dr. Jeremy: Mm-hmm. Um, either
Dr. Roxana: directly or family members. Um, I think the genesis of this program was, yes, both personal, but also in where the care was going, and definitely where Mayo Clinic was going, trying to accommodate the needs of our patients during the pandemic.
So it just happened that everything kind of happened at the same time. Uh, as, as you mentioned, uh, I did to have a personal. Um, unfortunate, uh, situation. Uh, my 7-year-old daughter, six, six and a half at the time was diagnosed with a brain tumor, um, in January of 2020.
As we unfolded through this journey and the treatment plan, Covid.happened, um, in March and April of that year, and we were in Rochester trying to get care and radiation treatment. Um, we needed to also do chemotherapy. And, um, a lot of the medical care, you know, got, um, as, as we know, very restricted very quickly. There was a lot of uncertainty, not only about what this virus could cause, but there was a lot of uncertainty for cancer patients.
Could we even access this lifesaving treatments? It’s a lifeline for people impacted by cancer to be able to get to the doctors to be able to get their treatment, and all of that was questioned, including for people in healthcare like me. I don’t know if I could bring my daughter in. Um, at around the same time, Mayo Clinic started to create and grow the program of hospital at home.
To really accommodate the needs of patients with Covid, but also the needs of patients with other medical and surgical illnesses that needed to seek care in hospitals that now are full, um, of patients. So the hospital at home grew very quickly. The experience of our Mayo Clinic staff with the hospital at home program grew very quickly.
The patient feedback was extremely positive. We were able to treat patients in their own homes with high acuity illnesses, with hospital level care, and doing so very in a very safe way.
Dr. Jeremy: Mm-hmm.
Dr. Roxana: So once I came back, my daughter passed away in 2021. Um, I came back to work, um, and I realized that I would’ve given anything, I would’ve given absolutely anything if I had the opportunity and the possibility to treat her in the home, to even have maybe blood work done in the home. Every trip to the hospital when she was so ill was worse than the disease itself. You know, it was very difficult.
Arundhati Parmar: Mm-hmm. Mm-hmm.
Dr. Roxana: So. I realized that if I would’ve had those chemotherapy drugs in my home, I would’ve given them to her.
And I started thinking, you know, that if I want this, there must be other people out there that would want this, that would want to have this, this opportunity, this benefit, the the possibility to care for their loved ones in the comfort of their own surroundings. So, coming back to work, I. Started thinking about what we build with the advanced care at home, the knowledge we accumulated, could we apply some of that to patients with cancer needing long-term care and leading long-term, you know, many trips.
Um, here. Can we decrease the burden of that by offering some of these treatments? In the home. I was, we were fortunate enough to have a, you know, I think union of like-minded individuals, you know, Dr. Jones was one of my partners from the very beginning. Um, other people here at Mayo Clinic. And most importantly, we had the support of our senior leadership here at Mayo Clinic that recognize that these, this is truly a need, our patient’s needs, um, come first at Mayo Clinic and this truly would, would serve a need.
So we were. Um, given I think the green light to do the very first pilot and, uh, test administration of treatment in the home for patients who needed lower acuity maintenance, chemotherapy, drugs, or biological drugs, and based on that initial, initial pilot, potentially expand and, and grow the program after that, if it was felt to be safe, feasible, and bring value to patients.
Arundhati Parmar: That makes sense. Um, Dr. Jones, I’d like you to jump in here. You know, ideas come from all sorts of places. Sometimes when people are in an emotional state, like I’m sure Dr. Dronca was, some of the ideas may not always make sense. Uh, why was this different? Uh, because it, it, it requires a certain amount of investment in resources to send nurses, to send, you know, people from, from the place where you normally use to delivering care to someone’s home.
So what was the, um, how did it make sort of business sense as well, I guess from that perspective?
Dr. Jeremy: Yeah, I, I think, um. I have to be honest, I think when Roxanna first came to me, so Roxanna is very kind. She was, she’s my mentor and so, you know, she came to me and said, I’m thinking of doing this. And obviously, you know, going through such an is uh, issue, I don’t know that I felt like early on that it was possible.
I, I was very not skeptical. I mean, I know Roxanna and I know that she puts her mind to something, she’ll get it done, but. But, uh, I, I have to say that I probably, although I was an early adopter, I I, there was probably a few weeks there where I said, boy, I don’t know if I can figure out how to make this work.
Um, but, you know, I, I think sort of part of this is going in and going through all of the, you know, types of chemotherapies, understanding, you know, where is the risk gonna be? We spent months going through that. Um, so we started getting into that, you know, what better about it? To talk about sort of the financial aspect or like, how do you make this work?
I, I think that you have to go back to sort of how did we get to where we are now? Uh, you know, we have these chemotherapy units. We, we started off all chemotherapy was in the, in the inpatient setting, and then we moved it into the chemotherapy unit. And I think the fact that we had sort of a chemotherapy unit, uh, was sort of an opportunity and kind of a, a burden, right?
So you have this space, so we have a new drug, we’re gonna just automatically give it in the chemo unit. So we didn’t really give that thought process of, you know, does this drug really actually have to be given in the chemo unit? Is there, you know, another possibility there. Um, and so, you know, we sort of started rethinking these things.
Um. We are still working on the, uh, sort of financial aspects of how to make this work. But what I can tell you is that as we go along, what we’re realizing is that the chemotherapy administration itself is really only part of the battle, right? So we give these drugs to patients. We have them sort of come into the unit, we.
Um, but they don’t really have the worst of the side effects that they’re gonna have while they’re in the unit, right? Mm-hmm. Um, and so by actually sort of democratizing this, bringing this into their home, it’s not just the infusion itself, but you know, uh, let’s say two or three days later when the patient develops, you know, severe nausea or perhaps diarrhea or something like that because we already have that document or that, that technology in the home, and they’re able to sort of contact us.
It turns out we’re actually able to, to stop those symptoms before they become a bigger issue, before the patient gets sicker and ends up having to come into the emergency room. And so what we’re finding in our sort of early, um, uh, uh, progress here is that we’re actually able to averthospitalizations, which are quite costly as well, so.
Um, you may even pay our, our goal is really to be at parody with that part, but then also to save money in the long run, sort of through that arc of care. Um, but, uh, as we go along, we’re finding out that we’re actually saving more money for, you know, patients going into the hospital. So from a financial aspect, um, it really is sort of having to look at that patient as a whole.
Arundhati Parmar: As opposed to
Dr. Jeremy: just sort of that one individual infusion appointment.
Arundhati Parmar: Got it, got it. Makes sense. Um, and then Dr. Dronca, can you talk about how you select patients? I’m assuming not every cancer patient is eligible to be part of this, um, cancer Care Beyond Walls program. How do you select?
Dr. Roxana: Absolutely. All right.
Um, so the idea of a program like Cancer, K Beyond Walls is really to look at what is safe. Um, from a drug perspective first, mm-hmm. A lot of the patients undergo maintenance, chemotherapy, immunotherapies, um, you know, in the home. And those drugs really have a very low rate of infusion reaction. So we started with that.
We looked at. drugs that, um, are stable to be transported. Um, so stable for 24 hours or more, um, between compounding in the chemo unit and when you administer to allow enough time to give them in the home. And also, uh, drugs that have a lower rate. Over infusion reaction right. When you give them. Mm-hmm. Um, those were the main considerations initially, in terms of the drugs.
Now we’ve expanding to a lot, we’ve expanded to a lot more drugs as we gain, um, experience with, you know, the process. So I would say that now we have a number of both biological drugs, immunotherapy drugs, hormonal drugs, as well as chemotherapy drugs. From a patient perspective, um, and a systems perspective.
Initially we looked at patients located in a geographical area that was covered by our vendor network, so mm-hmm. To connect the hospital with the patient. We needed, you know, somebody to transport the drugs. We needed home health nurses, and we also have a network, a paramedic network that we work with that covers the area.
So we initially started at a geographical area of about 30 to 35 miles around our Mayo Clinic, Florida. And now we are expanding to 65 to 75, uh, miles. And we’re thinking about going, um, a hundred miles around Mayo, Florida, with another project actually of expanding in the Florida panhandle. Mm-hmm. Where we’ll use.
Um, our command unit here at Mayo, Florida is the main, uh, unit to coordinate care, but shipping, you know, the drugs to the patient’s homes, um, at, you know, 2200 and 300 miles in the panhandle. From a patient perspective, we have a screening questionnaire as well, a social screening questionnaire to see if indeed, you know, it makes sense for the patient and the family, the home set up to have chemotherapy done in the home.
This is a pretty. Simple questionnaire is really looking at, you know, is the patient able to receive the treatment in the home? Are they able to be independent, you know, uh, themselves, or if they are not, do they have a caregiver that is willing to be engaged, um, during the treatment and in between, is the house set up for administration of chemotherapy?
Is that a minimal space where the home health nurse can come and, you know. Um, be able to set up the medical supplies. Um, is there, you know, safety in the home, both for the patient as well as the, you know, the, uh, uh, personnel coming into the home. Are patients okay with, um, strangers coming into their home?
You know, the, our staff that is installing the, uh, technology in the home, uh, for the ones for. Whom we are needing remote patient monitoring, the home health nurse, um, et cetera. So while it’s pretty easy, uh, I think it’s a, uh, there are a few very, um, you know, basic, um, check marks that we do before, um, um, setting up patients in the program.
And of course, you know, if the patients are willing to, uh, participate in the program and sign consent for this
Arundhati Parmar: Makes sense. Um. Dr. Jones, is there any plans? I’m, I’m assuming that this is not, uh, this program has not launched in Rochester. Is there any plans to do it in other regions where, uh, Mayo Clinic operates or you think there’s weather issues and all these issues that make it harder to do in Minnesota?
I used to live in Minneapolis,
Dr. Jeremy: no, so. Uh, so the short answer is yes. We have plans. We’re sort of actively ongoing, kind of, um, uh, further on in, in the process of plans to open at our destination medical centers, uh, in Rochester and Arizona. Mm-hmm. Uh, also at our Mayo Clinic health system. One of the sort of cool things about Mayo Clinic platform is that we also have our, um, Mayo Clinic, uh, care network hospital, so mm-hmm.
Non-owned, but affiliated hospitals, uh, 53, sorry, 64 hospitals, uh, throughout the world. Okay. Uh, we’ve actually been able to open a, uh, our randomized clinical trial, which Draka is the principal investigator for actually a, um, a hospital system in, um, in Grand Forks, North Dakota. So mm-hmm. It shows that, um, you know, really I think.
This comes back to allowing technology to help us sort of democratize the expertise and care. Um, and so obviously we can’t sort of, uh, you know. Have our nurses fly from here to North Dakota every day to give infusions. Mm-hmm. But that technology allows us to partner with nurses who are on the ground in, uh, North Dakota or, uh, we will soon in, in the Florida panhandle, uh, or potentially, uh, soon at some point, you know, in another country.
Mm-hmm. Um, it allows us to partner where it’s sort of more of a hub and spoke model, so you can have. Um, you know, remote expertise, um, but also help guide and [00:18:00] enable the, uh, the health centers closer to their home.
Arundhati Parmar: And then let me stay, you, stay with you for just a moment. You, uh, uh, Dr. Dr. Dronca mentioned like other people, other vendors that you, um, work with.
Dr. Jeremy: Yeah.
Arundhati Parmar: Are those like hospital at home companies, like Medically Home, who are the vendors that you rely on to deliver the sort of service at the home?
Dr. Jeremy: Yeah, absolutely. So, uh, certainly we have worked with medically home. Um, they’ve, they’ve done a great job.
Uh, but the, but our goal, uh, in the future is sort of to be agnostic of that. So there’s a minimum level of capabilities that have to have to be. That deliver chemotherapy. Um, but for all the supportive cares, for instance, the, um, health center, uh, in, in North Dakota, uh, they have their own, uh, home health agency within the hospital system.
And so this just becomes an issue of sort of allowing, again, the technology to sort of help with the guidance of this. Mm-hmm. Um, and the know-how. Uh, but um, my hope would be that we have a whole network of caregivers. Whether it’s nurses or pharmacists or phlebotomists, um, because that’s really where, and paramedics, that’s where you get really a network effect.
Where you can have, you know, the sort of, what I think is o obviously an overly simplistic uh, um, analogy, but if you think about, you know, you have Uber. If you have only one car, Uber doesn’t really work, right? You really need a network of cars, but you also need a network of people who need drive or who need cars, right?
And so you really have to sort of build on both sides of that. So make it beneficial for both sides. Um, we really see ourself as trying to build that network to show, uh, how to enable care like this.
Arundhati Parmar: And so it, when she first came to you, you were not sure about how this would work, and now you’re becoming more of a believer.
There is a way to scale this, you think logically and practically.
Dr. Jeremy: I think, uh, it will be the only way for it to scale. Um, I think that, um. You know, within Mayo Clinic, I, I’m sure this is at every academic medical center. Historically, we’ve sort of said we wanna own every step of the process. We wanna from, they want to.
But what we’ve realized, I think if you look at just clinical trials and, and really all around the world, is that we’re not reaching the patients that we need to reach. Mm-hmm. We’re not reaching all the patients. Right. And so, um, I think, you know, when you think about sort of a platform model. What that means to me is that it, you are creating a system that enables sort of the sharing of knowledge, the sharing of care in this case.
Um, and I think it’s the only way that we’ll be able to treat and to really sort of bridge these gaps that we hear about all the time. Where, you know, you have these sort of cancer care deserts, um. Realistically, you’re not gonna be able to go to all the places in the world and set up a large academic medical center.
That’s just not feasible. And so that’s really where I think technology can help us bridge that gap.
Arundhati Parmar: Mm-hmm. Uh, Dr. Dronca, I wanted to come back to you. Um, obviously this began with cancer and with. As you mentioned, sort of stable patients, you know, taking chemotherapy from a maintenance perspective. But what about patients that are, you know, trying experimental therapy, like they’re part of a clinical trial.
Um, have you alre, I believe you’ve already launched something, clinical trials as well. Can you expand upon that a little bit?
Dr. Roxana: Yes, that’s a great question. And really the goal ultimately is to be able to administer any type of treatment and especially, um, treatments, experimental therapies on clinical trials because the statistics that Dr.
Jones mentioned that were not able to reach all patients, this is even more painfully true regarding innovative therapies and clinical trials. Only a few patients national, uh, um, statistics show that. 10% of patients who qualify for clinical trials are actually enrolled in clinical trials. That’s right.
We know that patients who have access to clinical trials do better because every major breakthrough started in a clinical trial with Cancer Care Beyond Walls, we, our goals were, let’s first learn how to give standard of care, chemotherapy and immunotherapy, and then we can build. The whole infrastructure that need that we need for, um, experimental therapies.
Once we have this in place, we can move on to doing clinical trials. Once we learn how to walk, we can run. Mm-hmm. And I think we are absolutely there. Now we have started the very first clinical trial with subcutaneous nivolumab. When we started the trial, subcutaneous nivolumab was still an experimental drug, had not been yet.
FDA approved right now, is FDA approved for a number of indications, but, um, it actually was, um, very good because we started this, um, this trial, um, in an experimental phase and, and we were able to reach more patients. Um, with who needed subcutaneous nivolumab who potentially could not come to clinic, uh, to travel or were not candidates for the IV infusion.
Um, and again, we have been met with tremendous, uh, patient enthusiasm and, and feedback from that.
Arundhati Parmar: And then just for our audience, and even for my edification, um, what type of disease would require treat a treatment like nivolumab?
Dr. Roxana: So nivolumab is currently approved in approximately 30 different disease types.
Mm-hmm. Um, so where, um, everywhere where this indication is FDA approved, we are able to, um, give this, uh, to patients in their homes. Um, as long as the patients are willing to transition to a subcutaneous form of nivolumab, and again, they meet the eligibility criteria from the other standpoints. We have another clinical trial open at Mayo Clinic, which is a, um, randomized clinical trial that is looking at patients receiving a number of chemotherapy drugs or biological therapies or immunotherapies for a number of different cancer types.
Mm-hmm. And this trial is, um, set to accrue 200 patients. We have already accrued, um, 77 patients, and we presented actually the interim analysis results on the very first 50 patients that were accrued at, um, our national conference this year, asco. Mm-hmm. The interim analysis showed that 73% of patients strongly preferred treatment in the home.
18% of patients liked both, and only one patient actually, um, wished to continue to with treatment as, you know, standard in the chemotherapy infusion only. So tremendous, you know, patient, uh, acceptability of this model. We had zero safety, uh, signals, no infusion reactions in the home, and no other, um, side effects.
So we’re really excited to complete this trial because it has a number of. Endpoints that we believe will continue to, will help us to continue advocate for reimbursement of this model in the home and to change the regulatory framework that right now allows reimbursement in the chemotherapy unit to allow reimbursement of care regardless of the location.
Arundhati Parmar: Mm-hmm. Dr. Jones, I’ll, I’ll let you have the last word. You know we’re time right now in our healthcare system where. Hospitals are struggling with margins. Um, we hear every day from physicians upset over, you know, claim denials, um, upset over prior authorizations. Um, and the battle is so intense that I don’t know that people are thinking about the patient as much as they should.
And this seems to be very much a program where patient is at the center. You’re thinking about patient convenience, their, um, their satisfaction, uh, but is. Cost avoidance, which I gathered is one of the main reasons for doing something like this from a financial perspective is cost avoidance, uh, a strong enough reason for other health systems that may not have the [00:26:00] same financial footing that Mayo Clinic has to launch a program like this.
Dr. Jeremy: Yeah, I mean, it’s a great question. I think, um, these are obviously, if, if, if a model is not financially, you know, survivable, obviously this, this is not something that we’ll catch on. I, I think that, um, so let me just answer by, uh, sort of highlighting one other trial that, um, uh, Roxanna sort of missed. So, you know, as we had put this infrastructure together, one of our urology colleagues came to me and said, um.
Hey, I hear you guys are giving chemotherapy in the home. You know, I give chemotherapy, but I give it in the patient’s bladder and when I give it to the patient, they have to sit here for sometimes, you know, two, three hours in the office, right? Mm-hmm. Um, and so, um, this colleague, actually, Tim Lyon is his name, he’s, we’ve, uh, together launched a trial.
We’ve treated, I believe, five patients with. Intravesicular, so intra bladder chemotherapy in the home. Um, I say that as an example for number one. I think that as we build this infrastructure, the use cases are gonna continue to come. Mm-hmm. I think really the, the, what, what Roxanna was onto when I sort of missed it was that we have a gap of sort of looking at things, kind of, we do things the way we do them because that’s the way we do them.
Mm-hmm. And it takes someone like Roxanna to sort of come in and say, you don’t have to do it that way. And when you have people who are sort of, once you start outlining these things, it actually starts to move the needle forward, both in terms of reimbursement, but there’s other use cases, right? So now for that urology clinic, right?
So when I go to a hospital system, they say, you know, we can’t hire enough urologists. We have patients backed up. Their clinics are completely full. Well, part of that is that the patients are, you know, sitting there for two or three hours. So now you bring them an innovative care model that says, okay, well we’re gonna be able to actually take those patients out of your clinic.
And so the through prep of that clinic is much better. Similarly, when you talk about the chemo unit, right, these chemo units are very expensive to build, to uptake, to keep up. Uh, if your chemo unit is full, you know, that’s probably at a minimum, a $20 million build to build out more of the chemo unit space.
Well now this is actually offloading that capacity so that you can fill that chemo unit back up and you can actually take care of more patients. And so I think that this is just the beginning. I think there’s actually, um, you know, it is obviously we are very, um, cognizant and really focusing on, you know, the cost of care.
Um, but I think that really this is laying the foundation for multiple other services lines that we haven’t even really thought of yet. Um, but it takes that sort of, that that um, that instinct and that sort of bravery to come through like Roxanna did with this is what we’re gonna do. Um, and then once other people see that, they start thinking about,
Arundhati Parmar: go.
Dr. Roxana: I, I just wanted to add that this is a framework that applies to other chronic illnesses, and this is not an all or nothing model. It’s really a blended model of doing both treatments in the home versus treatments in [00:29:00] the brick and mortar facilities, depending on the needs. Of the patient and depending on the acuity of the regimen, so patients can have instead of 18 visits on campus, five visits on campus, but those visits are for the time that they get scans, multidisciplinary consultations, or the part of the regimen that is more intensive, and then you offload the other ones that are lower acuity.
In the home, so patient is not, you know, at home or you know, in the unit. It is just, you know, a journey that is very nicely coordinated and serving the needs of the patient at that point in time.
Arundhati Parmar: Well, I’m going to toss my usual journalistic objectivity and say that this story just was inspirational. The moment I read it, my eyes welled up.
So thank you both. And, um, Dr. Dronca, especially the fact that you turned grief into something so constructive is really, um, you know, notable. Thank you so much for your time.
Dr. Roxana: Thank you for having us.