By
Trial Library
September 18, 2024
In this informative conversation, Dr. Hala Borno, CEO and Founder of Trial Library, sits down with Dr. Douglas Flora, Executive Medical Director of Oncology Services at St. Elizabeth Healthcare, to discuss the vital role of clinical trials in community and academic hybrid settings. They explore the challenges of trial access, the critical shortage of research staff, and how innovative solutions like Trial Library are helping providers find trials more efficiently. Together, they delve into the pressing issues of equity in cancer care, patient recruitment, and the transformative impact of clinical trials on diverse populations.
"The idea that we might be able to connect those dots and get patients who don't look like me into trials more easily – any barrier that you can remove there is good for the system, and good for the people who are trying to do the studies with more equity in their control and experimental arms. But it is also a moral imperative for us as doctors, as healers."
– Dr. Douglas Flora, MD, LSSBB, FACCC
Dr. Hala Borno: What roles do clinical trials play in our clinical practice?
Dr. Douglas Flora: It’s a big part of who we want to be. So, it's an aspirational thing. We're a community academic hybrid. We have about probably 60 providers in our system now, and many of us are recovering academics that still believe in the power of clinical research, but for various reasons ended up in a strong community academic center. And so we have a full clinical research institute, we have tons of open clinical trials, probably 40 staff members that work specifically in research with CRCs, CRNs, regulatory finance, those sorts of things.
But we found that our enthusiasm for building a menu is limited by our ability to staff because CRCs and CRNs are hard to come by and it's sort of a training game between us and a bunch of CROs and other healthcare systems. Some of the difficulties are just finding people to do the work.
Dr. Hala Borno: That certainly resonates – that workforce shortage, especially in the context of COVID is a big pressing issue that's limiting cancer care overall, but certainly has implications for research programs. What is your context for the ease and speed in which providers can identify trials that are available within your healthcare system and even beyond?
Dr. Douglas Flora: And that's tough – we're trying. We do have CRCs that are diligent that really try and by hand screen all of our new patients. Obviously, that's labor intensive and not always feasible given the number of new patients who come in the door. We certainly try and T things up, you know, from the research team perspective for the doctor, so that that doctor on Monday might have a thing from the tumor board saying “This patient was screened and is eligible for a trial Z, they just need to have this and this and this to be eligible…”
Those are for our in-house trials. And we do use some apps and other things that are probably used a smattering, but there’s certainly room for improvement. We're not getting anywhere near the number of patients on trial that we want to.
Dr. Hala Borno: For our trial search solution, we really wanted to make it easy at the point of care to generate a list of trials. But on top of that, we integrated some services and the specific service and pain point that was identified is slot verification – that folks liken it to finding a flight, but not knowing if there's room on the plane. It's sort of a waste of time to even undergo that activity unless you're sure there are slots. So I’d love to hear, was that something that's also a pain point for your practice?
Dr. Douglas Flora: I love that. It's clever. I've not seen that anywhere and I think we've both seen patients where I've gotten them all keyed up that this is our best option and I send them to an academic center and the trial closed or the third spot that was available in that phase one trial filled up and they're not gonna be enrolling until they make sure that patient did well. So I love that idea.
I also love that your team has built an intuitive system. After 20 years in practice, I'm so used to cancer.gov and wading through hundreds and hundreds of pages to find a trial that is or isn't available for my patient. I love what you have done on the frontend here and that you have built a tool that will prescreen for me.
Dr. Hala Borno: Awesome, thank you. And you know, a big part of our mission, of course, is advancing access. We're a public benefit company, so really in our charter, we're committed to this social good of advancing access to clinical trials and we do that by partnering with community based practices that are serving diverse patient populations, what have you seen are other important ways to kind of move the needle on this that you think are impactful and would love to hear your perspective on it.
Dr. Douglas Flora: Obviously, the equity issue is pressing – that's not a moral thing that we only enroll people who look like me on trials, and we skip many communities. We have a community just maybe five miles east of me, and there's a 26 year median survival difference in two neighborhoods in downtown Cincinnati. One is elite on the hill and the other one is our sort of gentrified area and it really bothers me that we're not making progress here.
So think of the guy I treat as a 45 year old black male who is a father with prostate cancer at 50. That guy needs a trial. He has a different prostate cancer than I would as a middle aged white guy. The idea that we might be able to connect those dots and get patients who don't look like me into trials more easily – any barrier that you can remove there is good for the system and good for the people who are trying to do the studies with more equity in their control arms and in their experimental arms, but also a moral imperative for us as doctors, as healers. We can't just cure people who look like me.
Dr. Hala Borno: Couldn't say it any better. That's pretty phenomenal that you're committed to this and certainly that survival gap you're flagging is one I've never heard of that is quite so large within such a short distance. That's pretty staggering and scary.
And definitely suggests that access is an issue, social determinants of health are a clear issue. I would be worried that that's a legacy of redlining, but we gotta move the needle through targeted interventions that advance access, so I think it's phenomenal that you're keeping an eye on it.
I would love to just give you the floor for any other common ideas, things you're thinking about or think are important to be shared.
Dr. Douglas Flora: I think we're seeing a shift in the general landscape of oncology from separate silos of academic ivory towers and community programs, and we're seeing more and more academics becoming more community friendly and more community programs that are aspiring to do more studies, where we've got 10 phase one trials open, or by specifics, or transplants.
And as those come together, sort of like Cincinnati and Dayton or Minneapolis and Saint Paul. I'm seeing some opportunities there that now you have 80% of patients treated in the community by doctors that have access to trials.
And I'm hoping that will accelerate this where we're not enrolling the typical 3, 4, 5% as the menus get easier to access, as tools like yours make the steps for a busy doctor less onerous. Then we've removed something that might have precluded them from enrolling.
I just had this conversation with one of my doctors who knows he needs to do better enrolling.
He's like, “Yeah, but you just get so busy and then the day has gotten away from you and it's gonna take me an extra 30 minutes to screen them and get them into this trial. I'll just give him the standard, I'll do it the next time.” and they never do.
And so even though our numbers are climbing briskly, they're not at target, they're not at goal. And so I look forward to things that can help demystify this for the people who don't do research normally and maybe recruit a whole new class of oncologists that would not have participated in the community before because they didn't have help.
But also, maybe re-engage some of us who've been in practice for a while, who loved it as a fellow, loved it as a young attending, and then we've been around long enough that maybe you drift away in your practice patterns and don't bring up a trial every time to every patient.
You'll be glad to hear – I brought up trials three times today in three consecutive patients. So I'm still on the team. I still care about curing cancer and this is the only way we do it.
Dr. Hala Borno: That's phenomenal. Well, thank you so much. We are grateful for your time.
