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This represents the final issue of Journal of Oncology Practice (JOP) during our transition to a new Editor-in-Chief. Therese Mulvey, MD, and I have been filling in while Doug Blayney, MD, prepares for his tenure as President of the American Society of Clinical Oncology (ASCO) next year. Dr Blayney has taken JOP from its earliest inception and planning through the first formative years to find its valued place among the other ASCO publications. It has been a delight working with Dr Blayney, and I know that I speak for Dr Mulvey and the entire publications team in wishing him the very best as he extends his leadership skills to the Society as a whole.
The Feature article in this issue of JOP discusses integrating genetic risk assessment into clinical practice by covering the broad components of a genetic risk assessment program. The article includes understanding of basic cancer genetics and hereditary syndromes, taking a thorough family history, formal risk assessment, genetic testing, genetic counseling both before and after testing per ASCO recommendations, as well as follow-up. Another important feature of this review is a discussion of the common billing codes used for genetic testing and counseling. The issues for the practicing oncologist to consider when deciding whether to provide personal counseling, involve trained genetics counselor, partner with a local academic medical center or even establish a separate risk assessment clinic are thoroughly discussed. As a sequel, the reader is encouraged to read the Oncology Ethics Vignette, which provides a thorough case-based discussion of the ethical and legal implications of cancer genetic testing.
Original research articles of interest to practicing oncologists in this issue of JOP include one by Schwaderer et al1 evaluating a patient navigation system in a community radiation oncology practice applied to patients identified with “at-risk” disparities based on insurance status, age, race, and housing address. The authors report divergent results with navigated patients experiencing somewhat shorter times from referral to treatment, but fewer patients completing treatment. Clearly, additional studies of the potential role of navigator programs in improving the quality of cancer care are needed.
In the Current Clinical Issues section, Robinson et al discuss the challenges and opportunities when implementing an office-based intraperitoneal chemotherapy program. Though the clinical benefits of intraperitoneal chemotherapy in selected ovarian cancer patients have been demonstrated, such treatment is complex, time consuming, and requires advance planning among oncologists, nursing staff, pharmacy staff, and administrators. Maurie Markman extends the debate about the appropriate end points used in new drug approval in oncology by considering the cost of therapy. He focuses the discussion of the recent approval of bevacizumab by the US Food and Drug Administration (FDA) for first-line treatment of metastatic breast cancer. Though costs are not directly considered in the recommendations made by the Oncology Drug Advisory Committee or the FDA, Markman argues that the discussion about clinical end points would at least be muted if costly agents were not involved. Reimbursement, and therefore access to drugs, however, are increasingly driven by costs rather than observed clinical efficacy. In a counterpoint, Neal Meropol argues that the value of a treatment, often assessed as willingness-to-pay, represents an integration of the evidence of treatment efficacy and costs. It will take a national consensus if we are to change the paradigm to one of assessing the value of new cancer therapies and a deliberate choice not to pursue interventions of modest benefit where the value seems unacceptably low compared with other therapeutic options.