October 2024 Dallas Medical Journal

OCTOBER 2024 | DALLAS COUNTY MEDICAL SOCIETY

BRIDGING GAPS IN CANCER CARE: THE ROLE OF TEXAS’ CLINICAL TRIALS ADVISORY COMMITTEE HOW TO INVEST IN AND PROTECT YOUR CAREER

October 2024

Vol. 110 No. 10

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PRESIDENT’S PAGE

The Future of Cancer Care: Innovations and Challenges on the Horizon EV P/C EO L E T T E R

October: A Month of Awareness, Hope, and Action

EXECUTIVE VICE PRESIDENT & CEO

Jon R. Roth, MS, CAE

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HOUSE CALL

Bridging Gaps in Cancer Care: The Role of Texas’ Clinical Trials Advisory Committee CANCER CARE

The Benefits of Proton Therapy in Treating Recurrence or Second Primary Cancer

Ravina Linenfelser, DO David Miller, MD Sina Najafi, DO Erin Roe, MD, MBA BOARD OF DIRECTORS Deborah Fuller, MD, President Shaina Drummond, MD, President-Elect Gates Colbert, MD, Secretary/Treasurer Donna Casey, MD, Immediate Past President Neerja Bhardwaj, MD Sheila Chhutani, MD Philip Huang, MD, MPH Anil Tibrewal, MD

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Articles represent the opinions of the authors and do not necessarily reflect official policy of the Dallas County Medical Society (DCMS) or the institution with which the author is affiliated. Dallas County Medical Society does not endorse or evaluate advertised products, services, or companies nor any of the claims made by advertisers.

Claims made by any advertiser or by any company advertising in the Dallas Medical Journal do not constitute legal or other professional advice. You should consult your professional advisor. ©2022 DCMS. According to Tex. Gov’t. Code Ann. 305.027, all articles in Dallas Medical Journal that mention DCMS’s stance on state legislation are defined as “legislative advertising.” The law requires disclosure of the name and address of the person who contracts with the printer to publish legislative advertising in the DMJ: Jon R. Roth, MS, CAE, Executive Vice President & CEO, DCMS, PO Box 4680, Dallas, TX 75208-0680. Dallas Medical Journal (ISSN 0011-586X) is published monthly by Dallas County Medical Society, 140 E. 12th St., Dallas, TX 75203. (214) 948-3622. Postmaster - Send address changes to: Dallas Medical Journal | PO Box 4680 | Dallas, TX 752080680. Periodicals postage paid at Dallas, TX 75260 and additional post offices.

October 2024 • DALLAS MEDICAL JOURNAL | 1

PRESIDENT’S PAGE

The Future of Cancer Care: Innovations and Challenges on the Horizon Deborah Fuller, MD

I

n 1971, President Richard Nixon signed the National Cancer Act into law.

Since that time there have been three million cancer survivors in the 1970’s and today more than eighteen million cancer survivors. There are predicted to be over twenty-six million cancer survivors by 2040.

Mortality rates for cancers have decreased in the last three decades due to advances in cancer treatments along with decreases in tobacco use and earlier detection for some cancers. More than four million deaths have been prevented in the United States since 1991. Despite these advances, cancer deaths in the United States in 2024 are predicted to be 611,000 and worldwide nearly ten million.

Cardiovascular disease is still the leading cause of death in the United States, but dying of cancer is projected to surpass mortality rates for cardiovascular disease in the near future. The incidence rates for cancer are rising both in the United States as well as around the world. The WHO is predicting that by 2050 there will be a 77% increase in the incidence rates of cancer with thirty-five million new cases worldwide, a rise over the twenty million new cases in 2022.

Many cancers are theoretically preventable. According to the WHO, 30-50% of all cancers are preventable by addressing risk factors such as tobacco, alcohol use and obesity. Obesity is one of the greatest threats to cancer onset, fueling the development of at least thirteen cancers and is a known factor in early-onset cancers such as colorectal cancers in young adults. According to the World Obesity Atlas, more than half of the world population, more than four

billion people will be obese by 2035.

Currently, two thirds of Americans are obese or overweight. Also important is early detection and early prevention of infections connected to cancer incidence such as hepatitis and human papilloma virus.

With oncologic advances, the future of cancer care is shaped by emerging technologies and innovative approaches that promise more targeted, efficient, and comprehensive treatment options.

With cancer’s rising incidence and increasing complexity, it is imperative for the medical community to stay informed about these advancements.

The emerging care model for cancer care is rapidly shifting as there is more understanding of the biology of cancer and thus varied treatment options.

Oncology care will likely trend toward oncologists who specialize in specific cancer types rather than a generalist, as the pace of knowledge and innovation is increasing so rapidly that it would be difficult for a generalist to cover all disease types.

There has also been a consolidation of health care systems producing more of a community-based care model helping to change the dynamics of oncological care. As more patients seek their care closer to home, patients can now obtain increasingly complex care and clinical trial options locally, previously seen only in academic cancer treatment centers.

With an aging population and the increasing incidences of cancers, as well as the growing oncology workforce shortage, the United Sates faces a potential oncologic perfect storm.

Empowering advanced care professionals

2 | DALLAS MEDICAL JOURNAL • October 2024

to help manage the increasing workload is essential, along with the utilization of home care management to help decrease clinic over utilization for issues which could be managed at home.

The shift toward personalized medicine is also reshaping how we approach oncology. With a deeper understanding of cancer at the molecular level, oncologists can now offer more tailored treatment strategies. The utilization of next-generation sequencing (NGS) and biomarker identification allows us to classify cancers more precisely. As a result, molecular profiling is becoming a cornerstone in treatment planning, enabling oncologists to select therapies based on individual tumor characteristics.

Therapies targeting specific genetic mutations often result in fewer adverse effects compared to traditional chemotherapy, though resistance remains a concern. Monitoring patients for secondary mutations is crucial to adapting treatment as the cancer evolves. These genetic mutation targeted therapies have shown efficacy in nonsmall cell lung cancers and melanomas.

There are also advances in the development of anticancer vaccines.

Personalized messenger RNA and cellular cancer vaccines can target tumors directly and may also be used to boost the immune system response to tumor antigens. The success of HPV vaccines in reducing cervical cancer incidence highlights the potential impact of vaccination on cancer prevention and

treatment.

Early detection remains vital for improving cancer outcomes, and technological advancements are enhancing our ability to diagnose cancers at their most treatable stages. These immune and molecular advances are examples of learning to study and treat the whole patient by characterizing a patient’s particular cancer and immune system to maximize and individualize new modes of treatment such as antitumor vaccines and cellular therapies.

Utilization of Artificial Intelligence has shown impressive accuracy in diagnostic imaging of certain cancers. In mammography, AI can enhance radiologists’ ability to detect subtle patterns indicative of malignancy. As these algorithms become more sophisticated, they may serve as invaluable tools in both primary and secondary screening, potentially reducing false-positive rates and improving diagnostic accuracy.

Integrative and holistic approaches to cancer treatment and care are gaining recognition, not only for their ability to improve patients’ quality of life but also for its potential to enhance treatment efficacy when used alongside conventional

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therapies. Complementary therapies, such as acupuncture and mind-body interventions, have been shown to alleviate symptoms like nausea, fatigue, and anxiety, particularly for patients undergoing chemotherapy or radiation. Integrative approaches can improve patient adherence to treatment regimens and overall satisfaction with care.

As we strive to improve survival rates, palliative care is essential in managing symptoms and supporting patients’ psychological well-being.

The integration of palliative care early in the treatment process is associated with improved quality of life, and even prolonged survival in certain cancers.

Effective palliative care requires a multidisciplinary approach, involving pain specialists, mental health professionals, and social workers.

Digital health technologies are also transforming cancer care, particularly in terms of access, patient monitoring, and data integration.

Telemedicine has expanded significantly, allowing oncologists to reach patients in remote areas or those unable to travel. Virtual visits enable continuous care for patients on maintenance therapies and posttreatment follow-up.

The future of cancer care must also grapple with issues of access, equity,

and affordability to ensure that advancements benefit all patients as cancer care is not a one size fits all care approach.

Unfortunately, significant disparities exist in cancer outcomes based on socioeconomic status, geography, and race. Ensuring equitable access to innovative therapies requires policy reforms, investment in healthcare infrastructure, and outreach programs that address social determinants of health.

Physicians can advocate to legislators for policies that expand access and support clinical trial participation among underserved populations.

In conclusion, the future of cancer care is heralded by remarkable new innovations that hold the promise of more personalized, precise, and accessible treatments. However, realizing this future will require addressing ongoing challenges related to access, medical oncology physician shortages, affordability, and equitable care. Staying abreast of these advancements and advocating for patient-centered, evidencebased care is essential. With continued investment in research and a collaborative approach to tackling barriers, the oncology community is poised to make significant strides in the fight against cancer. DMJ

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EV P/C EO LETTER

October: A Month of Awareness, Hope, and Action Jon R. Roth, MS, CAE

E

very October, a sea of pink ribbons emerges across the United States, symbolizing a collective effort to raise awareness about breast cancer. This month, known as Breast Cancer Awareness Month, has become a powerful movement that not only educates the public about the disease but also honors those affected by it. But how did October come to be synonymous with cancer awareness, and what is the history behind this significant month?

The story of Breast Cancer Awareness Month begins in the early 1980s. In 1985, the American Cancer Society (ACS) and the pharmaceutical division of Imperial Chemical Industries (now part of AstraZeneca) collaborated to create a week-long event dedicated to promoting mammography as the most effective weapon in the fight against breast cancer. This initiative was spearheaded by Betty Ford, the former First Lady of the United States, who was herself a breast cancer survivor. Her public disclosure of her diagnosis and treatment in 1974 had already done much to break the silence surrounding the disease.

The success of this initial campaign led to the expansion of the event into a monthlong observance. October was chosen for its strategic timing, as it allowed for a concentrated effort to raise awareness before the holiday season.

The Rise of the Pink Ribbon One of the most recognizable symbols of Breast Cancer Awareness Month is the pink ribbon. This symbol’s journey began in 1991 when the Susan G. Komen Foundation handed out pink ribbons to participants in its New York City race for breast cancer survivors. The following year, the pink ribbon was adopted as the official symbol of National Breast Cancer Awareness Month.

The pink ribbon’s simplicity and visibility made it an effective tool for raising awareness. It quickly became a ubiquitous emblem, appearing on everything from clothing and accessories to sports equipment and even food packaging. The pink

ribbon not only signifies support for those affected by breast cancer but also serves as a reminder of the importance of early detection and ongoing research.

While October is primarily associated with breast cancer awareness, it has also become a time to highlight other types of cancer. For instance, October is also Liver Cancer Awareness Month and National Pancreatic Cancer Awareness Month. These observances aim to draw attention to the unique challenges and needs of those affected by these less common but equally devastating diseases.

The expansion of cancer awareness efforts during October reflects a broader trend in public health advocacy. By dedicating specific times to different types of cancer, organizations can tailor their messaging and outreach efforts to address the distinct characteristics and risk factors associated with each disease.

Breast Cancer Awareness Month has become a major driver of advocacy and fundraising efforts. Organizations like the Susan G. Komen Foundation, the American Cancer Society, and the Breast Cancer Research Foundation use this month to launch campaigns that raise millions of dollars for research, patient support, and education programs.

Fundraising events such as walks, runs, and galas are a staple of October’s activities. These events not only generate crucial funding but also foster a sense of community and solidarity among participants.

Survivors, patients, and their families often share their stories, providing inspiration and hope to others facing similar battles.

The impact of Breast Cancer Awareness Month extends beyond fundraising and advocacy. Public awareness campaigns have played a crucial role in changing perceptions and behaviors related to breast cancer. Increased awareness has led to higher rates of early detection, as more women are encouraged to undergo regular mammograms and self-examinations. These efforts proved successful as the percent-

4 | DALLAS MEDICAL JOURNAL • October 2024

age of women aged 50 to 74 who received a mammogram within the past two years increased significantly from 1987 to 2021. In 1987, about 29% of women in this age group had a mammogram. By 2021, this number had risen to approximately 80.5%.

Moreover, awareness campaigns have helped to destigmatize breast cancer. By bringing the disease into the public eye, these efforts have made it easier for individuals to talk about their experiences and seek support. This cultural shift has been instrumental in improving the quality of life for those affected by breast cancer.

As we look to the future, the challenge will be to build on the successes of Breast Cancer Awareness Month. This means finding ways to ensure that awareness translates into action, whether through increased funding for research, improved access to healthcare, or more comprehensive support for patients and their families.

It also means broadening the scope of awareness efforts to include a wider range of cancers and health issues. By fostering a more inclusive approach, we can ensure that all individuals affected by cancer receive the attention and support they need.

In conclusion, October’s designation as Breast Cancer Awareness Month has had a profound impact on public health in the United States. From its origins in the 1980s to its current status as a major driver of advocacy and fundraising, this month has played a crucial role in the fight against breast cancer. As we continue to raise awareness and support for this cause, let us also remember the importance of action and inclusivity in our efforts to combat cancer in all its forms. DMJ

Jon R. Roth, MS, CAE DCMS EVP/CEO

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HOUSE CALL Bridging Gaps in Cancer Care: The Role of Texas’ Clinical Trials Advisory Committee

by Laura Esterly

I

size means that many patients who enroll in trials must travel hours to reach treatment centers. This geographical barrier is compounded by the state’s diverse population, with a substantial portion of residents speaking languages other than English and Spanish.

Perhaps most significantly, Texas holds the dubious distinction of having the highest uninsured rate in the nation. This lack of health insurance coverage creates a substantial hurdle for many potential clinical trial participants.

These Texas-specific challenges layer over other common barriers faced by participants in clinical trials across the country. Dr. Gerber points out that eligibility criteria for trials are often strict and numerous. For instance, in lung cancer trials—in which the average patient age is about 71, and 85% are current or former smokers—many potential participants in trials are excluded due to comorbidities.

The complexity of trial protocols presents another hurdle. Some trials require monthly visits, while others demand weekly checkins. This frequency can interfere with work schedules, childcare

n the vast landscape of Texas healthcare, the Clinical Trials Advisory Committee (CTAC) stands at the forefront of advancing cancer research and treatment.

As part of the Cancer Prevention and Research Institute of Texas (CPRIT), CTAC plays a crucial role in shaping the future of

arrangements, and other daily responsibilities. Additionally, the

cancer care across the Lone Star State. Chaired by Dr. David E. Ger-

es—such as Vietnamese, various African languages, or Russian—

ber, a distinguished oncologist and researcher, CTAC is tasked with

can take weeks to procure, delaying enrollment and potentially

addressing the complex challenges of clinical trials and ensuring

excluding eligible participants.

that groundbreaking treatments reach patients in every corner of the state.

enrollment process itself can be burdensome, often involving lengthy consent forms and numerous additional procedures.

Language barriers further complicate matters. While many trials offer materials in Spanish, translations for other languag-

The issue of insurance coverage in clinical trials is particularly thorny. While some trials, especially those for mental health conditions, cover all aspects of care, cancer trials typically do not.

THE LANDSCAPE OF CLINICAL TRIALS IN TEXAS

In a typical Phase 3 cancer trial, half of the participants re-

Texas presents a unique set of challenges when it comes to con-

ceive standard treatment (such as IV chemotherapy or immuno-

ducting clinical trials. As the second-largest state in the U.S., its sheer

therapy), while the other half receive the same treatment plus a

6 | DALLAS MEDICAL JOURNAL • October 2024

HOUSE CALL new intervention. The trial doesn’t cover the cost of standard treatment,

THE PEOPLE BEHIND CTAC

which can run into hundreds of thousands of dollars per year. This finan-

Dr. David E. Gerber, a distinguished figure in the field of oncology, has

cial burden makes it nearly impossible for uninsured patients to partici-

been chair of CTAC since early 2024. With a medical degree from Cornell

pate, effectively shutting out a significant portion of Texas’s population

University and fellowship training at Johns Hopkins, Dr. Gerber brings a

from potentially life-saving treatments.

wealth of expertise to his role. As associate director for clinical research

OVERCOMING BARRIERS Recognizing these formidable challenges, CTAC has developed a multifaceted approach to increase access to clinical trials across Texas.

Central to this strategy are CPRIT’s innovative funding mechanisms.

One key initiative is the Clinical Trial Network Award. This program funds a lead institution with extensive experience in conducting clinical trials to partner with less experienced institutions across the state. This approach not only expands the geographical reach of trials but also builds capacity at smaller institutions, creating a more robust clinical trial infrastructure throughout Texas.

Dr. Gerber highlights two major networks that have emerged from this initiative. One is centered around MD Anderson Cancer Center, connecting Houston with sites in Galveston, Tyler, and an Austin suburb.

The other network, led by UT Southwestern in Dallas, includes sites in Fort Worth, Temple, Lubbock, and Abilene. These networks allow trials to approach a much broader and more diverse patient population.

Complementing this is the Clinical Trial Participation Award, designed to alleviate the personal expenses associated with trial participation.

at the Harold C. Simmons Comprehensive Cancer Center, he has contributed to over 120 peer-reviewed publications, primarily focusing on lung cancer.

Dr. Gerber’s impact extends beyond his research contributions. He is known for his commitment to mentorship, having guided numerous predoctoral and postdoctoral students over the past decade. His efforts in this area earned him an NCI Midcareer Investigator Award in Patient-Oriented Research. Moreover, Dr. Gerber’s influence reaches national policy levels, where he has helped to lift restrictions on nurse practitioners participating in clinical trials through the National Cancer Institute.

Several other physicians in Dallas serve on the ddvisory committee, including DCMS member Dr. Ronan Kelly, the director of oncology for the Charles A. Sammons Cancer Center and the chief of oncology for the North Texas Division of the BSWH system. Dr. Kelly performs translational and clinical research encompassing the discovery and development of new targeted and immunotherapeutic approaches in the prevention and treatment of gastroesophageal cancer and lung cancer, and he is

This program provides reimbursement for travel, food, and lodging ex-

the international principal investigator on a number of global phase II/

penses, addressing the fact that poorer patients often have to travel

III clinical trials in these disease areas.

twice as far as their more affluent counterparts to access clinical tri-

Together, leaders like Dr. Gerber and his colleagues embody CTAC’s

als. Dr. Gerber notes that one such program in Dallas has already re-

commitment to bridging gaps in cancer care and research across Texas.

imbursed nearly $200,000 to hundreds of patients, many from underrepresented groups.

FUTURE DIRECTION

CTAC also places a strong emphasis on increasing diversity in clini-

As CTAC looks to the future, several key priorities emerge. The com-

cal trials. The committee itself reflects this commitment, with members

mittee continues to focus on expanding access to clinical trials in un-

representing a variety of perspectives relevant to cancer clinical trials.

derserved communities, recognizing that geographical and socioeco-

These include researchers, pharmaceutical industry representatives,

nomic barriers remain significant challenges in Texas.

physicians from private practice and academic settings, and individuals with expertise in urban and rural healthcare delivery.

Looking to the future, Dr. Gerber envisions further expanding the committee’s expertise by including more non-physician voices, such as physician assistants, research nurses, and clinical trial coordinators. This diversification aims to bring a more comprehensive understanding of the challenges and opportunities in clinical trial implementation.

TRANSLATING RESEARCH INTO PRACTICE A core part of CTAC’s mission is to accelerate the translation of basic cancer research discoveries into clinical trials. The committee works to identify promising laboratory findings and facilitate their progression into human studies. This process involves close collaboration with researchers, clinicians, and industry partners to ensure that innovative ideas have the support and resources needed to move forward.

CPRIT’s funding mechanisms play a crucial role in this translational process. By supporting both basic research and clinical trials, CPRIT creates a pipeline for discoveries to move efficiently from the lab bench to the patient’s bedside. This integrated approach helps to overcome

There are plans to diversify the committee’s expertise further, bringing in more voices from various aspects of the clinical trial process. This expansion aims to provide a more comprehensive understanding of the challenges faced at every level of trial implementation and patient care.

CTAC also aims to strengthen collaborations with industry partners and other research institutions, both within Texas and beyond. These partnerships are crucial for bringing the latest innovations in cancer treatment to Texas patients and for ensuring that Texas-based research has a global impact.

The Clinical Trials Advisory Committee is a beacon of progress in Texas’s fight against cancer. By addressing the unique challenges faced by the state’s diverse population and vast geography, CTAC is working to ensure that every Texan has the opportunity to benefit from the latest advances in cancer research and treatment.

As clinical trials continue to evolve and new challenges emerge, the work of CTAC and its dedicated members will remain crucial. Their efforts not only improve the lives of cancer patients today but also pave the way for a future where cancer is no longer a life-threatening diag-

the oftn-cited “valley of death” in drug development, in which promising

nosis. The success of these initiatives depends on continued support and

ideas fail to progress due to lack of funding or support.

engagement from healthcare providers, researchers, policymakers, and

While specific breakthroughs from CPRIT-supported trials were not detailed in the provided notes, the impact of this approach is evident in the expanding network of clinical trial sites across Texas and the increasing number of patients gaining access to cutting-edge treatments.

8 | DALLAS MEDICAL JOURNAL • October 2024

the public. Together, we can build a stronger, more inclusive clinical trial landscape that serves all. DMJ

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CANCER CARE

The Benefits of Proton Therapy in Treating Recurrence or Second Primary Cancer

By Andrew Lee, MD, MPH, radiation oncologist and medical director of Texas Center for Proton Therapy

T

his year, more than 147,900 men and women will be diagnosed with cancer in Texas. However, for some patients, this is not their first-time navigating cancer. According to the National Cancer Institute, nearly one in five cancers detected today occur in a former patient, also known as cancer recurrence.

Recurrence can happen if the first treatment does not completely destroy all cancer cells in the primary site or elsewhere in the body, or the cancer cells grow back. This does not mean the cancer was treated insufficiently, but rather that some cancer cells were resistant and survived the treatment, later developing into detectable tumors. In other cases, patients may be diagnosed with a second primary cancer, which occurs when a new type of cancer is found in an individual who has a history of cancer.

Cancer patients who are exploring new treatment plans may ask, “What advanced therapy options are available for recurrent cancers?” followed by “Which cancer types do these commonly and effectively treat?” and “How do I know if I am a candidate based on my specific cancer?”

More than half of cancer patients receive standard radiation therapy to slow or stop the growth of cancerous cells, but it is not without potential risk. Some patients may experience acute or long-term side effects, which is why clinical teams statewide are continuing to research or evolve new forms of radiation therapy, such as proton therapy.

Proton therapy is a highly precise form of radiation, which may target recurrent cancers that were previously treated with standard radiation. This article will discuss how proton therapy works, recurrent cancer types that are commonly treated, benefits of this advanced radiation therapy, and how to know if your patient is an ideal candidate.

WHAT IS PROTON THERAPY? Proton therapy is a precise form of radiation therapy aimed at destroying cancerous cells by delivering high doses of radiation that conform to the shape, size, and depth

of each tumor. Essentially, proton therapy “paints” tumors layer by layer in three dimensions, allowing for more targeted treatment while minimizing radiation exposure to surrounding healthy tissues and organs.

When used as part of a multidisciplinary cancer care plan, studies show that proton therapy improves a patient’s ability to receive other concurrent or sequential therapies such as chemotherapy, immunotherapy, and/ or surgery. Proton therapy can treat tumors in sensitive areas of the body where highly complex cancers form, such as many recurrent or second primary cancers.

Pencil-beam scanning, also known as spot-scanning, is an advanced form of proton therapy that delivers ultra-fine, targeted radiation. This leading-edge therapy enables greater conformity in solid tumor treatments compared to traditional proton beam therapy. Pencil-beam scanning commonly treats tumors where standard radiation has been previously used or may not be the best option.

WHAT RECURRENT CANCERS ARE COMMONLY TREATED WITH PROTON THERAPY? Proton therapy may be an ideal treatment depending on a patient’s cancer type and stage. This advanced therapy can treat tumors that may be located in sensitive areas like the brain, head and neck, lung, and breast as well as gastrointestinal, genitourinary, and gynecologic regions. Proton therapy is commonly used to treat the following types of recurrent cancers: Brain and Spine Cancers Brain and spine cancers, such as medulloblastoma, chordoma, chondrosarcoma, and malignant meningioma, and gliomas can be highly complex. The accuracy of proton therapy makes it particularly useful in effectively treating tumors in the central nervous system, including the brain, skull base, brain stem, or spinal cord. Patients who require radiation therapy, such as those with brain and spine metastases or cancer recurrence, may

be good candidates for proton therapy.

Head and Neck Cancers Head and neck cancers are commonly found around the throat, nose, and mouth area. Proton therapy may be beneficial for these cancers because of its precision in targeting tumors and minimizing stray exposure around the salivary glands, swallowing muscles, oral mucosa, eyes, and healthy tissue.

Pencil-beam scanning is commonly used for head and neck tumors that are recurrent, irregularly shaped, difficult to reach, wrapped around other medical structures, or located near vital organs. As a result, patients may have fewer potential side effects such as difficulty swallowing, changes of voice, dry mouth, nerve damage, weight loss, or feeding tube use.

Lung Cancers Lung cancer remains responsible for the most cancer-related deaths in both men and women in Texas. Proton therapy may be an effective treatment for primary and recurrent lung cancers due to its targeted doses of radiation that help to preserve pulmonary function and reduce cardiac complications.

Childhood Cancers Childhood cancers are the most common cause of disease-related deaths among children outside the newborn period. Childhood cancers that can be treated with proton therapy include brain and spine tumors, chordoma, craniopharyngioma, ependymoma, Ewing sarcoma, germinoma and other germ cell tumors, lymphoma, medulloblastoma, neuroblastoma, rhabdomyosarcoma, sarcomas, amongst other tumors as well.

Proton therapy may be ideal for pediatric patients due to its minimal radiation exposure and reduced long-term side effects – which are key considerations for young patients whose bodies are still developing and growing.

This form of treatment also allows children to maintain their quality of life during treat-

October 2024 • DALLAS MEDICAL JOURNAL | 11

ment, have better functional outcomes afterwards, and reduce the risk of late secondary malignancies. Additionally, proton therapy centers typically offer specialized pediatric equipment, sub-specialists, clinical trials, and child life specialists to support patients and their families as they navigate cancer.

Breast Cancers Proton therapy may effectively destroy recurring cancerous cells while preserving nearby breast tissue (e.g., brachial plexus) and minimizing exposure to the heart, especially for women with left-sided breast cancer. This advanced form of radiation can also be used for those who underwent a lumpectomy or mastectomy and require radiation to their breast or chest wall.

Gastrointestinal, Genitourinary, and Gynecologic Cancers Proton therapy is effective in treating many types of primary or recurrent gastrointestinal cancers, including esophageal, liver, pancreatic, and stomach cancer. Additionally, patients with genitourinary cancers, such as bladder, prostate, and testicular cancer, and women with gynecologic cancers, including cervical, ovarian, and uterine

12 | DALLAS MEDICAL JOURNAL • October 2024

cancers, may also benefit from proton therapy due to the sensitivity of pelvic tissues.

WHAT ARE THE BENEFITS OF PROTON THERAPY FOR RECURRENT OR SECOND PRIMARY CANCERS? Proton therapy provides recurrent and second primary cancer patients with an advanced treatment option that can precisely target tumors near or overlapping in areas of the body previously treated with standard radiation therapy.

Proton therapy is noninvasive and performed as an outpatient procedure, allowing cancer patients to maintain their quality of life during and after treatment. Additional benefits of proton therapy include reduced amounts of radiation exposure, thus reducing the risk of side effects such as fatigue, nausea, headaches, breathing difficulties, and dry mouth.

While every cancer patient’s recurrence varies, many may be a potential candidates for proton therapy. Physicians are encouraged to refer their patient for a consultation to best determine if this form of advanced radiation treatment is a fit based on their patient’s individual cancer type and previous history. DMJ

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"WE'RE FROM THE GOVERNMENT AND WE'RE HERE TO HELP" "Those are the nine most terrifying words in the English language" President Ronald Reagan once quipped.

But when auditors or regulators threaten you, it's no laughing matter. You need aggressive intervention by a team of battletested specialists* to rebut the government's legions of lawyers, coders, auditors and forensic experts.

When facing "help" from the government, put Shaw corner.

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*Not certified by the Texas 14 | DALLAS MEDICAL JOURNAL • October 2024 Board of Legal Speciali ation

Diane Shaw and the attorneys of Shaw & Associates are seasoned allies for physicians and medical practices facing legal and compliance issues.

LEGAL CORNER

Insight into the the Hospital Price Transparency Rule

By Shaw & Wiar, Attorneys At Law

I

magine a grocery store without prices and staffed by eager salespeople; one would walk in with their credit card, gaze around at all the amazing options on the shelves, and, prodded by the sales team, would, instead of buying a bag of spinach and a steak, accidentally buy Aisle 12. Indeed, if one has ever used an app on their phone with in-app purchases or gone on a cruise ship, one discovers after an hour in an app or a week in the sun that they now have a huge bill with which to contend. When one cannot clearly see the prices upfront, and with the assurance that they can pay later, they become easily overburdened by debt. And when they’re sick, they’ll pay for anything. That’s why the Hospital Price Transparency Rule, which went into effect January 1, 2021, mandates that hospitals provide machine-readable prices to patients; however, these documents are not easily readable and most patients can’t easily understand them. Hospitals are also required to provide patients with an out-of-pocket cost estimator tool or payor-specific negotiated rates for at least 300 shoppable services, according to texashealth.org.

In addition, as of January 1, 2024, hospitals are also required to add

a footer link to their homepage that directs users to price transparency resources. According to Texas Health, “[a] February 2023 CMS report found that in 2022, 70% of hospitals complied with both components of the rule, up from 27% in 2021.”

But patients could still do with a lot of help. While hospitals must now make prices accessible to them, hospitals don’t exactly provide a menu and even if they did, patients wouldn’t necessarily know which items to choose. People go to the hospital to receive care and expertise that they couldn’t receive elsewhere, meaning that even if a patient knows the price, a hospital can still charge what it wants.

The only way to ensure actually fair prices in a hospital setting is via legislation, without undue influence from lobbyists. This, of course, is remarkably difficult. In the meantime, patients must request as much information as possible from the hospitals that serve them. Texas Health provides a handy tool that calculates the cost of a typical procedure. Simply select the hospital and then procedure you would like, enter any insurance info or select none, and the calculator will provide you an estimate of how much the procedure will cost DMJ

The Nutcracker

Presented by the Texas Ballet Theatre

Winspear Opera House Sunday, December 8, 2024 2:00 p.m.

October 2024 • DALLAS MEDICAL JOURNAL | 15

H E A LT H A L L I E S

New Doctor? How to Invest in and Protect Your Career

By Shaw & Wiar, Attorneys At Law

D

octors are like professional athletes; both have grueling schedules, spend years practicing one area of their fields, and are notorious for not investing their incomes well. One of the best tips if you’re a new doctor starting to invest is to think small. If you make around $200,000 a year, you’ll want to save a quarter and invest a quarter, meaning you’ll need to pretend you make half of what you actually do. The reason for this is simple: there is no discernible standard-of-living difference between a $100,000/year and a $200,000/year lifestyle, other than with a $200,000/year lifestyle you can more easily—and accidentally— spend a large percentage of your income on depreciating goods like cars.

A standard luxury 2021 car model costs about half of what the same model in 2024 costs. Unless you are already wealthy, never buy a new car; if you search a little bit, there are all sorts of deals on luxury vehicles that are only a few years old.

BE ACTIVELY KIND As you’ve heard, it’s who you know. This is fairly accurate, or accurate enough. Now, most people hate networking events; if you’re not a charmer, and most doctors aren’t, skip them. Go to conferences or children’s charity events, or help to rebuild houses after a hurricane. Be kind to everyone even if you’re not actually that kind; you never know whose life you can change or who can change yours.

WHAT TO DO WITH YOUR DEBT? If you’re like most doctors, you easily have $250,000 in student loan debt, which is at a minimum $2,000/month in repayment. Yikes! Should you throw everything you can at it? Of course! But without digging into your quarter of investment money or quarter savings. This means you will have to make sacrifices, but they will be well worth it. Instead of Cabo, go explore the nature around you or go to Florida’s white sand beaches—they’re far cheaper than Cabo and just as nice. Don’t overlook states like Arkansas or Oklahoma, either, where there is incredible natural beauty for not that much money. Or, if all else seems unappealing, take a cruise with some friends. Be creative. As your wealth grows, you’ll be able to pay off your debt exponentially faster.

PROTECT YOURSELF Your employer will almost certainly provide you with medical malpractice insurance as well as other forms of insurance. In your career, you will likely face audits, Texas Medical Board complaints/investigations, and maybe even lawsuits. Don’t worry. Care for your patients well and throw all the other stuff onto us. That’s what we do. If you ever find yourself worrying, stop and give us a call, and we’ll take care of everything. DMJ

RENT OR BUY? This will largely depend on your family situation, but keep in mind your commute to work. A good commute will limit a lot of stress.

If you’re single, there’s no need to buy. If you have a family, there’s nothing wrong with buying. After a few years, however, you absolutely should buy real estate. If you can afford to own your own medical office, you should, because medical facilities rarely depreciate or have trouble finding occupants. As a final piece of advice, you should never buy a piece of property, either for personal use or as an investment, in a condo or homeowners association . This will save you years of litigation and stress.

AVOID EXCESS Many doctors become friendly with an excess lifestyle. Avoid this, as it is entirely impractical and too expensive.

16 | DALLAS MEDICAL JOURNAL • October 2024

IN THE MEANTIME Save your quarter. If you decide to buy a house, use your investment quarter to do that. If not, take your quarter and go to Charles Schwab, Fidelity, or the like, and ask them to invest it for you. As a general rule, stick to the basics. There are many well-off people who never bought Microsoft stock in the 1990s or bitcoin.

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October 2024 • DALLAS MEDICAL JOURNAL | 17

SPONSORED

Professional Employer Organizations 101

By Insperity

P

rofessional Employer Organizations (PEOs) like Insperity contract with businesses and medical practices with five to 5,000 employees to provide human resources (HR), payroll and administrative services on their behalf. Each contract lays out exactly which employment functions will be performed. When contracting with Insperity, practices enter a co-employment structure and allows the practice and Insperity to share certain rights, duties and risks as employers.

The ownership of the practice does not change, even though the PEO takes on some employment obligations for a fee.

There are a few key pieces of information that can help determine if a PEO relationship works for an organization. When entering a co-employment agreement, Insperity will help practice leaders determine the HR functions and employment responsibilities they are willing to hand over, if the services and capabilities offered are a good fit and help communicate the new PEO structure with employees.

IDENTIFY HR PAIN POINTS It is important to first assess how a PEO can support the teams and the business. Certain functions that take a lot of time, such as payroll processing, and prevent HR leaders from more critical functions can save the practice time and money, plus lead to a more efficient group. Insperity offers a wide range of solutions, including employee benefits, HR admin and payroll, risk management, HR-related compliance, talent management, and HR support and technology.

Improved benefits are a huge factor for many practices turning to a PEO. Since Insperity has several clients and their employees in a co-employment, it provides greater purchasing power in the insurance marketplace.

Insperity can negotiate lower group insurance rates for health insurance, workers’ compensation and more. It is important to note that a collective agreement does not exist between the clients and Insperity, so employers remain responsible only for their own workers.

Beyond health benefits, there are opportunities for extended benefits, such as mental

health, financial education, and learning and development programs. When a medical practice offers a top-notch benefits package, it can attract and retain key personnel who can be hard to find in today’s labor market.

This is yet another added benefit of the coemployment relationship.

KNOW A PEO’S STRENGTHS The services PEOs offer and their approach to HR varies, so it is important to evaluate each PEO to determine if it is right for the practice. Leadership should evaluate the services provided, payment structure, technology platforms provided, employee benefits and professional development opportunities.

A PEO, including Insperity, assumes risks as part of the co-employment. Legally, businesses should understand how their responsibilities will evolve with taxes and meeting state or federal regulations. Insperity will take on the liability and obligation for withholding taxes from employees’ paychecks and for offering legally mandated benefits coverages, as well as protections in accordance with state and federal law.

COMMUNICATE WITH EMPLOYEES Leadership should communicate with staff to minimize confusion, as many may not be

18 | DALLAS MEDICAL JOURNAL • October 2024

familiar with Insperity or a PEO. If choosing Insperity, the service team will help the practice leadership highlight Insperity, the PEO, does not own the business , even though Insperity’s name is on the pay stub. Insperity clients maintain full ownership of their assets and operations. A simple way to explain it is that businesses outsource certain functions, such as accounting, and the practice is working with a PEO to outsource its HR or other obligations as an employer.

Insperity can work with employers to educate employees about a transition. An internal transition plan is helpful, and can include staff meetings and an informational guide, so employees understand the changes.

Medical practices that already work with PEOs benefit from greater productivity, access to better benefits and efficient operations. Insperity offers unbeatable support and innovative technology to help manage the practice’s most important asset, its people. DMJ Insperity is a leading provider of human resources, offering the most comprehensive suite of scalable HR solutions available in the marketplace. For more information about Insperity, call 972-409-4347 or visit www. insperity.com/bpa/Natalie.Storrs.

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October 2024 • DALLAS MEDICAL JOURNAL | 19

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Dallas County Medical Society (DCMS) does not endorse or evaluate advertised products, services, or companies nor any of the claims made by advertisers.

Claims made by any advertiser or by any company advertising in the Dallas Medical Journal do not constitute legal or other professional advice. You should consult your professional advisor.

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Shaw & Wiar, Attorneys At Law – Page 14 Texas Oncology – Page 17 TMA Insurance Trust – Inside back cover Texas Center for Proton Therapy – Back cover

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