DOI: 10.3322/caac.

21784

COMMENTARY

The future of cancer care at home: Findings from an

American Cancer Society summit

Arif H. Kamal MD, MBA, MHS1 | Paul P. Thienprayoon MBA, MS1 |

Marco H. M. Janssen MSc, PhD2 | Lisa A. Lacasse MBA3 | William L. Dahut MD1 |
Justin E. Bekelman MD4
1
American Cancer Society, Kennesaw, Georgia, USA
2
Philips, Amsterdam, Netherlands
3
American Cancer Society Cancer Action Network, Washington, District of Columbia, USA
4
University of Pennsylvania, Philadelphia, Pennsylvania, USA

Correspondence
Paul P. Thienprayoon, PO Box 42217, Cincinnati, OH 45242, USA.
Email: paul.thienprayoon@cancer.org

In February 2022, the White House announced the reignition of the
Cancer Moonshot Initiative with the goals of reducing the death rate
from cancer by at least 50% over the next 25 years and improving
the experience of people and their families living with and surviving
cancer. A core component of the Cancer Moonshot Initiative is the
facilitation of multisector partnerships to solve the compelling chal-
lenges faced in cancer care delivery. The American Cancer Society
(ACS) has a longstanding tradition of convening partners across the
cancer landscape, most notably through conferences, partner meet-
ings, advocacy coalitions, and coalescing of thought leaders through
roundtables. For example, the ACS and several patient advocacy
organizations, scientific organizations, and pharmaceutical partners
came together in October 2022 to launch the new ACS National
Breast Cancer Roundtable and the ACS National Cervical Cancer
Roundtable as “all‐hands‐on‐deck” coalitions to reshape cancer care.1
These Roundtables aim to both (1) identify the leading challenges in
detection and treatment within these cancers and (2) provide expert
guidance to providers, patients, payers, and policy makers regarding
evolutions needed to increase access and patient centricity of cancer
care. Beyond disease‐specific issues, the ACS and its partners have
also explored topics that span the cancer care continuum.
Currently, much of the attention given to innovation in oncology is
centered upon creating and delivering a rapidly expanding arma-
mentarium of anticancer treatments. Efforts to develop more novel,
personalized, and targeted therapies have been fruitful but also
continue to further highlight issues related to access. How treatments
are selected and delivered and how outcomes are monitored require
additional focus. Furthermore, how such efforts align with increasing
calls for patient centricity, meeting patients where they are both
figuratively and literally, requires a national discussion. Herein, we
describe the findings from the first effort of the ACS in convening
national leaders across multiple stakeholders, including the provider,
payer, government, and technology communities, to discuss cancer
care delivery at home.
IDENTIFYING CHALLENGES
This ACS Cancer Care at Home Summit convened in Cambridge,
Massachusetts, on October 26, 2022, using a “design‐thinking”
framework to identify the major issues in decentralized cancer care
delivery and plan for the next steps forward. The Summit convened 30
national leaders at the Philips North America campus using Chatham
House rules during which participants were guided in building a
shared mental model, framing the challenges and ideating around
barriers, defining opportunities, and sharing findings with each other
to determine next steps. To ensure that the ACS optimally used the
time dedicated by these senior leaders, untapping the immense po-
tential of the combination of participants in the room, and really
getting to actionable outcomes, the ACS invited the Philips Experience

-
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- COMMENTARY
Design Team to facilitate the Summit. The Experience Design Team
had experience in guiding discussions in this area, leveraging a recent
effort in developing a Caregiver Journey Map for Veteran caregivers
in partnership with the Elizabeth Dole Foundation and the Veterans
Administration. Together, the ACS and the Experience Design Team
used conversations with national leaders in cancer care delivered at
home to identify four major challenges along with issues that underly
barriers: (1) logistics/supply chain, (2) finance/payment, (3) patient
acceptance, and (4) regulatory. The participants also identified issues
that affect all four of those areas and must be included when ideating
around solutions such as health equity and social determinants of
health, care‐provider acceptance, and data interoperability and
ecosystem implications. Participants were split into four preselected
groupings to provide the right balance between domain knowledge
and “out‐of‐the‐box” thinking in each area.
THINKING CREATIVELY AND DEFINING
OPPORTUNITIES
Each group was led by an Experience Design facilitator who fostered
communication and captured points as the discussions occurred.
Conversations operated under Chatham House rules.2 Facilitators
homed in on common themes from the group discussions, and themes
were organized (or framed) into multiple “how might we” statements,
allowing for the groups to decide which areas were the most critical
or needed to be prioritized to successfully create cancer care delivery
at home. From there, the group participants focused on solutions that
would help solve the selected issue, which would then allow for
easier ability to approach the other “how might we” areas.
LOGISTICS/SUPPLY CHAIN
This group focused on issues related to the physical delivery of cancer
care at home, which resulted in six potential obstacles to adoption:
‐ Patient “fit”—“How might we enable the option for patients and
clinicians to make site‐of‐care decisions together?”
‐ Data exchange—“How might we seamlessly and securely enable
the data/information exchange across care settings, including the
home as a care site, in order to make the home a viable care
setting?”
‐ Supply chain—“How might we think about drugs/agents from the
beginning, for safety outside the hospital setting?”
‐ Staffing models—“How might we rethink staff workflows to include
home as a site of care option?” or “How might we support a more
flexible workforce to enable care in the home, efficiently, scalably,
and cost effectively?”
‐ Convenience—“How might we reduce patients' time spent in
transit (frequency, duration) in order to receive care?”
‐ Communication—“How might we facilitate the capture, exchange,
and evaluation of clinical and nonclinical data and information?”
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The group selected convenience as the most critical area to start
with because of the ability to change the narrative and open up new
opportunities. Changing the “how might we” to “what if”, the group
began ideating around “what if we considered treatment journeys
(including the home as a viable care setting option) designed around
convenience of the patient instead of optimizing cancer care for the
convenience of institutions and systems?” To do so, an approach of
rethinking the patient itinerary was selected. The vision called for a
change from the patient itinerary being a static, one‐time printed
handout given at the appointment when the treatment plan is
decided upon to a dynamic, digital itinerary with patient choices and
preferences integrated among critical, fixed elements in the care plan. To
do this, two steps were identified:
‐ Step 1: Set personal/profile preferences, such as:
� Opt out of high‐tech communications; prefer no‐tech or low‐
tech communications;
� Opting out of care at home or opt in, with attention to framing
of the decision for patients and for clinicians;
� Patient preference for isolation versus need for community/
connectivity;
� Patient comfort with in‐home care; and
� Is the patient in a care pathway that allows for home cancer
care?
‐ Step 2: A dynamic itinerary presents choices over time, asking
items like:
� Can I get more done in one visit?
� Can I opt for a telehealth visit?
� Can I get my blood drawn or get out‐of‐hospital imaging at
home?
� What is the most efficient way to deliver care: Can we eliminate
this visit altogether, or are additional telehealth consulta-
tions or face‐to‐face consultations required at the care‐provider
site?
‐ Additional considerations:
� Limit the number of decisions (decision fatigue); and
� Allow for clinician override.
Finally, to realize change, leaders must be willing to challenge the
status quo. This recommendation provides a goal to help simplify the
multitude of appointments needed by optimizing care plans accord-
ing to standard care pathways, introduce patient preference for their
conversations, and flag opportunities for more streamlined appoint-
ment coordination. Together, this vision combines the human touch
of patient navigation with optimized workflows that have ardent
efficiency.
FINANCIAL/PAYMENT MODEL
The challenge for this group was to translate existing knowledge on
costs, risks, benefits, and impact data into clear and actionable in-
sights for cancer care at home stakeholders. This team began

COMMENTARY
grouping issues into three distinct “how might we” buckets, which
became the top themes for overcoming this barrier:
‐ Redefining value—how might we:
� Preserve provider margin irrespective of site of care?
� Redefine incentives to match optimal care models?
� Finance nonreimbursed patient support services?
� Optimize payer models for care at home?
� Share cost savings with patients, caregivers, and providers?
‐ Total cost of care—how might we:
� Collect the most relevant cost data?
� Understand the real and longitudinal costs of care at home?
� Identify risks to the patient, provider, and payer from any po-
tential adverse health outcomes that might be associated with
care at home?
� Leverage care coordination to shift the cost of care?
‐ Expand context—how might we:
� Enable employer groups to support care at home?
� Align with community practices for care at home?
The group chose to further drill down on the two more critical
groupings of the three, provide new “how might we” questions, and
provide solutions to those barrier themes:
Redefine value
The workgroup used two questions to build a solution around
redefining questions: “how might we understand the real costs of
cancer care at home relative to outpatient, office, or hospital care?”
and “how might we identify benefits and risks to the patients and to
the providers associated with cancer care at home?” To do this, the
group recommended that the first solution to financial barriers was to
ensure information dissemination. This would require all stakeholders
to make available to patients and caregivers out‐of‐pocket expenses
and other financial costs associated with care at home relative to
care in office, outpatient, or hospital settings. In further detail,
leaders need to publish barriers to financially viable models. In
addition, those models would be augmented with stories of suc-
cessful implementation and alignment of incentives. Finally, the
group called on the ACS to lead cancer plan decision mapping and
criteria for success of cancer care at home programs.
Total cost of care
To guide solution design, for the total cost of care, the group
answered two questions: “how might we, as a nation, finance non-
reimbursed patient support services?” and “how might we share cost
savings with patients, caregivers, and providers?” The second solution
would require leaders to explore, test and validate new financial benefit
programs and products. This would include programs for direct
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financial reimbursement to caregivers delivering home care, home
care insurance policy products, and test those benefit programs with
the Center for Medicare and Medicaid Innovation and the Centers
for Medicare and Medicaid Services. Continuing with the total cost of
care, the group provided two additional questions to guide the third
solution: “how might we optimize payer models for care at home?”
and “how might we redefine incentives to match optimal care
models?”
PATIENT ACCEPTANCE
The patient‐acceptance group brought together six leaders who had
substantiative experience in cancer care at home delivery applica-
tions that allowed them to approach the subject differently from
the other three groups. Instead of grouping barrier areas and
selecting the one with the most opportunity, the facilitator and
group chose a different approach. Ideas were consolidated into
three main groups: what, how, and gains. For the what category, the
guiding question was, “what if patients opted out of care at home
rather than opting in?” There was also lengthy discussion around
leveraging the improved digital acceptance of care at home through
coronavirus disease 2019 (COVID) with regard to digital telehealth
consultations to also support additional care in the home. From
there, the ideas centered around topics/solutions that would allow
patients to opt in:
‐ There is a need to standardize and develop care goals with the
patient and caregivers.
‐ Patient stratification should be based on willingness, trust, and
ability to receive cancer care at home.
‐ If patients and clinicians could make care site decisions together,
care pathways would be more efficient and effective.
‐ There are opportunities for lay caregivers to extend and expand
care with appropriate support.
‐ Bundled services (infusion, palliative care, hospice, urgent care)
would provide more clarity and enablement with patients and
families.
‐ Exploration of the soft side, in which moving to the home poten-
tially decreases the patient‐to‐patient interactions and bonding
conversations during chemotherapy infusion.
To activate the what statements, how concepts were developed
to that would help increase patient acceptance:
‐ Symptom management, treatment response and patient status
monitoring could be provided at home, which would enable
improved care and system efficiency.
‐ Focusing on enabling care givers would enable better expectation
setting, training and adherence, support, and improved care.
‐ Focusing on demonstrating projects rather than controlled clinical
trials will give us the ability to learn fast.

4
- COMMENTARY
‐ Building off what has been done at the University of Pennsylva-
nia's Penn Center for Cancer Care Innovation,3 the next area to
validate is working at scaling across systems and/or employers.
‐ Also building off what has been done in care at home in other
diseases, such as type‐1 diabetes care, with out‐of‐hospital insulin
administration and in vitro fertilization with out‐of‐hospital sub-
cutaneous hormone administration.
From these concepts, the gains the national cancer population
could and needs to affect are improved health equity along with
improved patient, provider, and caregiver experience. In addition, it is
expected to garner increased patient satisfaction, improved care, and
lower costs across all stakeholders. These gains became the catalyst
for the group's opportunity build statement: “How might we stand up
an innovation laboratory to enable cross‐collaboration with
community‐based health systems, payers, and patients?”
REGULATORY BARRIERS
The facilitator guided the regulatory group, consisting of domain
experts, through current problems and started ideating areas of op-
portunity. From those discussions came seven “how might we”
statements:
‐ Affect employer care plans to enable/incentivize the adoption of
cancer care at home delivery programs;
‐ Shape clinical trials so that care at home is a foundational design
consideration for trials;
‐ Rethink reimbursements driven primarily by the location of where
care is delivered, rather than type of care outcomes;
‐ Drive public policy that would enable more care to be delivered
across state lines, create opportunities for licensing on a national
basis, and make COVID‐era practice changes critical to at‐home
and virtual care delivery permanent;
‐ Reduce institutional and vendor barriers for electronic health re-
cord use at home;
‐ Better leverage the Veterans Administration as a proving ground
to develop scalable out‐of‐hospital cancer care programs; and
‐ Influence financial incentives to enable the adoption of out‐of‐
hospital oncology programs/approaches.
The two “how might we” statements that the group chose to
work on were: “how might we drive change to enable more care to be
delivered across state lines” and “how might we rethink re-
imbursements?” For driving change across state lines, the group
found that many of the changes that were implemented in response to
COVID would enable cancer care at home and should be extended in
order for cancer care at home to be successful. Specifically looking at
licensing acceptance on a national basis, having a standard set across
state lines allows for cancer care at home to be better implemented
for all patients as opposed to different requirements in each state.
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Together, both approaches allow for more scalable use of expert
resources for patients, caregivers, and care providers. In addition,
telehealth programs to support home care can be more effectively
delivered. Finally, these measures are foundational for at home or
out‐of‐hospital care. The second statement, “how might we rethink
reimbursements,” called on national leaders to look for more in-
centives, and regulations to support those incentives, for more out‐
of‐hospital care with a new reimbursement model that would
reflect this new cancer care delivery approach. This would also have
to include changes to regulations that enable increased patient
preference in how and where they receive care. Finally, these regu-
latory changes will stimulate innovative delivery practices and the
data that support them.
NEXT STEPS
During the final session of the summit, the groups came together to
discuss these proposed approaches and interventions to gather
additional input, build understanding, and develop a shared approach
to move forward. One common topic in each of the break‐out groups
was the definition of care at home. Initially, the summit began with the
definition of care at home considered literally as the home of the
patient. As each group further discussed current state and chal-
lenges, the definition of care at home broadened to be better defined
as outside the hospital setting, of which the patient's home could be a
possible, but not the only, care setting. This change in definition
expanded the ideation space for the participants, leveraging some of
the more recent achievements in delivering care outside the hospital
setting during COVID. Another common area of discussion was the
need to plan, test, and develop these ideas in a controlled setting,
including all the major stakeholders. Integrated health systems like
the Veterans Administration, Kaiser Permanente, etc., could be
possible environments for these innovation laboratories. Finally,
there was a shared motivation to ensure that the findings of the
summit would continue to be built upon to maximize momentum and
minimize behavioral changes gained during the COVID pandemic.
The group requested the ACS, along with thought leaders, to execute
on these next steps:
1. The ACS to form a standing task force and communicate a go‐
forward clinical research plan to assess the health and financial
safety of home care; the ACS will be the convener and will foster
collaboration to assist in propelling these ideas forward and
broaden the discussions to additional key stakeholders, including
patient advocates, caregiver advocates, pharmacy, home infusion,
home care, risk‐bearing health systems, and other supply chain
partners, among others;
2. Disseminating a summary of conversations from the Summit to
stakeholders, including government and public entities and the
scientific community who will have a role to play in helping to
translate these approaches into action.

COMMENTARY
3. The ACS to convene a second summit in 2023 to continue to build
on the development of critical path approaches and include a
broader set of stakeholders as identified;
4. Collaborate with international teams (e.g., the European Union
Beating Cancer Plan) and then cross‐share learnings and chal-
lenges between the United States and global partners; and
5. The task force will seek partners to develop the cancer care at
home innovation laboratory for testing the concepts presented.
CONCLUSIONS
The successful delivery of cancer care, spanning from prevention
through early detection, treatment, and survivorship, as well as clinical
trials outside traditional medical facilities, represents a potential
seismic shift in oncology. Complementing the recent unprecedented
expansion of cancer treatment options, cancer care in the place a pa-
tient calls home could help address some longstanding barriers to
equitable access to care, particularly for populations marginalized
because of geography, travel requirements to get to care providers,
proximity to clinical trials, and overall financial burdens of cancer care.
We look forward to continuing to build partnerships and further dis-
cussions to explore the potential of, barriers to, and solutions to ach-
ieve a paradigm shift where appropriate to bring cancer care to the
patient rather than requiring the patient to go to cancer care.
A C K N O WL ED GM E N T S
Special thanks to the Phillips North America team of Marco Janssen,
PhD, and the Philips Experience Design Team for donating their re-
sources and time to facilitating this summit. There was no financial
relationship between the American Cancer Society and Philips with
the Cancer Care at Home Summit.
The following individuals participated in the American Cancer
Society Cancer Care at Home Summit: Arif Kamal, MD, MBA, MHS,
FASCO (Chief Patient Officer, American Cancer Society); Justin
Bekelman, MD (Director, Penn Center for Cancer Care Innovation at
the Abramson Cancer Center, University of Pennsylvania); Margaret
Mary Wilson, MD, MBA, MRCP, FNMCP (Chief Medical Officer and
Executive Vice President, United Health Group); David Shulkin, MD
(former Secretary of Veterans Affairs); Binoy Bhansali (Corporate
Vice President, SCAN Health Plan); Andrew Schutzbank, MD, MPH
(Corporate Vice President, SCAN Health Plan); Joy Bhosai, MD, MPH
(cofounder/Chief Executive Officer, Pluto Health); Hadly Clark,
MHSA (Associate Director, FasterCures, Milken Institute); Patricia
Cortazar, MD (Executive Group Medical Director, Genentech, Inc.);
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- 5
William Dahut, MD (Chief Scientific Officer, American Cancer Soci-
ety); Tara Friedman, MD (President, American Academy of Hospice &
Palliative Medicine); Mark Goldberg, MD (Board of Directors,
American Cancer Society); Stephen Grubbs, MD (Vice President Care
Delivery, American Society of Clinical Oncology); Kurt Merkelz, MD
(Senior Vice President and Chief Medical Officer, Compassus); Rak-
shit Sharma, MD (Chief Executive Officer, Agilix, Inc.); Andrew Her-
tler, MD (Chief Medical Officer, New Century Health); Rashi
Romanoff (Executive Vice President, Elizabeth Dole Foundation);
David Steuer (Director, Strategic Design, University of California‐San
Francisco Health); Inga Lennes, MD, MPH, MBA (Senior Vice Presi-
dent, Ambulatory Care and Patient Experience, Massachusetts
General Hospital); Lisa Lacasse, MBA (President, American Cancer
Society Cancer Action Network, Inc.); Marcus Neubauer, MD (Chief
Medical Officer, The US Oncology Network); Gaurav Singal, MD
(former Chief Data Officer, Foundation Medicine); Tawana Thomas
Johnson (Senior Vice President and Chief Diversity Officer, American
Cancer Society); John Wigneswaran, MD (Chief Medical Officer,
Walmart); David Johnson, MD (Chief Operating Partner, Rubicon);
Alexis Jackson, MSHA (Operations Administrator, Mayo Clinic); Vitor
Rocha (President, Cepheid); Marco Janssen (Portfolio Strat-
egy Leader Oncology, Philips); Kelly Gann, RN, MSN, CDCES (Di-
rector Clinical Operations, Philips); Kim Mingo (Vice President,
Government Relations, Philips); and Sanjay Gandhi, MD (Senior Di-
rector, Philips).
CO N F L I C T O F I N T E R E S T S T A T E M E N T
Arif H. Kamal reports personal fees from Homebase Medical outside
the submitted work and is chief executive officer of Prepped Health.
Justin E. Bekelman reports personal fees from AstraZeneca,
Healthcare Foundry, Reimagine Care, and United Healthcare outside
the submitted work. The remaining authors declared no conflicts of
interest.
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