JCO Oncology Practice Podcast

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Latest Episodes:

The Business of Radiation Oncology Practice: A Conversation with ASTRO President Neha Vapiwala Sep 21, 2026

Show notes

Dr. Chino speaks with ASTRO President Neha Vapiwala about her recent OP article, "Highly Variable, Complex, and Contextual: The Business of Radiation Oncology Practice," and the changing landscape of radiation oncology.

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Advocacy in Action: The Voice of Community Oncologists Aug 17, 2026

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Dr. Chino speaks with Leslie Busby, MD about advocacy in oncology with a focus on what community oncologists can do to safeguard high-quality, patient-centered care. Dr. Busby is the first author of "Importance of Physician Advocacy in the Fight to Protect Local Cancer Care" which recently published in JCO OP as part of a special series on the Business of Oncology Practice.

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A RoadMap to Achieve High Quality Care for All: Walking in Beauty and Strength with Past President Dr. Robin Zon Jul 20, 2026

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Dr. Chino speaks with ASCO President Dr. Robin Zon about leadership in oncology and what it takes to steer a global oncology society in turbulent times.

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Artificial Intelligence Among US Hematology-Oncology Fellows Jun 04, 2026

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Dr. Fumiko Chino talks with Dr. Evan Garrad, the first author of the JCO OP manuscript, "Artificial Intelligence Among US Hematology-Oncology Fellows: A Multicenter Survey of Education, Attitudes, and Clinical Use," which was simultaneously published with his oral presentation at ASCO 2026.

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Improving Cancer Care for Patients in the Carceral System May 18, 2026

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Dr. Chino welcomes Dr. Christopher Manz, a medical oncologist at Dana-Farber Cancer Institute, to discuss new research highlighting care gaps for those receiving care while in prison. Dr. Manz investigates cancer care delivery and payment policy and how they contribute to disparities in cancer outcomes, and is the first author of the manuscript, "Cancer Screening, Diagnosis and Treatment for Vulnerable Patients Incarcerated in United States Prisons" which is featured in JCO OP's May print issue.

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Cannabis Use in Survivors Apr 20, 2026

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Dr. Chino welcomes Dr. Timothy Pawlik and patient advocate Joey Tan discuss new research highlighting national data regarding cannabis use in cancer survivors. Dr. Pawlik is the senior author of the manuscript, "Patterns of Cannabis Use Among Cancer Survivors: Insights From the Behavioral Risk Factor Surveillance System" which is featured in JCO OP's April print issue.

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Diversity in Clinical Trial Enrollment in Key Oncology Trials: Are We There Yet? Mar 16, 2026

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Dr. Chino welcomes Dr. Jennifer Miller and breast cancer survivor Megan-Claire Chase to discuss Dr. Miller's recent OP article, "Representation of Women, Older Adults, and Racial and Ethnic Minoritized Patients in Pivotal Trials for U.S. Food and Drug Administration Novel Oncology Therapeutic Approvals, 2012-2021: Bright Spot Trials and Trends Over Time," highlighting new research about how we are doing with diversity in key cancer clinical trials TRANSCRIPT Dr. Fumiko Chino: Hello and welcome to Put into Practice, the podcast for the JCO Oncology Practice. I'm Dr. Fumiko Chino, an associate professor in Radiation Oncology at MD Anderson Cancer Center with a research focus on access, affordability, and equity. There are known problems in enrolling a representative sample on cancer clinical trials, with stark disparities within certain demographic groups, including age, sex, and race and ethnicity. Patients who are female, non-White, and at the age extremes, either younger or older, are known to be less likely to participate. With skewed patient participation, the validity of randomized data may be questioned, with some asking whether clinical trial results based on a charmed enrollment sample can truly be applied in routine practice. I'm happy to welcome two guests today to discuss new research highlighting how we are doing with diversity in key cancer clinical trials. Dr. Jennifer Miller, is Co-Director of the Program for Biomedical Ethics and an associate professor at Yale School of Medicine. Her research focuses on ethics, equity, and governance in research, development, and accessibility, as well as in the ethics of healthcare data sharing. She is the first author of the manuscript, "Representation of Women, Older Adults, and Racial and Ethnic Minoritized Patients in Pivotal Trials for US Food and Drug Administration Novel Oncology Therapeutic Approvals, 2012 to 2021: Bright Spot Trials and Trends Over Time," which is featured in JCO OP's March print issue. Megan-Claire Chase is a 10-year breast cancer survivor, patient advocate, and a current program director at SHARE Cancer Support, a national nonprofit that provides free education, assistance, and navigation services for people with breast and gynecological cancers. Since her treatment for stage 2A lobular cancer, she has worked to fill the gap of knowledge and advocacy for young patients with cancer, including through her blog, Life on the Cancer Train, and through the podcast, Our BC Life. Our full disclosures are available in the transcript of this episode, and we've already agreed to go by our first names for the podcast today. Jen and Megan-Claire, it's really nice to speak to you today. Dr. Jennifer Miller: Thank you for having us. Megan-Claire Chase: Thank you. Dr. Fumiko Chino: Jen, before we dig into the specific research, do you mind giving us a little bit of background about your work in bioethics and what led you to start this specific work on clinical trial diversity? Dr. Jennifer Miller: Yes, thank you so much. So, as you mentioned, I'm the Director of Bioethics for Yale School of Medicine and a professor of internal medicine at Yale. And then also in 2005, I co-founded a nonprofit called Bioethics International and direct a project called the Good Pharma Scorecard. In all of those roles, I'm focused on one big question: How can we help the 7 billion people around the world live a good life, a flourishing life? And in order to even talk about that bigger concept, we need to think about some basic things: access to clean water, housing, food, education, among other things, and a level of health. And there are so many determinants of health, but one of them is access to medicines and vaccines. And when you think about access to medicines, you have to think about the role of the pharmaceutical industry, given that it sponsors 75 to 90% conservatively of the clinical research supporting FDA approval of our new medical products. What's interesting is while the industry has a very stated noble mission, right, to 'cure, heal, and advance people's health', when you survey Americans in particular, 91% think that companies put profits before people and patients, so money before people and patients. And when you look at the media and the court cases, they're covering mostly scandals and outright ethics failures ranging from concerns about whether companies are telling you the truth about the safety and efficacy of new medicines and vaccines and worries about outright price gouging. And what's interesting is when I host a meeting every year with C-level executives from pharma, when I get them together and show them all of the concerns that stakeholders have about their patient centricity, I often hear the same two things: one, "Those are old issues that we fixed. If only you academics looked at more up-to-date data, you'd see that that is no longer a problem," right? And so they called the pricing problem a 'hoodie' problem because Martin Shkreli, he wore a hood, a black sweatshirt with a hood. But as we know, there's a widespread current and genuine pricing problem with medicines and vaccines. And then they said it was an outlier company, right? "That's one company in an otherwise sound industry or rogue employee in an otherwise good company, not the industry as a whole." And so when I walked away it's, wow, there's a black box. We actually don't know the ethical or patient centricity performance of pharma companies, of an individual company, of a product, of a trial, or of the whole industry as a whole, and it's really important to know this. And so, I got together a multi-stakeholder group and I said, "Hey, fine, I'm neutral. It's either a misperception, you're doing great and we need to build merited trust, or there really are some problems and we need to fix them and get them right for patients around the world." That's how I started the Good Pharma Scorecard, which is really designed to set ethics goals for the pharmaceutical industry and turn them into metrics so we can benchmark the performance of trials, products, and companies and then rate and rank them. What that does is it recognizes where there are good practices so we can study how they did it, but importantly to catalyze reform and change where needed for patients. We started by looking at the transparency of clinical research, right: do pharma companies tell you all the safety and efficacy data about new medicines and vaccines? And we were able to measurably move the needle. In other words, pharma companies really changed their practices as a result of getting their Good Pharma Scorecard ratings and rankings. And so we turned our attention and said, "What else should we tackle?" And the next thing we tackled was representation in clinical trial enrollment, for exactly the problem that you mentioned. We tend to test our new medicines on healthy, young, White males that don't represent the patient population in the US or other countries who end up taking products post FDA approval. Dr. Fumiko Chino: What a great narrative of how you kind of reached the point where you are doing this research. And again, I think you've highlighted that diversity in clinical trials is only one aspect of everything that could potentially be improved in healthcare in the United States. So I am so excited about what you're going to do next to address the next issue. But let me ping over to Megan-Claire. I know a little bit about you personally, but can you share with our listeners a little bit about your background and just discussing for example, the multiple hats you wear in life? You have a cancer survivor, you're a cancer caregiver, you're a patient advocate, and obviously you work at SHARE. So what is your origin story for Warrior Megsie? Megan-Claire Chase: Well, first of all, I always knew I would get cancer, and when people hear that, they're like, "Why would you say that? Like, why would you even, like, mention that out into existence," right? But it's no, like, I know my family medical history, at least mainly on my mother's side. And I'm an IVF result. It took my parents 8 years to even get pregnant, and then during the third month, my mother was diagnosed with ovarian cancer. And so, I like to say I'm literally a cancer because I was born in July. I was born 3 months early. I was supposed to be born the last week of October, and I was born July 3rd. And so the joke in the family is, I look nothing like my mother externally, but internally, I got all the issues. And so we really are both walking miracles, the fact that we did both survive this, but I knew, I just knew I would get ovarian or cervical cancer because that's where all of my issues were. So I had been monitored since I was 16. And then, of course, having other health issues, being born premature and all of that, and then ultimately, I had very strange symptoms. We hear the guidelines of breast cancer, and I had none of those. But I also was an advocate. So in my family, my parents are divorced, so I'll mainly be talking about my mother's side. My maternal grandmother, my Nana, she was the first biracial registered nurse at St. Vincent's in Bridgeport, Connecticut. And my grandfather was a mortician, so we're like, "Boy, aren't they like the perfect couple, you know? She helped you in life, and he helped you in death." But all of that to say, I was raised to know my patient right to change doctors, my patient right to ask questions, and my patient right to get pushy. And I did all the things. So we often hear, "Hey, you need to advocate for yourself." Well, even when you advocate for yourself, sometimes you're ignored because I'm a woman, then I'm a Black woman, and then I was under 40. So I wasn't even old enough to get a mammogram. And because there is that correlation between breast and ovarian, I was able to get one early and covered by insurance 100%, and they were like, "Hey, you're good. Come back when you're 40." But I kept having all these other strange symptoms, and I just kept pushing and pushing for close to two and a half years, and then it wasn't until the cancer was like, "Okay, we're going to have to just make a grand entrance because no one's believing you." Then everyone sprung into action, and it was because of all that, and I thought to myself, "Oh my God, if I'm being ignored and I am someone who's pretty darn vocal, what if English wasn't my first language? What if I didn't know my family medical history?" Like, I just went down the rabbit hole, and my background is in media and marketing, and I'm also a writer. And so I was very open with my diagnosis because I'm an only child too. So this is like huge. It was just too big for me to deal with alone, but also I wanted to like amplify the barriers that I was experiencing and then also losing my fertility. I mean, it was just so many things at once, and it was through that, I ultimately realized, "Hmm, this cancer journey, it's never really over." And that was how I came up with the name "Life on the Cancer Train" because I was like, I keep waiting to get off the stop permanently, and that's not happening. And though I am now in double digits of 'no evidence of disease', I call it my boyfriend NED. We've been in a long-term relationship now for 10 years and we're going to continue going strong. I've had so many other issues that no one prepared me for. And so I was doing a lot of advocacy work while I was in media and marketing, and then I was like, "Hmm, what would happen if I actually worked in this space? Like, imagine what I could do." And that's ultimately how I ended up finally working at SHARE Cancer Support remotely because I live in Atlanta, Georgia, so you may hear a slight twang every so often. And I am the Breast Cancer Program Director and host of Our BC Life podcast. And, you know, through all of that, I am known in Cancerland as Warrior Megsie because my hair came back curly. And, you know, so many people are like, "Oh, I would have loved for my chemo to turn my hair curly," and I'm like, "Well, I wanted my hair." Every time I look at myself, it's traumatic. Yes, do I rock it? Sure. I mean, when it was coming in looking like a chia pet, I was a little concerned, but every day I'm reminded of what I've gone through and what I continue to go through. And that's ultimately how I made my grand entrance into Cancerland. Dr. Fumiko Chino: Thank you for sharing that with us, and I know that this is not kind of how you wanted to find your mission in life, right? You would have been much happier to just live your previous existence without cancer, or just being a cancer caregiver, or just being an advocate, or just being a communicator and not being a cancer survivor on top of all of that. So, I do appreciate though that you took it for what it was, which is this is the path that you're walking down, and so let's try to make that path better for everyone, more comfortable, clearer, more outlined. And so I appreciate that. Now, Jen, do you want to walk us through your actual JCO OP study, what you did, what you found, why it matters? Dr. Jennifer Miller: Sure. Second plug for St. Vincent's in Bridgeport. My mom works there as well on Nine North, so I was so excited to hear that, that common touchpoint. So when we added the representation challenge to the Good Pharma Scorecard, we, obviously unsurprisingly, found abysmal representation of a variety of different groups or pretty much everyone. And we stepped back and we said, "What more can we do to measurably move the needle?" Because there have been 40-plus years of policy efforts to try to improve representation of women, older adults, and racial and ethnic minoritized patients among other groups, and we haven't measurably moved the needle for any group in cancer over the last 10 years. And that's shocking not to see any improvement in 10 years. That's a lot of time and there's been a lot of investment on this issue. And so, what we settled on was this idea of doing a bright spot analysis. The bright spot approach assumes that somebody, somebody's getting it right, and if we could find that bright spot and study how they do it, we might be able to develop generalizable guidance for everyone else to be able to repeat that positive behavior. That bright spot analysis was done with the FDA Oncology Center for Excellence with their support. And so, while the 10-year data looked abysmal, right, we hadn't seen any improvements overall, when we started to look by sponsor, it turns out there were some bright spots. There were some sponsors who were able to consistently adequately represent one group. They couldn't represent everybody, but they were getting one group, right, and we decided to focus on Black or Latino identifying patients. And we found 33 bright spots. So I'll tell you the overall data and then I'll talk a little bit about the bright spots. So we looked at a 10-year sample, novel oncology products approved by the FDA between 2012 and 2021, which was 111 novel cancer therapies sponsored by 70 different companies based on 121 pivotal trials enrolling over 50,000 patients around the world. And what we found was zero trials, zero trials adequately represented all the demographics we were looking at, which was sex, age, and racial and ethnic identity. And we were comparing enrolled participants to the patie…

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Medicare Advantage for People with Blood Cancers: Friend or Foe? Feb 16, 2026

Show notes

Dr. Chino welcomes Hari Raman, MD, MBA, author of "End-of-Life Care for Older Adults With Blood Cancers With Medicare Advantage Versus Medicare Fee-For-Service Insurance," to discuss new research highlighting how insurance type may affect receipt of quality end-of-life care for patients with blood cancers. TRANSCRIPT Dr. Fumiko Chino: Hello, and welcome to Put into Practice, the podcast for the JCO Oncology Practice. I am Dr. Fumiko Chino, an associate professor in radiation oncology at MD Anderson Cancer Center with a research focus on access, affordability, and equity. People with blood cancers may have prolonged clinical courses lasting years or decades and requiring specialty care. Prior research has shown that end-of-life care in this population may be suboptimal with higher hospitalization and lower hospice enrollment. Capacity for receiving appropriate specialty care has been a known concern with Medicare Advantage plans, but paradoxically, there may be unique advantages for those at the end of life. I am excited to welcome a guest today to discuss new research highlighting how insurance type may affect quality of end-of-life care for patients with blood cancer. Dr. Hari Raman, MD, MBA, is a clinical fellow in hematology-oncology at Dana-Farber Cancer Institute. He got his MBA from Harvard Business School in 2023 while doing his internal medicine residency at Brigham and Women's. His research focuses on quality care delivery and value in healthcare with a focus on hematological malignancies. He is the first author of the manuscript, "End-of-Life Care for Older Adults With Blood Cancer With Medicare Advantage Versus Medicare Fee-for-Service Insurance," which was featured in JCO OP's February print issue. Our full disclosures are available in the transcript of this episode, and we have already agreed to go by our first names for the podcast today. Hari, it is really wonderful to speak to you today. Dr. Hari Raman: Thank you so much, and I really appreciate this opportunity to join you. Dr. Fumiko Chino: I have been hosting this podcast for over a year, and I think you are actually our first guest who is still in their training. So, I love this, I am excited to have you here. Do you mind giving us an overview of kind of where you are in your career and what got you interested in this topic? Dr. Hari Raman: Yeah, no, of course. And again, I am really grateful to be here in training. I knew I wanted to care for patients, but as I continued training, particularly in my residency, I came to realize how many considerations around care delivery and the administration of healthcare actually exerts a significant influence on the patient care itself. And so while I was in training, I was really fortunate enough to receive an MBA while in residency to gain kind of a foundational understanding of how the business and financing of healthcare in the US, particularly, impacts care delivery and access. And as a clinical fellow at Dana-Farber, I have just been incredibly grateful to join Dr. Oreofe Odejide's lab here at Dana-Farber. She is actually the senior author of this study, where we have been able to examine care delivery and outcomes research for patients with blood cancers. This is really the intersection of both my clinical and academic interests given that my clinical focus will be caring for patients with lymphomas. Dr. Fumiko Chino: And you are at the tail end of your training, right? So, you are, you know, out the door, correct? Or maybe you are not out the door. Dr. Hari Raman: No, exactly. You hit it right on the head. I will actually be staying on as faculty here at Dana-Farber next year, and I am really excited to continue our research and also be able to care for patients with lymphoma starting quite soon, actually. Dr. Fumiko Chino: That is so exciting. So, within this calendar year, you will be setting up shop on your own. Dr. Hari Raman: That is the plan. Dr. Fumiko Chino: Wonderful. And it is amazing to have built this large group of collaborators again within the same hospital system and academic world where you did your MBA and your additional training, so that is phenomenal. Hopefully, you will continue working with the same people. Dr. Hari Raman: Yeah, exactly. You are exactly right. It is really so inspiring and also really we are really quite lucky here to be able to go down the hall and ask experts in healthcare policy what they think about some of our findings and really be able to get a rich discussion even within the walls of our own institution. So, I have been really grateful for that. Dr. Fumiko Chino: Now, before you discuss this specific new research, do you mind giving our listeners a little bit of an overview of what you see as the key differences between the traditional fee-for-service Medicare and Medicare Advantage? I know personally and, you know, I think within oncology we really commonly encounter problems with the MA plans. We have network restrictions, we have coverage limitations, we have obviously prior authorization burdens. But there is obviously a lot of advantages, otherwise, it would not have proliferated at such a rapid rate in sort of the modern era. Dr. Hari Raman: So crucially, the payment model for Medicare has been what we call fee-for-service, where the government or the Centers for Medicare and Medicaid Services, in this case, pays providers a set amount per service that they provide to their Medicare patients. In Medicare Advantage plans, private plans are actually paid on a risk-adjusted basis by the government or CMS to assume the total cost of care for patients. Theoretically, this would allow the government to have a somewhat predictable cost of care given that they are paying these monthly or bimonthly payments on a risk-adjusted basis and then also incentivize private plans to essentially limit the overall cost of care through various levers that they may be able to pull. I think you alluded to a really good point that part of these levers include things like restrictions on networks as well as potentially allowing patients to only go to certain providers or have certain hospitals in network. While this is something that we think about from a restriction perspective, the other part of this to note is that Medicare Advantage is a voluntary program that patients choose to go onto. As you can imagine, the way in which these payers are able to get patients to go onto their plans is through other offerings, such as lower premiums, more add-ons such as dental or vision insurance, including other things such as care coordination, which is really important for oncology patients, or even access to lifestyle things such as gyms and other services. Dr. Fumiko Chino: Yeah, I know that at least based on my own prior research that the populations that have traditional Medicare and the populations that have Medicare Advantage really are a little different. Do you mind commenting on that? Dr. Hari Raman: Yeah, and I think this also speaks to the offerings that Medicare Advantage plans often provide. What we have seen, particularly in the last decade, has been that Medicare Advantage plans tend to have enrollees that are more likely to be of a racial and ethnic minority group. Also, these patients tend to have lower incomes and are frequently dually eligible for Medicaid as well. I think this is both in part to the populations that Medicare Advantage payers are deciding to roll out to, but also in part because of the offerings that may be provided and may be disproportionately more attractive for patients who may have lower sociodemographic means. Dr. Fumiko Chino: One thing that has always struck me with some of the literature and the research around Medicare versus Medicare Advantage is that Medicare Advantage offers more to patients when they are well, but it may be more challenging to use if you have serious and complex medical conditions, and ironically, it is actually more expensive to CMS than traditional Medicare. It is a little push-pull with the sort of the rapid proliferation of the program. There is more than 50 percent of enrollees are now in Medicare Advantage as opposed to traditional Medicare. Now, do you mind walking us through your actual JCO OP study, what you did, what you found, why it matters? Dr. Hari Raman: So, I think as you astutely pointed out early on the podcast, we know that for patients with blood cancers or hematologic malignancies, they really face significant challenges at the end of life. This is even in comparison to patients who have solid cancers. This primarily manifests as having increased rates of hospital admissions, ICU stays, and even dying in the hospital near the end of life. This really detracts from the ability for patients to be able to spend more time with their loved ones at home, which is something that they frequently voiced when folks have done studies examining patient preferences. Furthermore, we have seen that patients with blood cancers actually have decreased hospice utilization. We know that hospice, which is a multidisciplinary support service that is really tailored to offer maximal comfort and support and care for both patients and their caregivers at the end of life, is quite diminished in patients with blood cancers, particularly in comparison to whether it is patients with heart failure or solid cancers and any other really end-of-life illness. And lastly, along the same piece of hospice, patients with blood cancers are also uniquely situated in a situation where they are required to have blood transfusions to support their quality of life, but also their blood counts. Oftentimes patients who are near the end of life require access to these transfusions, and the problem right now in our current models of hospice care is that hospice agencies are not equipped to provide access to palliative transfusions. This is primarily due to a mismatch in the financial reimbursement that they receive and the cost of providing access to transfusions. And so patients with blood cancers at the end of life are often forced to make really difficult tradeoffs between preserving access to blood transfusions versus enrolling onto hospice and then receiving all the benefits of hospice care that they may be able to receive once they enroll onto hospice. Our question really was to understand whether there may be modifiable risk factors, such as insurance type, which I mentioned in Medicare is optional in terms of either enrolling onto Medicare Advantage or fee-for-service, and see if that may impact the quality of care patients at the end of life, particularly with those with blood cancers. We performed a retrospective analysis using data from the Centers for Medicare and Medicaid Services. Our data spanned about five years from 2016 to 2020, and we really focused on patients who had insurance coverage by either the traditional Medicare fee-for-service or Medicare Advantage plans. Patients had to have had coverage for at least 15 months in a continuous fashion prior to their passing. In terms of how did we assess quality of care at the end of life, we focused on administrative metrics that have previously been validated both in surveys as well as focus groups of both patients and providers. This really focused on three key aspects: hospice use, rates of high-intensity healthcare utilization, which is broken up into things such as emergency department visits, ICU stays, as well as rates of in-hospital death, as well as rates of advanced care planning to see whether patients and their providers have had these discussions about what is important to them at the end of life before they ended up dying. We had access to about 70,000 patients in our study, about two-thirds of whom had fee-for-service insurance and about a third of whom had Medicare Advantage. When we thought about these individual metrics of quality of care at the end of life, we saw that about a little bit more than half of patients were enrolled in hospice across both cohorts. However, the Medicare Advantage patients tended to have higher odds of hospice enrollment with a nearly 11 percent increase in the odds of receiving hospice before they passed, as well as a decreased likelihood of having a very short hospice stay, which meant that patients who enrolled onto hospice with longer stays were able to more fully capture all the benefits of hospice. In terms of healthcare utilization, we also again saw that patients with Medicare Advantage plans were less likely to have two or more ED visits, less likely to have any ICU admissions in the last month of life, and had a nearly 25 percent reduction in the odds of dying in the hospital compared to those patients who were enrolled onto fee-for-service plans. In general, we found that overall that patients with Medicare Advantage seemed to have at least met administrative metrics for higher quality of end-of-life care compared to those with fee-for-service insurance across patients with blood cancers. Dr. Fumiko Chino: One thing I think that was really compelling about your research was that it actually showed a sort of flattening out of what are very large gaps in health equity in terms of different patient populations that may be more likely to die in the hospital, be more likely to receive aggressive care, and it did not seem that you were able to find a difference, which is, I think, good. Do you mind speaking more about that? Dr. Hari Raman: Yeah, exactly. To your point, we know that prior research has shown that patients who are particularly of racial and ethnic minority backgrounds tend to have higher rates of high-intensity healthcare utilization at the end of life and decreased hospice. As you mentioned earlier, similar to what we have seen in the national cohort, our Medicare Advantage cohort was also more likely to be from a racial and ethnic minority background. And so we then asked the question, well, do we see any differential changes in the benefits of Medicare Advantage, particularly at the end of life, across different racial and ethnic groups? We found that across our entire study, patients who were white versus patients who were non-white were equally as likely to receive benefits with regards to the kind of differential impact of Medicare Advantage versus fee-for-service, which I think was really interesting for us because we know that these patient populations are at very high risk for poor quality end-of-life care. Dr. Fumiko Chino: Now, your findings are really consistent with some other research that I have seen that shows that Medicare Advantage may really improve some metrics of end-of-life care, and I think this is mostly likely due in part at least to the hospice carve-out for MA plans where Medicare steps in to actually cover hospice payments and that kind of makes it free for MA plans to deliver. I would love your thoughts on this and please correct me if I am misunderstanding this situation. Dr. Hari Raman: I think you are exactly right, and I think this is a really interesting example of how policy can actually drive behavior. You see that as you mentioned, there is a financial incentive for Medicare Advantage plans to have patients enroll onto hospice. Just briefly to review, once patients enroll onto hospice, these Medicare Advantage plans are no longer responsible for the cost of care associated with that terminal diagnosis, and they stop receiving the risk-adjusted payments from CMS. However, they still receive rebates from CMS for the minimal amount of care not related to the terminal diagnosis. A study actually that came out of Brown earlier this year found that CMS may be spending up to 50 million dollars a year in extra payments to these Medicare plans after patients enroll onto hospice. I think the flip side really is that, you know, there is also a theoretical benefit for patients if we think that we are increasing access and enrol…

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Understaffed and Overbooked: The Problems with Maintaining Specialty Care in Rural Areas Jan 19, 2026

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Dr. Chino welcomes Dr. Erika Moen and Dr. Dan Zuckerman to discuss new research highlighting how specialist scarcity is felt by oncologists practicing in rural environments. Dr. Moen is the first author on "Rural Oncologists' Perceptions of Specialty Scarcity and Repercussions for Care Delivery: A Qualitative Study," which is featured in JCO OP's January 2026 issue. TRANSCRIPT Dr. Fumiko Chino: Hello, and welcome to Put Into Practice, the podcast for the JCO Oncology Practice. I'm Dr. Fumiko Chino, an Associate Professor in Radiation Oncology at MD Anderson Cancer Center, with a research focus on access, affordability, and equity. Rural oncology care has many challenges, including travel distance, limited specialty care, sparse clinical trial infrastructure, and financial barriers leading to worse outcomes and access for patients from diagnosis through survivorship care. Oncologists practicing in rural areas often have difficulties coordinating care with geographically distant providers and limited availability. This is made worse by known workforce gaps. I'm happy to welcome two guests today to discuss new research highlighting how specialist scarcity is felt by oncologists practicing in rural environments. Dr. Erika Moen, MS, PhD, is an Assistant Professor of Biomedical Data Science at Dartmouth. She is a health services researcher and leads a multidisciplinary team working to leverage network analysis to optimize cancer care delivery and patient outcomes. The long-term goal of Dr. Moen's lab is to improve equitable access to coordinated cancer care with a particular focus on rural populations. She is the first author of the manuscript, "Rural Oncologists' Perceptions of Specialty Scarcity and Repercussions for Care Delivery: A Qualitative Study," which was featured in JCO OP's first issue of 2026. Dr. Dan Zuckerman, MD, FASCO, is the director of GI oncology and staff medical oncologist at St. Luke's Cancer Institute in Boise, Idaho. The center encompasses eight locations and is the region's largest provider of cancer care, treating a catchment area of over 20 counties. He is past president of the Idaho Society of Clinical Oncology and has been active in ASCO, including past chair of the Clinical Practice and Innovation Committee. Our full disclosures are available in the transcript of this episode, and we've already agreed to go by our first names for the podcast today. Erika and Dan, it's really wonderful to speak to you today. Dr. Erika Moen: Hi, Fumiko and Dan. It's great to meet you both, and I'm looking forward to this discussion. Dr. Dan Zuckerman: Me as well. Thanks, Fumiko. Nice to meet you, Erika. Dr. Fumiko Chino: Erika, do you mind starting us off on how you got interested on how to try to optimize multidisciplinary care and why your focus is specifically in rural populations? Dr. Erika Moen: Yes, absolutely. When I was a new assistant professor, I knew I wanted to focus my research program on bringing together my methods expertise in patient-sharing network analysis, which involves using healthcare administrative data to identify networks of physicians who share the same patients, with my research interest in cancer care delivery. I remember reading an oncology workforce report published by JCO OP, and in that paper, there was a map visualizing county-level metrics of the number of oncologists per capita. And one of the things that immediately struck me was what I was seeing in rural areas. There would often be one county that had a relatively high density of oncologists, and it would be surrounded by counties with none. I wondered what the multidisciplinary referral networks of those physicians looked like and how physician departures or retirements would impact those patients and care teams. And because rural areas have known workforce shortages, and the delivery of high-quality cancer care depends on relationships between multidisciplinary specialists, these networks of physicians seemed critical to study and to support to maintain access to care for rural communities. Dr. Fumiko Chino: What a great summary about how you got interested in this and trying to marry the data science of it all with the actual care delivery, like what matters to patients on the ground, which is: "Am I going to be able to see a specialist focused on melanoma or am I just going to have to see a general oncologist?" So that's a phenomenal narrowing in on "this is the reason why I'm doing the research that I want to do." Now, Dan, congratulations on your recent nomination for the ASCO Board of Directors. I know that you have been passionate about improving quality care delivery for decades. Can you speak to your efforts in your home state and within ASCO to ensure that the science and technology and practice pattern advancements that we see at academic centers actually make it into the community? Dr. Dan Zuckerman: Yeah, I think about the 44 counties in Idaho, and I'd have to guess that most of us are concentrated in three or four of those. But you know, a great example: so I've been practicing out here for 18 years, when I left fellowship, we came to a center where we had autologous stem-cell transplant but not allo. And so you sort of ask about one of the greatest innovations recently in oncology has been CAR T-cell therapy. And we were thinking about and watching our patients with leukemias and lymphomas being sent to places like Seattle or Salt Lake and thinking about, as Idaho grew and our population, urban and rural, how could we provide for that? And so, really back in 2015, when I was director of our Cancer Institute, we got buy-in from our leadership, thankfully, to start building an allogeneic stem-cell transplant program with an eye to do allo, but also with an eye to know that we needed sort of that expertise in cellular therapies, all the way from lab to processing, to having the physicians and APPs and pharmacists to do that, so that we could deliver CAR T-cell within Idaho. And it took three years to build an allo program, and then we had planned to deliver CAR T-cell in 2020 and the pandemic happened. That delayed us by a year or two. But, you know, it's an example we're proud of, but it took a massive lift. I think originally it was close to a two-million-dollar pro forma with 19 FTEs, and we were fortunate to have leadership at St. Luke's and also a group of physicians who were willing to make that lift because we're not an academic center. But that's sort of one example where we've been successful in being able to bring some subspecialty care to a rural area, but it is incredibly difficult. And we still have gaps. So obviously I'm highlighting a place where we've been successful. Dr. Fumiko Chino: No, I love that you mentioned CAR T-cell because I know we did a recent podcast episode about access to CAR T and how providing CAR T within the community is obviously the next step, and yet it's so challenging. There's these logistic challenges, but you also have to have actual buy-in from the institutions to build the programs because they will not build themselves. And I think: Oh, you don't have CAR T-cell in your community within your county, within 10 counties? You didn't even have it within your state! And so, that's a phenomenal effort, and it required so much investments in people and dollars and just time. So, I completely respect that. And it dovetails really nicely into the next question to Erika, which is: the manuscript on deck that we're talking about really talks about the access to specialty care and how that can be very challenging in rural areas. Do you mind giving us an overview of the manuscript, kind of what you did, what you found, what you're excited about in terms of the next steps? Dr. Erika Moen: Sure. So, our study conducted and analyzed qualitative interviews from 20 oncology physicians across five sites that served a rural catchment area. And it was part of a larger project evaluating patient-sharing networks for cancer care. And we identified three major themes. The first was participant experiences related to the effects of physician shortages on care team expertise, collaborative relationships, and patient volume. The second related to the strategies that oncologists use when facing physician shortages, including referrals to outside health systems or generalists practicing outside their subspecialization, and reallocating time from other responsibilities. The third theme described the unintended consequences of these adaptive strategies, including greater patient travel burden, less optimal or delayed treatment, reduced access to clinical trials, and increased physician burnout and lower job satisfaction. We then developed a conceptual map showing the connections between these themes in the broader context of an oncology physician's departure. And I think I'm really excited about the effort to map some of these themes together because I think it can be informative depending on the adaptive strategies that are being used to try to manage a workforce shortage; different interventions might be more or less effective to ensure that the care teams and the patients are supported. Dr. Fumiko Chino: It's really interesting. It reminds me of, you know, I grew up in Indiana, and not a tiny town, but a small-town Indiana. My mom was practicing oncologist, and her referral patterns, so, for example, when she retired, her referring physicians had to figure out, "Well, who do we trust now? Who are we going to reroute our consults to now that you are no longer in service?" As it turns out, as someone who started a practice and then actually ultimately hired my sister, it was a very easy dovetail. Dr. Erika Moen: No, but I think that's exactly right. And the importance of trust really came through as a prominent challenge that was faced by physicians that did have someone depart. And I think it's just a human experience we can all relate to. Dr. Fumiko Chino: So Dan, I'll ping it right over to you because I would really love your thoughts about how the themes outlined in this study is something that you may find in your practice. So, for example, I know that you work at a large center, but with many referral in the community. For example, in GI oncology, I could imagine if someone retired who was a gastroenterologist in the community, that you would have this whole cascade of potential difficulties for you. Do you mind speaking about that? Dr. Dan Zuckerman: Yeah, no, for sure, Fumiko. And on a personal note, it's funny that we both have parents who are oncologists. So I, unlike your sister, I'm actually practicing with my dad here and he's imminently retiring. And what you mentioned about that legacy and that expertise and that trust in the community and what that means and who he'll hand his practice off to certainly resonates. But certainly talking about subspecialty care, and I think, you know, Erika and her group's paper really honed in on a key linchpin physician is often the surgeon. And so I do mostly GI medical oncology and for us, you know, we had two HPB surgeons for, you know, sort of the middle part of my career. And then the senior surgeon, who we had poached from Seattle and was, you know, sort of towards the tail end of his career, retired. But he was doing quite a bit of volume, but also was the sort of respected physician, was sort of the leader for that. And that definitely for at least a year or two was a challenge for us in terms of replacing his expertise, of putting more volume on his junior physician. Probably more pointedly, and I think Erika's paper points this out, is that we for a long time had a urologic oncologist who was just the key person for our GU program, was doing all the RPLNDs, the cystectomies. He was just 55, had a background in the military, and realized that he could go to the local VA and dial down for quality-of-life purposes because he was exhausted, because he was that key physician. So, he was seeing so many patients, he was the heart of the program, and then all of a sudden he left. And right in the midst of it now, we're scramble- literally scrambling in terms of are we sending these patients down to University of Utah, which is sort of our closest partner academic center? Is it the community urologist, who you know, haven't done that many cystectomies in a while and haven't done an RPLND in a decade, that we rely on? And so, yeah, we definitely feel it as a concrete example in our GU oncology program with just the departure of one physician has caused quite a bit of scrambling and quite a bit of changes in practice patterns. You know, Erika's paper also mentions possibly suboptimal care, so our patients not doing the standard neoadjuvant immunotherapy-chemotherapy with followed by cystectomy; are we doing more bladder preservation simply because we just don't have a surgeon to do it and patients don't want to travel? And so, the downstream impacts from the loss of expertise when you already have a scarce physician population are deeply felt every day. Dr. Fumiko Chino: Erika, one thing that really struck me from your work is that there was real difficulty, it seemed like, recruiting a truly rural sample provider. So, for example, all of the physicians in the study were at centers who had large rural catchment areas, but almost all of them worked at NCI-designated cancer centers. And I do typically think of those as being pretty well-resourced. So, it's very different than, for example, again my mom's community practice, where she was at one point the only radiation oncologist. So, I would love to hear from you about that perspective of sometimes even getting the voices of the people you want to hear from, how challenging that is. Dr. Erika Moen: Yeah, I agree completely. I'll start off by giving a big thanks to the physicians who did participate in our study, and perhaps some of them are listening. We did have more success recruiting when we were able to leverage a personal connection or a local champion, and these were often at other NCI cancer centers. We did try to recruit at outreach or community sites within those larger health systems and we had some success there. But I think it's going to be really important to understand which of our findings can generalize to community-based practices that aren't part of a larger integrated health system and identify the challenges that are more unique to care delivered outside of the context of a large health system. So yeah, I mean our sample is what it is, and I think some of the challenges will be universal but probably even greater or amplified in the places with fewer resources. Dr. Fumiko Chino: And I'll just say even for, for example, my mom's practice, which she, you know, was an independent practice, since she retired it has now been part of this sort of large conglomerate oncology practice. That may be also just how the wind is blowing in America in terms of consolidated care. Now Dan, there was a recent JCO OP analysis that was about the use of telemedicine oncology, and it highlighted that even after the telehealth boom of the pandemic, rural patients were still less likely to use telemedicine. They continued to have, for example, higher utilization of emergency services. And I'd really love your perspective on this. I know that you had recently helped transition your benign hem program to be an e-consult-based workflow. So I assume you're pretty familiar with some of the access issues that rural patients face. Dr. Dan Zuckerman: Yeah, that's a great point, Fumiko. And I think there's sort of two parts to that. The…

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Patient-Centered Head and Neck Cancer Survivorship Dec 15, 2025

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Dr. Chino talks with Dr. Talya Salz, the first author of the JCO OP manuscript "Impact of an Electronic Patient-Reported Outcome–Informed Clinical Decision Support Tool on Clinical Discussions With Head and Neck Cancer Survivors: Findings From the HN-STAR Randomized Controlled Trial (WF-1805CD)" which was published earlier this year simultaneous to the ASCO Quality Care Symposium. Jeff White, the Director of PR and Strategic Communications for the American Society for Radiation Oncology, also joins the conversation to provide the patient advocate perspective. TRANSCRIPT Dr. Fumiko Chino: Hello, and welcome to Put into Practice, the podcast for the JCO Oncology Practice. I'm Dr. Fumiko Chino, an Associate Professor in Radiation Oncology at MD Anderson Cancer Center with a research focus on access, affordability, and equity. Incidence of head and neck cancers is rising, primarily driven by HPV-positive oropharynx cancers, which are commonly diagnosed in younger people with overall excellent disease outcomes. Patient-centered cancer survivorship is a key evolving area of study, with the goal of improving quality of life after cancer treatment. This is particularly important for people in head and neck survivorship given large post-treatment symptom burden, including speech and swallowing problems, dry mouth and dental concerns, neck fibrosis, and pain. I'm happy to welcome two guests today to discuss new research on how to improve communication in cancer survivorship. Dr. Talya Salz, PhD, is an Associated Attending Outcomes Research Scientist at Memorial Sloan Kettering. Her research aims to improve the quality of life for cancer survivors, focusing primarily on late effects after cancer treatment. She is the first author of the JCO OP manuscript "Impact of an Electronic Patient-Reported Outcome-Informed Clinical Decision Support Tool on Clinical Discussions With Head and Neck Cancer Survivors: Findings From the HN-STAR Randomized Control Trial." This publication was simultaneously presented with the 2025 ASCO Quality Care Symposium. Mr. Jeff White is the Director of PR and Strategic Communications for ASTRO, the American Society for Radiation Oncology. He focuses on media outreach and manages ASTRO's social media channels in a way to expand knowledge and awareness about radiation oncology and its critical role in curing cancer. He was diagnosed and treated for an HPV-positive tonsillar cancer in 2023 and shared his story on RT Answers to help other patients understand the role of radiation, surgery, and chemotherapy in head and neck cancers. Our full disclosures are available in the transcript of this episode, and we've already agreed to go by our first names for the podcast today. Talya and Jeff, it's really great to speak to you. Dr. Talya Salz: Thank you for having me. Jeff White: Great to be here. Dr. Fumiko Chino: Talya, do you mind starting us off on how you got interested in trying to improve survivorship care, and specifically what gaps your research can fill? Dr. Talya Salz: My research is really shaped by my experiences trying to navigate the health care system. I had some health issues in my 20s, and as a recent college graduate in a new job with my brand new health insurance, I was really shocked at how hard it was for me to find doctors that I trusted. It was hard to communicate what I needed and to get insurance to cover my care. That experience really steered me toward a career that addressed reasons why patients, and we're all patients at some points in our lives, have difficulty getting care that's appropriate, that's needed, and that's patient-centered. So when I started doing health services research in cancer almost 20 years ago now, there was a growing consensus that after cancer treatment is over, after patients are told there's no evidence of disease, that they're cured, there are so many more health issues that can arise that had historically been neglected. And late effects of cancer treatment can last long after treatment is over, or they can pop up months or years later. All the distress and anxiety from cancer, that doesn't just vanish once the treatment is complete. One problem is that there's no agreement on who should manage late effects of cancer treatments after treatment is over. Survivors have fewer appointments with their oncology team, and these visits traditionally focus on monitoring for recurrences and new cancers. Many oncology providers feel that late effects of cancer are realistically difficult to manage in the brief post-treatment visits or that these issues are out of their purview. So survivors are typically expected to return to the primary care they were getting, or maybe they weren't even getting it, before their cancer. And a lot of research has shown that primary care providers feel ill-equipped to address all the health issues stemming from cancer and cancer treatments. Cancer survivors can feel a real burden by this transition from oncology-focused care to more general preventive care. In my survivorship research, I hope to understand and improve how cancer survivors' long-term health issues are managed as they navigate from cancer-focused to ongoing survivorship care. Dr. Fumiko Chino: What a great and thorough answer to that question. I love the idea that you took the kernel of your own experience and then translated that into an entire career to try to improve the lived experience of cancer survivorship and outlined so many key friction points that survivors really face when they transition into this long, hopefully, road of survivorship. Jeff, I think I've known you since the entirety of the eight years you've been at ASTRO, and I immediately thought of you as the perfect guest for this podcast focused on improving head and neck survivorship communication, as you are a communication specialist. Do you mind speaking a little bit about your role within radiation oncology and then how this became both the best and the worst background to have when you were yourself diagnosed with cancer? Jeff White: Sure. Yeah, as you mentioned at the intro, I've been with ASTRO for about eight years and was brought in to kind of elevate the specialty as much as possible, either through media relations, social media, and partnerships and other things like that. When I came to ASTRO, a lot of people were saying to me like, "Wow, how are you and why are you working in cancer every day? Like, that's pretty heavy and that's pretty intense." And my answer was always, "You know, cancer is not really an issue within my family." So I didn't feel a huge connection. I was concerned about health care and access and things like that, but I wasn't really personally connected to it. So I thought, you know, I've been working day in and day out reading about cancer, understanding the different types of treatments for the different types of cancers. There were a couple of moments, and I distinctly remember working with Dr. Paul Harari when he was the ASTRO president, who happens to be a head and neck cancer specialist. He was talking me through kind of the whole process for treatment, and I distinctly remember saying to myself, "I don't ever want to get head and neck cancer. That looks pretty rough." The irony is that here we are in 2023. I had a lump in my neck right after I had a physical, so I'd gotten all my... everything was good, my blood work was clean. And just this random lump appeared one day. So I went to my primary, and he was immediately concerned, "I think that you should go get it biopsied." And so that kind of started me down the path. The good news was is that when I had the lump examined, it was a benign cyst. So I breathed a sigh of relief, and the doctor was like, "Great." He's like, "If you want to get it removed, you might want to go see a surgeon." So I kind of casually made an appointment to see a surgeon just to kind of get this little annoyance removed. And within two minutes, the surgeon was like, "I don't think that's what that is." He's like, "I think you have tonsil cancer." So that kind of started me down the path to kind of learn more about it, and obviously was biopsied and it was confirmed that it was cancer. You know, that just took me down a whole path that I wasn't prepared for in any sort of way. I knew enough to be scared, but I also had no concept for what it really was until I kind of experienced it myself. Dr. Fumiko Chino: I know you're so well integrated into radiation oncology through your role within the society. Do you feel like that gave you a leg up, at least in terms of getting a second opinion or facilitating the actual care? Jeff White: I was able to connect with a radiation oncologist right away. I initially was told it was going to be three weeks to get a biopsy, and I just about fell apart because that was like... I couldn't possibly wait that long. So I will... you know, that was a blessing to have a connection in that respect. But I did, I shopped around. I live in Washington, D.C., so I am very fortunate that I have access to three top-notch facilities within a pretty close radius. I recognize that not every patient has that, but I was able to kind of find a place that kind of worked for me, that I felt comfortable with the team, I felt comfortable with the machines that I was going to be interacting with. I also distinctly remember being in a waiting room looking at the patient materials, kind of reading it and thinking, "I've got to use this experience for good. Like, it's the only thing that could kind of calm me down a little bit because I was so panicked." And I thought, "I've got to use this as a learning experience and something that I can share with other people, and that might make this whole odyssey feel like there's a purpose to the whole thing." Dr. Fumiko Chino: That's a lovely sentiment, the idea that you would use your lived experience to try to improve knowledge and education for other patients down the road once you got through it yourself. Now, Talya, just to feature a little bit on the actual manuscript, do you mind giving us an overview about what you did, what the HN-STAR trial found, and what are you excited about in terms of the next steps? Dr. Talya Salz: The goal of our trial was to improve the management of late effects for people who had finished treatment for head and neck cancer. As you talked about before, people with head and neck cancer can experience many ongoing challenges after treatment's complete. It's really sensitive anatomy, and there can be really aggressive treatments that can cause challenges with eating and breathing, speaking, movement, not to mention ongoing distress, fatigue, insomnia. There are comprehensive guidelines for the care of head and neck cancer survivors which include recommendations for monitoring and managing more than 20 of these late effects. The problem is integrating these recommendations into clinical care, and it may be hard to identify all the relevant concerns that survivors have and then manage them in a brief clinic visit. We've learned from research among people undergoing active cancer treatment that asking people about their symptoms with standardized surveys, what we call patient-reported outcomes, can improve their symptoms, their quality of life, their communication with their providers, and even survival. So my team hoped that we could use patient-reported outcomes in the post-treatment setting for head and neck cancer. To do this, we developed a web-based interface so that head and neck cancer survivors could complete surveys online, these are the PROs, about their symptoms before routine oncology visit. Those survey responses were used to identify concerns that reached a threshold that we deemed burdensome. We used that information to personalize a clinical decision support tool that the oncology provider could use in clinic on a computer or on a tablet. The clinical decision support tool presented each health concern and how burdensome it was to the oncology provider, and the provider could click on any of the concerns to see the guideline-based recommendations for management, whether the management was further testing, referrals to other providers, medications, or self-management. There's more to the web-based tool. This tool is called HN-STAR, but those are the pieces of HN-STAR that are relevant to today's discussion. We hoped that when oncology providers used HN-STAR, clinic discussions could focus on relevant symptoms and concerns. Basically, the goal was to streamline and tailor care based on survivors' concerns. In our trial of HN-STAR, we randomized 28 community oncology practices to either use HN-STAR or to provide usual care to head and neck cancer survivors in their practice. We enrolled 357 survivors at these practices. Survivors in both arms were asked to complete PROs for 26 concerns prior to a routine post-treatment follow-up visit, and after the visit, survivors in both arms were asked which concerns were discussed in clinic. What we found was that these were very symptomatic patients, with an average of seven and a half burdensome concerns. In both arms, an average of five concerns were discussed in clinic regardless of whether the survivor reported the concern as burdensome. However, in the HN-STAR arm, an average of four of survivors' burdensome concerns were discussed compared to an average of three burdensome concerns that were discussed in the usual care arm. So importantly for survivors in the HN-STAR arm, 59% of their burdensome concerns were discussed in the clinic visit compared to 45% of burdensome concerns for survivors in the usual care arm. This means that clinic discussions did not have a broader scope. The same number of concerns were discussed, but the discussions in the HN-STAR arm were more tailored to salient survivor concerns. This is not actually the main endpoint of our trial. We hope that these more tailored clinic discussions translate to improved care and improve health-related quality of life after a year, and we're still collecting these data. But we think it is really promising that this clinical decision support tool can streamline discussions between providers and head and neck cancer survivors. Dr. Fumiko Chino: Now, Jeff, I would really love your thoughts on this trial and then about your own, sometimes maybe bumpy, transition into survivorship. So for example, what has worked for you to facilitate good conversations with your oncology team? And I would imagine given your active role within cancer education and communication that you actually have a leg up on some other survivors, but I would also still guess that there's a lot of opportunities to improve. Jeff White: Oh, you'd be right on that. So the one thing that popped into my head as you were talking about this, Dr. Salz, was the timing of this. It really... getting my input or getting a patient's input at a certain point within the timeline is important, and it also... I like the idea that I could do it on my schedule versus feeling the pressure of being asked a question in person at the appointment because there's a lot of anxiety. You want to get the appointment over with, but like, if you have the time to really think through like, "You know, this actually is more problematic. I do want to kind of talk about that." I think that's very important. I'm a communicator by nature, and so I feel pretty comfortable sharing. Plus I knew my doctor before I became his patient. But I will also be honest that I was hesitant to do too much research into what was go…

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