Abby Burns (00:10):
From Advisory Board, we are bringing you a Radio Advisory, your weekly download on how to untangle health care's most pressing challenges. I'm Abby Burns.

Chloe Bakst (00:19):
And I'm Chloe Bakst.

Abby Burns (00:21):
Today, we're talking about cancer care. Now, obviously cancer plays a huge role in our healthcare ecosystem.

Chloe Bakst (00:28):
For providers, it's a major volume, revenue, patient loyalty driver, not to mention a differentiator in the market. For life sciences, it drives a lot of R&D spend and activity across diagnostics, treatment, and even survivorship support. When we think about payers and employers, cancer is one of the top drivers of trend year after year.

Abby Burns (00:49):
And of course, arguably most important, I think we can all appreciate the importance of having high-quality, cutting-edge cancer care available to us either as a patient, a caregiver, or a loved one.

(01:01):
That said, I think cancer care is actually a perfect microcosm for what really comes down to the crux of the challenge with the American healthcare system.

Chloe Bakst (01:09):
Which is how do we continue to drive clinical innovation, enable access to that care, and also not go bankrupt?

Abby Burns (01:16):
Yes.

Chloe Bakst (01:17):
Now, this is the healthcare system that has given us advancements in immunotherapy treatments like CAR-T, in genetic testing and precision medicine, and advanced diagnostics and early detection.

(01:28):
But oncology spending is projected to grow to $195 billion by 2029. To help us break down the biggest trends influencing oncology today, we've invited Advisory Board's specialty care expert Gaby Marmolejos back to the pod. Gaby, welcome to Radio Advisory.

Gaby Marmolejos (01:47):
Thanks for having me.

Abby Burns (01:47):
Gaby, I am so glad we're having this conversation for a few reasons. One, cancer care is a priority for, I think, every single sub-sector of the healthcare industry. And not just a priority, but one of the top priorities.

(02:08):
It's also a space where we're seeing almost this dichotomy between a pullback in federal funding for cancer research at the same time that we see, I believe, and you will tell me if I'm wrong, pretty considerable growth in the population affected by cancer, including prevalence rising among younger folks, people of working age.

(02:30):
So I know these things are directionally true, but to start our conversation, can you help us put some shape to these trends?

Gaby Marmolejos (02:37):
In terms of the pullback of federal funding, technically Congress has actually increased cancer research funding this year, for the NIH at least. And it's not a huge increase, but it is an increase, and Trump kind of walked back his reduction in federal funding.

Abby Burns (02:51):
Okay. I'm so glad you course corrected right from the jump. I didn't realize that had been reversed or not gone through.

Gaby Marmolejos (02:57):
The distribution of funding has still been slowed down because of different NIH policies. So, I think it's fair to say that people are not receiving as much funding, but technically cancer research funding has not been declining.

(03:11):
On the volume trends, we're definitely seeing growing cancer volumes, specifically in the older age population, but more recently there's been a development of younger early-onset cancers have been increasing, but still the large majority are among 65 older population.

(03:26):
And so we're especially expecting growing volumes for both treatment and diagnostic testing. And then more recently, we've been seeing a lot of growth in some of the newer, more novel therapies like adoptive cell transfer, or CAR-T, as well as other immunotherapies.

Abby Burns (03:44):
When we're talking about this volume growth, can you put some numbers to that?

Gaby Marmolejos (03:47):
Yes. In the outpatient setting, we're expecting 6% growth in screening and diagnostic five-year growth volumes. And then when we're talking about treatment, we're expecting 5% growth in outpatient treatment volumes. This is not including outpatient surgery, just because of the way that falls under different service lines. But in the outpatient surgery, cancer surgeries, we're expecting about 4 to 5% growth as well in the next 5 years.

(04:15):
And then in the inpatient setting, we're seeing more like a stagnation, I would say. And so we're seeing a 1.7% increase, but honestly, it's for the most part, just staying steady for the next few years. And that's part of because we're seeing more care move to the outpatient setting and more folks implement different measures to reduce inpatient admissions.

Chloe Bakst (04:35):
Yeah. Was there anything surprising to you, Gaby, when you were looking at these volume trends? Did anything stand out?

Gaby Marmolejos (04:42):
There was a small increase that we're projecting in medical oncology, so that was a little surprising, since in the past few years we've seen more of a decline. But I do think that might be related to some of the new novel therapies that usually start in the inpatient setting, that might be driving a little bit of growth in that setting.

Chloe Bakst (05:00):
You mentioned these novel therapies. You had mentioned a little bit earlier these new CAR T-therapy treatments. I think it's only been about nine years since the very first CAR-T treatment got FDA approval, which when we think about healthcare years, it's pretty light-speed evolution from launch of a new product to the growth that we're seeing today in terms of volume. When you're looking at the drug and innovation pipeline, what are you seeing there? What's our next CAR-T?

Gaby Marmolejos (05:30):
Oh, when you word it like that, it's scary to predict which one will be the next CAR-T, 'cause I mean the number of cancer programs that are open in CAR-T centers is pretty remarkable. But in the pipeline, we're definitely seeing a lot of movement, and this is a different type of therapy, but radiogland or radiopharmaceuticals definitely increasing in popularity. We're seeing a growing number of programs offer these types of therapies.

(05:52):
We're seeing a whole lot of new cell and gene therapies. And the thing that I find particularly interesting about the cell and gene therapy trials is a lot of them are focused on solid tumors. So a lot of cell and gene therapies are typically more focused on hematology. So, seeing so many of them target solid tumors is going to dramatically increase the number of patients that can access these therapies.

(06:14):
We're also seeing multi-specific, including bispecific therapies, and that has been one that is a little bit easier to administer than CAR-T, just because you don't have to deal with some of the same logistics as CAR-T. And then antibody drug conjugates is also an area where we're seeing a lot of new clinical trial starts.

Abby Burns (06:35):
I'm starting a word bank over here of words to look up after our conversation. What I'm hearing is there is almost a diversification of the pipeline. At least it is a diverse pipeline coming down the pike. I also think the pipeline is growing when we look at year-over-year FDA drug approvals. Can you talk to me about the size of the pipeline?

Gaby Marmolejos (06:58):
The numbers that we have in terms of US oncology medicine spending, we know that in 2024, $116 billion was spent on oncology medicine spending, which is a big chunk. And we know that the average annual increase in spending is about 13% from 2019 to 2024. And then we project it's going to continue to grow to almost $200 billion by 2029. And so, spending and the size of that market continues to grow.

Abby Burns (07:29):
That probably leads us into the crux of our conversation today. Every year, Advisory Board looks at what is happening in the oncology space. Gaby, you recently wrapped up our 2026-2027 oncology market trends research. If you had to sum up cancer programs' top priorities this year, what would you say those are?

Gaby Marmolejos (07:48):
I would say there are some long-standing priorities, but the one that really stood out to me this year in particular was more creating individualized personalized care pathways. I think that has been a growing area of focus, especially as we're seeing more precision medicine is really taking off.

(08:03):
We're seeing a lot of folks work on developing personalized protocols and therapies. And then with the use of artificial intelligence, it's just easier to now create more personalized care pathways. We're also seeing a movement to bring care closer to home. And so that's part of that side of care that we've talked about in the past few years.

Abby Burns (08:23):
Yeah, it strikes me that both of those things are very patient-centric, right? Individualized and closer to home. I want that. I want that for my loved ones.

Gaby Marmolejos (08:31):
Yeah, I would say that something I love about working with cancer programs is the patient experience and improving the outcomes as patients is always the number one priority. And so, everything is to that end. And I think that is why most of the initiatives that we're seeing are kind of in that direction.

Chloe Bakst (08:48):
I want to dig deeper into these trends that you've identified for us. And building off what you were saying about the patient-oriented care, I want to start by talking about patient access.

Abby Burns (08:57):
Yeah.

Chloe Bakst (08:58):
One of the tensions we've talked quite a bit about on Radio Advisory is this balancing act between the laundry list of these novel therapies that you were talking to us about earlier coming to market, and our ability as a healthcare ecosystem, and maybe more broadly as a society too, to enable access to them. What would you say is the current state of patient access to these many new and exciting cancer care innovations?

Gaby Marmolejos (09:25):
Well, I would say, especially if it comes to CAR-T, but certainly for a lot of novel therapies, access primarily is concentrated in urban academic settings. And so it's not that accessible. And I think there's a statistic that I've heard of only 20% of folks eligible for CAR-T actually receive the therapy.

(09:44):
And there's a lot of reasons for why that would be the case. Not just the logistical barriers and the cost barriers, but just geographically, you usually have to stay close to the facility where the CAR-T is being administered, and that can be very far from patients and very costly to even get close to that facility. And so I would say CAR-T and some of the novel therapies are not very accessible to folks that live outside of urban settings at this point.

Chloe Bakst (10:10):
I think it makes sense, given the complexity of what CAR-T treatment is. It's a cell therapy, requires a lot of complex administration, and it's for highly acute patients that we're seeing them localized to AMC specifically. What's needed to support more community-based cancer programs offering CAR-Ts or other types of these complex immunotherapies?

Gaby Marmolejos (10:35):
Well, there's an infrastructure needed to be able to offer these complex therapies. We've written a bit about this in the past. Actually, in fact, you, Chloe, have authored a great playbook about administering cell and gene therapies. And so part of the infrastructure is having a multidisciplinary team.

(10:52):
Typically, I would say that you usually need some kind of project champion with expertise in cellular therapies or hematology. So that in and of itself can be a barrier to some programs that don't have that kind of subspecialist. You need strategic partnerships. You need to partner with the academic centers who have been administering these therapies for a longer time period, who can share different care protocols with community programs.

(11:15):
You need to have training. Your staff needs to be trained in how to administer these therapies because they have a pretty specific toxicity profile that sometimes, especially if you're administering it outpatient, outpatient nurses don't always have the same kind of training that an inpatient nurse would have in terms of managing toxicities.

(11:32):
And then, if the community program is administering outpatient, you also need a robust patient monitoring program. I would say there's a huge infrastructure needed for a community program to deliver these therapies.

Abby Burns (11:45):
And given the fact that one of the trends you noted is that cancer programs are trying to move closer to the patients. Are you seeing progress here?

Gaby Marmolejos (11:53):
Yes. CAR-T in particular, we're seeing growing adoption across community hospitals. CAR T-cell therapy adoption grew across four newly authorized treatment centers, from fewer than 11 patients in 2023 to 22 patients in 2025, which I know seems like a small number, but is really remarkable considering the pretty few number of patients eligible and able to access CAR-T.

(12:16):
And then in the practice setting, we're seeing a growing number of patients receive bispecific antibody therapies. At the US Oncology Network, the number of eligible patients receiving bispecific antibodies grew from about 5% in October of 2022 to 73% in July of 2025.

Abby Burns (12:34):
Whoa, that is a massive growth, especially because, correct me if I'm wrong, the US Oncology Network is the largest oncological medical group in the country.

Gaby Marmolejos (12:44):
It's pretty incredible. And I think, frankly, the move to the practice setting was the most surprising to me, just because of... I told you about the infrastructure that you need for that, and so to see some of these therapies move to the practice setting is pretty remarkable.

Chloe Bakst (12:58):
We've been talking a lot about innovations in treatment, but I imagine there's also a lot happening within the world of cancer diagnostics and diagnosis. Gaby, tell me more about what you're watching in the world of diagnostics.

Gaby Marmolejos (13:12):
Well, there's a large focus in early detection, I think across the cancer space, and trying to catch cancers earlier than before. And one of the methods being used to that end is the use of multi-cancer early detection tests. Previously, we would've called them liquid biopsies, and so they're basically a blood test where you would be testing for multiple types of cancers. These tests have been growing in popularity, even though none of them are technically FDA-approved yet-

Abby Burns (13:40):
Oh, interesting.

Gaby Marmolejos (13:40):
... but you may have heard of a Grail's Galleri test. I think that one is one that's pretty popular. Exact Sciences has Cancerguard. And so, these tests are currently out on the market and they're also being tested in clinical trials. And so we're seeing a lot of movement into seeing whether these tests can identify cancers earlier than through traditional screening.

Abby Burns (14:00):
Gaby, this is perhaps a silly question, but why is early detection so important from a clinical perspective?

Gaby Marmolejos (14:07):
So, if we were going to give an example of breast cancer, you can see the five-year survival rate when breast cancer is diagnosed at a localized level is 99%, so very high survival rate. But once it's metastasized, once it's spread, that five-year survival rate decreases to 33%.

(14:23):
And then if you compare the cost between that at the localized stage breast cancer, average treatment cost is $30,000. And once it has spread or metastasized, it increases to $115,000.

Abby Burns (14:35):
Wow, almost four times greater.

Gaby Marmolejos (14:37):
And so for both the patient and both for the whole healthcare system, it is much better for us to catch cancers earlier.

Chloe Bakst (14:44):
I think I'm on board with the value proposition of this type of multi-cancer early detection testing. Yes, the earlier we catch it, the better the prognosis. But I do remember you just saying, Gaby, that none of these tests are FDA-approved yet. So if I'm putting on my skeptic hat for a moment, where actually are we in terms of MCED testing being part of the standard cancer care workflow?

Gaby Marmolejos (15:09):
I would say right now it's still limited to folks who are receiving them either through clinical trials, there are a lot of different large clinical trials underway at large cancer programs, or patients are receiving them through self-pay. So they might get them through a telemedicine provider or they might request that their local doctor request a prescription.

(15:31):
And if you do self-pay, these tests are about $700, so it is not widely accessible in that way. We're also seeing a small but growing number of employers and health plans piloting different said testing programs as, again, a way to focus on early detection.

(15:46):
But I do want to point out, I think I came into this having kind of a skeptic perspective on these tests, if I'm being completely honest, because they're not FDA-approved at this point. They're approved as a lab test, which has just different criteria. But as someone pointed out to me, at this point in time, only 14% of all cancers are currently diagnosed through traditional screening.

Abby Burns (16:12):
Wow.

Gaby Marmolejos (16:14):
14%. And so when I heard that statistic, it hit me that there's a large number of cancers for which we do not have a traditional screening method for. And so there is something valuable about these tests. And there are a lot of people through clinical trials that had their cancers diagnosed using these tests that otherwise would never have been detected through traditional screening.

Abby Burns (16:36):
I have to imagine that this is on some sort of policy roadmap. What's the policy environment around this right now?

Gaby Marmolejos (16:43):
Right now, these tests are currently working to get FDA approval as a screening test. Congress has actually recently passed a law that creates a path for them to receive reimbursement through Medicare. So they passed the Medicare MCED Screening Coverage Act. It was signed into law in February of this year.

(17:02):
And so what it does is that once any of these tests are FDA-approved, it gives Medicare the authority to cover these tests beginning in 2028. A lot of these trials are underway in the hopes of getting that first FDA approval.

Abby Burns (17:17):
The tension that's coming to mind for me is just the age-old question with diagnostics, which is what happens when patients screen positive, especially if this is allowing us to screen for more cancers than we've been able to screen for before?

Gaby Marmolejos (17:33):
Yes, that is actually a question that is trying to be answered in a lot of these trials. Interestingly enough, Baylor Scott & White Research Institute, they are currently launching one of the biggest clinical trials related to MCED testing.

(17:46):
And one of their research questions is trying to understand the best practices for implementing MCED, and really understanding potential patient distress that comes from these tests.

(17:57):
That's part of why the bar for FDA approval is so much higher, is they're trying to understand, "Is there a potential harm that comes with using these tests and does the benefit outweigh the risk of the testing?" is something that they're probably going to be evaluating.

Abby Burns (18:12):
Gaby, that actually perfectly tees up a conversation I want to have about balancing access and spend. But before we get there, there is one area that we haven't broached yet when talking about what cancer programs are focused on in 2026. And maybe this might be the longest conversation I've had in a while that hasn't yet mentioned AI.

Chloe Bakst (18:34):
Is it worth mentioning AI? Where are you seeing it show up in the cancer space, if at all?

Gaby Marmolejos (18:39):
Yes. It's kind of fascinating because I set out to ask cancer programs exactly, "In what ways are you using AI to support your strategic priorities?" And it was interesting to me how a good chunk of cancer programs I talked to, this is just not an area of focus. This not something that they're working on, or this is something where another department handles that. They'll say, "Oh yeah, our tech teams, they know all about our AIs. This is just not my job."

(19:04):
It's in a way not surprising, but it is surprising in that you hear so much about AI, you would think that everyone is using it. But I would say in the cancer space specifically, we're still in early stages of adoption. And in most cases, the tools that they're using is something like ambient documentation or maybe coding assistance, infusion scheduling, that sort of thing, but you're not seeing... A lot of where you're seeing the headlines, not every program is taking the more advanced AI solutions.

Chloe Bakst (19:33):
What's your theory as to why cancer leaders are maybe a little bit more passive in the AI space?

Gaby Marmolejos (19:40):
I would say that are certainly barriers to AI adoption across any type of program, but definitely apply in the cancer space, which is first financial constraints. AI solutions are increasingly expensive.

(19:52):
There's the legal liability. A lot of folks are concerned about data privacy protection, especially if you use a third-party vendor, not to mention just a little legal ambiguity of what happens if AI recommends something that is unwarranted.

(20:06):
And then I think in the cancer space, the hardest part is just a lot of the data that you would use is not centralized. A lot of cancer programs use clinical trial data that isn't always publicly available. And so these AI solutions, it is hard to integrate that data into them so that you're offering clinical recommendations or any kind of clinical guidance.

(20:29):
And not to mention just generally there's a sentiment and concerned about over-reliance on AI among cancer leaders. I spoke with an oncologist a while back and she was saying the most important skill she has is critical thinking skills as an oncologist. And she was concerned about the use of AI diminishing critical thinking skills.

(20:47):
And so, I think for those reasons, you're seeing a little slower adoption in the cancer space and a little bit more deliberate about what tools are we going to bring on and making sure that you can address those barriers.

Chloe Bakst (21:52):
This has been such an exciting and largely optimistic conversation. We have many incredible new tools that can advance cancer care. And I hate to be the person that pops that balloon, but I also think it's important to spell out what the financial impact or barriers are for the providers that are working very hard to try to get patients access to these innovations. Gaby, what are some of the challenges that providers are seeing when it comes to actually delivering on these innovations?

Gaby Marmolejos (22:23):
Well, the number one barrier that we're seeing has to do with financial reimbursement. So we're seeing last year Medicare passed different final rules that reduce payment for providers. In the Physician Fee Schedule, we saw it's up to 20% Medicare payment reduction for oncologists that practice in facility settings or deliver certain services like procedures and diagnostic imaging, and this is a result of changes to the RVU payment methodology.

Abby Burns (22:50):
Okay.

Gaby Marmolejos (22:51):
Also seeing that there was a 60% Medicare payment reduction for drug administration services delivered at physician-based campuses. And so, while most programs are not actually going to be affected by that, basically a site-neutral payment rule, those that do administer a lot of therapies in those settings are likely going to see a hit to margins. And we also are expecting potential further reductions in drug reimbursement rates, likely beginning next year for 340B-covered entities.

Abby Burns (23:21):
And we just so happen to have our 340B expert on hand. So Chloe, I'm actually going to toss the ball back to you. How does what is happening with 340B affect cancer programs in particular?

Chloe Bakst (23:35):
I think cancer programs are particularly vulnerable to changes to 340B. There's a lot looming in the 340B space right now. As Gaby mentioned, there's cuts coming in 2027, most likely for drug reimbursement. So that's chemotherapies or different infusions that are delivered in the outpatient setting. There's also potential changes to the way that programs access savings, whether that's a rebated model or an upfront discount.

(24:00):
There's different waves of legislation being considered at the state and federal level related to program reporting and transparency that could make it more expensive to simply operationalize and participate in the program.

(24:12):
There's also the fact that as the One Big Beautiful Bill Act and its implications for the Medicaid program go more into effect in 2027, we could see ripple effects on things like disproportionate share status that impacts 340B eligibility. So, all of this to say there's a lot happening in 340B.

(24:30):
And as cancer care programs think about their future goals, priorities, strategic planning, I'm absolutely sure that they're watching this anxious, about it, and are trying to figure out how to best prepare and defend against any changes to the program.

Abby Burns (24:46):
To put a fine point on it, how financially viable is outpatient cancer care absent 340B for providers?

Chloe Bakst (24:54):
I've heard from multiple leaders that it would be extremely difficult to keep the growth, the volumes that they currently maintain in their cancer centers without 340B savings. Also, I know that there are providers who don't have 340B who are making it work.

(25:11):
So, I don't want to say that it's impossible or that all cancer programs would close, but I do think it's fair to say that any significant change to 340B will have ripple effects on cancer programs that will be challenging to overcome.

Abby Burns (25:25):
So, we talked about a lot of what I'll call innovations today across screening, diagnosis, patient access, treatment. Gaby, as you look forward, what trends do you think we should be watching in the cancer care space?

Gaby Marmolejos (25:40):
We've already talked about the novel therapy landscape. I'm really looking forward to seeing the expanding indications that come in the novel therapy space.

(25:48):
Something I haven't mentioned, is part of the reason why this space is so exciting, is that a lot of times the way that traditional cancer treatment goes is there's a lot of toxicity involved, and these novel therapies are a lot more targeted, which reduces some of the toxicity levels.

Abby Burns (26:04):
Meaning fewer side effects for patients?

Gaby Marmolejos (26:06):
Fewer side effects for patients and they also just target the cancer cells a little bit more precisely. And then for certain cancers, they're the best treatment option available, especially for a lot of the hematology cancers.

(26:17):
And so, it's really exciting to see that we have more treatment options for a lot of cancers that have traditionally not had a lot of choices for treatment available. But then also, I think I'm really looking forward to seeing whether or not we are seeing more personalized care pathways.

(26:33):
We have already mentioned MCED, but there are other types of early detection methods that are currently in development as well. And I'm curious how much closer are we going to be able to get to more personalized screening recommendations, and be able to catch more cancers earlier outside of traditional screenings?

Abby Burns (26:49):
Exciting.

Chloe Bakst (26:50):
Well, Gaby, thanks for joining us on Radio Advisory.

Gaby Marmolejos (26:54):
Awesome. Thank you both for having me.

Chloe Bakst (27:01):
Abby, I'm walking away from this conversation feeling pretty optimistic and energized by the fact that there's a lot of innovation happening in cancer care right now.

Abby Burns (27:10):
Yeah, honestly, I felt like we could have kept talking to Gaby for ages. I certainly have so much more to learn about the intricacies of cancer care. I think what was most exciting to me was actually where Gaby started the conversation, with the push to get screening, diagnosis, treatment closer to patients. And she talked about that across a couple different levers.

(27:31):
One thing I want to call out for listeners is that Advisory Board will be hosting an oncology round table meeting in the fall, where we'll talk a lot more about all of these trends, and hopefully there's some really good opportunities to learn from peers in the industry and what other folks are doing.

Chloe Bakst (27:46):
And remember, as always, we're here to help.

Abby Burns (28:09):
New episodes drop every Tuesday.

Chloe Bakst (28:12):
If you like Radio Advisory, please share it with your networks, subscribe wherever you get your podcasts and leave a rating and review. Radio Advisory is a production of Advisory Board. This episode was produced by Rae Woods, Atticus Raasch, Abby Burns, and me, Chloe Bakst.

(28:27):
This episode was edited by Katy Anderson, with technical support provided by Dan Tayag, Chris Phelps, and Joe Shrum. Additional support was provided by Dominique Del Gaudio. We'll see you next week.