Disclaimer: Flare Capital Partners is an investor in Aetion, Cohere Health, HealthVerity, Inbound Health, Iora Health and VivorCare. See the broader Flare presentation here.

This is part one of a two-part series on innovation in cancer care delivery. In part one, we will discuss the complexity of end-to-end cancer care management, the unmet needs and how some emerging digital health players address these concerns. In part two, we will highlight the "next wave" and emerging trends of digital health-enabled cancer care delivery.

It's no secret: Cancer is patently complex.

Patients often struggle to grasp the complexities of the U.S. health system, and this confusion is often amplified after a patient receives a cancer diagnosis. The International Agency for Research on Cancer forecasts the number of new cancer cases worldwide will reach more than 29 million by 2040, compared with just over 18 million in 2018. As treatment protocols advance and people live longer, sometimes conquering one or more cancers in their lifetime, the perfect storm of chronic disease will rise and challenge our healthcare system in a variety of ways.

With this increase in the number of cancer survivors, organizations must be prepared to handle the ensuing impacts of long-term toxicities, recurrence of cancer, infertility issues, cardiovascular side effects and psychological after effects.

While research shows cancer has surpassed heart disease as the number one cause of death in some high-income counties in the U.S., we have not seen the same growth and adoption of digital platforms for cancer in the ways that we've seen for other chronic diseases, such as diabetes, musculoskeletal disease and chronic kidney disease. So why isn't more innovation occurring for cancer care delivery?

We seek to answer this question by understanding the key challenges opposing value-based cancer care and unbundling the most important aspects of care delivery to identify the key trends that will influence innovation for cancer care in the next decade.

The challenges of innovating in cancer care

While tailwinds from COVID-19 and healthcare consumerism have driven record-setting amounts of fundraising for early-stage digital health startups over the last three years, major challenges exist for cancer care delivery that makes this area a particularly difficult space to disrupt.

One reason progressive care models such as value-based and home-based care have not seen quicker adoption lies in the challenge associated with integrating, and often reintegrating, services around the care team. As we continue to innovate for cancer care delivery, organizations must be thoughtful about the reintegration of care (e.g., point solutions). In addition, new solutions must empower the care teams to bring the highest-quality tools while also raising patient and provider satisfaction – a tough balance to strike.

In speaking with Aaron Gerber, CEO and cofounder of Reimagine Care, he noted the integration of proper tools isn't the only challenge.

"When looking at specialty drugs, we need to consider both complexity [to administer the drug] and margin it generates for the healthcare system. We can then take a phased approach that begins with the lower complexity, lower margin drugs and expand over time, but only after demonstrating success and increased comfort with the patient's primary oncology team," he said. "Done well, this increases patient and provider experience while providing the opportunity to deliver very high-quality home and virtual care to patients."

Point-solution fatigue for payers and providers, specialty drug purchasing and the risk of the perceived changes' impact on profitability for existing business models often stifle collaboration across stakeholders.

Capital intensity associated with developing these robust solutions, often tied to platform development and the hiring costs for skilled clinicians and care providers, remains a concern for early investors as platform scale. Other challenges include the need to tightly integrate surgical care into the solution to tackle higher-acuity patient populations. Add to that the widening disparity of care for underserved and rural populations, traditionally served by community providers, and you quickly find yourself in a field of competing incentives and lagging business models.

Components of end-to-end cancer care

Key components of the cancer care continuum have been highlighted below to segment an otherwise dastardly set of services rendered across the patient journey. Aspects of the journey span the earliest stage of a patient's journey (such as reduction in sun exposure and tobacco use), to advanced care and end-of-life care planning.

While the greatest opportunity to disrupt traditional business models remains to be seen for cancer care, startups have increasingly attempted to enter different parts of the care continuum only to run into a slew of regulatory, incentive and integration hurdles imposed by incumbents in the space. In addition, the service-based aspects, such as diagnosis, treatment, survivorship and end-of-life care require strong coordination around other aspects, such as finances, education and family/caregiver support planning.

Innovation is beginning to take shape in different ways. Startups continue to address unmet needs by filling care gaps and supplementing existing treatment forms. However, services that have traditionally been nonrevenue-generating seem to be a common theme, where providers don't historically have the means to fund these initiatives, and payers are still too early in contracting for risk-based cancer models. Whether startups can generate sustainable profits in the short-term and demonstrate value to stakeholders, such as health systems and payers, remains an open question.

Despite keeping aspects of the biopharma and therapeutics space separate (we recognize there is a much broader biotechnology and therapeutics market for oncology, and numerous companies are driving innovation forward), the most prominent startup activity for care delivery has been in diagnostic services, treatment coordination and risk enablement.

On the earlier side of the patient continuum, prevention and risk-reduction solutions continue to face a strong headwind as organizations try to integrate preventative and screening-based services with their acute care counterparts. Balancing the fee-for-service nature of acute care delivery with value-based preventative services will be difficult; aligning incentives will be critical. We anticipate survivorship services (most notably, community and nutrition services) will continue to integrate more tightly upstream with aspects of acute care delivery and recurrence prevention (e.g., screening and diagnosis).

In this market map, we highlight several startups innovating across key categories. (See the broader Flare presentation here.)

Treatment: Leveraging data, care coordination and patient support tools to improve decision-making

Treatment is at the core of cancer care delivery, and we see various solutions being built across the category. Most of the existing cancer treatment plans consist of three core services: surgical intervention, systemic therapy and radiation treatment. Depending on the stage and presenting cancer, surgical intervention is often the primal form of treatment for early-stage diagnoses, and it's often complemented or augmented with both systemic (chemo, hormone and immunotherapy) and radiation therapy.

Startups, however, are addressing challenges around treatment pathways in different ways, focusing on things such as navigation, coordination, treatment recommendations (for an informed consumer) and patient support. We've also called out home care, given the rise of at-home treatment options (such as home infusion therapy and lab tests), although we recognize many aspects of home care in oncology fall under other categories, such as screening and diagnosis.

The industry has also seen a drastic increase in the availability of data (e.g., claims, EMR, diagnostics and imaging) over the last two decades to better manage cancer patients. In addition to Flatiron Health, various data platforms, marketplaces (e.g., HealthVerity and Graphite Health) and analytics-ready data enablers (e.g., Mendel and Aetion) have emerged to make data more accessible to researchers and clinicians. However, many challenges still exist for clinicians managing their patients through an evidence-based approach.

"Health systems today are often not set up to make decisions based on real-world data. Clinical trial data and other published data is readily available, but organizations are beginning to make the shift from the status quo of published evidence [expertise-driven] to real-world evidence [data-driven approach] in clinical practice," said Matt Bettonville, who leads Oncology Venture Investing at Emerson Collective.

Tools that use real-world evidence (RWE) to help providers answer questions and provide clinical-decision support in a timely manner, both standalone companies (e.g., Atropos Health) or those internally developed by health systems and academic medical centers, are expected to emerge in the coming years to drive more personalized treatment protocols.

The first area we unbundle within the treatment category is navigation.

Navigation

As technology continues to embed itself across the cancer care continuum, more opportunities have arisen for technology to bridge the gap between existing treatment regimes and ultimately provide more holistic and personalized levels of cancer care. Even if core treatments aren't fundamentally changing (e.g., surgical intervention), patients and physicians can fine-tune aspects of care to the patient using data and automation to support the management of symptoms, side effects, diet tracking, appointments, patient finances and overall coordination of otherwise disparate aspects of care.

Navigation services are in many ways the bedrock for patients navigating the complexities of care, and these services play a critical role to address patient's largely unmet needs. Players such as Jasper Health offer digital care management tools and a library of resources to assist patients with everything from handling side effects to financial planning. 

Care coordination

Care coordination is a sizeable subcategory within treatment that includes decision support tools to assist physicians with managing patient needs and, in theory, reduce administrative burden. One example is Preveta, a care coordination platform that takes disease protocols and translates them into personalized care navigation workflows. Through automated dashboards and refined data capture, systems aim to enable the clinician to capture additional patient data between visits. In turn, the software can help assess the data and get it back into the hands of the doctors quickly to improve treatment.

Another side of care coordination includes digital symptom management, which sits at the intersection of remote monitoring tools for patient-reported outcomes (e.g., Vinehealth and Reprosent) and proactive management of symptoms through companion apps. As these startups scale, it becomes increasingly important to demonstrate improved patient outcomes and ROI for customers (payers and providers) adopting the software. Engaging payers early also becomes an important factor for organizations seeking to enable risk and manage bundled services.

Alternatively, the route of collecting and aggregating patient data through digital patient support tools can develop into an attractive opportunity for pharmaceutical companies that seek to tap into unique patient data points (such as social determinants of health), which can help inform drug adoption and adherence, clinical trial enablement and multiple aspects of drug development.

Treatment recommendations and patient support

As patient data becomes more commoditized, and clinicians are inundated with the sheer volume of data and research publications that are not humanly possible to process, clinical decision support (CDS) tools and next-generation analytics companies that can provide the "so what" will play a central role in treatment recommendation and patient management.

While Merative (formerly IBM Watson Health) and other CDS vendors primarily rely on publicly available guidelines and research publications, a new class of digital health startups augments existing guidelines with real-world data (RWD) and real-world evidence (RWE) to provide a more data-driven way of treating cancer patients.

"You need RWE and analytics and decision support that oncologists can get behind," said Dan McCarthy, CEO of New Century Health and president of Evolent Health.

Players such as Atropos Health provide solutions that help physicians answer previously unanswered clinical questions using real-world clinical and administrative data in a timely manner. Digital health companies such as Outcomes4Me and Ciitizen emerge and try to support cancer patients in their journey to finding the right treatment options and appropriate clinical trials through education and patient support.

Lines continue to blur as provider organizations seek to create touchpoints earlier and earlier in a patient's journey by establishing digital front doors, and alternatively, pharmaceutical companies seek to gain access to more longitudinal data to support decision-making.

Home-based cancer care

The shift to home-based care for cancer has been in development for over a decade, but the recent changes in the regulatory environment have enabled certain forms of therapy to be administered in the comfort of a patient's home. Key changes, spawned in part by COVID-19, include the increased adoption and need for care administered in the home, and increasing pressures on the system due to rising costs in key areas of spend (including musculoskeletal, cancer and renal).

Players like Reimagine Care and Karkonos are tackling home infusions, lab draws and virtual visits with the goal of making care more affordable and more accessible. Meanwhile, others such as Inbound Health and Medically Home are enabling health systems to administer hospital-at-home for medium- and high-acuity patients, although the prime focus may not always be exclusively on cancer patients.

Questions remain around the level of involvement that health systems and payers will have in the expansion of home health in general. While it is still unclear exactly how and where health systems and AMCs will integrate into the broader ecosystem, startups are beginning to demonstrate (and justify) a key understanding of cost when developing these home-based capabilities for cancer.

As startups continue to make progress in certain areas of the treatment pathway, we expect to see more and more health systems and payers seeking partnerships with outside organizations as they expand their hospital-at-home and home-based services.

Enablement and risk-bearing entities: An effort to fundamentally shift the business model of cancer care to value

In the past, oncologists have been quite nervous about taking risks, even professionally, due to anxiety around specialty drug costs. For most medical groups, the technology needs are also too daunting as too many point solutions are often needed to properly manage populations. Payers are also still in the state of transitioning, as disagreement around the level of inclusion for specialty drug costs often results in a rate-limiting step for contracting.

While challenges persist, recent trends have enabled more and more oncology groups to begin moving toward risk. As Shawn Morris, CEO of Privia Health, said, "When asked about the possibility by investors and analysts, there are a few specialties that are high volume and can underwrite the risk from an actuarial standpoint in Medicare –orthopedics, GI, urology, ophthalmology and oncology. The success of moving into value-based arrangements and risk is based on proper alignment with physicians and payers and having the necessary tools, talent and technology [data] to manage risk."

Opportunities are expanding for startups and oncology groups to start with professional capitation and ultimately move upstream. These arrangements are mostly seen in the Medicare Advantage space, and as organizations continue to demonstrate improved outcomes, commercial opportunities may soon be on the horizon.

"Success in bearing risk is possible if you design the right methodology," Robin Shah, CEO and cofounder of Thyme Care, said. "This requires a deep understanding of the patient beyond their clinical factors, and to build that understanding, you need to develop trusted relationships with members. Without those relationships in place, you won’t be able to influence behavior change."

Different approaches

We see innovation in risk enablement taking many forms. Whether it is companies such as Transcarent (e.g., recently announced Transcarent Oncology Care) seeking to overhaul the employer self-insured business or companies taking a data-driven approach to improving broader patient care pathways, focusing on aspects such as tumor boards, many enablement platforms are emerging that drive collaboration across patients, providers and payers. Other players, such as Azra AI, are using artificial intelligence to interpret data in real time to inform diagnosis through care management. Thyme Care offers a nursing-led platform that is equipped with data and analytics to proactively support cancer patients' decision-making and coordination throughout the process. Cohere Health looks to align clinical and financial decisions holistically across an oncology patient's care journey, enabling better collaboration and decision-making toward high-value care.

If set up correctly, enablement platforms have the potential to offer a new way to navigate members to high-quality, low-cost care, even if that means moving them to the best and least expensive facility in a patient-friendly way. Recent business models have an important cost-focused distinction that is fundamentally different in many ways, compared with the traditional, revenue-focused activities introduced by large cancer centers in the early 2010s (e.g., CTCA collaborates to provide free air transportation for cancer patients) that were often established to grow an existing provider's footprint.

In summary, a fundamental shift from historic cancer care business models must take place so digital health innovation can be adopted more quickly. With the emergence of rebundling technologies and tech-enabled services, we expect the progress of risk-bearing and risk-enablement platforms to be a key aspect for accelerating the evolution of the cancer business model.

Screening and diagnosis: Tech advancements and home-enabled services generating unique access points

Early cancer screening and diagnosis can often be the difference between life and death for cancer patients. According to the American Cancer Society, the five-year relative survival rate between two colon cancer patients, one at the "localized" SEER stage (91%) and one at the "distant" SEER stage (14%), is staggering. The importance of early screening and detection of cancer is well-established and well-known to clinicians and patients alike.

Over the past two decades, remarkable improvements in technologies have allowed physicians to find cancer at an early stage, long before symptoms appear. From better imaging procedures to various breakthrough diagnostic tests (e.g., liquid biopsy, single-cell genomic testing and multi-OMICs), the ability to screen and diagnose cancers has taken a giant leap forward.

Diagnostics

Significant improvements in sequencing technology and cost led to the rise of companies like GRAIL, which pitches a multicancer early-detection test that can screen over 50 types of cancer through a single blood draw for roughly $1,000. In addition to improving novel screening and diagnostic tests, public and private sectors have also done their fair share of raising cancer screening awareness and improving access. From various cancer screening campaigns from the private sector and nonprofits to CMS making multiple cancer screening (e.g., breast cancer and colorectal cancer) part of the Medicare Part C Star Ratings measurement, screening and detection play a front and center role in this evolution of cancer care.

While significant technological and policy improvements have been made, many unmet needs still exist. Barriers include transportation to diagnostic sites, long wait times for specialists and access to genetic counselors. Digital health innovators can play a crucial role in addressing these unmet needs. From a patient access to screening standpoint, we have seen noninvasive, home-based diagnostic tests, such as Cologuard, that are being used and promoted by payers over the past decade (e.g., Humana's covering Cologuard for colorectal cancer screening).

Innovative virtual health and home-based diagnostics companies (e.g., EverlyWell) have emerged over the past decade to improve access to diagnostic tests that can be done at point-of-care or with samples collected at home. It is not inconceivable that platforms like EverlyWell will move beyond health and wellness tests and use their user base to improve cancer screening and detection. Other emerging players that will dramatically reduce access barriers include home phlebotomy companies (e.g., GetLabs and Sprinter Health) that could make the blood draw more accessible. They can also assist in ongoing patient management for those patients who are ultimately diagnosed with cancer and could be enrolled in home-based cancer management and clinical trials.

Education

Educating patients on the impact of clinical treatment and lifestyle change remains a largely unmet need, regardless of patient acuity or circumstance. Cancer centers have taken a proactive step over the last two decades to provide education tools and services to equip the patients with more information (including the rise of tech-enabled directories, e.g., Mayo Clinic's online resources and library), but results can often be described as "information overload," causing patients to feel overwhelmed.

Systematic reviews for advanced cancer patients and informal caregivers (e.g., spouse and family members) have three common areas of unmet need: psychological, physical and healthcare services information.

Some of the biggest educational gaps for patients lie in the benefits and side effects of treatment as well as lifestyle changes, both after the initial diagnosis and when transitioning from active treatment to survivorship. Education and care coordination startups are emerging that empower their patients with tools such as automated side effect support (e.g., Ankr) that can assist in ongoing, asynchronous patient management to provide important chronic management and population health data.

Survivorship: An emergence of digital-hybrid communities and nutrition support to help with a patient's changing lifestyle

Patients will desire more individualized support as treatment and patient management become more targeted and personalized. In today's social media-connected world, cancer patients seek to relate to patients like them. First-generation, patient-focused social networking sites like PatientsLikeMe emerged in the 2000s, while new patient communities such as Inspire and This is Living With Cancer have emerged to provide community support and guidance on treatment options in more recent years.

In addition to peer support networks, expert-guided virtual clinics, such as VivorCare, have emerged to offer customized support and tailored programs that help cancer survivors manage their care outside the hospital setting, starting with programs designed for mental health. Nutrition-as-medicine continues to take off, and while many startups are focusing on gastrointestinal care (in many cases, starting with IBD and IBS patients), startups are emerging (e.g., Savor Nutrition and Season Health) that are well-positioned to fill the gap for oncology patients with food-as-medicine, similar to how these players are managing patients with chronic diseases such as diabetes.

About the Authors: Ian Chiang is a partner at Flare Capital Partners, a healthcare technology and services-focused venture capital firm. Prior to joining Flare, he was the SVP of product and innovation and a founding member of CareAllies, Cigna’s family of multipayer provider services, population health management, value-based care enablement and home-based care businesses. Previously, he was a digital health entrepreneur and a former management consultant at McKinsey & Company.

Jonathon George​ is an MBA candidate at Kellogg School of Management and a Flare Capital Scholar. While at Kellogg, he interned at the Mayo Clinic in their Oncology Division and at OCA Ventures as an investor. Previously, he was a management consultant at Chartis focused on health systems and services.

A special thanks to Aaron Gerber, Dan McCarthy, Matt Bettonville, Ryan Langdale, Robin Shah, Shawn Morris and countless others for providing their time and insights through multiple interviews. The team at Flare interviewed 20+ executives, founders, investors, patients and leaders from across the country on topics related to oncology, innovation and tech-enabled services for cancer care delivery. This article would not be possible without their support.

Acknowledgement: OCA Ventures

Additionally, thanks to Bob Saunders, Dana Sun and the OCA Ventures team for their support and review of the research this summer. Jonathon interned with OCA Ventures on the Digital Health team and is grateful for OCA's insights, comments and collaboration throughout the process.