In elevating Duke’s endo-oncology care from clinic to program status in January 2022, the first priority for endocrinologist Afreen Shariff, MD, director of the new Duke Endo-Oncology Program and an associate director for the Cancer Therapy Toxicity Program at the Duke Cancer Institute’s (DCI) Center for Cancer Immunotherapy, was to address the access to care bottleneck and ensure patients see endo-oncologists in a timely manner by reducing the average 87-day wait time for referrals.
 
Nearly eight months later, the average wait time for receiving recommendations from the endocrine team at the Duke Endo-Oncology Program—a transdisciplinary program between DCI and the Division of Endocrinology, Metabolism and Nutrition—is now two days.
 
Shariff describes the solution as “an enhanced expert triage system that creatively utilizes an existing e-consult platform which makes seeing the right patient, at the right time, at the right place possible.”
 
Shariff created a cancer-focused electronic consult service with Duke Telehealth Services to provide expert triage through electronic consultations and acuity-based access to Endo-Oncology clinic providers. The intervention reduced wait times and significantly lowered hospital admissions for endocrine toxici­ties from 11% to 4% among Duke patients.

Her mission, Shariff explains, is to create a program that allows patients with incident and existing diseases of the endocrine system to continue effective cancer therapy while receiving the highest-quality care through innovation, collaboration, and compassion.

Endo-oncology is an emerging field that specializes in caring for patients with cancer who are living with new or pre-existing endo­crine disease. Both cancer and cancer treatments are associated with a wide variety of endocrine diseases, including pituitary dysfunction, new and worsening diabetes, steroid-induced hyperglycemia, drug-in­duced thyroid abnormalities, bone disease, and primary malignancies of endocrine glands resulting from direct damage or radiotherapy.
 
These effects are recognized readily in chemotherapy-treated patients and childhood cancer survivors. More recently, novel targeted cancer therapies, including those that target the insulin signal­ing pathway and immune checkpoints, for example, have become standard treatments for many aggressive tumors due to their success in preventing cancer pro­gression and improving cancer-free survival.
 
Shariff, who has more than seven years of experience in treating cancer and cancer treatment related endocrine toxicities, identified an unmet need for specialized cancer support and started an immunotherapy-focused clinic in 2017 to address it. The practice has grown during the past five years, and immunotherapeutic agents are now FDA approved for more than 30 malignan­cies.
 
“Demand has certainly grown since we started the program,” she says. “Initially in the clinic, we used to see only toxicities from cancer drugs. Now we are including patients with any endocrine side effect from cancer and cancer therapies. This really expanded the scope of our practice."
 
The Duke Endo-Oncology Program has four key target areas:

• Value-based subspecialty care for cancer patients
• Transdisciplinary clinical and research infrastructure development
• Multi-disciplinary col­laboration
• Education for patients, as well as oncology and endocrinology clinicians and trainees.

Endocrinology, Shariff explains, is “like an amoeba when it comes to oncology,” as it touches many different facets of cancer care. “Now we see oncologists thinking preemptively about these patients before starting therapy because we have a programmatic structure to support them.”
 
Shariff is also working with the Duke Institute of Health Innovation to develop an AI-assisted clinical decision tool to predict hospitalizations in cancer patients resulting from toxicities. Her vision is that the Endo-Oncology Program will support an end-to-end model by predicting, acting on, and preventing avoidable admissions resulting from common side effects seen in immunotherapy treated patients.

This service has earned Dr. Shariff an ACCC Innovator Award.