US Cancer Care in Crisis, Says IOM Report

Roxanne Nelson

September 13, 2013

The cancer care delivery system in the United States is "in crisis," according to an updated report from the Institute of Medicine (IOM) released September 10.

The IOM's first report on the quality of cancer care in the United States was released in 1999. More than a decade later, the "barriers to achieving excellent care for all cancer patients remain daunting," the new report notes. The growing demand for cancer care, coupled with rising costs, the complexity of the disease and its treatment, and a shrinking workforce, constitutes a crisis in cancer care delivery.

"Cancer care is often not as patient-centered, accessible, coordinated, or evidence-based as it could be," said IOM committee chair Patricia Ganz, MD, from the University of California Los Angeles, in a video discussing the report.

To address the increasing challenges that healthcare providers face in trying to deliver high-quality cancer care, this report "charts a new course for cancer care," and makes 10 comprehensive recommendations for improving the quality of cancer care.

Driving the Crisis

Dr. Ganz detailed some of the trends that are helping to drive the crisis. One is that both the number of cancer cases and the cost will likely keep rising. The number of older adults is expected to double from 2010 to 2030. Because age is one of the strongest risk factors for cancer, it is projected that the number of cancer survivors will increase by 30% from 2012 to 2022, and that there will be a 45% increase in cancer incidence by 2030.

Another trend is the workforce shortages that are occurring in many of the professions involved in providing care to cancer patients. In addition, training programs lack the ability to rapidly expand.

Also, there is now a significant reliance on family caregivers and direct-care workers to administer care, and they often have limited training and support. Thus, the care that is provided is frequently fragmented and poorly coordinated.

The cost of cancer care is another major issue. It continues to rise and is increasing faster than in other sectors of medicine. Cancer costs have jumped from $72 billion in 2004 to $125 billion in 2010, and it is anticipated that they will increase by 39%, to $173 billion, by 2020.

Finally, advances that have been made in our understanding of the biology of cancer have increased the amount of information that physicians must master to treat patients appropriately. Plus, the few tools that are currently available for improving the quality of cancer care tend not to be widely used, and all have serious limitations.

The IOM report points out that the complexity of cancer can impede the ability of clinicians to develop optimal plans of care with patients and their families. As a result, decisions about care are often not evidence-based, and many cancer patients are not receiving adequate explanations about their treatment and are often not well informed about the possible late effects of treatment and its long-term effect on health.

Additionally, many patients are not receiving palliative care to help manage the symptoms and adverse effects of treatment. This occurs most often because the clinician "lacks knowledge of how to provide this care" or how to make referrals, or does not "identify palliative care management as an important component of high-quality cancer care," the report notes.

Charting a New Course

To address these increasing challenges, the IOM wanted to "chart a new course for cancer care."

In response to the need for high-quality evidence-based strategies to properly guide cancer care and ensure the efficient and effective use of scarce resources, the IOM updated its 1999 report.

An independent committee of experts was tasked with examining "opportunities for and challenges to the delivery of high-quality cancer care and formulating recommendations for improvement."

The goal of the resulting recommendations was to ensure the delivery of high-quality cancer care across the full continuum, from diagnosis to end-of-life care. The committee concluded that too often decisions about cancer care are not evidence-based and that many patients don't receive palliative care to manage their symptoms or the adverse effects of treatment.

Cancer care is especially complex for older adults because a number of factors need to be taken into account when understanding their prognoses and formulating their care plans. These include altered physiology, functional and cognitive impairment, multiple comorbidities, increased adverse effects of treatment, distinct goals of care, and the increased importance of social support. The current healthcare delivery system is poorly prepared to address these concerns in a comprehensive fashion, according to the IOM report.

IOM Recommendations to Address Concerns and Meet Goals

Provide patients and their families with understandable information about cancer prognosis, treatment benefits and harms, palliative care, psychosocial support, and costs
Provide patients with end-of-life care that meets their needs, values, and preferences
Ensure coordinated and comprehensive patient-centered care
Ensure that all individuals caring for cancer patients have appropriate core competencies
Expand the breadth of data collected in cancer research for older adults and patients with multiple comorbid conditions
Expand the depth of data collected in cancer research through a common set of data elements that capture patient-reported outcomes, relevant patient characteristics, and health behaviors
Develop a quality healthcare information technology system for cancer that enables real-time analysis of data from cancer patients in a variety of care settings
Develop a national quality reporting program for cancer care as part of a learning healthcare system
Implement a national strategy to reduce disparities in access to cancer care for underserved populations by leveraging community interventions
Improve the affordability of cancer care by leveraging existing efforts to reform payment and eliminate waste


"Every person with cancer should receive state-of-the-art, high-quality, compassionate care," said Clifford A. Hudis, MD, president of the American Society of Clinical Oncology (ASCO), in a statement. "The IOM's recommendations offer a solid framework for achieving that goal by helping us improve the quality of care today while developing evidence for safe and effective treatments for tomorrow."

ASCO was one of 14 sponsoring organizations of this report.


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