Solution to US Cancer Care 'Crisis' Is Less Cancer Care

Nick Mulcahy

October 16, 2014

A solution to the troubles in the American cancer care delivery system can largely be found in the field of geriatrics and not traditional oncology, suggest the authors of an essay published online September 23 in Health Affairs.

That's because there is a need for a fundamental shift in cancer patient management — away from the current standard of aggressive treatment and toward a new standard that emphasizes overall well-being, say essayists Dr Carolyn Payne of Northwestern University, Evanston, Illinois, and Dr William Dale of the University of Chicago in Illinois.

They believe that the cancer care delivery system is currently in a state of "crisis," echoing the conclusion of a 2013 report from the Institute of Medicine.

The crisis includes spiralling costs of cancer care and an anticipated spike in the number of cancer cases as the Baby Boomer generation ages.

But most profoundly, the crisis is rooted in conventional thinking about cancer, the essayists suggest.

"We believe that this crisis is largely a result of our misconceptions about health," write Drs Payne and Dale.

The biggest misconception is the belief that all cancers should be aggressively treated, regardless of patients' age, health status, comorbidities, and likelihood of dying of other diseases, they argue.

Cancer gets priority in medical care, they say, because it is so feared: "cancer phobia" was coined as a term in 1955 and is still going strong, even if the phrasing has disappeared.

In a 2011 poll, Americans said the disease they feared most was cancer (41%), followed by Alzheimer's disease (31%); other diseases were all cited in small percentages.

The US government has made cancer a priority — the National Cancer Institute receives more funding than any other federal health institute, say the essayists.

But there is a major problem with the no-holds-barred "War on Cancer" approach. At a population-wide level, there are "more important health concerns" than cancer alone, particularly in older patients, according to Drs Payne and Dale.

Thus, clinicians need to "prioritize a patient's illnesses" and "focus less on cancer and more on other aspects of health," they assert, referring especially to older patients (> 65 years), who comprise most cancer patients (about 60%) and survivors (> 50%).

Support for this "new view" comes from a large, multidisciplinary study known as the National Social Life, Health, and Aging Project (NSHAP), which has been funded by the National Institutes of Health.

Study participants, all of whom were senior citizens and were "community-dwelling," were surveyed about their lives — health, finances, social engagements, relationships, and mental state.

The researchers employed 50 health-related characteristics, such as cancer status, blood pressure, depression, and physical functioning, to produce a health index, a measure of overall health.

One of the "most compelling" findings from the study was that a prior diagnosis of cancer was "not especially informative when predicting participants' current overall health status," say the essayists.

In the NSHAP study, a variety of factors — breaking a bone after the age of 45, poor mental health, disordered sleep, diabetes, cardiovascular disease, and frailty — were "much more important predictors" of health status than cancer.

Furthermore, people who had a "very good" or "excellent" health status were as likely to have cancer as those people with "fair" or "poor" health.

 
We were surprised to find just how un-important a prior cancer diagnosis was.
 

"We were surprised to find just how un-important a prior cancer diagnosis was in determining your current health," said Dr Dale about the NSHAP study in an email to Medscape Medical News.

The findings should not shock oncologists, suggest the essayists.

"Our finding that cancer may not be as harmful as other diseases should not be surprising. Many prevalent cancers are very treatable," they write. More breast and prostate cancer patients die of other causes than of their cancer, they say.

Dr Dale elaborated on the idea to Medscape Medical News: "There will always be special attention to a cancer diagnosis as long as it remains such a sudden, devastating disease. That being said, as cancer increasingly appears in older adults, who have many other problems, the need to think about cancer care in the context of one's overall health will be more and more important."

The overtreatment of cancer is a "disease-centric" mindset toward healthcare that often fails to improve patients' lives and puts our healthcare system in "crisis," say the essayists.

A solution to this approach would require a "new health care system" based on a "reconceptualization of health." In short, a holistic, patient-centered health system is needed to replace the disease-centric current model.

"Each patient's disease, or more likely multiple diseases, need to be considered in light of his or her overall function, psychology, financial situation, social support options and values," they write.

There are signs that oncology is shifting in the direction that essayists hope for, said Dr Dale.

"ASCO now has a very active 'supportive oncology' effort that is growing, and there is a community growing around 'geriatric oncology,'" he observed.

Three Big Changes Needed

However, Dr Dale also explained that three big changes are needed for the envisioned radical change in cancer care to occur.

First, "bundled" reimbursement is needed to tie together payment for "high-tech" specific treatments (eg, chemotherapy or surgery) with more "high-touch" care like geriatric assessment, physical therapy, and psychosocial counseling.

Second, new rules from the US Food and Drug Administration are needed that require new cancer treatments be tested in trials that include older patients with multiple other diseases or conditions. Thus, approved drugs would need to be more well-tolerated in general.

Third, better financial incentives are needed to encourage medical students to go into "high-touch specialties" like geriatrics, psychiatry, and primary care.

No relevant financial relationships were disclosed.

Health Affairs. 2013. Published online September 23. Full Text

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