State of US Cancer Care: Like a Dickens Novel?

Roxanne Nelson BSN, RN

March 15, 2016

The current American cancer care system presents a decidedly mixed picture, according to a new report from the American Society of Clinical Oncology (ASCO). Scientific and practice innovations and exciting progress in treatment are contributing to declining rates of cancer mortality.

However, these accomplishments are thwarted by persistent challenges that prevent the delivery of high-quality care to every cancer patient.

"As we release this report our nation has much to be encouraged about in cancer care," said Julie Vose, MD, president of ASCO. "We have seen mortality rates decline on the average of 1.5% annually over the past decade, with even greater declines for the 4 most common cancers.

"Additionally the number of survivors is expected to grow from 14.5 million in 2014 to 19 million by 2024," she said. "However all of these advances are set against a backdrop of unsustainable cost and a volatile practice environment."

These advances are set against a backdrop of unsustainable cost and a volatile practice environment.

The State of Cancer Care in America, 2016: A Report by the American Society of Clinical Oncology, published today in the Journal of Oncology Practice and presented at a Congressional briefing in Washington, DC, is ASCO's third annual assessment of national trends in cancer care delivery.

Speaking during the hearing, Representative Michael Burgess, MD, representing the 26th congressional district in Texas, echoed this seeming paradox of cancer care.

"Do you ever feel like you're living in a Dickens novel?" he asked, referring to The Tale of Two Cities. "It was the 'best of times and the worst of times'…on the science side, things are happening, particularly in your speciality, but on the policy side, things couldn't be any grimmer."

Dr Burgess, who serves on the House Energy and Commerce Committee and is Chairman of the House Energy and Commerce Subcommittee, noted that there were "some pretty rocky times, when no one could agree with each other and that was all in the headlines."

But there were accomplishments, one being the repeal of the sustainable growth rate (SGR) formula for physician reimbursement under Medicare. "It was a milestone to achieve," he said, "And one step forward in the process."

Progress Made

In 2015, the report notes, new and more sophisticated therapies entered the marketplace, screening capabilities were expanded, and mortality rates improved for a number of cancer types.

The US Food and Drug Admiration (FDA), for example, approved 15 new drugs and biologic therapies to a list of more than 180 anticancer agents and expanded indications for 12 previously approved treatments.

In 2015, the first biosimilar to an existing biologic product also received FDA approval, and thus paved the way for nonbranded products in the biological drug sphere.

President Barack Obama highlighted the need for precision medicine, and immunotherapy gained momentum within the cancer community.

There was also intensified interest in boosting funds for cancer research after a 10-year period of stagnant funding.

Congress increased fiscal year 2016 federal cancer research funding by 5.34% over the previous year, and the much touted "moonshot" initiative would commit over $700 million and pursue new collaborations to accelerate progress.

Complexity of Care

However, the report also notes that there is much room for improvement.

It highlights a number of critical issues that could hinder the ability to deliver on the promise of advances in cancer research and treatment.

For starters, the delivery of care has become increasingly complex. This year's report focuses on three areas that affect the complexity of cancer and its treatment: cancer screening, implementing precision medicine treatments, and the aging of the US population.

The complexity involved in implementing cancer screening is based on the need to avoid over- and under-screening and make appropriate screening decisions.

For precision medicine, the complexity lies in the struggle to manage overwhelming amounts of information about risks and benefits of genetic testing and its role in selecting treatment.

Finally, an aging population means there will be an increasing number of patients whose cancer will be complicated by comorbid conditions.

Affordability

Rising costs of cancer represents a growing fiscal challenge, commented Blase Polite, MD, MPP, from the University of Chicago and Immediate Past Chair of ASCO's Government Relations Committee. "The cost is expected to be $173 billion by 2020."

"The financial burden is two-fold," said Dr Polite. "It's the cost of cancer drugs themselves as well as the increased burden that patients face with rising deductibles and higher cost sharing by insurance companies."

Despite the passage of the Affordable Care Act (ACA), approximately 35 million nonelderly adults remain uninsured, and 31 million more are underinsured because their deductible and/or out-of-pocket costs are high relative to their household income.

Coverage across insurers and plans also remains inconsistent, and Medicaid expansion continues to be incomplete.

ASCO notes that one survey of clinical trial sites also found persistent denials of coverage for the routine costs of clinical trials, despite the ACA coverage requirement.

Cost of care is another issue, and one that continues to escalate. Most notable are the cost of cancer drugs and the growing patient burden associated with rising deductibles and cost shifting.

Some estimates suggest that as many as 10% to 20% of cancer patients may not be taking prescribed treatments because of cost.

"While drugs are overall a small part of cancer costs, they do receive a lot of attention, because of their alarming price tag and substantial price increase in recent years," Dr Polite said. "We understand that this is a major issue and we all have to get together to figure out how to solve."

Access Issues

The volatility in the oncology practice environment continues, with no let-up in sight.

Economic pressures, market dynamics, and shifts in payment policy have combined to put many independent community practices in jeopardy. Many have already closed their doors or been purchased by hospitals.

These trends and an increasingly constrained workforce raise concerns about how the cancer care system will cope with the projected surge in demand for cancer care in the not-so-far-off future.

At the hearing, Debra Patt, MD, MPH, from Texas Oncology, Austin, also pointed out that there are still ethnic and racial disparities in cancer care.

"They continue to exist in cancer patients arising from a complex set of factors."

For example, black Americans are 2.5 times more likely to develop cancer than white Americans, and black men 27% are more likely to die from cancer than white men.

ASCO points to three trends that may impede future access to high-quality cancer care.

There is an imbalance between the number of oncologists practicing in rural areas and the number of Americans living in these regions (5.6% vs 11%). Many cancer patients in rural communities have to travel a distance to access cancer care.

Dr Patt emphasized that "50% of the oncologists in this country reside in 8 states — California, New York, Texas, Florida, Pennsylvania, Massachusetts, Ohio and Illinois.

"So there is a geographic disparity in oncology care," she said.

A second trend is the dramatic increase in the number of cancer patients. Between 2010 and 2030, a 45% increase is projected, largely due to the aging of the US population.

"An important demographic is the proportion of cancer patients who are elderly," Dr Patt said. "The majority of cases are 65 years and older, and this demographic is growing."

Third, the oncology workforce is also aging. While the size of the overall oncology workforce has remained relatively stable, with more than 11,700 hematologists and/or medical oncologists providing cancer care, they are growing older. The specialty continues to age and about 20% of oncologists are now over the age of 64.

The expected growth in the number of oncologists entering the field by 2030 is not predicted to match the growth in patients. In addition, oncologists are largely practicing in metropolitan areas.

Health IT — Not There Yet

Another issue is the inconsistent adoption and lack of interoperability of health information technology (IT). The integration of electronic health records (EHRs) has the potential to significantly improve the quality of cancer care, but has led to significant administrative burdens. In turn, this reduces the time that physicians could be spending caring for patients, conducting research, teaching, and other professional activities.

Almost half (45%) of oncology practices surveyed by ASCO pointed to EHR implementation or its use as the leading practice pressure, surpassing all other pressures in 2015.

The incompatibility of different health IT systems currently in use by providers also inhibits the sharing of information that is needed for optimal cancer care.

New Strategies Needed

ASCO emphasizes that this new report points to the importance of capitalizing on new opportunities to deliver high-quality, high-value cancer care, primarily in four key areas: insurance coverage, payment reform, value of cancer care, and health IT adoption and interoperability.

They recommend the following as a means of addressing the barriers described in this paper:

  • It is imperative to ensure that all publicly funded insurance programs offer consistent and appropriate benefits and services for patients with cancer: This should include parity in benefits and coverage for oral and self-injectable cancer drugs and intravenous cancer drugs, and for clinical trial participation under Medicaid.

  • Multiple innovative payment and care delivery models need to be tested to identify feasible solutions that promote high-quality and high-value cancer care. Professional organizations should develop innovative care models that can be tested by the Center for Medicare & Medical Innovation and private payers as they explore better models to incentivize and support high-quality, high-value patient care.

  • Part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) effectively reversed required payment cuts and replaced SGR with a plan to return stability to the reimbursement of physician services by the Medicare program. But Dr Burgess emphasized that "the implementation of MACRA is also critical and I urge ASCO to weigh in on that, and see what is important to your patients." Dr Polite agreed. "As MACRA is implemented we need to make sure it is being done as Congress intended it to be."

  • ASCO calls on policy makers to take steps to make data sharing fast, efficient, and secure so that these new initiatives can achieve their potential for patients. Thus, it is imperative to advance health information technology that supports efficient, coordinatedcare across the cancer care continuum. Congress should require that health information technology vendors create products that promote interoperability, and policy makers should ensure that patients and providers do not bear the cost of achieving interoperable EHRs and that companies refrain from information blocking.

  • Finally, there is a dire need to recognize and address the unsustainable trend in the cost of cancer care. Professional organizations should develop and disseminate clinical guidelines, tools and resources such as Choosing Wisely in order to optimize patient care, reduce waste, and avoid inappropriate treatment. Congress should work with stakeholders to pursue solutions that will curb unsustainable costs for all stakeholders, and payers need to design payment systems that incentivize patient-centered, high-value care and invest in infrastructure that supports a viable care delivery system.

JOP. The State of Cancer Care in America, 2016: A Report by the American Society of Clinical Oncology. Published online March 15, 2016. Abstract

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