Despite advances in cancer risk assessment, prevention, disease detection, drug development, and health-care delivery, which have led to unparalleled reductions in cancer incidence and mortality, access to affordable health care and increased administrative burdens placed on oncology practices threaten to derail that progress, according to ASCO’s State of Cancer Care in America: 2017 report.1 Released at a press briefing on Capitol Hill in Washington, DC, on March 22, and published in the Journal of Oncology Practice, ASCO’s annual report highlights promising trends in oncology care, which are providing patients with more effective treatment options and a greater chance of survival than ever before.
Developments featured in the report include advances in precision medicine and immunotherapy; the U.S. Food and Drug Administration (FDA) approval of 16 new and expanded-use cancer therapies, as well as a liquid biopsy test for lung cancer mutations and a next-generation sequencing test to identify patients with advanced ovarian cancer; the emergence of big data initiatives such as ASCO’s CancerLinQ™; and a shift from fee-for-service payment models to value-based care delivery systems that improve care and reduce cost.
We estimate that because of the advances we have made, 2.1 million cancer deaths have been averted since 1991, and that’s when cancer deaths were at their peak.— Daniel F. Hayes, MD, FACP, FASCO
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“[Overall] cancer mortality rates were lower in 2016 than they’ve been in previous decades,” said ASCO President Daniel F. Hayes, MD, FACP, FASCO, Professor of Internal Medicine, the Stuart B. Padnos Professor in Breast Cancer, and Clinical Director of the Breast Oncology Program at the University of Michigan Comprehensive Cancer Center, during the press briefing. “We estimate that because of the advances we have made, 2.1 million cancer deaths have been averted since 1991, and that’s when cancer deaths were at their peak. That’s also when I was an early physician and faculty member, and I’ve seen these [advances] occur in my career, and it’s been remarkable.”
Still, the challenges remaining, including uncertainty about the proposed repeal of the Affordable Care Act (ACA) and its replacement and President Donald Trump’s proposed federal budget cut of nearly $6 billion from the National Institutes of Health (NIH), could profoundly impact advances in oncology care just as the demand for it is on the rise.
According to ASCO’s State of Cancer Care in America: 2017 report, the U.S. population is growing, changing demographically, and aging, all of which are contributing to record numbers of new cancer diagnoses, survivors, and cancer-related deaths. Despite projections of the increased number of cancer survivors over the next 10 years—from 15.5 million in 2016 to 20.3 million by 20262—cancer is expected to surpass cardiovascular disease as the leading cause of death in the United States by 2020.3
Financial Burden of Cancer
Although the ACA has been successful in helping 20 million Americans gain health insurance, the number of people remaining uninsured is a staggering 27 million. Even for those with health insurance, the financial burden of cancer can be devastating and, in some cases, life-threatening. According to ASCO’s report, about 1 in 3 working-age cancer survivors incurred debt as a result of treatment costs; 55% of those who incurred debt owed $10,000 or more, and 3% declared bankruptcy.
Financial strain as a side effect of cancer treatment can manifest as increased emotional and physical distress, which actually affects a patient’s chances of survival.— Melissa Dillmon, MD
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“Financial strain as a side effect of cancer treatment can manifest as increased emotional and physical distress, which actually affects a patient’s chances of survival,” said Melissa Dillmon, MD, Chair-Elect of ASCO’s State Affiliate Council Executive Subcommittee, medical oncologist at Harbin Clinic in Rome, Georgia, and a presenter at the press briefing. “As the cost of cancer care, and of cancer drugs in particular, continues to increase, insurers are shifting more and more of the financial burden of cancer care to the patient, and the result is that cancer patients are paying more for their care than ever before.”
Disparities in health care based on race, ethnicity, socioeconomic status, and geography, as well as a lack of sufficient numbers of oncologists to serve patients in rural areas—there is only 1 oncologist per 100,000 rural residents vs 5 oncologists per 100,000 urban residents, according to the report—are also contributing to poorer outcomes for cancer survivors.
“The takeaway is that the U.S. cancer care system is far from providing adequate health care to all of its citizens with cancer. As physicians and as public servants, it is our responsibility to work toward addressing these disparities,” said Dr. Dillmon.
Workforce Trends
With cancer diagnoses in 2016 up by nearly 2% from just the year before and a growing number of cancer survivors needing long-term ongoing care—a record 26.1 million survivors by 2040, according to ASCO’s report—oncologists are struggling to keep up with persistent practice pressures, including administrative, economic, technologic, and staffing constraints, which are draining resources and taking time away from patients.
According to findings from ASCO’s annual Oncology Practice Census survey and Workforce Information System detailed in the State of Cancer Care in America: 2017 report, 54% of respondents said that increasing practice/facility expenses, such as staffing, equipment, overhead, rent, and administrative, were a top pressure. Other concerns included drug pricing (41%) and implementing electronic health records (39%).
The survey also found that practices from common medical specialties spent a total of $15.4 billion and an average of 785 hours per physician annually to meet quality-reporting requirements. Moreover, on average, medical practices completed 37 prior authorization requirements per physician weekly, taking 16 hours of clinician time.
The Path Forward
Despite these challenges, the State of Cancer Care in America: 2017 report finds that progress is being made in the delivery of value-based cancer care. The report credits implementation of the Medicare Access and CHIP Reauthorization Act of 2015 with spurring development and implementation of innovative payment models to incentivize high-quality cancer care and movement toward a value-based model of reimbursement.
Left to Right: Robin Zon, MD, FACP, FASCO; Daniel F. Hayes, MD, FACP, FASCO; and Melissa Dillmon, MD.
To ensure continued advancements in more effective therapies for cancer and patient access to high-quality care, and to reduce administrative burden on physicians, ASCO made the following recommendations:
All people with cancer should have health insurance that provides access to affordable, high-quality cancer care delivered by a cancer specialist in a timely manner.
The federal government needs to provide adequate funding and infrastructure support for cancer research, continued funding for the Beau Biden Cancer Moonshot, and adequate resources for the FDA to review and approve the safety and efficacy of cancer therapies and diagnostics efficiently and quickly.
Public and private payers should work with oncology providers and patients to develop new payment reimbursement models that support patient-centered cancer care across health-care teams and care delivery settings and that the Centers for Medicare & Medicaid Services support testing of multiple payment models in oncology, including ASCO’s Patient-Centered Oncology Payment model.
Policymakers and payers must streamline and standardize documentation and reporting requirements to reduce the administrative burden on oncologists, so they are able to focus adequate time and resources on patients.
The Administration needs to speed implementation of provisions in the 21st Century Cures Act that promote interoperability of electronic health records and prevent information blocking.
ASCO appreciates that the ACA isn’t perfect, but as proposals to alter or replace the law move forward, Congress should ensure that patients have access to adequate coverage for all cancer-related services, especially for those who are vulnerable and underserved in our communities.— Robin Zon, MD, FACP, FASCO
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“ASCO appreciates that the ACA isn’t perfect, but as proposals to alter or replace the law move forward, Congress should ensure that patients have access to adequate coverage for all cancer-related services, especially for those who are vulnerable and underserved in our communities. And all individuals with cancer deserve and should have health insurance that guarantees access to high-quality cancer care delivered by cancer specialists in a timely manner, regardless of the patients’ income or health status,” said Robin Zon, MD, FACP, FASCO, Chair-Elect of ASCO’s Government Relations Committee and Vice President and Senior Partner at Michiana Hematology-Oncology in Mishawaka, Indiana, during the briefing. Speaking directly to congressional aides in attendance at the briefing, Dr. Zon implored them, as they go back to their representatives, to advocate for these patients.
“To ensure protected access, the current ban on preexisting limitations, prohibition of lifetime coverage gaps, and maintenance of guaranteed renewability should be preserved. Congress should also address ongoing disparities in Medicaid by modifying Medicaid coverage requirements to include coverage of clinical trials, which they don’t currently do,” said Dr. Zon. “ASCO is very eager to work with Congress and the Administration to ensure that the proposals to alter insurance coverage will include provisions to support the millions of cancer patients as well as survivors living in the United States today.”
She also reiterated the importance of providing adequate funding for the NIH and the National Cancer Institute (NCI) and asked that Congress reject the Administration’s budget proposal to cut $6 billion in NIH funding. “It would devastate the infrastructure of the NIH,” said Dr. Zon. “ASCO encourages Congress to reject that proposal and, in fact, try to promote increased support for federal agencies, specifically the NIH and the NCI.” ■
Disclosure: Drs. Hayes, Dillmon, and Zon reported no potential conflicts of interest.
References
1. The State of Cancer Care in America, 2017: A Report by the American Society of Clinical Oncology. J Oncol Pract. March 22, 2017 (early release online).
2. American Cancer Society: Cancer Treatment & Survivorship: Facts & Figures, 2016-2017. Available at www.cancer.org/acs/groups/content/@research/documents/document/acspc-048074.pdf. Accessed March 24, 2017.
3. Weir HK, Anderson RN, Coleman King SM, et al: Heart disease and cancer deaths—Trends and projections in the United States, 1969-2020. Prev Chronic Dis 13:E157, 2016.
