In March, ASCO published its second annual report, The State of Cancer Care in America: 2015.1 Its findings show a mixed landscape, on the one hand, spotlighting advances in therapy and improving survival rates, but on the other, describing a cancer care system under stress from increasing demand for services, disparities in access, skyrocketing health-care costs, and an aging oncology workforce.
The report’s assessment of the demographic, economic, and oncology practice trends that will impact cancer care in the United States over the coming years was delivered at a congressional news briefing in Washington, DC, by Richard L. Schilsky, MD, FACP, FASCO, Chief Medical Officer of ASCO; Philip Stella, MD, incoming Chair of ASCO’s Government Relations Committee and Medical Director of the Oncology Program at St. Joseph Mercy Hospital in Ann Arbor, Michigan; and Robin Zon, MD, FACP, FASCO, Chair of ASCO’s Clinical Practice Committee and a medical oncologist at Michiana Hematology Oncology in South Bend, Indiana. They were joined by Rep. Andy Harris, MD (R-MD), who talked about the need to focus resources at the National Institutes of Health on biomedical innovation and treatment in cancer care.
Progress and Challenges
According to the report, 2014 saw significant progress in the improvement in the 5-year cancer survival rate for many cancer types, contributing to a record 14.5 million cancer survivors, and in the availability of new drugs, medical devices, and tests for the diagnosis, treatment, or management of cancer. In addition to 10 new drugs and 4 new medical devices and tests approved last year by the U.S. Food and Drug Administration (FDA), more than 771 promising new cancer therapies are in the development pipeline.
However, the increase in the number of cancer survivors (and their need for long-term monitoring for late complications or side effects from treatment and secondary cancers) coupled with an aging population driving up cancer incidence (a 45% increase in cancer incidence is expected by 2030) are resulting in a growing demand for cancer care. In addition, the report’s findings show that in 2014, the first year of implementation of the Affordable Care Act, nearly 8 million Americans signed up for health insurance and millions more are obtaining access to insurance through the expansion of Medicaid and other programs, and those numbers are expected to rise significantly as full implementation of the new law takes effect. The consequences of all these factors, said the report, are adding pressure to an already strained and fragmented health-care system.
This year’s report also singled out the rise in obesity—more than one-third of adults and nearly one-fifth of children in America are now considered obese—as a major contributor to an additional 500,000 cancer cases over the next 15 years. Another emerging public health concern cited in the report is the use of electronic cigarettes, which experts fear may create new smokers.
Disparities in Care
Despite advances in more effective diagnostic strategies and treatment in cancer care, not all Americans are benefiting from the progress. For example, the ASCO report finds that African Americans are 2.5% more likely to develop cancer than whites and are 19.5% more likely to die from their disease.
“This is unconscionable when you think about it,” said Dr. Stella during the press briefing. “We’ve got to be able to start to focus on these issues not only scientifically, but in terms of access to care as well.”
Troubling Trends
Although ASCO reported that the number of hematologists and/or medical oncologists providing care in the United States grew a modest 1.6% to about 11,700 from the previous year, several troubling trends are projected to derail patient access to care. They include:
- An aging oncology workforce—Nearly 20% of oncologists are 64 or older.
- Poor oncology coverage in rural areas—Although more than 59 million Americans live in rural areas of the country, just 600 hematologists and medical oncologists (5.5%) serve those communities.
- The rise of professional burnout—Data in the report show that one-third of oncology fellows experience high levels of professional burnout (at least one event per week) and do not plan to work as many hours as senior colleagues. Failure to address physician burnout and other quality-of-life issues, warns the report, could lead oncologists to reduce their patient volume or retire at an earlier age. “Oncology is a very demanding field emotionally and intellectually,” said Dr. Zon. “We are dealing with patients who have a serious disease and may be dying, and are struggling to keep up with the pace of a rapidly advancing field.”
- Growing concerns over cost of care and financial sustainability of oncology practices—ASCO’s 2014 Oncology Census2 of more than 10,000 oncologists in community practices, hospitals, and academic facilities found that cost and payer pressures were the most pressing practice concerns, especially among physician-owned and hospital-based practices. Rising drug prices, growing administrative burdens caused by insurance issues (resulting in reduced time available for patient care), and practice consolidation (one-quarter of all community-based oncology practices report the likelihood of becoming affiliated with a hospital over the next year) have all added to practice uncertainty about the ability to stay in business.
“With regard to practices, no matter where we are, we are experiencing rough waters, and we don’t see it getting better any time soon,” said Dr. Zon. “In the time I’ve been in practice over the past 17 years, I’ve seen a shift in the landscape of where oncology is practiced. The survey shows that we have a serious problem. The reason we are so concerned about small community practices is because they really are the backbone of the U.S. cancer care delivery system, caring for more than one-third of all patients newly diagnosed with cancer.”
Quality and Value
The escalating cost of cancer care—according to the ASCO report, direct medical costs of cancer care are currently at $86 billion annually and could increase by as much as 39% by 2020—and questions about the sustainability of the U.S. cancer care delivery system continue to dominate concerns among both oncologists and patients. In response, ASCO is developing a framework for evaluating the value of new cancer treatment options across three domains: treatment efficacy, toxicity, and cost.
The Society aims to provide oncologists with tools needed to assess value of interventions and use these in discussing treatment options with their patients.
“As we move to addressing value, we’ve been interested in this area for some time,” said Dr. Schilsky. “ASCO has had a Cost of Care Task Force since 2007, and a couple of years ago, we transformed that [task force] into the Value in Cancer Care Task Force, because we realized that it is not all about cost. There are often times when very costly therapies are well justified and have high value because they have high impact. We still don’t have as many of those in cancer as we would like, but clearly it is a value proposition more so than strictly a cost proposition.”
Preliminary information about the initiative is available at asco.org/value.
Recommendations for Countering These Challenges
Overcoming the challenges outlined in the ASCO report will take effort from everyone involved in oncology care, including clinicians, researchers, and the broader cancer community, said Dr. Schilsky. “The solution has got to be that every one of us in the health-care system has to do our part to deliver the best-quality, evidence-based care, and to do it in a way that ensures access to all members of our population,” he said.
ASCO is recommending the following strategies to help address the challenges described in the report. They include:
Ensuring that all publicly funded insurance programs offer consistent and appropriate benefits and services for patients with cancer
- The Centers for Medicare & Medicaid Services (CMS) should standardize benefits and other program elements in Medicare and Medicaid.
- Congress should eliminate inconsistencies in coverage and benefits in Medicaid patients enrolled pre– and post–Affordable Care Act and ensure that Medicaid coverage includes clinical trials.
Pilot testing multiple innovative payment and care delivery models to identify feasible models that promote high-quality, high-value cancer care
- CMS should expand efforts to pilot alternative payment models to identify innovative strategies that allow practices flexibility to deliver high-quality, high-value care while containing cost.
- Congress should provide a fair, adequate, and stable payment environment for oncology practice, including repealing and replacing the sustainable growth rate (SGR) formula. [Editor’s note: The Medicare Access and CHIP Reauthorization Act of 2015, which eliminates the 21% cut in Medicare reimbursement, was passed by the House of Representatives on March 26 and by the Senate on April 14; President Barack Obama signed the bill into law on April 16.]
- Oncology professionals should engage in testing and evaluating new payment and care delivery models and in developing measures of accountability for the care delivered.
- Private insurers should partner with CMS, patients, and providers to test promising new payment and care delivery models to determine the impact of alternative strategies on the cancer care delivery system.
Promoting high-value care by advancing and supporting transparency and shared decision-making with patients
- CMS should make every effort to improve its publicly released data and provide appropriate information to help the public understand the context of the data.
- Congress should require that health information vendors create products that promote interoperability and enable researcher use of standardized data in a secure environment to advance high-quality health care.
- Oncology professions should discuss personal goals of care, potential treatment options, expected benefits, and the physical and financial impacts of treatment options with every patient with cancer.
- Private insurers should ensure that publicly shared information about providers is accurate, in context, and meaningful to the intended audience.
- Professional organizations should offer tools and information that facilitate and incorporate shared decision-making into practice.
Restoring Research Funding
Dr. Schilsky ended his remarks with an appeal to Congress to increase funding for the National Institutes of Health (NIH). “We are asking for support in appropriations of at least $32 billion for the NIH and $5.32 billion for the National Cancer Institute (NCI) for FY2016,” said Dr. Schilsky. “There is nothing more important to the future of our country than predictable, sustainable, inflation-adjusted increases in the NIH and NCI budgets.” ■
Disclosure: Drs. Schilsky, Stella, and Zon reported no potential conflicts of interest.
References
1. Kirkwood MK: The state of cancer care in America, 2015: A report by the American Society of Clinical Oncology. J Oncol Pract. March 17, 2015 (early release online).
2. ASCO Oncology Census: Continuing Practice Adaptation. Available at www.asco.org/practice-research/cancer-care-america-2015/asco-oncology-census-continuing-practice-adaptaton. Accessed April 21, 2015.
