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ASCO’s 2016 State of Cancer Report: Delivering High-Value Quality Care Remains Elusive

April 2016, Vol 7, No 3

On January 16, 2016, President Barack Obama promised a “moonshot” to accelerate national progress to combat cancer, but delivering on that promise faces many challenges. According to the American Society of Clinical Oncology (ASCO)’s third annual comprehensive assessment, The State of Cancer Care in America, 2016, despite the availability of promising new drugs and technologies, systems for delivering these therapies need revamping (J Oncol Pract. 2016 Mar 15. Epub ahead of print).

“Continued scientific and medical progress is urgently needed to improve cancer care, but treatment advances will only be as good as our ability to deliver them to patients,” stated ASCO President Julie M. Vose, MD, MBA, Chief, Division of Oncology/Hematology, University of Nebraska Medical Center, Omaha, in a press release. “If we hope to achieve Vice President Joe Biden’s goal of doubling the pace of progress, the work of strengthening cancer care delivery has to be pursued just as aggressively as the cancer research agenda.”

Cancer Care Has Become More Complex

Progress in cancer care, such as new, more sophisticated therapies; expanded screening capabilities; and improved mortality statistics for many types of cancer, has to be balanced against challenges that include a growing demand for cancer care, unchanged mortality for bladder and brain cancers and melanoma, and increased mortality rates for pancreatic and liver cancers.

In addition, the rates of cancer incidence and mortality vary by race and ethnicity. In 2015, African-American women had higher rates of breast cancer than other racial groups for the first time.

These trends underscore the need to improve outcomes for all patients with cancer. Three areas of cancer care have become more complex:

  • Screening
  • Implementing precision medicine treatments
  • The aging of the US population with a growing number of patients with comorbidities.

“Virtually every aspect of cancer care has become more complex in recent years, and this presents profound challenges. New approaches to cancer treatment are extending and improving lives, but they also raise tough questions about how to apply what we’re learning for patients quickly, efficiently and equitably,” Dr Vose stated.

Challenges and Pressures

Although screening improves mortality for breast, colorectal, and cervical cancers, the relationship between screening and mortality is not straightforward for other cancers. Thus, appropriate decisions should be based on the need to avoid overscreening and underscreening.

The report acknowledges that precision medicine has tremendous promise in expanding treatment options for specific groups of patients, yet the “overwhelming” data generated by genetic screening may not be actionable for many patients. Universal access to the best therapies remains a challenge. The current evidence suggests that the Affordable Care Act is a step forward in this regard. However, approximately 35 million people aged <65 years were uninsured in 2015, and an additional 31 million are underinsured, because their deductibles and/or out-of-pocket costs exceed their current incomes. Insurance coverage remains inconsistent across insurers and plans.

The “alarming” rising cost of cancer care has a profound impact on the lives of patients with cancer and their families, highlighting concerns about “financial toxicity.” An estimated 10% to 20% of patients do not adhere to their prescribed therapy, because they cannot afford it. Patients with cancer are more likely to declare bankruptcy than people without cancer.

Trends in the workforce reflect volatility in oncology practices. Many independent community practices are under siege while they grapple with economic pressures, market dynamics, and shifts in reimbursement policy. Moreover, these trends, along with an increasingly constrained workforce, raise questions about the capability of the US cancer care system to respond to the projected growth in demand for cancer care in the near future.

The oncologist workforce remains stable, with more than 11,700 hematologists and/or medical oncologists in the United States, but specialists continue to age and practices are concentrated in metropolitan areas, reducing the likelihood of delivering optimal cancer care in other areas of the country.

An ASCO survey that sampled several practice types showed that respondents are concerned about practice pressures, alternative payment models, clinical pathways, electronic health rec­ords, and costs of care. In fact, 45% of the survey respondents cited the use and implementation of electronic health records as the number one practice pressure in 2015.

The report states that the inconsistent adoption and lack of compatibility (ie, interoperability) of different health information technology (HIT) systems prevents sharing crucial information to optimize cancer care.

ASCO’s Recommendations for High-Value Care

ASCO’s report emphasizes 4 key opportunities for improving the delivery of high-value cancer care—insurance coverage, payment reform, value of cancer care, and the adoption and interoperability of HIT.

The key recommendations include:

  1. Expand publicly funded insurance programs to provide consistent and adequate benefits for patients with cancer. The report urges parity for the coverage of oral, intravenous, and self-injectable therapies and for participation in clinical trials under Medicaid
  2. Multiple payment and care delivery models should be tested to identify effective approaches to provide high-­quality, high-value care. The Medicare Access and CHIP Reauthorization Act of 2015 can further this goal
  3. Improve value in cancer care by working with stakeholders to develop alternate payment models as well as clinical guidelines and resources. The Choosing Wisely campaign is an example of an initiative that can reduce waste and optimize cancer treatment. ASCO has published a conceptual framework to help assess the value of treatment options and to develop treatment plans to fit with patients’ needs, values, and preferences
  4. HIT platforms are needed to support efficient coordinated care. Platforms to analyze big data, such as ASCO’s CancerLinQ, represent effective steps to make data-sharing more efficient.

Although the report cites the alarming and unsustainable trends in costs of care as part of the problem, it does not make specific recommendations aimed at the pharmaceutical industry. Rather, the recommendations are aimed at Congress, professional organizations, and stakeholders. ASCO is committed to working with policymakers to improve patient access to high-quality and high-value care.

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