Casing Cancer: ASCO Launches New Series on State of the Disease

Despite its importance as a vital indicator of overall population health status, cancer suffers from an information deficit – particularly when considered from a global perspective. The American Society of Clinical Oncology [ASCO], the lead professional group in this space, is now working to rectify at least part of the gap with the launch of the first of what will be an annual report on the state of cancer care in the US. What is novel about ASCO’s approach is the reports will focus not only on dry statistics about incidence and mortality but on the cost of cancer care and the economic fortunes of practicing oncologists fighting on the front lines of treatment. In addition to the state of the science itself, ASCO deems theselatter two factors as most critical in registering progress against this complex web of conditions that we call “cancer.”

The following are some key findings from this first report, The State of Cancer Care in America: 2014:

• By 2030, the number of new cancer cases will have increased by 45 per cent [from 1.6 million today to 2.3 million cases annually], making it the nation’s leading cause of death.  Aging of the US population will account for much of the increase.

• The positive news is that death rates from cancer have decreased by 20 per cent since the early 1990s; new medicines account for a significant portion of the gain – there are more than 170 FDA-approved anti-cancer drugs in use today, 18 new cancer drugs were approved by the FDA in 2013 alone.

• Two-thirds of cancer patients now survive at least five years after diagnosis, up from less than two years in the 1970s.  Hence the evolution of cancer toward a chronic condition will continue apace, with 13.7 million people at present listed as “cancer survivors.” This number is slated to reach 18 million by 2022, up by 35 per cent.  Many survivors, however, are not symptom free, so treatment for this recovery cohort will consume billions of dollars in additional health system costs.  For reasons largely unknown, former cancer patients are more susceptible than the general population to other disabling conditions like diabetes, osteoporosis and CVD.

• Health reform – the 2010 Affordable Care Act [ACA] – is putting unprecedented pressure on the cancer service supply chain, with an estimated 29 million people obtaining access to health insurance over the next three years.  Many will be placed under the subsidized, cash strapped Medicaid public insurance network, where reimbursement for crucial prevention and screening services are quite low.  The result?  Demand for qualified clinical care oncologists will vastly outstrip the supply and some oncologists will limit accepting new patients or leave the profession entirely.

•  Costs for treating cancer will continue to rise, from $104 billion in 2006 to $174 billion in 2020.  The report identified high drug prices as a factor, noting the trend toward novel therapies administered in combinations of two, three or more drugs.  “With newly approved drugs costing as much as $100,000 for a course of treatment, combination therapies are already becoming cost prohibitive for many patients, even those with insurance.” Significantly, the report puts ASCO on record as advocating “a more rational system for drug pricing, encompassing pricing, insurance coverage and evidence based practice.” This should include “a common method for assessing the relative value of cancer treatment options to drive treatment choices, insurance benefits and research priorities.” But ASCO stops short of favoring initiatives that might imperil drug industry innovation.

• The oncology workforce is under severe pressure to meet the rising demand for cancer care.  The workforce is aging:  today, more practicing oncologists are 64 years and older than age 40 and younger.  Thus, many experienced practitioners will be retiring soon, with broad implications for the state and quality of cancer care.  Rural oncology services will suffer disproportionately – only 3 per cent of oncologists practice in rural areas of the country, despite the fact that a fifth of the US population reside there.  Small group practices in the South, Midwest and the Mountain states will bear the brunt of the convergence between costs and demand.

• Surveys of the “burnout” rate among oncologists depict a rising curve.  A 2012 ASCO survey of 1,500 oncologists/hematologists found that 45 per cent agreed with this depiction, with 34 per cent stating they would like to leave their current position within the next two years for something less stressful.  This same survey found that oncology practices see an average of 74 patients per day.

• Oncology practices are responding to these pressures in two words – getting bigger.  Average practice size in 2013 was 15 physicians, compared to nine in 2012.   More than a quarter of practices in 2013 said they were likely to formally affiliate with a community hospital in the coming year.

• The biggest concern of oncology practices is cost and payer-related issues, with particular emphasis on lower reimbursement rates under the federal Medicare program for the over 65 population, whose eligible patients account for more than half of all new cancer diagnoses. This means that for the foreseeable future, government programs will drive oncology practice revenues.  This can create perverse incentives that actually raise costs, as evidenced by what the report states is a sharp increase in administering chemotherapy drugs in more costly hospital facilities as opposed to physician offices, which have been diverting patients to hospitals due to declining Medicare reimbursements for many chemotherapy products administered in-office.

•  A major shift is predicted in how these practices get paid.  At present, almost 80 per cent of practices are rewarded on a fee-for-service basis.  But 63 per cent of practices expect they will transition to some form of coordinated care model in the next few years.

• The search for service and management efficiencies at the practice level is increasing. Nearly 20 per cent of practices anticipate laying off administrative staff in the next year.  Another option is to reduce involvement in the conduct of clinical trials.  ASCO says this is an important issue to monitor, given the negative impact it is likely to have on new drug research.

A full text of the ASCO report can be accessed here: www.asco.org/stateofcancercare.