WASHINGTON—The American Society of Clinical Oncology has released its first-ever comprehensive report on cancer care in the United States, a sweeping assessment showing a troubling mismatch between the growing demand for care and an inadequate oncology workforce. ASCO calls it a “perfect storm” of challenges which could “undermine patients' access to life-saving advances.”
While the demand for cancer services will nearly double in 10 years, the new report, a 60-page document released at a Capitol Hill briefing here, projects that there will be a shortage of 1,487 oncologists by the end of the decade. In stark terms, this mismatch means that nearly 450,000 new cancer patients will likely face obstacles in getting the care they need.
The Institute of Medicine has also identified major problems in the cancer care delivery system. Its comprehensive 2013 report, “Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis,” painted a grim picture of increasing demand for care as the population ages, rising costs, increasing complexity in diagnosis and treatment, and oncology workforce shortages (OT 10/10/13 issue).
At the briefing, ASCO President Clifford A. Hudis, MD, Chief of the Breast Cancer Medicine Service at Memorial Sloan Kettering Cancer Center, said oncologists and other health care professionals have specific concerns that “access to the care we have developed is being threatened,” and that all those in the field feel a collective responsibility to address the issues detailed in the document.
The report, “The State of Cancer Care in America: 2014,” was “an ambitious undertaking,” he said, noting that ASCO intends to update it every year.
The Science Has Never Been More Promising
The science has never been more promising—“and that's why many of us are oncologists,” he said.
Asked by OT at the briefing how the field of oncology can attract young physicians to meet the increasing demand for cancer care, Hudis said: “Life-saving and life-extending advances in the cancer field will excite younger physicians and draw them to oncology. I think it starts with the investment in science and technology.”
He said that when he started out as a young physician, he had specifically chosen oncology because he believed he would see the greatest change in care in this specialty over the course of his career—“and in large measure I have not been disappointed.”
The ASCO report pinpoints oncology's aging workforce; in 2008, the proportion of oncologists age 64 and older surpassed the proportion under age 40 for the first time. For the last eight years the gap has continued to widen, with oncologists being slightly older than the general physician population. Currently, one of every five cancer specialists is over age 64.
Despite the finding that oncologists are generally satisfied with their careers, the report cites burnout as a potential problem, and states that professional organizations should monitor and address it.
The report also found that:
* By 2025 the number of new U.S. cancer cases is expected to grow by as much as 42 percent, requiring an estimated 15,721 hematologists/oncologists providing full-time equivalent care. But the supply of hematologists/oncologists is expected to grow by only 28 percent during that time. These numbers do not take into account increasing demand as a result of expanded insurance coverage under the Affordable Care Act, which could increase the need for hematologists/oncologists by an additional 130 specialists per year by 2025.
* The survival of small and mid-sized oncology practices, especially those in rural areas, is in jeopardy, with almost two-thirds of practices with one or two physicians reporting that they are likely to merge, sell, or close in the next year. Since the majority of cancer patients receive care in the community, this trend is a major threat to access to cancer services. While one out of five Americans lives in a rural area, only one out of 33 oncologists practices in a rural area.
* The costs of delivering cancer care are unsustainable, and are expected to escalate by 40 percent from 2010 to 2020.
* Disparities in access and outcomes caused by race and insurance coverage persist in the United States. The report notes that the death rate for African American males with cancer is 33 percent higher than that for white males, and 16 percent higher for African American females than that for white females. The incidence of cervical cancer in Hispanic women is twice that for white women.
At the briefing, Carolyn B. Hendricks, MD, PA, a breast cancer specialist in solo practice in Bethesda, MD, put a face on the challenges of small practices trying to stay in business: “I am seriously considering closing my practice,” said Hendricks, Chair of ASCO's Quality of Care Committee and a member of the National Mammography Board of Quality Assurance.
“I really want to preserve a small and nurturing practice,” she said, but the economics are against her. She described having to pay more than $3 million in advance for chemotherapy drugs; “I now have a significant amount of debt,” she said.
What is unfortunate for patients, she noted, is that they pay more out of pocket for chemotherapy in the hospital than they would in an outpatient setting in a practice such as hers.
The ASCO report is not all gloom and doom, however. “We are not here just to point out the problems… we want to develop solutions,” Hudis said. Thus, one of the report's recommendations is to develop and test new care delivery and payment models that preserve the viability of small community practices while supporting and encouraging new models of care delivery such as the patient-centered medical home.
ASCO data show that oncology practices seem to be increasing their use of advanced practice nurses and other non-physician care providers, a trend that can help oncologists make the most of their time with each cancer patient.
The report spotlights an innovative care delivery model in Iowa; ASCO collaborated with the University of Iowa to probe how oncology services are delivered in that state, which has many rural residents. Iowa sponsors visiting consulting clinics (VCCs) to provide cancer care on a set schedule (once a month or more) in rural locations. And although the VCCs provide greater access to oncology services in rural Iowa, the analysis has not been able to show whether patient outcomes were improved.
Nonetheless, lessons on care delivery for rural cancer patients from Iowa are promising, Hendricks told OT, and said she hopes it can be replicated in other parts of the country.
The ASCO report also recommends:
* Ending persistent financial threats to community practices caused by sequester-related cuts to Medicare physician payments, and by the sustainable growth rate (SGR). Medicare's reimbursement system “has become a source of tremendous instability within health care,” according to ASCO. Bipartisan legislation now before Congress would repeal the SGR, provide special support for practices in underserved areas, and move Medicare away from a fee-for-service system via innovative payment models.
* Removing disparities in access to cancer care, “in part by requiring health insurers to set benchmarks that include benefits and services essential to the care of all patients with cancer.”
* Embracing and supporting physician-led quality initiatives such as ASCO's national voluntary Quality Oncology Practice Initiative (QOPI) and CancerLinQ, a continuous learning health system.
Quality measures have to be specific to their field of medicine, noted Blase N. Polite, MD, MPH, Assistant Professor of Medicine at the University of Chicago, Chair-Elect of ASCO's Government Relations Committee, and Immediate Past Chair of the Health Disparities Committee.
“We're very, very proud of QOPI,” said Polite, noting that this voluntary quality-enhancement program has experienced much growth among oncologists since 2006 (more than 850 practices now participate). But, he noted, QOPI has to evolve with changes in the health care system. Polite called CancerLinQ, with its platform of continuous learning, the next generation of cancer care.
The report notes that QOPI participants have shown “demonstrable improvements in end-of-life care for adult patients with advanced cancers.” Rep. Earl Blumenauer (D-OR), who also spoke at the briefing, stressed the importance of helping patients articulate their health care wishes through advance-care planning, and respecting those wishes at the end of life.
This concept will “pay untold dividends” in patients' dignity and comfort, and will also save a great deal of money on unwanted cancer care, he said. “You are right on the money,” he told ASCO speakers, in recommending that oncologists have a conversation with their patients about the patients' wishes at the time of diagnosis—“This is a very important concept. Doing it right will help patients live longer.”
In March 2013 Blumenauer introduced the Personalize Your Care Act, bipartisan legislation that would provide Medicare and Medicaid coverage for voluntary consultations about advance-care planning every five years in the event of a change in health status. At the time he introduced the legislation, he said, “This bill will help ensure that every family has the tools, even during difficult and emotional circumstances, to manage end-of-life decisions.”
Related cancer-specific legislation, the Planning Actively for Cancer Treatment (PACT) Act (H.R. 2477), is being considered by Congress, and the National Coalition for Cancer Survivorship is actively urging support for that bill.
Further information about the ASCO report, including a link to a downloadable pdf, is available at asco.org/stateofcancercare