Online First/Online Only
Articles/items published ahead of print or only online.
Wednesday, March 25, 2015
BY MARY BROPHY MARCUS
Cancer patients may be getting a bad wrap among oncologists for being “demanding” and thus responsible for high health care costs, a new study suggests.
"I'd gone around to a lot of conferences and heard many speeches and doctors constantly saying that a lot of the reasons we order these unnecessary tests is that patients demand them. But this just wasn't my experience and I hadn't seen the data," study coauthor Ezekiel Emanuel, MD, PhD, Professor of Health Care Management and Professor of Medical Ethics and Health Policy in the Perelman School of Medicine at the University of Pennsylvania, told OT.
So he set out to explore the issue in more depth.
For the study, now online ahead of print in JAMA Oncology (doi:10.1001/jamaoncol.2014.185), Emanuel and his colleagues--Keerthi Gogineni, MD, MSHP; Katherine L. Shuman, MSN, RN; Derek Chinn; and Nicole B. Gabler, PhD, MHA--wanted to assess how often patients demand or request medical tests or treatments, what types of procedures and treatments they demand, and the clinical appropriateness of their requests. The researchers also asked how frequently clinicians complied with patient "demands."
A total of 60 oncologists from three Philadelphia-area outpatient oncology centers were surveyed between October 2013 and June 2014. There were 5,050 patient-clinician encounters involving 3,624 patients. Overall, 440 encounters (8.7%) included a patient demand or request for medical intervention. The physicians complied with 365 of what they deemed clinically appropriate demands.
Only 50 of the 440 encounters involved a demand or request for a clinically inappropriate intervention--and clinicians complied with only seven of those 50.
Of the 440 patient demands:
- 216 were for an imaging study;
- 68 were for palliative treatments (not including chemotherapy or radiation); and
- 60 were for lab tests.
The authors reported that factors including having lung or head and neck cancer, receiving active treatments, and having a fair or poor-quality patient-clinician relationship were associated with patients making demands or requests.
The authors concluded that the myth of the demanding oncology patient is just that--a myth. In most patient-clinician encounters that included a patient demand, the demand or request was appropriate. Inappropriate demands take place in only one percent of encounters, and oncologists comply with few of them.
"We were surprised by how infrequent the demands were, and we were very surprised that most of those demands were totally clinically appropriate according to the doctors, such as requests for palliative care, or a drug for insomnia, or some pain medication," Emanuel said.
In an accompanying editorial, titled “The Myth of the Demanding Patient” (doi:10.1001/jamaoncol.2014.185)
Anthony L. Back, MD, a medical oncologist at Fred Hutchinson Cancer Research Center, wrote: "The study hypothesis--that patient demands for treatments and scans drove unnecessary costs--was spectacularly unconfirmed when using data collected from physicians themselves."
Back, also Adjunct Associate Professor in Medical History and Ethics at the University of Washington School of Medicine and who has studied communication in his research, added in an interview that hostility from the patient tends to provoke hostility from the clinician, and that improved communication techniques could help improve the patient-doctor relationship.
"Things have improved in that most oncology programs have training in communication, but not many include what you'd call self-awareness work. This issue of when someone is hostile to you, you tend to react with hostility--That is not talked about much in the oncology community."
He explained that things can go wrong for patients in many ways and that patient anger is often more about frustration, not so much a personal issue with a clinician. "But what happens is that the oncologist takes it personally. It's really important for the oncologist to take a step back and ask, is this patient really just having a bad day or week? It's important not to blame yourself."
Communication, Communication, Communication
Also asked for his perspective, Yousuf Zafar, MD, MHS, a gastrointestinal oncologist and health services researcher at Duke Cancer Institute, said: "My first thought as I’m reading this study immediately go to patients who I’ve recently considered to have unreasonable demands. But when I think about that particular encounter, the more I think about it, the more I realize it wasn't about an unreasonable demand but rather a communication issue.
“Something I’ve tried to focus on is to understand what the patient's goals are. For example, a demand from a patient wanting more chemotherapy near the end of life probably stems from a goal to live longer or live better or have a better quality of life. If we focus on the end—i.e., feeling better--rather than on the means—chemotherapy—then the communication will improve."
A critical part of fellowship training should involve communication, he continued. “The majority of what we do day to day as oncologists is communicating with patients, educating, and making shared decisions in terms of treatments."
Zafar leads a monthly meeting with another colleague to discuss cases where communication interactions have been difficult with patients or families. The goal is to help understand the root causes of why those reactions occur, to help provide fellows with better skills.
"I think communication is a skill, and just like any other skill you can learn it. You can learn how to do bone marrow biopsy, you can learn how to manage chemotherapy toxicities, and we can learn how to communicate."
Back said patient can also learn to "own" their feelings and express them, which will help the clinician-patient relationship. “They can say, ‘I am really frustrated and irritable,’ because that helps let the doctor or nurse caring for them be more aware. If a patient says, ‘It just feels like we're not talking openly here,’ I think most doctors would step up to the plate and communicate better."
Emanuel summed up: "We can't blame the patients for high health care costs. The other message is that doctors have it in their power to change the nature of the relationship with their patients."
Wednesday, March 25, 2015
Robert C. Young, MD
The marvel of modern population genetics tells us that the human race originated in Africa and lived there in isolation for 150,000 years. Those who remained are the ancestors of most of the one billion people who live in Africa today. About 60,000 years ago a small group of about 1,000 to 2,500 people left the continent for unknown reasons, and it is this remarkably small group of people who become the ancestors of everyone else in the world.
This is but one of the many intriguing details that populate this well-structured book on ancestral science by Christine Kenneally, an award-winning Australian journalist and PhD linguist who became intrigued with genetics and genealogy during the search for information about her unknown grandfather. The result is a text that not only explores the power of modern genetics but also chronicles the use and misuse of genealogical information.
Over half of the book is focused on the development, growth, and applications of the increasingly sophisticated systems that can be used to probe one’s family tree. We learn of Ancestry.com with its 12 billion family records, FindMyPast.com, and the massive Mormon data base that is 32 times the size of the data in the Library of Congress. Genealogy studies, as the author points out, go back to the bible with its “Abraham begat Isaac” etc.
Genealogy surged in popularity with the European aristocracy and grew with the public’s fascination with possible personal connections to famous and infamous personalities. Kenneally also tells of the dark side of genealogy, with its roots in eugenics, Nazism, and its application of class against class.
She is candid about the controversies surrounding the field and the skepticism with which it is held by many scientists. To some it has “the real world verifiability of astrology”--a field occupied by “dilettante hobbyists.” She quotes Richard Lewontin, the famous Harvard biologist: “Why do we feel pride (or shame) for the action of others over whom we have no influence?”
The book, however, also takes a more humanistic view and provides examples of more positive aspects of tracing one’s lineage. Kenneally gets at the heart of genealogy’s emotional appeal with the analogy “then we probably should not feel any satisfaction when our favorite football team wins a game--Perhaps genealogy is no more complicated than the impulse to cheer for the home team,” she writes.
The book examines the origins of the eugenics movement and links it with the xenophobia of the 1880s, the distortions of Darwin’s theories, and the writings of an American Madison Grant, who in 1916 penned The Passing of the Great Race, which Hitler’s doctor, Karl Brandt, used as a defense at the Nuremburg trials. In Kenneally’s view, eugenics was not a science but simply a ruse used ‘to give long-standing social divisions a scientific rationale.”
But genealogy, Kenneally concludes, has value when it illuminates stories of populations whose past has been distorted by a biased historical record. She illustrates this with persuasive narratives of African-Americans, Jews, Australian convicts, and orphans.
She says she also believes that culture can contribute to enduring changes in human behavior and sites the work of Nathan Nunn and Leonard Wantchekon, who linked the loss of community trust brought about by the slave trade in the 19th century to the persistent disruption of the economy and lives in Africa a century later. This view is provocative but seems less than compelling. To her credit, she adds a note of skepticism: “No one is suggesting that lives of ancestors can be examined like a fortune-teller’s deck. Correlation is not Causation.”
The latter part of the book is devoted to the impact of modern genetics. Critical are the realizations that the Y chromosome is passed from father to son intact and that microsomal DNA is passed on only from the mother. That coupled with modern high-throughput genomics is accelerating our knowledge about ourselves at a breakneck pace.
For example, we now know that large populations of what was once the Mongolian Empire harbor the Y chromosome from Genghis Khan. Population genetics studies have uncovered the genetic origins of the British people. Science has established the presence of Neanderthal genes in almost all of us, along with genes from Denisovans, a pre-human race discovered only in 2010. Some of us no-doubt harbor genes from a yet-unidentified race.
But for individuals, modern genetics may not be so revealing. Going back 10 generations, we have 1,024 ancestors in that generation alone and the genetic contribution of each is minuscule. Indeed over successive generations much genetic information is lost and we are in “the odd position of being biologically unrelated to many of our blood relatives,” she writes.
While many of us would like to take some pleasure from finding we are related to Joan of Arc, Christopher Columbus, or William Shakespeare, genetically it’s not meaningful. By 16 generations back, we have 65,336 ancestors, and most have contributed little or nothing to us genetically. Furthermore, our DNA doesn’t tell us “what a person will look like, think like, or live like. They are records only of our ancestors; they tell us what once existed.”
The book also discusses the contribution of DNA to our understanding of race. DNA studies reveal that the concept of race is a myth. Simply put, the ways we differ from one another across racial or ethnic divides are far smaller than everything we have in common.
However, simply saying that race doesn’t exist doesn’t appear to be rapidly changing people’s minds. None the less, modern genetics has made us aware of just how much racial mixing has gone on throughout history.
Personal Genome Data
The book closes with candid discussions of what personal genome data actually reveal. Both the author and her husband had them done. Most of the information found, she says, was not illuminating or particularly informative. Her husband, worried about a family history of multiple sclerosis, was told that he was “less likely than the average person to develop MS.”
Why then does Kenneally, elsewhere in the book, seem surprised that doctors often don't look at this data when dealing with patients? She seems to answer her own question, commenting that 21st century genetics is not as determinative as we had hoped or feared: "Your genome is just the first hand that life deals you. How you play it is up to you."
2014, Viking, ISBN 0670025550; available in hardcover, paperback, Kindle, and audio editions
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Monday, March 23, 2015
BY MARK FUERST
Long-term clinical follow-up of patients with monoclonal gammopathy of undetermined significance (MGUS), regardless of risk stratification, may improve the outcome of those eventually diagnosed with multiple myeloma, according to a study now online ahead of print in JAMA Oncology (doi:10.1001/jamaoncol.2015.23).
“Our observations stress the importance of clinical follow-up in MGUS. The results reflect the importance of life-long follow-up for individuals diagnosed with MGUS, independent of risk score, and highlight the need for better risk models based on the biology of the disease,” said the lead author, Sigurdur Y Kristinsson, MD, PhD, Professor of Hematology at the University of Iceland and Karolinska University Hospital.
Multiple myeloma is always preceded by MGUS, a precursor condition characterized by a detectable monoclonal protein in patients without evidence of end-organ damage or other related plasma cell or lymphoproliferative disorders, he explained. “MGUS is very common and is detected in approximately five percent of persons age 70 or older. However, only a small proportion of MGUS progresses to a malignant disorder.
“In fact, the annual risk of progression to multiple myeloma or other related disorders is on average one percent, with varying risks according to risk groups.“
He said that current guidelines suggest (depending on the individual patient’s clinical risk score) life-long monitoring of those with MGUS to detect progression to multiple myeloma or related disorders. At the moment, though, the impact of annual monitoring on the outcome of patients who eventually develop multiple myeloma is unclear.
Asked for his perspective, one of the authors of an accompanying Invited Commentary (JAMA Oncology doi:10.1001/jamaoncol.2015.33), S. Vincent Rajkumar, MD, Professor of Medicine in the Division of Hematology at the Mayo Clinic, said: “This paper suggests that people with known diagnosis of MGUS seem to have better prognosis than those not known to have MGUS. The authors believe this finding is related to early diagnosis of multiple myeloma and justifies recommendation to follow MGUS patients. But it cannot be determined whether multiple myeloma patients with a known MGUS were followed more closely than those in whom an MGUS was not recognized. Therefore, it is difficult to attribute a causal relationship between follow-up and better prognosis.
“We feel the risk of myeloma-related disease is so low—two percent lifetime in low-risk MGUS patients--that there is no reason to change International Myeloma Working Group [IMWG] recomendations on follow-up,” Rajkumar continued. “Half of MGUS diagnoses are low-risk patients. Three to four percent of the U.S. general population over age 50 has MGUS, so about 5 million people in the U.S. have MGUS. It doesn‘t make sense to follow millions of people since only a small number will get the disease.”
In response, one of Kristinsson‘s coauthors, Ola Landgren, MD, Chief of the Myeloma Service at Memorial Sloan Kettering Cancer Center, said: “Any epidemiologic study is an association. In a 2010 study, Mayo Clinic researchers showed that MGUS patients have a greater association with multiple myeloma [Bianchi et al: Blood 1010; 116:2019-2025]. The results of our study are similar to another recent report [Go et al: Clinical Lymphoma, Myeloma & Leukemia 2015;15:177-186] that found fewer complications and longer survival in multiple myeloma patients with a prior diagnosis of MGUS compared with those diagnosed without a history of MGUS. And now we have epidemiologic evidence that diagnosis of MGUS impacts survival.
I think when two population-based studies show the same thing, this confirms that there is a true association.”
Using data from a large population-based study on nearly 15,000 multiple myeloma patients diagnosed in Sweden from 1976 to 2005, with follow-up through 2007, Kristinsson and colleagues estimated the impact of prior knowledge of MGUS diagnosis and comorbidities on multiple myeloma survival. About three percent of patients had been clinically diagnosed as having MGUS prior to their multiple myeloma diagnosis.
Patients with prior knowledge of having MGUS had a 14 percent longer overall survival from myeloma (median of 2.8 years), despite having significantly more comorbidities, than patients without prior knowledge of MGUS (median 2.1 years).
“Interestingly, the patients with low-risk MGUS (i.e., who had very low M-protein) had the highest risk of death. The observation that low M-protein concentration at MGUS diagnosis was associated with poorer multiple myeloma survival may reflect less frequent clinical follow-up,” Kristinsson said.
“Based on available data, we consider the main reason for the prolonged survival observed in our study to be that MGUS patients are evaluated more often for signs of multiple myeloma progression and may be diagnosed and started on anti-myeloma therapy at an earlier stage.”
Screening in Particular Risk Groups
Screening for MGUS in the general population could translate into earlier detection and treatment of multiple myeloma, Kristinsson continued. “By screening persons in particular risk groups, people with MGUS would be followed for signs and symptoms of a malignant transformation. According to our findings, this leads to better overall survival in those that progress.”
“It is important to note that most individuals with MGUS will never develop myeloma or a related disease. We do not at this moment recommend screening programs for MGUS. This needs to be discussed thoroughly, taking into account all aspects of this, including costs, benefits, and potential patient anxiety.”
But those diagnosed as having MGUS should have lifelong follow-up, he said. “As individuals with MGUS are at an increased risk of myeloma and other related diseases, it is recommended by the IMWG guidelines to follow these patients indefinitely. The current recommendations suggest less frequent monitoring for low-risk patients, but not the absence of follow-up for these individuals.
“Our observations stress the importance of clinical follow-up in MGUS, regardless of risk stratification.”
Practicing oncologists need to present patients in MGUS with information about the risk of progression to malignant neoplasm, which, on average, is one to two percent. “However, this varies somewhat based on risk stratifications. Patients should receive balanced information stressing both the overall very low risk of progression to malignant disease, but also what symptoms could signal such development and the need to consult their physician.”
Summing up, Kristinsson said his message to clinicians is: “Keep following MGUS patients and inform them about the signs and symptoms of progression, as we do not see these patients very often.”
MGUS Randomized Trial?
Rajkumar noted that the 2010 Mayo Clinic study (of which he was senior author) “showed that if we follow MGUS patients frequently, we do not catch much multiple myeloma. Only in 16 percent of MGUS patients did we have a timely diagnosis of multiple myeloma, based on careful follow-up.”
He said that at the Mayo Clinic, patients diagnosed with low-risk MGUS are checked at six months and then rechecked only if they develop symptoms that are suggestive of a multiple myeloma-related disorder. “Any MGUS patient who is not low-risk, we recommend checking at six months and one year thereafter indefinitely,” he said.
“In MGUS, everyone agrees that we should not screen low-risk patients because only small numbers go on to multiple myeloma. There is no proof that screening is helpful. Most MGUS diagnosis is made with an annual blood screen when patients come in for another condition. Annual follow-up of low-risk MGUS patients has to be proven by a randomized trial.”
But Kristinsson said that the hypothesis that detection and follow-up of MGUS may influence survival in multiple myeloma is unlikely to ever be tested in a prospective clinical study due to the large sample size needed and the very high resulting costs.
Landgren agreed that a randomized trial is never going to happen, and is not necessary: “Many questions in oncology, such as breast cancer screening and PSA testing, have not been proved in a randomized trial. It is not a practical solution to say that everything has to be done in a randomized trial.
“The consensus guidelines for MGUS follow-up were not developed from a randomized trial, but were based on observations. Now we have evidence to support the guidelines. The data do not change the guidelines, but help the guidelines to exist.”
In 2003, guidelines recommended that MGUS patients be followed annually, and the 2010 guidelines recommended that low-risk MGUS patients be followed less often. “The new data may indicate that that recomendation may not be in the best interest of individual patients in 2015,” he said, adding that it is always a challenge to write guidelines that use resources in a cautious way and offer patients the best potential benefits.
Costs of Screening
Rajkumar said, though, that the cost, inconvenience, and anxiety produced by the awareness of potential progression of a recognized MGUS, in addition to the low absolute risk of progression, probably override the possible potential benefit of screening for MGUS.
Landgren suggested the cost of long-term testing is low compared with the cost of a major disease with complications: “Current therapy for multiple myeloma could cost from $10,000 to $15,000 per month, for an extended time. If we look at the cost of complications in that light, then lifetime testing for MGUS patients is not that expensive. With a survival benefit now shown in two studies, it is difficult for an individual physician to say there is no benefit for screening.”
He likens this to preventive maintenance for an automobile: “If you never check your car‘s brakes, one day the brakes may fail, and you crash. If you can maintain your car, you can prevent a problem. The two new MGUS studies show that maintenance is better. If we follow low-risk MGUS patients annually, the issue is not that we can prevent progression, but if we monitor, we can act earlier and the patients live longer.”
With the advent of new biomarkers, in November 2014 diagnostic criteria for multiple myeloma stated there is no longer a need to wait for symptomatic disease, Landgren added. “Clinicians need to know we can detect multiple myeloma by doing a blood workup, and may find a patient has disease that requires treatment. An MGUS patient who has biomarker levels outside the cutoff may require multiple myeloma therapy. The two new MGUS studies therefore support guidelines to follow patients who have this precursor disease to myeloma.”
Friday, March 20, 2015
BY PEGGY EASTMAN
WASHINGTON—A newly released report from the American Society of Clinical Oncology on U.S. cancer care contains both good news about scientific advances and worrisome news about oncology practice.
The 64-page report, “The State of Cancer Care in America 2015,” provides an overview of practice trends and the current challenges facing oncologists. This is the second year in a row that ASCO has released a report on the state of U.S. cancer care (OT 3/10/14 issue).
“There’s good news and bad news in the landscape here,” said Philip Stella, MD, Chair-elect of the ASCO Government Relations Committee and Medical Director of the Oncology Program at St. Joseph Mercy Hospital in Ann Arbor, Michigan. As an example of real progress, Stella cited the 10 new cancer drugs approved by the Food and Drug Administration in 2014, along with nine new indications for already-approved drugs.
He pointed to immune-boosting therapies and targeted therapies as major advances in cancer treatment, calling the field of immunotherapy “very, very exciting.” Currently there are more than 770 cancer therapies in the research and development pipeline.
Stella noted that 30 years ago, for example, a pulmonologist would not send a lung cancer patient to a medical oncologist, because there was no therapy to offer. But now even lung cancer patients with metastatic disease are living longer because of effective drugs: “That’s in my career,” and today, two-thirds of cancer patients overall live five years beyond their diagnosis--“an amazing thing.”
45% Increase in Cancer between 2010 and 2030
But, said Stella, as more and more Americans are diagnosed and become cancer survivors, now numbering 14.5 million--there will be an increased demand for cancer care. The ASCO report projects that there is likely to be a 45 percent increase in cancer incidence between 2010 and 2030.
“Survivors have their own set of problems,” he noted. By mid-century the number of Americans over age 65 is expected to double, and although smoking rates are down, these Americans remain vulnerable to cancer because of age. In addition, the report states, obesity is expected to cause an additional 500,000 cancer cases by 2030
Racial & Ethnic Disparities Persist
More discouraging news is that racial and ethnic disparities in cancer screening and treatment continue to persist, with African-Americans diagnosed with cancer almost 20 percent more likely to die as a result of their cancer than whites are--“This is unconscionable,” he said.
Also of particular concern is that the oncology workforce may not be able to keep pace with the growing demands on it. “As we see the demand for oncology care increase, we may not have the supply to provide it,” said Robin Zon, MD, Chair of ASCO’s Clinical Practice Committee and a medical oncologist at Michiana Hematology Oncology, PC, in South Bend, Indiana.
Of real concern, she said, is that the oncology workforce is itself aging: There are now more oncologists over age 64 than under age 40. In fact, the ASCO report shows that oncologists younger than age 40 make up only 16 percent of the field, while the median age of oncologists is 52, and 50 percent of oncologists are over age 50.
Zon noted that while the field of oncology has never offered more treatment options to patients than today, it is highly demanding both emotionally and intellectually. Professional burnout is high, and--especially worrisome--it is high not just among practicing oncologists but also among fellows. In fact, the report notes that of 1,345 U.S. medical oncology fellows who participated in a survey, about 34 percent said they had high levels of burnout.
This proportion was not significantly different from the 33.7 percent observed among practicing oncologists in an earlier ASCO study. “We’re experiencing rough waters, and we don’t see it getting any better any time soon. It’s getting overly burdensome. There are real problems out there that are facing us,” Zon said, citing increased administrative work and high levels of paperwork.
She noted that more women are coming into oncology, with women now representing slightly more than 30 percent of oncologists (just below the 32.6 percent for women in medicine overall). Female oncologists are typically younger than male oncologists, with a median age of 46; pediatric hematology/oncology attracts the most number of women.
Asked by OT if these trends might lead to new practice patterns such as job-sharing to reduce burnout and accommodate female oncologists raising children, Zon said that is certainly one solution. “It’s not a difficult sell,” she said, noting that she could also envision older oncologists who want to decrease their hours working part-time and serving as mentors to younger oncologists coming into the field.
‘Volatile and Fluid State’
Oncology is currently in a volatile and fluid state, and has been well documented in recent years, the report notes that many oncology practices are merging, selling, or closing. In fact, one quarter of practices queried in 2014 projected the likelihood of affiliation with a community hospital in the next 12 months, similar to the number in the 2013 census. Some 18 percent indicated the likelihood of affiliation with another practice, and 17 percent indicated the likelihood of affiliation with an academic center.
Zon called small community practices the backbone of U.S. cancer care, and said these trends could adversely affect the cancer patients those practices serve. “We’re concerned that there will be problems with access,” she said. She described the downside of merging with a larger practice, citing the example of patients who come back to the oncologist they had before the merger crying because they want the small community practice they knew before.
Obtaining cancer treatment in rural areas is a special concern--“The rural areas have a serious problem with regard to access,” Zon said. “This is not a trivial matter.” For an older, sick cancer patient to travel a considerable distance to receive care places a burden on a patient who is already struggling with the multiple challenges of the disease.
According to the ASCO report, more than 59 million Americans live in rural areas, but only 5.5 percent of oncologists and hematologists practice in rural areas. Nearly three quarters of these rural practices (73.3%) have only one practice location.
In addition to concerns about an adequate workforce and patient access, one of ASCO’s major concerns is the high cost of cancer care and its continuing rise, Richard Schilsky, MD, ASCO’s Chief Medical Officer, said at the briefing. The report states that today the direct annual cost of U.S. cancer care is about $86 billion, the average monthly cost of a branded cancer treatment is $10,000 and--considering current levels of cancer incidence, survival, and cost--cancer care expenses could rise by as much as 39 percent between 2010 and 2020.
“I have to say that patients are really feeling the pinch” as they bear more of the financial share of their care, Schilsky said. He noted that while drugs represent one of the fastest growing cost segments of the health care delivery system, they are not the largest contributor to overall spending on U.S. cancer care. Rather, hospitals and outpatient facilities account for more than half of spending on cancer care.
Schilsky said ASCO is actively involved on a number of fronts in trying to lower costs while increasing quality, including ensuring that cancer treatments are evidence-based.
A substantial proportion of cost is in the last year of a cancer patient’s life, Schilsky said, “Oncologists still need to do a much better job in implementing palliative care and hospice care.” To that end, ASCO has a virtual learning collaborative to improve the use of high-quality palliative care in oncology.
He said that recognizing that the current means of paying oncologists is “broken,” ASCO has suggested that alternative payment models be explored, including the oncology medical home--“We think there are a range of payment systems that should be considered.” High on the list of payment reform is repealing Medicare’s outmoded Sustainable Growth Rate (SGR) formula--“every doctor in the United States wants this to happen,” Schilsky said.
Currently, the U.S. House of Representatives is actively working on a bipartisan plan to repeal the SGR, but Congress has repeatedly tried and failed to repeal the SGR formula, and has instead come up with short-term fixes--often at the last minute. “We’ve been on this precipice before,” Schilsky said. If Congress is really close this time, he said, he has a message for lawmakers: “If this is about to happen--just do it.”
Asked by OT if he is really hopeful about SGR repeal this time, he said: “It seems like the chance is greater than ever.”
Rep. Andrew Harris
Also speaking at the Congressional briefing was Rep. Andrew P. Harris, MD, (R-Md.), who worked as an anesthesiologist at Johns Hopkins Hospital for more than 30 years before being elected to Congress. “One of the things we have to get right is keeping the progress going,” he said of cancer research.
This includes supporting young investigators: “We [American researchers] are going to be the driver for a cure for cancer, I’m convinced,” he said. Harris, who serves on the House Appropriations Committee and several subcommittees, said the country needs to focus its resources on biomedical research and innovation, which will result in improvements in health worldwide, not just on American shores.
The new ASCO report recommends the following strategies to address the challenges identified in its pages:
1. Ensure that all publicly funded insurance programs offer consistent and appropriate benefits and services for patients with cancer. Specifically, the Centers for Medicare & Medicaid Services (CMS) should standardize benefits in Medicare and Medicaid; Congress should eliminate inconsistencies in coverage that exist between Medicaid patients enrolled pre- and post-Affordable Care Act to ensure that Medicaid includes coverage of clinical trials; and oncology professionals should be vocal about the essentials any health plan must have to achieve high-quality, high-value care.
2. Pilot-test multiple innovative payment and care delivery models to identify feasible models that promote high-quality, high-value cancer care. Specifically, CMS should expand its efforts to pilot alternative payment methods--beyond its Oncology Care Model--to give practices flexibility; Congress should provide a fair, adequate and stable payment for oncology practice, including repeal and replacement of the SGR formula; oncology professionals should test and evaluate new care delivery models; and private insurers should partner with CMS, patients and providers to test promising new payment and care delivery models.
3. Promote high-value care by advancing and supporting transparency and shared decision-making with patients. Specifically, CMS should make every effort to improve its publicly released data and provide information to help the public understand the context for the data; Congress should require that health information technology vendors create products that promote interoperability and enable research use of standardized data in a secure environment; oncology professionals should discuss personal goals of care, potential treatment options, expected benefits, and the physical and financial impacts of treatment with every patients with cancer; private insurers should ensure that publicly shared information about providers is accurate, in context and meaningful to the intended audience; and professional organizations should offer tools and information that help to incorporate shared decision-making into practice.
To Access the Full Report
The full report is available at www.asco.org/stateofcancercare and is also published as an article in the Journal of Oncology Practice, now online ahead of print.
Briefing speakers (left to right) Philip Stella, MD, chair-elect of ASCO’s Government Relations Committee; Robin Zon, MD, FACP, FASCO, chair of ASCO’s Clinical Practice Committee; and Richard Schilsky, MD, FACP, FASCO, ASCO Chief Medical Officer.
Monday, March 16, 2015
In an article now online ahead of print in Mayo Clinic Proceedings (doi.org/10.1016/j.mayocp.2015.01.014),
Hagop Kantarjian, MD, Professor and Chair of the Department of Leukemia at the University of Texas MD Anderson Cancer Center, and
S. Vincent Rajkumar, MD, the Edward W. and Betty Knight Scripps Professor of Medicine in the Division of Hematology at the Mayo Clinic, offer seven specific solutions to the problem of the high costs of cancer drugs:
· Allow Medicare to negotiate drug prices;
· Develop cancer treatment pathways/guidelines that incorporate the cost-benefit of cancer drugs (drug “value”), as occurs today in many other countries;
· Allow the Food and Drug Administration or physician panels to recommend target prices based on the magnitude of benefit (value-based pricing), as is practiced in many other developed countries;
· Eliminate “pay-for-delay” strategies;
· Allow the importation of drugs from abroad for personal use;
· Allow the Patient-Centered Outcomes Research Institute and other cancer advocacy groups to consider cost in their recommendations; and
· Create patient-driven grassroots movements and organizations (as happened during the AIDS epidemic) to advocate effectively for the interests of patients with cancer.
The five-page article concludes by noting that the vision and mission statements of many pharmaceutical companies include statements about the desire to help patients and cure diseases. Although many people have the perception that the only mission is to maximize profits “by any means” as a fiduciary duty toward shareholders and investors, the companies should also be judged by their corporate social responsibility, the authors write, pointing to the Access to Medicine Index (accesstomedicineindex.org), created in 2008, as an independent initiative that ranks the top research-based pharmaceutical companies in their efforts to make products “available, affordable, and accessible”--This is a valuable moral scale that applies to cancer drugs, Kantarjian and Rajkumar write.