WASHINGTON -- Delivery of cancer care in the U.S. is facing a crisis stemming from a combination of factors -- a growing demand for such care, a shrinking oncology work force, rising costs of cancer care, and the complexity of the disease and its treatment, says a new report from the Institute of Medicine. The report recommends ways to respond to these challenges and improve cancer care delivery, including by strengthening clinicians' core competencies in caring for patients with cancer, shifting to team-based models of care, and communicating more effectively with patients.
"Most clinicians caring for cancer patients are trying to provide optimal care, but they're finding it increasingly difficult because of a range of barriers," said Patricia Ganz, chair of the committee that wrote the report and a professor at the School of Medicine and School of Public Health, University of California, Los Angeles. "As a nation we need to chart a new course for cancer care. Changes are needed across the board, from how we communicate with patients, to how we translate research into practice, to how we coordinate care and measure its quality."
Changing demographics will place new demands on the nation's cancer care delivery system, as the number of adults older than 65 -- the segment of the population that accounts for most cancer diagnoses -- rapidly increases, the report says. In the United States, more than 1.6 million new cases are diagnosed each year; by 2030, cancer incidence is expected to rise by 45 percent to 2.3 million new diagnoses per year. The oncology work force may soon be too small to care for the rising number of people diagnosed with cancer, and training programs lack the ability to rapidly expand, the report says.
Adding to stresses on the system is the complexity of cancer and its treatment, which has grown in recent years with the development of new therapies targeting specific abnormalities often present only in subsets of patients. Incorporating this new information into clinical care is challenging, the report says. Given the disease's complexity, clinicians, patients, and patients' families can find it difficult to formulate care plans with the necessary speed, precision, and quality; as a result, decisions about cancer care are often not sufficiently evidence-based.
Another challenge is the cost of cancer care, which is rising faster than other sectors of medicine, having increased from $72 billion in 2004 to $125 billion in 2010, says the report. At the current rate, it will increase another 39 percent to $173 billion by 2020. And the single largest insurer for those over 65, the Centers for Medicare and Medicaid Services (CMS), is struggling financially.
The report recommends strategies for improving the care of cancer patients, grounded in six components of high-quality cancer care. The components are ordered based on the priority level with which they should be addressed.
Engaged patients. The cancer care system should support patients in making informed medical decisions that are consistent with their needs, values, and preferences. Cancer care teams should provide patients and their families with understandable information about the cancer prognosis and the benefits, harms, and costs of treatments. The National Cancer Institute, the Centers for Medicare and Medicaid Services, and other stakeholders should improve the develop¬ment and dissemination of this critical informa¬tion, using decision aids when possible.
Patients with advanced cancer face specific communication and decision-making needs, and cancer care teams need to discuss their options, such as revisiting and implementing advance care plans. However, these difficult conversations do not occur as often as they should; recent studies found that 65 percent to 80 percent of cancer patients with poor prognoses incorrectly believed their treatment could result in a cure.
An adequately staffed, trained, and coordinated work force. New models of team-based care are an effective way to promote coordinated cancer care and to respond to existing work-force shortages and demographic changes. And to achieve high-quality cancer care, the work force must include enough clinicians with essential core competencies for treating patients with cancer. Professional organizations that represent those who care for patients with cancer should define these core competencies, and organizations that deliver cancer care should ensure their clinicians have those skills.
Evidence-based cancer care. A high-quality cancer care delivery system uses results from scientific research to inform medical decisions, but currently many medical decisions are not supported by sufficient evidence, the report says. Clinical research should gather evidence of the benefits and harms of various treatment options so that patients and their cancer care teams can make more informed treatment decisions. Research should also capture the impacts of treatment regimens on quality of life, symptoms, and patients' overall experience with the disease. Additional research is needed on cancer interventions for older adults and those with multiple chronic diseases. The current system is poorly prepared to address the complex care needs of these patients.
A learning health care information technology system for cancer care. A system is needed that can "learn" by enabling real-time analysis of data from cancer patients in a variety of care settings to improve knowledge and inform medical decisions. Professional organizations and the U.S. Department of Health and Human Services should develop and implement the learning health care system, and payers should create incentives for clinicians to participate as it develops.
Translation of evidence into practice, quality measurement, and performance improvement. Tools and initiatives should be delivered to help clinicians quickly incorporate new medical knowledge into routine care. And quality measures are needed to provide a standardized way to assess the quality of cancer care delivered. These measures have the potential to drive improvements in care, inform patients, and influence clinician behavior and reimbursement.
Accessible and affordable cancer care. Currently there are major disparities in access to cancer care among individuals who are of lower socio-economic status, are racial or ethnic minorities, lack health insurance coverage, and are older. HHS should develop a national strategy that leverages existing commu¬nity interventions to provide accessible and afford¬able cancer care, the report says. To improve the affordability of care, professional societies should publicly disseminate evidence-based information about cancer care practices that are unnecessary or where the harm may outweigh the benefits. CMS and other payers should design and evaluate new payment models that incentivize cancer care teams to provide care based on the best available evidence and that aligns with their patients' needs. The current fee-for-service reimbursement system encourages a high volume of care, but fails to reward the provision of high-quality care.
The Patient Protection and Affordable Care Act is expected to make significant changes in accessibility and affordability of care, the report notes. Because much of the law has not been implemented, these issues will need to be revisited once the law's full impact is known.
The report was sponsored by the National Cancer Institute; Centers for Disease Control and Prevention; AARP; American Cancer Society; American College of Surgeons, Commission on Cancer; American Society of Clinical Oncology; American Society of Hematology; American Society for Radiation Oncology; California HealthCare Foundation; LIVESTRONG; National Coalition for Cancer Survivorship; Oncology Nursing Society; and Susan G. Komen for the Cure. Established in 1970 under the charter of the National Academy of Sciences, the Institute of Medicine provides independent, objective, evidence-based advice to policymakers, health professionals, the private sector, and the public. The National Academy of Sciences, National Academy of Engineering, Institute of Medicine, and National Research Council make up the National Academies. A committee roster follows.
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Report in Brief
INSTITUTE OF MEDICINE
Board on Health Care Services
Committee on Improving the Quality of Cancer Care:
Addressing the Challenges of an Aging Population
Patricia Ganz, M.D.1 (chair)
Distinguished University Professor
Schools of Medicine & Public Health
University of California, Los Angeles, and
Cancer Prevention & Control Research
Jonsson Comprehensive Cancer Center
Harvey Jay Cohen, M.D.
Walter Kempner Professor of Medicine, and
Director, Center for the Study of Aging
and Human Development
Duke University Medical Center
Timothy J. Eberlein, M.D.1
Bixby Professor and Chair
Department of Surgery, and
Spencer T. and Ann W. Olin Distinguished Professor; and
Director, Siteman Cancer Center at Barnes-Jewish Hospital
Washington University School of Medicine
Thomas W. Feeley, M.D.
Helen Shafer Fly Distinguished Professor of Anesthesiology,
Institute for Cancer Care Innovation, and
Division of Anesthesiology and Critical Care
University of Texas MD Anderson Cancer Center
Betty Ferrell, M.D., M.S.
Professor and Research Scientist
City of Hope
James A. Hayman
Department of Radiation Oncology
University of Michigan
Katie B. Horton, M.P.H., J.D.
Center for Health Policy Research
School of Public Health and Health Services
George Washington University
Arti Hurria, M.D.
Cancer and Aging Research Program
City of Hope
Mary S. McCabe
Memorial Sloan-Kettering Cancer Center; and
Division of Medical Ethics
Weill Cornell Medical College
New York City
Larissa Nekhlyudov, M.D.
Department of Population Medicine
Harvard Medical School; and
Department of Medicine
Harvard Vanguard Medical Associates
Mary D. Naylor, Ph.D., R.N.
Marian S. Ware Professor in Gerontology, and
New Courtland Center for Transitions and Health
University of Pennsylvania
School of Nursing
Michael N. Neuss, M.D.
Chief Medical Officer, and
Deptartment of Medicine
Vanderbilt University Medical Center
Noma L. Roberson, Ph.D.
Cancer Research Scientist
Roswell Park Cancer Institute (Retired)
Ya-Chen Tina Shih, Ph.D.
Section of Hospital Medicine, and
Program in the Economics of Cancer
Department of Medicine
University of Chicago
George W. Sledge Jr., M.D.
Chief of Oncology
Department of Medicine
Palo Alto, Calif.
Thomas J. Smith, M.D.
Director and Harry J. Duffey Family Professor of Palliative Medicine, and
Professor of Oncology
Johns Hopkins School of Medicine
Neil Wenger, M.D., M.P.H.
Department of Medicine
School of Medicine
University of California, Los Angeles
Laura Levit, J.D.
1 Member, Institute of Medicine