Despite considerable advancements made in cancer treatment — such as with precision medicine, genomic profiling and immunotherapies — persistent financial, coverage and delivery issues threaten patients’ access to these modalities, according to ASCO’s “State of Cancer Care in America: 2016” report.
“As we release this report, our nation has much to be encouraged about in cancer care,” Julie M. Vose, MD, MBA, FASCO, ASCO president and chief of the hematology and oncology division at University of Nebraska Cancer Center, said during a press briefing held on Capitol Hill. “We have seen mortality rates decline on average by 1.5% annually over the past decade, with even greater annual declines for the four most common cancers — breast, prostate, lung and colorectal. However, all of these advances are set against the background of increasingly unsustainable costs and a volatile practice environment.”
Julie M. Vose
Vose — along with Debra Patt, MD, MPH, MBA, vice-president of Texas Oncology in Austin and chair-elect of ASCO’s Clinical Practice Committee, and Blase Polite, MD, MPP, associate professor of medicine at The University of Chicago, immediate past chair of ASCO’s Government Relations Committee, and a HemOnc Today Editorial Board member — highlighted some of the key areas of concern that patients and practicing oncologists face.
These issues included the rapidly aging U.S. population and its expected effect on the cancer diagnosis rate; the high costs associated with cancer therapies; and the continued racial, ethnic, and gender disparities in medical treatment and among medical professionals.
“Many factors are increasing the complexity of cancer care,” Vose said. “Economic pressures, market dynamics and shifts in payment policy have combined to place many independent community practices in jeopardy. These trends, combined with an increasing constraint on the workforce, raise concerns about how the U.S. cancer care system will be able to respond to the expected surge in demand for cancer care over the upcoming years.”
The influence of cost, age
The escalating cost of cancer care was a critical issue addressed by the report.
Approximately 24% of Americans reported difficulty paying for prescription drugs, with 72% describing medication prices as “unreasonable,” according to the report.
This can lead patients to skip doses of medications or to complete cessation.
“This is not healthy when you are trying to cure cancer,” Vose said. “As pressures to control costs escalate, patients and other stakeholders are pursuing new payment and care delivery models that aim to lower spending while preserving quality.”
With 15 FDA approvals for cancer in 2015, it was a “landmark year in cancer innovation,” Patt said. “This is in addition to 12 drugs that were approved by the FDA with additional indications, as well as screening and diagnostic methodologies,” she added.
However, the development of new cancer therapies and the associated survival benefits have necessitated intricate and costly follow-up treatment, which can continue for years, according to Patt.
Further, the fact that most cancer cases are diagnosed among patients aged 65 years or older is likely to increase the cost of cancer care.
“As baby boomers reach retirement age, they are more likely to develop cancer,” Patt said. “If we look back to a decade ago, when the U.S. population was approximately 295 million, and compare that with today’s 320 million, that is an 8% increase. In that time, we have seen an 18% increase in new cancers.”
Further, there is concern that newly approved cancer therapies may not be as effective in older patients with cancer.
“If you think about a standard clinical trial in breast cancer that is approved for a 50-year-old patient with no comorbidities, the efficacy and toxicity reports may be different than that of a 75-year-old patient with the same stage of cancer, who has diabetes and doesn’t exercise every day,” Patt said. “This makes the delivery of cancer care more complex over time.”
The inclusion of older patients in clinical trials remains an unmet need.
“Clinical trial patients on average are younger and healthier than the average patients treated in the general population,” Patt said. “We need to increase participation among the elderly population.”
Racial, geographic shortcomings
ASCO’s report further highlighted persistent racial, ethnic and demographic disparities in cancer care.
“African Americans are 2.5-times more likely to develop cancer than whites, and African American men are 27% more likely to die of cancer than white men,” Patt said. “African American women are 11% more likely to die than white women.”
Further, because more than 50% of oncologists are located in only eight states, regional disparities may influence the receipt and success of cancer treatment.
“Eleven percent of Americans live in rural areas, yet only 5.6% of oncologists practice in rural areas,” Patt said. “Not only does that mean that patients with cancer have to travel in order to get routine treatment, but it also means that they might have delays in their diagnoses that could lead to diagnosis at a later stage.”
These factors are exacerbated by the fact that certain states have opted not to expand their Medicaid programs.
To understand the issues surrounding cancer care delivery, ASCO collected data from over 700 U.S. oncology practices in 21,000 sites of care, representing 13,000 oncologists and 1.1 million patients.
The survey findings confirmed the existence of racial disparities in treatment and geographic disparities in health care access, Patt said. Further, these disparities extended to medical professionals.
“There is an aging oncology workforce that is not representative of the patients they treat,” Patt said. “The proportion of women in the workforce is increasing, with women making up 31% of practicing oncologists in 2015.
“Among oncologists who are 39 years or younger, the proportion of women to men is almost identical,” Patt continued. “That is a gap that is changing over time.”
However, racial and ethnic minorities remain largely underrepresented in the medical profession and are not representative of the population they treat.
Hispanic individuals comprised less than 6% of the oncology workforce in 2015, whereas black individuals accounted for 2.3% of practicing oncologists. Further, despite the increase in female oncologists, these numbers have not increased among underrepresented groups.
“All of medicine faces a challenge in recruiting underrepresented racial and ethnic groups,” Patt said. “However, it is particularly difficult in subspecialties. We believe that collaborative efforts are needed across the entire education system to boost interest in medical professions in diverse populations, and to encourage young medical students to enter the oncology field and fill the unmet need.”
Recommendations for improvement
Oncology professionals surveyed for the report indicated several areas of concern, including payer pressure, the use of electronic health records and insurance issues.
During the press conference, Polite highlighted some of ASCO’S recommendations and positions for improvements in these areas.
“The costs associated with cancer care in the United States are rising more rapidly than costs in other medical sectors,” Polite said. “Given the current rate of growth, cancer-related costs are expected to be as high as $173 billion dollars by the year 2020.”
The implications of the rising costs bear implications for patients, survivors and oncologists alike.
“The financial burden, of course, is twofold,” Polite said. “There is the cost of cancer medicines themselves, and the increased burdens faced by patients in the forms of rising deductibles and higher cost-sharing for patients.”
Cancer drugs account for seven of the 10 most expensive reimbursable medications in the United States, according to Polite. Prescription drug costs among patients with insurance continue to run as high as $25,000 per year.
Further, insurance companies have used tiered payment and reimbursement formulas to place a greater financial onus on patients.
Under Medicare, IV medications are covered under Medicare Part B, with gap insurance used to pay outstanding co-pays and deductibles. However, oral cancer drugs are covered under Medicare Part D, which is subject to tiered payment systems.
“Oncologists don’t choose treatments based on whether they are IV or oral,” Polite said. “We look for the drug that makes the most sense for a given patient. Yet patients are subject to different cost burdens based on the drugs we choose, and that simply makes no sense based on the way that we practice medicine in 2016.”
The Cancer Drug Parity Act — which Congress introduced this year — would prohibit the implementation of payment schematics based on therapy type. Further, 40 states and Washington, D.C., have passed oral parity legislation. ASCO endorsed these legislative initiatives and advocated for increased federal and state legislation in this area.
In 2015, Congress introduced the Patient Access to Treatment Act to eliminate specialty tiers within insurance. However, in the report, ASCO urged for the continued focus on legislative avenues to reduce cancer costs.
“Congress and stakeholders need to continue to work toward a comprehensive approach to cancer care,” Polite said. “The rising cost of cancer drugs cannot simply be shifted onto the backs of patients and providers.” – by Cameron Kelsall
ASCO. The State of Cancer Care in America: 2016. Available at: www.asco.org/stateofcancercare.
Disclosure: Vose and Patt report leadership roles with ASCO. HemOnc Today could not confirm Polite’s relevant financial disclosures at the time of reporting.