In the past year or so, there have been several notable, “big-picture” reports about the state of cancer research, care and survival in the United States.
The American Cancer Society, The Institute of Medicine and ASCO all have produced status reports on progress in cancer.
Each document highlighted advances in survival — achieved through enhanced prevention, early detection and treatment — and emphasized future challenges, such as an aging population with an anticipated increase in cancer incidence, a lack of trained oncology specialists, an increased “burden” of cancer survivors with specific health care needs, and an almost limitless potential for increasing costs of care.
Common themes emerge from these reports, including the need for better coordination of care, use of outcome and quality metrics, efforts to address increasingly complex and costly treatments, navigation of payment reform and the switch from a volume-driven to value-driven health care system, and the importance of reducing disparities in cancer care and outcomes.
A ‘must read’
Continuing this trend, the American Association for Cancer Research recently published its fourth annual cancer progress report. It is an impressive document, comprising more than 100 pages of cancer statistics, attractive and informative graphics, and individual stories of people affected by cancer, linked by a nicely written narrative.
It makes a compelling case for the AACR’s primary message — that Congress should prioritize NIH and NCI funding for cancer research in a consistent manner, resulting in increases that are at least equivalent to the biomedical inflation rate.
This report is a “must read” for everyone involved in taking care of patients with cancer. It provides a wealth of data about recent successes and the remaining challenges in cancer treatment. It highlights the rapid projected increase in the number of cancer survivors over the next 10 to 20 years, describes some of the challenges associated with disparities in care, and goes some way to describe the impact of healthy lifestyle — in a broad sense — on cancer incidence, treatment and survival.
Not surprisingly, the primary emphasis of the report is the importance of research and scientific discovery to advances in cancer outcomes.
One illustration of this is the list of recently FDA-approved therapeutics. It underlines the extraordinary growth in targeted agents for cancer, driven by better understanding of the cellular pathways that drive different cancer types.
Another example is the description of how laboratory-based research into HPV’s role in cancer eventually has produced effective vaccines with the potential to prevent cervical cancer, as well as some head and neck cancers.
I could go on with many other examples, but the message is clear: Basic laboratory research and scientific discovery fuels advances in cancer care, and we slow the rate of progress if we reduce the fuel supply.
For those of us taking care of patients, the impact of basic research can sometimes be blurred by day-to-day issues such as clinic templates, work Relative Value Units, insurance coverage and meaningful use. The AACR report is an important reminder of how essential funding from the federal government and other sources is to our basic research effort.
Lack of specifics
So when I had finished reading the report, impressed by the data and convinced by the argument for more NCI funding, why did I feel that something was missing?
Like other previously released progress reports, it seems to me that the AACR document provides a comprehensive account of current status and challenges. Also common to all these reports is a broad statement of future needs. In the case of the AACR report, this comes down to one major recommendation: more funding.
What’s missing from all of these reports is specifics in terms of how to address the known challenges.
Easily said, of course. We all know, for example, that we face a major crisis in provision of health care to cancer survivors, based on increasing numbers of patients and a shortfall in the number of providers. Many solutions have been suggested, including increased reliance on primary care and mid-level providers, but developing the training, practice and funding infrastructure to allow this to happen has not been addressed in detail.
What needs to be done is clear. Developing strategies to do it is more difficult.
This is certainly not intended to be a criticism but more an observation that we now need to think of ways to convert big-picture vision statements into delivery of real change. More focus on health care delivery research in the context of cancer is one part of the solution to these problems.
The AACR report makes a powerful case for increased cancer research funding. The casual reader, however, might conclude that the emphasis of this funding should be on traditional laboratory biomedical research.
Because the authors acknowledge throughout the document the importance of behavioral, environmental and population sciences research within the cancer research community, they seem to have missed an opportunity to highlight the importance of funding all areas of cancer research in their conclusions.
Research into HPV is a good example. The efficacy of HPV vaccination is now established, but there are still major problems with vaccine uptake in many communities, ultimately limiting its effectiveness. So here is a case in point, where understanding the specifics of why vaccine uptake is poor is some areas would result in effective strategies to protect more people from a preventable disease.
The NCI recently announced funding initiatives to address this specific issue, and we can look forward to new data to guide us in educating the public and improving vaccination rates. This is an area of research funding for which we, as health care providers, need to advocate.
Bridging the gap
Access to the best prevention, detection and treatment interventions remains uneven. Disparities exist across many groups, including ethnic and racial minorities, as well as those who live in rural and frontier communities.
Addressing some of these disparities likely would have a rapid impact on cancer outcomes in the United States. Making the specific case for greater funding of research directed at health care delivery — eg, comparative-effectiveness research, disparities in health care, high-risk screening and prevention strategies, and big data initiatives — would have been a valuable contribution from AACR’s report.
Leveling the playing field in terms of access to cancer care has been a major priority defined by all of the recent reports. Many large cancer centers are actively involved in outreach efforts, developing networks of affiliates or other forms of partnerships with smaller, community-based systems. Although much of this effort is driven by the economy and by health care reform, increased access to the best cancer care is a major potential benefit of this effort, particularly for areas that are currently underserved.
As we develop these networks, we need to understand the most effective ways to engage providers and patients in the process of improving care. Many of the current efforts are based around sharing of care pathways, electronic medical records, joint participation in tumor boards, the use of telemedicine, etc.
Although many cancer centers move ahead with these interventions, we have virtually no idea whether they represent the most effective ways to affect cancer incidence and outcomes. Understanding barriers to clinical trial participation in minority populations has led to strategies to increase minority access and accrual. We need to apply the same energy and funding to understand how we can most effectively deliver the remarkable advances of recent years to all our citizens.
The status reports published in the past year provide us with a clear picture not only of what progress has been achieved for our patients, but also of the potential impact to our communities if we can convert all of the recent advances into effective interventions. Bridging the gap between discoveries and delivery should be a clearly defined priority area for cancer research.
For more information:
John Sweetenham, MD, FRCP, FACP, is HemOnc Today’s Chief Medical Editor, Hematology. He can be reached at firstname.lastname@example.org.
Disclosure: Sweetenham reports no relevant financial disclosures.