Crisis in U.S. Cancer Care Fueled by Rapid Growth of
Cancer-Prone Senior Citizens
1.6 million cases diagnosed annually; by 2030 cancer incidence to rise by 45% to 2.3 million per year mostly senior
citizens: IOM report - Video in Story
Sept. 11, 2013 - Delivery of cancer care in the
U.S. is facing a crisis stemming from a combination of factors and
probably first on this list is the rapid increase of senior citizens
people age 65 and older that account for most cancer diagnoses,
according to a new report from the Institute of Medicine. It also
identifies a shrinking oncology work force, rising costs of cancer care,
and the complexity of the disease and its treatment as contributors to
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
"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."
Delivering High-Quality Cancer Care
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.
Cost of cancer care grows faster than other
sectors of medicine
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 development and dissemination of this critical information, 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
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
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 community
interventions to provide accessible and affordable cancer care, the
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
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.
Committee on Improving the Quality of Cancer Care:
Addressing the Challenges of an Aging Population
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
Jay Cohen, M.D.
Walter Kempner Professor of Medicine, and
Director, Center for the Study of Aging
and Human Development
Duke University Medical Center
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
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
Ferrell, M.D., M.S.
Professor and Research Scientist
City of Hope
Department of Radiation Oncology
University of Michigan
Horton, M.P.H., J.D.
Center for Health Policy Research
School of Public Health and Health Services
George Washington University
Cancer and Aging Research Program
City of Hope
Memorial Sloan-Kettering Cancer Center; and
Division of Medical Ethics
Weill Cornell Medical College
New York City
Department of Population Medicine
Harvard Medical School; and
Department of Medicine
Harvard Vanguard Medical Associates
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
N. Neuss, M.D.
Chief Medical Officer, and
Deptartment of Medicine
Vanderbilt University Medical Center
Cancer Research Scientist
Roswell Park Cancer Institute (Retired)
Tina Shih, Ph.D.
Section of Hospital Medicine, and
Program in the Economics of Cancer
Department of Medicine
University of Chicago
Sledge Jr., M.D.
Chief of Oncology
Department of Medicine
Palo Alto, Calif.
Director and Harry J. Duffey Family Professor of Palliative
Professor of Oncology
Johns Hopkins School of Medicine
Wenger, M.D., M.P.H.
Department of Medicine
School of Medicine
University of California, Los Angeles
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