In September, the Institute of Medicine (IOM) of the National Academies issued its report, Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis,1 published more than a decade after its first study on the quality of cancer care in the United States. The authors of the new publication acknowledged that the “barriers to achieving excellent care for all cancer patients remain daunting,” and declared that the current cancer delivery system is in crisis.
The study authors agreed that much has been accomplished in the 14 years since the IOM’s previous report, Ensuring Quality Cancer Care,2 including increased screening, more precise diagnostics and surgical techniques, and the development of targeted molecular therapy. However, those advances, plus an aging population, rising cancer incidence, projected workforce shortages and soaring medical costs are also helping drive the current crisis—and potentially an even more calamitous one if nothing is done.
“The extreme challenges that we face now are different from the ones we faced in the late 1990s,” said
Patricia A. Ganz, MD, Chair of the 17-member multidisciplinary IOM committee that wrote the report. Dr. Ganz is Distinguished University Professor, University of California, Los Angeles Schools of Medicine and Public Health, and Director, Cancer Prevention & Control Research, Jonsson Comprehensive Cancer Center. “Now we have the advances from the Human Genome Project and we know that breast cancer is not 2 or 3 diseases—it is 10 diseases, and lung cancer may be 15 different diseases,” she said.
“We have very expensive diagnostic tests that we have to apply to every tumor in order to find the few that have specific treatable mutations,” Dr. Ganz continued. “We have targeted therapies that are very useful but are very expensive. The ability to deliver high-quality evidence-based care has been accelerated, but we have the aging of the population and looming workforce shortages placing great potential stress on the system.”
The numbers cited in the report tell the story of why the country’s cancer care system is in such a perilous state and likely to become worse unless a new approach is taken. According to the report, approximately 14 million Americans are survivors after a cancer diagnosis more than 1.6 million new cases are diagnosed each year. By 2022, the number of U.S. cancer survivors is expected to grow to 18 million and by 2030 cancer incidence is projected to climb to 2.3 million.
In addition, the number of older Americans is predicted to double between 2010 and 2030, contributing to a projected 30% rise in the number of cancer survivors from 2012 to 2022, and a 45% increase in cancer incidence by 2030. The cost of cancer care, which is escalating faster than other sectors of medicine, is also soaring and expected to rise from $125 billion in 2010—up from $72 billion in 2004—to $173 billon by 2020.
The rising costs are making care less affordable, according to the report, and creating disparities in patients’ access to high-quality cancer care. The increasing numbers of patients with cancer coupled with escalating costs to care for them is also resulting in a workforce shortage of oncology care professionals.
Framework for Change
The IOM report puts forth a conceptual framework, or blueprint, for a strategic approach to change, at the core of which is the delivery of comprehensive, patient-centered, evidence-based, high-quality care that is accessible and affordable to all U.S. patients. The IOM’s conceptual framework leads to 10 specific goals and their associated recommendations:
1. Provide patients and family members with understandable information at key decision points on such matters as cancer prognosis, treatment benefits and harms, palliative care, psychosocial support, and costs.
2. Provide patients with end-of-life care that is consistent with their needs, values, and preferences.
3. Provide patients with high-quality cancer care that is delivered by a diverse team of professionals to ensure coordinated and comprehensive patient-centered care.
4. Require cancer care teams to have the necessary skills through training, certification, and credentials to deliver high-quality care.
5. Provide evidence-based care by expanding the breadth of data collected in clinical trials through the enrollment of older adults and patients with comorbidities.
6. Expand the depth of data collected in clinical research through patient-reported outcomes, patient characteristics, and health behaviors.
7. Implement health-care learning and information technology, such as ASCO’s CancerLinQ™, that enables real-time analysis of data from cancer patients to inform medical decisions.
8. Develop a national quality-reporting program for cancer care.
9. Develop a national strategy to reduce disparities in accessing cancer care, especially in underserved populations that leverages existing community interventions to improve access to affordable cancer care.
10. Improve the affordability of cancer care by leveraging existing efforts to eliminate, e.g., choosing wisely, as well as reform payment strategy and reforms fee-for-service reimbursements to new payment models and eliminates duplications of services.
“What we have done in developing this conceptual framework for a high-quality cancer care delivery system is put the patient and patient-clinician interactions at the center. Cancer care needs to be tailored to every patient’s needs, and communication is central to that effort,” said Dr. Ganz.
To ensure quality care, patients need to understand their diagnosis, prognosis, and treatment plan—which should include palliative care to alleviate symptoms such as pain, fatigue, and insomnia, and psychosocial support across the treatment continuum—and make their preferences known, according to Dr. Ganz.
To accomplish the development of a higher-quality cancer care delivery system, the IOM authors urge all stakeholders, including medical teams, patients and their families, researchers, payers, industry, and federal agencies to work together toward a shared goal of improving the quality of life and outcomes for people diagnosed with cancer.
ASCO Commends Report
ASCO was among the 13 study sponsors of the IOM report. The Society applauded the recommendations by the committee members.
“Every person with cancer should receive state-of-the-art, high-quality, and compassionate care,” said ASCO President Clifford A. Hudis, MD, FACP. “The IOM’s recommendations offer a solid framework for achieving that goal by helping us improve the quality of care today while developing evidence for safe and effective treatments for tomorrow.” His statement continued:
For oncologists, continuously improving the quality of cancer care is at the core of our mission. This report provides important strategies we can use now to reach this goal and ASCO already has efforts in place that will advance many of the IOM’s recommendations. The Society’s Quality Oncology Practice Initiative (QOPI®) … is the first, national program to help practices improve the quality of care they deliver. In 2011, ASCO issued recommendations to improve physician-patient communication regarding the full range of care options for patients with advanced cancer. And now, ASCO’s Institute for Quality is developing CancerLinQ™, a groundbreaking effort to achieve the IOM’s vision of a learning health system that will revolutionize cancer care and achieve better outcomes for patients.
We commend the IOM for this landmark report and will work with policymakers, patients, health IT groups, and the oncology community to implement its recommendations.
Future of Cancer Care
Despite the challenges ahead, Dr. Ganz is optimistic that the goals set forth in the IOM report will result in higher quality of care for patients and a more accessible health-care system.
“With every crisis, there is tremendous opportunity for growth, and I think for most of our recommendations, various stakeholders are already working on achieving these goals,” said Dr. Ganz. “What we are really saying is that this is a blueprint—a plan to give us focus—and one that we can all rally around.” ■
Disclosure: Drs. Ganz and Hudis reported no potential conflicts of interest.
1. Levit L, Balogh L, Nass S, Ganz PA (eds): Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC; National Academies Press, 2013. Available at www.iom.edu/qualitycancercare. Accessed October 18, 2013.
2. Hewitt M, Simone JV (eds): Ensuring Quality Cancer Care. Washington, DC; National Academy Press, 1999. Available at www.nap.edu/openbook.php?record_id=6467. Accessed October 18. 2013.