ASCO Highlights Challenges, Hope in State of Cancer Care Report

Robin Zon, MD

The Affordable Care Act (ACA) has improved access to cancer care for millions of Americans, and many new drugs and new indications for existing cancer drugs were approved in 2016, but there are frontiers in improving cancer care that include information barriers, disparities in the availability of rural care, and stressors on physicians and oncology practices, ASCO said in its annual report State of Cancer Care in America: 2017, which was released today.

“This year’s State of Cancer Care report really shows that we’re in a time of rapid change all across the US cancer care delivery system,” said Robin Zon, MD, chair-elect of the ASCO Government Relations Committee.

One of the chief hurdles looming is providing ongoing care for the rising numbers of Americans who are diagnosed with cancer and who are surviving their cancer, thanks to improved therapies. ASCO said the number of cancer survivors is expected to grow by one-third, from 15.5 million in 2016 to 20.3 million by 2026. “Because more Americans receive a cancer diagnosis each year and more patients survive, ensuring patient access to affordable, high-quality care remains a critical challenge to the American healthcare system,” ASCO said.

Last year 5 new drugs and biologic therapies were added to the armamentarium of greater than 200 FDA-approved cancer fighting drugs, ASCO said. Use was expanded for 13 cancer therapies; and also approved were diagnostic tests including a liquid biopsy test for lung cancer mutations and a next-generation sequencing test to identify patients with advanced ovarian cancer who would be eligible for a particular cancer treatment. In addition to that, the 21st Century Cures Act signed into law late last year gave a start to the Moonshot for Cancer and precision medicine initiatives, ASCO noted.

The report briefly mentions the ongoing Republican-led ACA repeal and replace effort and the impact that could have on the number of covered Americans. “As proposals to alter or replace the ACA move forward, ASCO advocates for policies that provide for adequate coverage for cancer related services, especially for vulnerable and underserved communities,” ASCO said, noting that the ACA had by early 2016 added 20 million Americans to the ranks of the medically insured. “All individuals with cancer should have health insurance that guarantees access to high-quality care delivered by a cancer specialist.”

In an interview about the report, Zon said that ASCO is paying close attention to the proposals for health coverage changes. “We’re committed to working with policymakers on both sides of the aisle and the entire cancer community to provide equal access to affordable, quality healthcare for people with cancer,” she said.

“The report shows that access to affordable care continues to be a major challenge. Even when patients have health insurance, the cost of receiving treatment can be too high, with approximately one-third of working-age cancer survivors incurring debt as a result of treatment. Also, disparities—by race, ethnicity, geography, and other socioeconomic factors—continue to persist,” Zon said.

The report does not discuss the more recent 2018 budget proposal from President Donald Trump that outlines a major withdrawal of funding from certain health programs, such as $5.8 billion from the National Institutes of Health, which Trump has proposed in tandem with a $54 billion effort to strengthen the nation’s defense. However, ASCO has taken a position in opposition to the proposed budget change. Zon remarked, “Reducing NIH's funding by over 18% will devastate our nation's already fragile federal research infrastructure and undercut a longstanding commitment to biomedical science that has fueled advances in cancer prevention, diagnosis, and treatment.”

In addition, the ASCO report urges that the federal government “provide adequate funding and infrastructure support for cancer research in addition to funding for the Moonshot initiative to ensure ongoing development and delivery of promising new treatments for patients.”

Reporting on expanded practice census and trends surveys conducted in 2016, ASCO stated that rising cost pressures from staffing, equipment, overhead, rent, and administrative needs are top pressures for practices. Meanwhile, the report cited findings from one study that 49% of physician time is now spent on electronic health record and desk time versus 27% of time spent with patients. It said another study documented $15.4 billion spent on just meeting quality reporting needs. “Expenses such as these can compound other economic pressures (eg, drug costs, local conditions), which makes it increasingly difficult for oncology practices to remain financially viable,” the report said.

The report calls upon Congress, the Trump administration, and payers to streamline administrative requirements so that providers can give adequate attention to patients.

Of the 12,100 medical oncologists/hematologists practicing in the United States, 1 in 5 is nearing the retirement age of 64 or older, the report said. Gender parity is improving it said, with more women practicing oncology, but it said racial and minority representation continues to be stubbornly low. Women represented 32% of practicing oncologists in 2016, and slightly under one-half (46%) of oncologists under age 40 were women. That compares with a general physician workforce composed of 33% women in 2016, the report said.

Only 5.8% of practicing oncologists are Hispanic, versus a US Hispanic population of 18%, ASCO said. African Americans, despite comprising 13% of the population, represent only 2.3% of practicing oncologists. ASCO said it has program initiatives underway to improve diversity in the oncology sector.

Oncologists remain unevenly represented throughout the country, with 19% of Americans living in rural areas and only 6% of oncologists practicing in those sparsely populated regions. The report said one-quarter of all oncologists practice in New York, California, and Texas. Nevada, Idaho, and Hawaii are states that have fewer than 10 oncologists per 100,000 residents 55 years of age and older. The report said 75% of practices that responded to ASCO’s Oncology Practice Census in 2016 are using advanced practice providers to supplement the efforts of physicians.

ASCO said getting oncology care to underserved regions can be addressed partly through telehealth—the use of remote servicing devices, which is growing in practice. However, ASCO added that many physicians and other nononcologist providers feel underprepared for playing a supplemental role in delivering oncology care as patient numbers rise. Zon said the association is committed to “working with primary care and other specialties to be sure patients with cancer transition successfully from acute oncology care to survivorship, including those patients who live in underserved areas. Telehealth is one approach.”

“Some oncology practices have satellite clinics that provide care in otherwise underserved or rural communities. However, these clinics are under stress as cost and administrative burden rise, and some have had to close. We are hopeful that innovative payment models will better support team-based care and other creative solutions that remove access barriers for individuals in rural and underserved areas,” Zon said.

The report makes a plea that public and private payers work with the provider community to ensure that “policies provide sufficient resources and infrastructure to support novel approaches to care delivery.

As 2017 marks the implementation of the Medicare Access and CHIP Reauthorization Act (MACRA), which introduces the Oncology Care Model and incentive-based payment systems designed to lower costs and improve quality of care and outcomes, ASCO remarked that physicians will undergo a period of financial risk and uncertainty related to this rollout. “Although MACRA encourages movement away from fee for service into new payment models and APMs, the rules for these payment pathways remain poorly defined, and only a limited number of oncology specific Alternative Payment Models are available for oncologists who want to move to this payment pathway.”

The report highlights the potential in IT healthcare technology that is capable of “learning.” An ideal application of this technology in oncology is the use of data tools to evaluate outcomes in real-world populations, a slice of data that has so far been absent from the complete picture that physicians need to make optimal decisions in assigning therapies. There have been numerous public and private initiatives to capitalize on the opportunities in shared healthcare data, but many institutions are not willing to share information freely.

“Technology has given us an opportunity to improve patient care, but much of our success rests on EHR systems being able to communicate with each other,” Zon said. “ASCO supported the 21st Century Cures Act, which took steps to address interoperability of electronic health records (EHRs) and put restrictions on intentional information blocking.” The ASCO report calls for full implementation of the Cures legislation.

Overall cancer incidence over the past decade has declined, most remarkably in prostate, lung, colorectal, urinary, bladder, and stomach cancers, the report said, citing prevention efforts and infection control, as well as modifications in screening practices. The overall drop represents a negative change of 0.9% annually during that period, ASCO said. “Mortality rates for the most common cancers—breast, prostate, lung, and colorectal—have declined significantly over the past decade, each dropping 2% annually.”

Among the 5 new drugs and biologic therapies approved by the FDA last year, three treatments—atezolizumab (Tecentriq), venetoclax (Venclexta), and rucaparib (Rubraca)—were designated as breakthrough therapies, ASCO said. Atezolizumab is a PD-L1 inhibitor for bladder cancer, venetoclax is a BCL-2 inhibitor approved for chronic lymphocytic leukemia, and rucaparib is a PARP inhibitor for ovarian cancer.

In addition to the liquid biopsy approval, which enables nonsurgical testing, “last year brought approvals of new treatments targeting molecules important in the growth of certain types of kidney, lung, breast and blood cancer,” Zon said. “One of the key research highlights in immunotherapy research showed how immunotherapy can slow the growth of melanoma and for some patients with later stage melanoma, and in some cases extend survival.” Enthusiasm must be tempered by an understanding that even these breakthroughs often represent only small steps forward in the war against cancer, she said. “We are in our infancy in this field because not every patient benefits and, in some cases, benefits are short-lived.”

Other advances had less to do with new medicines and more to do with policy initiatives and promising negotiations, ASCO said. One such effort has ASCO and Friends of Cancer Research negotiating with the FDA to broaden patient eligibility restrictions for clinical trial participation. In addition, the National Cancer Institute is pursuing agreements with 20 to 30 pharmaceutical companies to create an NCI drug formulary that would provide researchers with access to drugs without having to negotiate independently with drug companies.

In conclusion, Zon said, “I do think that this report shows that there’s quite a lot of positive activity occurring in many different spheres. New, more effective treatments have been introduced, and we’re making steady progress towards rapid-learning health systems that will help us learn from an even larger patient population. I’m also encouraged by the momentum around value initiatives. Organizations, including ASCO, are continuing to look at how value frameworks or Alternative Payment Models will improve the evolution toward high-quality, value-based care. There’s a lot in the report that gives me hope.”

To download the full report, visit http://ascopubs.org/doi/10.1200/JOP.2016.020743.