America's cancer care crisis

Abstract

The publication of a new report from the US Institute of Medicine (IOM) on Sept 10 paints a stark picture about the current and future demands on the country's cancer service provision. America currently has 14 million cancer survivors, 4% of its population, with 1·6 million new cancer cases diagnosed every year. That figure is anticipated to reach 2·3 million by 2030 as the country grapples with an increasingly elderly population, a burgeoning obesity epidemic, plateauing of a reduction in tobacco use, and spiralling costs in the provision of cancer care. More worrying still, the report describes the US health system as fragmented and ill-prepared to deal with the current inequities in cancer services, especially the need to reach out to ethnic minorities and elderly people.Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis builds on a 1999 IOM report, which called for an improvement in the quality of US cancer care. Back then, although engaging parts of the oncology community at the time of its publication, the sad reality, acknowledged by authors of the new report, is that it failed to bring about substantive change in the way that US cancer services have been delivered since the turn of the millennium.The new report, while acknowledging recent progress in cancer services—such as increased screening, better diagnosis, more precise surgery, and the potential of targeted molecular therapy—also clearly defines America's cancer care crisis: the enormous amount of time patients spend on therapy, often having to manage toxic side-effects of treatment, the financial burden of funding treatment if not covered by health insurance, and the underuse of both palliative care and psychosocial support for patients and their families who, the report states, end up briefing consultants in a serial manner with no co-ordination or joining up of care via electronic health records. A gloomy picture indeed.The authors of the new report set out a framework for a strategic approach for change, including several recommendations for action. Central to their thinking is a conceptual framework with the aspirations of “delivering comprehensive, patient-centered, evidence-based, high-quality cancer care that is accessible and affordable to the entire US population”. Six areas are highlighted as being crucial to the implementation of this framework: effective engagement and communication with patients; an adequately trained, resourced, and coordinated workforce; evidence-based cancer care, including the use of data from trials enrolling older patients with cancer; an improved learning and information technology approach to cancer care, including the future use of key metrics to assess the quality of care; translating new evidence into clinical practice, including the public dissemination of performance-related practice; and the creation of cancer care that is accessible and affordable, in which clinicians are rewarded on the quality, rather than purely the quantity, of care provided.Laudable though this future vision of US cancer care is, there are very real concerns about how the principled aspirations of the report can translate into a change in the delivery of cancer services for patients. Although some recommendations—such as improved communication between clinicians and patients—can start today, other aspects of the report are inextricably linked to the complexity and fragmentation of a changing US health system, with its dizzying complexity of insurance plans, which may or may not cover an individual's access to cancer care. Meanwhile, 47 million uninsured Americans currently have no certainty of being able to access cancer services at all. Hope rests, of course, in the implementation of the Patient Protection and Affordable Care Act, which aims to extend coverage to an additional 25 million citizens by 2023; how it will improve cancer services, over and above its pledge to ensure improved cancer diagnosis through its cover of cancer screening programmes, remains uncertain.The IOM report, comprehensive and considered as it is, with strong (if not new) values about how cancer care in the USA should be delivered, can only be judged by its impact. To this end, the US oncology community must seize an opportunity—another opportunity, after the limited influence of the 1999 IOM report—to help put its new model for cancer care at the heart of America's health system. Otherwise, like its predecessor, it will remain just another report, to be consigned to history if it cannot translate into better—and fairer—cancer care for America. The publication of a new report from the US Institute of Medicine (IOM) on Sept 10 paints a stark picture about the current and future demands on the country's cancer service provision. America currently has 14 million cancer survivors, 4% of its population, with 1·6 million new cancer cases diagnosed every year. That figure is anticipated to reach 2·3 million by 2030 as the country grapples with an increasingly elderly population, a burgeoning obesity epidemic, plateauing of a reduction in tobacco use, and spiralling costs in the provision of cancer care. More worrying still, the report describes the US health system as fragmented and ill-prepared to deal with the current inequities in cancer services, especially the need to reach out to ethnic minorities and elderly people. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis builds on a 1999 IOM report, which called for an improvement in the quality of US cancer care. Back then, although engaging parts of the oncology community at the time of its publication, the sad reality, acknowledged by authors of the new report, is that it failed to bring about substantive change in the way that US cancer services have been delivered since the turn of the millennium. The new report, while acknowledging recent progress in cancer services—such as increased screening, better diagnosis, more precise surgery, and the potential of targeted molecular therapy—also clearly defines America's cancer care crisis: the enormous amount of time patients spend on therapy, often having to manage toxic side-effects of treatment, the financial burden of funding treatment if not covered by health insurance, and the underuse of both palliative care and psychosocial support for patients and their families who, the report states, end up briefing consultants in a serial manner with no co-ordination or joining up of care via electronic health records. A gloomy picture indeed. The authors of the new report set out a framework for a strategic approach for change, including several recommendations for action. Central to their thinking is a conceptual framework with the aspirations of “delivering comprehensive, patient-centered, evidence-based, high-quality cancer care that is accessible and affordable to the entire US population”. Six areas are highlighted as being crucial to the implementation of this framework: effective engagement and communication with patients; an adequately trained, resourced, and coordinated workforce; evidence-based cancer care, including the use of data from trials enrolling older patients with cancer; an improved learning and information technology approach to cancer care, including the future use of key metrics to assess the quality of care; translating new evidence into clinical practice, including the public dissemination of performance-related practice; and the creation of cancer care that is accessible and affordable, in which clinicians are rewarded on the quality, rather than purely the quantity, of care provided. Laudable though this future vision of US cancer care is, there are very real concerns about how the principled aspirations of the report can translate into a change in the delivery of cancer services for patients. Although some recommendations—such as improved communication between clinicians and patients—can start today, other aspects of the report are inextricably linked to the complexity and fragmentation of a changing US health system, with its dizzying complexity of insurance plans, which may or may not cover an individual's access to cancer care. Meanwhile, 47 million uninsured Americans currently have no certainty of being able to access cancer services at all. Hope rests, of course, in the implementation of the Patient Protection and Affordable Care Act, which aims to extend coverage to an additional 25 million citizens by 2023; how it will improve cancer services, over and above its pledge to ensure improved cancer diagnosis through its cover of cancer screening programmes, remains uncertain. The IOM report, comprehensive and considered as it is, with strong (if not new) values about how cancer care in the USA should be delivered, can only be judged by its impact. To this end, the US oncology community must seize an opportunity—another opportunity, after the limited influence of the 1999 IOM report—to help put its new model for cancer care at the heart of America's health system. Otherwise, like its predecessor, it will remain just another report, to be consigned to history if it cannot translate into better—and fairer—cancer care for America. America's cancer care crisis—is Europe any better?“The greatest wealth is health”, wrote poet Virgil more than 2000 years ago. However, his philosophy is rapidly being eroded by two factors: unequal access to optimum health care and increasing costs. Equitable and affordable cancer care is a lightning rod for this debate, exemplified by the recent Institute of Medicine (IOM) report Delivering high-quality cancer care: charting a new course for a system in crisis,1 and described as “America's cancer care crisis” in a recent Lancet Editorial (Sept 14, p 913). Full-Text PDF