The State of Cancer Care in America: 2015

The State of Cancer Care in America: 2015
The U.S. cancer care system remains
in a state of transition.

In 2014, the United States made significant progress in cancer care as demonstrated by improvement in the five year cancer survival rate for many cancer types and a record
14.5 million cancer survivors, as well as by the availability of 10 new drugs and several new tests for the diagnosis, treatment, or management of cancer.1
At the same time, a growing demand for cancer services, turbulence in the cancer care delivery system, and growing concerns about cost of care are creating uncertainties about the system’s capacity to continue to provide high-quality care for all
patients with cancer. These factors have focused attention on the need for better definitions of value and meaningful ways to assess quality. In this second annual
State of Cancer Care in America report, the American Society of Clinical Oncology (ASCO) chronicles the challenges currently facing the U.S. cancer care system. The report provides background and context to help understand what is happening today
in cancer care and describes trends in the cancer care workforce and diverse practice environment that may affect cancer care in the coming years.

1. CANCER CARE IN AMERICA: A SHIFTING LANDSCAPE
The American population continues to grow and age, driving up demand for cancer services to previously unseen levels. This report includes updates on progress in the field of cancer care and on the state of cancer incidence and survival.
f
Progress in cancer care.
In 2014, the U.S. Food and Drug Administration (FDA) approved 10 new drugs and several
new tests for the diagnosis, treatment or management of cancer, and more than 771 promising therapies are in the development pipeline.2,3
Advances in treatment have produced improvements in the five-year survival rate
for many cancer types, and there are now 14.5 million Americans who are cancer survivors today a number that continues to grow with each passing year.

Rapidly growing demand.
An estimated 1.6 million new cancers were diagnosed in 2014, with growing numbers
expected in future years. Demand for cancer care is being driven by newly insured patients, an aging population and long-term care needs of survivors. In 2014 the first
year of the insurance mandate of the Affordable Care Act (ACA)nearly eight million Americans registered through new insurance exchanges and millions more are gaining access to insurance through the expansion of private and governmental programs.4
As ACA implementation progresses, these numbers are expected to increase ignificantly.

Persistent inequities.
The benefits of cancer screening and treatment advances have not been experienced
evenly across racial and ethnic groups, as evidenced by differences in incidence and mortality rates. Although the Affordable Care Act has successfully expanded
access to insurance and cancer care services, millions of Americans remain uninsured, while other individuals with public and private plans continue to lack sufficient
coverage for high-quality cancer care.

Emerging public health concerns.
This year, the ASCO report addresses two new issues with potential to influence demand for cancer services:

Obesity.
In the United States today, more than one third of adults and nearly one fifth of children are considered obese. Public health experts are concerned about a range of serious health consequences. There is mounting evidence that obesity leads to at least eight forms of cancer and affects survival.5
Obesity is responsible for more than 84,000 cancer cases annually, and this number is expected to rise substantially in future years 6,7 yet the link between obesity and cancer is largely unrecognized by the public.

Electronic cigarettes.
Electronic cigarettes are advertised to American consumers as a safe alternative
to smoking but these claims lack adequate scientific support. The U.S. Food & Drug Administration (FDA) currently only regulates electronic cigarettes marketed for therapeutic purposes, but it has proposed expanded regulations covering all electronic cigarettes. This authority is important because electronic cigarettes are becoming popular among smokers and non-smokers alike, including nearly two million U.S. adolescents.

For these reasons, ASCO and public health experts support the expansion of FDA’s authority and are calling for research to assess potential direct and indirect health effects of these devices.

2. THE ONCOLOGY WORKFORCE
ASCO regularly monitors the size, distribution and diversity of the U.S. oncology workforce to identify trends that could affect access to care. The Society’s latest analysis identified several key issues:

Number of oncologists constant despite growth in demand. In 2014, approximately 11,500 hematologists and/or medical oncologists provided care to U.S. patients with cancer, a modest 1.6 percent increase from the previous year.9
Altogether, more than 18,000 physicians provide oncology subspecialty patient care, including gynecologic oncology, pediatric hematology/oncology, radiation oncology, and surgical oncology.10

Additionally, more than three thousand advanced practice providers provide oncology care across the country, including nurse practitioners, doctors of nursing practice, and physician assistants. Advanced practice provider employment is growing rapidly, enhancing the pipeline of providers who might choose a career in oncology.

Aging workforce, declining interest in private or solo practice careers.
Consistent with last year’s report,oncologists are aging with oncologists ages 65 years and older continuing to outpace those entering the field (ages 40 years and younger). Women continue to increase their share of the workforce and occupy nearly
half (48 percent) of hematology/oncology fellowship slots.11

In contrast, the number of ethnic and racial minorities in oncology remains discouragingly low.

New to this edition of the report, ASCO covers practice decisions made by new entrants into the oncologist workforce. In a 2014 survey of medical oncology fellows, a majority (55.8 percent) of respondents indicated a preference for university-based clinical practice or research, whereas 36.8 percent indicated they were likely to choose non-academic community or private practice settings. Among oncologists presently working in a practice setting, young oncologists are more likely
to work in group practice and less likely to work in solo practice than their older colleagues.10

Rural settings underserved.
Oncology continues to experience uneven geographic distribution of its workforce. Relative to where Americans ages 55 and older reside (who account for the majority of new cancer cases), Washington, DC, and Massachusetts have the most oncologists, whereas Hawaii and Nevada have the fewest. For the more than 59 million Americans living in rural areas, a diagnosis of cancer can present unique challenges to obtaining high-quality care for their disease, including long travel distances and decreased access to specialists, and state-of-the-art diagnostics,treatments and technologies.12-14

ASCO’s 2014 analysis of oncology locations identified approximately 600 hematologists and medical oncologists (5.5 percent) practicing in rural care sites.9,15

States investing in outreach, monitoring workforce.
Two state-based research initiatives conducted in Iowa and Nebraska examined access in underserved areas and pointed to strategies that may serve to inform efforts in other communities across the United States. In Iowa, community hospitals and health centers in remote areas are offering cancer services by employing visiting oncologists, thereby significantly expanding patient access in the state.16

In nearby Nebraska, where 47 percent of residents live in rural areas and cancer is
the leading cause of death, researchers found that the number of oncologists increased by 3 percent and the number of oncology nurse practitioners and physician
assistants increased by more than a third (37 percent and 36.1 percent, respectively) from 2008—2012.17

These increases provided additional provider capacity within Nebraska although not in rural areas.

Burnout a continuing problem.
A recent survey of medical oncology fellows found that more than a third of respondents experienced high levels of burnout (at least one event a week)a rate similar to that reported among practicing oncologists.18

3. THE STATE OF ONCOLOGY PRACTICE
This report highlights findings from ASCO’s third annual census of U.S. oncology practices, conducted in 2014, along with related data from other sources.

ASCO Oncology Census: continuing practice adaptation.
Nearly 1,000 (n=974) U.S. oncology practices participated in this year’s census study, representing more than 10,000 individual oncologists. In a continuing trend toward consolidation, one quarter of community-based practices signaled the likelihood of pursuing hospital affiliation in the next twelve months.

Shifts in practice staffing and administration.
The number of practices reporting multi-specialty services remained high in 2014, especially among academic and hospital-based practices. A majority (52 percent)
of practices responding to the ASCO Oncology Census employed advanced practice providers, accounting for more than 2,700 advanced practice nurses and 1,100
physician assistants.

Practice financial health and management.
In 2014, cost and payer pressures persisted as the most pressing practice concerns, especially among physician-owned and hospital-based practices. Drug prices were also
a major concern among physician-owned practices. Academic practices were primarily concerned with clinical research issues and competitive pressures.

Preauthorization a growing concern.
The time clinicians and their staff spend dealing with insurance companies reduces the time available for patient care and remains a burden on practices. Preauthorization
the requirement that clinicians get prior approval from patients’ insurance providers before ordering certain tests or administering certain treatments is an area of
particular concern among oncology practices. A recent survey of ASCO state affiliate organizations found that preauthorization requirements increase demands on staff time, delay or interrupt patient care, decrease patient satisfaction, and complicate medical decision making.

Drug shortages in cancer care.
Drug shortages remain a relatively small but persistent pressure on practices.
According to a 2014 survey of oncology practices, policy changes enacted in 2011 and 2012 may have helped avert or mitigate drug shortages consistent with findings from several recent governmental analyses. Survey respondents reported that they often address shortages by recommending different treatment regimens, working directly with manufacturers to obtain available drugs, contracting or sharing drugs available
from other local providers, or contracting with other drug distributors.

Safe handling of chemotherapy drugs.
The regulation of chemotherapy safety often occurs at the state level, and several states have been active in recent years in developing new rules in this area. State-level efforts are typically informed by available guidelines and ecommendations. In 2014, the medical oncology community worked collaboratively to develop standards
and to help support communications and educational efforts with policymakers at the state level to ensure that regulations promote safety and are easily adopted
when applied to the day-to-day operations of practices.

340B Drug Pricing Program.
The 340B Drug Pricing Program requires drug manufacturers to provide price discounts to certain hospitals and other health care facilities that qualify as covered entities. Some have questioned the rapid expansion of the 340B Drug Pricing
Program in terms of both the number of eligible facilities and the number of eligible drug claims.19,20,21
This was a focus for both Congress and the Administration in 2014,but there has been no regulatory action to refine the program to date.10

4.QUALITY AND VALUE IN CANCER CARE
Defining and delivering high-value care was a key focus across the oncology community in 2014 and will continue to dominate health reform efforts in the year ahead. Cost
of care continues to drive practice and payment reform initiatives, quality measurement and improvement efforts, and a focus on data and transparency is more broadly viewed as a means of informing consumer choice.

Focus on cost.
In the last decade, the average monthly cost of cancer treatment has more than doubled to $10,000.22
A handful of treatments now cost more than $100,000 annually per patient, and as cancer therapy moves toward use of multiple such agents, concerns about cost have grown. Payers and policymakers are focused on strategies to better define value and engage patients in selecting high-value options.

Response to cost: targeting utilization.
Health insurers and policymakers have pursued a variety of strategies to control cost while preserving or enhancing quality.These include: administrative controls on utilization (e.g., preauthorization for costly therapies and clinical
pathways), development of alternative payment models, and quality monitoring. There has also been a strong emphasis on creating more informed and value conscious consumers.

Quality assessment and performance improvement.
Greater availability of metrics and tools to analyze clinical data are expanding the way that oncologists learn and improve care quality. Quality measurement and improvement are central elements in virtually every payment reform model proposed this year. Notably, the Centers for Medicare & Medicaid Services the single
largest payer for health services in the United States is increasingly expecting providers and practices to demonstrate their commitment to improving quality
of care. Other organizations are also advancing national quality measurement and methods to improve performance.

Big data.
The use of large and complex data sets to inform cancer treatment and care delivery is a growing focus. Numerous big data projects are underway among private and public organizations, including ASCO’s rapid learning system, CancerLinQ; data sharing among
pharmaceutical companies through Project Data Sphere; PCORnet by the Patient-Centered Outcomes Research Institute; and several initiatives of private companies
such as IBM and Optum