lunes, 24 de agosto de 2015
Food sustainability
The new focus on sustainability. The Dietary Guidelines for Americans and for our planet
5 tips for sustainable eating
Seeing Past the Supermarket
Sustainability is a topic of increasing importance asparagus_grocerystoreas consumers become more interested in learning what lies beyond the supermarket. Where does food come from? How was it grown? Where was it produced? Sustainability is a multi-faceted issue, in which the food production system and sustainable diets play a crucial role.
What is sustainability?
Jeffrey D. Sachs, an expert on sustainable development and director of the Earth Institute at Columbia University, wrote: “Like all living species, humanity depends on nature for food and water, materials for survival, and safety from dire environmental threats, such as epidemics and natural catastrophes. Yet for a species that depends on the beneficence of nature, or on what the scientists call ‘environmental services,’ we are doing a poor job of protecting the physical basis of our very survival!” (1)
As we refer to it here, sustainability means the enactment of practices that fulfill the needs of society while protecting the physical basis of our long term survival, our environment. We cannot have a secure food supply unless that food supply is sustainable.
Why is a sustainable food supply important?
The world’s population is rapidly expanding, and it is estimated there will be over 9 billion people on our planet in as little as 25 years. (1) It is essential that food sustainability be an international priority to ensure that the rapidly expanding population will have both enough food to eat, and access to high quality, nutritious foods.
Food systems throughout the world are currently not sustainable, even though at present almost a billion persons are not getting enough food and most of the 7 billion inhabitants of the world eat diets poor in quality.
Many people don’t realize that food production places enormous demand upon our natural resources, with agriculture alone responsible for up to 30 percent of global greenhouse gas emissions – with almost half caused by livestock production alone.
The present rate of greenhouse gas accumulation is driving climate change at a rate that is unprecedented in human history and that will have disastrous effects on food production unless we change alter our present course.
At present, agriculture also accounts for the majority of deforestation, total freshwater withdrawals, and loss of species in marine systems. (2)
Working toward a sustainable food supply is crucial, but it won’t be achieved without a shift in the way our food is produced. Systems of food production affect everything from the nutrient value of crops and food products, to the health of livestock, the environment, and even the economy.
A 2013 report from the Union of Concerned Scientists highlights the importance of changing the current farming practices in the U.S.(3):
A more diversified farm landscape produces a healthier mix of crops and livestock for local and regional markets. The positive effects are numerous, including benefits for the environment, better nutrition and health for consumers, and improved local economies in farm areas.
Shifting the American diet to include less processed food and meat, and more fruits and vegetables, would create a more diversified farm landscape – away from the current system that is primarily corn- and soybean-dominated.
Vegetables, fruits, and nuts currently account for only 2 percent of U.S. crop acreage. By contrast, nearly 60 percent is devoted to cereal grains and seeds grown primarily for the production of edible oils.
The greatest uses of corn and soybeans include fuel (ethanol and biodiesel), livestock feed, and ingredients such as high-fructose corn syrup, which are used in highly processed food products with low nutrient value. Only 10% of grains grown in the U.S. are for direct consumption by humans.
FAOcharts
Domestic utilization of grain from FAO 2009: Includes wheat, rice, barley, maize, rye, oats, millet, sorghum, and other cereals. Data on maize used for ethanol was only available for U.S. The United States uses 15% of the total grain used in the world. Graphic adapted from Jahn JL, Stamper MJ, Willet WC (in press). Food, Health and the Environment: A Global Grand Challenge and its Solutions. Daedalus. (4)
Food sustainability is an urgent matter that depends on collaborative efforts from governments, the private and public sectors, as well as individuals. Supply and demand works both ways—a shift in the food production landscape depends on a shift in our diets. We must be aware that our food choices ultimately impact more than just ourselves, and primarily plant-based diets are best for both health outcomes and the environment. In the end, what’s good for the planet is good for us too.
What can I do to promote sustainability?
Consumers have more power than they realize. While people often feel that taking care of the environment is too great an issue for one person to make a difference, the sum of each individual’s actions can have a powerful impact. The following are some ways you can promote sustainability:
1. Examine your personal food choices.
As explained in the Union of Concerned Scientists report:
• If Americans ate fruits and vegetables at recommended levels, U.S. farmers would grow a lot more of these foods.
• Changes in demand for meat and dairy products—either up or down—would have significant implications for how much grain U.S. farmers grow. This is because farm livestock consume grains in such large quantities.
2. Eat less red meat (5), and you can help the environment.
As outlined in a 2013 FAO report (6):
• Beef (41%) and cattle milk production (19%) account for the majority of livestock emissions, with pig meat (9%) and poultry meat and eggs (8%) contributing as well.
3. Practice mindful eating.
By taking the time to truly savor your meal – being aware of your actual hunger and eating until you’ve had just enough – you can minimize food waste.
• Learning to eat in accordance with your hunger, and avoiding overeating, has benefits for both your waistline and for the environment.
4. Choose a food guide that enhances both personal and planetary health.
As outlined in a Union of Concerned Scientists report, Harvard’s Healthy Eating Plate recommends less dairy consumption and less red meat relative to the USDA’s MyPlate. While both guides emphasize eating an abundance of fruits and vegetables, The Healthy Eating Plate helps you choose more sustainable food options. (3)
• Learn about and support efforts to produce foods in ways that reduce green house gas emissions and that are more environmentally friendly in other ways as well. This will usually mean foods that are also fresher, flavorful, and healthier.
Sustainability News
References
1. Sacks JD. The Age of Sustainable Development. New York: Columbia University Press; 2015.
2. Rockström J, Willett W, Stordalen GA. An American Plate That Is Palatable for Human and Planetary Health. Huffington Post. March 26, 2015. http://www.huffingtonpost.com/johan-rockstrom/post_9225_b_6949716.html.
3. Union of Concerned Scientists. The Healthy Farmland Diet: How Growing Less Corn Would Improve Our Health and Help America’s Heartland. October 2013. http://www.ucsusa.org/food_and_agriculture/solutions/expand-healthy-food-access/the-healthy-farmland-diet.html.
4. Jahn JL, Stampfer MJ, Willett WC (in press). Food, Health and the Environment: A Global Grand Challenge and its Solutions. Daedalus.
5. Menus of Change. Rethinking Meat. March 31, 2014. http://www.menusofchange.org/news-insights/news/rethinking-meat.
6. Food and Agriculture Organizations of the United Nations. Tackling Climate Change Through Livestock. October 21, 2014. http://www.fao.org/ag/againfo/resources/en/publications/tackling_climate_change/index.htm.
The Dark Side of Lawns
The Dark Side of Lawns
You can have a thick and healthy sea of green without polluting water, harming wildlife, and endangering the health of your family and pets.
By Beth Huxta November 26, 2010
Americans spend so much money and time on their lawns, you'd think we either eat or sell grass. More land in the United States is planted in turf—32 million acres—than in corn. The typical American lawn sucks up 10,000 gallons of supplemental water (non-rainwater) annually.
What's worse, the U.S. Environmental Protection Agency estimates that about 80 million U.S. households dump nearly 90 million pounds of herbicides and pesticides on lawns in a year. In fact, lawn care is as much of a danger to our health and the environment as conventional agriculture is.
Does that mean you—and every other organic gardener—must give up having a nice swath of grass where you, the kids, and the dog can frolic carefree? No, not if you follow the 6-step Organic Lawn Plan. You (and your neighbors) will be surprised to see you can have a thick, lush lawn without toxic treatments.
Fools for Fertilizer
The conventional lawn-care industry has sold most homeowners on the need to apply synthetic fertilizer three or four times a season. What's wrong with that?
Nutrient waste. Synthetic fertilizers are chemically processed into concentrated, water-soluble nutrients that are available to plants immediately. But when there is more than the grass can take up, the excess washes out of the grass's root zone and into the watershed. The problem is compounded by the tendency of many homeowners to apply more fertilizer than even the manufacturers recommend.
This nutrient leaching is no small environmental problem. Every summer in the Gulf of Mexico, an area roughly the size of Connecticut is choked with vast algae and phytoplankton blooms, due in part to tons of synthetic nitrogen and phosphorus fertilizer runoff from the Mississippi River. As the algae dies and decomposes, it uses up the available oxygen, making the area uninhabitable for sea life. The polluted runoff water that contributes to this "dead zone" comes from each of the 31 states between the Rocky and Appalachian mountain ranges that eventually drain into the gulf. This scenario is so widespread that several states, Canadian provinces, and municipalities have imposed bans on fertilizers containing phosphorus.
Weed and feed. The situation gets worse with the widely popular "weed and feed" products that combine a synthetic lawn fertilizer and herbicide in the same bag. "No lawn is 100 percent weeds, but people are spreading these chemicals over the entire lawn," says Paul Tukey, author of The Organic Lawn Care Manual and spokesperson for SafeLawns.org. So if your lawn is 2 percent weeds, 98 percent of the herbicide product applied to the lawn serves no purpose, and it may wash into rivers and streams, leach into groundwater, or volatize into the air we breathe. One of the most common herbicides in weed and feed products, a chemical called 2,4-D, has been linked to human health problems, including an increased risk for non-Hodgkin's lymphoma.
Mystery ingredients. The EPA requires fertilizer and pesticide manufacturers to list only "active" ingredients on a product's label. The manufacturers are not legally required to disclose the inert ingredients, which can include harmful quantities of heavy metals. Inert ingredients in a lawn chemical will not kill your weeds, but there is no guarantee that they will be nontoxic to you or your pets.
Problems from Pesticides
Contaminated water. Herbicides and pesticides from lawns also get into our water supply. A study of 12 urban streams in the Seattle metro area found 2,4-D in every stream and 23 different types of pesticides, including five that were present in concentrations high enough to kill aquatic life. The researchers found a correlation between the pesticides polluting the sampled streams and the sales of lawn and garden chemicals from local retailers. And the U.S. Geological Survey's National Water-Quality Assessment Program found that 90 percent of the stream and fish samples surveyed contained at least one pesticide.
Threatened wildlife. Of the 30 most commonly used lawn pesticides, 16 pose serious hazards to birds, 24 are toxic to fish and aquatic organisms, and 11 have adverse effects on bees.
Harmful to Health
Lawn chemicals don't just turn up in the environment. A study of indoor air pollutants found 2,4-D in 63 percent of homes. A different study demonstrated that levels of 2,4-D in indoor air and on indoor surfaces increased after it was applied on lawns.
Not child's play. Lawn chemicals get tracked indoors, often onto surfaces where kids play. The National Academy of Sciences reports that 50 percent of contact with pesticides occurs within the first five years of life. Such repeated contact has been linked to numerous diseases in children; for instance, researchers reporting in the Journal of the National Cancer Institute found that exposure to garden pesticides can increase the risk of childhood leukemia almost sevenfold.
Women's health. Contact with low levels of pesticides increases miscarriage rates, and a study recently published in the American Journal of Epidemiology documented a link between residential pesticide use and breast cancer risk in women. Researchers at the Harvard School of Public Health found that frequent exposure to pesticides increased the incidence of Parkinson's disease by 70 percent.
Pets smart. Like small children, pets can't read the "Keep Off—Pesticide Application" signs on your lawn or your neighbor's. A study revealed that exposure to lawns treated with herbicides four or more times a year doubled a dog's risk of canine lymphoma, while the Journal of the American Veterinary Medical Association reported that, when exposed to chemically treated lawns, some breeds of dogs were four to seven times more likely to suffer from bladder cancer.
Go Green Guide
You can help improve the environment and reduce human exposure to lawn chemicals by raising awareness in your community about the dangers of conventional lawn care and the benefits of organic turf.
Educate your neighbors. Post a "Pesticide-Free Lawn" sign in your yard (find them online at beyond pesticides.org) and talk with your neighbors about the problems with lawn chemicals. Share the simple organic lawn maintenance plan in this article.
Create a demand. Request that your local nursery carry organic fertilizers and lawn products.
Be a positive example. The best way to draw attention to the benefits of an organic lawn is to grow healthy, beautiful grass organically.
Be politically active. Write to local officials to let them know you're concerned about lawn-chemical use in your community and urge them to consider repealing preemption laws, which restrict municipalities from passing local pesticide ordinances that are stricter than state policy.
Facts and Tips
American homeowners use up to 10 times more pesticides per acre of lawn than farmers use on an acre of crops.
Reduce H2O flow: Help droughtproof grass by watering it thoroughly but infrequently, so that it develops deep roots.
Deep roots: A square foot of lawn contains 850 grass plants and 392,000 miles of roots.
Home, safe home: Mowing grass high is as effective at controlling weeds as herbicides, which endanger children's health.
Newbie hint
Control weeds before they germinate, and fertilize your grass with the natural, organic weed and feed: corn-gluten meal. Apply 20 pounds per 1,000 square feet, advises Chip Osborne of livinglawn.org. Put it down in early spring, when forsythia is in bloom, but avoid using corn-gluten meal after overseeding, since it kills grass seeds as well as weed seeds.
Master's Tip
Apply phosphorus to your lawn only after testing. Even organic sources of phosphorus can seriously affect water quality, and most lawn soils don't need it. Phosphorus-free fertilizers have a middle number of "0".
Tags: lawn caregrassherbicideschemicalspesticidesorganic gardening
Your Privacy Rights. | About Us.
You can have a thick and healthy sea of green without polluting water, harming wildlife, and endangering the health of your family and pets.
By Beth Huxta November 26, 2010
Americans spend so much money and time on their lawns, you'd think we either eat or sell grass. More land in the United States is planted in turf—32 million acres—than in corn. The typical American lawn sucks up 10,000 gallons of supplemental water (non-rainwater) annually.
What's worse, the U.S. Environmental Protection Agency estimates that about 80 million U.S. households dump nearly 90 million pounds of herbicides and pesticides on lawns in a year. In fact, lawn care is as much of a danger to our health and the environment as conventional agriculture is.
Does that mean you—and every other organic gardener—must give up having a nice swath of grass where you, the kids, and the dog can frolic carefree? No, not if you follow the 6-step Organic Lawn Plan. You (and your neighbors) will be surprised to see you can have a thick, lush lawn without toxic treatments.
Fools for Fertilizer
The conventional lawn-care industry has sold most homeowners on the need to apply synthetic fertilizer three or four times a season. What's wrong with that?
Nutrient waste. Synthetic fertilizers are chemically processed into concentrated, water-soluble nutrients that are available to plants immediately. But when there is more than the grass can take up, the excess washes out of the grass's root zone and into the watershed. The problem is compounded by the tendency of many homeowners to apply more fertilizer than even the manufacturers recommend.
This nutrient leaching is no small environmental problem. Every summer in the Gulf of Mexico, an area roughly the size of Connecticut is choked with vast algae and phytoplankton blooms, due in part to tons of synthetic nitrogen and phosphorus fertilizer runoff from the Mississippi River. As the algae dies and decomposes, it uses up the available oxygen, making the area uninhabitable for sea life. The polluted runoff water that contributes to this "dead zone" comes from each of the 31 states between the Rocky and Appalachian mountain ranges that eventually drain into the gulf. This scenario is so widespread that several states, Canadian provinces, and municipalities have imposed bans on fertilizers containing phosphorus.
Weed and feed. The situation gets worse with the widely popular "weed and feed" products that combine a synthetic lawn fertilizer and herbicide in the same bag. "No lawn is 100 percent weeds, but people are spreading these chemicals over the entire lawn," says Paul Tukey, author of The Organic Lawn Care Manual and spokesperson for SafeLawns.org. So if your lawn is 2 percent weeds, 98 percent of the herbicide product applied to the lawn serves no purpose, and it may wash into rivers and streams, leach into groundwater, or volatize into the air we breathe. One of the most common herbicides in weed and feed products, a chemical called 2,4-D, has been linked to human health problems, including an increased risk for non-Hodgkin's lymphoma.
Mystery ingredients. The EPA requires fertilizer and pesticide manufacturers to list only "active" ingredients on a product's label. The manufacturers are not legally required to disclose the inert ingredients, which can include harmful quantities of heavy metals. Inert ingredients in a lawn chemical will not kill your weeds, but there is no guarantee that they will be nontoxic to you or your pets.
Problems from Pesticides
Contaminated water. Herbicides and pesticides from lawns also get into our water supply. A study of 12 urban streams in the Seattle metro area found 2,4-D in every stream and 23 different types of pesticides, including five that were present in concentrations high enough to kill aquatic life. The researchers found a correlation between the pesticides polluting the sampled streams and the sales of lawn and garden chemicals from local retailers. And the U.S. Geological Survey's National Water-Quality Assessment Program found that 90 percent of the stream and fish samples surveyed contained at least one pesticide.
Threatened wildlife. Of the 30 most commonly used lawn pesticides, 16 pose serious hazards to birds, 24 are toxic to fish and aquatic organisms, and 11 have adverse effects on bees.
Harmful to Health
Lawn chemicals don't just turn up in the environment. A study of indoor air pollutants found 2,4-D in 63 percent of homes. A different study demonstrated that levels of 2,4-D in indoor air and on indoor surfaces increased after it was applied on lawns.
Not child's play. Lawn chemicals get tracked indoors, often onto surfaces where kids play. The National Academy of Sciences reports that 50 percent of contact with pesticides occurs within the first five years of life. Such repeated contact has been linked to numerous diseases in children; for instance, researchers reporting in the Journal of the National Cancer Institute found that exposure to garden pesticides can increase the risk of childhood leukemia almost sevenfold.
Women's health. Contact with low levels of pesticides increases miscarriage rates, and a study recently published in the American Journal of Epidemiology documented a link between residential pesticide use and breast cancer risk in women. Researchers at the Harvard School of Public Health found that frequent exposure to pesticides increased the incidence of Parkinson's disease by 70 percent.
Pets smart. Like small children, pets can't read the "Keep Off—Pesticide Application" signs on your lawn or your neighbor's. A study revealed that exposure to lawns treated with herbicides four or more times a year doubled a dog's risk of canine lymphoma, while the Journal of the American Veterinary Medical Association reported that, when exposed to chemically treated lawns, some breeds of dogs were four to seven times more likely to suffer from bladder cancer.
Go Green Guide
You can help improve the environment and reduce human exposure to lawn chemicals by raising awareness in your community about the dangers of conventional lawn care and the benefits of organic turf.
Educate your neighbors. Post a "Pesticide-Free Lawn" sign in your yard (find them online at beyond pesticides.org) and talk with your neighbors about the problems with lawn chemicals. Share the simple organic lawn maintenance plan in this article.
Create a demand. Request that your local nursery carry organic fertilizers and lawn products.
Be a positive example. The best way to draw attention to the benefits of an organic lawn is to grow healthy, beautiful grass organically.
Be politically active. Write to local officials to let them know you're concerned about lawn-chemical use in your community and urge them to consider repealing preemption laws, which restrict municipalities from passing local pesticide ordinances that are stricter than state policy.
Facts and Tips
American homeowners use up to 10 times more pesticides per acre of lawn than farmers use on an acre of crops.
Reduce H2O flow: Help droughtproof grass by watering it thoroughly but infrequently, so that it develops deep roots.
Deep roots: A square foot of lawn contains 850 grass plants and 392,000 miles of roots.
Home, safe home: Mowing grass high is as effective at controlling weeds as herbicides, which endanger children's health.
Newbie hint
Control weeds before they germinate, and fertilize your grass with the natural, organic weed and feed: corn-gluten meal. Apply 20 pounds per 1,000 square feet, advises Chip Osborne of livinglawn.org. Put it down in early spring, when forsythia is in bloom, but avoid using corn-gluten meal after overseeding, since it kills grass seeds as well as weed seeds.
Master's Tip
Apply phosphorus to your lawn only after testing. Even organic sources of phosphorus can seriously affect water quality, and most lawn soils don't need it. Phosphorus-free fertilizers have a middle number of "0".
Tags: lawn caregrassherbicideschemicalspesticidesorganic gardening
Your Privacy Rights. | About Us.
viernes, 21 de agosto de 2015
The State of Cancer Care in America 2015. ASCO
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.
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 significantly.
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 years6,7 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.8
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 9
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 recommendations.
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.
5.
CONCLUSION AND RECOMMENDATIONS
Although the U.S. cancer care system faces many challenges, it is capable of meeting these expectations through mobilization of cancer clinicians and researchers
and the broader healthcare community in this unique time of dramatic change and significant opportunity. Below are strategies ASCO believes can play an important
role in addressing the challenges described in this report:
Ensure all publicly funded insurance programs offer consistent and appropriate benefits and services for patients with cancer.
•CMS should standardize benefits and other program elements across Medicare and Medicaid.
•Congress should eliminate inconsistencies in coverage and benefits that currently exist between Medicaid patients enrolled pre- and post-Affordable Care Act
and ensure that Medicaid includes coverage of clinical trials.
•Oncology professionals should articulate the essential services any plan must include to achieve high-quality, high-value care.
Pilot test multiple innovative payment and care delivery models to identify feasible models that promote high quality, high-value cancer care.
•CMS should expand its efforts to pilot alternative payment models beyond its Oncology Care Model to identify innovative strategies that allow practices flexibility to deliver high-quality, high-value care while containing cost.
•Congress should provide a fair, adequate, and stable payment environment for oncology practice, including repeal and replacement of the sustainable growth rate
(SGR) formula.
•Oncology professionals should engage in testing and evaluating new payment and care delivery models and in developing measures of accountability for the care
delivered.
•Private insurers should partner with CMS, patients, and providers to test promising new payment and care delivery models so the impact of alternative strategies
on the entire cancer care delivery system can be determined.
Promote high-value care by advancing and supporting
transparency and shared decision making with patients.
·CMS should make every effort to improve its publicly released data and provide appropriate information to help the public understand the context for the data.
•Congress should require that health information technology vendors create products that promote interoperability and enable research use of standardized
data in a secure environment to advance high-quality health care.
•Oncology professionals should discuss personal goals of care, potential treatment options, expected benefits, and the physical and financial impacts of treatment
options with every patient with cancer.
•Private insurers should ensure that publicly shared information about providers is accurate, in context, and meaningful to the intended audience.
•Professional organizations should offer tools and information that facilitate and help routinely incorporate shared decision making into practice.
ASCO will continue to track and evaluate the ever-shifting landscape in cancer care over the coming year, will continue to support cancer care providers as they negotiate these growing pressures, and will work with policymakers and other stakeholder organizations to ensure that changes in the system support access to high-quality, high-value care for all cancer patients.
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.
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 significantly.
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 years6,7 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.8
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 9
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 recommendations.
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.
5.
CONCLUSION AND RECOMMENDATIONS
Although the U.S. cancer care system faces many challenges, it is capable of meeting these expectations through mobilization of cancer clinicians and researchers
and the broader healthcare community in this unique time of dramatic change and significant opportunity. Below are strategies ASCO believes can play an important
role in addressing the challenges described in this report:
Ensure all publicly funded insurance programs offer consistent and appropriate benefits and services for patients with cancer.
•CMS should standardize benefits and other program elements across Medicare and Medicaid.
•Congress should eliminate inconsistencies in coverage and benefits that currently exist between Medicaid patients enrolled pre- and post-Affordable Care Act
and ensure that Medicaid includes coverage of clinical trials.
•Oncology professionals should articulate the essential services any plan must include to achieve high-quality, high-value care.
Pilot test multiple innovative payment and care delivery models to identify feasible models that promote high quality, high-value cancer care.
•CMS should expand its efforts to pilot alternative payment models beyond its Oncology Care Model to identify innovative strategies that allow practices flexibility to deliver high-quality, high-value care while containing cost.
•Congress should provide a fair, adequate, and stable payment environment for oncology practice, including repeal and replacement of the sustainable growth rate
(SGR) formula.
•Oncology professionals should engage in testing and evaluating new payment and care delivery models and in developing measures of accountability for the care
delivered.
•Private insurers should partner with CMS, patients, and providers to test promising new payment and care delivery models so the impact of alternative strategies
on the entire cancer care delivery system can be determined.
Promote high-value care by advancing and supporting
transparency and shared decision making with patients.
·CMS should make every effort to improve its publicly released data and provide appropriate information to help the public understand the context for the data.
•Congress should require that health information technology vendors create products that promote interoperability and enable research use of standardized
data in a secure environment to advance high-quality health care.
•Oncology professionals should discuss personal goals of care, potential treatment options, expected benefits, and the physical and financial impacts of treatment
options with every patient with cancer.
•Private insurers should ensure that publicly shared information about providers is accurate, in context, and meaningful to the intended audience.
•Professional organizations should offer tools and information that facilitate and help routinely incorporate shared decision making into practice.
ASCO will continue to track and evaluate the ever-shifting landscape in cancer care over the coming year, will continue to support cancer care providers as they negotiate these growing pressures, and will work with policymakers and other stakeholder organizations to ensure that changes in the system support access to high-quality, high-value care for all cancer patients.
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