Curing the cancer crisis

Last week, the Institute of Medicine declared a crisis in the system for delivering care to the more than 1.6 million who contract cancer and the 500,000 people who die each year from the more than 100 forms of the disease.

It would be facile and wrong to suggest that the more than $100 billion spent by the government since President Nixon declared war on cancer was wasted. Better drugs, better regimens and better forms of radiation and surgery have taken the overall five-year cancer survival rate to 60% of patients compared to 40% a half century ago, although some of that improvement is an artifact of early detection.

Public health approaches to combating cancer have made enormous strides. While lung cancer is still the most prevalent form of the disease, its incidence is finally on the downswing because of the high-profile battle waged by public health authorities against smoking and Big Tobacco. The environmental movement's campaigns for cleaner air and water also played a role in reducing the incidence of many cancers.

But the IOM report chose not to emphasize those important advances. Rather, it focused on the quality of care currently being delivered by the nation's healthcare system—the hospitals and large oncology practices that treat millions of people every year, which is a $125 billion enterprise, slated to grow to $173 billion by 2020.

In many crucial areas, progress has been scant. Far too many patients today do not receive the palliative care they need to manage symptoms and side effects. Many patients, especially those in the latter stages of the disease, have unrealistic expectations of what modern medicine can achieve. Communication between physicians and patients is poor.

And, in what ought to be the takeaway message for providers, care is often poorly coordinated. Not only is it variable across care sites and sometimes within the same practice, but also oncologists are all too often not on speaking terms with best practices and latest clinical practice guidelines.

Changes clearly are needed.

First and foremost, the opportunity for the greatest progress in combating cancer will come not from better drugs, but from using drugs better. Ending unwarranted variation in care will lead to better outcomes and reduce costs as it has in other areas of medicine.

Learning how to engage late-stage cancer patients in meaningful end-of-life discussions has the potential to save the healthcare system enormous sums by avoiding useless treatment. Focusing on better and earlier use of palliative care and pain management has the potential to significantly improve the quality of life for patients given a realistic appraisal of their prognosis.

Better coordination of care will also improve the patient experience and reduce costs. A typical breast cancer patient today may go through two or three forms of treatment, each with its own specialist. She doesn't need a medical home. She needs a medical concierge who can navigate the system's complexities, explain choices and avoid duplication of services.

But what the system needs most of all is the ability to learn from its experiences. The report called for turning cancer care into a “learning system,” where data about performance measures, therapy choices and outcomes are measured so they can be later analyzed to determine what worked best for which patients.

That's how progress in childhood cancers was achieved (now over a 90% survival rate). The nationwide Children's Oncology Group registers every child with cancer in a clinical trial that collects information about treatment regimens and outcomes. While new drugs played a role, over the decades the most significant progress came from constantly adjusting and changing therapies to incorporate the latest knowledge about what had worked best.

Right now, despite the increasing presence of electronic health records, none of that information is collected from the more than 1 million adults who receive cancer treatment each year. The American Society of Clinical Oncology has begun collecting data for a small subset of breast cancer patients. But the cancer treatment complex as a whole hasn't gotten to square one. Until it does, the war on cancer will remain bogged down in the trenches.

Merrill Goozner is the editor of Modern Healthcare

Follow Merrill Goozner on Twitter: @MHgoozner