ASCO: Cancer Deaths Down, But Costs 'Unsustainable'

Good news: Mortality rates for many cancers are dropping. The challenge: Hospitals and health systems will be serving a new kind of patient—older, sicker, and harder to treat—says a report from the American Society of Clinical Oncology.

When it comes to the quality of cancer care, an oncologist is the person to consult. For anyone looking for advice about the high cost of cancer drugs, a doctor is probably not the first option.

But the American Society of Clinical Oncology's exhaustive 2016 "The State of Cancer Care in America" has a lot to offer on that front.

The report, presented at a Tuesday Capitol Hill congressional briefing, will disappoint those expecting another rant against $140,000, bankruptcy-inducing cancer drugs. Instead, while ASCO calls cancer costs "unsustainable," it makes the pharmaceutical industry's argument that notoriously expensive new meds are not the only element of care fueling the dramatic increases.

Despite the generic name, this is the state of cancer according to practicing oncologists—not patients, payers, or hospitals. So, if you are looking for an update on the state of cancer care and delivery, this is where you'll get the doctors' view.

The result: There's a lot of good news and a lot of bad news—sometimes in the same package. There's a lot going on with cancer.

"Cancer care in the United States remained a mixed picture in 2015. Declining mortality rates, growing numbers of survivors, and exciting progress in treatment were set against the backdrop of increasingly unsustainable costs and a volatile practice environment," the report states.

 One example:

"Precision medicine offers notable advantages to patients in need of expanded treatment options. However, physicians and patients are struggling to manage overwhelming amounts of

information about risks and benefits of genetic testing—and its role in selecting treatment.'

The report is an important document, says Randall Holcombe, MD, the chief medical officer for cancer at the Mount Sinai Health System. He was not involved in the report's preparation, but says he is impressed with its scope.

"It is a really fantastic report," Holcombe says. "It has a ton of information in it that is really timely and essential reading for hospital leadership, as well as practicing oncologists."

Here are some of the key quality messages in the report:

• Care is getting more complex and some oncologist are not equipped to deliver the complicated new treatments.
• Demands on oncologists will grow, as demographics leave more Baby Boomers on oncology's doorstep.
• But, since oncologists are aging as well, there may be fewer of them to treat patients.  
• And, as patients get older, they have more comorbidities.
• Oncologists are struggling with their HIT systems, as well as variations in "cancer pathway" treatment guidelines.

"These trends… raise concerns about how the US cancer care system will be able to respond to the projected surge in demand for cancer care in the coming years, driven by the aging of the US population," says Julie Vose, MD, the president of ASCO, and an oncologist at the University of Nebraska Medical Center in Omaha. She spoke at the briefing Tuesday.

More Survivors; Unique Care Needs
In a way, the cancer care delivery system needs to adjust to meet the needs of its own success. Good news: mortality rates for many cancers are dropping. The challenge: hospitals and health systems with be serving a new kind of patient, who has been treated for and survived cancer. The report cites research that estimates the number of cancer survivors will grow to 14.5 million from 9 million by 2024.

Hospitals should take note, Holcombe cautions: "Cancer survivors are people who are relatively healthy, but have unique health care needs and require surveillance for their primary malignancies as well as secondary malignancies."

And while ASCO notes that the FDA approved 12 new cancer drugs last year (good news) the costs are high. Many of them are intravenous drugs that have to be delivered in the hospital and that could boost inpatient costs. The effect of biosimilars and upcoming changes in Medicare payment for cancer drugs on hospitals may be hard to predict.

With growing complexity of care and the aging of the oncology physician workforce, hospitals need to be thinking about setting up multidisciplinary teams, Holcombe says. And that can be difficult for some systems to do efficiently. Other items in the report that touch on quality of care and stand out:

• While mortality is dropping for some cancers, it is increasing for others, including liver and pancreatic cancer.
• Racial disparities persist and may be getting worse: For example, in 2015, breast cancer incidence rates for African American women was higher than for any other racial group, described in the report as "a troubling development" because African American women have higher mortality rates than other women.

So what of costs? The report repeatedly notes that the cost of new drugs is a problem, but makes the point that drivers of high cost of cancer "are varied, including development of new technologies and treatments, consolidation of oncology practices into hospital-based practices where care costs more, and rising drug prices.

Costs associated with newly insured patients, expanded prevention and screening programs, and growing populations of new patients with cancer and survivors will also likely contribute to future cost increases."

So, while it may not address the drug cost issue with the same urgency at others in the cancer care community, the ASCO report does cover the topic "extensively," Vose says. She agrees that, while drugs are a factor, the cost of care is also driven by costs such as imaging, delivery of care, and infrastructure needs.

It is probably unfair to expect a rant from ASCO on drug prices. They hardly ignore the matter and this is a long, tempered view. Also, like most non-profits, specialist organizations and patient groups rely on corporate support for meetings and other projects and often that support comes from drug makers.

So, some groups are in an awkward position when the interest of the pharmaceutical industry conflict with the needs of other constituents, such as patients.

Here's an idea I've heard. Some of these new drugs don't work a whole lot better than existing therapies. For example, they may offer only a few months of added survival, not the so-called cure former President Jimmy Carter seems to have experienced.

Doctors would do well to counsel their patients about the true benefits of the drugs, their costs, and the quality of life they can expect in those extra few months. The term that's kicking around–financial toxicity–could be added to the list of side effect as doctors help patients make choices about care.

As hospitals absorb more oncology practices and more of the expensive new drugs need to be delivered via IV, they will own a bigger slice of extreme drug prices. So, that's something hospitals chiefs might should be discussing with their cancer teams.