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Cancer Care In Crisis? The Institute of Medicine’s Report: Delivering High-Quality Cancer Care: Charting a New Course For a System in Crisis; Part I: The Current Landscape

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 A few months ago, the Institute of Medicine released the prepublication proofs of a massive report on the state of oncology care, saying that it was in crisis in the United States. I learned about it from an email that focused on the crisis part of the title. I was both immediately concerned and immediately thought that GRACErs would want to know about it. So, I emailed Dr. West, promising a GRACE post. I did not realize at the time that the report was 323 pages on my iPad and how busy work would be, so it’s taken a little while to read all of it! In doing so, I realize that the “crisis” part is far from the most important part of this document. Rather, it is more a logical charting of the changing nature of our system, the challenges to optimal care that result, and the practical solutions about how to address these. I think that this report is a big deal–the Institute of Medicine itself is a big deal—they have a history of providing quality, high-impact reports on US healthcare which policy makers and stakeholders listen too. And, there are some big ideas here with the potential to improve cancer care delivery and address changes in the system. As my intention is mostly to provide a plain-English, summarized version of some of the key content, I will simply follow the organization of the report. Also, the report is massive, requiring some editorial choices. My choices will be guided not only by importance, but also by the extent that topics are already covered by GRACE; I will focus more on the topics with limited existing coverage on GRACE because I feel that the content is not already represented here and will be brief on the topics already covered. I will try to make up for some of this glossing by referring to tables, figures, and boxes in the original report that can supplement my posts meaningfully without requiring reading the full report. This section represents the introduction; more installments will follow as I write them.


Our population is aging; the number of older adults is expected to double between 2010 and 2030. As many cancers are more common in older adults, the number of cancers will therefore increase—by 2030, we expect a 45% increase in cancer incidence. Right now, more than half of cancer diagnoses and more than 2/3 of cancer deaths are in people at least 65 years old. Therefore, increasing, good oncology is geriatric oncology. This is particularly applicable to lung cancer, where, right now, the median age of presentation is 71. Not only is our population getting older, the older population is getting older—in 2010, 14% of older adults were at least 85 years; by 2050, this proportion is expected to increase to more than 21%. Cancer care for older patients is more complex as older patients tend to have greater numbers of health problems, tend to take more medicines, have distinct goals of care and have increased need for social support. Our health system is already poorly prepared to comprehensively address these concerns. Of note for those considering reading the report (or sections of it) there’s a lot of great information on the priorities of older patients and geriatric assessment as well as racial and gender trends that are worthy of reading at the beginning of chapter two.


From 1980 to 2000, the yearly cancer incidence increased by 66%, leading to a shortage of skilled healthcare workers to care for cancer patients. The expansion of the cancer population driven by the aging of our population will exacerbate the shortage. While it’s a great problem to have, the average survival time following a cancer diagnosis is growing longer; longer survival means more total cancer patients which means yet more health care workers needed to provide follow-up and survivorship care. Medical training programs lack the ability to rapidly expand to address this shortfall, leading to threat of much greater crisis. Family and loved ones of patients already administer a significant amount of care despite limited training and support. The care delivered by the professional system is often fragmented and poorly coordinated.


The cost of health care in the US is very high and continues to rise. In 2011, the US spent $2.7 trillion in health care; stated another way, we spent 18% of our gross domestic product. This proportion of GDP is expected to rise to almost 25% of GDP by 2037. To an extent, it may make sense for a rich country to spend a lot of its resources on better health for its citizens. However, these costs are rapidly rising and many economists feel that they threaten our nation’s economic stability. The direct costs of medical care for cancer account for 5% of national health care. Many of our cancer medicines are very expensive. The FDA approves cancer drugs based on evaluations of safety and efficacy, but does not consider issues of cost or cost effectiveness in its decisions.


One of the most traditionally accepted ideas in health care economy was the idea of a “health care triangle” – with any given level of medical knowledge; adjustment of any limb of the triangle would affect the other. The three arms are quality of care, access to care, and cost of care. Traditionally, a major issue of the increased cost of care was decreased access to care—as the cost of care goes up, the cost of insurance goes up, which decreased the number of people who can afford it. The affordable care act (otherwise known as ACA or “Obamacare”) seeks to increase access to care, while limiting costs by increasing the pool of healthy people who are insured and increasing preventative services. More specifically, the act empowers states to expand Medicaid eligibility categories and to raise the income threshold for Medicaid eligibility. Under ACA, states can elect to allow all non-elderly, non-disabled citizens who are legal US residents to be eligible, as long as income is below 133% of the federal poverty level (stated another way, $30,000 for a family of 4). The reach of the law is now limited by state-level decisions as a consequence of the Supreme Court’s June 2012 decision. While the court did basically uphold the ACA, it ruled that states were not obliged to increase Medicaid eligibility to maintain existing subsidies. As a result, while 31 states and the District of Columbia plan to expand Medicaid, 6 states remain undecided (as of 6/2013) and 21 states are not expanding. Those living in states without expansion will have the choice of turning to the Health Insurance marketplaces (thus far not working very well) or remain uninsured. Young adults will have the option to remain on their parents’ insurance until age 26.


The ACA also seeks to improve the quality of insurance provided. The law prohibits common practices traditionally used by insurance companies to limit eligibility such as charging higher premiums for pre-existing conditions or placing lifetime limits on benefits for specific conditions. The act will substantially increase access to preventative care such as cervical, breast and colon cancer screening, including shifting more of the cost of these preventative services (read “suffering preventing” and “cost preventing”). It prohibits denial of coverage to individuals participating in cancer clinical trials. I’ve spent a lot of space on the affordable care act (Obamacare) because it is so important, so controversial and so poorly understood by the general public (despite great passion on the part of many, on both sides of the aisle, with poor understanding of what’s actually in there). That said, I’ve still been pretty brief. For those who want to learn more, the end of chapter two of the report has a great table summarizing what’s in Obamacare that I highly recommend for a quick primer.


Please stay tune for part II: Patient-Centered Communication and Shared Decision Making. I hope to post it within the next few days.


One Response to Cancer Care In Crisis? The Institute of Medicine’s Report: Delivering High-Quality Cancer Care: Charting a New Course For a System in Crisis; Part I: The Current Landscape

  • ssflxl says:


    dr Weiss, I saw the title in some news section, but didn’t realize the report is really a book!! Thanks for this abbreviated version.
    I look forward to reading the rest of your article.


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