The National Cancer Policy Summit Opportunities and Challenges in Cancer Research and Care (2011) / Chapter Skim
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The National Cancer Policy Summit: Opportunities and Challenges in Cancer Research and Care
The National Cancer Policy Summit: Opportunities and Challenges in Cancer Research and Care
Pages 1-44
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With panel presentations and discussions led by experts in topics such as healthcare policy, oncology research, public health, palliative care, and behavioral economics, the Summit explored policy issues related to cancer research, implementation of healthcare reform, delivery of cancer care, and cancer control and public health needs. These discussions among Summit participants and Forum members will guide the Forum's strategic planning and ensure that NCPF activities are responsive to priorities in the cancer community.
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Yet the 1 In this workshop summary, the Affordable Care Act refers to the final version of the healthcare reform law, including the Patient Protection and Affordable Care Act (P.L.
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, Dr. Dalton said that it described the direction in which cancer research and care should be heading, adding, "It's a grand idea, but it doesn't exist yet and must be built in an iterative process." He noted that the healthcare reform legislation will help foster a rapid learning healthcare system, with its support of accountable care organizations.
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Dalton envisions being able to survey a database to find the most appropriate patients for enrollment in a clinical trial and contacting them directly about their participation. Policy makers will also find a rapid learning healthcare system useful for conducting comparative effectiveness research and cost analyses, he added.
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Dr. Ellen Sigal, chairperson and founder of Friends of Cancer Research, also stressed the need for interoperability of health information systems and the data collected by government agencies.
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Glasgow, and the Cancer Research Network, consisting of 14 health maintenance organizations (HMOs) around the country, also has a lot of expertise and publications on this topic.
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Dr. Dickersin added that observational studies are very important for identifying harms associated with treatments and such studies are already commonly included in systematic reviews that focus on harms, but much work remains to develop the methodology for using observational data in systematic reviews more broadly.
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Ballard-Barbash cited the HMO Cancer Research Network as an example of a rapid learning healthcare system. This collaboration of HMOs around the country covers 11 million patients and, in one year, diagnoses more than 100,000 cancer patients.
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" EVIDENCE-BASED MEDICINE In addition to primary research conducted in randomized clinical trials and observational studies, evidence-based medicine relies upon systematic reviews and comparative effectiveness studies to ascertain which treatments work best for which patients.
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Dr. Dickersin's final suggestion was that systematic reviews be required before clinical trials are funded and that the purpose of the trials should be put within the context of a systematic review.
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Participants made several suggestions for what the elements of a financially sustainable model of cancer care would be, including the following: • ncentives that are aligned with costs and quality I • alue-added or appropriate care that is indicated by evidence-based V medicine • Quality standards • Coordinated care that has a team or network approach • Innovative payment schemes Appropriate Incentives Dr. Everson pointed out that incentives drive the use of procedures, and the financial incentives currently in the healthcare system contribute to the fragmentation of care in many settings, with little coordination between the outpatient and inpatient settings or from primary care to specialty care.
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Mr. Robert Erwin, president of the Marti Nelson Cancer Foundation, suggested preparing formal cancer care protocols.
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Dr. Ubel also asserted that to use behavioral economics effectively to advance cancer care, the following challenges must be met: • etter definition of what behavioral economics means in the health B care setting • etermination of where behavioral economics has the greatest D chance of improving medical care and health behavior • etermination of ways to encourage medical experts to train in D behavioral economics and vice versa • etermination of ways to broaden the behavioral economics D research agenda so that interventions are designed to account both for people's rational and for their irrational tendencies
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Dr. Scott Ramsey, member of the Fred Hutchinson Cancer Research Center, added that most economists agree that the big driver for healthcare cost increases is unrestrained, uncritical adoption of new medical technologies.
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Dr. Lichter suggested that the cost of cancer care can be reduced substantially if more appropriate care is provided.
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Ms. Mary McCabe, director of the Cancer Survivorship Program at Memorial Sloan-Kettering Cancer Center, suggested determining which cancer survivors are at high risk for recurrence or late effects of their treatment and should be followed by oncologists, versus those that can be adequately followed and cared for by their primary care physicians.
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Ms. McCabe noted that finances drive what healthcare practitioners are able to provide for cancer survivors and suggested thinking about who should be providing survivorship cancer care, as well as how to move cancer patients through a system that is a continuum of care that makes sense and has quality controls.
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Dr. John Seffrin, chief executive officer of the American Cancer Society, noted that any financially sustainable system for providing cancer care has to control the current high costs of providers.
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Dr. Lowy added that "although the bulk of cancer medicine is devoted to the screening and treatment of people who have cancer, we also need to focus on trying to look at the issue of risk reduction and what we can do before cancer actually develops." Cancer prevention efforts should not be seen as being confined to the realm of the clinic or of public health, Dr.
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Dr. Seffrin pointed out that about 60 percent of all human cancers are avoidable during a normal human life span by applying what is already known today about cancer risk reduction (IOM, 2003a)
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This was echoed by another participant later during the discussion. "If we don't do a better job demonstrating not just the health benefits, but the return on investment and economic benefits of preventive health, policy makers will see the economic benefit of raiding preventive health funding as opposed to looking at the long-term benefits of getting the public more aware of the health issues," this participant said, adding that in addition to policy makers, it is important for employers and health insurers to know the economic benefits of supporting preventive health measures.
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Obesity seems to have no effects on cancer risk for certain tumors, such as head or neck tumors, while increasing the risk of developing mostly hormonerelated cancers, including postmenopausal breast cancer, colon cancer, endometrial cancer, pancreatic cancer, thyroid cancer, and kidney cancer, according to Dr. Ballard-Barbash.
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The CDC's Task Force on Community Preventive Services3 summarizes evidence in cancer-related areas, such as tobacco use, diet and exercise, and interventions to increase use of cancer screening. Alternatively, there could be more targeted outreach to those at higher risk of developing cancer or of cancer recurrence, by using cancer registries.
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Dr. Richard Pazdur, director of the Office of Oncology Drug Products at FDA, concurred that there is a lack of assessment of quality-of-life and symptom issues in clinical trials.
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Ballard-Barbash also suggested focusing on patient-centered economic issues, such as those tied to patient out-of-pocket expenses and lost productivity due to the chronic, late effects of cancer, which dwarf the healthcare costs related to cancer treatment. Palliative Care and End-of-Life Care Palliative care and end-of-life care were a major focus of many comments.
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Dr. Meier suggested focusing on how to increase access to palliative care in the essential benefits package of nationally approved health insurance
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The National Quality Forum has called for palliative care as a high priority in standard healthcare packages, Dr. Meier said, and stressed the importance of "bringing that to implementation and reality for cancer patients in this country." Dr.
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The project will bring together about 400 professionals from 200 cancer centers to present what evidence there is about family caregiving and ways to improve it. She noted that the bulk of evidence in this area is in regard to family caregivers of Alzheimer's disease patients and that "there really has been very little attention to caregiving in oncology." Some family members take the role of patient advocate, which is another role that needs support in cancer care, some participants suggested.
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Ubel. The National Cancer Policy Forum will further explore the concept of shared decision-making and examine current models for how to improve it at a workshop on "Patient-Centered Cancer Treatment Planning" in February 2011.6 Survivorship Care Given the growing numbers of cancer survivors, some participants called for focusing on standards of care for cancer survivors.
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She noted that in the past 5 years, several observational studies have shown a correlation between physical activity and improved survival for breast and colon cancer. She recommended more studies, including randomized, controlled trials related to physical activity, weight control, and cancer survivorship to assess the effects of these health behaviors on various tumor subtypes, including molecular subtypes if that molecular information is known.
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The issue here is, do the NCI's structure and its programs really address the need to fully exploit this molecular science and targeted therapies? " Recognizing the importance of genomics to cancer research, NCI recently created a new Center for Cancer Genomics, Dr.
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Pazdur noted mirrors what is currently being done in academic comprehensive cancer centers. The motivation for this restructuring was to encourage more consistency of review and improved career building of the FDA staff through increased interaction among FDA staff and outside academic investigators, he said.
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Dr. Rothenberg suggested that traditional end points for cancer clinical trials, such as overall survival, may not be adequate, especially for assessing the value of newer targeted therapies, and should perhaps be supplanted by other end points that are biologically significant and predictive of outcome but have not served as a basis for regulatory review or approval.
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Pazdur suggested such collaborations could be fostered with appropriate incentives, such as increased market exclusivity. FDA successfully used incentives to encourage drug companies to test their adult drugs in pediatric populations, he said.
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Dr. Pazdur added that "it doesn't work in the economics sphere to be a protectionist, nor does it work in the scientific sphere." He suggested that the Cooperative Groups, which are responsible for running many of the major clinical trials of oncology drugs in this country, coordinate their efforts with international studies.
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. over 15,000 deaths per day globally." HEALTHCARE REFORM -- AFFORDABLE CARE ACT Dr.
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Both she and Dr. Seffrin noted that such a package could specify palliative care, for example.
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• nsurers cannot drop coverage because of an individual's par I ticipation in a clinical trial. The legislation prohibits the denial of coverage of routine care costs of participants in certain clinical trials, including FDA-approved drug trials and federally funded clinical trials that treat cancer or other life-threatening diseases.
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• T he Patient-Centered Outcomes Research Institute will be established. • T he Center for Medicare and Medicaid Innovation will align pay ment incentives in areas of treatment planning and follow-up care planning with nationally recognized evidence-based guide lines for cancer care.
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States are also responsible for the risk adjustment systems within the insurance exchange, which will ensure that health plans have appropriate incentives to cover people with higher costs. "We have tremendous potential for improvement in cancer care associated with the implementation of the Affordable Care Act, but effective implementation is going to rely heavily on the states.
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While the ACA provides coverage of routine care costs related to clinical trial participation for state-regulated insurance and employersponsored plans, this provision is not applicable to Medicaid, although states may cover the routine costs associated with clinical trial participation through their own funding initiatives (Rosenbaum et al., in press)
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For example, health IT is often looked upon as the solution to many ongoing challenges in cancer research and care, but there are also many challenges associated with implementing effective, integrated IT systems. Many participants emphasized the need to both increase the quality and lower the cost of cancer care.
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2010b. A foundation for evidence-driven practice: A rapid learning system for cancer care: Workshop summary.
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2010. Early palliative care for patients with metastaic non-small-cell lung cancer.
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