Workforce, practice challenges jeopardize ability to meet growing demands of cancer care

An ASCO report released earlier this spring outlined several alarming trends that may dramatically influence the way in which cancer care is delivered.

The number of patients with cancer continues to climb due to so-called “good” problems, such as improvements in screening practices and increased availability of health insurance, and the development of effective targeted treatments has contributed to a record number of cancer survivors.

However, these trends coincide with a projected oncologist shortage triggered by retirements and high rates of burnout. A lack of oncologists in rural regions, as well as the regulatory and payment burdens that community practices face, also threaten patients’ access to quality care.

“We’re all very excited about the tremendous progress we have made, clearly exhibited by the higher percentage of patients who are living beyond 5 years with cancer,” Blase N. Polite, MD, MPP, assistant professor of medicine at the University of Chicago and incoming chair of the ASCO Government Relations Committee, told HemOnc Today. “However, we also know that this is coming at an incredible cost to the system.”

The ASCO report, The State of Cancer Care in America: 2014, calls for revised payment models — as well as quality care measures and metrics that are unique to oncology — to eliminate or minimize the effects of these challenges. Programs designed to reduce burnout among oncologists and evaluate the benefits of visiting consulting clinics in rural areas also are under evaluation.

HemOnc Today spoke with several clinicians and researchers about the issues outlined in the report, as well as the need for — and potential barriers associated with — strategies designed to improve access to cancer care.

“We would like to change the way we deliver cancer care in this country, but that absolutely has to be coupled with dynamic, specific quality reporting measures,” Polite said. “This is the future — not just for oncology, but for other specialties across the country.”

‘Good’ problems to have

Several entities have released estimates predicting sharp increases in cancer rates. For example, WHO’s World Cancer Report 2014 projected a 57% increase in cancer incidence worldwide in the next 2 decades.

“When this is first appreciated by the lay public and the press, it’s sometimes seen as a problem,” Clifford A. Hudis, MD, chief of the Breast Cancer Medicine Service at Memorial Sloan Kettering Cancer Center and immediate past president of ASCO, said during a presentation when The State of Cancer Care in America: 2014 was released. “I want to be very clear: This increase in incidence is a reflection of broad successes across health care. The number one risk factor for cancer across the population remains aging. Hence, if we enable people to live longer, we will see more cancer.”

Patients also are living longer with cancer. Data from ASCO indicate that about 67% of Americans with cancer now live at least 5 years after their diagnosis, a benchmark met by fewer than 50% of patients in 1975.

The American Cancer Society projects the number of cancer survivors in the United States will reach 18 million by 2022, a 31% increase from the previous decade.

“All of these patients will need ongoing care and support from cancer care providers,” Hudis said. “These are good problems to have, but we need to plan for them in order to be able to meet these challenges. It’s a very simple problem of supply and demand.”

Changes in health care delivery also may strain the system.

A study by Yang and colleagues published in January in the Journal of Oncology Practice predicted that the Affordable Care Act, if fully implemented, could increase the demands on oncologists by 500,000 patient visits every year.

Yet, the increase in insured Americans is another “good” problem. A study by Robbins and colleagues published in Cancer in April found uninsured males aged 15 to 39 years were 1.8 times more likely to be diagnosed with distant-stage disease than those who were privately insured. Females were at 1.5 times greater risk.

“Most oncologists know of patients who were denied access to needed care, received delayed treatment, or were harmed or humiliated by the process,” Kantarjian and colleagues wrote in a commentary piece published in Cancer earlier this year. “Oncologists face this moral dilemma on a daily basis with new patients diagnosed with cancer who are uninsured. It is our view that the ACA offers oncologists the ability and peace of mind to deliver the best care available without worries about compromises related to economic issues.”

Still, even if patients are insured, access will be key.

“The US cancer care system is among the best in the world. It is highly innovative, and it has delivered and led the innovations that have changed the outcomes for patients with cancer around the world,” Hudis said. “But at the same time, it faces a near-perfect storm of challenges that could threaten its sustainability and its ability to innovate and lead. It’s a threat to access to care, and if you can’t get care, you can’t get good care.”

Oncologist burnout

ASCO projects a 42% increase in patients with cancer by 2025 but only a 28% increase in oncologists, creating a shortfall of about 1,500 physicians. Based on estimates that the average oncologist sees about 300 new patients a year, the shortage would affect nearly a half-million patients.

The problem is exacerbated by the fact that, for the past 6 years, the number of oncologists aged 64 and older — and, thus, nearing retirement — has exceeded the number of those aged 40 and younger.

The longstanding concern about oncologist burnout likely will affect — and be affected by — the workforce shortage.

“The provision of oncology care in the United States is becoming increasingly complex, and with a lot more treatment options, there’s a lot of pressure on the oncology workforce,” Michael Kosty, MD, medical director of Scripps Cancer Center at Scripps Clinic and director of the clinic’s hematology/oncology fellow training program, said in an interview. “If you have people who are not functioning at peak efficiency, that’s going to create workforce shortages.”

Kosty was part of a team of researchers who analyzed data from 1,117 oncologists who completed surveys about burnout and work–life balance. The researchers published two related studies in the Journal of Clinical Oncology in March.

Nearly half of the oncologists surveyed (44.7%) reported at least one symptom of burnout (emotional exhaustion and/or depersonalization).

Oncologists worked an average of 57.6 hours per week. Each additional hour per week spent with patients was associated with a 2% to 4% increase in the risk for burnout, yet risk for burnout decreased by 4% to 5% per 1-year increase in oncologists’ age.

“Burnout can result in increased provider impairment, including alcohol abuse, and suicide,” Kosty said. “People who aren’t focused might be prone to mistakes. As physicians are increasingly partnering with non-physician providers as the head of patient-care teams, if that physician is experiencing issues, the whole team is affected.”

The rate of oncologists who indicated they were dissatisfied with their work–life balance exceeded that reported in a national cross-sectional survey of 7,000 physicians (52.4% vs. 36.9%).

Researchers found women (OR=0.458) and oncologists who spent more time with patients (OR=0.977 for each additional hour) were less likely to be satisfied with work–life balance.

The findings have consequences with regard to access to care. Of the oncologists surveyed, 26.5% reported a moderate or higher likelihood that they would reduce their clinical hours in the next year, 34.3% reported a moderate or higher likelihood of leaving their current position within the next 2 years, and a 28.5% planned to retire before the age of 65 years.

“Medical oncologist burnout is a perception with a practicing medical oncologist who feels that their practice is extremely rewarding, who really enjoys taking care of their patients, but who feels that their increased workload and administrative burdens have driven them to make a decision to leave their practice,” Carolyn B. Hendricks, MD, an oncologist at the Center for Breast Health in Bethesda, Md., and chair of ASCO’s Quality of Care Committee, said during a presentation about ASCO’s State of Cancer Care report. “This will exacerbate the anticipated shortage in the workforce.”

Programs designed to reduce physician burnout should begin in medical school to help aspiring clinicians recognize the signs of burnout — such as sleep deprivation and substance abuse — and address them, Kosty said.

A study by West and colleagues, published in April in JAMA Internal Medicine, indicated that 9 months of small-group programs intended to increase mindfulness, reflection and shared experience reduced depersonalization, emotional exhaustion and overall burnout, with benefits continuing at least 1 year after study completion.

Despite the prevalence of burnout and reported dissatisfaction with work–life balance, the surveys analyzed by Kosty and colleagues showed 82.5% of oncologists were satisfied with their careers and 80.4% were satisfied with their specialty.

“It’s important to distinguish between liking what you do and being burned out by it,” Kosty said. “I think most of us go into oncology because it provides an opportunity to truly help people.”

Geographic disparities

Threats to care access likely will be most pronounced in rural and small community practice settings.

Although 19% of Americans live in rural areas, only 3% of oncologists practice in these regions, according to ASCO’s report. The number of oncologists per 100,000 people range from 15.3 in the District of Columbia to 1.6 in Wyoming. Some communities in Wyoming, South Dakota, Texas and Hawaii only have practicing oncologists aged older than 64 years, and 70% of US counties analyzed have no practicing oncologists.

ASCO partnered with the University of Iowa to determine how differences between rural and urban settings within the state affected access to cancer care.

Marcia M. Ward, MA, PhD, professor in the department of health management and policy at the University of Iowa, and colleagues evaluated 2004 to 2010 data from the Iowa Cancer Registry. They published their results in three studies in the Journal of Oncology Practice.

Ward and colleagues determined patients who needed radiation therapy traveled a mean 25.8 minutes to the nearest facility; however, patients who lived in small rural areas traveled three times farther than those who lived in urban settings.

Among patients who needed chemotherapy, those who lived in designated hospital service areas where a local oncologist was based traveled a mean 21 minutes for treatment. However, the estimated 37% of patients who lived in areas where only visiting oncologists or no oncologists practiced traveled an average of 58 minutes for treatment.

In addition, 12.3% of newly diagnosed patients decided not to receive treatment. Non-treatment was more common among patients who received their treatment recommendations at non-accredited cancer programs, and patients who did not consult an oncologist, radiation therapist or surgeon.

“The first choice that a patient is making, and also that their providers are recommending to them, is if they should go to an NCI cancer center to be diagnosed,” Ward told HemOnc Today. “But that’s already a choice that a patient is making to receive a treatment recommendation, and that says something about their type of cancer, their willingness to travel, and their desire to seek out comprehensive care.”

It also is difficult to determine whether Iowa is representative of other rural US regions, Ward said. “Frontier” or “recreational” rural areas — which are determined by lower population densities — might have less access.

A study by Johnson and colleagues, published in Lung Cancer in March, indicated patients with cancer who lived in rural areas of Georgia were more likely to have unstaged disease (OR=1.63; 95% CI, 1.45-1.83). They also were less likely to receive radiation (OR=0.89; 95% CI, 0.82-0.96) and chemotherapy (OR=0.92; 95% CI, 0.85-0.99).

A database review by Nguyen-Pham and colleagues, published in Annals of Epidemiology, found patients who lived in rural areas were 1.19 (95% CI, 1.12-1.27) times more likely to be diagnosed with late-stage breast cancer than those who lived in urban areas.

The results from Iowa also might reflect the state’s older and more economically homogenous population.

“Iowa might lean more toward the average, and not show some of the extremes that are probably apparent in other places of the country,” Ward said. “We can also look at poverty and insurance rates, which are certainly big factors in terms of access to care.”

A study by Tao and colleagues, published in Blood, found patients with diffuse large B-cell lymphoma who lived in lower socioeconomic status neighborhoods had a 34% (95% CI, 27-40) increased risk for death from all causes, and a 24% (95% CI, 16-32) increased risk for death from lymphoma.

The decline of small community practices — which consist of one to two physicians — also threaten access to care.

Data from the ASCO report showed 63% of small practices indicated they were likely to merge, sell or close within the next year.

The shifting size of practices has been evident: In 2012, 34% of oncology practices consisted of one to two physicians, and 29% had seven or more. A year later, 28% were small practices, and 42% had seven or more physicians.

“These small practices deliver a significant proportion of the medical oncology care in the United States,” said Hendricks, who has a solo practice. “More than one-third of new cancer patients in the US are seen in small practices. We can anticipate that a practice closure can present significant hardship for patients.”

Most small-practice closures are due to financial issues, particularly from Medicare sequestration, Hendricks said.

“Over the past several years, the increasing cost of chemotherapy drugs has risen while reimbursement of chemotherapy drugs has fallen, really taking my practice to the tipping point,” Hendricks said. “What are my options? Purchase, merge, sell or close.”

Potential solutions

ASCO and other organizations are evaluating ways to meet these challenges and improve care delivery.

Several hospitals are establishing visiting consulting clinics to expand access to cancer care in rural areas. A study by Tracy and colleagues published in Health Services Research Journal in October 2013 found the median driving time to the closest oncology clinic in Iowa declined from 51.6 minutes to 19.2 minutes when visiting consultant clinics were taken into account. Ward and colleagues found these clinics more than doubled the rate of chemotherapy administered in those areas, from 10% to 24%.

“The visiting oncology clinics, and all the visiting specialties, are filling a gap,” Ward said. “How else would we solve the problem? By perfectly matching the cancer cases and where they occur with a supply of care that people need. I don’t know how you would do that.”

The NCI Community Cancer Centers Program, established in 2007, also aims to reduce disparities by improving the quality of care at community hospitals. In 2013, 21 community hospitals were partnered with NCI-designated cancer centers to enhance research and care.

ASCO also has introduced platforms for oncology metrics and measures, including the Quality Oncology Practice Initiative (QOPI) and the Cancer Learning Intelligence Network for Quality (CancerLinq).

“You absolutely cannot talk about cost control in health care and in cancer care specifically without linking it to quality measures and outcomes,” Polite said. “We need to make sure we’re providing very strong care to patients who need it, and not giving treatments that aren’t going to have any value for others.”

QOPI evaluates the performance of 850 registered practices twice a year against more than 100 measured recommendations. Since its launch in 2006, there has been increased adherence to day-to-day practice measures, including the administration of adjuvant chemotherapy in breast cancer, colorectal cancer and NSCLC, as well as HER-2 and KRAS testing, Polite said.

However, more adherence is needed in the social arena of patient care — including counseling about infertility risk, as well as end-of-life and palliative care — and “thou shall not” markers, such as not giving granulocyte colony–stimulating factor in patients who have a lower than 20% risk for febrile neutropenia.

ASCO is streamlining QOPI with electronic medical records, and what is known as eQOPI is expected within the next year.

CancerLinq will take QOPI to the next level by providing real-time data to clinicians on contemporary treatment courses and outcomes.

“We in medicine have lagged behind in the technological revolution,” Hudis said. “Our charts are pen and paper, and even when they’re electronic, they’re facsimiles of pen and paper. We have not kept up. CancerLinq is our groundbreaking attempt to overcome this, to deliver clinical decisions support, quality measures and metrics, benchmarking against standards and guidelines so that all patients treated at any office anywhere in the country have access through their doctors to state-of-the-art care.”

Programs like CancerLinq can help reduce an oncologist’s regulatory burden and burnout, and increase patient access to care.

“We all know that the practice of medicine right now is very inefficient,” Polite said. “Some of that inefficiency is on the providers, but much of it is based in the way regulatory and payment processes work. The more we streamline that, the more we’ll be allowed to do what we want to do, which is take care of patients with the information available at our fingertips. We’re in the early stages of this, and this is the time to make sure we do it right.” – by Alexandra Todak

References:

American Cancer Society. Cancer Treatment & Survivorship Facts & Figures: 2012-2013. Available at: www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc-033876.pdf. Accessed May 13, 2014.

American Society of Clinical Oncology. The State of Cancer Care in America: 2014. J Oncol Pract. 2014;10:119-142.

Johnson AM. Lung Cancer. 2014;83:401-407.

Kantarjian HM. Cancer. 2014;doi:10.1002/cncr.28673.

NCI. NCI Community Cancer Centers Program. Progress Report 2013. Available at: http://ncccp.cancer.gov/files/2013_NCCCP_Progress_Report_final508.pdf. Accessed on May 13, 2014.

Nguyen-Pham S. Ann Epidemiol. 2014;24:228-235.

Robbins AS. Cancer. 2014;120:1212-1219.

Shanafelt TD. J Clin Oncol. 2014;32:678-686.

Shanafelt TD. J Clin Oncol. 2014;32:1127-1135.

Tao L. Blood. 2014;published online ahead of print April 4.

Tracy R. Health Serv Res. 2014;48:1719-1729.

Ward MM. J Oncol Pract. 2013;9:20-26.

Ward MM. J Oncol Pract. 2014;10:20-25.

Ward MM. J Oncol Pract. 2014;10:26-31.

West CP. JAMA Intern Med. 2014;174:527-533.

WHO. World Cancer Report 2014. Available at: www.iarc.fr/en/publications/books/wcr/wcr-order.php. Accessed on May 13, 2014.

Yang W. J Oncol Pract. 2014;10:39-45.

For more information:

Carolyn B. Hendricks, MD, can be reached at the Center for Breast Health, 6410 Rockledge Drive, Suite 506, Bethesda, MD 20817.

Clifford A. Hudis, MD, can be reached at Memorial Sloan Kettering Cancer Center, 1275 York Ave., New York, NY 10065; email: hudisc@mskcc.org.

Michael Kosty, MD, can be reached at Scripps Clinic Torrey Pines, 10666 N Torrey Pines Road, La Jolla, CA 92037; email: mkosty@scripps.edu.

Blase N. Polite, MD, MPP, can be reached at The University of Chicago Medicine, 5841 S. Maryland Ave., Chicago, IL 60637; email: bpolite@medicine.bsd.uchicago.edu.

Marcia M. Ward, MA, PhD, can be reached at College of Public Health, S161 CPHB, 145 N. Riverside Drive, The University of Iowa, Iowa City, IA 52242; email: marcia-m-ward@uiowa.edu.

 

 

Are community practices the ideal setting for chemotherapy administration?

Community cancer centers are the ideal setting for frontline cancer care, providing high-quality, cost-effective and accessible treatment in patients’ own communities.

Over the past 40 years, we have developed the most comprehensive cancer care delivery system in the world. The combination of treatment advances, incentives to move medical care from the inpatient to outpatient settings, and the entrepreneurial spirit of academically trained oncologists created the nation’s cancer treatment foundation: community cancer care. In these settings, positive outcomes have been documented by falling mortality rates and increasing longevity following cancer diagnoses.

Unfortunately, the landscape of cancer care is rapidly changing as large medical complexes swallow up community cancer clinics, in the process creating treatment access issues — especially in rural areas — and increasing costs for insurers (including Medicare), cancer patients and taxpayers. In 2005, close to 90% of chemotherapy was administered in physician-run community cancer clinics as opposed to hospital outpatient facilities. By 2011, that percentage had fallen to less than 70%. Over the past 7 years, 288 cancer clinics have closed and 469 practices — typically with multiple clinics — have merged or affiliated with hospitals. In addition to creating treatment cracks, costs increase as cancer care is consolidated into the hospital setting. A Milliman study documented that Medicare pays $6,500 more per patient annualized for cancer care in outpatient hospital facilities; senior citizens with cancer pay $650 more in out-of-pocket costs. Another study conducted by IMS Health found that reimbursement for chemotherapy administration in hospital outpatient facilities are on average 189% higher than in community cancer clinics for patients aged younger than 65 years who had private insurance.

Higher costs not only tax already burdened insurers and patients, they also can actually adversely impact cancer care and, in turn, drive the cost of cancer care even higher. Analyzing adjuvant hormonal treatment for breast cancer shows that, as patients’ out-of-pocket costs increase, the likelihood of continuing treatment falls. IMS Health researchers reported that sites of cancer care that have higher patient cost-sharing not only can impact patient outcomes when treatment is dropped but also can increase the overall cost of cancer care.

Certainly, large academic centers play a vital role in the delivery of cancer care, especially less common types of cancer, and in the continued search for the “cure.” There has always been a symbiotic relationship between community cancer clinics and academic cancer centers. However, the consolidation of cancer care by large medical complexes is clearly driving up costs and, in the process, possibly adversely affecting outcomes. The ideal setting for cancer care is the community cancer clinic setting, and we should be protecting the backbone of community cancer care, not dismantling it.

References:

Community Oncology Practice Impact Report. Community Oncology Alliance. 2013. Available at: www.communityoncology.org/UserFiles/Community_Oncology_Practice_Impact_Report_6-25-13F.pdf. Accessed May 20, 2014.

Innovation in cancer care and implications for health systems: Global oncology Trend report. IMS Institute for Healthcare Informatics. 2014. Available at: www.imshealth.com/portal/site/imshealth/menuitem.762a961826aad98f53c753c71ad8c22a/?vgnextoid=f8d4df7a5e 8b5410VgnVCM10000076192ca2RCRD. Accessed May 20, 2014.

Results of Analyses for Chemotherapy Administration Utilization and Chemotherapy Drug Utilization, 2005-2011 for Medicare Fee-for-Service Beneficiaries. The Moran Company. 2013. Available at: https://media.gractions.com/E5820F8C11F80915AE699A1BD 4FA0948B6285786/01655fe9-7f3d-4d9a-80d0-d2f9581673a1.pdf. Accessed May 20, 2014.

Site of Service Cost Differences for Medicare Patients Receiving Chemotherapy. Milliman. 2011. Available at: http://us.milliman.com/insight/health/Site-of-Service-Cost-Differences-for-Medicare-Patients-Receiving-Chemotherapy. Accessed May 20, 2014.

For more information:

Ted Okon is executive director of the Community Oncology Alliance, a nonprofit organization that represents providers and their patients in the community oncology setting. He can be reached at Community Oncology Alliance, 1101 Pennsylvania Ave., NW, Washington, DC 20004; email: tokon@coacancer.org. Disclosure: Okon reports no relevant financial disclosures.

Chemotherapy may be delivered safely and effectively in community practices; however, more specialized treatments should be delivered in large cancer centers.

The science of oncology is changing incredibly quickly, and that is leading to an ever-increasing number of molecular discoveries that are clinically actionable. There is great excitement in a number of therapeutic areas that were only pipedreams just a few years ago, including targeted therapies, immune checkpoint blockade, chimeric antigen receptor T-cell therapy and antibody–drug conjugates. The speed of progress is accelerating, and both cancer diagnosis and cancer therapy are increasingly complex. We are rapidly moving into an era in which there will be no “common malignancies.” Each cancer type will be subdivided based on molecular makeup. Distinct therapies already are available for some of these subtypes, with more on the way.

Moving forward, it is difficult to envision how individual general oncologists will be able to stay fully up to date on state-of-the-art therapy for all types of cancer. Guidelines are helpful, but expert opinions from a multidisciplinary team with expertise in specific cancer types is increasingly important. These teams also have experience dealing with the toxicities and other unique aspects of newer and more specialized therapeutic strategies that go beyond traditional chemotherapy.

We need to respond to this great opportunity to provide our patients with new and better treatments, while also assuring quality, dealing with a shortage of oncologists, keeping costs down and responding to the many other changes taking place in our health care environment. This requires increasing levels of collaboration between general community oncologists and oncology subspecialists who are most often located at academic cancer centers. Together, these teams will need to determine where therapy can be delivered most safely, effectively and efficiently for individual patients.

For some patients, such as those receiving standard chemotherapy, delivery in community practices close to home will continue to be the best option. However, increasingly, more specialized treatments will need to be delivered at cancer centers where there is greater experience in selecting, delivering, monitoring response of and managing the toxicities of these new and exciting approaches to cancer therapy.

George J. Weiner, MD, is director of the Holden Comprehensive Cancer Center at the University of Iowa and vice president/president-elect of the Association of American Cancer Institutes. He can be reached at University of Iowa Carver College of Medicine, Department of Internal Medicine, 200 Hawkins Drive, Iowa City, IA 52242; email: george-weiner@uiowa.edu. Disclosure: Weiner reports no relevant financial disclosures.