The first-ever comprehensive assessment of challenges facing the U.S. cancer care system suggests that patient access to cancer care will be threatened as growing demand for care outstrips the supply of oncologists, and as cost pressures force the closure of small physician practices that form the backbone of care in many communities. 

The State of Cancer Care in America: 2014, a landmark report released today by the American Society of Clinical Oncology (ASCO) and highlighted at a Congressional briefing, examines how oncologists are trying to adapt to a growing demand for services, changes in healthcare delivery systems and to the economic pressures of maintaining small practices.

The report also recommends specific steps to preserve patient access, while improving the quality of care and slowing a projected rise in costs.

Advances in cancer treatment, screening and prevention have produced a dramatic decline in cancer deaths in recent decades, with a record 13.7 million cancer survivors living in the United States.

Yet, due largely to the aging of the population as well as lifestyle changes, the number of new cancer cases in the United States is projected to increase by as much as 42 percent by 2025. At the same time, the total annual U.S. cost of cancer care is projected to reach $175 billion by 2020, an increase of 40 percent from 2010. 

"We're facing a collection of challenges, each one of which could keep cancer treatment advances out of reach for some individuals." said ASCO President Clifford A. Hudis, MD, FACP. "Collectively, they are a serious threat to the nation's cancer care system which already is straining to keep up with the needs of an aging population. Without immediate efforts to address these threats to oncology practices, we're at real risk of failing tomorrow's cancer patients."

Shortage of nearly 1,500 physicians will have far-reaching impact 

Despite a near doubling of demand for cancer care services, the number of oncologists will likely grow by only 28 percent, leaving a projected deficit of 1,487 physicians in just over a decade.

In more concrete terms, given that an oncologist sees an average of 300 new patients each year 2, nearly 450,000 new patients are likely to face obstacles in getting life-saving care. 

ASCO reports that the projected shortfall is driven in part by an aging oncology workforce and impending wave of physician retirements. Currently, nearly 1 of every 5 cancer specialists is over the age of 64.

In 2008, the number of oncologists over age 64 exceeded those under 40 for the first time, and ASCO projects this gap will widen. 

"When patients first hear the word 'cancer,' one of the last things they should have to worry about is finding a qualified doctor," said Dr. Hudis. "Any delay or disruption in cancer treatment can be devastating and stressful. We need to plan and invest to avoid that, pursuing everything from leveraging technology and innovative practice models to using non-physician providers as part of teams providing patient care." 

ASCO's workforce analysis has found that oncologists are already in short supply in many rural communities.

Only three percent of oncologists practice in rural areas, where nearly one in five Americans lives. More than 70 percent of U.S. counties analyzed by ASCO have no medical oncologists at all.

ASCO report raises concern about viability of small and mid-sized practices

Further complicating the supply of cancer care services is a growing concern about survival of smaller independent practices, especially in American's rural communities. According to an ASCO survey of 530 U.S. oncology practices representing more than 8,000 oncologists, small and mid-sized community practices (those with six or fewer physicians) are under tremendous financial pressure due to recent cuts to Medicare physician payments and other factors.

These practices, concentrated in the South and West, serve more than one-third of new patients, according to ASCO's research. 

Nearly two-thirds of small oncology practices (those with only one or two physicians) reported that they are likely to merge, sell or close in the next year. In small towns and rural communities, small practices are often the primary providers of cancer care, enabling people to receive high-quality, personalized treatment close to home.

Closure of these practices will worsen potential workforce shortages, making access to care that is already uneven worse still. 

"Patient access to cancer care is directly tied to the survival of smaller, community practices. Access to convenient, high-quality cancer care shouldn't depend on where you live, but it often does," said Dr. Hudis.

"For people who are very sick, often elderly, with compromised immune systems and struggling with great fatigue and discomfort, travelling long distances for care is not just inconvenient, but potentially harmful. It is important that Americans understand the effects of the policy decisions we are making. If we want convenient access to cancer care we will have to agree to act accordingly."

Quality initiatives, new care delivery models moving forward to address cancer care challenges 

The ASCO report describes several important trends that could improve the quality and value of cancer care and lessen, though not eliminate, the impact of projected oncology workforce shortages.

ASCO data show, for example, that practices appear to be increasing their use of advanced practice nurses and other non-physician providers, a step that will be critical to help oncologists focus their efforts where most needed.

ASCO and many oncology practices are also exploring new healthcare payment and delivery models that reward high quality care, reduce administrative burden and better compensate practices for the intensive services needed by patients with cancer.  

To leverage technology, ASCO is developing CancerLinQ™, a rapid learning health system that will provide oncologists -- regardless of geographic location -- personalized guidance and real-time quality feedback to enhance patient care.

Recommendations:  Support novel cancer care delivery and quality efforts

The State of Cancer Care in America: 2014  makes clear that action by Congress and other policymakers is critical to head off emerging threats. ASCO calls on federal policymakers to help create an environment where quality patient care can thrive. This includes working with the oncology community to:     

Develop and test new healthcare delivery and payment models that preserve the viability of small community practices while encouraging high-quality care. 
End persistent financial threats  to community practices caused by sequester-related cuts to Medicare physician payments and by the sustainable growth rate (SGR) formula -- Medicare's current reimbursement system that has become a source of tremendous instability within health care and a perennial threat to care for millions of seniors.

Embrace and support physician-led quality initiatives such as ASCO's established Quality Oncology Practice Initiative (QOPI®) and the CancerLinQ™ learning health system currently under development.

Congressional committees have introduced the SGR Repeal and Medicare Provider Payment Modernization Act of 2014 (S. 2000/H.R. 4015) that would eliminate the flawed SGR system, provide special support for practices in underserved areas, and support an array of innovative healthcare payment, delivery and quality initiatives, including several key recommendations in the ASCO report. 

"The U.S. cancer system is among the best in the world, but it simply cannot continue to meet the growing needs of patients with cancer unless fundamental, systemic change is pursued," said Dr. Hudis. "Fortunately, lawmakers have introduced widely supported legislation, which will make meaningful progress toward addressing many of the challenges outlined in our report. We encourage Congress to seize this unprecedented opportunity, and act now." 

Source: ASCO visit www.asco.org/stateofcancercare