Is the US Cancer Care System in Crisis? The IOM Report

Craig Deligdish, MD

October 2013, Vol 4, No 8 - From the Editor

On September 10, 2013, the Institute of Medicine (IOM), part of the National Academy of Sciences, published a 315-page report, titled “Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis”. The incredible effort necessary to generate this report was based in part on the 1999 effort by the IOM, titled “Insuring Quality Cancer Care.” The new report calls for improvements in the use of evidence-based guidelines, electronic data, and quality monitoring, with a focus on providing high-quality care at the end of life and a commitment to improving cancer treatment for all populations of patients.

The Committee on Improving the Quality of Cancer Care was made up of a team of well-respected oncologists and other researchers, and was assisted by policy experts, leaders of professional organizations, and community oncologists. Clearly, there is room for improvement in our cancer delivery system. As noted in the report, several studies have suggested that cancer care could be more patient-centered. Attempts to better coordinate care, to deliver evidence-based care, and to enhance palliative and end-of-life care can all be improved.

However, the report’s title is misleading, stating that there is a “crisis” in the cancer delivery system. A crisis is defined by the Oxford Dictionary as “a time of intense difficulty, trouble, or danger” and as “a difficult or dangerous situation that needs serious attention” in the Merriam-Webster Dictionary. We all agree that the number of patients diagnosed with cancer has significantly increased during the past 20 years, and will continue to increase, with a rising number of cancer survivors. Workforce shortages resulting from an aging physician population and the limited training of new oncologists will exacerbate this problem. The cost of cancer care continues to rise at rates that exceed the gross domestic product and the cost of treating other diseases, and the cost of healthcare in the United States is significantly greater than in other industrialized countries.

There are certainly opportunities to improve the commitment of the oncology community to evidence-based treatment, and there are huge opportunities to develop and apply systems that collect and disseminate outcomes data to ensure best practices. However, classifying our country’s cancer delivery system as being in crisis is a less-than-accurate portrayal of the current state of cancer care and is potentially detrimental to our patients, their families, and to the providers who strive to improve the care that patients with cancer receive on a daily basis. Although there are tremendous opportunities in all aspects of our cancer delivery system, to suggest that the delivery system is in crisis could be construed as overreaching and alarmist.

Significant Progress in Cancer Diagnosis and Treatment
During the past 20 years, there have been tremendous strides made in the diagnosis and treatment of patients with cancer. Mortality rates, overall survival, and quality of life have dramatically improved for many patients with cancer. The number and variety of treatments for diseases that were in some cases untreatable have increased substantially. In addition, the toxicity of many treatments has been dramatically reduced by improvements in the development and the availability of supportive care agents to the point that many patients with cancer who are undergoing treatment today can do so without having their treatment interfere with their daily lives.

There has been improvement in screening rates, and there is clearly much greater focus on palliative care and on hospice care than in 1999. There are many more resources available in numerous parts of the country for the underserved population to receive treatment for cancer. The Affordable Care Act has provided significant support to make care available to the entire US population. Other aspects of the law preclude penalties for preexisting illness and provide funding for healthcare innovation, programs that enhance patient engagement, and initiatives that address payment methodology. Although the new IOM report summarizes these accomplishments, they can be lost in the report’s title, recommendations, and summaries, as well as in the sound bites that follow the publication of a report such as this one.

The IOM should be commended for its attempts to define high-quality cancer care and for its focus on addressing the cost of cancer care. We may have a long way to go and a tough road to hoe before we win the “war on cancer.” Academic, hospital-based, and community oncologists, as well as all providers of care to patients with cancer, have made dramatic contributions and will continue to do so in the hope of eradicating this disease. I and others remain hopeful that the lessons of the IOM’s 1999 report, and those in the 2013 report, will be efficiently adopted, implemented, and executed.