Jan 14, 2012
As you know, oncology is changing rapidly, and we’re challenged to keep up with these changes while we work to anticipate the future. Understanding and preparing for what lies ahead is vital to the growth and health of our profession.
To answer this challenge, ASCO’s Board of Directors has embarked upon a "far horizon" planning process. As part of this effort, they have identified the following six issues they believe will profoundly impact the practice of oncology in the future:
1. The move to oral therapies will bring dramatic changes to the business models of medical oncology practices. What are some of the specific consequences of this change that oncology should be prepared to address?
2. The ability to rapidly aggregate and analyze vast amounts of clinical and patient reported data will drive huge changes in clinical care for cancer patients, including treatment decisions, measurement of outcomes, and workforce composition. How should we prepare to address this?
3. The rising cost of health care will change the notion of what is valued and paid for in cancer care. Do you agree and, if so, what specific changes will take place?
4. Health information technology is driving profound changes in our ability to aggregate and analyze large amounts of clinical information, which will affect the design, feasibility, strategy, and cost of clinical research. What are the consequences of this and how should we prepare?
5. Cancer is poised to be the leading cause of death internationally, with the highest incidence occurring outside the U.S. where access to cancer information and health care is improving. How will globalization of the cancer care community affect oncologists?
6. Genomics will significantly transform cancer research and clinical practice. What are some of the specific consequences—for research and practice—that oncology should be prepared to address?
We are asking all ASCO members to join an important dialogue concerning these issues. If you are not already logged in to ASCOconnection.org, please log in now and comment on one or more of the issues listed above. What do you believe are the implications for the future of oncology and how might ASCO best respond?
I hope you’ll put aside some time today and as much critical time as you are able during the next two weeks to enliven the discussion. Your comments in collaboration with others will provide essential information to augment the Board’s process of planning for the future of oncology.
This virtual discussion will conclude on January 27, 2012.
Thank you in advance for your participation.
Regards,
Allen S. Lichter, MD
ASCO Executive Vice President and Chief Executive Officer
Comments
David L. Graham, MD, FASCO
Jan, 17 2012 2:30 PM
Genomics has a real potential to beneficially impact the global costs of Oncology care. Clinical trials are already underway to determine if genomic evaluation can help identify patients with certain presentations of cancer that can be benefitted by adjuvant chemotherapy. There is a much larger population, particularly in presentations of prstate cancer, that may be able to use genomics to determine who does not require intervention. Weighing a $2000 evaluation against a course of therapy with a cost that can easily run into 5 figures is not difficult.
Michael A. Thompson, FASCO, MD, PhD
Jan, 17 2012 2:56 PM
1. Oral therapy
There should be parity for oral vs. IV therapies. Physicians should be reimbursed based on cognitive aspects of medicine rather than what they prescribe. This will need to be done in a comprehensive manner.
2. Workforce planning
I suspect parallel changes in IT, mobile health (mHealth), and participatory medicine will propel changes in how we practice medicine. Hopefully physicians can focus on cognitive aspects of medicine and less on clicking boxes to optimize coding and billing. ASCO can help direct these changes which will likely involve teams of care dispersed over geographic space with new technologies.
3. Cost
In future clinical trials we will need embedded correlative studies (biomarkers) as well as pharmacoeconomics. We all will need to be more cognizant of the "value" of our diagnostics, prognostics, and therapeutics. We will need to figure out how to get new and better drugs to market safely, but more cost effectively. Novel trial designs and stastical designs should be considered.
4. Health information technology (HIT)
HIT/EMR/EHR changes are somewhat tumultuous now as practices adopt new EMRs. Harvesting this potential (if set up properly) data will take 5-10 years. Energy and money should be used to help design these properly. Much of the expenses on current EMRs will be found to not yield viable outcome data as currently implemented. Large health systems will have a better chance of delivering outcomes data. Mayo Clinic was doing this long before computers. They and others should be looked to as examples.
5. Globalization of the cancer care community
In some developing nations newer, expensive chemotherapeutics are bankrupting health systems. I'm not sure what the answer is to that. The ability to share digital files including photos, CT images, labs, etc. gives us the opportunity for experts to help in geographically disparate areas. That doesn't solve all health care disparities or pay for everything, but is one potentially positive step that ASCO can influence and guide.
6. Genomics
I am highly interested in pharmacogenetics (1-few genes) and pharmacogenomics (whole genome). I did my PhD in the field. The concepts of predicting drug response has been around for a long time and has not (to date) lived up to the hype. That is obviously changing with BRAF and ALK inhibitors, EGFR directed therapy, etc. I think the real challenge will be dealing with the informatics of understanding low level risks in an additive and networked fashion for a genome worth of genes. We will need to understand this in the context of tumor types, patient characteristics, and environmental factors. Much of the "easy" genetics is done. This is an exciting area but will be more like a large engineering project rather than single concepts that individual physicians can carry in their heads.
Abdul-Rahman Jazieh, MD, MPH
Jan, 17 2012 6:11 PM
The three common factors that will remain pertinent throughout the time irrespective of all the changes are: Money, manpower and access to care.
1. Cancer Care Funding:
A. All efforts should be exerted to minimize the prices of new medications through compressing the development expenses by using better selection methods of study participants and decide early on whether the drug is worth further development or not.
B. Develop creative way for disease assessment that requires minimal imaging tests.
C. Develop various models for fundraising for cancer care such as charitable organization, NGO, and other mechanisms.
D. Enhance cost effectiveness approaches for treatment decisions by including it as an objective in the approval process; develop an easy model for use by health care organization and professionals, and train professionals on how to apply this knowledge.
ASCO’s Potential Role: Work on and encourage policies and initiatives related to funding and work on cost effectiveness models and programs.
2. Health Care Professionals (Manpower): Besides addressing the shortage in number, the future requires preparation of the oncology health care professionals in a different way; otherwise this will be the major limiting factor for cancer care. We should equip the current and future oncologists with different kind of skills in order to keep up with the rapid changes of science. Otherwise, we will have a major gap between the state of the science and the care in the clinic. I believe oncologists should be better prepared with following skills:
A. knowledge of how to apply evidence-based medicine. How to adapt and implement guidelines into real-life practice? Sometimes, the change in practice may be faster than any group’s ability to adjust and disseminate guidelines. For example, when a targeted therapy is approved for first line, then what happens to second and third line selection? How to decide on what to do next?
B. Technology skills to be able to survive the virtual world of medicine.
C. New skills in research, especially in the field of pragmatic research where every clinic is a research laboratory and everything one does is “data” that feeds information into a “mother board” that makes sense out of it and gives you feedback.
ASCO’s Potential Role: To help oncologists identify the practice-changing findings and incorporate those into practice. The oncology education should be demystified with emphasis on what does help the physicians provide good care to their patients. (What they should know is more important than what is nice to know.) Every time there is a positive research study presented at ASCO or any other meeting, ASCO should ask whether this is a practice-changing finding or not? And if so, a special session should take place about the changes of the care of the whole disease, such as workup and subsequent lines of treatment. Immediately after the ASCO meeting, there should be a consensus about the situation so we do not leave oncologists scratching their heads and leave patients in suspense.
3. Access to Care: The importance of access to facilities is obvious, but inpatient services should be minimized while home care and outpatient care should be expanded. Family-centered care, oncology home care programs, and others may help address some of these.
Access to medications is very critical; especially for expensive medications. Various approaches such as patients assistance programs, proper generic medication use, and lower prices of new targeted therapies would make the medications more affordable.
Making genetic and molecular testing more affordable is also critical as the first step in getting the proper treatment and lower the cost of care.
ASCO’s Potential Role: Encourage relevant initiatives including research projects and policies that address disparities and access to care.
As an international leader, ASCO has the responsibility to help address all the above issues worldwide. While ASCO cannot address many direct patient-care issues in different countries, it certainly can play a major role in the global war against cancer through capacity building of well-trained oncologists who have good grasps of the issues discussed earlier from local and regional perspectives.
L. Michael Glode, MD, FACP, FASCO
Jan, 17 2012 11:05 PM
Genomics - while there is great promise in avoiding the use of ineffective drugs in patients who lack the target, two issues will not be easily resolved: 1) metastases from differing sites as well as the primary clearly will have differing expression profiles; 2) the plasticity of the genome will allow "smart" tumors to escape most targeted approaches eventually. That said, the potential long term control that can be achieved with driver mutations in some patients will be worth pursuing. Prostate cancer and the recent advances returning to our well known driver, the AR, is an example.
Cost - The reality is that "we" cannot afford the current models or drugs. Rationing must be embraced along with a more realistic evaluation of cost/benefit. Third line therapies with limited benefit measured in a few months of survival with a relatively low quality of life must give way to earlier implementation of compassionate palliative care and education about this approach will need to be extensive for both patients and care providers.
Heather Marie Hylton, PA-C
Jan, 26 2012 8:24 PM
Workforce and technology: With the looming workforce shortage, it is essential that we be able to deliver quality care to our patients with utmost efficiency. Technology must enhance and facilitate processes to ensure the focus of cancer care remains on our patients. Likewise, redundancy in forms from payors needs to be eliminated as do similar barriers to providing patient care.
Cost of health care: The divide between what is valued and what is paid for is widening. Cost sharing is gaining much momentum amongst insurers, and gone are the days when patients were responsible for minimal health care-related expenses from their own pockets. Payors are clamping down on where patients can be treated and how much they are willing to pay for patients to receive their cancer care. The burden on patients and families is too much, and this payment system strategy is not sustainable.
Patients need to be counseled on the cost of cancer care so that they are able to incorporate this knowledge into their treatment decisions and be able to continue with the course of therapy they choose without concern of financial devastation.
I would encourage us to offer Palliative Care intervention at the time of diagnosis as a means to further improve our patients' journey with their disease and therapy. What is to be gained by not doing so?
We need to be realistic about the therapies we offer patients and have the courage to not offer treatment of little potential benefit. This represents a change in the culture of cancer care for some and is not likely to be an easy transition though arguably necessary.
Steven J. Ketchel, MD
Jan, 27 2012 8:35 PM
ORAL THERAPY
I feel that this will deifinitely affect our ability to keep or infusion centers open. I think we need to be reimbursed for all the time our financial counselors spend finding the money for the patients to pay for these expensive drugs so that it is at least a break even proposition.
ABILITY TO HANDLE DATA
The biggest impediment is that it is technically impossible for us to share data. How can we determine best practices or outcomes with different therapies when we can't send our data to a central repository for analysis.
COST
I think the cost of therapy is a big problem. . I envision that there will be rationing of health care much like there was when kidney dialysis started. I don't know how best to do it but would like for it to apply across all levels of income so we don't have a two tier system.
HIT
Again, as in number 2 above, I think the biggest problem is how to integrate all the data we collect
GLOBALIZATION
I don'tthink it will affect North American oncologists but I believe it will benefit those in the rest of the world. Again, paying for the medications is a big potential problem.
GENOMICS
This is the up and coming method to understand the initiation of and the treatment of cancer. We need to make sure that all oncologists understand the nomenclature and are able to find the pathways that they need to understand. We need to facilitate entrance of patients on to clinical trials. Changes are already being made to clinical trials to use genomic information in the operation of the trial.