This timely manuscript by Bunnell and Shulman highlights critical issues that challenge our ability to provide care to cancer patients in the next 20 years. Each of the concerns the authors identify has a momentum of its own. In combination, they have the makings of a perfect health care storm. The time to further address these matters is now.
Demand for Cancer Care Will Increase
This year, an estimated 1.6 million new cases of cancer will be diagnosed in the United States.[1] By 2030, this number is expected to increase by 45%, to 2.3 million new cases. Notably, older adults and minorities will have the highest rates of increase; specifically, 70% of all cancers will be diagnosed in people aged 65 years or older, while 28% of all cancers will be diagnosed in minorities.[2] As Bunnell and Shulman note, resource utilization is the highest in the 12 months following an initial diagnosis of cancer. Due to changing demographic trends, the demands for oncology services will dramatically increase in the next 20 years, burdening an already fragmented US health care system. In addition to the projected growth of the U.S. population, improvements in cancer screening and advances in treatment have resulted in larger numbers of cancer patients and cancer survivors. Both groups will require ongoing medical care from a multidisciplinary team of physicians and other healthcare providers. The overall costs to treat cancer may explode as the cost of treating an individual cancer patient continues to increase and the number of cancer patients continues to grow.
There Will Be a Shortage of Oncologists, Geriatricians, and Primary Care Physicians
There are not enough oncologists and geriatricians to meet the expected increased demand for cancer care. Forty million adults in the United States are aged 65 years or older, and the earliest of the baby boomer generation turns 65 in 2011. By 2030, the number of people aged 65 years or older is expected to reach 72 million.[3] A recent study by the American Association of Medical Colleges and the American Society of Clinical Oncologists (ASCO) revealed that the nation will face a shortage of 2,550 to 4,080 oncologists by 2020.[4] The number of geriatricians is also expected to decrease, resulting in the need to integrate geriatrics training into existing oncology fellowship programs. These issues are further compounded as greater numbers of physicians approach retirement age. In 2007, a survey of oncology program directors was conducted to ascertain whether actions have been taken to increase the number of training positions.[5] The report found that there has not been a significant increase in the number of positions offered between 2007 and academic year 2013.[6] Lack of sufficient funding was cited as the main reason for the lack of increase, as well as competing training programs.[6] In order to increase the number of adequately trained physicians in the oncology workforce, ASCO, in conjunction with the John A. Hartford Foundation, has supported fellowship programs in geriatrics and oncology that to date have trained 28 geriatric oncologists.[7, 8] Efforts have been focused on identifying research priorities and mentoring of junior faculty in this field so that the issues facing older adults with cancer can be addressed as soon as possible.
To adequately prepare for the increase in the number of patients from minority populations, existing oncology training programs must also familiarize trainees with culturally sensitive issues. Topics include culturally-specific communication and beliefs surrounding cancer screening, diagnosis, and treatment, as well as differences in patterns of care and clinical outcomes. Future clinical trials should actively engage recruitment of minority and older patients, since these groups have traditionally been underrepresented in clinical trials. Finally, training programs for other specialties should emphasize the promotion of effective cancer prevention and screening efforts in order to minimize the incidence of cancer in the coming years.
Cancer Survivorship Care Needs to Be Firmly Established
A report recently published by the Institute of Medicine identified a wide range of physical and psychosocial issues affecting cancer survivors, and it emphasized the need for additional research in this area.[9] Cancer survivors require appropriate follow-up care of their primary cancer, face increased risks for developing second cancers, and often seek medical care for long-term effects resulting from cancer treatment. In addition to cancer-related follow-up care, survivors also require regular health care services for prevention, screening, and treatment of common age-related medical conditions.
Unfortunately, research suggests that cancer survivors will receive fewer health care services for non-cancer medical conditions than matched controls, as well as less routine preventive health care [10]. Possible reasons include the nonspecific roles that primary care physicians and specialists play in the survivorship phase of the cancer continuum, as well as potential lack of awareness regarding recommended follow-up care for specific types of cancer.
Recently, considerable attention has been focused on identifying those health care professionals who may be best suited to coordinate routine follow-up (surveillance) care for cancer patients.[11] Efforts to integrate primary care providers into the clinical care team during the cancer survivorship phase need to include ongoing education about long-term effects related to treatment, risk for second malignancies, and appropriate surveillance practices. Major cancer centers have already begun transitioning survivors to primary care practices directed at cancer survivorship. It is critical that communication between the follow-up team and the primary oncologist be coordinated in advance. Several models of care have been proposed, since the needs and levels of preparedness of primary care practitioners may vary from region to region. The need for proper education of primary care physicians, along with additional challenges to delivery of appropriate health care to cancer survivors, needs to be addressed quickly, as the population of cancer survivors continues to increase in numbers.
Potential Options to Assess and Optimize Value
Lastly, the authors discuss issues around the assessment and creation of value in cancer treatments. Comparative effectiveness research (CER) has the potential to compare the effectiveness of several approaches to the prevention, diagnosis, and treatment of disease in order to help effect clinical decisions and policy determinations. To generate meaningful data, uniform outcome measures must be established, and patients’ preferences for adverse effects should be included in CER studies. This type of analysis should be utilized to help develop optimal strategies for patient care.
We applaud the work of Bunnell and Shulman. Failure to make adjustments to accommodate changes in the social and political landscape will make conditions ideal for the perfect health care storm to strike. We should seize and act upon opportunities to expand our oncology training programs, to develop and implement models of cancer survivorship follow-up care, and to acquire real-world data to assess the values of competing cancer therapies. It is incumbent upon us to do so.
Financial Disclosure: The authors have no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.
