|
||||||||||||||||
|
||||||||||||||||
|
||||||||||||||||
|
| ||||||||||||||||||||||||||||||||
|
||||||||||||||||||||||||||||||||
Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page R1
Erin Balogh, Margie Patlak, and Sharyl J. Nass, Rapporteurs
National Cancer Policy Forum
Board on Health Care Services
OCR for page R2
THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001
NOTICE: The project that is the subject of this report was approved by the Governing
Board of the National Research Council, whose members are drawn from the councils
of the National Academy of Sciences, the National Academy of Engineering, and the
Institute of Medicine.
This activity was supported by Contract Nos. HHSN261200900003C and 200-2011-
38807 between the National Academy of Sciences and the National Cancer Institute and
the Centers for Disease Control and Prevention, respectively. In addition, the National
Cancer Policy Forum is supported by the American Association for Cancer Research, the
American Cancer Society, the American Society of Clinical Oncology, the Association
of American Cancer Institutes, Bristol-Myers Squibb, C-Change, the CEO Roundtable
on Cancer, GlaxoSmithKline, Novartis Oncology, the Oncology Nursing Society, and
Sanofi Oncology. The views presented in this publication do not necessarily reflect the
views of the organizations or agencies that provided support for the activity.
International Standard Book Number-13: 978-0-309-26944-5
International Standard Book Number-10: 0-309-26944-X
Additional copies of this workshop summary are available for sale from the National
Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-
6242 or (202) 334-3313; http://www.nap.edu.
For more information about the Institute of Medicine, visit the IOM home page at:
www.iom.edu.
Copyright 2013 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America
Cover credit: Design by Casey Weeks.
The serpent has been a symbol of long life, healing, and knowledge among almost all
cultures and religions since the beginning of recorded history. The serpent adopted as a
logotype by the Institute of Medicine is a relief carving from ancient Greece, now held
by the Staatliche Museen in Berlin.
Suggested citation: IOM (Institute of Medicine). 2013. Delivering affordable cancer care
in the 21st century: Workshop summary. Washington, DC: The National Academies Press.
OCR for page R3
OCR for page R4
The National Academy of Sciences is a private, nonprofit, self-perpetuating society of
distinguished scholars engaged in scientific and engineering research, dedicated to the
furtherance of science and technology and to their use for the general welfare. Upon the
authority of the charter granted to it by the Congress in 1863, the Academy has a man-
date that requires it to advise the federal government on scientific and technical matters.
Dr. Ralph J. Cicerone is president of the National Academy of Sciences.
The National Academy of Engineering was established in 1964, under the charter of
the National Academy of Sciences, as a parallel organization of outstanding engineers.
It is autonomous in its administration and in the selection of its members, sharing with
the National Academy of Sciences the responsibility for advising the federal government.
The National Academy of Engineering also sponsors engineering programs aimed at
meeting national needs, encourages education and research, and recognizes the superior
achievements of engineers. Dr. Charles M. Vest is president of the National Academy
of Engineering.
The Institute of Medicine was established in 1970 by the National Academy of Sciences
to secure the services of eminent members of appropriate professions in the examination
of policy matters pertaining to the health of the public. The Institute acts under the
responsibility given to the National Academy of Sciences by its congressional charter to
be an adviser to the federal government and, upon its own initiative, to identify issues
of medical care, research, and education. Dr. Harvey V. Fineberg is president of the
Institute of Medicine.
The National Research Council was organized by the National Academy of Sciences in
1916 to associate the broad community of science and technology with the Academy’s
purposes of furthering knowledge and advising the federal government. Functioning in
accordance with general policies determined by the Academy, the Council has become
the principal operating agency of both the National Academy of Sciences and the
N
ational Academy of Engineering in providing services to the government, the public,
and the scientific and engineering communities. The Council is administered jointly by
both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles
M. Vest are chair and vice chair, respectively, of the National Research Council.
www.national-academies.org
OCR for page R5
WORKSHOP PLANNING COMMITTEE1
PATRICIA A. GANZ (Co-Chair), Professor, University of California,
Los Angeles, School of Medicine & Public Health, Division of
Cancer Prevention & Control Research, Jonsson Comprehensive
Cancer Center
YA-CHEN TINA SHIH (Co-Chair), Director, Program in the
Economics of Cancer, University of Chicago, IL
PETER B. BACH, Attending Physician, Memorial Sloan-Kettering
Cancer Center, New York, NY
EZEKIEL J. EMANUEL, Diane v.S. Levy and Robert M. Levy
University Professor, Vice Provost for Global Initiatives, University of
Pennsylvania, Philadelphia
THOMAS J. KEAN, President and Chief Executive Officer, C-Change,
Washington, DC
SCOTT RAMSEY, Director, Cancer Prevention Program, Division of
Public Health Science, Fred Hutchinson Cancer Research Center,
Seattle, WA
LOWELL E. SCHNIPPER, Theodore and Evelyn Berenson Professor of
Medicine, Harvard Medical School, Clinical Director, Cancer Center,
Chief, Hematology/Oncology, Beth Israel Deaconess Medical Center,
Boston, MA
DEBORAH SCHRAG, Associate Professor of Medicine, Harvard
Medical School, Dana-Farber Cancer Institute, Boston, MA
Project Staff
ERIN BALOGH, Study Director
PAMELA LIGHTER, Research Assistant
MICHAEL PARK, Senior Program Assistant
SHARYL J. NASS, Director, National Cancer Policy Forum
ROGER HERDMAN, Director, Board on Health Care Services
1Institute of Medicine planning committees are solely responsible for organizing the
workshop, identifying topics, and choosing speakers. The responsibility for the published
workshop summary rests with the workshop rapporteurs and the institution.
v
OCR for page R6
NATIONAL CANCER POLICY FORUM1
JOHN MENDELSOHN (Chair), Director, Khalifa Institute for
Personalized Cancer Therapy, MD Anderson Cancer Center,
Houston, TX
PATRICIA A. GANZ (Vice Chair), Distinguished University Professor,
University of California, Los Angeles, Schools of Medicine & Public
Health, Director, Cancer Prevention & Control Research, Jonsson
Comprehensive Cancer Center
AMY P. ABERNETHY, Associate Professor of Medicine, Duke
University School of Medicine, and Director, Duke Cancer Care
Research Program, Durham, NC
RAFAEL G. AMADO, Senior Vice President & Head of R&D,
GlaxoSmithKline-Oncology, Collegeville, PA
FRED APPELBAUM, Director, Clinical Research Division, Fred
Hutchinson Cancer Research Center, Seattle, WA
PETER B. BACH, Attending Physician, Memorial Sloan-Kettering
Cancer Center, New York, NY
EDWARD BENZ, JR., President, Dana-Farber Cancer Institute and
Director, Harvard Cancer Center, Harvard School of Medicine,
Boston, MA
MONICA BERTAGNOLLI, Professor of Surgery, Harvard University
Medical School, Boston, MA
OTIS BRAWLEY, Chief Medical Officer and Executive Vice President,
American Cancer Society, Atlanta, GA
MICHAEL A. CALIGIURI, Director, Ohio State Comprehensive
Cancer Center, Columbus, OH
RENZO CANETTA, Vice President, Oncology Global Clinical Research,
Bristol-Myers Squibb, Wallingford, CT
MICHAELE CHAMBLEE CHRISTIAN, Retired, Washington, DC
WILLIAM DALTON, Chief Executive Officer, M2Gen Personalized
Medicine Institute, Moffitt Cancer Center, Tampa, FL, and Chair,
American Association for Cancer Research Science Policy &
Legislative Affairs Committee
1Institute of Medicine forums and roundtables do not issue, review, or approve indi-
vidual documents. The responsibility for the published workshop summary rests with the
workshop rapporteurs and the institution.
vi
OCR for page R7
WENDY DEMARK-WAHNEFRIED, Associate Director for Cancer
Prevention and Control, University of Alabama at Birmingham
Comprehensive Cancer Center
ROBERT ERWIN, President, Marti Nelson Cancer Foundation,
Davis, CA
ROY S. HERBST, Chief of Medical Oncology, Yale Cancer Center,
New Haven, CT
THOMAS J. KEAN, President and Chief Executive Officer, C-Change,
Washington, DC
MICHELLE M. Le BEAU, Arthur and Marian Edelstein Professor of
Medicine and Director, Comprehensive Cancer Center, University
of Chicago, IL, and President, Association of American Cancer
Institutes
DOUGLAS R. LOWY, Deputy Director, National Cancer Institute,
Bethesda, MD
DANIEL R. MASYS, Affiliate Professor, Biomedical Informatics,
University of Washington, Seattle
MARTIN J. MURPHY, Chief Executive Officer, CEO Roundtable on
Cancer, Durham, NC
BRENDA NEVIDJON, Clinical Professor and Specialty Director,
Nursing & Healthcare Leadership, Duke University School of
Nursing, Durham, NC, and Past President, Oncology Nursing
Society
STEVEN PIANTADOSI, Director, Samuel Oschin Comprehensive
Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA
LISA C. RICHARDSON, Associate Director for Science, Division of
Cancer Prevention and Control, Centers for Disease Control and
Prevention, Atlanta, GA
DEBASISH ROYCHOWDHURY, Senior Vice President, Global
Oncology, Sanofi Oncology, Cambridge, MA
YA-CHEN TINA SHIH, Director, Program in the Economics of Cancer,
University of Chicago, IL
ELLEN SIGAL, Chairperson and Founder, Friends of Cancer Research,
Washington, DC
STEVEN STEIN, Senior Vice President, U.S. Clinical Development and
Medical Affairs, Novartis Oncology, East Hanover, NJ
JOHN A. WAGNER, Vice President, Clinical Pharmacology, Merck and
Company, Inc., Rahway, NJ
vii
OCR for page R8
RALPH R. WEICHSELBAUM, Chair, Radiation and Cellular
Oncology, and Director, Ludwig Center for Metastasis Research, The
University of Chicago Medical Center, IL
JANET WOODCOCK, Director, Center for Drug Evaluation and
Research, Food and Drug Administration, Rockville, MD
National Cancer Policy Forum Staff
SHARYL J. NASS, Director
LAURA LEVIT, Program Officer
ERIN BALOGH, Associate Program Officer
PAMELA LIGHTER, Research Assistant
MICHAEL PARK, Senior Program Assistant
PATRICK BURKE, Financial Associate
SHARON B. MURPHY, Scholar in Residence
ROGER HERDMAN, Director, Board on Health Care Services
viii
OCR for page R9
Reviewers
This workshop summary has been reviewed in draft form by individu-
als chosen for their diverse perspectives and technical expertise, in accor-
dance with procedures approved by the National Research Council’s Report
Review Committee. The purpose of this independent review is to provide
candid and critical comments that will assist the institution in making its
published workshop summary as sound as possible and to ensure that the
workshop summary meets institutional standards for objectivity, evidence,
and responsiveness to the study charge. The review comments and draft
manuscript remain confidential to protect the integrity of the process. We
wish to thank the following individuals for their review of this workshop
summary:
LINDA S. ELTING, The University of Texas MD Anderson Cancer
Center
ROBERT ERWIN, Marti Nelson Cancer Foundation
ROBERT J. GREEN, Cancer Clinics of Excellence
JOSEPH LIPSCOMB, Rollins School of Public Health and
Winship Cancer Institute, Emory University
JEFFREY PEPPERCORN, Duke University Medical Center
JOANNE SCHOTTINGER, Southern California Permanente
Medical Group
ix
OCR for page R10
x REVIEWERS
Although the reviewers listed above have provided many constructive
comments and suggestions, they did not see the final draft of the workshop
summary before its release. The review of this workshop summary was
overseen by Melvin Worth. Appointed by the Institute of Medicine, he
was responsible for making certain that an independent examination of
this workshop summary was carried out in accordance with institutional
procedures and that all review comments were carefully considered. Respon-
sibility for the final content of this workshop summary rests entirely with
the rapporteurs and the institution.
OCR for page R11
Contents
INTRODUCTION, 1
A FINANCIAL CRISIS IN HEALTH CARE, 3
Drivers of Health Care Costs, 8
Cancer Care Costs, 9
Financial Burden on Patients with Cancer, 13
Questionable Value, 15
CURRENT CHALLENGES, 16
Inappropriate Incentives, 16
Unrealistic Expectations, 19
Overuse and Misuse of Interventions, 21
Variable Care, Lack of Best Practices, and an Inadequate
Evidence Base, 24
Legal and Regulatory Issues, 26
Assessing Value, 27
POSSIBLE SOLUTIONS, 29
Patient and Clinician Communication and Education, 30
Best Practices in Cancer Care, 36
Evidence Base for Clinical Practice and Reimbursement, 48
Financial Incentives Aligned with Affordable, High-Quality
Cancer Care, 56
Delivery System and Reimbursement Changes, 60
WRAP-UP, 66
REFERENCES, 67
APPENDIX, 75
xi
OCR for page R12
OCR for page R13
Boxes and Figures
BOXES
1 Possible Solutions to Improve the Affordability and Quality of Cancer
Care Highlighted by Individual Participants, 4
2 ASCO’s Quality Oncology Practice Initiative (QOPI), 39
3 ASCO’s Top 5 List, 40
4 ASCO’s CancerLinQ Rapid Learning Initiative, 54
FIGURES
1 Total health expenditure per capita and gross domestic product per
capita, 2007, 6
2 Projected annual family health insurance premium costs and average
household income in the United States, 7
3 Monthly and median costs of cancer drugs at the time of Food and
Drug Administration approval, 1965–2008, 11
4 Medicare spending for Part B drugs administered in physicians’
offices or furnished by suppliers, 12
5 Prevalence of high total financial burdens among non-elderly adults
by medical condition and insurance status, 14
xiii
OCR for page R14
xiv BOXES AND FIGURES
6 Substitution of intensity modulated radiotherapy (IMRT) for
3-D conformal radiotherapy in prostate cancer, 2001–2005,
and the rapid adoption of brachytherapy as the sole modality of
radiotherapy in breast cancer treatment, 2002–2006, 17
7 Trends in radiology scans in the United States, 1991–2006, 23
8 UnitedHealthcare use of Avastin (bevacizumab), 2009–2011, 38
9 Reduction in diagnoses of colorectal cancers at Kaiser Permanente,
2008–2011, 48
10
Comparison of evidence generation for targeted cancer therapies
pre- and post-approval by the Food and Drug Administration, 50
11
Dissemination of accountable care organizations (ACOs) in the
United States, 64
