In his 2022 State of the Union Address, President Biden declared: “Let’s end cancer as we know it.” It’s a sentiment he is sure to return to in a speech on Monday. No doubt this is a bold ambition and a worthy goal for a disease that is currently the second leading cause of death in the United States.
The President is “supercharging” the 2016 Cancer Moonshot effort launched during the Obama administration. The supercharged Cancer Moonshot calls for cutting the cancer death rate by at least 50% over the next 25 years and aims to “improve the experience of people and their families living with and surviving cancer.”
When it comes to improving cancer outcomes, much attention is paid to investments in diagnostics, clinical research and novel therapies. However, an equal amount of focus should be given to ensuring more patients have access to the high-quality care and treatment options that already exist. It has been estimated that approximately 25% of deaths (around 130,000 Americans annually) occur because cancer patients do not have access to or are unable to take advantage of optimal evidence-based care that is available today.
Cancer is a complex and difficult journey, characterized by complicated diagnostics, highly specialized treatment options and a myriad of touchpoints with the healthcare system. There is broad evidence defining the insights, skills, and tools necessary to help patients successfully navigate their cancer journey, but a variety of barriers exist in actually bringing this evidence to the care delivery system.
One of the keys to overcoming these challenges is in value-based care design. In this context, value is bringing every patient the right care at the right time, reducing unnecessary tests and treatments, days spent in a hospital, and associated costs. In order to be effective, value-based design requires innovative payment models between payers and providers, structured to reward achieving higher-value care. Notable examples of such models include the Oncology Care Model (OCM), a 5-year program that provided financial incentives for oncologists to reduce total cost of care while reaching benchmark performance targets, as well as its recently announced successor program, the Enhancing Oncology Model.
The experience of the cancer journey–and its outcomes– can be transformed by addressing critical support needs at pivotal phases of the journey, navigating the patient through clinical touchpoints and addressing psychosocial barriers. Through value-based care models that align the incentives of all stakeholders, effective, evidence-based care coordination along the cancer journey can measurably improve outcomes, enhance the patient experience, and lower costs.
Peri-diagnostic phase: Improving patient access is key to better outcomes
The peri-diagnostic phase is considered the earliest stage in a patient’s cancer journey, when a cancer diagnosis is suspected but not yet confirmed. This is often a difficult period for the patient, filled with uncertainty and anxiety. During this stage, access to the right care at the right time is critical, but far too often impeded.
One important example of this is access to primary care. Primary care providers play an important role in early cancer detection, given they are able to spot worrying symptoms through regular annual physicals and screenings. However, around 25% of Americans lack access to primary care. What’s more, in 2019 over one-third of Medicare beneficiaries did not visit a primary care physician within the last year. Studies have shown that for certain cancers, clinical outcomes, quality of life, and overall survival are all improved with a shorter time to diagnosis. Healthcare stakeholders must be incentivized to invest in programs that facilitate greater access to ongoing primary care to improve timely interventions at this early but critical stage in the cancer journey.
For patients who do have a PCP, other access challenges often exist. If a PCP suspects one of their patients has cancer, they will direct the patient to get further testing or to see an oncology specialist. Getting to the appropriate specialist can be challenging due to a host of factors. For example, access to quality care might be limited depending on where the patient lives, their race or ethnicity, their ability to pay office co-pays or transportation fees, and a myriad of other challenges. These social determinants of health are a source of variability and inequity in access to cancer care.
Thankfully, there are many programs that seek to address the issue of equitable access. An example of one such program is cancer navigation, which reduces barriers to care by ensuring all patients receive optimal support outside the four walls of the oncology clinic, regardless of external factors. If a patient is struggling to access care for any number of psychosocial reasons, a cancer care navigator, equipped with a “whole-person” (holistic) view of a patient, can provide information on financial assistance programs, coordinate rideshare services, or guide them to government-sponsored or community resources. With the right assistance, gaps in care can be addressed and patients can be quickly and seamlessly connected to the appropriate specialist support, as soon as they need it.
Treatment phase: Coordinated care outside the four walls of the clinic
Once cancer treatment begins, effective coordination between the different members of the care team can help reduce patient morbidity, mortality and costs while improving patient and caregiver experience. However, given the inherent complexities, logistics and longitudinal nature of cancer care, this level of coordination can be especially difficult.
Care navigation can play a valuable role during this time period as well. A dedicated cancer care navigator can act as an extension of the provider team, serving as their eyes and ears outside of the clinic by monitoring the patient’s health status more closely during the treatment course. This can be accomplished through systematic and proactive collection of patient-reported outcomes (PROs). In today’s digital world, patients can benefit significantly from systems that monitor health status remotely, intervene when appropriate, and keep the entire care team informed.
Such monitoring can spur clinical intervention when appropriate, help reduce ED visits and hospitalizations, and improve the patient and caregiver experience. Proactive symptom management programs have shown to lead to a 60% reduction in ED visits and 50% reduction in hospitalizations in some cases. In addition, PROs can be critical in helping physicians design interventions that address a patient’s unique needs. By leveraging these approaches, patient monitoring and care can be “always on” rather than restricted to in-office physician visits.
Survivorship phase: Paving a clear path forward
Following treatment, many patients will be on medication, sometimes for the rest of their lives, and their cancer will be cured or treated effectively as a chronic condition. As of January 2019, there were an estimated 16.9 million cancer survivors in the United States, a number that is projected to increase to 22.2 million by 2030.
A large number of these patients will also have a medical comorbidity, further complicating their care journey. A clear plan for how other chronic conditions will be managed, how surveillance for recurrent cancer will be determined, and steps to prevent and/or detect new cancers is necessary. It is important for the care team to have access to standardized, patient and provider-friendly tools that clarify who is responsible for what aspect of care, thus improving outcomes as well as the patient experience.
End of life: A care plan that aligns with patient goals
If treatment fails to halt or reverse the effects of the disease, a different set of decisions need to be made. Too often, arduous and costly treatment continues to the very end of life, despite minimal chance of a meaningful benefit. Ongoing discussions between patients, providers, and caregivers about the patient’s goals, preferences, and decisions for future care, known as advance care planning (ACP), can help assure that low-value care is avoided near the end of life. One study showed that approximately 70% of US adults express preferences for less aggressive treatments near the end of life and that 89% say that doctors should discuss end-of-life preferences with their patients. However, the rate of these discussions occurring between patients and their doctors is very low, and documentation of the outcome of these discussions even lower.
There are multiple system, provider, and patient factors at play for these low rates. Solutions that include a standardized approach to engaging the patient through a trusted care team member, such as a care navigator, who can communicate both with the patient and provider in a systematic way, can facilitate these discussions and ensure clear and consistent documentation of their outcomes.
Referrals to hospice care (inpatient or at-home) can significantly improve patient quality of life, and giving patients and their caregivers agency in these decisions is critical to delivering quality care. Designated care navigators can help the patient, caregiver and clinician team manage that difficult transition to end-of-life care with compassion and the patient’s best interests in mind. In the NY/NJ area (known for being one of the most expensive regions in the U.S. to receive healthcare), improving hospice utilization in cancer patients undergoing active treatment has led to up to $18,990 per patient in annual cost savings.
A better journey with better results
While ambitious, the Cancer Moonshot’s goals are achievable, using tools that already exist. Novel therapies and breakthrough research will always be helpful levers, but substantial progress toward effective and affordable cancer care can be made simply through the more equitable delivery of proven interventions, and the use of existing technology that brings those interventions to scale. To “fuel” the Moonshot initiative even further, we must also explore alternative payment models that effectively align the incentives of stakeholders across the cancer care continuum to deliver higher-value care at a lower cost.
It’s time to fundamentally improve the cancer journey, while ensuring that resources are used more wisely. The pandemic showed that the healthcare system can respond and evolve when confronted by an existential threat. With cancer care, there is a great deal that can be done now to significantly improve experience, outcomes and costs. We only need to better apply the expertise and tools we already have at hand.
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