Stop Cancer Now!Leslie J. Kohman, MD

Professor of SurgeryMedical Director, Upstate Cancer Center

Syracuse, NY

August 18, 2011

UPSTATE CANCER CENTER

•Cancer accounted for 7.6 million deaths (around 13% of all deaths) in 2008. 

•Deaths from cancer worldwide will rise to over 11 million in 2030.

•More than 70% of all cancer deaths occur in low- and middle-income countries.

Why so much cancer?

• Awareness• Accounting• Improved detection• AGING POPULATION

Causes of Cancer

USA 2011

• 1,596,670 new cancer cases– 1 in 4 deaths– 2nd only to cardiovascular disease

• 571,950 deaths (1,500 / day)– 30% caused by tobacco use– 33% related to overweight or obesity,

physical inactivity, and poor nutrition– 9% caused by infection– Sun exposure, environmental factors

Costs of Cancer in 2010

• $263.8 billion: – $102.8 billion for direct medical costs – $20.9 billion for lost productivity due to illness– $140.1 billion for lost productivity due to

premature death

Most cancer is preventable

Association of Insurance with Cancer Care Utilization and Outcomes

CA: A Cancer Journal for CliniciansVolume 58, Issue 1, pages 9-31, 24 FEB 2009 DOI: 10.3322/CA.2007.0011http://onlinelibrary.wiley.com/doi/10.3322/CA.2007.0011/full#fig10

We need to improve

• Prevention!

• Early Detection

• Treatment and Access

• Palliative Care Services

• Healthcare Workforce

• Policy

How to Improve Cancer Care

• Awareness

• Advocacy

• Policy

• Research (improving care)

• Education (creating care providers)

• Funding (accessing care)

Prevention

• How are we doing?

• Can we do better?

More preventable causes and how to avoid them:

• Sun exposure and tanning (65-90% melanomas; most non-melanoma skin cancers)– Use sunscreen– Don’t tan!

• Infections – HPV vaccination (90% cervical cancer;

penile, anal and head and neck)– Hepatitis B vaccination (90% liver

cancer)

Colonoscopy

• 41.8 million average-risk people aged 50 years or older have not been screened for colorectal cancer

• 40% of colonoscopies on Medicare patients unnecessary:– Normal < 10 years ago– Older than 75

• Total cost $100 million

Early Detection(Screening)

• How are we doing?

• Can we do better?

Screening ≠ Prevention

Cancer Screening

Prevention Early Detection

Cervical

Colorectal

Breast

Evidence-based screening tests:

– Mammograms women age 50-74• Q 2 years

– Colonoscopy women and men age 50-74• Q 10 years

– Pap smears women with a cervix age 25-60• Q 3 years

Awareness

Treatment

5-year survival

1975-1977 50%

Now 68%

Cancer Drug Shortages:the real rationing

• 34 generic cancer drugs

• 14 in short supply

• Many new drugs cost up to $90,000 per patient, extend life by only a few months

• Older curative cancer drugs, $3 per dose, unavailable

Why?

• Oncologists, not patients, buy the drugs

• Generics drop prices by 90%

• Medicare Prescription Act of 2003 limits drug price increases

• Low profit margins

• No quick fix

Palliative Careand

Hospice

• Many cancer patients receive chemotherapy in the last few months of life

• Receiving chemotherapy is correlated with a delay in referral to hospice. 

• Why do doctors provide treatments that are medically futile? – expectations for treatment by patients and families– uncertainty about a patient's prognosis– legal pressure

• patients who overestimate their likelihood of long-term survival are more likely to experience a “bad” death

• improved quality of life • Improved mood • Less aggressive care at the end of life • longer survival.

N Engl J Med 2010;363:733-42.

• According to a Duke University study, hospice care saves Medicare on average $2,300 per patient.

Healthcare Workforce

Projected Numbers of Women 40 Years and Older and Radiologists per 100,000 Population by Year

Year

Baseline 2003

2005 2010 2015 2020 2025

No. of women ≥ 40 y

68,357,000 70,197,000 75,265,000

79,633,000

83,888,000 88,583,000

No. of radiologists per 100,000 women

21.1 20.6 19.4 18.5 17.9 17.5

% Change -2.3 -5.9 -4.4 -3.5 -2.3

Cumulative % change

-2.3 -8.0 -12.1 -15.2 -17.1

•Note—Data are from the U.S. Census Bureau and the 2003 survey of radiologists conducted by the American College of Radiology. Column totals may not be exact due to rounding errors.

Why?

• lack of interest in the field

• fear of lawsuits

• stress of interpretation

Colonoscopy

• since 1994, screening-aged population increased 50%

• Capacity exists to screen within 1 year using fecal occult blood testing

• Up to 10 years to screen using flexible sigmoidoscopy or colonoscopy.

• Might need as many as 32,700 more gastroenterologists in the US to meet demand.

Research

• 11 million cancer survivors are alive today, due to the lifesaving benefits of cancer research.– Basic science research– Translational research– Clinical Trials

“Cancer is more willful and calculating than previously imagined”

AACR, 2011

• We have focused on only 2% of the genome

• 90% of protein-encoding cells in our bodies are microbes

• Their signaling is dramatically complex

Hallmarks of Cancer 2000

Hallmarks of Cancer 2011

NIH (NCI) Funding

• Funds 80% of non-profit medical research

• Leads to US patents, spurring economic growth

• Supports training biomedical research workforce, the foundation of our knowledge-based economy

• Engine for innovation to reduce health care costs and improve productivity

Economic Impact

• $2.21 return for every NIH dollar spent.– $50.5 billion in new state business

• more than 350,000 jobs

• wages in excess of $18 billion in the 50 states

• another 800,000 supporting jobs in the private sector

NCI Grant Funding

• Fiscal 2011 paylines for RO1s:– New investigators 10%– Established investigators 7%

• Career Development (K) Awards:– Falling number of awards– Pay line 22%

Clinical Trials

• > 50% children< 5% adults

• Barriers:– Time– Eligibility criteria– Insurance issues– Shortage of older drugs

Policy Issues

Research Funding

Unintended Consequences…..

Medicare Modernization Act of 2003 (MMA)

Cuts to Medicare reimbursement for cancer care $14.7 billion from 2004-2013

•Community cancer clinics, which treat 84% of Americans with cancer, have experienced a more than 25% decrease in the payment of drug administration services from 2004 through 2009.

•Costs of pharmacy facilities and providing quality treatment planning are not reimbursed.

•Oftentimes, Medicare reimbursement does not even cover the actual acquisition costs of cancer drugs.

Patient Protection and Affordable Care Act

• Mandates that insurers cover certain cancer screenings

• Does NOT require insurers to cover follow-up tests if an abnormality is found.

• Does NOT address many workforce challenges• Does NOT establish loan forgiveness programs

in specialties facing workforce shortages• Does NOT repeal SGR

PolicyJoint Committee on Deficit Reduction

$1.2 Trillion in cuts

AT RISK:• Medicare payments to physicians (>50% cancer pts)• Graduate medical education funding • Medicare payment for oncology and other drugs

administered by physicians • Medicare imaging payments • Medical research programs at NIH and AHRQ • Public health initiatives • Discretionary portions of the Affordable Care Act

What’s the Solution?

Action Plan

• Increase political commitment • Research and education • Develop standards and tools • Facilitate networks at global, regional and

national levels• Strengthen health systems • Transfer best practices to developing countries• Strategies for cancer prevention and control

Bending the Cost Curve in Cancer CareNEJM | May 25, 2011 | Topics: Cost of Health CareThomas J. Smith, M.D., and Bruce E. Hillner, M.D.

Bending the Cost Curve in Cancer CareNEJM | May 25, 2011 | Topics: Cost of Health CareThomas J. Smith, M.D., and Bruce E. Hillner, M.D.

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