A new study released earlier this month from the Journal of Clinical Oncology forecasts a major shortage in radiation oncologists across the coming decade. Seeking to replicate the work done by ASCO forecasting future demand for medical oncologists, researchers at MD Anderson conducted a comprehensive assessment of radiation oncology supply and demand. According to their findings, between 2010 and 2020, the total number of patients receiving radiatoin therapy as their initial course of treatment will grow by 22% (from 470,000 to 575,000), while supply of FTE radiation oncologists will grow by just 2%. They estimate to meet this new demand the number of radiation oncology residents would have to double for the years 2014 to 2019. While the gap isn't as significant as in medical oncology, it is sizable and currently there are no plans to address it.
Valuable data embedded in the study
When ASCO released their medical oncology study, there was some great data embedded within, and the same holds true here. The data that caught my eye in particular are their forecasts of patients receiging radiation in 2010 and 2020. I've reproduced their table below:
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Earlier this month, the Archives of Internal Medicine published a study which examined the prevalence of physical symptoms among cancer patients experiencing pain and/or depression. Not surprisingly, all 405 patients included in the analysis reported at least one physical symptom. Fatigue (97.5%), difficulty sleeping (79%) and pain in limbs or joints (78%) were the most common. Overall the presence of physical symptoms was very high - 15 of the 22 symptoms assessed were reported by more than half of patients.
Given that pain and depression are very common among cancer patients, and these study findings suggest they are highly correlated with other debilitating symptoms, the authors call on cancer providers to improve their symptom management efforts. They note that while patients indicate they are bothered by their symptoms, they do not necessarily report them to their care team. Consequently the onus falls on providers to proactively and repeatedly ask patients about their well being.
The multidisciplinary clinic, in which a patient sees all of his or her providers - medical oncologist, radiation oncologist and surgeon - in consecutive visits, concluding with a consensus treatment recommendation has long been held up as the gold standard in cancer care. That said, there is surprisingly little data documening the value - at least from a clinical perspective. So, this press release
from the UNC Lineberger Cancer Center
caught my attention. UNC researchers recently published a study in the journal Urologic Oncology
showing a multidisciplinary approach to to care changed the initial diagnosis or treatment in almost 65% of cases. The study evaluated 269 prostate cancer patients who came to their multidisciplinary second opinion clinic. Changes in diagnosis were most common in bladder cancer (44%), followed by kidney (36%), testicular (29%) then prostate (22%). This is striking data and speaks to the importance of multidisciplinary collaboration in not only determining optimal treatment, but also simply confirming the diagnosis.
Comparative effectiveness continues to be a hot topic (although not as hot as ACOs) and we're beginning to see early steps towards taking this idea and making it reality. The Patient Centered Outcomes Research Institute was established through the reform law and the infrastructure is gradually being developed - the goal of this group is to establish and execute the national comparative effectiveness agenda. Everyone agrees we lack good comparative effectiveness data and they seek to address this shortcoming. Questions remain though as to how this data will be used to impact coverage and payment decisions, and Peter Bach and Steven Pearson address this head on in their recent article, "How Medicare Could Use Comparative Effectiveness Research in Deciding on New Coverage and Reimbursement," published in this month's Health Affairs. The reason I want to bring this to your attention is they use radiation therapy for the treatment of prostate cancer as their case study.
Linking payment and coverage
The model they propose would link payment and coverage from the outset. Medicare would continue to base coverage on whether the service is "reasonable and necessary," but they would make a simultaneous evaluation of the service's comparative effectiveness, assigning it to one of three categories and assigning payment accordingly:
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Last year we reported on UnitedHealth Group's pilot program for episode-based payments in chemotherapy (see this blog post, and slide 42 in this webconference). They've just released an update on the program and I wanted to share the details with you given the appetite for news on emerging payment models in oncology.
Mechanics of the model
The mechanics are very similar to what we profiled last year. The pilot is being tested at five clinics and applies to three tumor sites - breast, lung and colon. Doctors will decide in advance what regimens they'll use. United will then calculate the profit they'd typically make on those regimens and pay them this amount plus the costs for managing the patient's care - note, United also covers the acquisition costs of the drugs. If, during the course of care, the doctor opts to use additional or different drugs, United will cover the cost of those drugs, but not pay the doctor anything additional. Thus, their income should not be impacted by the bundle - rather, they can focus on caring for the patient.
Measuring outcomes to refine the model
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in the Washington Post has been making the rounds and so I wanted to share it - I think it outlines well the challenges we face with many screening services, not just mammography. In the article a nurse practitioner explains in detail why she chooses not to undergo routine mammography. It's a good read, whether or not you agree with her.
As part of our research for our 2010 National Meeting series, we have been studying survivorship programs. One of the challenges in designing these programs is that the survivor population has a vast and diverse set of needs. But, of course, cancer programs have limited resources to invest in new services to meet these needs. In an effort to figure our which services would be of greatest value, several member institutions have conducted surveys or focus groups with post-treatment patients. Unfortunately, they have found the results are often conflicting and not especially helpful for strategic planning.
The underlying issue seems to be that patients don't necessarily identify with the term "survivor." Either they are unfamiliar with its use in the oncology community, or they simply feel that the term is not appropriate for them. That's the sentiment expressed by Elaine Schattner, an oncologist and a breast cancer survivor, who wrote an article earlier this week on the topic for Slate (available here).
Regardless of what terminology you use, there is of course a real need to work with patients to help them stay healthy and adjust to life after a cancer diagnosis. We'll tackle this issue from multiple sides during the second day of our national meetings.
Several years ago, women's health vendor Hologic introduced the concept of 3D digital breast tomosynthesis, a new technology thought to revolutionize the breast imaging specialty by increasing the performance of standard 2D digital mammography. Interest from the health care community immediately sparked, with many experts indicating breast tomosynthesis could ultimately supplant digital mammography as the modality of choice for the screening and diagnosis breast cancer in any setting. Despite its promise, the years came and went, but still no tomosynthesis product. The lack of clinical data, a very complicated FDA reviewal process, unclear indications for use, and myriad other factors were, and still are, to blame. Now, it appears one very important and cumbersome barrier to tomosynethsis development is beginning to budge.
Last Friday, the FDA's Medical Devices Advisory Committee - a group consisting of clinicians, statisticians, patient advocates, and industry representatives - convened to advise the FDA on whether or not to proceed with approval for Hologic's Selenia Dimensions 3D tomosynthesis system. In a 12-0 vote, the panel overwhelmingly, and somewhat surprisingly, came out in favor of the FDA approving the device and moving forward in the pre-market approval (PMA) process. While many radiologists, technologists, administrators, and members of industry anxiously await the final decions from the FDA, last week's panel recommendation to proceed in the formal FDA review process marks a historic first step towards a definitive answer.
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