• Breaking: Many cancer patients are old, and are sick with other things too

    This year, about 1.6 million Americans will be newly diagnosed with cancer. By 2030, cancer incidence will rise to about 2.3 million. The United States spends about $125 billion on cancer care. That’s only five or six percent of the nation’s health care bill. It’s still an impressive amount of money, talent, and medical resources. In some ways, cancer care displays the absolute best American medicine has to offer. Breakthrough medications such as Gleevac have extended and improved many lives.

    As I’ve mentioned here, my dad received excellent and caring treatment for a frightening kidney cancer through Brigham and Women’s Hospital and the Dana-Farber Cancer Institute. Whenever I’m having a bad day, I re-read the words: “Your father appears to be free of cancer.” He’s again thriving at age 84, sending me emails I can’t answer about quantum mechanics or how to program my Apple TV.

    Hundreds of thousands of patients have much worse experiences. Many patients have sadder medical outcomes, of course. It’s more than that. Whatever the prognosis, many receive fragmented, financially-burdensome, confusing, or insensitive care that fails to meet their basic needs.

    Two weeks ago, the Institute of Medicine released a new tome: Delivering high-quality cancer care: charting a new course for a system in crisis. The IOM devoted many pages to one issue that is surprisingly obvious, yet remains unaddressed: The current mismatch between the way cancer care is typically organized and the reality that most cancer patients are older people who are often sick with other conditions.

    Ironically, the same challenges that make geriatric care so necessary also lead older adults to be systematically under-represented in trials of new cancer treatments and drugs. Anyone who has designed a clinical trial or conducted health services research can imagine some of the reasons why. Researchers who conduct clinical trials seek to identify and to demonstrate clear patient benefit—benefit that is almost always defined in terms of patient survival.

    Testing a new drug to see if it helps patients live longer, intervention researchers have obvious reasons to choose relatively homogeneous populations of cancer patients who experience low prevalence of confounding conditions and few competing mortality risks. Researchers have obvious reasons to avoid patients who have serious comorbidities, who have uncertain family supports, who might have cognitive impairments, or who might have adverse reactions to toxic medications. These more-vulnerable patients die sooner. They add random variability and managerial complexity to both the treatment and the control groups, requiring larger sample sizes and more costly study designs.

    In other words, it’s generally easier and cheaper to recruit younger patients. The oncology and gerontology communities have known about this problem for a long time. Yet the problem persists.

    Twenty-four new cancer drugs were approved between 2007 and June 2010. Although most cancer patients and survivors during this period were over age-65, seniors accounted for only about 33% of the patients included in registration trials. Only about ten percent of trial participants (in studies for which pertinent data were readily available) were over the age of 75. Cancer care teams thus lack key information required to make proper care decisions for most of their patients.

    Our cancer care system also does a poor job of coordinating care for older people when cancer is one of many medical challenges requiring careful management, and, sometimes, the right balance of intervention and restraint. Despite excellent technology, pharmaceutical treatments, and surgical interventions, we often fail to treat cancer patients with the transparency, coordination, and humanity everyone deserves.

    Viewed as a system, American cancer care has basic defects. I see in my father’s face the face of someone else who might someday occupy a similar room. As we baby boomers age, we’d better make sure that our nation’s cancer system does better job than it currently does.

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    • I commented earlier this week that the crisis in health care is attributable largely to the explosion in the number of cases of chronic illnesses, cancer being one of them, but that most people think their health risk is to experience an injury or a curable disease or condition. Indeed, health insurance is designed, not for the risks of chronic illnesses but the risks of a treatable injury or illness. I’m more aware of chronic illness because I live with my brother, who was diagnosed with leukemia over ten years ago, and have shared his experience of deteriorating health, lots of health care, exhaustion of financial assets, inability to continue work, loss of health insurance, harassment by debt collectors for debts incurred for health care, competition for drug trials, and the enormous generosity of oncologists and other physicians who have kept him alive and been his advocate. Yes, you read the previous sentence correctly. The disconnect between the way health care is funded and the way it is delivered is so stark that one wonders if it was designed by someone residing on Mars and for Martians. Even Obamacare, with all of its improvements, will not prevent working Americans from exhausting their savings and becoming dependent on the charity of others if they suffer a chronic illness – the caps on out of pocket expenses are too high and the exclusion from the caps non-covered services is too large a hole. As the reality of chronic illness affects more and more families, however, I would expect some improvements, including a greater concern for seniors with cancer described by Pollack. I must add that reading Pollack restores my faith in scholars and the academy.

    • I just returned from the fall meeting of Cancer Clinics of Excellence (www.cce.us.com), a nation wide group of oncology practices trying to address issues in providing care. Disclosure=I have a business interest in CCE’s success. Dr. Sharyl Nass, one of the authors of the IOM report that you reference above, was our keynote speaker Thursday night.
      I think that you have identified a big and very difficult problem. The interests of Pharma require quick and clean approval of their products while the payors would like to limit the use of novel agents since each recently approved treatment typically runs $100,000 per year. The peoples’ interests are being poorly represented in this struggle by a political process mired in posturing, demagoguery, and vituperation. The physician community needs to step up to the plate, but we are candidly overburdened by many demands including declining incomes, more documentation, family needs, etc. I think that we oncologist will have to find a way to do this…the politicians seem incapable.
      Look, early referral to palliative care has been shown to prolong life and save money. Any politician speaking of death panels deserves our contempt. We oncologist should be speaking out.
      I will say that maybe some things are a little better. In the 1970’s and 80’s it was common for clinical trials to specifically exclude people over 65; now we do not use a number, but the trials do exclude people with limited life expectancies and comorbidities.

    • Thank you so much for sharing your story. Little by little things are improving. But not enough or fast enough.

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