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.