Zon Discusses ASCO's State of Cancer Care Report

Robin Zon, MD

Many significant milestones were achieved in oncology, according to the fourth annual State of Cancer Care in America report from ASCO, released this week. In an interview with OncLive, Robin Zon, MD, chair-elect of the ASCO Government Relations Committee, responded to questions about key issues raised in the report.

The report covers new drugs approved by the FDA as well as new indications for existing cancer fighting medicines. It talks about the Affordable Care Act (ACA) and the extended access to care for millions of Americans. It also discusses ASCO’s interest in seeing federal funding continue for cancer discovery and clinical trials programs.

Also discussed are obstacles that remain to be surmounted. There are disparities in care between rural and urban population zones. There are imbalances in the number of female oncologists versus male and white oncologists versus black and Hispanic, and there is a need to break down barriers that prevent health information from flowing to research programs and institutions that could use that data to improve healthcare, ASCO wrote in its report.

OncLive: What are the key takeaways from this year’s report?

Below are Zon’s answers to questions about the report posed by OncLive.Zon: This year’s State of Cancer Care report really shows that we’re in a time of rapid change all across the US cancer care delivery system. There are a few key points that really stick out to me:

First, we’re seeing a wave of new patients with cancer as our population grows and ages. We’re also seeing more survivors of cancer—proof that we’ve made great progress over the past several decades. All of these patients and survivors will require continued access to quality care.

At the same time, we’re hearing from oncology professionals that increasing administrative burdens and cost-sharing measures are making it harder for them to spend time with their patients. This is clearly an issue that will need to be addressed, particularly as the patient population continues to grow.

Second, the report shows that access to affordable care continues to be a major challenge. Even when patients have health insurance, the cost of receiving treatment can be too high, with approximately one-third of working-age cancer survivors incurring debt as a result of treatment. I’d also add that disparities—by race, ethnicity, geography, and other socioeconomic factors—continue to persist.

The report highlights the improvements in coverage for Americans under the ACA. Where does ASCO stand on the repeal and replace effort?

I do think that this report shows that there’s quite a lot of positive activity occurring in many different spheres. New, more effective treatments have been introduced, and we’re making steady progress towards rapid-learning health systems that will help us learn from an even larger patient population. I’m also encouraged by the momentum around value initiatives. Organizations, including ASCO, are continuing to look at how value frameworks or alternative payment models will improve the evolution toward high-quality, value-based care. There’s a lot in the report that gives me hope.We’re taking a careful look at all of the health reform proposals. We’ve developed a set of patient-centered principles that guide all of our positions on continued efforts on healthcare reform. We’re committed to working with policymakers on both sides of the aisle and the entire cancer community to provide equal access to affordable, quality health care for people with cancer. Access to health care coverage is a hallmark of those principles.

The report also praises the bipartisan 21st Century Cures Act for supporting discovery, but the proposed cut in funding for the National Institutes of Health could undermine that achievement. ASCO opposes the administration’s budget outline, which would cut $6 billion from the National Institutes for Health (NIH). Reducing NIH's funding by over 18% will devastate our nation's already fragile federal research infrastructure and undercut a longstanding commitment to biomedical science that has fueled advances in cancer prevention, diagnosis, and treatment.

We have consistently said that the funding included in the 21st Century Cures Act should supplement— not supplant—predictable increases in the NIH’s budget, which are critical to continue promising research efforts.

Is telehealth the only answer to improving access to oncology care in rural areas, or are there other initiatives and possibilities?

What’s the solution for improving the preparedness of nononcology providers for addressing the needs of the rising cancer population?

How do you read the future of smaller independent practices that are struggling with electronic health record (EHR), financial, administrative and other challenges?

What do the past year’s FDA drug and diagnostic test approvals signify for success in the war on cancer?

We know this is the first step in a longer process and we look forward to working with Congress and the administration to ensure such cuts do not take effect.As part of overall practice transformation and innovation occurring across the system, oncology practices are exploring ways to better coordinate and deliver care to all communities. That includes working with primary care and other specialties to be sure patients with cancer transition successfully from acute oncology care to survivorship, including those patients who live in underserved areas. Telehealth is one approach. Some oncology practices have satellite clinics that provide care in otherwise underserved or rural communities. However, these clinics are under stress as cost and administrative burden rise, and some have had to close. We are hopeful that innovative payment models will better support team-based care and other creative solutions that remove access barriers for individuals in rural and underserved areas.ASCO partners with the American College of Physicians and the American Academy of Family Physicians on an annual Cancer Survivorship Symposium, where our members jointly benefit from education and research that can begin to address common challenges. ASCO maintains a workforce information system and is regularly monitoring access issues related to this.There has been a continued shift of independent practices to hospital-based over the past several years. Increasing administrative duties and expense will continue to challenge practices, especially small independent practices. ASCO remains committed to offering education and assistance to practices through the healthcare transformation. Although we cannot project the total impact on smaller practices at this time, ASCO will continue to monitor the situation and advocate for all patients to have access to cancer care, regardless of their geography.In 2016, the FDA approved 5 new drugs/biologics for the treatment of cancer, expanded the indications of 13 drugs already approved to treat additional types of cancer, and approved several new cancer diagnostic tests—including 2 novel types of tests: a liquid biopsy test for lung cancer mutations and a next-generation sequencing test to identify patients with advanced ovarian cancer eligible for a particular cancer treatment.

Where have we seen our greatest victories against cancer subtypes in 2016?

These approvals demonstrate the rapid advances and the increasing complexity of cancer treatment. Oncology specialists have more treatment options to offer to patients with cancer, but discussing these options with patients requires time and attention to detail, as well as clinical decision support to understand how to help patients weigh the benefits and risks of various options.Last year brought approvals of new treatments targeting molecules important in the growth of certain types of kidney, lung, breast and blood cancer. Also, the first test for “liquid biopsy” was approved by FDA in 2016 for lung cancer. This technology allows physicians to assess cancer-driving tumor mutations through a simple blood draw, as opposed to invasive tissue biopsies, which in turn facilitates selection of optimal treatment and monitoring changes in the status of the tumor over time.

In the current political and business climate, will it be possible to make headway against the practice of information blocking—refusal by institutions to openly share health data for research purposes?

Is there potential in 2017 to ease the administrative/EHR burden on physicians so they can spend more time directly with patients?

In general, however, immunotherapy research continues to transform the landscape. One of the key research highlights in immunotherapy research showed how immunotherapy can slow the growth of melanoma and some cases of later stage melanoma, and in some cases extend survival. We are in our infancy in this field because not every patient benefits and, in a proportion of cases, benefits are short-lived.Technology has given us an opportunity to improve patient care, but much of our success rests on EHR systems being able to communicate with each other. ASCO supported the 21st Century Cures Act, which took steps to address interoperability of EHRs and put restrictions on intentional information blocking. One of the recommendations outlined in the State of Cancer Care in America report is the full implementation of the Cures legislation, and ASCO is monitoring this issue very closely.Increasing time with the EHR and administrative work does take time away from the patient and is leading to physician burnout. This is a serious problem for all specialties and all providers. That said, part of the 21st Century Cures Act is geared toward reducing administrative burden, so speedy implementation of this provision is needed.

The report cites a lack of MACRA awareness among physicians. Does this mean oncologists as well?

What progress have we made toward the value transition in 2016?

In addition, ASCO has ongoing activities to address areas identified as burdensome by providers. One area members identified is in the world of clinical oncology pathways. ASCO is addressing these concerns and has published guiding principles as well as criteria to guide the development of future pathways.Yes, it does, but ASCO is actively working to help our members get up to speed. We offer an online Quality Payment Program toolkit with a growing range of tools and educational materials at asco.org/MACRA. The toolkit includes webinar recordings and slides from the MACRA education series, the “Top 10 List for MACRA Implementation in 2017,” and factsheets on various aspects of quality reporting. Additionally, ASCO has—and will continue to—offer sessions on MACRA at our in-person meetings, including the ASCO Annual meeting, Best of ASCO meetings, and there was a MACRA session at the inaugural ASCO Oncology Practice Conference in early March.As a practical matter, the transition from volume to value is occurring primarily through practice transformation driven by MACRA implementation. ASCO has invested heavily in both educating and assisting practices in preparing for these changes. This includes providing a robust quality measurement and improvement program, a practice certification program, assistance with transforming to an oncology medical home, and a portfolio of measures that demonstrate high value, high quality performance. It also includes a quality training program that now reaches an international audience. We have also constructed an alternative payment model that supports value based payment. Our plan is to submit this model for review by the Physician Technical Advisory Committee this summer.

ASCO has also developed a value framework designed to support physicians and patients as they explore and select treatment options that best meet their individual needs. A task force is currently working on refining this model with the goal of making it accessible to physicians and patients at the point of care.

For more information and a link to the report, visit http://www.asco.org/research-progress/reports-studies/state-cancer-care-america-2017