Tuesday, January 31, 2012

A Survey of Battlefields in the War on Cancer: Oncologists Reporting from the Front Lines

In 2008, we launched an oncology market surveillance program, “Oncologists Look at Oncology: Prognosis for U.S. Cancer Care.” We were moved to do this by what we were hearing from oncologists as we conducted in-depth interviews with them on behalf of our clients. Our clients in the field, who range from small startups to leading “Big Pharma” companies, shepherd innovative molecules from the bench to the clinic and, if successful, to the commercial marketplace. But over 35 years after the “War on Cancer” was famously declared by President Nixon in 1971, what we were hearing from oncologists on the front lines of cancer care was a sense of frustration, even despair.

A significant part of oncologists’ frustration at the time was financial. In 2006, Medicare and Medicaid reimbursement to physicians for in-office intravenous cancer medications was cut dramatically. Private practice oncologists had been earning 50 percent or more of their total personal income from profits on IV medication -- profits earned directly from reimbursement paid by public and private payers. The industry published fictional “average wholesale prices” (AWP) that set the reimbursement physicians would receive, but physicians were able to purchase drugs at prices substantially below AWP. Centers for Medicare and Medicaid Services’ updated reimbursement policy based on actual average selling prices rationalized reimbursement but changed the game for oncologists.

But loss of personal income wasn’t the only thing that seemed to have disheartened oncologists. They told us that they were sending more patients to hospitals for drug administration when coverage was uncertain -- even though patients generally feel more comfortable receiving treatment in familiar, less institutional treatment settings -- because private practices could no longer absorb unreimbursed drug costs. They told us that they were unable to treat patients with the best available care because of patients’ inability to afford requisite out-of-pocket co-payments. They told us that they did not see how providers or patients or payers could keep pace with the escalating costs of new cancer therapies. They told us that their colleagues were retiring and their children were pursuing specialties other than oncology because both financial compensation and lifestyle were better in procedure-oriented fields.

We decided that it was important to check in with oncologists periodically about their perspectives on cancer care, and to put some statistics around the sort of anecdotal laments we hear on a daily basis. Today, oncologists are very optimistic about our growing understanding of the biology of cancer and the ability of novel therapies to lengthen and improve quality of life in patients with cancer diagnoses. That’s good news. But oncologists doubt that we will be able -- individually or collectively -- to afford the innovations, and they also doubt there will be enough oncologists to care for patients.

In “The Emperor of All Maladies: A Biography of Cancer,” Pulitzer prize-winning author Siddhartha Mukherjee has written a powerful history of “the men and women who have waged a battle against cancer for four thousand years” and he describes the book as “a military history.” The rising cost of care and our strained capacity to pay for it has put us on the horns of a dilemma. If that dilemma does not oblige us to accept defeat in that war, it will force us to redefine the meaning of victory -- not just how long patients live, but also how appropriately and expensively they are cared for until they die.

Over the coming weeks, we will be discussing our survey data in greater detail and sharing how physicians and cancer patients are likely to rescale the terms of success in these best and worst times of scientific abundance and financial scarcity.

“Oncologists Look at Oncology: Prognosis for U.S. Cancer Care,” is an oncology market surveillance program launched by National Analysts Worldwide in 2008; each wave surveys 200 U.S. oncologists recruited from the Epocrates physician web panel.

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