Cancer care in 2017: the promise of more cures with the challenges of an unstable health care system

This past year will likely be remembered as one of breakthrough advances in reducing the burden of cancer, with some landmark “firsts” coming out of the US Food and Drug Administration (FDA). Among the notable approvals were the first CART [chimeric antigen receptor T-cell] immunotherapies – tisagenlecleucel (Kymriah) for B-cell precursor acute lymphoblastic leukemia, and axicabtagene ciloleucel (Yescarta) for relapsed or refractory large B-cell lymphoma; the first US-approved biosimilar for cancer, bevacizumab-awwb (Mvasi) for multiple types of cancer; and first-time approvals for neratinib (Nerlynx) as an extended adjuvant therapy for early-stage human epidermal growth factor receptor 2 (HER2)-overexpressed/amplified breast cancer, and avelumab (Bavencio) for the treatment of metastatic Merkel cell carcinoma. But our excitement about those advances will undoubtedly be tempered by the continued challenges in expanding access to better quality health care, piloting more effective payment models, and consolidating delivery systems.

Our excitement has also been tempered by the rapid rise in the cost of effective biologic, immunologic, and targeted therapies. With the approval of trastuzumab-dkst (Ogivri), the first targeted biosimilar for HER2-positive breast and gastrointestinal cancers, we can look forward to price decreases possibly in the 20%-30% range over time from a targeted therapy with remarkable clinical efficacy. We know that approved biosimilars have demonstrated clinical efficacy along with similar minor biologic diversity that is also seen in the reference biologic.¹ We can also hope that increasing competition among biosimilar and reference compounds will lead to improvements in production methodologies that can allow further price reductions so that even more patients can gain access to these highly effective therapies.

In addition, the first FDA approval for the next-generation sequencing (NGS) FoundationOne profiling test and the rapid announcement by the Centers for Medicare & Medicaid Services (CMS) that it will cover the cost of that testing brings us a step closer to knowing which patients most likely will or won’t benefit from costly and toxic targeted therapies. Along with the many clinical trials studying which mutations predict which efficacies of individual or combinations of targeted agents, the approval and CMS coverage policy will help us improve value to our patients; when we can recommend the most beneficial therapies and avoid futile ones.

Finally, the approval for the DigniCap Scalp Cooling System for patients on chemotherapy for all solid tumors is of great importance. Pending coverage availability, it may influence some patients to get chemotherapy they might otherwise have forgone to avoid hair loss (see related article).

More consolidation: the best of all worlds?

In my 27 years in private practice, during which practice revenues grew with the favorable profit margins on novel therapies, forward-thinking physician leaders piloted innovations in oncology electronic medical records (EMRs), the delivery of team-based care, clinical research partnerships, and more comprehensive care services to better serve diverse communities, including those in rural areas. At my previous practice, that included adding clinicians to our group to serve patients at hospital clinics in 2 counties in southern California, each county with populations larger than 15 states. Our private practice worked with these public entities to bring state-of-the art care and private practice efficiencies to the uninsured and underserved in our region.

Unfortunately, revenues plummeted with changes in reimbursement after passage of the Medicare Modernization Act in 2003 and they continue to destabilize and reduce the number of community practices across the country. Many oncologists and oncology practices, including mine, chose to join larger academic or hospital systems or larger oncology networks at a time they are also facing growing pressures to contain costs, focus on out-patient care, complex clinical trials, and expanded access to care.

Although we may lament the shrinking landscape of private oncology practices, we can also be inspired by the physicians who have joined ranks with the better-funded, better-resourced, more traditional hospital and academic systems. These larger systems have more resources, more clincial trial offerings, staffing, technology, and analytics to expand value-based care initiatives to larger numbers of patients.

The hub-and-spoke models of oncology care with integrated networks linked by technology, and networked into larger analytic and decision support systems such as CancerLinQ, the health information technology program of the American Society of Clinical Oncology (ASCO),² could facilitate documentable delivery of comprehensive, evidence-based care, moving us closer to meeting the Quadruple Aim of optimal health care: improving the patient experience of care (including quality and satisfaction); improving the health of populations; reducing the per capita cost of health care; and improving the work life of those who deliver care.^3,4

Payment reform: working to align incentives