News & Analysis
Cancer Care Shows Signs of Strain as Patients Live Longer Mike Mitka, MSJ
T
he leaders of the American Society of Clinical Oncology (ASCO) have looked into the future of US cancer care, and they don’t like what they see. To change that vision, ASCO has published a report describing cancer care in 2014 and the expected socioeconomic issues oncologists face in the next 7 to 16 years. The report also highlights areas of concern that, if addressed in the next few years, should ease the anticipated burdens (http://tinyurl .com/lar8y2n). According to ASCO, by 2030, the number of new US cancer cases is expected to increase by 45%, making the disease the nation’s leading cause of death. By 2025, demand for oncology services will increase by at least 40%, while the supply of oncologists will increase less than 30%, creating a shortfall of about 1500 oncologists. Meanwhile, annual cancer care costs are projected to increase from $104 billion in 2006 to more than $173 billion in 2020.
More Cancer Survivors Although the ASCO estimates appear to be bad news, they actually reflect good news. The increase in new cancer cases, which will
strain the supply of oncologists, means individuals are living longer and avoiding other causes of death, such as cardiovascular disease, the current number one killer. The soaring cancer care costs reflect, in part, an evergrowing population of cancer survivors (increasing from 13 million in 2014 to 18.5 million in 2025) and the development of new (and costly) drugs that extend life, if not help cure a particular cancer. The impetus for the report, said Clifford A. Hudis, MD, ASCO president and medical oncologist, is to document the current state of cancer care and provide annual updates so oncologists can track whether they are making progress addressing some serious issues. “In science, you cannot know anything if you can’t measure it,” said Hudis, who is also chief, breast cancer medicine service, at Memorial Sloan Kettering Cancer Center in New York City. “For the first time, we’ve tried to measure what’s going on.” For now, the report notes, access to qualitycancercareremainsuneven.Accesstocare is disproportionately worse for black and Hispanic individuals compared with whites, and a quarter of those without health insurance
By 2025, demand for oncology services will increase by at least 40%, outstripping the supply of oncologists.
forgo medical care, including cancer screening,becauseofcost.Thereportalsosaidnewly approved drugs, sometimes costing more than $100 000 for a course of treatment and often used in combination therapy, are costprohibitiveformanypatients,eventhosewith health insurance. The current oncology workforce also needs some reconfiguring or incorporation of innovative ideas so cancer care can be delivered where patients live, the report said. Today, the vast majority of oncology care specialists are concentrated in certain regions of the country, generally in urban areas. Indeed, only 3% of oncologists are based in rural areas, which contain 20% of the US population. Nationwide there are 3.8 oncologists per 100 000 individuals. Washington, DC, has the highest concentration of oncologists, at 15.3 per 100 000 individuals, while Wyoming has the lowest, at 1.6 per 100 000 individuals. The report also noted that there are lower percentages of black and Hispanic physicians in oncology than in many other medical specialties.
Practice Fatigue Another factor affecting the oncology workforce today and in the future is practice fatigue experienced by many oncologists. At a March 11 press conference announcing the release of the report, Carolyn B. Hendricks, MD, a medical oncologist practicing in Bethesda, Maryland, said 45% of oncologists feel burned out, 27% are likely to reduce clinical hours, 35% are likely to leave their current positions, and a significant number want to retire before age 65 years. Practice size is also changing, she noted, putting further pressure on the oncology community to deliver quality care to underserved regions. A 2013 ASCO census found 63% of small practices reported they were likely to merge, sell, or close operation in the next year. Depending on whether practices just change affiliation, move to a new location, or shut down, these changes could create access problems for many patients. “Why is this important?” Hendricks asked. “The fact is, it is these smaller practices that are delivering a significant proportion of cancer care in the United States.”
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JAMA May 7, 2014 Volume 311, Number 17
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Yale University User on 05/14/2015
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News & Analysis
The report does offer recommendations to change the current and anticipated cancer care environments. For Hudis, a key to making improvements is identifying exactly what defines quality. “Value has been such a daunting problem that we’ve shied away from it,” Hudis said. “It’s clear that we’ll have to think much more carefully in determining the value of interventions and creating incentives to guide us to provide that value.” One major recommendation is that oncologists should identify and test promising care delivery models that provide quality care to patients regardless of who they are or where they live, even with workforce restraints. Bayard L. Powell, MD, chief, section on hematology and oncology at Wake Forest University School of Medicine in WinstonSalem, North Carolina, is testing a
delivery model as his hospital continues to see the patient population grow at a time of restrained resources. “We are working on increasing our attention to survivorship,” Powell said. “Our program is run by an oncologist with the help of a physician assistant or nurse practitioner, where we transition these patients back to their primary care physicians, giving them an outline of care and alerts for when to send them back to us.” Powell added that oncology’s challenges mirror health care in general. “For all medical disciplines, there’s a sense that more is needed,” Powell said. “Patients are living longer, and that’s a good thing. We have more effective treatments, so more patients can benefit from our care.” Correction: This article was corrected online May 16, 2014.
Stroke Risk May Be Increased After Shingles Episodes Jill Jin, MD, MPH
©iStock.com/Sean_Gao
N
ew evidence suggests that shingles, which can occur in individuals who previously had chicken pox (varicella), may be associated with an increased risk of stroke in the weeks to months following a shingles episode. Researchers at the London School of Hygiene and Tropical Medicine analyzed medical records from millions of general practice patients in the United Kingdom from 1987 to 2012 and identified more than 6500 individuals with both shingles and arterial stroke during this period. When they looked at the time points at which strokes occurred in relation to the shingles episodes, they found that the rate of stroke was significantly higher during the first 6 months after a shingles episode compared with before a shingles episode (approximately 63% higher during the first month, 42% higher during the second and third months, and 23% higher during the fourth through sixth months). Individuals who did not receive antiviral treatment during their shingles episodes had an even higher rate of stroke compared with those who did receive such treatment. In addition, although the case numbers were smaller, individuals in
whom shingles affected the trigeminal nerve seemed to have a higher rate of stroke than those in whom other nerves were affected. The authors suggest 2 possible mechanisms in which shingles might increase stroke risk. First, the overall higher level of inflammation in the body during a severe systemic infection causes a state in which the blood is more prone to clotting, which can lead to stroke. Second, the shingles virus, varicella-zoster virus, can also spread into the nerves of the blood vessel walls, leading to defective blood vessels that are more likely to allow both clots and bleeding, which can lead to stroke. This study is the first to examine the association between shingles and stroke in a time-dependent fashion, including only individuals with both shingles and stroke and focusing on the length of time between the 2 events. The authors state that their findings have implications for both clinical medicine and public health, underscoring the importance of antiviral treatment for shingles as well as shingles vaccination, which, in the United States at least, remains underused.
news@JAMA FROM JAMA’S DAILY NEWS SITE
Slowing ALS Progression With Diet A high-calorie, high-carbohydrate diet may safely treat amyotrophic lateral sclerosis (ALS), a progressive neurological disorder commonly known as Lou Gehrig disease. Researchers randomly assigned 20 patients with advanced ALS to a diet for weight maintenance or a high-calorie diet that also was either high in fat or high in carbohydrates. Those on the high-carbohydrate diet had the fewest adverse events: 23 among 8 patients compared with 42 among 6 patients in the weight maintenance group and 48 among 6 patients in the high-fat group. Previous studies have shown that moderately obese patients with ALS lived longer and their disease progressed more slowly than underweight patients. http://jama.md/1gYOKi6 FDA Proposes Food Labeling Changes After 20 years, the “Nutrition Facts” label on most food packages in the United States is getting a facelift. The US Food and Drug Administration (FDA) has proposed several changes to the nutrition facts box, originally created to make it easier for consumers to choose healthier foods. The proposed changes include replacing the current “recommended” serving size with one that more accurately represents what people actually consume as a serving and making the number of calories per serving more prominent. http://jama.md/1jwSQ0g Do Multivitamins Protect Vision? A recent study that examined the relationship between multivitamins and vision came up with mixed results. Data from the Physicians’ Health Study II, which included more than 14 000 male physicians, showed 1817 cases of cataracts developed during the 11-year follow-up: 872 in those taking a multivitamin and 945 in the placebo group. This translated into a 15.2% rate of cataracts in the multivitamin group vs a 16.4% rate in the control group, a small but statistically significant difference, given the large number of individuals in the trial. There was no difference in age-related macular degeneration rates between the 2 groups. http://jama.md/Obt9Gn
For more on these stories and other medical news, visit http://newsatjama.jama.com.
jama.com
JAMA May 7, 2014 Volume 311, Number 17
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Yale University User on 05/14/2015
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Cancer Care Shows Signs of Strain as Patients Live Longer Mike Mitka, MSJ
T
he leaders of the American Society of Clinical Oncology (ASCO) have looked into the future of US cancer care, and they don’t like what they see. To change that vision, ASCO has published a report describing cancer care in 2014 and the expected socioeconomic issues oncologists face in the next 7 to 16 years. The report also highlights areas of concern that, if addressed in the next few years, should ease the anticipated burdens (http://tinyurl .com/lar8y2n). According to ASCO, by 2030, the number of new US cancer cases is expected to increase by 45%, making the disease the nation’s leading cause of death. By 2025, demand for oncology services will increase by at least 40%, while the supply of oncologists will increase less than 30%, creating a shortfall of about 1500 oncologists. Meanwhile, annual cancer care costs are projected to increase from $104 billion in 2006 to more than $173 billion in 2020.
More Cancer Survivors Although the ASCO estimates appear to be bad news, they actually reflect good news. The increase in new cancer cases, which will
strain the supply of oncologists, means individuals are living longer and avoiding other causes of death, such as cardiovascular disease, the current number one killer. The soaring cancer care costs reflect, in part, an evergrowing population of cancer survivors (increasing from 13 million in 2014 to 18.5 million in 2025) and the development of new (and costly) drugs that extend life, if not help cure a particular cancer. The impetus for the report, said Clifford A. Hudis, MD, ASCO president and medical oncologist, is to document the current state of cancer care and provide annual updates so oncologists can track whether they are making progress addressing some serious issues. “In science, you cannot know anything if you can’t measure it,” said Hudis, who is also chief, breast cancer medicine service, at Memorial Sloan Kettering Cancer Center in New York City. “For the first time, we’ve tried to measure what’s going on.” For now, the report notes, access to qualitycancercareremainsuneven.Accesstocare is disproportionately worse for black and Hispanic individuals compared with whites, and a quarter of those without health insurance
By 2025, demand for oncology services will increase by at least 40%, outstripping the supply of oncologists.
forgo medical care, including cancer screening,becauseofcost.Thereportalsosaidnewly approved drugs, sometimes costing more than $100 000 for a course of treatment and often used in combination therapy, are costprohibitiveformanypatients,eventhosewith health insurance. The current oncology workforce also needs some reconfiguring or incorporation of innovative ideas so cancer care can be delivered where patients live, the report said. Today, the vast majority of oncology care specialists are concentrated in certain regions of the country, generally in urban areas. Indeed, only 3% of oncologists are based in rural areas, which contain 20% of the US population. Nationwide there are 3.8 oncologists per 100 000 individuals. Washington, DC, has the highest concentration of oncologists, at 15.3 per 100 000 individuals, while Wyoming has the lowest, at 1.6 per 100 000 individuals. The report also noted that there are lower percentages of black and Hispanic physicians in oncology than in many other medical specialties.
Practice Fatigue Another factor affecting the oncology workforce today and in the future is practice fatigue experienced by many oncologists. At a March 11 press conference announcing the release of the report, Carolyn B. Hendricks, MD, a medical oncologist practicing in Bethesda, Maryland, said 45% of oncologists feel burned out, 27% are likely to reduce clinical hours, 35% are likely to leave their current positions, and a significant number want to retire before age 65 years. Practice size is also changing, she noted, putting further pressure on the oncology community to deliver quality care to underserved regions. A 2013 ASCO census found 63% of small practices reported they were likely to merge, sell, or close operation in the next year. Depending on whether practices just change affiliation, move to a new location, or shut down, these changes could create access problems for many patients. “Why is this important?” Hendricks asked. “The fact is, it is these smaller practices that are delivering a significant proportion of cancer care in the United States.”
1720
JAMA May 7, 2014 Volume 311, Number 17
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Yale University User on 05/14/2015
jama.com
News & Analysis
The report does offer recommendations to change the current and anticipated cancer care environments. For Hudis, a key to making improvements is identifying exactly what defines quality. “Value has been such a daunting problem that we’ve shied away from it,” Hudis said. “It’s clear that we’ll have to think much more carefully in determining the value of interventions and creating incentives to guide us to provide that value.” One major recommendation is that oncologists should identify and test promising care delivery models that provide quality care to patients regardless of who they are or where they live, even with workforce restraints. Bayard L. Powell, MD, chief, section on hematology and oncology at Wake Forest University School of Medicine in WinstonSalem, North Carolina, is testing a
delivery model as his hospital continues to see the patient population grow at a time of restrained resources. “We are working on increasing our attention to survivorship,” Powell said. “Our program is run by an oncologist with the help of a physician assistant or nurse practitioner, where we transition these patients back to their primary care physicians, giving them an outline of care and alerts for when to send them back to us.” Powell added that oncology’s challenges mirror health care in general. “For all medical disciplines, there’s a sense that more is needed,” Powell said. “Patients are living longer, and that’s a good thing. We have more effective treatments, so more patients can benefit from our care.” Correction: This article was corrected online May 16, 2014.
Stroke Risk May Be Increased After Shingles Episodes Jill Jin, MD, MPH
©iStock.com/Sean_Gao
N
ew evidence suggests that shingles, which can occur in individuals who previously had chicken pox (varicella), may be associated with an increased risk of stroke in the weeks to months following a shingles episode. Researchers at the London School of Hygiene and Tropical Medicine analyzed medical records from millions of general practice patients in the United Kingdom from 1987 to 2012 and identified more than 6500 individuals with both shingles and arterial stroke during this period. When they looked at the time points at which strokes occurred in relation to the shingles episodes, they found that the rate of stroke was significantly higher during the first 6 months after a shingles episode compared with before a shingles episode (approximately 63% higher during the first month, 42% higher during the second and third months, and 23% higher during the fourth through sixth months). Individuals who did not receive antiviral treatment during their shingles episodes had an even higher rate of stroke compared with those who did receive such treatment. In addition, although the case numbers were smaller, individuals in
whom shingles affected the trigeminal nerve seemed to have a higher rate of stroke than those in whom other nerves were affected. The authors suggest 2 possible mechanisms in which shingles might increase stroke risk. First, the overall higher level of inflammation in the body during a severe systemic infection causes a state in which the blood is more prone to clotting, which can lead to stroke. Second, the shingles virus, varicella-zoster virus, can also spread into the nerves of the blood vessel walls, leading to defective blood vessels that are more likely to allow both clots and bleeding, which can lead to stroke. This study is the first to examine the association between shingles and stroke in a time-dependent fashion, including only individuals with both shingles and stroke and focusing on the length of time between the 2 events. The authors state that their findings have implications for both clinical medicine and public health, underscoring the importance of antiviral treatment for shingles as well as shingles vaccination, which, in the United States at least, remains underused.
news@JAMA FROM JAMA’S DAILY NEWS SITE
Slowing ALS Progression With Diet A high-calorie, high-carbohydrate diet may safely treat amyotrophic lateral sclerosis (ALS), a progressive neurological disorder commonly known as Lou Gehrig disease. Researchers randomly assigned 20 patients with advanced ALS to a diet for weight maintenance or a high-calorie diet that also was either high in fat or high in carbohydrates. Those on the high-carbohydrate diet had the fewest adverse events: 23 among 8 patients compared with 42 among 6 patients in the weight maintenance group and 48 among 6 patients in the high-fat group. Previous studies have shown that moderately obese patients with ALS lived longer and their disease progressed more slowly than underweight patients. http://jama.md/1gYOKi6 FDA Proposes Food Labeling Changes After 20 years, the “Nutrition Facts” label on most food packages in the United States is getting a facelift. The US Food and Drug Administration (FDA) has proposed several changes to the nutrition facts box, originally created to make it easier for consumers to choose healthier foods. The proposed changes include replacing the current “recommended” serving size with one that more accurately represents what people actually consume as a serving and making the number of calories per serving more prominent. http://jama.md/1jwSQ0g Do Multivitamins Protect Vision? A recent study that examined the relationship between multivitamins and vision came up with mixed results. Data from the Physicians’ Health Study II, which included more than 14 000 male physicians, showed 1817 cases of cataracts developed during the 11-year follow-up: 872 in those taking a multivitamin and 945 in the placebo group. This translated into a 15.2% rate of cataracts in the multivitamin group vs a 16.4% rate in the control group, a small but statistically significant difference, given the large number of individuals in the trial. There was no difference in age-related macular degeneration rates between the 2 groups. http://jama.md/Obt9Gn
For more on these stories and other medical news, visit http://newsatjama.jama.com.
jama.com
JAMA May 7, 2014 Volume 311, Number 17
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Yale University User on 05/14/2015
1721
