Oncology & Genomics

Examining the variation in cancer care

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Each year, 8.8 million people die of cancer worldwide1 with nearly 2 million of them in Europe. That’s 280 deaths per 100,000 in Europe as compared to the 189 per 100,000 in the US. And in 2018, there were an estimated 3.91 million new cases of cancer (excluding non-melanoma skin cancer) in Europe. Although Europe only contains 9 percent of the world population, it shoulders a 25 percent share of the global cancer burden.2

With all of our advances in risk assessment, prevention, disease detection, drug development, and care delivery, why are one out of every six people dying of cancer worldwide?3 And why the huge difference between Europe and the US?

As one would expect, the answer is complicated. Overwhelming amounts of patient data and a lack of resources can hamper physicians’ ability to provide optimal care. Patient-centered factors—such as treatment adherence, health behaviors, patient preferences, psychological outlook—can also influence incidence and outcomes. In addition to all of these, variation in care can lead to different outcomes. In other words, not all cancer patients, regardless of the type of cancer, receive the same care and have the same outcomes. But why? Is geography or genetics? Access or cost? The answer is all of the above—and then some. Here we explore just some of the factors that can contribute to the variation.

Research is not finding its way to clinical practice

The good news is that research remains focused on finding a cure and clinical research continues to grow worldwide. Between 2010 and 2014, researchers published 88,529 cancer-related papers.4 The bad news? Keeping up with all that research is next to impossible. A study published in the Journal of Global Oncology found that while clinicians treating cancer patients in low- and middle-income countries (LMICs) are aware of cancer treatment guidelines, they are not consistently applying those guidelines for a multitude of reasons. Among the biggest: the facilities are inadequate, guidelines are not applicable to the local setting, and the amount of information in the guidelines is too complex and overwhelming.5

Geography causes barriers, too

A paper exploring cancer care access inequalities found that the services at high-volume centralized facilities are generally more effective with better outcomes than those services provided in rural areas. Additionally, lack of access to strong primary and secondary care services results in patients not receiving care in a timely manner—leading to the majority of patients presenting with advanced disease.6

And for those living in LMICs, cancer is also the result of communicable diseases—such as hepatitis B and C leading to hepatocellular carcinoma and human papillomavirus leading to cervical cancer—that could be prevented by nationwide vaccination programs.7

While most recognize that geography is a barrier, Finland is trying an experiment to bridge the gap between rural and urban care as noted in a recent Politico article. A national tumor group comprised of different types of specialists work together to examine a remote patient’s case. If they agree the local hospital is up to the task of treatment, the group charts out a treatment plan. If not, the patient is told they will have to travel to get the care needed.

Even medicines are not available everywhere

While cancer treatment and care require a multidisciplinary approach, lack of access to cancer medicines results in variation as well. A recent survey conducted in 49 European countries by the European Society for Medical Oncology showed substantial differences in out-of-pocket costs for patients and the availability of many cancer medicines.8 In some countries, promising new medicines may not yet be approved by regulatory bodies. Many get stuck in red tape, including the processes involved in marketing authorization, health technology assessment, and pricing and reimbursement—which together can take more than four years.9 In other countries, payers may not be willing to reimburse providers, requiring patients to pick up the tab themselves. This is especially true of new medicines that do not yet have a track record of improving overall survival and quality of life for cancer patients.

Costs are prohibitive, even with insurance

Regardless of the available medicines, a substantial portion of patients with cancer is not accessing or receiving adequate care because of its financial burden. Even among insured individuals, a cancer diagnosis can be financially disastrous—up to 78 percent of survivors experienced financial hardship as a result of their cancer.10 Yet, only 1 percent of global health financing is directed to non-communicable diseases (NCD), which includes cancer, and is vastly disproportionate to the actual NCD burden.11 Meanwhile, oncology costs are expected to rise 7 to 10 percent  annually throughout 2020, exceeding $150 billion globally.12 Patients in poorer countries face an even greater burden—per capita spending on health is $92 in low-income countries versus $5,205 in high-income countries.13

AI may be part of the solution

At IBM Watson Health,™ we’re working hard to help close the care gap through advancements in artificial intelligence (AI). We believe AI has much to offer in many areas of complex decision-making because of its ability to digest vast quantities of diverse data, disseminate new learning quickly and incorporate factors that are specific to each case and patient. While AI cannot replace trained physicians, our AI-based solutions are helping oncologists assess information from a patient’s medical record, evaluate medical evidence and find potential treatment options ranked by level of confidence and supported with clinical evidence. We’re also helping clinical trial coordinators meet enrollment targets by finding more potential patients. And we’re helping patients learn about and consider clinical trial treatment options that previously they may not have even known existed. There is no panacea for cancer care variation—and there are more factors at work than mentioned here—but even understanding the forces creating the variation is a step in the right direction.

[1] Prager GW, Braga S, Bystricky B, et al. Global cancer control: Responding to the growing burden, rising costs and inequalities in access. ESMO Open 2018. Accessed at https://esmoopen.bmj.com/content/3/2/e000285 on November 25, 2018.

[2] Ferlay, J. et al. Cancer incidence and mortality patterns in Europe: Estimates for 40 countries and 25 major cancers in 2018. European Journal of Cancer, Volume 103 , 356 – 387

[3] Prager GW, Braga S, Bystricky B, et al. Global cancer control: responding to the growing burden, rising costs and inequalities in access. ESMO Open 2018. Accessed at https://esmoopen.bmj.com/content/3/2/e000285 on November 25, 2018.

[4] Cancer Research Current Trends & Future Directions. Elsevier, 2016.

[5] Oncology Guidelines Usage in a Low- and Middle-Income Country. Journal of Global Oncology. Published online April 11, 2018. Accessed at http://ascopubs.org/doi/full/10.1200/JGO.17.00136?utm_source=TrendMD&utm_medium=cpc&utm_campaign=J_Glob_Oncol_TrendMD_0 on November 25, 2018.

[6] Prager GW, Braga S, Bystricky B, et al. Global cancer control: Responding to the growing burden, rising costs and inequalities in access. ESMO Open 2018;. Accessed at https://esmoopen.bmj.com/content/3/2/e000285 on November 25, 2018.

[7] Prager GW, Braga S, Bystricky B, et al. Global cancer control: Responding to the growing burden, rising costs and inequalities in access. ESMO Open 2018. Accessed at https://esmoopen.bmj.com/content/3/2/e000285 on November 25, 2018.

[8] Association of European Cancer Leagues. Let’s Talk Access: White Paper on Tackling Challenges in Access to Medicines for All Cancer Patients in Europe. October 2018. Accessed at https://www.europeancancerleagues.org/wp-content/uploads/ECL-Lets-Talk-Access-White-Paper.pdf Jan 6, 2019.

[9] Association of European Cancer Leagues. Let’s Talk Access: White Paper on Tackling Challenges in Access to Medicines for All Cancer Patients in Europe. October 2018. Accessed at https://www.europeancancerleagues.org/wp-content/uploads/ECL-Lets-Talk-Access-White-Paper.pdf Jan 6, 2019.

[10] Gordon LG, Merollini KM, Lowe A, et al. A systematic review of financial toxicity among cancer survivors: We can’t pay the co-pay. Patient. epub ahead of print on October 31, 2016.

[11] Open database by IHME. http://www.healthdata.org/data-visualization/financing-global-health.

[12] Medicines Use and Spending in the U.S.A Review of 2016 and Outlook to 2021. https://www.iqvia.com/institute/reports/medicines-use-and-spending-in-the-us-a-review-of-2016.

[13] Open database by World Bank. http://wdi.worldbank.org/table/2.12.

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