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Equity of Care and Disparities in Cancer Mortality Remains a National Challenge

BCRF investigator Dr. Daniel Hayes discusses how ASCO is addressing inequalities in breast cancer care.

During ASCO’s annual meeting in June, BCRF investigator Dr. Daniel Hayes, spoke of the challenges and urgency in ending disparities in cancer outcomes. Here are excerpts from BCRF’s conversation with then outgoing ASCO President Dr. Hayes. You can listen to his full presidential address here.

BCRF: Both ASCO and AACR (American Association for Cancer Research) have made statements identifying cancer disparities as priorities. What spurred this new focus?

Dr. Hayes: Cancer mortality as declined more than 20 percent in the last 20 years. Breast cancer mortality has seen even bigger declines. That’s great news, but there is a clear-cut regional difference in cancer mortality, not only nationwide but even county by county. What explains these differences in mortality is not epidemiology, but delivery of care. Differences in delivery of care could be due to access but also standardization, where patients are not receiving recommended care for their disease.

When you're diagnosed with cancer, where you live should not dictate whether you live. We need to standardize oncology care across the cancer continuum and make it accessible to patients across the cancer community.   

BCRF: How is ASCO addressing inequalities in breast cancer care?

Dr. Hayes: ASCO is addressing inequities in cancer care in two ways: by advocating for support of delivery of high-quality care and by generating guidelines and improving practice pathways.

ASCO’s Clinical Practice Guidelines Committee conducts deep dives into specific topics, such as tumor markers in breast cancer, to develop clinical guidelines around these topics.  Combined with established best practices in clinical care, these evidence-based guidelines are the best way to standardize care.  All of the advances in the world, however will not make a difference if they are not used properly or even offered to patients who can benefit.

ASCO is actively engaged in shaping Medicare’s change from a fee-for-service model to the new Quality Payment Program. The program is a new compensation model based on the value of care provided. The Quality Payment Program was implemented as part of the Medicare Access and CHIP Reauthorization Act (MACRA) to ensure quality care for the most vulnerable patients, the elderly, disabled or poor enrolled in Medicaid or Medicare. Doctors have to demonstrate that they have provided value, not just service, to get fully reimbursed. And if they don't, their reimbursement is reduced. Although it will be difficult, this change in our reimbursement model is the right thing to do.  Led by Dr. Steve Grubbs, our vice-President for the ASCO Department of Clinical Affairs, we are working hard to develop and provide tools for our membership that will permit them to make the transition from fee for service to Quality-based reimbursement as easily and painlessly as possible.

That raises the issue of what is value? That's not easy, but nonetheless, we can at least begin to come up with measures that document good quality care and that's what the guidelines and the pathways do. If you adhere to the pathways, you're probably providing good quality care. And likewise, we can apply the value framework to the cost of drugs based on the relative benefit observed in a clinical trial. In other words, we can put numerical value on the net health benefit of a drug. Led by Dr. Lowell Schnipper, ASCO has published a “Values Framework” that is designed to quantify relative benefit, toxicity, and cost of a given cancer therapy, so that a patient and her or his doctor can have a rational and informed discussion about whether that treatment is right for her or him.

We’re not there yet, but were moving in the right direction. 

Read more of our conversation with Dr. Hayes in part one:advances in precision medicine and part three: the global cancer epidemic.

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