National Health Reform Law and Policy Project: A Framework for Comparative Analysis of Legislative Proposals and their Implications for Cancer Prevention, Detection, Treatment, and Survivorship

Cancer, Cancer Treatment, and Health Insurance

In 2008, cancer claimed over 566,000 lives. Cancer accounts for 1 of every 4 deaths in the US and remains the second leading cause of death in the US, surpassed only by heart disease.¹ There are currently over 11 million Americans alive who have been diagnosed with cancer at some point in their lives. This includes the estimated 1.4 million new cases of cancer diagnosed in 2008 alone, as well as the millions of Americans who have been successfully treated for cancer and require ongoing care.

Cancer care can best be understood as a series of interventions that exist along a comprehensive spectrum of care.² The continuum of care begins with efforts to prevent cancer and to detect cancer in its earliest stages when it occurs. Strategies to promote healthy lifestyles-to help people stop smoking, maintain healthy weights, exercise regularly and to get recommended cancer screenings-reduce the incidence of avoidable cancer and cancer deaths.³ Once an abnormal cancer screening test is obtained, the next phase in care involves expedient and appropriate follow-up to confirm a cancer diagnosis and classify the extent of disease through procedures such as biopsy and staging. Diagnostic studies are used by care providers to provide prognostic information and formulate a treatment plan.

Cancer treatment often involves surgery, chemotherapy, or radiation therapy, which are delivered through basic physician services, prescription drugs, and hospital-based care. Advances in cancer treatment such as bone marrow and stem cell transplants, immunotherapy, and targeted therapy, have also emerged and continue to be developed. Additionally, as various groups work to paint a clearer picture of what high-quality cancer care looks like-care that is well-coordinated, patient-centered and evidence-based-the elements of cancer care have expanded. Quality cancer care can also be understood to include access to multidisciplinary teams with social workers, patient navigators, and other mental health and psychosocial support systems; access to high-volume cancer centers of excellence and cancer specialists; access to clinical trials and innovative, effective therapies; use of electronic medical records and health information technology to facilitate coordinated care; documented cancer care plans; and culturally and linguistically sensitive care.⁴

Cancer survivorship is now understood as a distinct phase in the cancer continuum. Survivorship care includes prevention of recurrent and new cancers, appropriate surveillance for cancer recurrence, efforts to address the after-effects of cancer and its treatment and ongoing care coordination.⁵ For individuals who ultimately face a losing battle with cancer, high quality end-of-life care becomes essential and may encompass ongoing curative efforts, palliative care, meeting psychosocial needs, and hospice involvement.

At every stage, the accessibility, affordability and quality of health insurance coverage is crucial. Indeed, numerous studies show that uninsured patients are more likely to present with advanced-stage cancers than those with insurance and are more likely to die from their cancer.^{6 , 7 , 8 , 9} We also know that the presence of health insurance coverage alone is not enough; health care accessibility, affordability and quality are equally crucial, particularly where the patients are members of population groups that have experienced historic disadvantage within the health care system.^{10 , 11} To be sure, the presence of insurance coverage alone is the single most dominant factor in influencing health care access and affordability, but it is by no means the only factor. How insurance interacts with health care - and how the health care system interacts with patients - matter deeply. Indeed, numerous studies show significant disparities in cancer treatment and outcome, even among comparably insured patients.^{12 , 13 , 14 , 15}

Since 1971, when the "War on Cancer" was launched, the nation has witnessed a vast investment of treatment and research resources and a concomitant improvement in cancer survival rates, attributable by experts to earlier diagnosis and more effective treatments. However, looming challenges still exist. Despite the medical advances, research has shown that individuals with cancer are still not receiving the basic care that has been shown to be effective. For example, more than 20 years ago, experts agreed that certain women with early-stage breast cancer could be successfully treated through a combination of breast-conserving surgery with radiation therapy.¹⁶ However, recent studies show that up to one-third of women who should have received radiotherapy after surgery did not, and that these women were twice as likely to die from breast cancer than those who had received radiation.^{17 , 18 , 19} Similarly, for patients with colorectal cancer, standard adjuvant chemotherapy regimens have been shown to improve survival.²⁰ Although more patients are now receiving standard therapy, recent studies show that up to one-half of eligible patients still do not receive chemotherapy.²¹

Furthermore, significant disparities in cancer screening, treatment and survival persist, and efforts at primary prevention remain weak.²² Health care professionals who specialize in treatment of medically underserved populations, even when insured, report major access barriers and severe problems in assuring specialty referrals.^{23 , 24} The high cost, inefficiency, and inadequacies within the delivery system, tolerated and even exacerbated by insurance coverage and payment practices, unquestioningly hinder proper care. For example, despite evidence of effectiveness, most insurers do not pay for treatment navigation and may not cover all necessary survivorship care.^{25 , 26 , 27}