Shift Happens: The Impact of Change on Health Care Delivery

1. Shift Happens: The Impact of Change on Health Care Delivery Len Lichtenfeld, MD, MACP Deputy Chief Medical Officer Impact Conference June 18, 2009

3. Total Number of Deaths Avoided from 1991-1992 to 2005

4. Cancer Remains a Formidable Challenge in 2009 • 1.48 million new cases • More than 1 million cases of non-melanoma skin cancer • 62,280 cases of in situ breast cancer and 53,120 cases of in situ melanoma • 562,340 deaths

6. Trends Affecting Cancer In 2020 Early detection technologies will offer an improved ability to predict risk and detect disease at the molecular level, and will result in the emergence of a “pre-cancer” survivor population

7. death No man’s land Risk/precancer *Cancer Neoplasia Clonal patches/field Microneoplasia *Cancer IEN microcancer Expanding size, subclones Microneoplasia Proliferation Apoptosis Genetic/epigenetic 3p, 9p, p16, p53 EGFR, K-ras, PI3K... Invasion/angiogenesis Metastases Molecular/cellular changes Convergence Molecular targeting Prevention Therapy Intervention The PreventionTherapy Convergence LESION, TUMOR Clinical symptoms* Clinical detection* Microscopic disease 0 10102 104 105 106 107 108 109 1010 1011 1012 (1 mm3/1 mg) (1 cm3/1 g)(1 l/1 kg) Number of cells (volume/mass) Lippman, Heymach

8. Trends Affecting Cancer In 2020 The survivor population will nearly double by 2020, driven by the aging of the baby-boomer population and improved cancer survival rates

9. Estimated Number of Cancer Survivors in the United States from 1971 to 2005 U.S. 2005 cancer prevalence counts are based on 2005 cancer prevalence proportions from the SEER 9 registries and 1/1/2005 U.S. population estimates based on the average of 2004 and 2005 population estimates from the U.S. Census Bureau. Source: Ries LAG, Melbert D, Krapcho M, Stinchcomb DG, Howlader N, Horner MJ, Mariotto A, Miller BA, Feuer EJ, Altekruse SF, Lewis DR, Clegg L, Eisner MP, Reichman M, Edwards BK (eds). SEER Cancer Statistics Review, 1975–2005, National Cancer Institute. Bethesda, MD, based on November 2007 SEER data submission, posted to the SEER Web site, 2008.

10. Previvor

11. 2006 From Cancer Patient to Cancer Survivor: Lost in Transition Maria Hewitt, Sheldon Greenfield, and Ellen Stovall, Editors, Committee on Cancer Survivorship: Improving Care and Quality of Life, Institute of Medicine and National Research Council

12. Essential Components of Survivorship Care Prevention of recurrent and new cancers, and of other late effects; Surveillance for cancer spread, recurrence, or second cancers; assessment of medical and psychosocial late effects; Intervention for consequences of cancer and its treatment, for example: medical problems such as lymphedema and sexual dysfunction; symptoms, including pain and fatigue; psychological distress experienced by cancer survivors and their caregivers; and concerns related to employment, insurance, and disability; and Coordination between specialists and primary care providers to ensure that all of the survivor’s health needs are met.

13. Trends Affecting Cancer In 2020 New delivery models will continue to proliferate (such as mini-clinics) amidst a shortage of oncologists, PCPs, and nurses, leading to further fragmentation of the delivery system

17. Health Care Reform

18. The Unknowns • Prevention • Regional Variation • Health Information Technology • Comparative Effectiveness