The Challenges That Lie Ahead

Raoul Concepcion, MD

Editor-in-Chief of

Urologists in Cancer Care

Director of Clinical Research Urologic Surgeon Urology Associates, PC Nashville, TN

As many of us are keenly aware, the coming 12 months present some very challenging times in the medical community. Having just returned from the 4th Annual Meeting of the Large Urology Group Practice Association (LUGPA), the issues that confront our specialty, and society, were made painfully clear to all who were in attendance.

Economically, we are moving quickly toward the fiscal cliff that Federal Reserve System Chairman Ben S. Bernanke warned of earlier this year. Due to pending legislative events expected to hit in January, there will be a projected 50% reduction in the 2013 budget deficit (from $1.2 trillion to $560 billion) and potential flattening of the debt curve for the next decade. Many economists predict that this may result in a short-term recession, slowing of economic recovery, and more than likely an increased tax burden for all Americans.

Even more sobering is our current national debt–running around $17 trillion as I type and increasing with every key stroke. The first keynote speaker at the LUGPA meeting, Robert Laszewski, president of Health Policy and Strategy Associates, Inc, in Alexandria, Virginia, noted that although entitlement spending is the major driver of our runaway deficit, the Medicare program has the pole position. If Medicare continues to go unchecked without significant payment reform, it will for all intents and purposes consume our resources and bankrupt the country in the years to come. As a result, alternative methodologies to pay providers will be developed, and the likely intent of those methodologies will be to pay all of us less. Not redistribute, not keep things even–less.

My good friend and colleague, Neil D. Shore, MD, of Carolina Urologic Research Center in Myrtle Beach, South Carolina, moderated a program at the LUGPA meeting on advances in the management of patients with castration-resistant prostate cancer (CRPC). The session provided a comprehensive overview of the advances and complexities that currently confront the practicing urologist. The good news for our patients is that there are many new therapies already available, and more on the horizon, that provide hope and the potential for long-term survival. However, there are no existing data on sequencing or combinatorial therapy.

One of the problems with obtaining these data is that in most trials, the FDA still requires a primary endpoint of overall survival. This hampers our ability to gather data quickly, since such trials take years to complete.

Another difficulty that we all face is the rising cost of oncologic care. While the drug component is the fastest-rising element within that sector, it does not actually represent the largest cost to the healthcare system. With all of our medical advances, we now simply have more cancer patients to manage. And with every patient comes the associated costs of therapy, including monitoring (lab, advanced imaging, etc), procedures, office visits, and hospitalizations. The challenge, given the economic landscape, is how to pay for these new therapies that clearly have a survival advantage and better side-effect profile, but individually carry a high price tag. Patients and their doctors face a difficult conundrum, given the economic downturn and loss of personal and corporate income versus trying to obtain/deliver quality care.

As physicians, we take the Hippocratic Oath on completion of our medical school training to always try to do what is best for our patients and do no harm. It is a lifetime plan that we try to formulate for those who come to us for help and medical expertise. Given the many obstacles in the way of providing quality care for cancer patients, it is disappointing to me that many of our leaders in government–in either party–seem to only have a two-, four-, or six-year commitment and will do whatever it takes to get them to the next election. They may win elections, but their constituents, patients, and our country end up losing by this short-sighted strategy.