A great deal is known about who gets cancer and who dies from it, but little data exist on the quality and cost of cancer care in California. This CHCF Almanac report looks at what we know in our state.
More than one million Californians alive today have been diagnosed with some form of cancer, even though the statewide rates of new cancers and deaths have declined over the last two decades, according to a report from the California HealthCare Foundation.
The most recent data available show California has lower rates of new cancer diagnoses and deaths than the United States average, with the diagnosis rate dropping 9% and deaths falling 22% over the last 20 years, according to the report, One Million Lives: Cancer in California.
In the same time period, California's rate of childhood cancer deaths fell almost 22% and death rates associated with breast, prostate, colorectal, and lung cancers for all ages each declined by 30% or more.
These positive trends are tempered by striking disparities in cancer diagnosis and death rates among minority Californians, with African Americans dying at the highest rate from all types of cancers. While Whites had the highest rate of new breast cancers (140 cases per 100,000 people versus 126 for African Americans), African Americans had the highest mortality rate (34 cases per 100,000 people versus 24 for Whites).
The report cites significant gaps in the data that are available to researchers, noting that information on quality and cost of cancer care is not currently collected.
"This report reveals many useful facts about cancer in our state, among them prevalence, mortality, and the unacceptable disparities in diagnosis and outcomes, especially in our African American communities," said Mark D. Smith, MD, MBA, president and CEO of the California HealthCare Foundation.
"But the gaps in available information make it challenging to get an accurate picture of the quality of the care we are providing," said Smith. "Are we delivering care as effectively as we could be? Are providers communicating with patients about their treatment plans in ways they can understand? Bottom line: Are we making a difference in the lives of cancer patients?"
Other key findings from the report are:
- In 2009, breast and prostate cancer together accounted for nearly half of all cancers in California.
- Mortality rates in California for African Americans were 30% to 90% higher than in other groups for all cancers, and two to six times higher for prostate cancer in 2009.
- Over the last 12 years, the majority of national spending on cancer care has shifted from hospital inpatient stays (64% in 1997) to outpatient and office-based care (58% in 2009).
- In 2010, the five most expensive cancers represented over half of all cancer spending nationally.
- In California in 2008, private insurance and Medicare were the two largest payers for cancer care, each accounting for 40% of all spending.
- In 2007, cancer patients in California were more likely to be admitted to the hospital or ICU in the last month of life than were patients across the US.
- Despite the recognized desire of most patients to die at home, one-third of Medicare cancer patients in California with a poor prognosis died in a hospital in 2007. California also used hospice less than many other states for cancer patients at the end of life.
Progress in Prevention and Treatment
In general, greater progress has been made in reducing cancer death rates than in decreasing the number of newly diagnosed cancers. Notable exceptions are lung and colorectal cancers for which new diagnoses have declined dramatically since 1989 (falling 30% and 28% respectfully) — the likely result of California's efforts to reduce smoking and increase screening for colorectal cancer.
The report also found wide variation in incidence and mortality rates across California regions. Los Angeles County, the most populous county in the state, had a relatively low rate of new cancer diagnoses while many of the state's rural northern counties had relatively high cancer incidence and mortality rates.
Treatment Moves from Hospital to Clinic
Between 1997 and 2009, national expenses for cancer treatment showed a shift from care being delivered during hospital inpatient stays to care being delivered during outpatient and office visits. Typically, costs are reduced when care is shifted to outpatient settings, yet cancer expenditures increased almost fivefold over the last two decades. One reason for the sharply increasing cost of cancer care is the rise in the use and cost of prescription medications, which today represents nearly one-fifth of all California cancer expenses.
Cost and Quality Data Lacking
The report describes the difficulties in tracking the quality of cancer care and the cost of treatment, noting that cancer treatment is spread across multiple providers and settings of care and may be paid for by multiple payers. "The good news is that advances in medicine are helping many cancer patients live better and longer lives," said Stephanie Teleki, PhD, senior program officer at CHCF.
"Still, in California we don't have easily accessible data sources that comprehensively track the details of care from initial diagnosis through all courses of treatment — a journey that represents significant use of health care services, considerable expense, and a wide variety of treatment approaches," said Teleki. "And we know little to nothing about cancer patients' experiences of care or how they view the outcome of their treatment."
Interviews are available upon request.
This report is published as part of the CHCF California Health Care Almanac, an online clearinghouse for key data and analysis examining California's health care marketplace. Find all Almanac reports at www.chcf.org/almanac.
About the California Health Care Foundation
CHCF is dedicated to advancing meaningful, measurable improvements in the way the health care delivery system provides care to the people of California, particularly those with low incomes and those whose needs are not well served by the status quo. We work to ensure that people have access to the care they need, when they need it, at a price they can afford.
CHCF informs policymakers and industry leaders, invests in ideas and innovations, and connects with changemakers to create a more responsive, patient-centered health care system.