- Email: [email protected]
Reproducing our species and finding solutions
Comment
3
4
5
6
Canellos GP, Anderson JR, Propert KJ, et al. Chemotherapy of advanced Hodgkin’s disease with MOPP, ABVD, or MOPP alternating with ABVD. N Engl J Med 1992; 327: 1478–84. Moccia AA, Donaldson J, Chhanabhai M, et al. International Prognostic Score in advanced-stage Hodgkin’s lymphoma: altered utility in the modern era. J Clin Oncol 2012; 30: 3383–88. Viviani S, Zinzani PL, Rambaldi A, et al. ABVD versus BEACOPP for Hodgkin’s lymphoma when high-dose salvage is planned. N Engl J Med 2011; 365: 203–12. Gallamini A, Hutchings M, Rigacci L, et al. Early interim 2-[¹⁸F]fluoro-2deoxy-D-glucose positron emission tomography is prognostically superior to international prognostic score in advanced-stage Hodgkin’s lymphoma: a report from a joint Italian-Danish study. J Clin Oncol 2007; 25: 3746–52.
7
8
9
Diehl V, Franklin J, Pfreundschuh M, et al. Standard and increased-dose BEACOPP chemotherapy compared with COPP-ABVD for advanced Hodgkin’s disease. N Engl J Med 2003; 348: 2386–95. Skoetz N, Trelle S, Rancea M, et al. Effect of initial treatment strategy on survival of patients with advanced-stage Hodgkin’s lymphoma: a systematic review and network meta-analysis. Lancet Oncol 2013; 14: 943–52. Engert A, Haverkamp H, Kobe C, et al. Reduced-intensity chemotherapy and PET-guided radiotherapy in patients with advanced stage Hodgkin’s lymphoma (HD15 trial): a randomised, open-label, phase 3 non-inferiority trial. Lancet 2012; 379: 1791–99.
Reproducing our species and finding solutions This is the third of three Comments on existential problems of radiation oncology
1256
This third and final Comment in a series on the existential questions facing radiation oncology explores the ability of radiation oncologists to reproduce themselves at a sufficient rate to preserve the specialty and then considers potential solutions to the problems posed in all three Comments. Graduate medical education is based on the principle that the trainee will achieve competency in a series of skills over a defined period under the supervision of qualified mentors. In most countries, this process is supervised by a designated accreditation agency. In the USA, for example, the Accreditation Council on Graduate Medical Education (ACGME) is responsible for accreditation through a peer-review process based on standards and guidelines. The most acute graduate medical education problem in the training of radiation oncologists is the ability of training programmes to generate sufficient cases for trainees to treat to become competent in paediatric radiation oncology and brachytherapy. Paediatric radiation oncology is the best example of the shortcomings of the training and accreditation process. In the USA, the ACGME standards require that in 4 years a trainee “must treat at least 12 pediatric patients of whom a minimum of nine have solid tumors” with the considerable leeway that “in certain circumstances, the procedures in radiation therapy and patient availabilities justify counting a patient twice for purposes of resident logs”.1 For example, one resident might count a patient with medulloblastoma as a teaching case when simulating craniospinal irradiation, whereas a second resident might count the same case when simulating the boost field to the primary tumour. In a 4-year residency programme, this means that a
trainee must see 12 cases every 4 years or an average of three cases per year of training. There are about 74 million children in the USA and about 12 000 new cases of childhood cancer per year. With the best available data for the indications for radiation therapy, this translates to about 3000 (new or retreatment) cases per year. With 647 radiation oncology residents on duty each year in the USA and 87 radiation oncology residency programmes, and assuming that all patients go to academic centres with residencies, no patients are treated in private practices, all patients are considered teaching cases, and the geographic and referral patterns are uniform (all very big assumptions), this means the average resident will see 4·6 paediatric radiation therapy cases per year.2 Because about a third of paediatric radiation therapy involves the treatment of CNS tumours, a fifth the treatment of sarcomas, a tenth leukaemia, and a tenth lymphoma, this means that in the course of a 4-year residency, the ACGME would consider a trainee competent if he or she had seen and treated four paediatric CNS tumours, two sarcomas, one leukaemia, one lymphoma, and four miscellaneous cases. Would any reasonable person consider someone competent to treat adult breast cancer, or any other cancer, if they had seen only one case in a 4-year residency? Yet the USA has a system which deems someone competent if they have seen, over a 4-year period, one case each of Wilms’ tumour, neuroblastoma, rhabdomysoarcoma, medulloblastoma, and brain-stem glioma. Similar calculations can be done for brachytherapy to show an equivalent problem. Radiation oncologists need to give careful thought to the problem of graduate medical education productivity. In some work settings, productivity does not change www.thelancet.com/oncology Vol 14 December 2013
Comment
with time. In 1970, for example, a half-hour musical performance by a quartet required the expenditure of 2 man-hours. In 2014, the performance of the same music by a quartet would also call for the expenditure of 2 man-hours. Any attempts to increase productivity in this situation would be viewed with concern by critics and audiences alike.3 In most other sectors, however, labour-saving productivity growth occurs rapidly when one uses productivity enhancing automation. In 1970, we required separate (and bulky) devices for word processing, mathematical calculations, listening to music, and communication. Now, all these functions can be done with a single small wireless device that we carry in our pockets. In graduate medical education, however, little has changed. In 1970, lecturers spoke from a dias to an audience taking notes. Now, although there have been relatively minor transitions from latern slides to overhead projectors to PowerPoint slides, education is still fundamentally done by lecturing from a dias to students. Indeed, Hippocrates, Galen, and William Harvey would be perfectly comfortable teaching in today’s classes as long as one told them to speak into the microphone rather than raise their voice over the din of Kos, Rome, or London. New graduate medical education models are desperately needed. What are some practical solutions to the problems raised in these Comments? First, we must establish a standard of what is considered sufficiently disruptive and a novel innovation in radiation oncology to warrant the highest standards of clinical evidence. I believe that a four-fold test is appropriate. An innovation should be deemed an indication for randomised clinical trials where: (1) the therapy is sufficiently novel that retraining or recredentialing of physicians or physicists is needed; (2) where the risk of benefit could be matched or off-set by a potential risk of harm; (3) where the innovation introduces new and unpredictable biology; and (4) when the price of innovation is so high to the health system that major opportunity costs are engendered.4 Unfortunately, the track record of radiation oncology in responding to high level evidence is poor. Globally, radiation oncologists have shown reluctance to practice evidence-based single fraction radiotherapy in the treatment of uncomplicated painful bone metastasis or to avoid radiotherapy in older women with low risk of breast cancer.5,6 We might be better off if we implemented what we already know works rather than www.thelancet.com/oncology Vol 14 December 2013
chasing something yet unknown. For a large part of medical practice we do not know what works, but we pay for it anyway.7 One of the best innovations we can hope for is a reliable low-cost radiotherapy unit for the less developed world. Would we not all be better off if we spent more time talking about, and striving to solve, the problem of the complete absence of radiation therapy services in economically low-income countries than of protons for high-income countries? There will be some who respond that “nobody needed a randomised trial of simulation versus non-simulation or cobalt 60 versus linear accelerators”. This, however, represents selective historical memory. There is a big difference between debating the difference between a few hundred thousand dollars or euros (use of a simulator vs not) and a few hundred million dollars or euros (treating with photons vs protons). Furthermore, there have been many so-called innovative technologies introduced into clinical practice and then discarded after substantial patient harm and unnecessary cost (eg, thermo-mammography, 111In-indium capromab pendetide, coronary artery brachytherapy, autologous bone marrow transplantation for adult breast cancer). What should we be studying? I think a reasonable agenda would be as follows. First, we should follow the guidelines of the research agenda of the Radiation Oncology Institute.8 We should study radiation quality and safety. Recent highly publicised scandals show that we, as a specialty, could benefit by increasing the chance we actually hit the tumour by use of a properly calibrated beam.9 We should also study the outcomes of currently available competing radiation therapy methods because new and expensive radiation therapy technologies have been introduced without evidence showing incremental benefits compared with alternatives. Second, the debate on innovation and expensive technology in radiation oncology would not be a serious debate were it not, at its heart, about price. Regarding proton therapy, I believe that proton therapy should be reimbursed at the same rate as photon therapy. The profit incentive should be taken out of the equation. For those who complain that this is interfering with the free marketplace, one can respond that we already interfere in the free marketplace regarding the price of tobacco, milk, racehorses, agricultural subsidies, weapons manufacture, and vaccines. Third, we should 1257
Comment
study whether it is possible to move patients to existing facilities, rather than building more. It makes more sense to move the patient to machine than the machine to the patient. I am always surprised by the complaint of health-care systems, that they cannot transport patients where they need to go, but there is no place in the world where you cannot get a cold beer or carbonated drink. Do we value the transport of beer or soft drinks more than sick people? Fourth, one could simply wait. When I was a college student, a pocket calculator that did addition and subtraction cost US$500. The odds are high that, with time, the pricing bubble for particle therapy will collapse. Finally, the problem of graduate medical education could be solved, at least partly, with technology. We should strive to supplement clinical instruction and textbooks with online courses. One should also consider cross-border residency education. Cancer in children and adolescents accounts for 1·4% of all cancers worldwide, but 4·8% of cancer in Africa— mainly because of differences in age composition and life expectancy. 94% of all deaths from cancer in people aged up to 14 years are in countries of low and middle income.10 Because most of the paediatric cancer burden is in low and middle income countries, these are the best locations to train residents in paediatric radiation oncology. However, the more we, as a specialty, promote the use of more complex radiation therapy machines, the more we will restrict the access of middle and low income countries to any form of external-beam
radiation therapy. Equipment manufacturers will have no incentive to engineer, manufacture, and sell simple low-cost machines. All radiation oncologists have a part to play in solving the existential problems facing the specialty, no matter who or what caused these problems. As AJ Heschel taught, few are guilty, but all are responsible. Edward C Halperin New York Medical College, Valhalla, NY 10595, USA [email protected] I declare that I have no conflicts of interest. 1
2 3 4 5
6 7 8
9 10
Accreditation Council For Graduate Medical Education. Program requirements for graduate medical education in radiation oncology, 2009. http://www.acgme.org/acgmeweb/Portals/0/PFAssets/ ProgramRequirements/140_EIP_PR205.pdf (accessed Nov 5, 2013). Brotherton SE, Etzel SI. Graduate medical education, 2011–2012. JAMA 2012; 308: 2264–79. Baumol WJ, Bowen WG. On the performing arts: the anatomy of their economic problems. Am Econ Rev 1965; 55: 495–502. Retlig RA, Jacobson PD, Farguhar CM, Aubry WM. False hope: bone marrow transplantation for breast cancer. Oxford: Oxford University Press, 2007. Chow E, Hahn CA, Lutz ST. Global reluctance to practice evidence-based medicine continues in the treatment of uncomplicated, painful bone metostaces despite level 1 evidence and practice guidelines. Int J Rad Oncol Biol Phys 2012; 83: 01–02. Giordano SH. Radiotherapy in older women with low-risk breast cancer: why did practice not change? J Clin Oncol 2012; 30: 1577–78. Welch HG. Testing what we think we know. New York Times (NY). Aug 19, 2012: A19. Bekelman JR, Brawley OW, Densy Jo, et al. A research agenda for radiation oncology: results of the radiation oncology institute’s comprehensive research needs assessment. Int J Rad Oncol Biol Phys 2012; 84: 318–22. Bogdanich W. The radiation boom: Radiation offers new cures, and ways to do harm. New York Times (NY). Jan 23, 2010. Magrath I, Steliarova-Foucher E, Epelman S, et al. Paediatric cancer in low-income and middle-income countries. Lancet Oncol 2013; 14: 104–16.
Should oncologists support the Affordable Care Act?
B Boissonnet/Bsip/Science Photo Library
The Affordable Care Act (ACA) or ObamaCare is today the law of the land in the USA. However, attempts continue to reverse, defund, or slow down its implementation based on ideological convictions. Most Americans do not know what it provides, so clarification of its simple premises would be helpful. Some benefits of the ACA are: first, 30 million of the 50 million uninsured US citizens will gain insurance coverage; second, children can remain on their parents’ insurance, if they wish, up to the age of 26 years; third, insurance companies cannot deny coverage for pre-existing medical disorders, or cancel insurance if someone gets sick, they also cannot cap the amount of care received in a patient’s lifetime, or deny coverage 1258
on clinical trials; fourth, the cost of care is reduced and money is saved on medications for senior citizens on Medicare (gradual closing of the part D coverage gap, known as the donut hole, which forces patients to pay for out-of-pocket drug costs after a certain financial threshold is reached); fifth, insurance companies must spend 80–85% of collected insurance funds on health care (this value was as low as 50–60%).1 The ACA offers comprehensive coverage for private health care, increases choice of cover, does not create a single-payer system, and does not reduce quality of care. It does not force individuals to change insurance, as long as the policy complies with the ACA requirements to include basic benefits and to exclude exorbitant www.thelancet.com/oncology Vol 14 December 2013
3
4
5
6
Canellos GP, Anderson JR, Propert KJ, et al. Chemotherapy of advanced Hodgkin’s disease with MOPP, ABVD, or MOPP alternating with ABVD. N Engl J Med 1992; 327: 1478–84. Moccia AA, Donaldson J, Chhanabhai M, et al. International Prognostic Score in advanced-stage Hodgkin’s lymphoma: altered utility in the modern era. J Clin Oncol 2012; 30: 3383–88. Viviani S, Zinzani PL, Rambaldi A, et al. ABVD versus BEACOPP for Hodgkin’s lymphoma when high-dose salvage is planned. N Engl J Med 2011; 365: 203–12. Gallamini A, Hutchings M, Rigacci L, et al. Early interim 2-[¹⁸F]fluoro-2deoxy-D-glucose positron emission tomography is prognostically superior to international prognostic score in advanced-stage Hodgkin’s lymphoma: a report from a joint Italian-Danish study. J Clin Oncol 2007; 25: 3746–52.
7
8
9
Diehl V, Franklin J, Pfreundschuh M, et al. Standard and increased-dose BEACOPP chemotherapy compared with COPP-ABVD for advanced Hodgkin’s disease. N Engl J Med 2003; 348: 2386–95. Skoetz N, Trelle S, Rancea M, et al. Effect of initial treatment strategy on survival of patients with advanced-stage Hodgkin’s lymphoma: a systematic review and network meta-analysis. Lancet Oncol 2013; 14: 943–52. Engert A, Haverkamp H, Kobe C, et al. Reduced-intensity chemotherapy and PET-guided radiotherapy in patients with advanced stage Hodgkin’s lymphoma (HD15 trial): a randomised, open-label, phase 3 non-inferiority trial. Lancet 2012; 379: 1791–99.
Reproducing our species and finding solutions This is the third of three Comments on existential problems of radiation oncology
1256
This third and final Comment in a series on the existential questions facing radiation oncology explores the ability of radiation oncologists to reproduce themselves at a sufficient rate to preserve the specialty and then considers potential solutions to the problems posed in all three Comments. Graduate medical education is based on the principle that the trainee will achieve competency in a series of skills over a defined period under the supervision of qualified mentors. In most countries, this process is supervised by a designated accreditation agency. In the USA, for example, the Accreditation Council on Graduate Medical Education (ACGME) is responsible for accreditation through a peer-review process based on standards and guidelines. The most acute graduate medical education problem in the training of radiation oncologists is the ability of training programmes to generate sufficient cases for trainees to treat to become competent in paediatric radiation oncology and brachytherapy. Paediatric radiation oncology is the best example of the shortcomings of the training and accreditation process. In the USA, the ACGME standards require that in 4 years a trainee “must treat at least 12 pediatric patients of whom a minimum of nine have solid tumors” with the considerable leeway that “in certain circumstances, the procedures in radiation therapy and patient availabilities justify counting a patient twice for purposes of resident logs”.1 For example, one resident might count a patient with medulloblastoma as a teaching case when simulating craniospinal irradiation, whereas a second resident might count the same case when simulating the boost field to the primary tumour. In a 4-year residency programme, this means that a
trainee must see 12 cases every 4 years or an average of three cases per year of training. There are about 74 million children in the USA and about 12 000 new cases of childhood cancer per year. With the best available data for the indications for radiation therapy, this translates to about 3000 (new or retreatment) cases per year. With 647 radiation oncology residents on duty each year in the USA and 87 radiation oncology residency programmes, and assuming that all patients go to academic centres with residencies, no patients are treated in private practices, all patients are considered teaching cases, and the geographic and referral patterns are uniform (all very big assumptions), this means the average resident will see 4·6 paediatric radiation therapy cases per year.2 Because about a third of paediatric radiation therapy involves the treatment of CNS tumours, a fifth the treatment of sarcomas, a tenth leukaemia, and a tenth lymphoma, this means that in the course of a 4-year residency, the ACGME would consider a trainee competent if he or she had seen and treated four paediatric CNS tumours, two sarcomas, one leukaemia, one lymphoma, and four miscellaneous cases. Would any reasonable person consider someone competent to treat adult breast cancer, or any other cancer, if they had seen only one case in a 4-year residency? Yet the USA has a system which deems someone competent if they have seen, over a 4-year period, one case each of Wilms’ tumour, neuroblastoma, rhabdomysoarcoma, medulloblastoma, and brain-stem glioma. Similar calculations can be done for brachytherapy to show an equivalent problem. Radiation oncologists need to give careful thought to the problem of graduate medical education productivity. In some work settings, productivity does not change www.thelancet.com/oncology Vol 14 December 2013
Comment
with time. In 1970, for example, a half-hour musical performance by a quartet required the expenditure of 2 man-hours. In 2014, the performance of the same music by a quartet would also call for the expenditure of 2 man-hours. Any attempts to increase productivity in this situation would be viewed with concern by critics and audiences alike.3 In most other sectors, however, labour-saving productivity growth occurs rapidly when one uses productivity enhancing automation. In 1970, we required separate (and bulky) devices for word processing, mathematical calculations, listening to music, and communication. Now, all these functions can be done with a single small wireless device that we carry in our pockets. In graduate medical education, however, little has changed. In 1970, lecturers spoke from a dias to an audience taking notes. Now, although there have been relatively minor transitions from latern slides to overhead projectors to PowerPoint slides, education is still fundamentally done by lecturing from a dias to students. Indeed, Hippocrates, Galen, and William Harvey would be perfectly comfortable teaching in today’s classes as long as one told them to speak into the microphone rather than raise their voice over the din of Kos, Rome, or London. New graduate medical education models are desperately needed. What are some practical solutions to the problems raised in these Comments? First, we must establish a standard of what is considered sufficiently disruptive and a novel innovation in radiation oncology to warrant the highest standards of clinical evidence. I believe that a four-fold test is appropriate. An innovation should be deemed an indication for randomised clinical trials where: (1) the therapy is sufficiently novel that retraining or recredentialing of physicians or physicists is needed; (2) where the risk of benefit could be matched or off-set by a potential risk of harm; (3) where the innovation introduces new and unpredictable biology; and (4) when the price of innovation is so high to the health system that major opportunity costs are engendered.4 Unfortunately, the track record of radiation oncology in responding to high level evidence is poor. Globally, radiation oncologists have shown reluctance to practice evidence-based single fraction radiotherapy in the treatment of uncomplicated painful bone metastasis or to avoid radiotherapy in older women with low risk of breast cancer.5,6 We might be better off if we implemented what we already know works rather than www.thelancet.com/oncology Vol 14 December 2013
chasing something yet unknown. For a large part of medical practice we do not know what works, but we pay for it anyway.7 One of the best innovations we can hope for is a reliable low-cost radiotherapy unit for the less developed world. Would we not all be better off if we spent more time talking about, and striving to solve, the problem of the complete absence of radiation therapy services in economically low-income countries than of protons for high-income countries? There will be some who respond that “nobody needed a randomised trial of simulation versus non-simulation or cobalt 60 versus linear accelerators”. This, however, represents selective historical memory. There is a big difference between debating the difference between a few hundred thousand dollars or euros (use of a simulator vs not) and a few hundred million dollars or euros (treating with photons vs protons). Furthermore, there have been many so-called innovative technologies introduced into clinical practice and then discarded after substantial patient harm and unnecessary cost (eg, thermo-mammography, 111In-indium capromab pendetide, coronary artery brachytherapy, autologous bone marrow transplantation for adult breast cancer). What should we be studying? I think a reasonable agenda would be as follows. First, we should follow the guidelines of the research agenda of the Radiation Oncology Institute.8 We should study radiation quality and safety. Recent highly publicised scandals show that we, as a specialty, could benefit by increasing the chance we actually hit the tumour by use of a properly calibrated beam.9 We should also study the outcomes of currently available competing radiation therapy methods because new and expensive radiation therapy technologies have been introduced without evidence showing incremental benefits compared with alternatives. Second, the debate on innovation and expensive technology in radiation oncology would not be a serious debate were it not, at its heart, about price. Regarding proton therapy, I believe that proton therapy should be reimbursed at the same rate as photon therapy. The profit incentive should be taken out of the equation. For those who complain that this is interfering with the free marketplace, one can respond that we already interfere in the free marketplace regarding the price of tobacco, milk, racehorses, agricultural subsidies, weapons manufacture, and vaccines. Third, we should 1257
Comment
study whether it is possible to move patients to existing facilities, rather than building more. It makes more sense to move the patient to machine than the machine to the patient. I am always surprised by the complaint of health-care systems, that they cannot transport patients where they need to go, but there is no place in the world where you cannot get a cold beer or carbonated drink. Do we value the transport of beer or soft drinks more than sick people? Fourth, one could simply wait. When I was a college student, a pocket calculator that did addition and subtraction cost US$500. The odds are high that, with time, the pricing bubble for particle therapy will collapse. Finally, the problem of graduate medical education could be solved, at least partly, with technology. We should strive to supplement clinical instruction and textbooks with online courses. One should also consider cross-border residency education. Cancer in children and adolescents accounts for 1·4% of all cancers worldwide, but 4·8% of cancer in Africa— mainly because of differences in age composition and life expectancy. 94% of all deaths from cancer in people aged up to 14 years are in countries of low and middle income.10 Because most of the paediatric cancer burden is in low and middle income countries, these are the best locations to train residents in paediatric radiation oncology. However, the more we, as a specialty, promote the use of more complex radiation therapy machines, the more we will restrict the access of middle and low income countries to any form of external-beam
radiation therapy. Equipment manufacturers will have no incentive to engineer, manufacture, and sell simple low-cost machines. All radiation oncologists have a part to play in solving the existential problems facing the specialty, no matter who or what caused these problems. As AJ Heschel taught, few are guilty, but all are responsible. Edward C Halperin New York Medical College, Valhalla, NY 10595, USA [email protected] I declare that I have no conflicts of interest. 1
2 3 4 5
6 7 8
9 10
Accreditation Council For Graduate Medical Education. Program requirements for graduate medical education in radiation oncology, 2009. http://www.acgme.org/acgmeweb/Portals/0/PFAssets/ ProgramRequirements/140_EIP_PR205.pdf (accessed Nov 5, 2013). Brotherton SE, Etzel SI. Graduate medical education, 2011–2012. JAMA 2012; 308: 2264–79. Baumol WJ, Bowen WG. On the performing arts: the anatomy of their economic problems. Am Econ Rev 1965; 55: 495–502. Retlig RA, Jacobson PD, Farguhar CM, Aubry WM. False hope: bone marrow transplantation for breast cancer. Oxford: Oxford University Press, 2007. Chow E, Hahn CA, Lutz ST. Global reluctance to practice evidence-based medicine continues in the treatment of uncomplicated, painful bone metostaces despite level 1 evidence and practice guidelines. Int J Rad Oncol Biol Phys 2012; 83: 01–02. Giordano SH. Radiotherapy in older women with low-risk breast cancer: why did practice not change? J Clin Oncol 2012; 30: 1577–78. Welch HG. Testing what we think we know. New York Times (NY). Aug 19, 2012: A19. Bekelman JR, Brawley OW, Densy Jo, et al. A research agenda for radiation oncology: results of the radiation oncology institute’s comprehensive research needs assessment. Int J Rad Oncol Biol Phys 2012; 84: 318–22. Bogdanich W. The radiation boom: Radiation offers new cures, and ways to do harm. New York Times (NY). Jan 23, 2010. Magrath I, Steliarova-Foucher E, Epelman S, et al. Paediatric cancer in low-income and middle-income countries. Lancet Oncol 2013; 14: 104–16.
Should oncologists support the Affordable Care Act?
B Boissonnet/Bsip/Science Photo Library
The Affordable Care Act (ACA) or ObamaCare is today the law of the land in the USA. However, attempts continue to reverse, defund, or slow down its implementation based on ideological convictions. Most Americans do not know what it provides, so clarification of its simple premises would be helpful. Some benefits of the ACA are: first, 30 million of the 50 million uninsured US citizens will gain insurance coverage; second, children can remain on their parents’ insurance, if they wish, up to the age of 26 years; third, insurance companies cannot deny coverage for pre-existing medical disorders, or cancel insurance if someone gets sick, they also cannot cap the amount of care received in a patient’s lifetime, or deny coverage 1258
on clinical trials; fourth, the cost of care is reduced and money is saved on medications for senior citizens on Medicare (gradual closing of the part D coverage gap, known as the donut hole, which forces patients to pay for out-of-pocket drug costs after a certain financial threshold is reached); fifth, insurance companies must spend 80–85% of collected insurance funds on health care (this value was as low as 50–60%).1 The ACA offers comprehensive coverage for private health care, increases choice of cover, does not create a single-payer system, and does not reduce quality of care. It does not force individuals to change insurance, as long as the policy complies with the ACA requirements to include basic benefits and to exclude exorbitant www.thelancet.com/oncology Vol 14 December 2013