Hellen Gelband - Böcker

Increasingly over the past five years, uncertainty about reimbursement for routine patient care has been suspected as contributing to problems enrolling people in clinical trials. Clinical trial investigators cannot guarantee that Medicare will pay for the care required, and they must disclose this uncertainty to potential participants during the informed consent process. Since Medicare does not routinely "preauthorize" care (as do many commercial insurers) the uncertainty cannot be dispelled in advance. Thus, patients considering whether to enter trials must assume that they may have to pay bills that Medicare rejects simply because they have enrolled in the trial. This report recommends an explicit policy for reimbursement of routine patient care costs in clinical trials. It further recommends that HCFA provide additional support for selected clinical trials, and that the government support the establishment of a national clinical trials registry.These policies (1) should assure that beneficiaries would not be denied coverage merely because they have volunteered to participate in a clinical trial; and (2) would not impose excessive administrative burdens on HCFA, its fiscal intermediaries and carriers, or investigators, providers, or participants in clinical trials. Explicit rules would have the added benefit of increasing the uniformity of reimbursement decisions made by Medicare fiscal intermediaries and carriers in different parts of the country. Greater uniformity would, in turn, decrease the uncertainty about reimbursement when providers and patients embark on a clinical trial.

In our societya (TM)s aggressive pursuit of cures for cancer, we have neglected symptom control and comfort care. Less than one percent of the National Cancer Institutea (TM)s budget is spent on any aspect of palliative care research or education, despite the half million people who die of cancer each year and the larger number living with cancer and its symptoms. Improving Palliative Care for Cancer examines the barriersa "scientific, policy, and sociala "that keep those in need from getting good palliative care. It goes on to recommend public- and private-sector actions that would lead to the development of more effective palliative interventions; better information about currently used interventions; and greater knowledge about, and access to, palliative care for all those with cancer who would benefit from it.

It is innately human to comfort and provide care to those suffering from cancer, particularly those close to death. Yet what seems self-evident at an individual, personal level has, by and large, not guided policy at the level of institutions in this country. There is no argument that palliative care should be integrated into cancer care from diagnosis to death. But significant barriers-attitudinal, behavioral, economic, educational, and legal-still limit access to care for a large proportion of those dying from cancer, and in spite of tremendous scientific opportunities for medical progress against all the major symptoms associated with cancer and cancer death, public research institutions have not responded. In accepting a single-minded focus on research toward cure, we have inadvertently devalued the critical need to care for and support patients with advanced disease, and their families. This report builds on and takes forward an agenda set out by the 1997 IOM report Approaching Death: Improving Care at the End of Life, which came at a time when leaders in palliative care and related fields had already begun to air issues surrounding care of the dying.That report identified significant gaps in knowledge about care at the end of life and the need for serious attention from biomedical, social science, and health services researchers. Most importantly, it recognized that the impediments to good care could be identified and potentially remedied. The report itself catalyzed further public involvement in specific initiatives-mostly pilot and demonstration projects and programs funded by the nonprofit foundation community, which are now coming to fruition.

For more than 50 years, low-cost antimalarial drugs silently saved millions of lives and cured billions of debilitating infections. Today, however, these drugs no longer work against the deadliest form of malaria that exists throughout the world. Malaria deaths in sub-Saharan Africaa "currently just over one million per yeara "are rising because of increased resistance to the old, inexpensive drugs. Although effective new drugs called a /artemisininsa are available, they are unaffordable for the majority of the affected population, even at a cost of one dollar per course. Saving Lives, Buying Time: Economics of Malaria Drugs in an Age of Resistance examines the history of malaria treatments, provides an overview of the current drug crisis, and offers recommendations on maximizing access to and effectiveness of antimalarial drugs. The book finds that most people in endemic countries will not have access to currently effective combination treatments, which should include an artemisinin, without financing from the global community. Without funding for effective treatment, malaria mortality could double over the next 10 to 20 years and transmission will intensify.

The successes that have been achieved in treating childhood cancers stand as beacons against the less dramatic improvements for adults with cancer. Progress began to accelerate in the 1960s and 1970s, as treatment regimens were built up, primarily by building combinations of chemotherapeutic drugs. However the near absence of research in pediatric cancer drug discovery threatens to halt the progress in childhood cancer treatment achieved during the past four decades. Making Better Drugs for Children with Cancer identifies the major issues to be addressed in developing new agents for childhood cancers, the gaps in research and development, and the steps that have been suggested to move the process forward. This report also makes a new proposal to capitalize on today's science to bring new treatments to children's cancers.

Cancer is low or absent on the health agendas of low- and middle-income countries (LMCs) despite the fact that more people die from cancer in these countries than from AIDS and malaria combined. International health organizations, bilateral aid agencies, and major foundations—which are instrumental in setting health priorities—also have largely ignored cancer in these countries. This book identifies feasible, affordable steps for LMCs and their international partners to begin to reduce the cancer burden for current and future generations. Stemming the growth of cigarette smoking tops the list to prevent cancer and all the other major chronic diseases. Other priorities include infant vaccination against the hepatitis B virus to prevent liver cancers and vaccination to prevent cervical cancer. Developing and increasing capacity for cancer screening and treatment of highly curable cancers (including most childhood malignancies) can be accomplished using "resource-level appropriateness" as a guide. And there are ways to make inexpensive oral morphine available to ease the pain of the many who will still die from cancer.

Volume  3,  Cancer,  presents  the  complex  patterns  of  cancer  incidence  and death around the world and evidence on effective and cost-effective ways to control cancers. The DCP3 evaluation of cancer will indicate where cancer treatment  is  ineffective  and  wasteful,  and  offer  alternative  cancer  care packages that are cost-effective and suited to low-resource settings. Main messages from the volume include:Quality matters in all aspects of cancer treatment and palliation.Cancer registries that track incidence, mortality, and survival, paired with systems to capture causes of death are important to understanding the national cancer burden and the effect of interventions over  time.Effective  interventions  exist  at  a  range  of  prices.  Adopting “resource appropriate" measures which allow the most effective treatment for  the  greatest  number  of  people  will  be  advantageous to countries.Prioritizing resources toward early stage and curable cancers is likely to have the greatest health impact in low income settings.Research prioritization is no longer just a global responsibility.Providing cancer treatment requires adequate  numbers  of  trained healthcare  professionals  and  infrastructure beyond  what  is  available  in  most  LMICs,  especially  low  income  countries. Careful patient monitoring is a requirement of good quality cancer care and this often involves laboratory tests in addition to clinical examination. Even if financing were immediately available to build or expand a cancer control system, reaching capacity will take many years.