‘High-Volume Centers Better at Complex Cancer Treatments’

WASHINGTON—Cancer patients are better off seeking treatment at high-volume institutions when they require complicated cancer surgery or chemotherapy, according to a new report from the National Cancer Policy Board (NCPB). It listed pancreatic cancer surgery, removal of all or part of the esophagus, and removal of pelvic organs as examples of such procedures.

“We found compelling evidence that immediate survival rates are two to three times higher for patients undergoing complicated cancer surgery or chemotherapy in settings that perform many such procedures,” said NCPB vice chair Joseph Simone, MD, medical director of the Huntsman Cancer Foundation & Institute at the University of Utah. That, however, “doesn’t necessarily mean they would be getting inferior care outside high-volume centers,” he added.

Although estimates are imprecise, “a relatively large share of high-risk surgery is taking place in lower-volume settings,” the NCPB said. It cited as an example estimates that one-quarter to one-half of surgical procedures for pancreatic cancer take place in low-volume facilities.

The NCPB was formed 2 years ago as part of the National Academy of Sciences’ Institute of Medicine (IOM). The report, “Ensuring Quality Cancer Care,” released at a press conference, was paid for by the National Cancer Institute, Centers for Disease Control and Prevention, American Cancer Society, Amgen Inc., and Abbott Laboratories.

The board said cancer survival begins with diagnosis and recommended that decisions about initial cancer treatments be made by an experienced medical professional. “Frequently, one has a single chance at the very beginning of treatment to obtain a cure or an optimal result. If that chance is lost, it may not be possible to recover it,” Dr. Simone said.

Robert Young, MD, president of Fox Chase Cancer Center, said that the board sought to encourage cancer patients to enter into the treatment decision-making process armed with as much information as possible, and to ask detailed questions about their therapy.

An Optimal System

NCPB outlined what it considers an optimal system of cancer care, which Dr. Simone summarized: “There should be an agreement on a plan of care by the patient and the provider. Decisions should be made on the advice of an experienced specialist. Patients should have access to all resources necessary for carrying out the plan. Providers should disclose all options to the patient.”

Moreover, he said, a need exists to coordinate services for patients, “and we found a great gap in what we think is the best patient package for psychosocial support and pain control in the terminal patient.”

At the press conference, IOM president Kenneth I. Shine suggested that the failure to do a better job delivering effective cancer care stems in part from self-interest. “It is not always in the best interests of providers, the institutions, and others to provide this information or to provide it in a form that allows comparability. One of the things we are particularly concerned about, not only in cancer, is that institutions provide accurate data that are comparable, so you can compare apples and apples.”

NCPB, however, found no simple explanation for the problems it highlighted, and declined to point specifically at managed care. “The problem is quality,” said Jane Sisk, PhD, professor of health policy and management, Columbia University’s School of Public Health. “Looking at the totality of the evidence, it is not a particular problem of managed care. Studies indicate a great variation among both managed care and nonmanaged care systems in the kinds of care that cancer and other patients receive.”

Nor is cost alone the determining factor. “It would be attractive to be able to point to one, two, or three things that were the cause,” Dr. Young said. “The answer is that there is no simple answer.”

New Standards

The board urged the federal government and health care providers to develop new standards to help improve the overall quality of cancer care and to serve as yardsticks to hold providers and insurers accountable. “Total quality improvement initiatives, disease management programs, and implementation of clinical practice guidelines all have the potential to improve care within health systems,” the report concluded.

Although the board recommended the use of guidelines based on the best available evidence for prevention, diagnosis, treatment, and palliative care, it did not endorse any existing guidelines or approaches. “We recognize that guidelines aren’t magical in themselves, but they provide an infrastructure to measure quality of care,” Dr. Young said. “We see this guidelines tool as a continuing quality improvement strategy and not as an enforcement strategy.”

The board found a dearth of broad, reliable data on the degree to which the most effective cancer treatments are used in the United States. “Panel members were struck by what evidence existed because it suggested that state-of-the-art cancer care is erratically applied,” Dr. Young added.

The report strongly urged a significant improvement in the nation’s ability to measure and monitor quality of care. “Based on the best available evidence, some individuals, we know, do not receive effective care. The size of this problem is not known. We believe, however, that it is substantial,” Dr. Simone said.

Two Examples

He cited two examples. Although the effectiveness of radiation after lumpec-tomy for breast cancer is well established, one study found that only 24% of women over age 80 receive radiation after that procedure. “We don’t know why this is the case: whether they were offered this treatment and refused or they were not offered the treatment because of their age,” Dr. Simone said. He also cited data that 42% of cancer patients receive inadequate pain control.

“NCPB will continue to examine the issues raised in its new report through workshops and meetings with health agencies,” Dr. Simone said. Board members will also make detailed presentations about the report at professional meetings, including the American Society of Clinical Oncology meeting in May.

Other recommendations of “Ensuring Quality Cancer Care” include:

Quality of care at the end of life must be ensured, in particular the management of cancer-related pain and timely referral to palliative and hospice care.

Federal and private research sponsors should invest more in clinical trials to address questions about cancer care management.

A cancer data system is needed that can provide quality benchmarks for use by hospitals, provider groups, and managed care systems. NCPB itself plans to hold a series of workshops this year to address such issues and how best to do quality monitoring and to identify the resources need to improve the data system related to quality issues.

Sponsors of cancer care research should support studies of recently diagnosed individuals to assess the patterns of cancer care and factors associated with the receipt of good care.

Services for the uninsured and underinsured should be enhanced. Some financial assistance programs exist for cancer patients, but “they do not substitute for adequate insurance coverage for cancer treatment,” the board said.

Studies are needed to find out why specific segments of the population (certain ethnic groups, the elderly) do not get appropriate cancer care. “These studies should measure provider and individual knowledge, attitudes, and beliefs, as well as other potential barriers to access to care,” NCPB concluded.