Date: April 6, 1999
Contacts: Dan Quinn, Media Relations Officer
Dumi Ndlovu, Media Relations Assistant
(202) 334-2138; e-mail <>

System-Wide Changes Needed To Ensure
High Quality Cancer Care

WASHINGTON -- Patients who need complicated cancer surgery or chemotherapy should be treated at facilities that perform a high volume of these procedures, says a new report from the National Cancer Policy Board of the Institute of Medicine and the National Research Council. Survival rates immediately following these procedures are two to three times higher in more experienced settings, according to several studies reviewed in the report. Such procedures include removal of all or part of the esophagus, surgery for pancreatic cancer, removal of pelvic organs, and complex chemotherapy treatments.

"Although it is clear that institutions with extensive experience are the best providers of difficult cancer treatments, many questions remain regarding how to provide the best care to patients," said board vice chair Joseph Simone, medical director, Huntsman Cancer Foundation and Institute, University of Utah, Salt Lake City. "Improving cancer care in all settings will require new efforts to track the quality of cancer care by all providers, including individual health plans."

The board outlined what it considers to be an optimal system of cancer care, and determined that for many people, this ideal is not met. Efforts to diagnose and treat cancer, as well as to coordinate and improve care, rest with individual health care providers and insurers, and quality varies from setting to setting.

To help improve overall quality, the federal government and private health care providers should develop new standards to which providers and insurers would be held accountable, the board says. Also, sponsors of research should invest in new clinical trials to learn more about the most effective ways to prevent, treat, and screen for cancer.

Approximately 8 million Americans required some form of cancer care last year, including more than 1.2 million who were newly diagnosed. The four most common cancers -- prostate, breast, lung, and colon/rectum -- account for more than half of all new cases.

The report outlines several elements that are essential to quality cancer care. Decisions about initial cancer management -- which are critical to the survival of a patient -- should be made by experienced medical professionals. These professionals and their patients should agree upon a plan that outlines the goals of care; patients must have access to all resources necessary to implement the plan, and care providers should disclose all information on appropriate treatment options. Health professionals also must establish a way to coordinate the many services a patient receives, and to provide psychosocial support services and compassionate care.

Systematic Quality Assurance

Efforts to measure the quality of care for most types of cancer are just beginning in the United States. The most-studied relationship between delivery of care and health outcomes is in patients with breast cancer, where early detection through mammography screening has been shown to reduce mortality by 20 percent to 39 percent.

But studies of mammography screening suggest that there is significant variation from one location to the next in the technical quality of the radiographic images, as well as the way the images are interpreted. Quality measurements show several common problems, including underuse of mammography to detect cancer early; lack of adherence to professional standards for diagnosis; inadequate patient counseling about treatment options; and underuse of radiation therapy and chemotherapy after surgery. As a result of these shortcomings, some women are less likely to survive cancer, the report says, and others experience a lower quality of life.

It is not clear whether the types of problems documented in breast cancer treatment are also common to other cancers. New quality measures should be developed to demonstrate that health care systems and physicians provide good care, and work constantly to improve it. Use of quality assurance mechanisms should be a requirement to receive funding from Medicare and Medicaid, the report states. And the results that health plans attain should be disseminated widely to large insurance purchasers, health providers, consumer organizations, individuals with cancer, policy-makers, and health services researchers.

In addition to new quality assurance mechanisms, the board said several issues must be addressed to improve the system of care:

> Patients must be ensured quality care at the end of life, especially to manage cancer-related pain. Many suffer pain needlessly, and their treatment wishes often are ignored by their physicians and other health providers.

> Services for the underinsured and uninsured should be enhanced. High deductibles, co-payments, or coverage gaps often contributed to excessive out-of-pocket expenses for most patients, and an estimated 7 percent of all people diagnosed with cancer have no insurance at all.

> Research is needed to understand why some segments of the population, including members of certain racial and ethnic groups and older patients do not receive appropriate cancer care. Cancer survival rates are lower among many ethnic groups and poor Americans.

A roster of board members follows. The study was funded by the National Cancer Institute, the Centers for Disease Control and Prevention, the American Cancer Society, Amgen Inc., and Abbott Laboratories. The National Cancer Policy Board is a joint activity of the Institute of Medicine and the National Research Council -- private, non-profit organizations that provide advice on science, technology, and health under a congressional charter granted to the National Academy of Sciences.

Copies of Ensuring Quality Cancer Care are available from the National Academies Press on the Internet at or by calling 202-334-3313 or 1-800-624-6242. Reporters may obtain a pre-publication copy from the Office of News and Public Information at the letterhead address (contacts listed above).

Commission on Life Sciences

National Cancer Policy Board

Peter Howley, M.D. (1,2)(chair)
George Fabyan Professor and Chair, Department of Pathology
Harvard Medical School

Joseph Simone, M.D. (vice chair)
Medical Director, Huntsman Cancer Foundation & Institute
University of Utah
Salt Lake City

John Bailar, M.D.(2)
Chair, Department of Health Studies
University of Chicago

Norman Daniels, Ph.D. (2)
Professor of Philosophy, Department of Philosophy
Tufts University
Newton, Mass.

Joseph Davie, M.D., Ph.D. (2)
Vice President of Research
Biogen Inc.
Cambridge, Mass.

Robert Day, M.D., M.P.H., Ph.D.
Emeritus President and Director, and
Member, Division of Public Health Sciences
Fred Hutchinson Cancer Research Center

Kathleen Foley, M.D. (2)
Chief, Pain Service, Department of Neurology
Memorial Sloan-Kettering Cancer Center
New York City

Bertie Ford, M.S., R.N., O.C.N.
Manager, Oncology Research and Registry
Grant/Riverside Hospital
Columbus, Ohio

Ellen Gritz, Ph.D.
Professor and Chair, Department of Behavioral Sciences
M.D. Anderson Cancer Center

Elizabeth Hart
President and Chief Executive Officer
Hart International

Thomas Kelly, M.D., Ph.D. (1)
Boury Professor and Chair, Department of Molecular Biology and Genetics
Johns Hopkins University School of Medicine

John Laszlo, M.D.
Independent Consultant

William McGuire, M.D. (2)
Chief Executive Officer
United Health Care Corp.
Minnetonka, Minn.

Diana Petitti, M.D.
Director, Research and Evaluation
Kaiser Permanente Medical Care Program
Pasadena, Calif.

Amelie Ramirez, Dr.P.H.
Associate Professor, Department of Medicine
Baylor College of Medicine
San Antonio

John Seffrin, Ph.D.
Chief Executive Officer
American Cancer Society

Jane Sisk, Ph.D.
Professor, Division of Health Policy and Management
Joseph L. Mailman School of Public Health
Columbia University
New York City

Ellen Stovall
Executive Director
National Coalition for Cancer Survivorship
Silver Spring, Md.

Frances Visco
National Breast Cancer Coalition
Washington, D.C.

Robert Young, M.D.
Fox Chase Cancer Center


Maria Hewitt, Study Director

Robert Cook-Deegan, Board Director

(1)Member, National Academy of Sciences
(2)Member, Institute of Medicine