has created a cancer survivorship tool kit to help patients advocate for care that meets these quality standards (http://www.canceradvocacy.org/).

With nearly half (45 percent) of new cases of breast cancer occurring among women age 65 or older, the Medicare program has an interest in ensuring the delivery of quality care to its beneficiaries. The agency overseeing the Medicare program, the Centers for Medicare and Medicaid Services (CMS), has systems in place to monitor quality of care, but assessments to date on cancer-related care have focused on breast cancer screening (IOM, 2003). Assessments of the delivery of psychosocial care are hampered by the lack of validated measures of quality. The National Quality Forum (NQF) is a not-for-profit membership organization created in 2000 to develop and implement a national strategy for healthcare quality measurement and reporting (http://www.qualityforum.org/, accessed April 18, 2003). In 2002 the NQF formed a Cancer Care Quality Measures Steering Committee to reach consensus on a core set of quality measures. Breast cancer is one of the focus areas of this activity, as well as symptom management and palliation.

There is more experience with quality of care measurement for breast cancer care, relative to other types of cancer care (IOM/NRC, 2000). The Foundation for Accountability (FACCT), for example, developed a set of breast cancer quality indicators which included satisfaction with care, and quality of life as measured by the Cancer Rehabilitation Evaluation System (CARES) instrument (see Chapter 3 for a description of this instrument). The Providence Health System uses FACCT to assess breast cancer care within its 17 member institutions (located from California to Alaska) (http://www.providence.org/Oregon/Programs_and_Services/Research/CORE/performance, accessed April 18, 2003). More direct measurement of the provision of psychosocial care within systems of care have not yet been performed, but could likely be incorporated into assessments of satisfaction of care. In a review of quality-of-care measure that could be used to assess oncology practice, Mandelblatt and colleagues suggest that rates of clinical assessment of the need for psychological support services (both group and individual) could be documented and serve as a process measure of rehabilitative care (Mandelblatt et al., 1999). Evaluations of the feasibility and value of such quality of care assessments are needed.

Many barriers need to be overcome to meet the psychosocial needs of women with breast cancer. Lack of access to health care is a general societal problem in America. An estimated 8 percent of women with breast cancer lack health insurance coverage, and many more have inadequate health insurance coverage for even basic health care needs. Health insurance cov-