Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia (2005)

The objective of cancer prevention is to avoid the development of cancer through the use of interventions that eliminate or reduce exposures to the causes of cancer (e.g., tobacco and other carcinogens, obesity). In health care’s arsenal of weapons to fight cancer, prevention holds tremendous potential (IOM, 2003). The Georgia Cancer Coalition (GCC) could harness much of the untapped potential of cancer prevention by working to close the gap between what is known and what is practiced in the common, everyday routines of physicians’ offices. Among the first steps GCC might take to prevent unnecessary cancer morbidity and mortality are encouraging the use of evidence-based, effective means to help smokers quit smoking, as well as seeking to ensure that effective cancer screening procedures are used as recommended (see Chapter 4, Detecting Cancer Early) (IOM, 2003).

The Institute of Medicine (IOM) Committee on Assessing Improve-

ments in Cancer Care in Georgia recommends that Georgia adopt 10 quality indicators related to cancer prevention (Box 3-1). Four recommended measures are related to smoking rates and smoking cessation interventions. Smoking is the cause of 30 percent of all cancers, and almost one in four adults and high school students in Georgia smoke. The fifth recommended measure tracks obesity. Obesity is another major risk factor for cancer, but evidence-based solutions for reducing obesity are more elusive than those available for reducing smoking. The final five measures are measures of various cancer incidence rates. Cancer incidence rates are the ultimate indicators of the success of prevention efforts. With sustained meaningful improvement in cancer prevention, Georgia should eventually experience declining cancer incidence rates.

The 10 quality measures pertaining to cancer prevention recommended for Georgia are identified in this chapter. In addition, the rationale for the IOM committee’s selection of these measures is provided. For each measure, there is a section providing a brief explanation of the evidence underlying the measure (the “consensus on care”) and a description of what is known about the gap between the evidence and current practice (“knowledge vs. practice”). Also provided near the end of this chapter is a brief section on the potential data sources for the 10 recommended measures related to cancer prevention. The chapter concludes with one-page summaries of each

quality measure, including specifications for calculating the recommended measures. Chapter 4 (Detecting Cancer Early), Chapter 5 (Diagnosing Cancer), and Chapter 6 (Treating Cancer) are similarly organized.

The IOM committee recommends four measures to monitor smoking interventions in Georgia. Two of them are measures for routine surveillance of adult and adolescent smoking rates:

• Measure 3-1—Adult smoking rate—the proportion of adults who smoke cigarettes.

• Measure 3-2—Adolescent smoking rate—the proportion of adolescents who smoke cigarettes.

The other two are measures to monitor delivery of recommended smoking cessation interventions:

• Measure 3-3—Smokers who receive advice to quit—the proportion of adult smokers who were advised to quit smoking during a visit with a doctor, nurse, or other health professional.

• Measure 3-4—Smokers who are recommended pharmacotherapy to assist in quitting smoking—the proportion of adult smokers whose doctor, nurse, or other health professional recommended or discussed medication to assist quitting smoking.

Cigarette smoking accounts for at least 30 percent of cancer-related deaths and a staggering 87 percent of lung cancer deaths (ACS, 2004). Smokers are 20 times more likely than never-smokers to develop lung cancer (Alberg and Samet, 2003). Smoking is also a major cause of cancer of the larynx, oral cavity, throat, and esophagus and is a contributing cause in the development of cancers of the bladder, pancreas, liver, uterine cervix, kidney, stomach, colon and rectum, and some leukemias. An individual who quits smoking or refrains from starting smoking will experience substantial and immediate health benefits (U.S. DHHS, 2004).

If tobacco use does not begin in childhood or adolescence, it is unlikely to start in adulthood. Most adult smokers have their first cigarette before age 18, and more than half are daily smokers by age 18 (U.S. DHHS, 1994). Smokers who quit before age 50 have one-half the risk of dying in the next 15 years compared with continuing smokers. The benefit is even greater for

younger smokers who quit (Peto et al., 2000). The U.S. Surgeon General’s office has estimated that after 10 years abstinence, the risk of lung cancer is 30 to 50 percent of the risk for continuing smokers (U.S. DHHS, 1990).

There is a wealth of evidence documenting how health providers can influence adult smokers to quit and an extensive body of clinical guidelines promoting the use of these interventions (U.S. DHHS, 2004). More than 100 randomized controlled clinical trials have shown modest but statistically significant reductions in tobacco use for adult smokers who receive physician counseling (Fiore et al., 2000; USPSTF, 2002). The likelihood of quitting smoking increases with the intensity of counseling (Fiore et al., 2000).

In its most recent review of the evidence on the efficacy of smoking interventions, the U.S. Preventive Services Task Force (USPSTF) concluded that, compared with no intervention, smoking-cessation interventions that include screening, behavioral counseling (as brief as 3 minutes), and pharmacotherapy delivered in primary care settings, are effective in helping adult smokers quit smoking and remain smoking-free after 1 year (USPSTF, 2002). Numerous pharmacotherapies approved by the Food and Drug Administration—including bupropion, nicotine gum, nicotine transdermal patches, inhalers, and nasal sprays—have been shown to be safe and effective for treating tobacco dependence. Success in abstaining from smoking among people who use these pharmacotherapies ranges from 18 to 31 percent, as compared with 10 to 17 percent among people who do not use them (Fiore et al., 2000).

In addition to the literature on clinical interventions, there is a substantial literature on community-based strategies for reducing exposure to environmental tobacco smoke, encouraging tobacco-use cessation, and discouraging the onset of tobacco use in children and adolescents (CDC, 2000).¹ Increasing the cost of tobacco and tobacco control programs that include mass media campaigns are among the strategies that have been shown to reduce the initiation of tobacco use among children and adolescents (Hopkins et al., 2001).

Unfortunately, little is known about the effectiveness of physician

counseling of children and adolescents in preventing smoking initiation or promoting cessation (USPSTF, 2002).

Smoking is common in Georgia, as it is elsewhere in the United States. About 23 percent of the state’s adults and high school students smoke cigarettes (Table 3-1). More than 10 percent of Georgia’s sixth- to eighth-grade boys say they smoke cigarettes.

Despite the persuasive body of evidence supporting interventions to help smokers quit, many health providers do not follow the well-established guidelines for helping their smoking patients quit the habit. Nationwide, for example, in 2000 only 62 percent of adult smokers reported that their doctor had advised them to quit during a routine office visit in the previous year (AHRQ, 2003).

Smoking prevention and cessation has been recognized by GCC as an essential part of the fight against cancer. Approximately 37 percent of GCC’s funds since 2001 have been invested in tobacco use prevention (GCC, 2003). Tracking smoking rates and the delivery of smoking cessation interventions will help GCC monitor its impact on the leading preventable cause of cancer.

The IOM committee recommends that GCC regularly monitor rates of adult obesity in the state:

• Measure 3-5—Adult obesity rate—the proportion of adults who are obese.

Obesity is commonly defined using the formula based on weight and height known as the body mass index (BMI). Persons with a BMI of 30 or higher are considered obese. BMI is calculated as weight (in pounds) divided by height (in inches squared) multiplied by 703.² The chief causes of obesity are a sedentary life style and a high-calorie diet (Friedenreich, 2001; Kritchevsky, 2003).

Reporting adult obesity trends will be fundamental to tracking Georgians’ risk for developing cancer. There is evidence that weight control may play an especially important role in the metabolic conditions amenable to carcinogenesis (Friedenreich, 2001). Numerous studies of cancer incidence show a relationship between increasing weight gain and the onset of cancer (IOM, 2003; Key et al., 2004). Recent estimates indicate that about 10 percent of breast and colorectal cancers can be attributed to overweight and obesity, and 25 to 40 percent of kidney, esophageal (adenocarcinoma), and endometrial cancers (Vainio and Bianchini, 2002).

Weight loss of only 5 to 10 percent of total weight provides health benefits such as improved lipid levels and blood pressure rate. However, it is not known if weight reduction in adult life meaningfully reduces one’s risk of developing cancer.

Despite growing scientific evidence on the role of obesity in the epidemiology of cancer, there is a little evidence on the efficacy of any specific approach to preventing or treating obesity. The USPSTF recommends that clinicians screen all adults for obesity and offer intensive counseling and behavioral interventions for optimal weight loss (USPSTF, 2003). In its 2003 review of the evidence, the USPSTF found that the most effective interventions combine nutrition education and diet and exercise counseling with behavioral strategies to increase physical activity and help change eating habits.

Adult obesity rates have been steadily increasing in Georgia, rising from under 11 percent in 1990 to almost 24 percent in 2002 (Figure 3-1) (CDC, 2003). Despite this epidemic of obesity in Georgia and elsewhere in the United States, it appears that health care providers rarely counsel their patients regarding weight issues. In Georgia, the vast majority (81.8 percent) of adults in 2000, overweight or not, reported that they did not get

FIGURE 3-1 Obesity by body mass index, Georgia, 1990-2002.

SOURCE: CDC, 2003.

professional advice about weight control in the previous year (CDC, 2004a). It is not known whether Georgians were more likely to receive professional advice about their weight if they were obese. Nationally, about 43 percent of obese persons say that a health care professional had advised them to lose weight during a routine checkup in the previous year (Mokdad et al., 2001).

The IOM committee recommends that GCC routinely monitor the overall incidence of cancer as well as the specific incidence of breast, colorectal, lung, and prostate cancers (see below).

• Measure 3-6—Cancer incidence rate (all sites)

• Measure 3-7—Breast cancer incidence rate

• Measure 3-8—Colorectal cancer incidence rate

• Measure 3-9—Lung cancer incidence rate

• Measure 3-10—Prostate cancer incidence rate

Cancer incidence rates are important measures of the burden of cancer in a population, usually expressed as the number of newly diagnosed cancers

per 100,000 population at risk.³ The population used depends on the rate to be calculated. For cancer sites that occur in only one sex, the sex-specific population (e.g., males for prostate cancer) is used. Table 3-2 shows the estimated incidence of the four leading types of cancers in Georgia in 2000: breast, colorectal, lung, and prostate.

Incidence data are fundamental to planning and evaluating cancer control programs. If, for example, Georgia succeeds in significantly reducing smoking rates, real progress, over the long term, will be evident in the state’s cancer incidence data, especially for lung cancer. Similarly, if Georgia markedly improves the quality and prevalence of colorectal cancer screening, this will ultimately be apparent in a corresponding decline in the incidence of colorectal cancer. Some caution is required in interpreting incidence rates since, in the short term, incidence may appear to increase in underscreened populations or with the introduction of more sensitive screening techniques.

The data for the 10 prevention-related quality-of-cancer-care measures recommended for Georgia may be drawn from two sources: population surveys and tumor registries. As shown in Table 3-3, some data sources are Georgia based and others are national.

The Behavioral Risk Factor Surveillance System (BRFSS), sponsored by the Centers for Disease Control and Prevention (CDC), will be an essential source of information on Georgians who are at risk for cancer because of smoking or dietary habits. The BRFSS is specifically designed to produce annual, state-level estimates of population trends in behaviors related to cancer and other diseases. BRFSS field operations are managed by state health departments, so Georgia will have considerable flexibility to exploit the full potential of the survey. Furthermore, national-level findings are available on the CDC website and will provide useful benchmarks for Georgia to assess its progress. The Georgia Youth Tobacco Survey will be essential to monitoring adolescent smoking rates. At present, the survey only targets adolescents enrolled in school. Georgia should consider expanding the survey to reach an especially vulnerable population, teenagers who do not attend school. Tumor registries are the principal data source for computing cancer incidence rates. Further information about potential data sources is presented in Chapter 2, Concepts, Methods, and Data Sources and in Appendixes A and B.

The application of evidence-based preventive services could help reduce the burden of cancer in Georgia. A considerable body of research has shown, for example, that smoking cessation interventions such as brief, behavioral counseling and pharmacotherapy are effective in helping adult smokers quit and remain smoking-free for 1 year. In this chapter, the IOM committee has recommended 10 quality-of-cancer-care measures to gauge GCC’s success in closing the gap between what is known about cancer prevention and what is practiced in the common, everyday routines of Georgia’s physician offices.

The following section contains summary descriptions of the quality indicators presented in this chapter. These quality indicators were drawn from a variety of clinical practice setting organizations, federal programs, provider groups, and other sources. See Appendix A for descriptions of each of these organizations, including their classification schemes for grading clinical recommendations and characterizing evidence.

ACS (American Cancer Society). 2004. Cancer Facts & Figures 2004. Atlanta, GA: ACS.

AHRQ (Agency for Healthcare Research and Quality). 2003. National Healthcare Quality Report. Rockville, MD: U.S. DHHS.

Alberg AJ, Samet JM. 2003. Epidemiology of lung cancer. Chest. 123(1 Suppl): 21S-49S.

ASCO (American Society for Clinical Oncology). 2003. American Society of Clinical Oncology policy statement update: tobacco control—reducing cancer incidence and saving lives. J Clin Oncol. 21(14): 2777-86.

CDC (Centers for Disease Control and Prevention). 2000. Strategies for reducing exposure to environmental tobacco smoke, increasing tobacco use cessation, and reducing initiation in communities and health-care systems. A report on recommendations of the Task Force on Community Preventive Services. MMWR. 49(RR-12).

——. 2003. Behavioral Risk Factor Surveillance System, Trends Data, Georgia, Obesity: By Body Mass Index. [Online] Available: http://apps.nccd.cdc.gov/brfss/Trends/trendchart.asp?qkey=10010&state=GA [accessed November 26, 2004].

——. 2004a. Behavioral Risk Factor Surveillance System, Prevalence Data: Georgia 2000, Weight Control. [Online] Available: http://apps.nccd.cdc.gov/brfss/display.asp?cat=WC&yr=2000&qkey=4390&state=GA [accessed November 26, 2004].

——. 2004b. Behavioral Risk Factor Surveillance System, Prevalence Data: Georgia 2002 Colorectal Cancer Screening. [Online] Available: http://apps.nccd.cdc.gov/brfss/display.asp?cat=CC&yr=2002&qkey=7400&state=GA [accessed November 26, 2004].

——. 2004c. Behavioral Risk Factor Surveillance System: Questionnaires. [Online] Available: http://www.cdc.gov/brfss/questionnaires/questionnaires.htm [accessed November 26, 2004].

Fiore MC, Bailey, WC, Cohen, SJ, Dorfman SF, Goldstein MG, Gritz ER, Hegman RB, Jaen CR, Kuttlee TE, Lando HA, Mecklenburg RE, Mullen PD, Nett LM, Robinson L, Stitzer ML, Tomasello AC, Villejo L, Wiwers ME, Baker T, Fox BJ, Hasselblad V. 2000. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: U.S. DHHS, Public Health Service.

Friedenreich CM. 2001. Physical activity and cancer prevention: from observational to intervention research. Cancer Epidemiol Biomarkers Prev. 10(4): 287-301.

GCC (Georgia Cancer Coalition). 2001. Strategic Plan. Atlanta, GA: GCC.

——. 2003. Mobilizing Georgia, Immobilizing Cancer. Atlanta, GA: GCC.

GDPH (Georgia Division of Public Health). 2004. OASIS Web Query—Death Statistics. [Online] Available: http://oasis.state.ga.us/webquery/death.html [accessed April 2004].

Hopkins DP, Briss PA, Ricard CJ, Husten CG, Carande-Kulis VG, Fielding JE, Alao MO, McKenna JW, Sharp DJ, Harris JR, Woollery TA, Harris KW. 2001. Reviews of evidence regarding interventions to reduce tobacco use and exposure to environmental tobacco smoke. Am J Prev Med. 20(2 Suppl): 16-66.

IOM (Institute of Medicine). 2003. Fulfilling the Potential of Cancer Prevention and Early Detection. Curry S, Byers T, Hewitt M, Editors. Washington, DC: The National Academies Press.

Kanny D, Powell KE, Copes K. 2002. Georgia Youth Tobacco Survey, 2001. Atlanta, GA: Georgia Department of Human Resources, Division of Public Health, Tobacco Use Prevention Section.

Key TJ, Schatzkin A, Willett WC, Allen NE, Spencer EA, Travis RC. 2004. Diet, nutrition and the prevention of cancer. Public Health Nutr. 7(1A): 187-200.

Kritchevsky D. 2003. Diet and cancer: what’s next? J Nutr. 133(11 Suppl 1): 3827S-3829S.

Martin LM, Chowdhury PP, Powell KE, Clanton J. 2004. Georgia Behavioral Risk Factor Surveillance System, 2002 Report. Atlanta, GA: Georgia Department of Human Resources, Division of Public Health, Chronic Disease, Injury, and Environmental Epidemiology Section.

McTigue KM, Harris R, Hemphill B, Lux L, Sutton S, Bunton AJ, Lohr KN. 2003. Screening and interventions for obesity in adults: summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 139(11): 933-49.

Mokdad AH, Bowman BA, Ford ES, Vinicor F, Marks JS, Koplan JP. 2001. The continuing epidemics of obesity and diabetes in the United States. JAMA. 286(10): 1195-2000.

National Center for Chronic Disease Prevention and Health Promotion. 2003. YRBSS Youth Risk Behavior Surveillance System. [Online] Available: http://www.cdc.gov/nccdphp/dash/yrbs/index.htm [accessed August 26, 2004].

NCI and CDC (National Cancer Institute and Centers for Disease Control and Prevention). 2004. State Cancer Profiles. [Online] Available: http://statecancerprofiles.cancer.gov/incidencerates/incidencerates.html [accessed July 9, 2004].

NCQA (National Committee for Quality Assurance). 2004. Advising Smokers to Quit. [Online] Available: http://www.ncqa.org/programs/radd/expanded%20web%20version/advising_smokers_to_quit.htm#Measure [accessed August 2004].

Peto R, Darby S, Deo H, Silcocks P, Whitley E, Doll R. 2000. Smoking, smoking cessation, and lung cancer in the UK since 1950: combination of national statistics with two case-control studies. BMJ. 321(7257): 323-9.

U.S. Cancer Statistics Working Group. 2003. United States Cancer Statistics: 2000 Incidence. Atlanta, GA: U.S. DHHS, CDC, and NCI.

U.S. DHHS (U.S. Department of Health and Human Services). The Health Benefits of Smoking Cessation. Rockville, MD: U.S. DHHS, Public Health Service, Centers for Disease Control, Center for Chronic Disease Prevention and Health Promotion, Office of Smoking and Health. DHHS Publication No. (CDC) 90-8416.

——. 1994. Preventing Tobacco Use Among Young People: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Public Health Service, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health.

——. 2000. Healthy People 2010: Understanding and Improving Health. 2nd edition. Washington, DC: U.S. Government Printing Office.

——. 2004. The Health Consequences of Smoking: A Report of the Surgeon General. Atlanta, GA: U.S. DHHS, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office of Smoking and Health.

USPSTF (U.S. Preventive Services Task Force). 2002. Guide to Clinical Preventive Services. Counseling to Prevent Tobacco Use and Tobacco-Caused Disease. Rockville, MD: AHRQ.

——. 2003. Screening for Obesity in Adults. What’s New from the U.S. Preventive Services Task Force. Rockville, MD: AHRQ.

Vainio H, Bianchini F. 2002. IARC Handbooks of Cancer Prevention. Volume 6: Weight Control and Physical Activity. Lyon, France: IARC Press.