An approved cancer program must provide specific state-of-the art diagnostic and treatment services in all medical disciplines that a person with cancer may need. The standards applied to institutions are not limited to surgery. Adherence to accepted clinical practice guidelines (e.g., AHCPR's Management of Cancer Pain) and the provision of discharge planning are, for example, among the standards used to evaluate programs.

A major initiative of the Comission on Cancer, in collaboration with the American Cancer Society, is the National Cancer Data Base (NCDB), which currently collects data routinely from 1,600 hospitals in all 50 states on all the patients with cancer they treat. With the program now in its sixth year, more than half of U.S. patients newly diagnosed with cancer are included. Basic demographic information about the patient, type and stage of cancer, and nature of the treatment given are reported electronically. Aggregate data from the country are available publicly. In addition, each hospital is given back its own data in summary form, which it can use to compare with national data ("benchmarking"). The national data allow problem areas to be pin-pointed (e.g., widespread use of an inappropriate treatment for a particular type of cancer) and the observation of trends over time in such characteristics as stage at diagnosis, percentage of patients who have complete staging information, and type of treatment given. Results of NCDB analyses are published regularly in professional journals (NCDB, 1999).

In addition to routine data collection, each year two Patient Care Evaluation (PCE) studies are carried out, focusing on specific cancer types or general treatment issues. More extensive data are collected for these special studies, allowing a more detailed analysis of how patients are treated, with the data again fed back to hospitals so that they can see how they compare in the national spectrum. Specific information on each disease is included. For example, the breast cancer section of the report featured quality benchmarks such as completeness of disease staging according to the American Joint Committee on Cancer (AJCC), percentage utilization of breast conservation surgery for early breast cancers, and percentage of patients undergoing BCS who also received adjuvant radiotherapy. The NCDB expects an increase in hospital participation in the coming years, and it will make outcomes data available on-line. NCDB estimates that three out of every four U.S. patients with cancer will be reported on by the year 2000 (American College of Surgeons, 1999).

The findings of the American College of Surgeons' Commission on Cancer survey will soon be used as part of JCAHO' s accreditation process for JCAHO-accredited organizations that house a cancer center. The collaboration is an attempt to increase the visibility of approved cancer programs, share information on standards and survey process, and increase consumer access to health care organization performance information. Reports will allow approved programs to benchmark their performance with that of other programs (ACS/CoC, 1998).

Association of Community Cancer Centers

To promote quality improvement among cancer centers, the Association of Community Cancer Centers (ACCC), a membership organization for cancer centers, has published "Standards for Cancer Programs," a description of an "ideal" cancer program (ACCC, 1997) (see Box 6.5). The standards are based on expert opinion rather than a systemic review of evidence. ACCC has not undertaken a study of the extent to which these standards have been met.

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