include providing cancer screening to low-income populations and monitoring the achievement of cancer-related public health goals (see Chapter 6). Elsewhere in the federal government, the Agency for Health Care Policy and Research disseminates information about clinical practice guidelines to health providers and supports health services research aimed at understanding the links between the organization and delivery of health care and the resulting health outcomes (see Chapter 7). The federal Health Care Financing Administration (HCFA), as the nation's largest payer for health care, has established quality assurance programs targeting cancer care and is developing tools to more effectively monitor the quality of cancer care delivered to Medicare beneficiaries (see Chapter 6).

Although there are numerous sites within the federal government whose programs and research directly relate to the quality of cancer care, there is no system in place to coordinate these efforts. This has not always been the case. Although the effort failed, an attempt was made during the 1970s to coordinate federal and private cancer research programs through the National Cancer Program.

The 1971 War on Cancer Act (P.L. 92-218) created a National Cancer Program, headed by the director of the NCI to coordinate both federal and private cancer research programs (McGeary, 1997). The National Cancer Program concept saw NCI as primarily a research agency that was also involved in translating research into applications to improve prevention, diagnosis, treatment, and rehabilitation efforts. The National Cancer Program was not supposed to become the cancer care system, but it was supposed to interact enough with the system through planning and coordination to improve the delivery of patient care. These broader coordination and planning goals that should have extended the reach of the National Cancer Program beyond NCI to other federal and private parties could not be met, and when the 1971 act was recodified in 1978, the scope of the program was redefined to include only NCI (McGeary, 1997).

Cancer care is often provided as part of research initiatives; consequently, the current National Cancer Program intersects with the health care delivery system. The majority of children with cancer, for example, fall within an NCI-sponsored system of care because they are participants in NCI-sponsored research protocols (Simone and Lyons, in press). Furthermore, a system of NCI-funded cancer centers extends research opportunities to community hospitals throughout the country. Nevertheless, most cancer care services are provided by hospitals and centers falling outside the purview of the National Cancer Program, and there is no national effort to coordinate the disparate federal efforts related to the quality of cancer care.

The lack of national coordination in cancer-fighting efforts in the public, private, and voluntary sectors is a problem that hinders progress against cancer, according to the findings of the NCI-appointed National Cancer Advisory Board (NCAB) in their review of the National Cancer Program in the early 1990s (NCAB, 1994). In its final report, the NCAB recommended that the National Cancer Program should extend "beyond research to its application to the people and include all non-research, non-governmental, and community constituents whose actions impact the cancer problems" (NCAB, 1994). To date, the legislative authority to have the National Cancer Program coordinate federal and nonfederal cancer programs has not been reinstated (McGeary, 1997).



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