Cancer care is optimally delivered in systems of care that:

RECOMMENDATION 1: Ensure that patients undergoing procedures that are technically difficult to perform and have been associated with higher mortality in lower-volume settings receive care at facilities with extensive experience (i.e., high-volume facilities). Examples of such procedures include removal of all or part of the esophagus, surgery for pancreatic cancer, removal of pelvic organs, and complex chemotherapy regimens.

Many aspects of the delivery of health care can potentially affect its quality. There is convincing evidence of a relationship between treatment in higher-volume hospitals and better short-term survival for individuals with several types of cancer for which high-risk surgery is indicated (e.g., pancreatic cancer, non-small-cell lung cancer). Several studies show very large effects, with lower-volume hospitals having postsurgical mortality rates two to three times higher than hospitals that do more such procedures. A dose-response effect is also evident to support the finding that as volume increases, so do good outcomes. The findings cut across cancer types and systems of care, sharing the common element of complicated medical or surgical intervention. Although estimates are imprecise, a relatively large share of high-risk surgery is taking place in lower-volume settings (e.g., from one-quarter to one-half of surgical procedures for pancreatic cancer).

More limited data show a relationship between surgery performed at higher-volume hospitals and better outcomes for men with prostate cancer who undergo radical prostatectomy and for women who undergo breast cancer surgery. A few studies of the management of other types of cancer (i.e., testicular cancer, leukemia) also show a relationship between higher volume and better outcome. This volume-outcome relationship appears to be strong, and consistent with findings from other areas of complex care (e.g., coronary revascularization procedures).

Even in the absence of extensive data for each particular cancer type and stage, evidence strongly indicates that health outcomes are better in high-volume settings for highly technical cancer management.

RECOMMENDATION 2: Use systematically developed guidelines based on the best available evidence for prevention, diagnosis, treatment, and palliative care.

Total quality improvement initiatives, disease management programs, and implementation of clinical practice guidelines all have the potential to improve care within health systems. Information about clinical practice can serve as a powerful tool to change physician and patient behavior and to improve the use of effective treatments. The experience with oncology practice guidelines has been mixed, however, with some examples of success, but other examples of failure to change provider behavior or outcomes. Many guideline efforts have failed because of flaws in the way the guidelines were developed or implemented. Evidence suggests that care can be improved when providers themselves are involved in shaping guidelines and when systems of accountability are in place. Such efforts must be intensified.



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