Nurses and social workers are also essential providers of cancer care. More than 17,000 nurses are certified by the Oncology Nursing Society as oncology nurses (ONS, 1998). These nurses have extensive experience with the management of cancer, including the administration of chemotherapy, monitoring of pain and nausea, and patient counseling and education. An estimated 1,000 social workers with special training in oncology provide psychosocial services to people with cancer and their families (Susan Hedlund, Association of Oncology Social Workers, personal communication to Maria Hewitt, September 1998).

Cancer care often involves numerous practitioners across a variety of settings, physicians' offices, outpatient diagnostic centers, hospitals, nursing homes, patients' homes, and hospices, making communication and coordination of care difficult. Comprehensive and coordinated care management refers to the ability to fully access necessary services and to have components of care efficiently planned and integrated. Clear and ongoing communication among care providers and among providers, patients, and family members is a prerequisite to coordinated care. Too often, adults newly diagnosed or suspected of having cancer see one doctor and then others sequentially, without having an overall plan of care devised at the outset by, or in consultation with an interdisciplinary team. This can have deleterious consequences because the first treatment offers the best chance for cure and because every treatment used may limit subsequent treatment options (Moore, 1985).

Sites of Cancer Care

Although the locus of cancer care in the past has been the hospital, an increasing number of cancer care services, from diagnostic imaging to the administration of chemotherapy, are being shifted from the hospital to outpatient settings. According to the NAMCS and the NHAMCS, most cancer-related adult ambulatory care is provided in physicians' offices (89 percent), with the balance (11 percent) provided in hospital outpatient departments (Table 2.3).2 Relatively few types of cancer account for more than three-quarters (79 percent) of all adult ambulatory visits—female breast; skin (nonmelanoma); lymphomas and leukemias; prostate; colon and rectum; and lung and respiratory cancers (Table 2.3). Management of cancer-related symptoms and the need for follow-up care and pre-or postoperative checks are among the most common reasons for adults' making cancer-related ambulatory care visits (Table 2.3). Chemotherapy is administered during about one in five adult ambulatory care visits (22 percent). As would be expected given the age of onset of most cancers, more than one-half (56 percent) of adult ambulatory care visits are made by the elderly, and Medicare is the principal source of payment for adult ambulatory care visits (Table 2.3).

In 1997, nearly 1,000 hospital-based cancer care programs discharged 276 or more patients with a primary diagnosis of cancer (Comarow, 1997; Ehrlich, 1997). These hospitals range from relatively small, community-based hospitals to large referral centers that treat cancer patients exclusively. Available evidence suggests that cancer patients are concentrated in a few U.S. hospitals. Only one in three of the 5,080 general hospitals in the United States has a cancer program approved by the American College of Surgeons' Commission on Cancer (AcoS-COC)


 These estimates exclude ambulatory care visits to radiologists and to hospital radiology clinics. These providers are excluded from the NAMCS and the NHAMCS.

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