Based on the best available evidence, some individuals with cancer do not receive care known to be effective for their condition. The magnitude of the problem is not known, but the National Cancer Policy Board believes it is substantial. The reasons for failure to deliver high-quality care have not been studied adequately, nor has there been much investigation of how appropriate standards vary from patient to patient.

The means for improving the quality of cancer care, which involve changes in the health care system, are the first five of a total of ten recommendations of the National Cancer Policy Board. Implementation of these recommendations may vary by locality and by system of care with, for example, different mechanisms needed in rural versus urban areas, or for particularly high-risk or underserved populations.

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.



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