ASCO Initiates Study of Quality of Cancer Care

ASCO—The American Society of Clinical Oncology (ASCO) has embarked upon “one of the most important and far reaching initiatives ever undertaken by any medical specialty society—the National Initiative on Cancer Care Quality (NICCQ),” Joseph S. Bailes, MD, outgoing ASCO president, said at the Society’s 36th annual meeting held in New Orleans.

“This initiative is intended to build, for the first time, a comprehensive cancer quality monitoring system for the United States,” he stated in his presentation at the presidential symposium.

The initiative is ASCO’s response to a 1999 report by the Institute of Medicine (IOM) National Cancer Policy Board suggesting that cancer care does not always meet expected standards.

ASCO’s partners in the initiative are the American College of Surgeons, American Society for Therapeutic Radiology and Oncology, Oncology Nursing Society, Society of Surgical Oncology, and Society of Gynecologic Oncologists.

The Susan G. Komen Breast Cancer Foundation is providing $1 million in funding to support the initiative. Other sponsors are Agouron, Amgen, Aventis, Bristol-Myers Squibb Oncology, Immunex, Ortho Biotech, and the National Pharmaceutical Council.

An ASCO task force selected early breast cancer (stages I to III) and colorectal cancer (stages II and III) as the first cancers for study, and chose researchers at Harvard Medical School and the RAND Corporation to conduct the study.

Eric Schneider, MD, MSc, Harvard School of Public Health and Brigham and Women’s Hospital, said that the initiative has three objectives:

 To develop, evaluate, and refine quality of care measures for common cancers.

 To develop a prototype for a measurement system that would evaluate the quality of cancer care on a national and ongoing basis.

 To assess the feasibility, reliability, and validity of both the quality of care measures and the system of measurement.

The researchers will focus on the process of care (the specific clinical services patients receive) and the outcomes of care (survival, functional capacity, and quality of life).

The measures of cancer care to be used in the initiative are organized within seven domains that follow the natural course of illness and treatment.

 Diagnosis and staging.

 Initial clinical management (surgery, systemic adjuvant therapy, and radiation therapy if indicated).

 Patient preferences and inclusion in decision-making.

 Referrals and coordination of care.

 Management of treatment toxicity.

 Psychosocial support.

 Surveillance after initial therapy.

For each of these domains, he said, quality measures have been drafted. “Each quality measure focuses first on whether or not a patient should receive specified care,” Dr. Schneider said. “If the answer to that question is yes, then we ask if the patient actually received the specified care. This formulation allows us to create an if/then statement.”

As an example, he described a quality measure for the initial surgical management of colon cancer. “If the patient has definitive resection of a malignant tumor of the colon and stage II or III disease, then at least 2 cm of the margins of the operative specimen should be free of tumor.”

A measure for use of systemic adjuvant therapy in colon cancer reads: “If the patient has definitive resection of a malignant tumor for stage III colon cancer, then the patient should start adjuvant chemotherapy within 6 weeks of surgical resection.” He noted that the regimen used would be compared to a list of regimens considered acceptable based on evidence available at the time care was delivered.

Launching the Study

To implement the initiative, patients with a diagnosis of cancer will be identified, using the National Cancer Data Base, and a subset of patients will then be selected for quality of care assessment, said Katherine Kahn, MD, professor of medicine at UCLA and a researcher at the RAND Corporation.

The research will begin in three cities, Cleveland, Houston, and Los Angeles, she said. The number of hospitals in these cities ranges from 16 in Houston to 81 in Los Angeles.

“Across these cities, there is a range of racial and ethnic distributions,” Dr. Kahn said, and within the cities, a range of hospitals will be selected to best represent the characteristics of each site. Up to 50 patients per hospital will be selected for the study.

The researchers will use two data sources—patient self-report surveys and a clinical detailed review of the patient’s medical record. Outcomes will be assessed 3 to 4 years after diagnosis.

The time line for completing the study is aggressive, Dr. Kahn said. Hospital and patient recruitment will take place during a 10-month period beginning in June 2000. Data collection will begin in the fall. “We will present progress from the initiative at this meeting next year,” she said.