ASCOThe American Society of Clinical Oncology (ASCO) has
embarked upon one of the most important and far reaching
initiatives ever undertaken by any medical specialty societythe
National Initiative on Cancer Care Quality (NICCQ), Joseph S.
Bailes, MD, outgoing ASCO president, said at the Societys 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 ASCOs 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.
ASCOs 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 Womens Hospital, said that the initiative has three objectives:
To develop, evaluate, and refine quality of care measures for
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.
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
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 sourcespatient self-report
surveys and a clinical detailed review of the patients 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.