Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis
In the United States, approximately 14 million people have had cancer and more than 1.6 million new cases are diagnosed each year. However, more than a decade after the Institute of Medicine (IOM) first studied the quality of cancer care, the barriers to achieving excellent care for all cancer patients remain daunting. Therefore, in 2012, the IOM convened a committee of experts to examine the quality of cancer care in the United States and formulate recommendations for improvement. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis presents the committee’s findings and recommendations.
A System in Crisis
The committee concludes that the cancer care delivery system is in crisis. Care often is not patient-centered, many patients do not receive palliative care to manage their symptoms and side effects from treatment, and decisions about care often are not based on the latest scientific evidence.
The cost of cancer care also is rising faster than many sectors of medicine — having increased to $125 billion in 2010 from $72 billion in 2004 — and is projected to reach $173 billion by 2020. Rising costs are making cancer care less affordable for patients and their families and are creating disparities in patients’ access to high-quality cancer care.
There also are growing shortages of health professionals skilled in providing cancer care, and the number of adults age 65 and older — the group most susceptible to cancer — is expected to double by 2030, contributing to a 45 percent increase in the number of people developing cancer. The current care delivery system is poorly prepared to address the care needs of this population, which are complex due to altered physiology, functional and cognitive impairment, multiple coexisting diseases, increased side effects from treatment, and greater need for social support.
The committee proposes a conceptual framework for improving the quality of cancer care (see figure). It comprises six interconnected components: (1) engaged patients; (2) an adequately staffed, trained, and coordinated workforce; (3) evidencebased care; (4) learning health care information technology (IT); (5) translation of evidence into clinical practice, quality measurement and performance improvement; and (6) accessible and affordable care.
Engaging Patients, Developing a Coordinated Workforce
In a high-quality cancer care delivery system, cancer care teams should support all patients in making informed medical decisions by providing patients and their families with understandable information at key decision points on such matters as cancer prognosis, treatment benefits and harms, palliative care, psychosocial support, and costs of care. To reach this goal, the committee recommends that the federal government work with other stakeholders to improve the development and dissemination of this critical information, using decision aids when possible. And professional educational programs should provide cancer care team members with formal, comprehensive training in communication.
Patients with advanced cancer should receive end-of-life care consistent with their needs, values, and preferences. This will require cancer care teams to revisit and implement patients’ advance care plans—which detail the type of care patients would want to receive if they become unable to speak for themselves—and to place a primary emphasis on palliative care, psychosocial support, and timely referral to hospice for end-of-life care.
High-quality cancer care is provided by diverse teams of professionals. The cancer care team, in coordination with primary/geriatrics teams and specialist care teams, should implement patients’ care plans and deliver comprehensive, efficient, and patient-centered care. To promote such teams, federal and state legislative and regulatory bodies should eliminate reimbursement and scope-of-practice barriers to team-based care, and academic institutions and professional societies should develop interprofessional education programs to train the workforce in team-based cancer care.
Moreover, it is critical that cancer care delivery organizations require members of cancer care teams to have the necessary skills to deliver highquality cancer care, as demonstrated through training, certification, or credentials.