Dr. Shulman is Deputy Director, Clinical Services, and Director of the Center for Global Cancer Medicine, Abramson Cancer Center; and Professor of Medicine, Hospital of the University of Pennsylvania, Philadelphia.
Lawrence N. Shulman, MD
IN 2008, WHEN ALLEN LICHTER, MD, FASCO, then Chief Executive Officer of ASCO, called and asked me to be the ASCO representative to the Commission on Cancer, I had little idea of what this meant and the road it would take me on. But I was not one to refuse Allen. The journey since has been both engaging and challenging. I knew the Commission on Cancer was the accrediting body for hospital cancer programs, and I knew it had standards and quality metrics against which programs were assessed, but beyond that, the Commission on Cancer was a mystery to me. The year 2008 was the same year I joined ASCO’s Quality of Care Committee and became its Chair in 2011. In 2013, I became Chair of the Commission on Cancer’s Quality Committee.
I have been a devoted ASCO member for more than 30 years, and in my opinion the impact of ASCO on our field is immeasurable. However, it wasn’t until the early 2000s that ASCO really began to focus on quality and care delivery and how it might impact oncology practice in a broad way. The Quality Oncology Practice Initiative (QOPI®) was an ambitious undertaking that very quickly worked its way into the fabric of so many oncology practices. During my tenure on ASCO’s Quality Committee, I was able to participate in QOPI’s development first hand. QOPI remains a mainstay of ASCO’s quality work, focused on physician practices, but it also remains a voluntary process. We are grateful so many oncology practices participate.
The QOPI program has a plethora of quality measures to use, and traditionally they have been assessed by patient chart audits on a representative sample from a practice. There are two aspects to QOPI—participation and certification. Practices can participate but not seek certification, which requires an audit and practice assessment, or do both.
“The Commission on Cancer is in a unique position to change practice broadly across the United States with the institution of new standards and quality measures.”— Lawrence N. Shulman, MD
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Introduction of Quality Metrics
AT THE SAME TIME, the Commission on Cancer began to introduce quality metrics into its accreditation program. There are several key differences between the programs that are worth noting. The Commission on Cancer has many fewer quality measures, but they are all meant to be derived from data present in hospital cancer registries and the National Cancer Database, which is a compilation of registry data from all 1,500 Commission on Cancer–accredited hospital cancer programs. The quality measures assess all patients eligible and treated at the individual program and are derived automatically from National Cancer Database. In addition, a subset of Commission on Cancer quality measures are accountability measures, and programs must meet them or address deficiencies in the course of accreditation.
In 2016, I was elected Chair of the Commission on Cancer, a 2-year term with potential renewal for an additional 2 years. I accepted this honor and responsibility because I believe in the Commission on Cancer mission: The Commission on Cancer is a consortium of professional organizations dedicated to improving survival and quality of life for cancer patients through standard-setting, prevention, research, education, and monitoring of comprehensive quality care. The Commission on Cancer sits under the auspices of the American College of Surgeons, is strongly supported by the American Cancer Society, and includes representatives from 57-member organizations (including ASCO), which span both cancer-related professional societies as well as patient advocate groups. When the Commission on Cancer was formed in 1922, surgery was the only treatment option for patients with cancer, thus its position under the American College of Surgeons. Now, obviously, cancer is a highly multidisciplinary disease, and the current composition of the Commission on Cancer reflects that.
Changing Practice Through New Standards and Quality Measures
ACCREDITATION BY the Commission on Cancer is valued by many hospital cancer programs, as evidenced by the fact that 1,500 hospitals voluntarily undergo accreditation and work to meet the necessary standards. This gives the Commission on Cancer a wide breadth of influence over cancer care in the United States. The Commission on Cancer is in a unique position to change practice broadly across the United States with the institution of new standards and quality measures.
One example is a quality measure requiring 12 or more regional lymph nodes be removed and analyzed in colon cancer resections. When this measure was introduced in 2003, roughly half of the patients in Commission on Cancer–accredited programs met this standard, which was routinely reported back to all cancer programs. In 2015, more than 90% of patients meet this metric.
“Our field is continually evolving, and quality standards must match that evolution.”— Lawrence N. Shulman, MD
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Another example of the influence of the Commission on Cancer is the adoption of synoptic pathology reports. The College of American Pathologists (CAP) developed synoptic reports to improve the reading and reporting of cancer pathology, but initially they were inconsistently utilized. CAP is represented on the Commission on Cancer, and Standard 2.1 was created; it reads: “The Commission on Cancer requires that 95% of eligible pathology reports that include a cancer diagnosis are formatted using synoptic reporting and incorporate the required data elements outlined in the current applicable surgical case protocols and summary checklists of the College of American Pathologists publication, Reporting on Cancer Specimens.” This standard led to rapid implementation of the CAP synoptic reports, with high rates of utilization.
Similarly, in 2012 the Commission on Cancer created a Standard 3.3, which required, beginning in 2015, a subset of patients with cancer treated with curative intent to receive a treatment summary and survivorship care plan. The landmark Institute of Medicine report “From Cancer Patient to Cancer Survivor: Lost in Transition” was published in 2005, but few cancer programs had followed its recommendations. Adoption of this standard, though, caused all Commission on Cancer-accredited programs to address these issues for our cancer survivors. Data from 2015 and 2016 show that some programs have met the standard, whereas others have struggled.
Debate Over Survivorship Care Plans
ALTHOUGH IT was clear this standard had gotten the attention of the 1,500 Commission on Cancer–accredited hospitals, the structure of the standard and the validity of it were questioned. Some thought there was not sufficient evidence to support the use of survivorship care plans, and others thought all patients should receive one, and anything less than that reflected not meeting all patients’ needs. In response, the Commission on Cancer held roundtable discussions among its members, representing a broad array of stakeholders. In addition, the leadership of the Commission on Cancer, including me, met with the ASCO Survivorship Committee and engaged in a robust discussion of the current state of programs attempting to address this standard, and of potential roads forward. In the summer of 2017, the Commission on Cancer participated in a special National Cancer Policy Forum workshop on survivorship, where this dialogue was continued.
With input from these forums, the Commission on Cancer retained the standard as part of its accreditation process. In addition, the percent of patients treated with curative intent who needed to receive a survivorship care plan was capped at 50%, which in the short term was thought to reflect an attainable goal. Finally, there was a strong consensus that delivery of a survivorship care plan was not sufficient and that cancer programs would be required to designate a survivorship coordinator, form a survivorship committee to work with the coordinator, and produce an annual report outlining currently available survivorship service as well as plans for the future to enhance those services.
This process reflects the Commission on Cancer approach to all standards. They are continually reviewed and evaluated, particularly in regard to their import for a high-quality cancer program. Our field is continually evolving, and quality standards must match that evolution. Both the Commission on Cancer and ASCO play important roles in assessing and improving cancer care in the United States, in complementary ways. The quality work of both organizations must go on. ■
DISCLOSURE: Dr. Shulman reported no conflicts of interest.
Disclaimer: This commentary represents the views of the author and may not necessarily reflect the views of ASCO or The ASCO Post.