Every organization should periodically perform a self-evaluation of its mission and worth based on that mission. The Commission on Cancer (CoC) is marking its 100th anniversary—certainly a cause for celebration, but also a reason to reflect on its meaning and accomplishments. To begin this process, it is important to recall the CoC mission statement (see Figure 1).
To assess the overall performance of the CoC, this article identifies the topic areas and programs influenced by the CoC.
Value to cancer programs
Cancer programs clearly perceive value in the accreditation process, as 1,500 have voluntarily sought and received accreditation. This process involves considerable work on the part of the programs and requires a fee. CoC accreditation is not required by any regulatory agency and, therefore, cancer programs can provide care with or without accreditation equally. Therefore, these accredited programs have spoken through their actions in affirming the worth of CoC accreditation and its associated activities. Although individual programs will value different aspects of CoC accreditation, several features stand out (see Figure 2). They are:
- Assistance in establishing a cancer program structure
- Assistance in establishing services essential for cancer care
- External assessment of the program
- Data with which to assess quality performance against National Cancer Database (NCDB) benchmarks
- A framework to guide program development, and in this activity most constructively work with hospital administrators
No other organization in the U.S. provides these standards and guidance to cancer programs. Although the National Cancer Institute (NCI) evaluates large comprehensive cancer centers, these facilities represent only a fraction of the cancer programs in the U.S. and provide care for a small minority of cancer patients. NCI Comprehensive Cancer Centers need to meet certain quality metrics, but many of the metrics the CoC focuses on are not included in these evaluations; therefore, many of the NCI Comprehensive Cancer Centers voluntarily seek CoC accreditation as well. It is important to note that most cancer programs in the U.S. have only the CoC to look toward as a partner to assess program development and quality of care.
Quality metrics
The CoC establishes quality metrics that can be monitored through the NCDB. Cancer programs have their data for these metrics automatically transmitted to them, together with benchmarks that are considered as adequate performance standards as well as comparison performance of other CoC programs, including those in their region and programs of a similar size and type. By holding programs accountable and sharing these data, individual program performance can improve along with the overall performance of cancer programs across the U.S.
This ability to move the needle on quality cancer care was demonstrated by a study of the quality metric requiring that at least 12 regional lymph nodes be removed during a colon cancer resection. Between the time this metric was introduced in 2003 and 2015, there was substantial improvement in performance across all cancer program types. This metric also emphasized the need for a team approach to cancer care quality, requiring that the surgeon remove the necessary number of lymph nodes and the pathologist dissect and identify all of the lymph nodes removed. Both of these specialists came to understand that they collectively were responsible for performance and needed to work as a team.
Though this standard can be viewed as a way to help individual programs improve the quality of their care, it has a nationwide effect on the quality of cancer care. Because CoC-accredited cancer programs care for more than 70 percent of the cancer patients in the U.S., the benefit is substantial.
Program development
As part of the accreditation standards, programs are required to offer specific services to patients. These standards outline what are considered to be critical components of cancer care, and implementation of these standards has had a major impact on care delivery across the U.S. A prime example of an accreditation standard advancing care is that of care provided to cancer survivors. The Institute of Medicine’s (IOM’s) landmark report, From Cancer Patient to Cancer Survivor: Lost in Transition,* was published in 2006 and was a call for the establishment of cancer survivorship programs and the delivery of cancer survivorship care plans to all cancer patients.
In the years following the IOM report, few cancer programs in the U.S. developed survivorship programs and even fewer created survivorship care plans for their patients. In 2012, the CoC began development of Standard 3.3, which required the delivery of survivorship care plans to an increasing number of cancer patients treated with curative intent. This standard was introduced in 2015, and 1,500 cancer programs across the U.S. began tackling the challenge of developing these survivorship care plans.
The standard generated a tremendous amount of discussion and effort, along with considerable controversy about whether the need to deliver survivorship care plans was data-driven and how programs were to institute these plans from a practical point of view. What is not controversial is that this put cancer survivorship on the radar of the 1,500 CoC-accredited cancer programs, covering more than 70 percent of U.S. cancer patients. This standard generated a national reckoning about the survivorship care we were providing. The CoC standard was discussed at meetings organized by the National Cancer Policy Forum, American Cancer Society, American Society of Clinical Oncology, and NCI. This standard resulted in shared learning between cancer programs and the CoC and ultimately led to the CoC’s decision to continue the standard in revised form. Support for continuing the standard by a number of these stakeholder groups was an indication that the CoC was playing a crucial role in advancing survivorship care in the U.S.
NCDB
The NCDB exists only because cancer programs voluntarily agree to undergo CoC accreditation and submit cancer registry data. Without these programs, no data would be transmitted to NCDB. It is the most comprehensive cancer database in the U.S., with more than 35 million patient records. The NCDB makes possible the quality measures programs described earlier in this article, providing value to individual cancer programs and, as importantly, providing a broad view of cancer care across the U.S. These metrics enable clinical studies by providing a look at national performance around a quality measure (such as the colon 12 lymph node resection measure), which gives a unique window into national performance and its evolution.
Nothing is more powerful than data to both better understand the current state of care and identify gaps in care where interventions could be designed to improve outcomes for patients. Anecdotal opinions from health care professionals will always be met with skepticism and are unlikely to lead to meaningful change. Good data are hard to ignore and, in fact, beg to be addressed. NCDB has played a critical role in this regard.
The Participant User File (PUF) program has made NCDB data available to health services researchers at CoC-accredited programs. This data availability is another advantage of CoC accreditation. In the last several years, data obtained from the PUF program has led to hundreds of publications that rapidly have expanded our knowledge of cancer care in the U.S. for countless diseases and clinical scenarios. Studies from the PUF program have been presented at major scientific meetings and published in high-impact journals, reflecting the value of the data and the PUF program.
CoC as the convener of cancer care stakeholders
A unique and vital component of the CoC’s work is the convening of a large number of cancer care-related organizations to optimize care in the U.S. The CoC comprises more than 55 professional organizations and patient advocacy groups. This forum is truly unique, with no other similar forum that meets regularly and works together to evaluate and raise the level of cancer care in the U.S. Representatives from these organizations learn from each other and together drive the mission of the CoC. This diverse set of perspectives on cancer care ensures that the CoC can apply a holistic approach to its work. Member organizations have the opportunity to work on, and lead, specific committees, including Accreditation, Quality Integration, and Advocacy. When the accreditation standards were reviewed and revised, resulting in the release of Optimal Resources for Cancer Care, which took effect in January 2020, they represented the hard work of representatives from all of these organizations, which guaranteed a broad and balanced approach to the development of these standards.
Conclusion
The CoC occupies a unique position in cancer care in the U.S. in so many ways. No other organization has the breadth or impact of the CoC on cancer programs, stakeholder organizations, and cancer-related research. But most of all, its impact is felt by patients who have benefited directly from the resultant improvements in cancer care in this country.
*Institute of Medicine and National Research Council. 2006. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press. Available at: https://doi.org/10.17226/11468.
