New York State Comprehensive Cancer Control Plan

III. Treatment

The ability to provide effective, high quality, accessible and affordable treatment to people

with cancer is an essential component of cancer control, with profound implications that can include the difference between life and death, or temporary and permanent disability. Treatment is interwoven with many other areas of focus in this Plan, including quality of life, palliative care, and health personnel. An optimal treatment plan will incorporate all stages and levels of care and will be concerned with the coordination and integration of medical, social, psychological and community provider contributions. At the center of this is the person living with cancer.

In New York State, there is a large and sophisticated treatment system that expends approximately $4 billion annually.1 The primary treatment modalities for cancer are surgery, radiation, and chemotherapy. Tens of thousands of doctors, nurses, radiologists, and others provide cancer-related care. Most of the 250 hospitals in NYS treat cancer patients in addition to numerous outpatient chemotherapy and radiation treatment sites. The dollars expended on cancer treatment services by the public far surpasses the expenditure of funds on preventive and early detection measures.

To further improve quality, this chapter advocates a system in which evidence-based standards of care are utilized in treatment decisions, clinical guidelines are revised and used as appropriate by health care providers as part of continuous quality improvement, cancer patients provide input about their satisfaction with the services they receive (this information will then be utilized to make changes, when needed), patients and primary care doctors have access to cancer care specialists, and updated information on the efficacy of treatments tested via clinical trials is available to providers and consumers, among others. Such a form of cancer control is fundamental to the principles established for clinical practice.2,3

Physicians, public health practitioners, policy makers and health care consumers are deluged with information about the best approaches to prevention, treatment and health care delivery. Evidence-based medicine has the goal of helping providers and consumers make informed decisions about prevention and treatment based on the best available scientific evidence. The strategies outlined in this chapter provide a basis for maximizing our efforts to address cancer through improved evidencebased medicine.

The National Cancer Institute (NCI) has also recognized the need to develop standards of care that acknowledge best practices and work toward national norms. To that end, NCI is working with other partners to track quality of care through a new initiative, the Cancer Care Outcomes Research and Surveillance Consortium. Policy and practice guidelines are expected to result when a link between care and outcomes can be better quantified and qualified.4

Many improvements in public health and health care delivery have been achieved, including increased professional expertise, improved understanding of the complexities of delivering community-based services and greater availability of program results through evaluation. Such improvements have reinforced the value of coordinated cancer control programs. As we continue our efforts in strategic directions for New York State, we recognize that coordination of cancer control activities is essential to maximize resources and achieve desired cancer control outcomes.

Treatment values also extend beyond standards of care and best practices. The non-clinical factors of socioeconomic status, age at diagnosis, body image concerns, financial eligibility considerations, and cultural mores all influence the potential for compromised outcomes. The literature has demonstrated, in particular, that African Americans are 33% more likely than Whites to die from cancer.5 This appears to be associated with a lack of access to care and not to any higher predisposition to a negative cancer progression. Arecent issue of the Journal of the National Cancer Institute indicated that "... when African-American and White patients receive the same basic treatment for colon cancer, i.e. surgery followed by chemotherapy, they fare equally well." The Black males had a 65% overall survival rate compared to 66% for the White patients. The recurrence-free survival rate for the Black cohort was 57% contrasted with 58% for White patients.6

Treatment services are extensive in New York and accessible to most of our population Nonetheless, some shortages in New York may exist in certain areas, particularly the rural regions of the state. Further research to characterize the healthcare cancer workforce is needed. Financial access may also need to be addressed. Although approximately 85% of our population has public or private insurance coverage that will pay for most surgical, radiation and chemotherapy services, about 15% of our population has no insurance coverage for cancer treatment and a significant additional percentage has inadequate coverage.7

GOAL 1: QUALITY OF CARE: CURRENT TREATMENT

  • By 2010, increase the availability of the best cancer care to all New Yorkers.

STRATEGIES

  • Increase awareness among the public and providers of standards of care for effective treatment and quality cancer care.
  • Make information on cancer site-specific treatment options, benefits and disadvantages, survivorship issues and other information easily available to consumers.
  • Provide access to appropriate care for all age, racial, ethnic, geographic and socioeconomic groups.
  • Encourage quality of care programs at all treatment sites including studying the feasibility of utilizing American College of Surgeons (ACoS) certification of hospitals as a quality of care tool.
  • Test ways to increase use of clinical guidelines among providers and awareness of clinical guidelines among consumers.
  • Conduct research on and assessments of the quality of cancer treatment in New York State.
  • Identify and promote the use of age appropriate, culturally and linguistically appropriate information.
  • By 2006, increase cancer survivors’ satisfaction that cancer-related effects (e. g. pain, fatigue, nutrition) are managed effectively.

GOAL 2: COMPREHENSIVE SCOPE OF QUALITY OF CARE RESOURCES (see also Quality of Life Section)

  • By 2010, encourage best practice delivery systems recognizing the chronic nature of cancer, including ongoing supports and navigation for families, rehabilitation, education, social and legal services.

STRATEGIES

  • Develop ways for cancer survivors to routinely rate their satisfaction with cancer treatment services.
  • Engage cancer treatment facilities in plans to support and monitor cancer treatment across the continuum of cancer care.
  • Encourage cancer treatment facilities to develop active quality of care programs that engage and support people being treated and their caregivers.
  • Engage organizations to provide support for individuals without active caregivers who are under treatment for cancer.
  • Enhance access to supportive services including transportation, housing, nutrition, outpatient treatment and wellness programs.
  • The ability to provide effective, high quality, accessible and affordable treatment to people with cancer is an essential component of cancer control . . .
  • Disseminate materials relating to the short- and long-term effects of cancer treatment, targeting specific groups in need of this information (childhood cancer survivors, older women, etc.).
  • Encourage research on survivorship issues and the impact of different factors on outcomes.

The ability to provide effective, high quality, accessible and affordable treatment to people with cancer is an essential component of cancer control...

GOAL 3: QUALITY OF CARE: INTEGRATION OF SERVICES

  • By 2010, integrate existing cancer treatment services and develop strategies to reduce service gaps.

STRATEGIES

  • In rural areas, explore increasing the use of telemedicine as a way to document cancer treatment, data, support services, and financial help to improve the quality of cancer treatments.
  • Explore with managed care organizations, comprehensive case management to meet the range of patient needs.
  • Explore patient navigator systems that utilize a variety of cancer professionals, e. g. oncology social workers to ensure the seamless transition between services and agencies, and assess the costs and benefits (both medical and social) of case management/ health navigator models.
  • Encourage integrative care networks that coordinate the range of services required by patients.
  • Collaborate with health care providers throughout the state toward regional tumor boards and meetings of multidisciplinary teams to discuss treatment options for patients with challenging cancer cases.
  • Develop methodologies to assess the need for cancer services by type.
  • Review research findings and encourage the incorporation of evidence-based complementary and alternative therapies into cancer treatment plans.

GOAL 4: TREATMENT INFORMATION RESOURCES

  • By 2010, assess knowledge among, and information dissemination to, health providers and consumers.

STRATEGIES

  • Determine the baseline number of contacts to cancer information services in New York and track contact rates on an ongoing basis.
  • Identify networks of cancer specialists who can provide diagnostic and treatment consultation to primary care physicians in medically underserved areas.
  • Identify telecommunication systems among medical providers to facilitate their participation and collaboration in a provider network.
  • Identify systems for up-to-date information on clinical trials for health care providers and consumers.
  • Make available information related to age appropriate treatment, that is culturally and linguistically suited to target populations.
  • Make available current regional or local cancer resource catalogs/ directories that provide information on cancer institutions, specialists, providers, research, therapies, and support services, including financial.

An optimal treatment plan will be concerned with the coordination and integration of medical, social, psychological and community provider contributions.

GOAL 5: GEOGRAPHIC ACCESS TO CARE

  • By 2010, geographic access issues will be identified and reduced.

STRATEGIES

  • Determine the capacity of cancer treatment services by type throughout New York State.
  • Use existing data to evaluate cancer care by type of facility, geography, and other variables.
  • Define the essential components of a delivery system for cancer care that assures certain basic services are available locally, and more specialized services are reasonably accessible.
  • Assess regionalization of cancer services, beginning with treatment involving high risk, low incidence procedures.
  • Assess service availability and accessibility as related to the needs of vulnerable populations, such as immigrant populations, incorporating cultural sensitivity and ability to address language barriers effectively.

GOAL 6: FINANCIAL ACCESS TO CARE

  • By 2010, assure that high quality cancer treatment and services are accessible to New York State residents, regardless of socioeconomic status, geography or race/ethnicity.

STRATEGIES

  • Assess the availability of insurance coverage for cancer treatment.
  • Encourage health insurance and managed care plans to support prompt access to appropriate cancer treatment, supportive services and clinical trials.
  • Encourage managed care organizations to remove barriers to timely referral to out-of-network providers for medically appropriate care when necessary.
  • Promote reimbursement structures that facilitate access to multiple levels and loci of care, inclusive of all patient needs.
  • Use existing data to evaluate cancer care by type of facility, geography, and other variables.
  • Support educational and outreach efforts directed at prevention and early detection as promoted throughout this Plan.
  • Identify and promote the use of culturally and linguistically appropriate information.

References

  1. Figures extrapolated from data provided in American Cancer Society & New York State Department of Health, New York State Cancer Facts & Figures 2002. New York, NY. American Cancer Society, Eastern Division;2002.
  2. Guyatt G, Nishikawa JA. Proposal for enhancing the quality of clinical teaching: results of a department of medicine’s educational retreat. Medical Teacher; 1993(15):147-161.
  3. Rosenberg W, Donald A. Evidence based medicine: an approach to clinical problem solving. British Medical Journal; 1995(310):1122-1127.
  4. U.S. Department of Health and Human Services. 2001 Cancer Progress Report. Bethesda, MD: U.S. Department of Health and Humans Services, National Institutes of Health, National Cancer Institute;2001.
  5. Clegg LX, Li FP, Hankey BF, Chu K, Edwards BK. Cancer survival among U.S. whites and minorities: a SEER program population-based study. Archives of Internal Medicine; 2002(162):1985-1993.
  6. McCollum AD, Catalano PJ, Haller DG, et al. Outcomes and toxicity in Black and Caucasian patients in a randomized adjuvant chemotherapy trial for colon cancer. Journal of the National Cancer Institute;2002(94):1160-1167.
  7. U.S. Department of Health and Human Services. 2001 BRFSS Summary Prevalence Report. Atlanta, GA: U. S. Department of Health and Human Services, Centers for Disease Control and Prevention;2002.
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