The new Chair of the American College of Surgeons (ACS) Commission on Cancer (CoC), Lawrence N. Shulman, MD, FACP—the first medical oncologist to lead the Commission—aims to continue the CoC tradition of being the standard-bearer for high-quality cancer care while using his experiences as a clinical oncologist and health care organization leader to further advance the program.
Dr. Shulman’s October 2016 election to lead the CoC, the multidisciplinary consortium of health care organizations that the ACS established in 1922 to improve the quality of oncologic care, speaks to an accomplished career in comprehensive cancer care. He currently is deputy director for clinical services, Abramson Cancer Center; director, Center for Global Cancer Medicine, University of Pennsylvania (UPenn); and professor of medicine, Hospital of the University of Pennsylvania Perelman School of Medicine, Philadelphia. In addition to being an active practice physician since graduating from Harvard Medical School, Boston, MA, in 1975, he was a key participant in several clinical innovations while he practiced for affiliated Harvard Medical School hospitals. Examples include leading the development of the Harvard Community Health Plan’s first dedicated hematology-oncology unit; leading a team to develop one of the first computerized chemotherapy order entry systems in the U.S. at Brigham and Women’s Hospital, Boston; leading the development of multidisciplinary disease-based clinical programs and quality programs at Dana-Farber Cancer Institute, Boston; and leading the development of a nationally recognized cancer care network throughout New England via the Dana-Farber/Brigham and Women’s Cancer Center.
Since joining UPenn in 2015, he has served as the lead for clinical cancer services for all the university’s hospitals, a role that parallels his responsibilities as Chair of the CoC. “At UPenn, I share responsibility for operations, quality, cost negotiations with payors, and other related activities. In several ways, my work with the Commission is a reflection of the work I do at my home institution,” Dr. Shulman said.
Dr. Shulman served on the American Society of Clinical Oncology (ASCO) Quality of Care Committee, eventually as its chair. Partly based on this work, ASCO nominated him to be one of their two representatives on the CoC. Dr. Shulman’s work in quality for ASCO contributed to his selection as Chair of the CoC Quality Integration Committee. Due to his success in that role, he was nominated and elected as CoC Chair.
David P. Winchester, MD, FACS, Medical Director for ACS Cancer Programs, noted the significance of Dr. Shulman’s election: “Dr. Shulman was selected from a large group of surgeons and other cancer professionals as the first medical oncologist in the history of the CoC to serve in this important leadership role. Since assuming this position in October 2016, Dr. Shulman has demonstrated a broad knowledge of the workings of a complex organization dedicated to the cancer patient. His leadership crosses all disciplines related to cancer,” Dr. Winchester said.
Beyond his extensive clinical and leadership background in cancer care, Dr. Shulman’s tenure as Chair of the CoC’s Quality Integration Committee and his prominent role in developing quality cancer infrastructure in low-resource settings around the world are unique experiences that provide context for his appointment and for the importance of developing, maintaining, and advancing cancer care in the U.S. and globally.
Developing the CQIP report
In the modern health care landscape, “quality” is the unifying watchword for physicians, patients, and health care organizations. The College has a leading presence in the area of surgical quality improvement through several programs, such as the ACS National Surgical Quality Improvement Program and the Trauma Quality Improvement Program. That commitment to quality improvement also is apparent in the CoC through its National Cancer Database (NCDB) and Cancer Quality Improvement Program (CQIP).
CQIP is a product of the Quality Integration Committee, which Dr. Shulman chaired from 2013 to 2016. The period during which he presided over the committee was significant, as the first CQIP report was released in 2013 to the more than 1,500 CoC-accredited cancer centers in the U.S. The cancer data in the CQIP 2013 report were far-reaching and novel in a report of this size, providing short- and long-term quality and outcomes data, which Dr. Shulman and the CoC maintain are particularly useful when delivered directly to the centers. “There’s a tremendous amount of data that we thought needed to be codified and sent out to the programs to say, ‘You need to look at all these data and share them throughout your program and hospital,’” he said.
“We felt these data should be seen by the registrars and the cancer committees of the individual hospitals, but also by the leadership of the hospitals, including the chief executive officer, chief financial officer, chief operating officer, and so on. We put together a report that focused on a number of quality metrics, including the ones we routinely measure, and started increasing that number,” Dr. Shulman said. “We looked at 30- and 90-day surgical mortality for six complex cancer surgeries. We looked at both unadjusted and risk-adjusted survival for a number of the more common cancers and a number of other parameters, including insurance status, miles traveled to the cancer center, and the time from diagnosis to first treatment.” Disbursing these data directly to the cancer centers and to all levels of leadership allows for a level of standardized quality control that previously would have been impossible. And using these data is not only a suggestion—since the first CQIP report was released, the requirements for CoC reaccreditation have included bringing in hospital leadership to understand the data and providing evidence that the organization is actively applying the data in their treatment centers.
In developing the CQIP report, the Quality Integration Committee also worked to develop disease- and condition-specific quality metrics and collaborated with specialty organizations to be sure they harmonized with quality efforts from the CoC’s partners. “For example, when we developed bladder cancer quality metrics, we partnered with the American Urological Association; when we did melanoma metrics, we partnered with the Society for Surgical Oncology; and so on. We didn’t want these to be done by the Commission in isolation—we wanted these to be done with our fellow organizations, to capitalize on their expertise, and to gain consensus,” Dr. Shulman said.
He also worked to develop a group of Commissioners, now known as Site-Specific Leaders, who had expertise in those disease groups so that the CoC can link with the specialty societies and act as resources for the NCDB staff when they have disease-specific questions.
Global cancer care development
Cancer care in the U.S. and other developed nations is a sophisticated, multidisciplinary process that has built upon more than a century of medical infrastructure. But cancer is a global health care issue, and despite its omnipresence in the developed world, its burdens are felt disproportionately in low-income, low-resource areas and countries, which are often ill-equipped to handle the patients it afflicts.
To address these disparities, Dr. Shulman has dedicated a significant share of his career to improving cancer care in several under-resourced countries. He entered this field by way of two well-known names in global health care—Paul Farmer, MD, PhD, Kolokotrones University Professor of Global Health and Social Medicine, Harvard Medical School, and Jim Yong Kim, MD, PhD, President of the World Bank. Drs. Farmer and Kim co-founded Partners in Health (PIH), a not-for-profit health care organization that brings modern medical interventions to low-resource settings. Both were trainees under Dr. Shulman’s supervision at Harvard Medical School in the late 1980s.
“Paul was working in Haiti primarily through the 1990s and early 2000s, and he would call me about cancer patients who would show up at his clinic,” Dr. Shulman said. “In 2008, he and [Dr.] Kim contacted me and asked if I could help to set up cancer care infrastructure in Rwanda and Haiti, and I said yes.” Dr. Shulman has been materially involved with the work as PIH’s senior oncology advisor since 2011. Through a partnership with the Dana-Farber Center for Global Cancer Medicine, of which he has been director since 2012, Dr. Shulman and PIH have been able to establish comprehensive cancer care centers in Rwanda and Haiti.
The Butaro Cancer Center of Excellence, Burera, Rwanda, which opened in 2012, has been a notable success for the Center for Global Cancer Medicine, Dr. Shulman said. It is a primary cancer treatment center for the nation, providing treatment at no cost to patients. In addition to patient care, oncologists from Dana-Farber work closely with Rwandan physicians via weekly consults, and clinicians from Dana-Farber, UPenn, and Dartmouth College’s Geisel School of Medicine, Hanover, NH, regularly make extended consulting visits.* The center provides treatment to approximately 1,500 new patients a year and, to date, has taken care of more than 5,000 patients since it opened. “I think the center has become a model for what you can do in a very resource-constrained setting, which Rwanda clearly is,” Dr. Shulman said.
The center at the Hôpital Universitaire de Mirebalais, Haiti, also has brought much-needed care to a region that historically has lacked it, but the journey was more complicated because of the 2010 earthquake that ravaged the country. “At the time the earthquake occurred, we were building a small hospital to take the place of the clinic in Cange [the site of the original PIH location], where Paul had originally worked,” Dr. Shulman said. “The government came to us and asked us to help build a national hospital,” he said, which turned out to be the Hôpital Universitaire de Mirebalais that opened in April 2013. As in Rwanda, Dana-Farber clinicians and staff assist with treatment, train local physicians and nurses, and lay the groundwork for cancer care.† Treatment is, again, provided free of charge.
As director of the UPenn’s Center for Global Cancer Medicine, Dr. Shulman now leads the cancer care program in Botswana, a nation in which UPenn has had a presence in other medical areas for 15 years. Dr. Shulman’s expertise in medical oncology has allowed them to expand their former human immunodeficiency virus-focused treatment to include cancer care, and his ties with PIH have opened their sites to UPenn trainees, students, and staff of all levels.
Identifying gaps, increasing value
Dr. Shulman was elected to head the Commission at a time of considerable change in U.S. health care. Aside from broader political uncertainty regarding health insurance coverage, “The challenge that is facing us as a nation is the intersection between quality and cost,” Dr. Shulman said, and attempting to increase the former without increasing the latter. His goals as Chair, and the direction of the CoC’s attention, will in part be dedicated to balancing the two sides of the health care equation to provide the greatest value to patients.
Part of understanding where the CoC should be heading involves looking into cancer care in the U.S. and seeing the areas where it is lacking—where quality could be better—and developing interventions to improve care and increase value. “There are areas where we aren’t doing as well as we could,” Dr. Shulman said. “Rectal cancer, for instance, is one of those areas where we can see that treatment is more consistently of higher quality in Europe than in the U.S., which is an unnerving finding.” To increase the quality of cancer care in the U.S., the CoC plans to launch the National Accreditation Program for Rectal Cancer (NAPRC) this year. As the ACS National Accreditation Program for Breast Centers does for breast cancer, the NAPRC will accredit cancer centers that hold to high standards of rectal cancer treatment. As Chair, Dr. Shulman wants to identify other areas in which cancer care is of variable quality.
Another area where Dr. Shulman believes the CoC can play a more direct role in addressing quality and cost concerns is with oncology medical home accreditation. An oncology medical home is a primary oncologist or oncologic practice that acts as the focal point for coordinating the patient’s comprehensive cancer care. Having a dedicated coordinator for patients’ cancer treatments and the processes in place to better care for patients can have a positive effect on quality, efficiency, and cost of care.‡ “This Commission hasn’t been very involved in that space previously, but we did a pilot test of Oncology Medical Home accreditation visits, which is in the domain of trying to improve quality and cost effectiveness of care,” Dr. Shulman said. The CoC has performed approximately 10 pilot surveys and is now determining whether to pursue the program on a national scale.
The CoC also has been engaged in ongoing talks with national payors and insurers, such as Blue Cross Blue Shield Association, about what they can learn from the organization about measuring quality and how it relates to cost. Dr. Shulman believes that the CoC, a national leader in driving quality of cancer care, needs to stay relevant in the quality and cost space. “We have over 1,500 accredited hospitals, which covers about 70 percent of cancer patients in the U.S. There’s no other organization that’s attached in such a direct way to the performance of so much of cancer care in the country,” Dr. Shulman said. “I think we’re in a special position where we can both influence the direction of cancer care and try to help solve some of the overarching problems in U.S. health care, as well.”
*Dana-Farber Cancer Institute. Center for Global Cancer Medicine: Rwanda Partnership. Available at: www.dana-farber.org/Adult-Care/Treatment-and-Support/Treatment-Centers-and-Clinical-Services/Center-for-Global-Cancer-Medicine.aspx#Rwanda_Partnership. Accessed May 18, 2017.
†Dana-Farber Cancer Institute. Center for Global Cancer Medicine: Haiti Partnership. Available at: www.dana-farber.org/Adult-Care/Treatment-and-Support/Treatment-Centers-and-Clinical-Services/Center-for-Global-Cancer-Medicine.aspx#Haiti_Partnership. Accessed May 5, 2017.
‡Community Oncology Alliance. Oncology Medical Home Initiative: Overview. Available at: www.medicalhomeoncology.org/UserFiles/COA_Oncology_Medical_Home_Initiative_9-21-12.pdf. Accessed May 18, 2017.