Improving cancer care through quality measures: Putting evidence to work with the CoC

Table 1: Organizations involved in defining and measuring breast cancer quality care

  • ACS CoC
  • ACS National Accreditation Program of Breast Centers
  • Quality Oncology Practice Initiative of the American Society of Clinical Oncology
  • American Society of Breast Surgeons
  • Society of Surgical Oncology
  • American Society for Radiation Oncology
  • NQF
  • Physician Quality Reporting System of the Centers for Medicare and Medicaid Services
  • PPS-Exempt Cancer Hospital Quality Reporting Program mandated under the Affordable Care Act
  • American Medical Association Physician Consortium for Performance Improvement
  • College of American Pathology
  • National Comprehensive Cancer Network
  • National Consortium of Breast Centers

The emphasis on quality health care has continued to increase in recent years in the U.S. However, defining and then measuring quality fairly and appropriately can be a challenge, and keeping up with the large number of organizations involved in this evolving process can be daunting. Cancer and specifically breast cancer quality measures are being developed by a host of often jointly collaborating organizations and subsidiary groups (see Table 1), and the types of quality measures for breast cancer may be grouped into at least six general categories (see Table 2).

Strong evidence has emerged from prospective, randomized trials and other high-quality clinical research in oncology, which is useful in determining the optimal treatment currently available—not just for each major cancer type, but for each stage of each disease site. This evidence serves as the basis for detailed, accessible national guidelines for cancer care, such as those that the National Comprehensive Cancer Network (NCCN) has developed.

However, inconsistencies in care persist across the country, resulting in some patients being unable to receive the proven and optimal care that would maximize their outcomes. If all patients with a cancer diagnosis had access to and were offered the evidence-based care they deserve, outcomes would improve and fewer patients would die from cancer without any additional breakthrough in treatment. To achieve this goal, the development, measurement, and reporting of quality measures in cancer care are necessary. Increasingly, insurers, accrediting bodies, the federal government (the largest insurer), and the public expect us to find ways to measure quality, report our outcomes, and minimize deviations from evidence-based care.

Raising the bar

The American College of Surgeons (ACS) Commission on Cancer (CoC) collects more than 100 individual data points regarding the treatment of every cancer patient at more than 1,500 CoC-accredited hospitals. Certified cancer registrars collect and submit the data. CoC hospitals treat approximately 70 percent of all new patients diagnosed with cancer annually in the U.S. The data collected resides in the National Cancer Data Base (NCDB), which contains the records of more than 30 million cancer patients. Long-term follow-up also allows the examination of survival rates. In addition to emerging as a powerful tool for research and national cancer control efforts, the NCDB enables the CoC to measure and report specifics of cancer care individually to CoC-accredited hospitals.

The CoC has adopted a panel of clinically proven, specific quality measures and provides this information to participating hospitals. The CoC also submits appropriate measures to the National Quality Forum (NQF) for potential endorsement. CoC quality measures currently address cancers of the breast, lung, esophagus, stomach, colon, and rectum. New measures are planned, which will address other disease sites including melanoma, sarcoma, gynecologic, and urologic. These measures will be adopted in collaboration with leaders from premier disease-site societies in each field.

Table 2: Categories of quality measure for breast cancer

  • Breast cancer risk assessment
  • Appropriateness of care (diagnostic and imaging, pathologic, surgical, medical, radiation, and follow-up)
  • Timeliness of breast cancer care
  • Patient-centered satisfaction with care
  • Treatment-related complication rates
  • Breast cancer care outcomes (recurrence and survival)

CoC quality measure categories

Three levels of quality measures are considered: accountability, quality improvement, and surveillance. Accountability measures are supported by the highest level of medical evidence (usually prospective randomized clinical trials), indicating that it is appropriate to expect nearly all patients to be considered for the treatment. Quality improvement measures are strongly supported by the literature and are considered optimal care, but supporting evidence often is less definitive than for accountability measures. Finally, surveillance measures report patterns of care that the CoC believes hospitals should monitor, but for which no optimal pattern of care is known, and for which patterns of care may vary for legitimate reasons.

The CoC has adopted five breast cancer accountability or quality improvement measures and the NQF has endorsed four of them. These four NQF-endorsed measures are summarized in Table 3. The fifth breast quality measure that the CoC has adopted states that patients undergoing mastectomy and having four or more positive lymph nodes should be offered radiation therapy in addition to the surgical procedure. This measure will be submitted for NQF consideration this year.

The CoC confidentially reports compliance levels with quality measures to all 1,500 accredited hospitals. However, federal law mandates public reporting of compliance with two of the NQF-endorsed breast cancer quality measures (NQF 0220 and 0559 from Table 3) for 11 prospective payment system (PPS)-exempt cancer hospitals starting in 2014. This “report card” of quality measure compliance for the 11 PPS-exempt hospitals will be available for public review on the Medicare Hospital Compare website at

Through collaboration with societies devoted to breast surgery, radiation oncology, and medical oncology, additional breast cancer measures will be adopted. Lastly, collaboration with the Alliance for Clinical Trials in Oncology will ensure the more rapid incorporation of new knowledge and development of important quality measures to facilitate timely practice implementation.

Table 3: Four NQF-endorsed CoC breast cancer measures (as of October 2012)*

  • Post-breast conservation surgery irradiation:
    Percentage of female patients, age 18 to 69, who have their first diagnosis of breast cancer (epithelial malignancy), at American Joint Committee on Cancer (AJCC) stage I, II, or III, receiving breast conserving surgery, who receive radiation therapy within one year of diagnosis (NQF 0219)
  • Adjuvant hormonal therapy:
    Percentage of female patients, age 18 and older at diagnosis, who have their first diagnosis of breast cancer (epithelial malignancy), at AJCC stage I, II, or III, whose primary tumor is progesterone or estrogen receptor-positive recommended for tamoxifen or third-generation aromatase inhibitor (considered or administered) within one year of diagnosis (NQF 0220)
  • Combination chemotherapy is considered or administered within four months (120 days) of diagnosis for women under age 70 with AJCC T1c, or stage II or III hormone receptor-negative breast cancer:
    Percentage of female patients, age 18 and older at diagnosis, who have their first diagnosis of breast cancer (epithelial malignancy), at AJCC stage T1c, or stage II or III, whose primary tumor is progesterone and estrogen receptor-negative recommended for multi-agent chemotherapy (considered or administered) within four months (120 days) of diagnosis (NQF 0559)
  • Needle biopsy to establish the diagnosis of cancer precedes surgical excision/resection:
    Percentage of patients presenting with AJCC stage group 0, I, II, or III disease, who undergo surgical excision/resection of a primary breast tumor, who undergo a needle biopsy to establish diagnosis of cancer preceding surgical excision/resection (NQF 0221)
*National Quality Forum. Endorsement summaries. Available at: Accessed June 13, 2013.

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