Initial management of breast and colorectal cancer care in the United States is generally "consistent with evidence-based practice," but with substantial variations in quality across the nation and low adherence in many quality measures that suggest "opportunities for improvement."

Those are conclusions from the National Initiative for Cancer Care Quality (NICCQ) nationwide study lead by the American Society of Clinical Oncology (ASCO). The study was undertaken in response to a 1999 report by the Institute of Medicine that recommended establishing a quality monitoring system for cancer care. The NICCQ results were published online this month in advance of the February 1 issue of ASCO's Journal of Clinical Oncology.

NICCQ examined patterns of care for 1,287 breast cancer and 478 colorectal cancer patients in 5 U.S. cities (Atlanta, Cleveland, Houston, Kansas City, and Los Angeles). To evaluate patient care, the researchers developed "explicit quality measures" of care for breast (36 separate measures) and colorectal (25 measures) cancers spanning diagnosis, surgery, adjuvant therapy, managing treatment toxicity, and posttreatment surveillance. Patients were then surveyed and provided permission for researchers to review their medical records.

Based on that review and those measures, NICCQ found that breast cancer patients received 85 percent of recommended care and colorectal patients received 77 percent of recommended care. Compared with prior studies, NICCQ results "show strikingly higher adherence to processes of care believed to be essential for improving the outcomes of patients with breast and colorectal cancer," the researchers summarize. These overall rates of adherence are also higher than those found for care of other noncancer chronic diseases. The researchers note, "It may be that the urgency of a new diagnosis of cancer focuses the attention of patients and providers on assuring treatment in a way that chronic diseases, especially silent ones such as hypertension or diabetes, cannot."

Nonetheless, "given adherence rates of less than 85 percent on almost half of the quality measures, our results suggest many opportunities to improve the quality of cancer care," the investigators add. For example, although most of the patients received proper adjuvant chemotherapy after surgery, "patients were often not prescribed a dose of the chemotherapy that was consistent with published regimens, and many began therapy more than 8 weeks after surgery."

Further, there was significant variation - as much as a twofold difference in some measures - in adherence across the five metro areas for seven of the breast cancer quality measurements and one of the colorectal treatment standards, although no city showed consistently higher adherence than the other locales. As an example, the proportion of breast cancer patients who received proper adjuvant chemo doses ranged from 32 to 75 percent among the five metro areas.

"Viewed from the perspective of the patient with breast or colorectal cancer, a person with a new diagnosis of cancer has approximately a one in five chance of failing to receive elements of cancer care consistent with the best evidence in the literature and expert-defined standards of clinical practice," the NICCQ researchers conclude.

NCI Deputy Director and Deputy Director for Cancer Care Delivery Systems Dr. Mark Clanton applauded the NICCQ study as the first comprehensive study of cancer quality-of-care issues. It provides new insights to help steer NCI's strategic initiatives to provide "leadership and research focus that analyzes the systems by which care is delivered and to make quality cancer care more accessible to all patients, especially the underserved and disadvantaged populations," Dr. Clanton noted.

By Bill Robinson