Cancer Care Equity and Collaboration

Health care in the United States is extraordinarily variable, and that’s not confined to cancer care. Across the board nationwide, the care patients receive is often neither optimal nor guideline-concordant.

At the 2022 Oncology Clinical Pathways Congress, Lawrence N Shulman, MD, Abramson Cancer Center University of Pennsylvania, summarized the status of health care in the United States in his presentation, “How Can Pathways Be Leveraged to Improve Academic-Community Cancer Care Collaboration?”

“In maternal mortality, per 100,000 live births, the [United States] has much poorer statistics than our European colleagues,” Dr Shulman said, noting an almost 10-fold difference in the United States (19) as compared to Norway (2). “It’s incumbent upon us to try to figure out why this is. And the same things that apply to other medicines apply to cancer as well.”

Dr Shulman presented a study from the National Cancer Database displaying survival by hospital type for advanced lung cancer as well as survival rates in breast cancer. In addition to the varying survival rates, the study also noted that only 9% of the patients are treated in NCI-comprehensive cancer centers, 24% at academic centers, and 67% at community hospitals.

“That’s how it should be,” he said of the treatment locations. “We want patients to get high-quality care close to home, with doctors who they know.”

A study on the removal of 12 or more lymph nodes that were then analyzed for resected colon cancer showed not only that from 2003 to 2015 there was a steady increase in compliance among different types of care centers, but also that the gap between compliance narrowed considerably. This was a direct result of sharing data with the hospitals, which gave them the opportunity to make quality improvement interventions.

“Over 12 years, all hospital types showed improvements and the disparities between hospital types largely went away,” he said. “You give people back the data of how they’re doing, you set the standards, and you can do better. But I would argue that under very few circumstances do we give doctors back data about what they’re doing. We don’t give people back those data and I think that’s a big problem.”

It's particularly problematic in the complicated field of oncology, where new drugs are being rapidly developed and guidelines are constantly changing.

Dr Shulman pointed to a New Yorker article, The Bell Curve, which reenforced his interpretation that medical outcomes are the sum of many parts and details, people and systems are critical, and quality results are a confluence between people and systems. To expound on the final thought, Dr Shulman offered up an example of a pilot and his aircraft, where both need to be in top shape to be successful.

“The aviation industry has a remarkable safety record. But it relies on the individual excellence of the pilot and the systems, which is the plane,” Dr Shulman said. “You have a lousy pilot and a great plane, the outcome may not be all that good. If you can have an excellent pilot and but the plane is flawed, the outcome is also not likely to be all that good. And I think that’s very similar to the way we all now practice medicine.”

In cancer care, the therapies and systems are complex, which presents challenges for clinicians. The ideal is for systems to support, not thwart, high-quality care, so clinicians can focus on patients and their respective details, Dr Shulman said.

“I don’t think we’re anywhere close to that in medicine at this point,” he added. “The systems, in fact, are distractions and there are barriers to providing excellent care, and pathways are one of the steps we can take to get to the right place.”

Dr Shulman then discussed some potential solutions. “We need to start to work as networks,” he said. “Hospitals that bond together to work together to raise the level of care. But systems need to support the delivery of shared expertise, bilateral patient flow, and incentives.”

Pathways are a way to get there, Dr Shulman shared, but it’s critical that the four stakeholders—patients, clinicians, health system, and payers—are all considered in the creation of pathways.

He mentioned the University of Pennsylvania Health System’s Penn Cancer Service Line as an example of this. The service line consists of six hospitals and ambulatory and cancer centers, and all but one are in the same EHR, so the pathways work to quickly spread information throughout the system.

To create pathways, Dr Shulman suggested the option of buying “out of the box.” For the future, a potential wish list for pathway creation would include a tool integrated to the EHR that is standardized, reflective of both national guidelines and local practice preferences, is linked to order entry, is measurable, and is linked to payers for pre-authorization.

Quality care is the result of human expertise and systems, and neither will work well without the other, Dr Shulman concluded.