Understanding high-quality cancer care

A summary of expert perspectives




The Institute of Medicine (IOM) report Crossing the Quality Chasm proposed 6 aims for high-quality healthcare: effective, safe, timely, efficient, equitable, and patient-centered, and emphasized care coordination. Through interviews with nationally recognized experts in healthcare quality, perspectives on barriers and facilitators to achieving these aims for cancer patients were elicited.


In all, 23 peer-nominated experts with diverse backgrounds in policy, healthcare, patient advocacy, and research were individually interviewed. They were asked about barriers and facilitators to achieving high-quality cancer care, and information technology or other innovations that might improve the quality of cancer diagnosis, treatment, and surveillance. Interviews were tape-recorded and transcribed. Two analysts independently reviewed and coded each transcript using ethnographic software to elucidate key themes.


The major perceived barrier to providing high-quality cancer care was unnecessary variation in cancer care because of lack of standardization or adherence to guidelines during diagnosis, treatment, and surveillance. Additional barriers included insufficient teamwork and communication among multidisciplinary care teams, lack of patient awareness and empowerment, diagnostic delays during provider transitions, and excessive reimbursement for treatment. Experts suggested improving cancer patients' experiences by standardizing care, adhering to guidelines, and using “patient navigators” and an interoperable electronic medical record accessible to patients and providers at multiple facilities.


Some of these solutions have been developed and tested, whereas others have not. It is hoped that these suggestions provide impetus for new research, accelerating progress toward achieving the IOM's vision for high-quality cancer care. Cancer 2008. © 2008 American Cancer Society.

The Institute of Medicine (IOM) report Crossing the Quality Chasm proposed 6 aims of high-quality healthcare.1 Care must be effective (based on best evidence), safe from avoidable errors, timely (avoiding unnecessary delays), efficient (avoiding or reducing waste), equitable regardless of sociodemographic characteristics, and patient-centered. Patient-centered care is based on physician–patient communication that elicits an understanding of the patient as a whole person, tailors care to patient preferences, and shares decision-making regarding treatment.2 These 6 aims were proposed for the quality of healthcare in general; however, they may be specifically applied to the quality of cancer care.

Although not among the 6 IOM aims, coordination of care across multiple providers and settings was prominent in the report. Mishaps, delays, and inefficiencies during transitions affect overall quality of care.1 Because multiple handoffs characterize typical cancer care, we included coordination of care as a seventh ‘aim’ for this study.

These 7 aims encompass major concerns regarding the quality of cancer care noted in previous reports.3 To explore the barriers to and facilitators of high-quality cancer care, we interviewed recognized experts in cancer care, cancer research, information technology (IT), and the quality of healthcare in general. We elicited their opinions on barriers and facilitators to achieving the IOM aims, and innovations (particularly those related to IT) that could potentially improve cancer care quality. Results from this study, along with data from a literature review, focus groups, and organizational site visits, will inform the development of a model to guide quality improvement in cancer care.


The study was supported by the Cancer Research Network (CRN), a National Cancer Institute (NCI)-funded consortium of 11 research organizations associated with nonprofit, integrated delivery organizations.4 Investigators from 4 CRN centers—Group Health, Henry Ford Health System, the Meyers Primary Care Institute of the Fallon Clinic and the University of Massachusetts, and Harvard Pilgrim Health Care—consulted on the study.

Interviews with national experts in cancer care were 1 source of information for an NCI contract to study cancer care quality. To identify potential experts, we reviewed the literature and solicited nominations from NCI and project consultants. We encouraged nominations from geographically diverse, national sources; few nominations were actually CRN participants. From the nominations, we identified 26 experts who could collectively provide broad-ranging perspectives on the quality of cancer care. The nominees included policy experts, cancer care providers, advocacy group leaders, and researchers.

We developed a semistructured, open-ended interview guide to elicit experts' opinions on major problems in cancer care quality, barriers contributing to those problems, facilitators that ameliorate the problems, and IT or other creative innovations that might improve quality across the continuum of care. We encouraged ‘out-of-the-box’ thinking, as many of the experts had experience in creating and testing new innovations in the quality of cancer care. Because end-of-life care has received such intensive scrutiny,5 the interview focused on phases of cancer care from initial suspicion through detection, diagnosis, acute treatment, and posttreatment surveillance.

We recruited participants through email and telephone communication; 23 (88%) agreed to participate. Three authors (E.A.B., L.T., C.W.) conducted telephone interviews with the 23 experts, whose areas of expertise are summarized in Table 1. Each respondent gave verbal informed consent for us to conduct and audiotape interviews. The Group Health Institutional Review Board approved the study procedures.

Table 1. Interviewees' Areas of Professional Expertise
Area of expertiseNo. of experts
Policy experts
 Cancer care3
 Patient advocacy3
Cancer care providers
 Veterans Affairs1
 Rural/nonurban oncology1
 Health plan oncology3
 Radiation oncology1
 Comprehensive Cancer Center clinical research1
 Cancer communications1
 Community-based clinical research3
 Health services3
Total no. of experts23

Using ethnographic software (Atlas.ti), we analyzed the transcripts of recorded interviews and interviewers' notes. Three investigators independently reviewed the same 3 randomly chosen transcripts identifying major and minor themes and integrated them into a coding scheme. Two of the investigators who conducted the analysis independently reviewed the remaining transcripts. To reach consensus on the coding scheme, each investigator coded half the transcripts using the same list of codes; then they coded the other's half to validate and further refine the codes. Once all transcripts were coded, we generated a list of dominant themes. All experts' names and organizations were anonymized in the analyses and final report.


Experts identified barriers and facilitators relevant to achieving all 6 IOM aims; Table 2 lists the barriers and facilitators by aim. Table 3 organizes experts' specific recommendations, including suggested IT innovations, by aim and 3 phases of cancer care—diagnosis, treatment, and follow-up. Below, we present the results by 5 key themes noted across the interviews: 1) lack of standardization and adherence to guidelines; 2) lack of teamwork and care coordination; 3) the importance of transitions during diagnosis; 4) lack of patient awareness and empowerment; and 5) impact of reimbursement on treatment.

Table 2. Dominant Barriers and Facilitators to the Institute of Medicine Aims for Providing High-Quality Cancer Care
Institute of medicine aimBarriersFacilitators
  1. EMRs indicates electronic medical records; IT, information technology.

Safe• Lack of standardization/adherence to guidelines• Published performance measures
• Lack of care documentation/tracking• EMRs
• Clinical trials that can be generalized to real-worldcircumstances
Effective• Lack of standardization/adherence to guidelines• Participating in clinical trials
• Lack of clinician awareness of new research onsymptoms and treatments• Outcome-based performance measures
• Money to support reviewing new research
Patient-centered• Patient anxiety• Patient navigators
• Lack of patient awareness and education• Social support from family/community
• Increasing patient awareness and empowerment
• Interactive websites
• Videos or other IT innovations that improve shareddecision making
• Quality-of-life performance measures
Timely• Difficulty in scheduling appointments• Online appointment scheduling
• Lack of patient awareness and education• Dedicated screening centers
• Lack of access to care
Efficient• Lack of standardization/adherence to guidelines• Risk-adjusted reimbursement system
• Incentives to conduct expensive procedures• Outcome-based performance measures
• Lack of clinician awareness of new research on symptomsand treatments
Equitable• Disparities in access to care among poor, uninsured andunderinsured, minorities, and rural patients• Telemedicine in rural areas
• Lack of patient awareness and education• Dedicated screening centers
• Improved access to information technology innovations
Coordinated• Inadequate coordination of care between all specialties involved• EMRs that integrate all care documentation
• Lack of care documentation and tracking• IT innovations that improve access to information
• Difficulty in scheduling appointments• Online appointment scheduling
Table 3. Potential Solutions and Innovations to Improve the Quality of Care During Key Phases of Cancer
Institute of medicine aimDiagnosisTreatmentFollow-up
  1. IT indicates information technology; EMRs, electronic medical records.

Safe• Use IT to provide automated warnings in pathology systems• Publicly report performance measures
• Use EMRs to provide warnings on medication interactions• Use EMRs to improve and standardizecare documentation
Effective • Develop a clinical trials consortium to increase access and standardization of care• Develop a clinical trials consortium to increase access and standardization of care
• Publicly report outcomes to increase patient expectations• Publicly report outcomes to increase patient expectations
Patient-centered• Use patient navigators to improve patients' access to information and provide emotional support• Use patient navigators to improve patients' access to information and provide emotional support• Use patient navigators to improve patients' access to information and provide emotional support
 • Measure and track quality of life• Measure and track quality of life
• Develop interactive websites that promote treatment planning and shared decision making 
• Use videos that explain pros and cons of treatment to improve shared decision making
Timely• Use telemedicine to facilitate pathology consults, treatment, and symptom management in rural areas• Use telemedicine to facilitate pathology consults, treatment, and symptom management in rural areas• Use telemedicine to facilitate pathology consults, treatment, and symptom management in rural areas
• Develop dedicated screening centers that let patients make appointments without referrals• Use EMRs to facilitate online appointment scheduling
Efficient • Develop a risk-adjusted reimbursement system that gives doctors incentives to care for patients, not just treat them 
• Publicly report performance measures
Equitable• Develop dedicated screening centers that let patients make appointments without referrals• Use telemedicine to facilitate treatment in rural areas 
Coordinated• Use EMRs to integrate all diagnostic, treatment, and follow-up information, and improve communication between oncologist and primary care physician• Use EMRs to integrate all diagnostic, treatment, and follow-up information, and improve communication between oncologist and primary care physician• Use EMRs to integrate all diagnostic, treatment, and follow-up information, and improve communication between oncologist and primary care physician

Lack of Standardization and Adherence to Guidelines

Experts noted wide variation in diagnostic testing, surgery, treatment for recurrent or late-stage disease, and care for posttreatment survivors. One expert stated that the choice of diagnostic test or treatment plan was very “provider-centric” and “that variability just leads to costs and errors.” The following statement describes how lack of standardization during diagnosis can also cause delays in diagnosis:

“The most urgent problem is variability in how patients … are … worked through the system when they need a diagnosis. Patients…go through all different methods of how they're tested … so some people…move very quickly through the system … but other people … take years before they get a diagnosis that they have cancer.”

Inadequate standardization and documentation in surgical treatment was also a concern, leading, in some views, to unnecessarily high rates of cancer in surgical margins.

“The big black box in cancer therapy is the surgery… the quality of the surgery is probably the single most important thing determining the outcome of curable patients …. For curable patients…the surgery is extremely important and there is good-quality surgery and bad-quality surgery.”

Several experts felt that lack of standardization and adherence to guidelines were closely related to physicians' levels of expertise and ability to monitor new research and guidelines. Lack of experience and expertise often leads to “wide variability in the choice of … diagnostic tests … in breast cancer, whether a needle biopsy is done or a surgical biopsy is done” and “whether a needle biopsy is done appropriately.” Inadequate standardization was even more prevalent during follow-up care, where, as 1 expert suggested, guidelines are nonexistent:

“The IOM report states all of the areas that we need to focus on … [including] lack of clear follow-up care procedures. We are lacking guidance on … the most appropriate post-treatment surveillance strategies.”

Several experts mentioned that electronic medical records (EMRs) could help reduce variation during the diagnostic and treatment phases through warning systems for misdiagnoses in pathology labs and medication errors. Wider use of consensus performance measures, such as hospital mortality rates, could spur efforts to improve care:

“Every state should publish hospital mortality … and [find] a way to get that information back to the physician responsible for the care and [motivate] patients to start using physicians who adhere to those standards.”

Enrolling patients in a clinical trial could also increase standardization during cancer treatment and follow-up, because trials follow specified protocols. Enrollment in a clinical trial provides a “plan for careful follow-up and attention to the patient's symptoms and possible complications.” One expert suggested that establishing local consortia of cancer treatment centers that promote clinical trials would increase enrollment, and subsequently increase treatment standardization for a larger population.

Lack of Teamwork and Care Coordination

Most cancer patients do not receive care from multidisciplinary care teams in which providers plan and coordinate care together. One expert described early breast cancer care as ”sequential referral”:

“The usual mechanism for a patient being treated in the community is [patients] go to their GP and say ‘I think I felt a lump.’ He/she says, ‘Yes, you have a lump, and I'm going to send you to the radiologist to do mammography.’ … [If] available in the local community, they might do a needle biopsy. Then you'd go see the pathologist, and … [if] the finding … is positive, you're sent to a surgeon, who then does an operation and, depending on the finding, … sends the patient to a radiation oncologist or medical oncologist and vice versa.”

A disintegrated approach to care can thwart every IOM aim, particularly effective, safe, and patient-centered care. One expert suggested that uncoordinated care also influences equity, because achieving coordinated care is more difficult for patients with less access to care. Another expert emphasized that the complexity of cancer requires multiple physicians: rarely does 1 physician oversee every aspect of a patient's treatment. The absence of interoperable informatics systems contributes to the problem of uncoordinated care at every phase, but particularly during treatment:

“Even if it's one doctor doing the whole process, that one human being can't possibly hold in their head all of the guidelines, … requirements, and … data necessary to treat a patient. So we have a physical limitation on the ability of the provider … to access the information they need—and … lack of informatics capabilities is a huge problem.”

During follow-up, insufficient coordination and communication between the oncologist and primary care physician, as well as inadequate documentation for care planning, all result in poor transitions back to primary care after treatment is complete. One expert characterized this problem as, “huge,” commenting:

“[It is not clear] who should take the lead and how should these visits be dispersed so that we're efficient as well as effective … . The patients don't know what they ought to be doing and what would be most important for them in the future.”

Experts recommended improving the coordination of care and communication between providers during all phases of cancer care by using EMRs or other informatics tools to connect providers in different places.

“We need to design a way for the relevant information to be in front of the entire team …. The imaging [is] in one physical location, the pathologist, … clinical oncologist, … [and] surgical oncologist may be in … other location[s] … . They may or may not talk to each other, so we need to take informatics and design capability and say, ‘Look, the relevant information about patient A needs to be in front of this entire…virtual team at the same time.’”

IT was also posited to help patients living in rural areas. One expert suggested using “telehealth” and putting technology in homes and clinics to improve care coordination and access in rural areas by “bringing the expert opinion to a remote place. All information needed for treatment can be provided remotely.” Another suggested that patients carry a hand-held electronic device containing their medical history when seeing clinicians in different places during the various phases of cancer, or when getting a second opinion:

“A patient could have a thumb … drive where all their medical information could be put… . As they go from doctor to doctor, especially if it is in some kind of standard format, the nurse could plug it in and bring it up on the screen. They don't have to rewrite all this bull—every time you go in … . They do it one time, and then the physician who sees them could add … ‘Saw the patient September 3, 2006, … did a CT scan … .’ So they would have a medical record they could carry in their purse or pocket.”

Timely Transitions During Diagnosis

Some experts expressed serious concern about achieving timely care during diagnosis. Reasons proffered for delays included patients' anxiety and fear of cancer, difficulty scheduling certain screening tests, and incomplete understanding regarding follow-up after abnormal diagnostic tests and surveillance for detection of recurrence:

“[Patients] don't get follow-up because they're scared; they don't get follow-up because they can't get the appointment they want …. The doctors don't necessarily know all this stuff, and the patients are scared; and once it falls through the cracks, it's gone forever.”

Access to cancer care influences timeliness during diagnosis. Experts commented that under- or uninsured patients are also more likely to live in poverty, have limited knowledge regarding symptoms and screening, and lead lifestyles that may raise their cancer risk. These barriers often lead to delays in diagnosis, late-stage disease, and poor prognosis:

“The … uninsured just don't have an easy way in, and even the people who are on Medicaid…still tend to come in with late disease …. People who are on Medicaid have no better outcome in cancer survival than people who are uninsured …. I believe the reason … that many people on Medicaid are still coming in late is … because they're poor.”

Experts thought informatics and EMRs may offer solutions for improving timely care during diagnosis, such as online appointment scheduling. Another suggestion to conserve critical time during diagnosis was to create dedicated screening centers at which patients could make an appointment without a referral, for example, for a colonoscopy. Experts recommended that we explore how different IT modalities can be tailored to patient characteristics. Two experts also suggested using informatics to provide remote diagnostic consultation for those living in rural or hard-to-reach areas:

“Some places are … developing ways that … studies or pathology slides can … be reviewed at a distance for additional input.”

Lack of Patient Awareness and Empowerment

Patients' passivity and lack of awareness may lead to delays in diagnosis because of an incomplete grasp of the significance of symptoms. Patients may also experience intense anxiety, especially while awaiting test results to confirm a diagnosis. They may be unsure of where to go, whom to see, which tests to have, and what questions to ask. One expert stated the most urgent problem in the quality of cancer care during diagnosis was patients' uncertainty about the implications of cancer:

“[Patients don't know] whether they're gonna live or die and also key … decisions that they need to make and how to make them and how to understand better what's happening to them.”

Others raised similar issues concerning treatment, indicating that patient-centered care is difficult to achieve when patients do not take responsibility for their own treatment and survival. Many patients do not feel empowered to ask questions or seek a second opinion, thus decreasing the opportunity for any shared consideration of treatment options. When patients are not given adequate information regarding their treatment, insufficient awareness persists during follow-up:

“Even though they may have had 6 or 9 months of treatment, [patients] may not really understand what was done to them. They may not understand…short- and long-term effects of their treatment …. They may not understand what surveillance tests they need and who's going to be doing what for them; and more importantly, their primary care physician may not have had any communication [with their oncologist] about what actually went on during their treatment.”

Some experts suggested that “patient navigators” (volunteers, healthcare employees, or social workers) could help patients through their cancer journey, from diagnosis through follow-up care, by encouraging empowerment and facilitating understanding of their cancer care. Experts said that care could be more patient-centered if it incorporated not only clinical support but also social support from family and community. Navigators, family members, and other patient advocates could “… assist people to get into and through the medical care system.”

The Internet, informatics, and online resources were also emphasized as ways to help patients to become more informed and empowered about their care and available treatment options:

“It was probably 10 years ago almost now, that at least a subset of patients stopped asking, ‘Tell me what to do Doc,’ and … increasingly have asked, ‘Doc, tell me what all this information that I've downloaded off the Web and I actually understand pretty well now means for me.’… [We have] to understand the patient's preferences and values, as opposed to just making a blanket recommendation as if the patient's perspective didn't matter.”

Some experts emphasized making patients more aware of relevant trials and treatment opportunities while they are considering different options. They did not specify how to increase patients' awareness of trials, but suggested using videos to explain pros and cons of treatment options to improve awareness, shared decision-making, and patient-centeredness. One expert suggested developing interactive Websites that:

“… allow a woman or her physician … to put in her risk factors for her new diagnosis of breast cancer. Then it shows her very clearly, on a bar graph, what her expected survival is, what the advantage in that survival would be if she took adjuvant treatment …. You can plug in all the factors, and you might find, if you have a stage I, ER-positive breast cancer, … it would only give you a 2% increase in survival, whereas … [in] another situation it might be 25% …. It helps patients make a more informed decision about whether [to] have treatment.”

To improve patient-centered care, some experts recommended measuring patients' experiences throughout their cancer journey. These measures could include quality of life and patients' perspectives on their quality of care:

“Quality-of-life instruments are increasingly used in clinical trials, but I think they also have a good place in clinical care delivery … . I've been very interested in the Web-based versions … that allow patients to record their quality-of-life issues when they're not in the office and then bring that information to an office visit.”

Impact of Reimbursement on Treatment

Experts felt that the incentive from current reimbursement policies to treat cancer patients with chemotherapy often led to providers overtreating and recommending more expensive procedures and pharmaceuticals.

“[We have] a perverse reimbursement system that rewards procedures and … chemotherapy. Whereas both are important, they're, to quote the IOM again, … frequently overused, underused, or misused.”

The experts noted that some physicians decide treatment options on the patient's ability to pay, stating that care is “stratified; if you have money you get offered this, this, and this; if you don't have that money you don't get offered this, this, [or] this.” Others noted that reimbursement motivated some physicians to treat late-stage patients when palliation might be more appropriate:

“Instead of sitting down with Grandma, holding her hand, and talking to her about the futileness of treating her advanced…cancer and helping her understand the nature of her death and the importance of hospice, … we are actively treating her … . Instead of doing all that nice stuff, doctors treat Grandma, because they make more money treating Grandma.”

One expert suggested employing a risk-adjusted reimbursement system to motivate clinicians to provide effective and efficient care, particularly during the expensive treatment phase:

“Wouldn't it be breathtaking if [it were] risk-adjusted? … The tough cases you get points, and the easy cases you get points taken away … . You get paid more if the patient does better. That would incent people to have the patients do as well as possible.”


Despite the diversity of backgrounds and expertise among our 23 experts, they expressed considerable agreement regarding the predominant issues in cancer care quality. A prevailing barrier to providing high-quality care in every phase was lack of standardization and adherence to guidelines. Cancer care varies unnecessarily, with inconsistent adherence to guidelines, as previous studies have demonstrated.6 Some variation is a function of the experience and training of treating physicians,7 whereas some may stem from the absence of consensus guidelines even when a treatment has been proven effective.8 Lack of standardization is particularly problematic during diagnosis and treatment, when variability in tests or treatment received can lead to poor outcomes.9, 10

Experts suggested reinforcing guidelines using performance measures, and publicly disclosing these measures so that patients start expecting providers to reach certain standards. The development, use, and reporting of standardized performance measures sounds simple enough; however, these tasks are more challenging than they seem.11–14 The IOM report on cancer quality recommended a core set of quality measures,3 which precipitated a flurry of activity in quality measurement.15, 16 Our experts included several key players in quality-related activities such as the National Initiative for Cancer Care Quality17 and the Quality Oncology Practice Initiative, whose progress and evaluations will be important to monitor.18

Given the multidisciplinary nature of cancer care, the experts identified lack of connectivity among a patient's clinicians as a second major barrier to quality care. Their disparate, unconnected providers work serially to deliver diagnostic and treatment services, with communication and coordination challenges that hinder provision of optimal care.19–22 Coordination was considered to be important at every phase of the patient's journey from suspicion of cancer to surveillance after treatment.23

Most experts believed that IT systems, particularly EMRs, could greatly improve documentation, access to information, and communication and coordination among providers.24–26 However, we know of no published studies evaluating the impact of EMRs on cancer care quality. They also suggested that informatics tools could be used to develop “virtual care teams” through remote consultation or telemedicine, which would improve care and coordination, especially for patients in rural areas. These kinds of systems have been reported and are currently under evaluation.24, 27

Patient navigators could improve communication among providers and patients' experiences as they negotiate the handoffs associated with diagnosis and the initiation of therapy. Most patient navigator programs described in the literature have focused on assisting underprivileged cancer patients through the barriers associated with access to screening and follow-up care.28, 29 Navigators, especially if knowledgeable concerning the clinical issues facing patients, might be especially helpful during the diagnostic and treatment phases, but this has not been studied to our knowledge.

Experts emphasized patient empowerment and awareness as important facilitators of high-quality cancer care. Patients empowered to ask questions could improve patient-centered care by enhancing shared decision-making. Several studies have documented the benefits of shared decision-making and eliciting patients' preferences.30–34 Informatics and patient navigators could also provide useful, tailored information and support to patients. Such Internet-based tools have already proven effective in providing patients with appropriate information.35–37

The experts cited delays in diagnosis as the most worrisome barrier to receiving timely care, noting that patient and family anxiety runs extremely high during the diagnostic phase and even brief delays can increase anxiety. IT interventions could offer emotional support, improve appointment-scheduling, and increase communication between patients and providers. Surprisingly, we found few reports addressing the delays in diagnosis and associated anxiety levels. Delays are directly related to patient stress levels and outcomes, so interventions and innovations to reduce delays deserve additional study.

Reimbursement was also noted as impeding cancer care quality. Oncologist reimbursement rewards infusion, not the provision of information or emotional support. This presumably contributes to unnecessary treatment, but may also lead to undertreatment if the patient lacks insurance or cannot pay for the most effective treatments.38, 39 Among experts' ideas to reform payment were case-based or risk-adjusted reimbursement systems, and pay for performance programs that would reward providers with better outcomes. We know of no previous studies that have examined this in cancer care.

Limitations of the current study include that only 23 people were interviewed, including no patients. We did not collect data regarding the experts' demographics. However, we chose nationally and internationally known experts in a wide range of professions to share their opinions on cancer care quality in the U.S. Therefore, many other cancer clinicians, researchers, and policy-makers across the country are likely to share their views.

In conclusion, our group of experts noted major barriers and facilitators to all of the IOM aims for achieving high-quality cancer care during every phase of the patient's journey. Many suggested ways to improve patients' experiences, particularly by broader dissemination of IT innovations, as well as patient navigators. Some of these ideas have been tested; however, these interviews show we must accelerate the pace of innovation and research on interventions that aim to improve the quality of cancer care. We hope the ideas described here will stimulate new funding and research—ultimately improving cancer care quality for all patients.


This study was conducted within the Cancer Research Network, a consortium of research organizations affiliated with nonprofit integrated healthcare delivery systems and the National Cancer Institute. We thank the project consultants (Drs. Jerry Gurwitz, David Nerenz, Charles Safran, Hugh Straley, and Jane Weeks) for their advice at all stages of the project. We also thank Dr. Andrea Altschuler for her help with the qualitative analysis.