Frederick Greene, MD, FACS
The Commission on Cancer (CoC)—now 100 years old—is a consortium of professional organizations dedicated to improving survival and quality of life for patients with cancer through standard-setting, prevention, research, education, and the monitoring of comprehensive quality care, according to Frederick Greene, MD, FACS, a surgical oncologist at the Levine Cancer Institute in Charlotte, NC, and self-proclaimed “unabashed supporter of oncology nurse and patient navigators.” A total of 59 organizations make up the CoC, and AONN+ is a “major player,” he said.
At the AONN+ 13th Annual Navigation & Survivorship Conference in New Orleans, he explained that the basis for the CoC is standardization of care. Whether a patient visits a community hospital, academic center, or National Cancer Institute comprehensive cancer center, there should be no variation in the care they receive at any of its 1540 accredited institutions.
According to Dr Greene, constant improvement and change is a cornerstone of being CoC accredited. For example, when it comes to Standard 4.8 (Survivorship Programs), providers should make sure to identify resources needed to improve the 3 identified services offered (if barriers were encountered), as this demonstrates that the program is being monitored and evaluated.
“You want to make things better for every patient who comes into your purview,” he advised.
Looking at specific populations can help navigators to identify best practices in the field. Dr Greene noted a hospital program he encountered recently, designed to increase focus on referring appropriate patients to adolescent and young adult (AYA) navigators.
“We’re seeing cancer in younger and younger populations, and our AYA cancer groups are so important,” he said. “This is one of the areas that I think our navigation community can really get involved in as a best practice.”
He also pointed out the importance of navigation programs marketing themselves and highlighting their successes. Standard 1.1 asks for a letter of authority from a hospital’s leadership that demonstrates the facility’s efforts to support its cancer program over a 3-year period.
“I’ve read a lot of these letters from hospital CEOs and presidents, and I’ve never seen anything relating to the navigation community in these letters,” he said. “So, if you work on the cancer committee or have anything to do with giving information to the leadership of your institution, let them know what happened over that 3-year period. If you brought in a genitourinary or head and neck navigator, or if your hospital supported navigators going to annual navigation meetings, these are the kinds of things that we want to see in these letters.”
According to Dr Greene, changes to quality improvement measures (Standard 7.1) have recently been underway. For example, a new breast measure (effective as of June 2022) states that a person’s first therapeutic breast surgery in a non-neoadjuvant setting should be performed within 60 days of diagnosis for patients with American Joint Committee on Cancer clinical stage I-III breast cancer.
“Here’s where navigators come in, because you get involved with a new patient with breast cancer at the time of their diagnosis, and you’re with them until they get their treatment,” he said. “Unfortunately, this benchmark is not being met at many institutions, but having good navigators involved, we can meet that benchmark.”
Another quality issue dealing with the importance of timing applies to patients with melanoma. A new measure states that adjuvant systemic therapy be administered within 6 months of surgery, or recommended for eligible patients with stage IIIB-D resected melanoma.
“Again, here is where navigators play an important role in making sure they’re getting their melanoma patients to adjuvant therapy in a timely fashion,” he added. “I’m very excited about this particular benchmark going forward.”
Dr Greene pointed out the importance of navigators understanding cancer staging, since they should be advising patients based on their stage. Navigators are often better equipped to explain these concepts to patients when compared with physicians and can keep them from running to the Internet for an explanation of their diagnosis.
A new benchmark in head and neck cancer—and the first CoC benchmark in this malignancy—states that time to initiation of postoperative radiation therapy should be less than 6 weeks for patients with surgically managed head and neck squamous-cell carcinoma. “This is a very important new benchmark,” he noted.
Finally, according to Dr Greene, Standard 8.1 (Addressing Barriers to Care) was developed for the navigation community. The concept of this standard is that cancer committees choose one specific barrier to care, analyze it in depth, and develop recommendations to address it. He emphasized the importance of choosing only one barrier (eg, financial toxicity). “This one is giving many hospitals a difficult time, because they’re looking at so many different barriers,” he said. “Look at one specific area, and go forward with that.”
Creating a Tumor Board for Financial Toxicity
Dr Greene concluded with a best practice from his own institution in regard to Standard 5.2 (Identifying and Measuring Psychosocial Distress in Cancer Patients).
“Working with our navigation community, we’re measuring the stressors that patients go through,” he said. “And financial toxicity is one of those major stressors.”
Patients increasingly list financial distress as a key problem in their care and view this as a major factor in their quality of life. So, at Levine Cancer Institute, a multidisciplinary team of financial counselors, navigators, social workers, and interested clinicians in medical, surgical, and radiation oncology collaborated to improve financial toxicity in their patients. In 2019, they developed a Financial Toxicity Tumor Board (FTTB), which now meets biweekly.
They started by creating a yearly schedule outlining which type of patient would be discussed each month (eg, July = head and neck; September = breast). Attendees plan to present 2 or 3 patients who have sustained major financial toxicity, and they prepare just as they would for any multidisciplinary tumor conference, Dr Greene explained. They are welcome to submit cases for any FTTB, but they must submit at least 1 case on the month their section is listed.
“Navigators have come to these conferences 100% of the time, because the navigator plays such an important role in dealing with patients who are stressed with financial toxicity,” he said. “But the beauty of this is getting the clinicians to come who haven’t yet fully understood the role of financial toxicity.”
These FTTBs involve not only financial counselors, social workers, and navigators, but every provider involved in the care of a patient, including residents, oncology fellows, and others in training. They consider many of the main factors contributing to financial toxicity—copays, out-of-pocket expenses, and other external factors—but they have also made a concerted effort to consider what might be contributing to financial toxicity within their own institution, and how they might mitigate that. In 2019 alone, they looked at over 1700 patients as part of the FTTB and were able to identify and save $55 million within their healthcare system. They have now provided $1.3 million in copay assistance for their financially challenged patients.
“For those of you who work in academic centers, this is a wonderful opportunity to involve people who are in the early stages of their lives as clinicians,” he said. “The FTTB really has made a difference in our institution, and I think it can work just as well at your institutions for your population of patients.”
The CoC offers ongoing online education, workshops, and other resources (FAQs, resource documents, and templates in CoC Datalinks).
“Education is so important, and we have to keep looking at these standards all the time, because if we don’t, we will become irrelevant,” said Dr Greene. “All organizations need change, so we have to keep changing going forward.”
More from Dr Greene on Financial Toxicity
A Different Kind of Hospital Conference
Frederick Greene, MD, FACS