Unsupported Browser
The American College of Surgeons website is not compatible with Internet Explorer 11, IE 11. For the best experience please update your browser.
Become a member and receive career-enhancing benefits

Our top priority is providing value to members. Your Member Services team is here to ensure you maximize your ACS member benefits, participate in College activities, and engage with your ACS colleagues. It's all here.

Become a Member
Become a member and receive career-enhancing benefits

Our top priority is providing value to members. Your Member Services team is here to ensure you maximize your ACS member benefits, participate in College activities, and engage with your ACS colleagues. It's all here.

Membership Benefits
ACS Cancer Research Programs

Cancer QI Initiative Helps Increase Treatment Compliance

Laurie J. Kirstein, MD, FACS, Anthony D. Yang, MD, MS, FACS, Eileen Reilly, and Rebecca A. Snyder, MD, MPH, FACS

December 6, 2023

The best outcomes are achieved when patients complete guideline-recommended cancer treatment. For some cancer patients, missing radiation therapy (RT) sessions during active treatment may increase the risk of local recurrence.1,2

Studies estimate that patients miss more than 20% of RT treatments. Incomplete or missing RT appointments may serve as a warning sign of additional risk factors that negatively affect outcomes, including psychosocial concerns, lack of social support, and transportation and accessibility issues.3,4

The ACS Commission on Cancer (CoC) accreditation program includes a “Barriers to Care” standard in which programs must “identify one patient-, system-, or provider-based barrier to accessing health and/or psychosocial care and develop and implement a plan to address the barrier.” However, program staff members have traditionally had difficulty in identifying meaningful and sustainable ways to address these barriers and have expressed interest in receiving help in meeting the standard.

In order to better support programs in addressing barriers to care, the Breaking Barriers national quality improvement (QI) initiative was launched in January 2023, by the CoC and the National Accreditation Program for Breast Centers (NAPBC), with support from the ACS Cancer Programs. This QI project seeks to reduce the rate of patient RT “no-shows” by 20%.

The focus on RT appointments in the Breaking Barriers project was chosen as the initial target for identifying actionable barriers to treatment because there are data to support that three or more missed RT treatments can be detrimental to patient outcomes.

Concentrating the project on RT treatments also is advantageous for QI in that they occur in a set number of treatments during a defined time period, which makes them particularly amenable to collecting data on missed treatments and the reasons for these no-show appointments.

While some breaks in treatment are unmodifiable (toxicity), others—specifically those related to social and/or psychosocial barriers to care—can be identified, addressed, and mitigated with the creation of standardized processes.

There are 354 CoC- and NAPBC-accredited programs in the US that participate in the Breaking Barriers QI project. The ACS Cancer Programs is helping develop local processes to track patient attendance at RT treatment appointments and classify the specific reasons for missed appointments.

In addition to understanding the no-show rate and identifying and prioritizing common barriers to care leading to missed RT appointments, programs also are instructed to develop a community asset map or a listing of community resources that address patient drivers of health outside of the walls of the clinic.

These resources may include ride-share services, food banks, mental health services, community support groups, and more. Programs are encouraged to consider their patient population’s sociodemographic characteristics, including education, language, and spiritual and religious affiliations when seeking out community partners. The community asset map can be used to help identify solutions to reduce the major social and psychosocial drivers of missed RT treatment appointments at their institution.

At the initiation of the project, programs were required to submit a letter of support from their radiation oncology clinic leadership and identify the members of their local Breaking Barriers multidisciplinary QI team. Programs currently are submitting bimonthly data on patients missing three or more treatments, reported by disease site. In addition, programs also submit survey data on organizational readiness, current systems, and workflows for addressing no-shows and feasibility and effectiveness of implementation strategies.

The ACS Cancer Programs is supporting this QI project by providing participating programs with guidance, resources, and consultation throughout the project life cycle. Specific forms of support include data collection resources, education in quality and process improvement methods, assistance with approaches to identify local barriers to care and specific ways to address the barriers, project assistance “office hours,” and educational webinars. The webinars also include presentations by participating hospitals that address best practices, experiences, and challenges.

Preliminary data have revealed that 91% of Breaking Barriers project programs had patients missing three or more RT treatments. The most common reasons for patient no-shows to RT appointments are illness not related to treatment toxicity, transportation challenges, psychosocial issues, and healthcare-related system inefficiencies.

Data will continue to be collected and analyzed for the remainder of the 2023 calendar year. Programs will then have the opportunity to continue participation in 2024.

The first year of the project has focused on data collection, instituting processes for identifying no-show patients, and distinguishing the specific reason why the patient missed the appointment.

In 2024, programs will identify one barrier and participate in cohort learning with other programs that also self-selected that barrier. Together, with support from the ACS Cancer Programs, they will share strategies, resources, and best practices and, ultimately, reduce barriers to care and achieve improved outcomes for all their cancer patients.

Dr. Anthony Yang is the vice chair of quality, the H. H. Gregg Professor of Cancer Research in the Division of Surgical Oncology, and associate director of the Surgical Outcomes and Quality Improvement Center within the Department of Surgery at the Indiana University (IU) School of Medicine in Indianapolis. He also is the CoC cancer liaison physician at IU Health West Hospital in Avon.

Dr. Laurie Kirstein is a breast surgical oncologist at Memorial Sloan Kettering Cancer Center and an associate professor of surgery at the Weill Cornell Medical College, both in New York City. She also is the current Chair of the CoC Education Committee and Education Liaison for ACS Cancer Programs.

  1. Morris BB, Hughes R, Fields EC, et al. Sociodemographic and clinical factors associated with radiation treatment nonadherence and survival among rural and nonrural patients with cancer. Int J Radiat Oncol Biol Phys. 2023;116(1):28-38.
  2. Ohri N, Rapkin BD, Guha C, et al. Radiation therapy noncompliance and clinical outcomes in an urban academic cancer center. Int J Radiat Oncol Biol Phys. 2016;95(2):563-570.
  3. Chiang YY, Chou YC, Chang KP, et al. Missed radiation therapy sessions in first three weeks predict distant metastasis and less favorable outcomes in surgically treated patients with oral cavity squamous cell carcinoma. Radiat Oncol. 2020;15(1):194.
  4. Chow R, Hasan S, Choi JI, et al. Effect of treatment interruptions on overall survival in patients with triple negative breast cancer. J Natl Cancer Inst. 2023;115(9):1029-1035.