The role of National Cancer Institute-designated cancer center status: observed variation in surgical care depends on the level of evidence.

Agreat deal of effort is currently being devoted to helping health care purchasers, both patients and payers identify hospitals providing better quality care. The term “center of excellence” is often used to promote a given institution as having expertise in a particular area. Within oncology, the National Cancer Institute (NCI) Cancer Centers Program identifies centers of excellence primarily based on their research programs, but it also emphasizes the association between strong research and excellence in clinical care, education, community outreach and other critical components of cancer care.1 The NCI designates institutions as either comprehensive cancer centers, which demonstrate significant research activities in each of 3 major areas—laboratory-based research, population-based research, and clinical research—and which have substantial multidisciplinary research efforts or cancer centers, which are primarily focused in one or more of these scientific areas. As of 2010, the NCI recognizes 44 comprehensive cancer centers and 20 cancer centers. Institutions with NCI-designated cancer center status are expected to be a major source of discovery in cancer, including the development of more effective approaches to care and the creation of effective research dissemination strategies.2 Previous studies have shown improved surgical outcomes at NCI-designated cancer centers, particularly for 30-day mortality rates.3–5 These studies also reported improved long-term outcomes for colon and rectal cancer at NCI-designated cancer centers, but long-term survival was similar for other cancer sites. Little work has investigated differences between NCI-designated cancer centers and other institutions on process measures, or whether the appropriate care is provided.6,7 Concordance with practice guidelines is currently one approach to determining whether appropriate care was provided. The goal of practice guidelines is to close the gap that exists between best evidence and current practice.8–10 However, due to increasing pressure to define and measure appropriate care, guideline creation has often outpaced evidence generation. As a result, many guidelines are based on less than level 1 evidence11 and often rely on expert consensus.12 Prior research has shown that lower-level evidence can lead to surgical practice that is less adherent to guidelines and results in greater variability in care among institutions.13,14 Little is currently known about the role that center of excellence status may play in this observed increase in institutional variation when strong evidence is lacking. Eleven practice guidelines for 5 cancer sites (thyroid, gastric, rectal, colon, or breast cancer) that are commonly treated by general surgeons and general surgery subspecialists, including surgical oncologists and breast, endocrine, and colorectal surgeons, were identified previously by our group.15 These guidelines were further examined to determine the role of NCI-designation in institutional variation for guidelines based on level of evidence. We hypothesize that when there is strong evidence to support a guideline, there will be general consensus, minimizing practice variation between NCI-designated centers and other institutions. However, when a guideline is based on less definitive evidence, greater variation based on NCI-designation will be observed. A better understanding of the relationship between level of evidence and guideline concordance will shed important light on institutional variation in the surgical care of cancer patients. If our hypothesis is true, institutions that are not NCI-designated cancer centers are providing appropriate care when there is high quality evidence to support it, providing reassurance to patients and providers that care is equivalent for these cases. When the supporting evidence is less clear, it is a greater leap to equate guideline concordance with higher quality care because the right approach to care has not been definitely determined.