Breaking barriers in cancer care

Access to timely, uninterrupted cancer treatment is crucial for patient outcomes, yet barriers like financial constraints, logistical challenges and emotional strain can disrupt care. UT Southwestern (UTSW) Medical Center in Dallas, in collaboration with the American College of Surgeons (ACS), is working to overcome these obstacles with its commitment to improving patient support and reducing missed treatments. By leveraging the ACS’ “Breaking Barriers” initiative, UTSW is paving the way for more accessible, high-quality cancer care across diverse communities.

Care standards and innovation

The ACS, founded in 1913, originated from the Clinical Congress of Surgeons of North America, established in 1910. With a membership of over 90,000 surgeons and surgical team members worldwide, the ACS is a premier professional organization in the surgical field.¹ In 1922, the ACS established the Commission on Cancer (CoC), a consortium of professional organizations dedicated to improving survival rates and quality of life for cancer patients through standards-setting, prevention, research, education and quality monitoring of comprehensive cancer care.²

By employing a multidisciplinary approach, the CoC has established standards for care delivery, cancer prevention improvement and verification of accredited organizations through routine surveys and data oversight. The ACS invites organizations to join the CoC in advancing equitable cancer care nationwide by supporting and upholding its accreditation standards. CoC membership requires active involvement in specific oncology fields and providing supporting data on programs aligned with the CoC’s focus areas.³

Receiving accreditation from the ACS is a prestigious recognition for cancer programs worldwide. Once accredited, these sites are given annual or routine quality initiatives, as well as guidelines for education and treatment standards.

“Breaking Barriers”: Reducing missed treatments in radiation therapy

The ACS Commission on Cancer’s “Breaking Barriers” initiative is a two-year national quality improvement project designed to explore how reducing missed radiation therapy appointments (or “no-shows”) can improve access to high-quality oncology care for patents across diverse communities and care settings. The project aims to enhance each program’s capacity to identify barriers that prevent cancer patients from receiving timely, complete radiation therapy and to implement sustainable solutions to overcome these challenges.⁴

Barriers to cancer treatment can stem from a variety of factors — physical, emotional, psychological, social, financial, ethnic, geographic, spiritual and cultural. Some are anticipated, like the toxicity of chemo-radiation in head and neck cancer patients, while others are unexpected, such as deep vein thrombosis or pulmonary embolism in lung cancer patients. Furthermore, some barriers are modifiable, while others are not. Interruptions in radiation therapy, which can negatively impact patient outcomes, often arise due to both predictable and unforeseen obstacles. These interruptions may indicate systemic challenges requiring broader reform, such as improved supportive care, or they may be specific to individual programs. Monitoring missed treatments provides valuable data, allowing programs to enhance patient outcomes through shared quality initiatives.

Radiation therapy offers an excellent model for measuring barriers to care due to its structure of daily treatments over several weeks, typically Monday through Friday. Moreover, all radiation therapy facilities use record-and-verify systems that track treatment delivery and record the number of delays between planned and actual treatment dates. In the program’s first year, the focus is on collecting baseline data, understanding the unique needs of local cancer patients, developing a patient outreach system, and prospectively tracking the reasons for missed appointments. In the second year, focus will shift to identifying one or two key reasons for missed appointments and implementing targeted interventions (including community-based referrals) to sustainably address these barriers. The project will also prioritize scalability and sustainability.⁵

UT Southwestern’s commitment to comprehensive cancer care

UTSW established its Comprehensive Cancer Program in 1991, now encompassing more than 500,000 square feet as the largest comprehensive cancer program in North Texas. Notably, UTSW’s active memberships within the ACS, American College of Radiology (ACR) and National Cancer Institute (NCI) reflect its commitment to quality initiatives and support its application to the Breaking Barriers project.

At UTSW, we’re committed to providing our patients with high-quality health care in a medically safe environment at every step of their evaluation and treatment. It is a commitment that we back with action. In 2010, UTSW launched a Quality Improvement Program to oversee clinical quality and patient safety throughout the Medical Center. Since that time, we have implemented many improvement strategies aimed at providing the best possible care for patients and their loved ones. When it comes to our patients’ health, perfection is our goal and our unrelenting mission.⁶

At UTSW, measuring quality and safety information and making it readily available is important for two primary reasons: first, it helps continually improve all aspects of patient care, and second, it assists empowers patients to make informed decisions regarding their medical care. To better serve patients, UTSW employs various quality and safety measures, comparing its performance at both the national and state levels. These measures demonstrate how well UTSW has been providing appropriate care for common conditions and ensuring patient safety.⁷

With this quality mission in mind, UTSW’s Department of Radiation Oncology joined the CoC Breaking Barriers project with application in April 2023, committing to participate in both Year 1 and Year 2 data collection as well as initiatives to ensure that patient support and interventions are reviewed and completed.

ACS and UTSW join forces to address and improve missed treatments

To begin, UTSW established protocols for documenting and recording any treatment interruptions. Using Mosaiq — a system in place for more than 15 years — staff can assign statuses like “No Show,” “Break” and “Cancelled” for each treatment, ensuring consistent reporting. Radiation therapists also document specific reasons for any breaks in treatment, providing essential data for assessment and quality improvement. 

Using the Mosaiq Assessment or a similar tool like the record-and-verify Varian ARIA Oncology Information System, UTSW enables discrete data collection and reporting. This streamlined, organized setup provides staff with an efficient approach to documentation, ensuring compliance with the required information.

Year 1 data collection focused on reviewing missed treatments for patients receiving treatment for head and neck, gynecological and gastrointestinal cancers. These cancer types typically require longer treatment plans, making it crucial to minimize unplanned breaks or missed treatments to optimize treatment success. Data from Mosaiq was imported into Tableau to build a comprehensive report tracking the total number of patients treated and missed treatment sessions, respectively, within these diagnostic categories.

A full review across all diagnostic groups showed that the missed treatments averaged below 12% for most of the year, with occasional outliers related to patient non-compliance appearing in the latter part of the year despite supportive efforts. As shown in the graph, Year 1 findings consistently stayed under 12% overall. Analysis revealed that most missed treatments were patient-initiated, with only a small fraction due to transportation or financial issues. Common patient-initiated reasons included forgetting appointments, feeling unwell or unmotivated, unresponsiveness to staff outreach or general non-compliance with treatment schedules.

In the first six months of Year 2, missed treatments for the measured diagnosis groups remained below 10%, with continued staff compliance in using the Mosiaq Assessment tool. Improvement efforts also focused on optimizing workflows for transportation and housing support, along with providing targeted onsite patient support services through social work as needed. UT Southwestern’s Department of Radiation Oncology has had a longstanding commitment to effective patient support, and enhanced data collection on patient-initiated reasons for missed treatments has reinforced the need for mental and emotional support alongside practical resources to help patients complete their treatment plans.

Key takeaways and lasting impact

Implementing initiatives like Breaking Barriers successfully requires clear directives and strong buy-in from both leadership and staff, supported by robust reporting tools and well-defined guidelines. The ACS is a brilliant organization that has been instrumental in equipping healthcare leaders with sustainable, data-driven solutions. This project highlights UTSW Department of Radiation Oncology’s solid foundation in quality improvement and patient-centered care, demonstrating how comprehensive documentation and a sustained focus on patient support can drive meaningful improvements in cancer treatment.

Notes:

1. American College of Surgeons. “Who We Are.” Available from: https://www.facs.org/about-acs.
2. ACS Commission on Cancer. “Breaking Barriers: Addressing NO Show to Improve Access to Care.” Feb. 3, 2023. Available from: https://bit.ly/4fukbkd.
3. ACS. “Breaking Barriers Quality Improvement Collaborative.” Available from: https://bit.ly/3ZgHEQ5.
4. Ibid.
5. Ibid.
6. University of Texas Southwestern Medical. “Quality and Safety.” Available from: https://bit.ly/3CHCXWP.
7. Ibid.