Benchmarking the Current Landscape: Insights From an Association of American Cancer Institutes Survey on Academic Cancer Service Lines

Abstract

PURPOSE

A cancer service line (CSL) in academic medical centers provides a patient-centered approach aimed at enhancing the patient experience and clinical outcomes, managing financial operations, increasing access to clinical research, and reducing health disparities. In 2023, the Association of American Cancer Institutes (AACI) Physician Clinical Leadership Initiative (PCLI) Steering Committee conducted a survey to evaluate the current state of CSLs with respect to governance, leadership, organizational, and financial structure and function.

METHODS

The survey was electronically sent to cancer center directors and administrative directors at 107 of AACI's 108-member cancer centers, achieving a response rate of 70%. Survey participation was voluntary, and no compensation was provided.

RESULTS

Fifty-eight (77%) of the 75 survey respondents (which included 40 National Cancer Institute–designated cancer centers) had a defined CSL with only 35 (60%) using a formal charter. All CSL leadership teams included physician leaders, and 44 (76%) centers included their cancer center director within this leadership. More than 28 key services were identified as parts of the CSL structures. Most respondents reported that strategic planning (88%), quality and safety (83%), and regional alignment (78%) were key responsibilities. Twenty-six (45%) centers reported a policy defining a funds flow from the health system to the cancer center. Performance assessment for the CSLs included metrics related to growth and finance, access and services, quality and outcomes, and academics.

CONCLUSION

These results demonstrate the diverse nature of CSLs across academic medical systems within the United States. Furthermore, given the complexity faced by academic cancer centers in establishing and expanding their CSLs, AACI remains committed to working closely with its members to identify best practices focused on innovative and value-based cancer care.

INTRODUCTION

A cancer service line (CSL) integrates multidisciplinary services to ensure comprehensive, coordinated, and patient-centered care with the goal of providing state-of-the art cancer care with novel clinical trial opportunities. Developing an organizationally strong CSL can be challenging in academic medical centers (AMCs) as the clinical, research, and teaching missions are traditionally organized by different departments in a School of Medicine (SOM). These SOM departments are variably connected to their National Cancer Institute (NCI)–designated (or developing) cancer center whose focus is on advancing innovative cancer-related basic, clinical, translational, and health sciences research that addresses the needs of the community.^1,2 Furthermore, many faculty within cancer centers receive their academic position, promotion, and salary with criteria defined by each department and approved in the SOM. Funds flow to the CSL and/or cancer center may be admixed from professional billing within the physicians' practice plan and from hospital billing through the health system and may or may not be linked to a faculty member's salary or performance. Given the financial pressures facing health systems and the declining federal research funding, AMCs may experience misaligned priorities and funding streams across their enterprises. This misalignment may compromise the organizational and resource support essential to sustaining a successful academic and clinical cancer program. Therefore, it is critical for an effective CSL to operate with a shared vision of governance, structure, function, and funds flow within a matrixed academic health system.

CONTEXT

• Key Objective

• What is the governance, leadership, organizational, and financial structure of the Association of American Cancer Institute member cancer centers that responded to a survey about cancer service lines (CSLs)?

• Knowledge Generated

• The survey identified 58 of 75 (77%) respondents with organized CSLs and included the composition of the leadership team, reporting relationships including between health systems and Schools of Medicine, the services and specialties, funds flow arrangements, and metrics. Several differences between National Cancer Institute–designated cancer centers and nondesignated centers were identified in the analyses.

• Relevance

• The findings in this survey provide a framework for benchmarking, strategic planning, and funding, helping cancer centers to build and optimize a CSL structure and to align clinical and academic missions within evolving health care systems.

The Association of American Cancer Institutes (AACI) represents 108 leading academic and freestanding cancer research centers in North America. Recognizing the critical role of academic and freestanding health system cancer programs in disseminating and supporting the implementation of life-saving cancer prevention, diagnostics, and treatments across all populations, the Physician Clinical Leadership Initiative (PCLI) Steering Committee, an elected body of leaders within the AACI, aimed to identify cancer centers with CSLs and describe the leadership, organizational structure, financial models, and functions of these CSLs. Assessing the current landscape of clinical cancer care in CSLs across institutions provides valuable information to cancer centers and their affiliated AMCs. The PCLI sought to identify potential best practices in CSL structure and governance, with the goal of advancing multidisciplinary cancer care with integrated clinical research to ensure innovative and value-based care for all patients.

METHODS

Study Sample

In July 2023, the AACI PCLI designed a 29-question, mixed-methods descriptive survey consisting of multiple choice and short answer questions to evaluate the current state of CSLs among AACI's membership (Data Supplement, online only). At that time, AACI had 108 academic cancer center members. The survey was sent to 107 members, excluding a national military hospital. This survey was deemed institutional review board–exempt.

Design

To help standardize responses to this survey, the CSL was defined as the following: “While institutions define CSLs differently, they share the goal of providing coordinated cancer care across the health system within and across clinical tumor programs.” This definition was approved by the PCLI and the survey was piloted and/or reviewed at 15 AACI centers.

Each respondent answered three questions related to their center's characteristics. After these questions, respondents answered whether their cancer center had a defined CSL. If not, the respondent completed two additional questions inquiring why there was not a service line and how their cancer services were currently organized in lieu of a service line. These centers completed no additional questions. Respondents reporting that their institution had a service line were directed to complete the remaining 24 questions.

Procedure

SurveyMonkey surveys were sent electronically to the cancer center directors and administrators, and either they, or their designated leadership, completed the survey. The surveys were sent out on July 31, 2023 (time point-1), and again on August 24, 2023 (time point-2), and surveys were closed on September 18, 2023. Chi-square tests (GraphPad Prism) were used to assess the differences between NCI-designated and non–NCI-designated centers in evaluating questions related to leadership and funds flow.

RESULTS

Center Demographics

Of the 107 centers, 75 responded to the survey. Sixty-three categorized their center type as matrixed in a SOM and/or health system, seven as basic laboratory (without clinical services), and five as freestanding. Within the cohort of 68 centers that offered clinical care, 42 were NCI-Designated Comprehensive Cancer Centers, five NCI-Designated Cancer Centers, and 21 were nondesignated NCI centers, with 18 seeking designation (Fig 1).

FIG 1.

CSL demographics. CSL, cancer service line; NCI, National Cancer Institute.

Ten cancer centers (15%) responded that they did not have a defined CSL, with seven of these being NCI-designated centers. Of these centers, 50% responded that they did not have a defined CSL, either because of new leadership or health system reorganization. Three center respondents noted that because of state or institutional/health system structure, they did not have a mechanism for creating a formal CSL. Two center respondents explained that their CSL reports up through functional units (ie, nursing, inpatient services).

CSL Governance and Leadership

Of the 58 cancer centers with a defined CSL, 40 (69%) had NCI designation (37 are NCI comprehensive and three are NCI-designated) and 18 did not have NCI designation (17 seeking designation and one not designated). These 58 cancer centers with a defined CSL provided information about their service line governance and leadership. Thirty-five centers (60%) had a formal charter that defined governance and outlined the purpose, authority, roles and responsibilities, and membership of the CSL. Of the 23 respondents without a defined charter, 11 (48%) are NCI-designated centers.

The cancer center director was reported as one of the primary operations leaders of the CSL in 44 of the centers (76%; Fig 2A). The makeup of the leadership team was not statistically different between the 40 centers with NCI designation and the 18 without (P = .88, Fig 2B). All CSLs had a primary physician leader representing a variety of specialty backgrounds, with 32 (55%) being hematologists and medical oncologists, followed by 15 (26%) surgeon specialists (surgical oncology, otolaryngology, and urology), five (9%) gynecologic oncologists, four (7%) radiation oncologists, one (2%) pathologist, and one (2%) cardiologist. Furthermore, cancer center directors were more often the primary physician leader in centers without NCI designation than those that were designated: nine of 40 at NCI-designated centers versus seven of 18 at non–NCI-designated centers (P = .02).

FIG 2.

CSL leadership team composition: (A) All centers with a CSL. Respondents were able to select more than one answer. (B) Distribution percentage of the leadership team by NCI (n=40) and non-NCI designated (n=18) cancer centers. Number of responses written above each bar. CSL, cancer service line. NCI, National Cancer Institute.

Fifty-seven centers (98%) reported having more than one CSL leader. These 57 CSL leadership teams included a business/administrative leader (43, 75%) and/or a nursing leader (31, 54%). The direct reporting structure for each of the CSL physician leaders was varied and included 36 (62%) with a reporting line to a health system executive, 26 (45%) with a reporting line to the cancer center director, and 26 (45%) with a matrixed reporting structure. Additional answers for the CSL physician leader included reporting lines to a SOM Dean, Chancellor, Department Chairs, and Vice Presidents of Clinical Affairs.

Of the 43 centers with CSL administrative leaders (MBA or other business degree), their reporting relationships varied with 17 administrative leaders having a matrixed reporting structure. Thirty-five reported to a health system administrative executive, 23 reported to the cancer center director, and 13 to other individuals.

For the 31 nursing leaders of a CSL, their reporting relationships varied. Fifteen nursing leaders specified a matrixed reporting structure. Eighteen reported to a health system nurse executive, 14 to a health system administrative executive, 10 to a CSL executive, nine to a CSL administrative executive, and 14 to other individuals.

In addition to the primary leadership, membership on the CSL Executive Committees included a wide variety of individuals ranging from clinical medical directors (39, 67%), division/department chiefs or chairs (35, 60%), medical oncologists (35, 60%), surgical oncologists (33, 57%), hospital nursing leadership (22, 38%), health system CEO/senior vice president (22, 38%), and Physician Practice Plan leaders (17, 29%).

CSL Organizational Structure and Function

More than 28 key services were identified in the CSLs (Fig 3). Although hematology and medical oncology, radiation oncology, and/or surgical specialties were in every CSL, pathology (31, 53%) and radiology (28, 48%) were not. Most centers provided direct oversight for several supportive services inclusive of nurse navigation (50, 86%), social work (45, 78%), nutrition (43, 74%), behavioral health/cancer health psychology (37, 64%), palliative care (37, 64%), and cancer lay navigation (33, 57%). Supportive services less commonly included pain and occupational/physical therapy (23, 40% each), and sexual health programs (17, 29%; Fig 4).

FIG 3.

Services provided by the cancer service line.

FIG 4.

Support services within CSL oversight. CSL, cancer service line.

When queried about the key CSL responsibilities, the center respondents reported that strategic planning (51, 88%) and quality and safety (48, 83%) were a primary focus, with regional growth and alignment (45, 78%), ambulatory operations (44, 76%), and budgeting and margin management (43, 74%) also noted in most CSL responsibilities. Clinical trials integration was included in 38 (66%). Forty-four (76%) centers reported the use of multidisciplinary clinics for individuals with a new diagnosis of cancer (data not included in Fig 5). Figure 5 details the degree of integration for each of these services.

FIG 5.

CSL executive committee key responsibilities. CSL, cancer service line.

CSL Financial Structure

Twenty-six (45%) centers reported a policy or document defining a funds flow from the health system to the cancer center. Although less than half of the survey respondents had a funds flow, NCI-designated centers (23 of 40) were statistically more likely to have a defined funds flow process than nondesignated centers (three of 18; P = .009). When asked whether hospital billing (also referred to as technical fees) and/or professional billing (also referred to as professional fees) were included in the funds flow to the cancer center, 12 centers reported both hospital and professional billing, 13 centers reported only hospital billing, and only one center reported professional billing. Budgetary decisions for the CSL were influenced by profit and loss statements from clinical revenue (39, 67%), market share/growth (31, 53%), and philanthropic support (31, 53%), while other sources were also noted as contributing to these decisions (Appendix Fig A1, online only).

Of the 58 respondents with a CSL, the health systems provided a funds flow or in-kind support for discretionary funding to the cancer center director (37, 64%), large capital expenses (36, 62%), faculty salaries (33, 57%), and/or recruitment (30, 52%). In addition, support was provided to the centers for their clinical research work from reduced pricing for research (26, 45%), support of pharmacy research personnel (24, 41%), salary support for clinical trials' investigators (19, 33%), and support for clinical trials (15, 26%; Appendix Fig A2). Health systems also contributed to the tumor programs/disease-specific teams (23, 40%) and education (24, 41%). The majority of cancer centers (37, 64%) reported that their health system tracked clinical trial accrual (data not included in Appendix Fig A3). Thirty-one (53%) indicated no defined process for cancer center directors to allocate health system revenue to center activities while more NCI-designated centers (19 of 40) had a defined process than nondesignated centers (12 of 18; P = .007). Cancer center directors frequently use these funds for faculty support and recruitment, and to support clinical and basic research (Appendix Fig A3).

Most of the centers reported that billing and collections, revenue cycle, coding, financial management, health information management, information technology (IT), marketing and communications, and patient registration were centralized health system shared services (Appendix Fig A4).

CSL Metrics

Performance assessment for the CSLs included metrics related to growth and finance, access and service, quality and outcomes, and academics. These metrics pertained to new patient visits, utilization of resources such as radiation, infusion, surgery, financial performance, timeliness of care, patient and provider satisfaction, safety outcomes, therapeutic clinical trial accrual, and investigator-initiated trial development, with details in Appendix Table A1.

DISCUSSION

The AACI survey was performed to identify academic cancer centers with CSLs and to define their governance, leadership, organizational, and financial structure and function. Of the 68 clinical cancer centers that responded to this survey, the majority were NCI-Designated Cancer Centers (47, 69%) or centers seeking NCI designation (18, 26%). Ten (15%) centers (10, 15%) lacked a defined CSL, including several NCI-designated centers (7, 10%).

Of the 58 centers with a CSL, 60% had formal charters. Charters define the leadership and service line responsibilities as well as establish a formal integration of cancer clinical services with the research activities. This integration is important for continuation of, or future attainment of, NCI designation, given that the P30 CCSG defines the cancer center director's authority to include oversight of the inpatient and outpatient clinical research facilities and the appointment and evaluation of individuals critical to linking oncology care to clinical research.² In 76% of the centers with a CSL, the cancer center director was a member of the CSL leadership team, further ensuring that the CCSG research mission and cancer care are aligned to support the Center Director (having) some influence, or control, of the CSL.³

In addition, the survey identified dyad and triad team leadership approaches with a physician and administrator or a physician, administrator, and nurse, respectively. At the 40% of centers without a charter, leadership may not be empowered with authority or fiscal responsibility for the CSL; this, in turn, may contribute to a potential lack of integration with the health system and SOM. It is vital to establish and define the leadership structure with the CSL mission in a document to ensure the health system and the SOM are both aligned and committed to the mission of the cancer center. Although a complex and important issue, our survey did not address how the SOM and health system oversee their cancer center structure. Furthermore, this survey is also limited in that it was not designed to address differences between NCI-designated and nondesignated cancer centers, although differences were identified through analyses of leadership structure and funds flow.

In 2016, the NCI-ASCO Teams in Cancer Care Delivery Project was established to expand research on and define the importance of cancer care teams as a mechanism toward ensuring the delivery of high-quality, well-coordinated care across the cancer care continuum for individuals with cancer.^4,5 Key to patient-centered care is the development of a CSL with the structure and function linked to its diverse team of cancer specialists and support personnel. In this survey, the CSL care team composition of medical and radiation oncologists, specialty surgeons, and personnel involved in survivorship and support programs was present in most centers. Fewer teams included those focused on cancer pain, occupational or physical therapy, and sexual health—supportive services integral for developing a patient-centered cancer program.

CSL key responsibilities consisted of strategic planning (88%), quality and safety (83%), regional alignment (78%), and ambulatory operations (76%). Although this survey did not evaluate how CSLs interact with their networks, as AMCs expand to regional academic health systems with community hospitals and other cancer care delivery sites, CSLs will be incumbent to support advanced cancer care, access to trials, and patient support services at these locations. Reaching underserved groups is also a goal as well as a requirement for the CCSG to demonstrate Community Outreach and Engagement (COE). The CSL should therefore include all sites of care in its plans and structure, and include representatives from community locations and the COE team. Although 81% of the centers include clinical trial accruals as a key metric for success, adding a measured outcome related to minority and underserved accruals would be important as well.

As AMCs prioritize dedicated CSLs, executive-level support for the resources necessary to build state-of-the-art clinical and academic infrastructure will enable both CSL growth and a strong financial margin.^6,7 With advances in cancer risk assessment and diagnosis aided by the use of artificial intelligence, novel targeted therapies for treatment, and the increasing need for survivorship care, there are new opportunities for longer-term relationships with patients. CSLs must now be organized to span the cancer continuum and be attentive to trends such as more value-based care.⁸ This will require new models for services, expanding the expertise that supports the CSL (eg, IT and data analytics, financial analysts) and organizational support and investment for care delivery innovation.⁹ Academic CSLs, however, present unique challenges because of the breadth of specialties involved, the need to support basic and translational research and integrate clinical trials into care delivery, and the complexity of organizational structures and reporting lines.² These topics are included in the survey, but merit further exploration as AMC CSLs plan for the future.

In this survey, most academic centers had funds flow support from health system and/or professional funds flow to the center director for use in support of the academic mission. CCSG guidelines require institutional leaders in NCI-designated cancer centers to provide the long-term stable support necessary to accomplish Cancer Center objectives,² which may include a formula-based return to the center of financial resources from clinical revenue.² Although this survey identified shared responsibility between the health system and cancer center for functions such as revenue cycle and information management, an area for future exploration will be to evaluate how a health system, SOM departments, and the cancer center share in the contribution margin resulting from any quality and value improvements from the service line development.

Incorporating CSLs into NCI-designated cancer centers aligns with the NCI's emphasis on fostering innovation and excellence in both research and patient care. Although the NCI recognizes the importance of developing robust CSLs, formal guidelines for their governance, leadership, organization, and financial accountability have yet to be established. As a potential next step, the NCI could consider offering structured recommendations to support cancer centers in standardizing CSL practices. Such guidance could help ensure that the high standards seen in the research domain under the CCSG are mirrored in clinical operations. With the landscape of cancer care increasingly emphasizing value-based care, the development of CSL-specific guidelines from the NCI could encourage integration between academic missions and health system operations, fostering collaboration that maximizes both patient outcomes and organizational sustainability.

This study demonstrates that health systems and cancer centers have CSLs that are varied in their maturity and alignment with their cancer center missions. Furthermore, laying the framework for CSL governance, leadership, organizational structure, and financial operations within AMCs—while prioritizing innovative and value-based cancer care—is a complex undertaking. To this end, following the initial results of this survey presented at the AACI/Cancer Centers Administrators Forum (CCAF) Annual Meeting in Washington D.C. on October 1, 2023, AACI members were interested in sharing best practices of CSLs across the country resulting in the formation of a CSL Roundtable. It is envisioned that this Roundtable will guide future studies to determine the efficiency and effectiveness of this structure and to measure the return on investment that CSLs provide to our cancer centers, SOMs, health systems, and, most importantly, to our patients.

APPENDIX

FIG A1.

Budgetary support for CSL. CSL, cancer service line.

FIG A2.

Services by HS revenue. HS, health system.

FIG A3.

HS revenue to director. HS, health system.

FIG A4.

Embedded services. CSL, cancer service line.

TABLE A1.

CSL Performance Metrics

Performance Metrics Tracked by CSL Balanced Scorecard Metrics	Percentage	Responses (No.)a
Growth and finances
No. of new patient visits (benign hematology, hematology malignancies, medical oncology, radiation oncology, gynecology oncology, surgical oncology, survivorship, palliative care, and others such as dermatology, head and neck surgery, orthopedic oncology, neurologic oncology [neurology and neurosurgery], and urologic oncology)	98.28	57
No. of radiation therapy courses of treatment	87.93	51
No. of infusion cases per day per site	87.93	51
Gross revenue (quarterly, biannual, or annual)	86.21	50
No. of cancer surgeries	82.76	48
No. of new chemotherapy or immunotherapy infusion starts	81.03	47
Labor expense	77.59	45
No. of days for a clinician/provider to close an encounter	74.14	43
Market share	72.41	42
No. of screening visits/procedures (for select tumor programs such as breast cancer, prostate cancer, cervical cancer, ovarian cancer, colorectal cancer, and lung cancer)	70.69	41
Productivity index	70.69	41
Percentage of patients originating outside core service area (proxy for our ability to draw patients from far away)	63.79	37
Percentage of new visits generated by internal referral	41.38	24
Other (please specify)	6.90	4
Access and services
Time to first new appointment	94.83	55
Aggregated Press Ganey score (on the basis of individual physician scores)	74.14	43
Other (please specify)	13.79	8
Quality and outcomes
Patient satisfaction/Press Ganey scores	89.66	52
Safety outcomes/events	86.21	50
Survival measures (tumor- and stage-specific)	72.41	42
Teammate/employee engagement score	67.24	39
Time from diagnosis to first definitive therapy	65.52	38
Physician engagement metrics	63.79	37
Referral to palliative care within 90 days of death	48.28	28
No. of receiving multidisciplinary care	37.93	22
Other (please specify)	10.34	6
Academics
No. of therapeutic clinical trial accruals	84.48	49
Total No. of clinical trial accruals	81.03	47
No. of investigator-initiated trials written	74.14	43
Other	22.41	13

Abbreviations: CSL, cancer service lines.

^a Columns do not add to 100% as respondents were able to select more than one answer.

AUTHOR CONTRIBUTIONS

Conception and design: Paula M. Fracasso, Nicole L. Simone, Stephanie J. Si Lim, Lee G. Wilke

Administrative support: Hailey Honeycutt, Kate Shaw, Kendra Cameron

Collection and assembly of data: Hailey Honeycutt, Kate Shaw, Kendra Cameron

Data analysis and interpretation: Paula M. Fracasso, Nicole L. Simone, Stephanie J. Si Lim, Lee G. Wilke

Manuscript writing: All authors

Final approval of manuscript: All authors

Accountable for all aspects of the work: All authors

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

Benchmarking the Current Landscape: Insights From an Association of American Cancer Institutes Survey on Academic Cancer Service Lines

The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated unless otherwise noted. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/op/authors/author-center.

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