Foreword: Understanding and Influencing Multilevel Factors Across the Cancer Care Continuum

Even as medicine and technology advance, people in the United States do not always receive the benefit of high-quality health care. Despite highly sophisticated medical centers and a robust biomedical research enterprise, the United States consistently ranks below many other industrialized nations in such measures as life expectancy, infant mortality, and comparative measures of quality (1). The Institute of Medicine’s 1999 study on Ensuring Quality Cancer Care (2) suggested that best practices in cancer care delivery are not consistently followed. A year later, the Institute of Medicine published the landmark report, To Err is Human: Building a Safer Health System (3), showing that the failure to follow best practices afflicts the health-care system as a whole. Clearly, if providers were more consistent in following optimal practices, quality of care and health outcomes would improve.

This is simpler to say than to accomplish, particularly when it comes to the care for many cancers. Care for cancer is often more complex and longer in duration than for many other ailments. Acute health problems often require a single visit to single clinician. Chronic diseases, like most cancers, may require a team of practitioners—including physicians, surgeons, nurses, technicians, social workers, nutritionists, physical therapists, and psychologists-—and care may be ongoing over months or years. Successful care requires a higher degree of coordination and integration, and care for the whole patient extends beyond the period of direct medical treatment (4).

Many studies emphasize the importance of patient engagement and the significant impact that social, political, and economic systems have in shaping patient behavior (4,5). Successful management of cancer and its sequelae often requires sustained behavioral change. The success of the patient in following physician-recommended practices will depend in part on the actions of the physician and also on the socioeconomic circumstances of the patient, the support of family and community, and numerous other influences on patient choices and actions. Sound management of patients with cancer requires sensitivity to the high degree of variability among patients in different circumstances and environments.

The harder challenge is applying the right practices precisely where and when they are indicated. Patients and providers need decision tools to help them determine the best mix of interventions in light of the particular circumstances and needs of the patient. A recent evaluation of progress in cancer care since 1999 suggests that we have yet to achieve the goal of consistent evidence-based care in an integrated way that is supportive and patient centered (6). The goal, moving forward, is to ensure that all services for cancer patients are delivered at a uniformly high quality. This is the motivation behind this volume, which lays the foundation for a robust evidence base on multilevel interventions, elucidating the complexity of the task and providing a framework for future research.