Key Takeaways
- Cancer patients who frequently miss radiation appointments experience worse clinical outcomes than those who complete their recommended treatment.
- Transportation barriers, unrelated illnesses, and not wanting to continue with treatment are the most common reasons patients miss radiation appointments.
- Providing patients with structured and individualized support can reduce missed radiation therapy appointments by almost half, a national quality improvement project found.
CHICAGO — A national quality improvement program led by the American College of Surgeons (ACS) found that transportation barriers and illness are among the top reasons cancer patients miss critical radiation therapy appointments — and that providing hospitals and patients with structured support can reduce missed appointments by up to 40%.
The results of the initiative, involving data from more than 90,000 cancer patients, are published in the Journal of the American College of Surgeons (JACS).
Research shows that up to 20% of cancer patients in the U.S. miss two or more of their recommended radiation appointments, increasing their risk of cancer recurrence and death . Despite the importance of radiation therapy in treating cancer, treatment often requires daily visits for several weeks, which can be time-consuming and challenging to complete.
Launched by the ACS Cancer Programs in January 2023, Breaking Barriers was a two-year national quality-improvement program that helped hospitals and cancer centers accredited by the ACS Commission on Cancer (CoC) and National Accreditation Program for Breast Centers (NAPBC) identify and reduce the causes behind missed radiation appointments.
"With advances in cancer care, we now have treatments that can drastically improve survival rates. Patients only receive those benefits if they complete their recommended care," said Laurie Kirstein, MD, FACS, senior author of the JACS study and chair of the ACS CoC. "Missed appointments were identified by the ACS CoC and NAPBC as an area of concern where we have the power to turn the tide and better support hospitals and patients."
Dr. Kirstein is a breast surgical oncologist at Memorial Sloan Kettering in New York, seeing many cancer patients with radiation therapy in their treatment plans.
Over two years, 194 hospitals and cancer centers accredited by the ACS CoC and NAPBC participated in Breaking Barriers. In the first year, centers identified the main patient-reported barriers to receiving radiation treatment across seven cancers: breast, prostate, gynecologic, gastrointestinal, rectal, lung, and head and neck.
Centers then implemented solutions using an ACS toolkit and attended webinars and peer sessions during the second year of the program. About half of the participants were integrated cancer networks or community cancer programs, and approximately 10% were safety-net hospitals, which serve large numbers of patients on government insurance.
Patients who missed three or more radiation appointments ("no-show" rates) during their cancer treatment were logged — a threshold the research team deemed significant enough to impact patient care. Appointments canceled due to uncontrollable factors (weather delays, clinic closures) were excluded. More than 90,000 patients were prospectively tracked during the study period.
Study Results
- Four main barriers identified: Transportation barriers (62%), illness unrelated to cancer treatment (37%), conflicting appointments (17%), and not wanting to continue with treatment (9%) all contributed to missed appointments.
- No "one-size fits all" solution: The same barrier may impact patients differently based on location and context, the authors said. For instance, transportation issues may involve distance or a lack of affordable public transit. Illness often included depression and anxiety as reasons for missed care.
- Missed appointments reduced by almost half: About 71% of participating hospitals and centers saw a decrease in no-show rates. Hospitals and centers reduced missed radiation appointments by almost 40% at the patient level — from 8.3% at baseline to 5% at the end of the second year. At the hospital level, median no-show rates decreased by 32% — from 8.2% at baseline to 5.6%. This translated into an increase of more than 1,600 patients who completed their care.
- Cancer-specific and regional differences: Gynecologic, gastrointestinal, and breast cancers saw notable reductions in missed appointments compared with prostate and lung cancers. Regionally, hospitals and centers in the South and Midwest saw the greatest reduction in missed appointments, whereas those in the Northeast saw less improvement, which the authors noted could indicate that the Northeast faces different barriers.
- Multiple interventions needed: Hospitals and centers implemented an average of four interventions. Enhanced electronic health record systems to automate appointment reminders, improved workflows to help patients find affordable, reliable transportation, and hiring patient navigators to follow up with patients were associated with lower no-show rates.
- Community hospitals at risk: Community hospitals (treating 100-500 new patients yearly) had the highest percentage of no-show rates (11.6%) at baseline. Rates dropped only to 10.5%, suggesting that community hospitals may need more tailored support.
"This research highlights the distinct challenges cancer patients face throughout their treatment journey — and showed us how a large-scale quality improvement project can address those challenges," Dr. Kirstein said. "As cancer care providers, we need to be aware of the obstacles that patients face when seeking care and develop feasible, innovative ways to support both hospitals and patients."
The authors acknowledged that hospital-reported data from the study may not capture all the nuanced challenges patients face during cancer radiation treatment. Future work will focus on applying the Breaking Barriers framework to other areas, such as chemotherapy adherence, and exploring region-specific support for hospitals and centers.
Study co-authors are Kelley Chan, MD, MS; Eileen Reilly, MSW; Lauren M Janczewski, MD, MS; Sharon Gentry, MSN, RN; Camille Biggins, MHA; Bruce Haffty, MD; Charles Shelton, MD; Anthony D Yang, MD, MS, FACS; and Ronald J Weigel, MD, PhD, MBA, FACS.
Learn more about Breaking Barriers .
Citation: Chan K, Reilly E, Janczewski LM. Results of an American College of Surgeons Prospective National Quality Improvement Collaborative to Successfully Overcome Barriers to Cancer Care Across the US . Journal of the American College of Surgeons, 2025. DOI: 10.1097/XCS.0000000000001637
