January 10, 2019
5 min read

Choosing quality cancer care: The effect of branding

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“A brand is a reason to choose.”

– Cheryl Burgess

Evidence for the relationship between patient volumes and quality of cancer care is strong.

John Sweetenham, MD, FRCP, FACP
John Sweetenham

Multiple studies have analyzed the relationship between care quality and/or outcomes for all cancer treatment modalities and, on the whole, concluded that high-volume centers perform better. Typically, but not invariably, these studies have compared smaller community-based facilities with large academic cancer centers or health care systems.

Quality and outcomes comparisons across hospitals are, of course, fraught with difficulties regarding case mix, population demographics, socioeconomic factors and, even in 2019, problems with access to reliable quality data at many medical centers. Despite this, many centers leverage their superior quality and outcome metrics as a part of their brand identity and promote these data either directly to the public or indirectly through references to various national rankings.

Affiliated cancer programs

The effects of hospital rankings on patient behavior are unclear, but there is at least some evidence that national rankings such as U.S. News & World Report’s “America’s Best Hospitals” do have an effect on market share and patient volumes — whether that is driven by patient choice or by referring provider practices is unclear.

The use of these metrics for gaining additional referrals brings problems.

No one would argue that all patients should have access to the highest-quality cancer care. That said, as the number of people affected by cancer increases with changing demography, major centers face capacity constraints, meaning they have to be somewhat selective in which patients they see (which, in itself, could be a source of bias that might skew their quality and outcomes data).

It’s highly improbable that most major cancer centers could handle the additional volume that might come their way if all patients “voted with their feet” and chose their services.

Additionally, this doesn’t solve the fundamental problem — smaller, lower-volume facilities would see even fewer patients and, thereby, would be unlikely to improve.

One potential solution to some of these challenges has been the trend for smaller hospitals to establish affiliations with larger academic cancer centers.

This has many potential advantages. For the smaller centers, there is an opportunity to engage with a larger organization to adopt aligned quality metrics, common care pathways and access to clinical trials, and to gain market advantage from the adoption of the larger center’s brand. For the larger centers, there is an opportunity to improve outreach efforts, increase accrual to clinical trials, extend the footprint of brand recognition and, ultimately, draw more referrals, especially of complex cases, to the center.


Most importantly, this model offers many potential advantages for the patient. As I have written in a previous editorial, there are many data supporting the benefits of receiving cancer care close to home. Enabling patients to receive high-quality care with minimum disruption to lifestyle, finances and support systems yields benefits that have been well documented, and the benefits extend not only to patients, but also to their caregivers. Sharing the expertise of major centers with affiliates provides patients with access to emerging therapies, clinical trials and, when necessary, seamless referral for complex care — or at least, that’s the aspiration.

Like many academic cancer centers, we at Huntsman Cancer Institute have developed an affiliate program. We have done this to enhance our threefold mission of patient care, research and education, with the primary goal of reducing and ultimately eliminating cancer care disparities related to location.

We strive to provide a uniform level of excellent care across our region, while ensuring all our patients access to appropriate clinical trials. We also hope to engage our affiliates in quality improvement projects, our treatment planning conferences and in our educational activities.

Impact on patient choice

Evaluating the true impact of affiliate relationships is a work in progress.

Although we can follow various “process” metrics such as access, patient experience and quality measures, the real issue of whether we are improving the lives of our patients remains, to a large extent, elusive. There is some emerging evidence that the public is beginning to take notice of, and potentially act on, the developing affiliate partnerships, at least when it relates to cancer surgeries.

In Annals of Surgical Oncology, Chiu and colleagues report on how Americans view “brand-sharing” arrangements between specialty cancer hospitals and smaller hospitals with a focus on complex cancer surgery. Although the results of the survey are largely hypothetical, posing more questions than they answer — the majority of those surveyed had no experience of cancer — they demonstrate how branding and affiliation efforts may influence patient attitudes and behavior.

Researchers presented survey respondents with a hypothetical situation in which they required complex cancer surgery and were given a choice between having this surgery in an unaffiliated hospital close to home, a large highly ranked cancer center more than 1 hour in traveling time from home, or a smaller local hospital that is affiliated with a large center. Additional questions focused on perceptions of quality of surgery and care.

The high-level results of the study are very interesting. Faced with the choice between a large center and a small, unaffiliated hospital, 85% of respondents stated they would be prepared to travel more than 1 hour to receive care at the larger center.


However, if given the option of care at a local affiliated hospital, 31% of these patients changed their preference — about half of the patients thought that surgical safety and quality would be equivalent at the affiliate and the larger center. The demographic of this group was, in my mind, counterintuitive — those who opted for the local, affiliated hospital had a higher education level and lived in urban areas — contrasting with a number of previous surveys that suggest this group is more inclined to seek “ranked” cancer organizations.

Overall, these results suggest that the message of the potential benefits of affiliation networks are getting through to the public.

Brand affirmation

The results pose two major challenges for us as cancer care providers.

Firstly, we need to determine whether these perceptions are justified. At the moment, there are very few data that show improvements in outcomes for affiliated vs. nonaffiliated hospitals. If such differences do exist, it’s important to understand whether they represent the influence of the larger center on the smaller one, or whether they reflect the ability of larger centers to select high-quality partners in the first place.

Secondly, given the public perception of these affiliations, we need to maintain constant attention to quality care and outcomes at all our points of care to ensure we live up to the affiliation “promise.” Sharing best practices for clinical care and research through organizations such as National Comprehensive Cancer Network and ASCO are important resources in this regard.

Most importantly, high-quality, accessible cancer care through branded affiliate hospitals is an important and desirable trend. We need to keep a laser focus on quality and outcomes to honor the public’s trust in the cancer care we provide at all locations and to affirm our brand, or more importantly, our quality and value as “reasons to choose.”


Chiu AS, et al. Ann Surg Oncol. 2018;doi:10.1245/s10434-018-6868-9.

Pope DG. J Health Econ. 2009;doi:10.1016/j.jhealeco.2009.08.006.

For more information:

John Sweetenham, MD, FRCP, FACP, is HemOnc Today’s Chief Medical Editor for Hematology. He also is senior director of clinical affairs and executive medical director of Huntsman Cancer Institute at The University of Utah. He can be reached at john.sweetenham@hci.utah.edu.

Disclosure: Sweetenham reports no relevant financial disclosures.