Cancer center affiliates—local hospitals that partner with and typically share the brands of better-known cancer hospitals—are becoming increasingly prevalent. In many cases, these affiliations can help to extend a cancer center’s reach to an underserved area or help provide an additional level of expertise to a community hospital. However, patients seeking treatment may view cancer centers and their affiliates as one and the same without grasping important differences between the institutions.

Highlighting one such difference, a study published April 12, 2019, in JAMA Network Open found that outcomes for complex cancer surgery were generally better at top-ranked cancer hospitals than at their affiliates. For the study, researchers analyzed Medicare data from 2013 to 2016 and compared 90-day survival rates from 59 top hospitals, as ranked by U.S. News & World Report, to their 343 affiliate hospitals. The researchers focused on surgeries to remove all or part of the colon, pancreas, lung, stomach or esophagus, finding significant mortality differences in all surgeries except esophageal surgery. The largest survival differences were in stomach surgeries, with 90-day mortality rates of 5.4% in the top-ranked cancer centers, compared to 10.7% at affiliates. Additionally, 39 of 49 top-ranked cancer hospitals had surgery mortality rates that were better than the national average, while just 17 of the 49 hospitals’ affiliated networks had rates that were better than the national average. (Ten hospitals and their networks were not included in this part of the study because the affiliated hospitals did not have adequate surgical volume to make reliable comparisons.)

“The take home from this is not to say that every affiliate hospital is unsafe, because they are not [unsafe],” says Daniel J. Boffa, a thoracic surgeon at Yale Medicine in New Haven, Connecticut, who was an author of the study. “For those patients who are investigating where they have care, they need to acknowledge that, in general, there are real differences between the affiliate and the top-ranked hospital, and not assume they are the same. The affiliate may still be a great choice for them, and it may be the best option in their area.”

What is concerning to Boffa is that consumers may think cancer centers and their affiliates provide identical care. Boffa and his colleagues published research in the March 2019 Annals of Surgical Oncology showing that 85% of 1,010 Americans surveyed indicated they would travel an hour to a top-ranked cancer center rather than go to a local hospital for complex cancer surgery. However, 31% of those who said they would travel indicated they would choose the local hospital if it had an affiliation with a top-ranking cancer center, according to the survey. “Those are the people that we are really concerned about, because they can go anywhere, and yet that belief that the facilities are the same caused them to change their mind simply because the sign had changed,” says Boffa. “Those are the people that are really at risk for making a decision that is not in line with their priorities.”

Cynthia Chmielewski, a patient advocate who has been living with multiple myeloma since 2008, remembers how excited she was in 2013 to learn that the University of Texas MD Anderson Cancer Center in Houston was teaming with Cooper University Hospital in Camden, New Jersey. Chmielewski was not looking to change her care from Penn Medicine’s Abramson Cancer Center, which is a part of the University of Pennsylvania Health System in Philadelphia. However, it was comforting for her to know she might have access to different clinical trials and multiple myeloma specialists if her treatment stopped working.

“I thought all the clinical trials in myeloma that were offered at MD Anderson would now be offered in Camden, and I wouldn’t have to travel to Houston to be a part of the trial,” she says. But when she spoke with one of the MD Anderson multiple myeloma specialists she knew through her work as a patient advocate, Chmielewski learned that MD Anderson wasn’t offering clinical trials for multiple myeloma at the Camden location, she says.

“Even I was confused, and I’m a patient advocate,” says Chmielewski. “The average patient thinks the affiliate is the same thing as the cancer center. I think there needs to be patient education about what it means.”

Cancer center affiliations can take on many forms. MD Anderson, which has placed first or second every year for cancer care since the U.S. News & World Report first started providing hospital rankings in 1990, has relationships with more than 25 hospitals and health systems through four membership types around the world. Partner membership, which is the highest affiliate level and a distinction that Cooper University Hospital shares with seven other facilities​ in the U.S, means the “hospitals must integrate clinical care operations with MD Anderson and mirror how we deliver cancer care,” says Michael E. Kupferman, a head and neck surgeon who is senior vice president of clinical and academic network development at MD Anderson.

These partnerships help hospitals that serve a wide a range of health issues benefit from MD Anderson’s clinical care models, which are based on years of cancer research and experience with patients, Kupferman says. “Our goal is to help other organizations expand on their cancer care delivery systems to provide access to patients who don’t have the resources to go to an NCI-designated comprehensive cancer center.”

As part of MD Anderson’s agreements with other hospitals, Kupferman says, they provide peer-to-peer consultations, help facilities implement multi-disciplinary tumor boards, and provide ongoing education and training in MD Anderson’s evidence-based practices, including those in prevention, screening and survivorship care.

Boffa hopes his study will encourage cancer hospitals to examine surgical outcomes at hospitals and their affiliate networks. “My hope is that this is a bit of a wake-up call [for hospitals] that a significant portion of the public believes that the affiliation means the care is the same, and that we have data that shows the care is not,” Boffa says. “It’s a great opportunity for the hospitals that are already linked together to look at this and say, ‘Wait a minute, we should be the same, or if we are not the same, how can we make things better across the board?’” One solution, Boffa says, might be to move some surgeries to a central hospital and provide resources to travel to the main hospital.

This is a strategy already practiced at the University of Pennsylvania Health System, which sends its chief of thoracic surgery to an affiliated hospital site regularly to see patients who may need surgical consultations for lung cancer. If surgery is required, it occurs at the main hospital, says Lawrence Shulman, a medical oncologist who has studied quality issues within cancer centers and who leads the Cancer Quality program for Penn Medicine’s health system. Penn Medicine owns six hospitals, all within two hours of the main cancer center in Philadelphia. “We are able to do this because all of our hospitals are relatively close to each other,” Shulman says.

Shulman notes the research on surgical outcomes at affiliates is similar to previously published findings on quality of care differences among cancer hospitals in general. For example, Shulman and others published data in the January 2018 Journal of Oncology Practice​ that showed survival rates for patients with stage III breast cancer and stage IIIB or IV non-small cell lung cancer were best at National Cancer Institute-designated comprehensive cancer centers, followed by academic medical centers, large community hospitals and small community hospitals. A number of studies have shown that surgical outcomes for complex cancer surgeries are better in centers with a high number of surgeries versus those with low numbers, Shulman says. Cancer center affiliates generally serve fewer patients than top-ranked cancer centers.

“This study is showing in a different way the same thing as earlier studies, which is really that the name matters less than the volume and expertise that is present,” says Shulman, who also serves as the executive committee chair of the Commission on Cancer, a program of the American College of Surgeons that offers accreditation to cancer facilities that meet criteria for providing high levels of patient-centered care.

Boffa, Kupferman and Shulman all recommend that cancer patients practice due diligence—no matter where they seek cancer treatment. Boffa suggests asking specific questions about a health care provider’s experience and number of surgeries completed, and to seek out any available data about surgical outcomes. He stresses that each affiliate is different—for example, a few affiliates in the study had better surgical outcomes than the main cancer center. Patients considering an affiliate should ask questions about what the affiliation means, including whether doctors from the large cancer center are practicing at the affiliate and how involved they will be in care, says Boffa. “I would treat it as if they were interviewing the health care provider for the privilege of caring for them,” he says.

Marci A. Landsmann is the managing editor of Cancer Today.