Innovating Cancer Care Delivery: the Example of the 4R Oncology Model for Colorectal Cancer Patients

  • Julia TrosmanEmail author
  • Christine Weldon
  • Sheetal Kircher
  • William Gradishar
  • Al BensonIII
Lower Gastrointestinal Cancers (AB Benson, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Lower Gastrointestinal Cancers

Opinion statement

Care delivery innovation is necessary to address the growing complexity of cancer care across specialties and integrate new diagnostics, treatments, and services into care delivery. Informed by Cancer Care Delivery Research (CCDR), multilevel intervention research, and other disciplines, this article describes the 4-step cancer care delivery innovation cycle. The cycle guides collaborative efforts of cancer clinicians, researchers, patients, and other stakeholders to systematically define care delivery problems and formulate, test, and implement care innovations to effectively address problems. We illustrate the 4 steps of the innovation cycle with the example of developing the 4R Oncology Model for colorectal cancer (4R is Right Information and Right Care for the Right Patient at the Right Time). The 4R is a multilevel intervention informed by CCDR, the team science, and lessons learned from other models, such as survivorship care planning. We offer additional considerations for balancing the need to innovate with concerns about constrained resources and overextended workforce. We suggest to focus on care delivery models which are synergistic with other efforts and do not require extensive information systems support in earlier cycles of development.


Care delivery models Cancer care delivery 4R Oncology Model Care delivery innovation Care delivery redesign Systems engineering in cancer care delivery Project management in care delivery 


Compliance with Ethical Standards

Conflict of Interest

Julia Trosman has received consulting fees (paid to Center for Business Models in Healthcare, Glencoe, IL) from Genentech.

Christine Weldon has received consulting fees (paid to Center for Business Models in Healthcare, Glencoe, IL) from Genentech.

Sheetal Kircher declares that she has no conflict of interest.

William Gradishar declares that he has no conflict of interest.

Al Benson III has received research funding from Novartis, Acerta Pharma, Celgene, Advanced Accelerator Applications, Merck Sharpe & Dohme, Taiho Pharmaceuticals, Bristol-Myers Squibb, and MedImmune/AstraZeneca; has received consulting/advisory fees from Bristol-Myers Squibb, Guardant Health, Eli Lilly & Company, Exelixis, Purdue Pharma, Xcenda, inVentiv Health, Inc., Axio, Genentech, Bayer, Merck, Rafael Pharmaceuticals, and Terumo; has served as a Data Monitoring Committee member for Astellas, Infinity Pharmaceuticals, and Merck Sharpe & Dohme; has given CME presentations for Harborside, meeting presentations for the National Comprehensive Cancer Network; and has served on an Editorial Board for Emron.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References and Recommended Reading

Papers of particular interest, published recently,4 have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Taplin SH, Anhang Price R, Edwards HM, Foster MK, Breslau ES, Chollette V, et al. Introduction: understanding and influencing multilevel factors across the cancer care continuum. J Natl Cancer Inst Monogr. 2012;2012(44):2–10. Scholar
  2. 2.
    •• Kent EE, Mitchell SA, Castro KM, DeWalt DA, Kaluzny AD, Hautala JA, et al. Cancer care delivery research: building the evidence base to support practice change in community oncology. J Clin Oncol. 2015;33(24):2705–11. This aricle provides important context and approach for the emerging field of cancer care delivery research: it outlines the agenda, scope, and focus of cancer care delivery resaerch and describes its key attributes.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Crossing the quality chasm: a new health system for the 21st century. Washington (DC); 2001.Google Scholar
  4. 4.
    Mariotto AB, Yabroff KR, Shao Y, Feuer EJ, Brown ML. Projections of the cost of cancer care in the United States: 2010-2020. J Natl Cancer Inst. 2011;103(2):117–28. Scholar
  5. 5.
    Shanafelt TD, Gradishar WJ, Kosty M, Satele D, Chew H, Horn L, et al. Burnout and career satisfaction among US oncologists. J Clin Oncol. 2014;32(7):678–86. Scholar
  6. 6.
    Spinks T, Albright HW, Feeley TW, Walters R, Burke TW, Aloia T, et al. Ensuring quality cancer care: a follow-up review of the Institute of Medicine’s 10 recommendations for improving the quality of cancer care in America. Cancer. 2012;118(10):2571–82. Scholar
  7. 7.
    Levit L, Balogh E, Nass S, Ganz PA, editors. Delivering high-quality cancer care: charting a new course for a system in crisis. Washington (DC); 2013.Google Scholar
  8. 8.
    Shih YC, Ganz PA, Aberle D, Abernethy A, Bekelman J, Brawley O, et al. Delivering high-quality and affordable care throughout the cancer care continuum. J Clin Oncol. 2013;31(32):4151–7. Scholar
  9. 9.
    Freund KM, Battaglia TA, Calhoun E, Darnell JS, Dudley DJ, Fiscella K, et al. Impact of patient navigation on timely cancer care: the Patient Navigation Research Program. J Natl Cancer Inst. 2014;106(6):dju115. Scholar
  10. 10.
    Rodday AM, Parsons SK, Snyder F, Simon MA, Llanos AA, Warren-Mears V, et al. Impact of patient navigation in eliminating economic disparities in cancer care. Cancer. 2015;121(22):4025–34. Scholar
  11. 11.
    Establishing effective patient navigation programs in oncology: proceedings of a workshop. The National Academies Collection: Reports funded by National Institutes of Health. Washington (DC); 2018.Google Scholar
  12. 12.
    Kuntz G, Tozer J, Snegosky J, Fox J, Neumann K. Michigan Oncology Medical Home Demonstration Project: first-year results. J Oncol Pract. 2014;10(2):104. Scholar
  13. 13.
    Colligan EM, Ewald E, Keating NL, Parashuram S, Spafford M, Ruiz S, et al. Two innovative cancer care programs have potential to reduce utilization and spending. Med Care. 2017;55(10):873–8. Scholar
  14. 14.
    Liu B, Song Y, Liu D. Recent development in clinical applications of PD-1 and PD-L1 antibodies for cancer immunotherapy. J Hematol Oncol. 2017;10(1):174. Scholar
  15. 15.
    Kroschinsky F, Stolzel F, von Bonin S, Beutel G, Kochanek M, Kiehl M, et al. New drugs, new toxicities: severe side effects of modern targeted and immunotherapy of cancer and their management. Crit Care. 2017;21(1):89. Scholar
  16. 16.
    Cukier P, Santini FC, Scaranti M, Hoff AO. Endocrine side effects of cancer immunotherapy. Endocr Relat Cancer. 2017;24(12):T331–T47. Scholar
  17. 17.
    Lee L, Cheung WY, Atkinson E, Krzyzanowska MK. Impact of comorbidity on chemotherapy use and outcomes in solid tumors: a systematic review. J Clin Oncol. 2011;29(1):106–17. Scholar
  18. 18.
    Edwards BK, Noone AM, Mariotto AB, Simard EP, Boscoe FP, Henley SJ, et al. Annual report to the nation on the status of cancer, 1975-2010, featuring prevalence of comorbidity and impact on survival among persons with lung, colorectal, breast, or prostate cancer. Cancer. 2014;120(9):1290–314. Scholar
  19. 19.
    Zullig LL, Jackson GL, Provenzale D, Griffin JM, Phelan S, van Ryn M. Transportation: a vehicle or roadblock to cancer care for VA patients with colorectal cancer? Clin Colorectal Cancer. 2012;11(1):60–5. Scholar
  20. 20.
    Zafar SY. Financial toxicity of cancer care: it’s time to intervene. J Natl Cancer Inst. 2016;108(5).
  21. 21.
    O’Connor JM, Kircher SM, de Souza JA. Financial toxicity in cancer care. J Community Support Oncol. 2016;14(3):101–6. Scholar
  22. 22.
    Tran G, Zafar SY. Financial toxicity and implications for cancer care in the era of molecular and immune therapies. Ann Transl Med. 2018;6(9):166. Scholar
  23. 23.
    Siegel RL, Miller KD, Jemal A. Cancer statistics, 2016. CA Cancer J Clin. 2016;66(1):7–30. Scholar
  24. 24.
    Kalyan A, Kircher S, Shah H, Mulcahy M, Benson A. Updates on immunotherapy for colorectal cancer. J Gastrointest Oncol. 2018;9(1):160–9. Scholar
  25. 25.
    Noone AM, Howlader N, Krapcho M, Miller D, Brest A, Yu M, Ruhl J, Tatalovich Z, Mariotto A, Lewis DR, Chen HS, Feuer EJ, Cronin KA, editors. SEER Cancer Statistics Review, 1975-2015, National Cancer Institute. Bethesda, MD,, based on November 2017 SEER data submission, posted to the SEER web site, April 2018.
  26. 26.
    Bailey CE, Hu CY, You YN, Bednarski BK, Rodriguez-Bigas MA, Skibber JM, et al. Increasing disparities in the age-related incidences of colon and rectal cancers in the United States, 1975-2010. JAMA Surg. 2015;150(1):17–22. Scholar
  27. 27.
    Kosty MP, Hanley A, Chollette V, Bruinooge SS, Taplin SH. National Cancer Institute-American Society of Clinical Oncology teams in cancer care project. J Oncol Pract. 2016;12(11):955–8. Scholar
  28. 28.
    Centers for Medicaid and Medicare Services. Oncology Care Model. Accessed 10/15/2018.
  29. 29.
    National Cancer Institute. Cancer Care Delivery Research (CCDR) within the NCI Community Oncology Research Program (NCORP). Accessed 10/15/18.
  30. 30.
    Patel MI, Moore D, Blayney DW, Milstein A. Transforming cancer care: are transdisciplinary approaches using design-thinking, engineering, and business methodologies needed to improve value in cancer care delivery? J Oncol Pract. 2014;10(2):e51–4. Scholar
  31. 31.
    Milstein A, Shortell S. Innovations in care delivery to slow growth of US health spending. JAMA. 2012;308(14):1439–40. Scholar
  32. 32.
    •• Parry C, Kent EE, Forsythe LP, Alfano CM, Rowland JH. Can’t see the forest for the care plan: a call to revisit the context of care planning. J Clin Oncol. 2013;31(21):2651–3. This article describes an important example of challenges of and approaches to developing care delivery models, focusing on survivorship care planning. The conceptual framework for survivorship care planning is very useful and may inform development of conceptual models in other cancer care delivery settings.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Spradlin D. Are you solving the right problem? Howard Business Review; 2012.Google Scholar
  34. 34.
    Stange KC, Breslau ES, Dietrich AJ, Glasgow RE. State-of-the-art and future directions in multilevel interventions across the cancer control continuum. J Natl Cancer Inst Monogr. 2012;2012(44):20–31. Scholar
  35. 35.
    Charns MP, Foster MK, Alligood EC, Benzer JK, Burgess JF Jr, Li D, et al. Multilevel interventions: measurement and measures. J Natl Cancer Inst Monogr. 2012;2012(44):67–77. Scholar
  36. 36.
    Ballard-Barbash R. Multilevel intervention research applications in cancer care delivery. J Natl Cancer Inst Monogr. 2012;2012(44):121–2. Scholar
  37. 37.
    Clauser SB, Taplin SH, Foster MK, Fagan P, Kaluzny AD. Multilevel intervention research: lessons learned and pathways forward. J Natl Cancer Inst Monogr. 2012;2012(44):127–33. Scholar
  38. 38.••
    Weaver SJ, Jacobsen PB. Cancer care coordination: opportunities for healthcare delivery research. Transl Behav Med. 2018;8(3):503–8. Scholar
  39. 39.
    Tiro JA, Kamineni A, Levin TR, Zheng Y, Schottinger JS, Rutter CM, et al. The colorectal cancer screening process in community settings: a conceptual model for the population-based research optimizing screening through personalized regimens consortium. Cancer Epidemiol Biomark Prev. 2014;23(7):1147–58. Scholar
  40. 40.
    Birken SA, Mayer DK. Survivorship care planning: why is it taking so long? J Natl Compr Cancer Netw. 2017;15(9):1165–9. Scholar
  41. 41.
    Tevaarwerk AJ, Sesto ME. Continued challenges to the adoption and implementation of survivorship care plans. J Oncol Pract. 2018;14(10):573–6. Scholar
  42. 42.
    •• Jacobsen PB, DeRosa AP, Henderson TO, Mayer DK, Moskowitz CS, Paskett ED, et al. Systematic review of the impact of cancer survivorship care plans on health outcomes and health care delivery. J Clin Oncol. 2018;36(20):2088–100. This article provides an important insight into the cyclical development and related challenges of cancer care delivery innovation. It reviews the evidence of effectiveness of the survivorship care planning model, reflects on gaps and challenges of the trajectory of this model over the last decade, and proposes a way forward toward. The content of this artcile is highly instructive for development of innovative cancer care delivery models.CrossRefPubMedGoogle Scholar
  43. 43.
    Christensen CM. The innovator’s dilemma: when new technologies cause great firms to fail. Boston: Harvard Business School Press; 1997. ISBN 978-0-87584-585-2Google Scholar
  44. 44.
    Christensen CM, Raynor ME. The innovator’s solution: creating and sustaining successful growth. Boston: Harvard Business School Press; 2003. ISBN 978-1-57851-852-4Google Scholar
  45. 45.
    Beswick C, Geraghty J, Bishop D. Building a culture of innovation: a practical framework for placing innovation at the core of your business. London, Philadelphia: Kogan Page; 2015.Google Scholar
  46. 46.
    Hamel G. The why, what, and how of management innovation. Harvard Business Review; 2016.Google Scholar
  47. 47.
    Goldenberg J, Mazursky D. Creativity in product innovation. Cambridge University Press; 2002. ISBN: 9780511674464Google Scholar
  48. 48.
    Loehrer S, Feeley D, Berwick D. 0 New rules to accelerate healthcare redesign. Bold aspirations to guide healthcare organizations during an era of reform. Healthc Exec. 2015;30(6):66 68–9.PubMedGoogle Scholar
  49. 49.
    Fanjiang G, Grossman JH, Compton WD, et al. Building a better delivery system: a new engineering/health care partnership. Washington, DC: National Academies Press; 2005.Google Scholar
  50. 50.
    Osarogiagbon RU, Rodriguez HP, Hicks D, Signore RS, Roark K, Kedia SK, et al. Deploying team science principles to optimize interdisciplinary lung cancer care delivery: avoiding the long and winding road to optimal care. J Oncol Pract. 2016;12(11):983–91. Scholar
  51. 51.
    Henry E, Silva A, Tarlov E, Czerlanis C, Bernard M, Chauhan C, et al. Delivering coordinated cancer care by building transactive memory in a team of teams. J Oncol Pract. 2016;12(11):992–9. Scholar
  52. 52.
    Lee SJ, Clark MA, Cox JV, Needles BM, Seigel C, Balasubramanian BA. Achieving coordinated care for patients with complex cases of cancer: a multiteam system approach. J Oncol Pract. 2016;12(11):1029–38. Scholar
  53. 53.
    Noyes K, Monson JR, Rizvi I, Savastano A, Green JS, Sevdalis N. Regional multiteam systems in cancer care delivery. J Oncol Pract. 2016;12(11):1059–66. Scholar
  54. 54.
    Tevaarwerk AJ, Klemp JR, van Londen GJ, Hesse BW, Sesto ME. Moving beyond static survivorship care plans: a systems engineering approach to population health management for cancer survivors. Cancer. 2018;124:4292–300. Scholar
  55. 55.
    Patel MI, Moore D, Milstein A. Redesigning advanced cancer care delivery: three ways to create higher value cancer care. J Oncol Pract. 2015;11(4):280–4. Scholar
  56. 56.
    Zapka J, Taplin SH, Ganz P, Grunfeld E, Sterba K. Multilevel factors affecting quality: examples from the cancer care continuum. J Natl Cancer Inst Monogr. 2012;2012(44):11–9. Scholar
  57. 57.
    McDonald KM, Sundaram V, Bravata DM, Lewis R, Lin N, Kraft SA et al. Closing the quality gap: a critical analysis of quality improvement strategies (Vol. 7: Care Coordination). AHRQ Technical Reviews. Rockville (MD); 2007.Google Scholar
  58. 58.
    Proctor EK, Landsverk J, Aarons G, Chambers D, Glisson C, Mittman B. Implementation research in mental health services: an emerging science with conceptual, methodological, and training challenges. Admin Pol Ment Health. 2009;36(1):24–34. Scholar
  59. 59.
    Rapkin BD, Weiss ES, Lounsbury DW, Thompson HS, Goodman RM, Schechter CB, et al. Using the interactive systems framework to support a quality improvement approach to dissemination of evidence-based strategies to promote early detection of breast cancer: planning a comprehensive dynamic trial. Am J Community Psychol. 2012;50(3–4):497–517. Scholar
  60. 60.
    Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4:50. Scholar
  61. 61.
    •• Chambers DA, Glasgow RE, Stange KC. The dynamic sustainability framework: addressing the paradox of sustainment amid ongoing change. Implement Sci. 2013;8:117. This article provides the rationale and approach to an ongoing, cyclical process of improving and sustaining heatlh care innovations, and is highly relevant to cancer care delivery models’ implementation and ongoing enhancement.CrossRefPubMedPubMedCentralGoogle Scholar
  62. 62.
    • Rapkin BD, Weiss E, Lounsbury D, Michel T, Gordon A, Erb-Downward J, et al. Reducing disparities in cancer screening and prevention through community-based participatory research partnerships with local libraries: a comprehensive dynamic trial. Am J Community Psychol. 2017;60(1-2):145–59. This article describes how a novel methodology for implementeting care delivery innovations could used in practice.CrossRefPubMedPubMedCentralGoogle Scholar
  63. 63.
    Freund KM. Implementation of evidence-based patient navigation programs. Acta Oncol. 2017;56(2):123–7. Scholar
  64. 64.
    National Comprehensive Cancer Netowrk. Accessed 10/15/2018.
  65. 65.
    Edwards MJ, Campbell ID, Lawrenson RA, Kuper-Hommel MJ. Influence of comorbidity on chemotherapy use for early breast cancer: systematic review and meta-analysis. Breast Cancer Res Treat. 2017;165(1):17–39. Scholar
  66. 66.
    Taplin SH, Barlow W, Urban N, Mandelson MT, Timlin DJ, Ichikawa L, et al. Stage, age, comorbidity, and direct costs of colon, prostate, and breast cancer care. J Natl Cancer Inst. 1995;87(6):417–26.CrossRefGoogle Scholar
  67. 67.
    Biagi JJ, Raphael MJ, Mackillop WJ, Kong W, King WD, Booth CM. Association between time to initiation of adjuvant chemotherapy and survival in colorectal cancer: a systematic review and meta-analysis. JAMA. 2011;305(22):2335–42. Scholar
  68. 68.
    Wasserman DW, Boulos M, Hopman WM, Booth CM, Goodwin R, Biagi JJ. Reasons for delay in time to initiation of adjuvant chemotherapy for colon cancer. J Oncol Pract. 2015;11(1):e28–35. Scholar
  69. 69.
    Brezden-Masley C, Polenz C. Current practices and challenges of adjuvant chemotherapy in patients with colorectal cancer. Surg Oncol Clin N Am. 2014;23(1):49–58. Scholar
  70. 70.
    Nokes S, Kelly S. The definitive guide to project management: the fast track to getting the job done on time and on budget. Pearson Education; 2007.Google Scholar
  71. 71.
    Dinsmore PC, Cooke-Davies TJ. Right projects done right: from business strategy to successful project implementation. Wiley; 2005.Google Scholar
  72. 72.
    Project Management Institute. A guide to the project management body of knowledge: PMBOK(R) Guide 5th Edition. Project Management Institute, Inc. 2013. ISBN-10: 1935589679.Google Scholar
  73. 73.
    HBR Guide to Project Management (HBR Guide Series). Harvard Business Review. 2013. ISBM 978–1–4221-8729-6.Google Scholar
  74. 74.
    •• Trosman JR, Carlos RC, Simon MA, Madden DL, Gradishar WJ, Benson AB 3rd, et al. Care for a patient with cancer as a project: management of complex task interdependence in cancer care delivery. J Oncol Pract. 2016;12(11):1101–13. This article describes the 4R Oncology Model in detail, highlightes its synergies with the team-based care model and offers an approach to its implementation in clinical practice.CrossRefPubMedPubMedCentralGoogle Scholar
  75. 75.
    Weldon CB, Friedewald SM, Kulkarni SA, Simon MA, Carlos RC, Strauss JB, et al. Radiology as the point of cancer patient and care team engagement: applying the 4r Model at a patient’s breast cancer care initiation. J Am Coll Radiol. 2016;13(12 Pt B):1579–89. Scholar
  76. 76.
    Weldon CB, Trosman JR, Perez CB, Kulkarni SA, Khan SA, Hansen NM, et al. Results from a pilot of an innovative 4R Cancer Care Delivery Model in early breast cancer: impact on timing and sequencing of guideline recommended care. J Clin Oncol. 2018;36(suppl; abstr 561).Google Scholar
  77. 77.
    Trosman JR, Weldon CB, Perez CB, Kulkarni SA, Khan SA, Hansen NM, et al. Results from a pilot of an innovative 4R Cancer Care Delivery Model: impact on patient self-management. J Clin Oncol. 2018;36(suppl; abstr 6527).Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Julia Trosman
    • 1
    • 2
    Email author
  • Christine Weldon
    • 1
    • 2
  • Sheetal Kircher
    • 2
    • 3
  • William Gradishar
    • 2
    • 3
  • Al BensonIII
    • 2
    • 3
  1. 1.Center for Business Models in HealthcareGlencoeUSA
  2. 2.Northwestern University Feinberg School of MedicineChicagoUSA
  3. 3.Robert H. Lurie Comprehensive Cancer CenterNorthwestern University Feinberg School of MedicineChicagoUSA

Personalised recommendations