The story of cancer treatment in the United States is one of hope, with survival rates today presenting a stark contrast to those of just a few decades ago. In fact, the American Cancer Society (ACS) reports that the five-year survival rate for cancers diagnosed between 2002 and 2008 is 68 percent, up from the 49 percent found between 1975 and 1977.

But the organization’s Cancer Facts & Figures 2013 report is also tempered by the realities of what’s yet to come. While incidence rates are declining for most types of cancer, others are on the rise, such as melanoma, thyroid, and pancreas. And in 2013 alone, about 1.7 million new cancer cases are expected to be diagnosed.

The treatment landscape is about to see some new challenges, too. Cancer is a disease of aging, and more than 70 million baby boomers are heading into the over-60 population. Add to that healthcare reform’s call for accountable care, influence on physician integration, and coverage of the currently uninsured.

Pushing the care environment forward are new approaches to delivery, including a focus on outpatient care enhanced through a team-based approach, technology playing an ever-more critical role, and an overhaul of treatment spaces to provide control—as well as a sense of optimism—to patients during a time when they may not be feeling it otherwise.

“In designing these facilities, it’s about creating a space that not only reflects the cutting-edge technology and the extraordinary knowledge that’s at work to solve the problems of cancer, but it’s also to really create an environment that’s about life, and about thriving, growing, and recovering quickly from this dreaded disease,” says Rick Kobus, senior principal, Tsoi/Kobus & Associates (TK&A; Cambridge, Mass.).


Streamlining care
Like the shift seen in survival rates, cancer care environments have also changed drastically from what they were 30 years ago, with 85 to 90 percent of care now delivered in the community through outpatient centers. With that trend has come a push toward a team-based approach that involves multidisciplinary groups of caregivers, from surgeon to radiologist to pathologist.

“When those physicians are located in different facilities, it’s a challenge for patients to get the big picture of their whole care plan. What providers are realizing is if we can facilitate a place where our caregivers can be together and consult patients through team care, not only are the outcomes better but the patients are finding they’re getting better and higher quality care,” says Jason Schroer, associate principal/senior vice president, HKS Inc. (Dallas).

However, reintegrating once-private-practice physicians into a hospital-run program as well as bringing surgeons into the outpatient setting isn’t always easy, says Jake Jones, vice president, facilities design and development, Oncology Solutions (Decatur, Ga.). “For oncology specifically, the integration of the surgical piece and the multidisciplinary care aspect takes a lot of operational change and a lot of re-educating the physicians as to the value to them and to the patients. In terms of facilities, there’s a complement of clinical space that needs to be included and designed around that model,” he says.

For example, the MemorialCare Todd Cancer Institute Pavilion at Long Beach Memorial Medical Center (Long Beach, Calif.), a new 64,000-square-foot, $32 million facility scheduled to open in July and designed by C|A Architects, will collocate the hospital’s outpatient cancer services under one roof. There, physician office space is designed in a “timeshare” model, with various specialists sharing space on a day-to-day basis.

In fact, the integrated approach taken at the facility also includes wellness pieces, such as a rehab gym, yoga space, demonstration kitchen, therapy session rooms, and space for acupuncture and massotherapy.

“We know that people seek out these kinds of services and that we would like to be able to marry all of the Eastern medicine tools with Western medicine, and have one integrated program so our doctors will know what their patients are doing,” says Cathy Kopy, executive director, Todd Cancer Institute.

At the Duke Medicine Cancer Center in Durham, N.C., designed by TK&A, collocation principles were used in the efficient placement of services, as well, so patients wouldn’t have to traverse the campus to make regular visits to the lab, radiology, or imaging. “We have to recognize that very often these patients have limited mobility, that the treatment is exhausting, and that it’s really important to provide these diagnostic tools and place them at convenient locations for the patient,” Kobus says.

Adjusting the placement of services also prevents bottlenecks that often occur in cancer treatment facilities and improves throughput of patients, especially for pieces like registration, insurance co-pays, lab results, pharmacy pick-ups, etc. Another example of streamlining can be found in moving departments traditionally maintained in the acute care setting, such as imaging, and instead operating them right from the outpatient cancer center.

“I think folks know that they have to manage care delivery at a better cost, in a more effective way, especially with accountable care. Lean process planning has been a real addition to the design, construction, and planning of these facilities in past years,” says Kelley Simpson, senior partner, Oncology Solutions.


Tech tips
Another way team-based care must be supported in the physical space is through the installation of necessary technology to support telemedicine efforts. “Since a cancer patient often has many different doctors and caregivers as part of a core plan, [technology] can help break down those barriers and provide better care,” Schroer says.

Cancer treatment itself is also technology-intensive and requires a great deal of coordination right from the outset of any project. To start, MRIs alone advance so quickly that spaces where they’re housed are often built out last by contractors so the very latest equipment can be installed, says Mike Gritters, executive vice president, healthcare services, McCarthy Building Cos.(Newport Beach, Calif.). Plus, “because MRI machines become outdated every three to six years, contractors have to design a way to get the large, heavy equipment out of the building when it’s time to replace it,” he adds.

Also gaining ground on the technology front are hybrid operating rooms featuring intraoperative MRIs incorporated into a space to merge the latest imaging technology of a radiology suite with a traditional OR. “The technology enables complex cases to undergo both open and minimally invasive surgery techniques in the same room,” Gritters says.

On a more extreme end of the cancer technology spectrum is proton therapy, which requires tremendous infrastructure support beyond what’s needed for traditional radiation equipment.

But across the board, Schroer says when it comes to technology and radiation therapies, patients want to know it&rsquo
;s there, but they don’t want to feel it. “As designers, we’re doing everything we can to minimize the harshness that may come with technology. Some ways we’ve done that is to introduce daylight. Sometimes we can introduce greenery or plant life. We’ve even looked at using technology that allows you to project pictures of a patient’s family on the wall,” he says.

And while care providers have had success in reducing radiation stints with complements of treatments in pill form, it’s expected that technology will still be required for some time. With that in mind, spaces must be designed to support the unknown.

“For instance, we’ll design a building with a higher floor-to-ceiling height, and that would allow for whatever that technology may become 10 years from now to be bigger and still be easily plugged and played into that space,” Schroer says. “We may overdesign a structure in certain areas to know it’s flexible to bring in new technology over time.”

Giving control back
While the complexity of treatment equipment continues to escalate and become more high-tech, requirements for the physical space aren’t necessarily moving in the same direction.

“The patients’ desire and need to be in a more relaxed, much less clinical, and more intimate space when they’re receiving treatment and care—those things are at different ends of the spectrum. But that’s what the new cancer treatment facilities really need to be,” says Jim Eaton, vice president– healthcare division leader, Haskell (Jacksonville, Fla.).

Dr. Nancy Davidson, director of the University of Pittsburgh Cancer Institute and UPMC CancerCenter, says that this personalized treatment approach was a critical component in planning the new Mario Lemieux Center for Blood Cancers, a 24,000-square-foot long-term outpatient treatment facility at UPMC’s Hillman Cancer Center in Pittsburgh. (For more, please see "Photo Tour: The Mario Lemieux Center For Blood Cancers.")

To start, the center’s must-haves for design included patient-centered, homelike elements that support the long periods of time that most patients normally spend there, often arriving in the morning and not leaving until well into the afternoon.

“That requires a certain attention to the treatment facility’s ambiance that is especially important because patients may be there for such long periods of time,” Davidson says, noting the innate difference between the design of cancer centers and traditional outpatient spaces.

“We wanted materials that would be familiar and that would express a sense of calm,” adds David Wells, principal, Radelet McCarthy Polletta (Pittsburgh), the architect on the Mario Lemieux project. Thankfully, that goal is easier to achieve today, Wells says, citing advancements that have been made by manufacturers in offering flooring, upholstery, and other materials suited for infection control, without a clinical look and feel.

“We needed to balance and be very cognizant of those aspects to achieve the level of quality and soothing appearance of the space,” he says.

Gritters, of McCarthy, notes that plans to create calming spaces oftentimes call for structural considerations, too, such as installation of water features or natural materials like wood and stone. “In the patient spaces, abundant use of windows and skylights are also used to bring in natural light,” he says.

Designers must also consider the long amount of time spent at these facilities from the perspective of providing services and various space options.

“Patients need to eat, so we need to provide food service that’s located away from treatment areas so as not to cause scent issues for those who are sick. And retail space is definitely a helpful thing to have in a cancer center,” says Kate Wendt, associate principal and director of interior design for TK&A, of everything from on-site pharmacies to wig and prosthetics boutiques that provide one-stop shopping. Wendt adds that other ideal space options include education/resource centers and respite spaces like rooftop gardens and outdoor patios.

Looking forward
With baby boomers promising growth in cancer care, the industry sector continues to brace for the full impact of healthcare reform.

“The biggest issue many of our clients face today is physician integration and how that affects their facilities, because many of them are integrating what once was a hospital outpatient infusion clinic with the private practice environment. So that’s an issue, and how to expand existing facilities or build new to accommodate that growth,” Oncology Solutions’ Simpson says.

And while research and technology advancements have successfully yielded higher rates of survivorship for cancer patients, that fact, too, has an effect on how health systems are planning cancer spaces for the future. “These patients are living much longer and the whole survivorship planning aspect of ongoing testing and intervention is a really big issue, and it’s how to accommodate that whole cancer population in their long-term facilities adoption plan,” Simpson says.

TK&A’s Wendt concurs, noting that the rate of survivorship has “transformed the way cancer centers are designed. In most all of them, there are spaces set aside for community outreach and also for training. For survivors, there are club rooms where they can meet on a regular basis,” she says.

At the new Todd Cancer Institute, preparing for more survivors translates to planning spaces that support a lifetime of wellness services. “It’s one thing to survive your cancer, but you need to survive it and then thrive,” Kopy says.

Jennifer Kovacs Silvis is managing editor of Healthcare Design. She can be reached at