When Sarah Rodriguez scheduled her radiation appointments for breast cancer, she felt ready. Until the reality hit: her nearest cancer center was 45 minutes away, and she didn’t have reliable transportation. Missing three sessions stretched her treatment across months, leaving her with a nagging question: was she putting herself at greater risk?

Rodriguez’s struggle isn’t unique. Up to 20% of cancer patients in the United States miss two or more recommended radiation therapy appointments, and the consequences are serious—increased rates of cancer recurrence and higher mortality. Yet a groundbreaking national quality improvement initiative shows that this problem isn’t inevitable.

Breaking Down the Barriers

The American College of Surgeons (ACS) launched a two-year program called Breaking Barriers in January 2023, tracking data from more than 90,000 cancer patients across 194 hospitals and cancer centers. The findings, published in the Journal of the American College of Surgeons, revealed why patients miss appointments and what actually works to get them there.

“With advances in cancer care, we now have treatments that can drastically improve survival rates,” said Dr. Laurie Kirstein, FACS, lead author of the study and chair of the ACS Commission on Cancer. “Patients only receive those benefits if they complete their recommended care.”

The research identified four primary obstacles:

• Transportation problems (62%) – The single biggest barrier, ranging from lack of affordable public transit to living far from treatment centers
• Non-cancer-related illness (37%) – Including depression and anxiety that often accompanies a cancer diagnosis
• Scheduling conflicts (17%) – Other medical appointments or personal obligations competing for time
• Patient decision to discontinue (9%) – Patients choosing to stop treatment on their own

Real Solutions That Moved the Needle

Here’s what surprised researchers: there’s no one-size-fits-all fix. A transportation barrier in rural Texas looks different from one in urban New Jersey. So hospitals got creative.

Participating centers implemented an average of four interventions, with measurable results. Approximately 71% of hospitals and centers reduced their no-show rates. At the patient level, missed radiation appointments fell from 8.3% to 5% by the end of year two—a 40% reduction. That translated to more than 1,600 additional patients completing their entire course of treatment.

The most effective strategies included:

• Enhanced electronic health record systems that automated appointment reminders
• Improved workflows to help patients find affordable, reliable transportation options
• Patient navigators who followed up directly with patients to address barriers

Dr. Kirstein, a breast cancer surgeon at Memorial Sloan Kettering in New York who treats many patients requiring radiation therapy, emphasizes the human element. “As providers, we must be aware of the obstacles patients face when seeking care and develop feasible and innovative ways to support both hospitals and patients,” she said.

Uneven Progress Across the Country

The initiative didn’t eliminate disparities—it exposed them. Hospitals in the South and Midwest saw the greatest improvements in reducing missed appointments, while Northeast facilities showed less progress. This geographic variation suggests that different regions face distinct challenges requiring tailored approaches.

Community hospitals proved particularly vulnerable. Those treating 100 to 500 new cancer patients annually started with the highest no-show rates at 11.6%, dropping only to 10.5% despite interventions. Researchers suggest these smaller facilities may need additional, specialized support.

The reduction was most pronounced for gynecological, gastrointestinal, and breast cancers, while prostate and lung cancer patients showed smaller improvements—pointing to cancer-specific factors worth investigating further.

Why This Matters Beyond the Numbers

Radiation therapy demands commitment. Most patients need daily sessions for weeks. Miss several appointments, and the treatment loses effectiveness. The cumulative effect of a 40% reduction in missed appointments ripples through entire treatment populations.

“This research highlights the distinct challenges cancer patients face throughout their treatment journey,” Kirstein explained, “and showed us how a large-scale quality improvement project can address these challenges.”

The study had limitations—hospital-reported data may not capture every nuance of a patient’s experience—but the scale is impressive: over 90,000 patients tracked prospectively, excluding canceled appointments due to uncontrollable factors like weather or clinic closures.

What’s Next

The ACS plans to expand the Breaking Barriers framework to other treatment types, including chemotherapy adherence. Researchers are also exploring how to provide region-specific support that acknowledges local infrastructure and population needs.

For hospitals already implementing these strategies, the path forward is clear: invest in navigation support, fix your reminder systems, and solve the transportation puzzle. It’s unglamorous work—no new drug, no surgical innovation—but it’s how hospitals ensure the treatments they offer actually reach patients who need them.

For patients like Rodriguez, the difference between missing appointments and completing treatment often comes down to whether someone at the hospital asked the right question: “What’s stopping you from getting here?”