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Rules of the Road: Bringing Big-City Cancer Care to Small-Town America

21st Century Oncology is the premier provider of cancer care services across multiple modalities, the largest radiation oncology provider and one of the largest groups of urologists in the U.S. For more than 30 years, 21st Century Oncology has been committed to providing state-of-the-art, academic quality radiation therapy and other cancer treatments in a patient-centric setting focused on continuous innovation.

It’s never good news to get a cancer diagnosis, but it’s even worse if you live in small-town America and don’t know where to turn.

The top half-dozen metropolitan areas—New York, Boston, Los Angeles, and so on—have phenomenal arrays of cancer treatment options for practically every form of the disease. But what if you live in a small town?


The level of care in small towns frequently lags behind what’s available in the biggest cities, and travel to those cities requires enormous time and expense. That’s an aspect of the disease that few people think about: the emotional and financial drain on cancer patients and their families when they have to make regular trips to the big city.

So, if you’re a doctor, a hospital, or a medical entity of any sort planning to offer cancer care in small towns—and thereby eliminate the need to travel to big cities—you’ve got to do it right.

Here are six “Rules of the Road” for treating cancer in small towns, provided by Kim Commins-Tzoumakas, CEO of 21st Century Oncology.

Rule One: Treat the whole person. “A cancer patient is more than just a diagnosis,” Commins-Tzoumakas says. “The individual is a human being with fear and concern about what’s going to happen next. You can’t treat a person as if they were just a medical chart. You’ve got to step back and look at the big picture with the individual—what is she going through? What kind of counseling might she need in addition to the physical treatment? What does her family need? Does she need nutritional or other support? You’ve always got to look at the whole person and not just the diagnosis.”

Rule Two: Have great doctors and empower them to manage each other. “We have a Physician Advisory Committee and a Physician Quality Committee,” Commins-Tzoumakas says, “which is composed of physicians covering each of our oncology subspecialties. These committees are focused on quality of care, research protocols, strategic growth and best practices. So, we’re able to share best practices across the country and ensure that we are physician- and patient-centric in all that we do. This leadership model allows us to implement  best practices the right way as things change—and in our field, change is a constant”

“It’s not enough to have the best doctors. You also have to have structures in place to ensure that they are providing the same level of care that patients would receive in the big cities. It’s a combination of having great doctors and a top-notch system for providing them the tools to be successful. That’s how we’re able to provide the best care.”

Rule Three: Having the best equipment is a smart investment in your doctors and your patients. “We are in locations like rural Alabama, North Carolina, West Virginia, and Mariana, Florida—places that don’t normally have access to the best equipment and academic-quality physicians. We strive to put the newest technology into each of our locations so we’re able to provide radiation therapy, medical oncology, and surgical specialties that you might expect to find only in places like Boston, New York, or Chicago. Because cancer is what we do, we can focus our investment.

“Sometimes health care providers are concerned about the price tag of all this new equipment and hospitals have a unique challenge of having to provide equipment for a multitude of specialties. From my experience, when you can provide the highest level of care through academic level physicians and research along with advanced technology, it pays off from a business perspective.”

Rule Four: Don’t tie up your doctor with too much administrative responsibility. “Doctors operate in a highly regulated environment,” Commins-Tzoumakas says. “At the same time, just as we try to acknowledge the humanity of our patients, we also acknowledge the humanity and uniqueness of each of our doctors! We don’t give them specifics on how many patients they must see in a given day, or precise guidelines for how to treat them; rather, we provide the framework and the regulatory guardrails and offer as much back office support as we can.  They can then spend their time doing what they love…treating and caring for our patients.

“We trust their judgment and give them the flexibility to run their practices in keeping with the best interest of their patients. If they’re going to do something unorthodox, like dress up in a costume because it’s a patient’s 90th birthday, we say, go for it, and they do!”

“If a patient is really struggling financially, sometimes our team members or doctors will bring in food for them, or notify non-profit foundations, such as the CARE foundation, that there is a patient who needs help. Doctors do best when they are not overly bogged down by administrative burdens and have a team that supports the patients they treat. They need opportunities to demonstrate their humanity.”

Rule Five: When it comes to business arrangements, get creative. “21st Century Oncology does not own real estate,” Commins-Tzoumakas says. “We lease space, but we own the equipment. As for our models, we have many, in some locations we take the burden off the hospitals in a community and provide the management and physicians for their centers, in others we joint venture with local hospitals or partners.  In other locations, we operate free-standing oncology programs. We don’t have one size fits all and that is why it works. 

“In today’s highly regulated environment with shrinking reimbursement, financial success for the small providers isn’t simple. Oncology is a complex business with very expensive equipment and infrastructure for radiation and extremely expensive drugs for medical oncology.  The key to financial success is demonstrating to payors that we are the lower cost alternative for their patients, with the same quality of research, technology and expertise. To have success in this field, you’re going to have to get creative by proving you are the low-cost, high quality provider and if you can do that in the patient’s neighborhood, everyone wins. 

Rule Six: Hug your patient. “I know it sounds crazy,” says Commins-Tzoumakas, “but in our treatment centers we believe in doing out-of-the-box things that provide results and improve the well-being of our patients. As we were building our core values, one of our doctors said a key part of that holistic care to patients includes hugging his  patients on every visit. Of course, it’s done with the patients’ consent in a caring and nurturing manner but this has spread through our dream team in center after center.  Most people need that physical contact and reassurance that all is going to be okay. Maybe they’re isolated and don’t have great support relationships. People need hugs!

“Notably, we have doctors who do dance therapy or find other ways to enhance the well-being of each patient, beyond the normal treatment plan.”

In short, Commins-Tzoumakas says, “Patients in small-town America are just as entitled to outstanding cancer care as patients in the big cities. If you follow the rules that we follow, the result is excellence, and that benefits everyone—the patients, their families, their communities, and also the doctors who are motivated to do their best. Everybody wins.

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