Center Annual Report

Colorectal Cancer Awareness Collaboration AU Digestive Health Center 

Date: March 26-28, 2019

Outcomes:  127 Attendees; 11 Surveys; 5 FIT Tests distributed East Georgia Cancer Coalition

Head and Neck Cancer Screening

Date: April 26, 2019

Outcomes: 34 participants screened. 8 were found to have reason for further evaluation/follow up.

 

Accountability and Quality Measures promote improvements in care delivery and are the highest standard for measurement. Accountability and Quality measures are the standard of care derived from evidence-based data, including multiple randomized control trials.

Breast Measures

• nBx - Image or palpation-guided needle biopsy (core or FNA) is performed to establish diagnosis of breast cancer (Quality Measure)
• MASTRT - Radiation therapy is considered or administered following any mastectomy within 1 year (365 days) of diagnosis of breast cancer for women with >= 4 positive regional lymph nodes (Accountability Measure)
• BCSRT - Radiation is administered within 1 year (365 days) of diagnosis for women under the age of 70 receiving breast conservation surgery for breast cancer (Accountability Measure)
• MAC - Combination chemotherapy is considered or administered within 4 months (120 days) of diagnosis for women under 70 with AJCC T1cN0M0, or stage IB - III hormone receptor negative breast cancer (Accountability Measure)
• HT - Tamoxifen or third generation aromatase inhibitor is considered or administered within 1 year (365 days) of diagnosis for women with AJCC T1c or stage II or III hormone receptor positive breast cancer (Accountability Measure)

Colon Measures

• ACT - Adjuvant chemotherapy is considered or administered within 4 months (120 days) of diagnosis for patients under the age of 80 with AJCC Stage III (lymph node positive) colon cancer. (Accountability Measure)
• 12RLN - At least 12 regional lymph nodes are removed and pathologically examined for resected colon cancer (Quality Measure)

Gastric Measure

• G15RLN -At least 15 regional lymph nodes are removed and pathologically examined for resected gastric cancer (Quality Measure)

Lung Measure

• LCT - Systemic chemotherapy is administered within 4 months to day preoperatively or day of surgery to 6 months postoperatively, or it is considered for surgically resected cases with pathologic, lymph node-positive (pN1) and (pN2) NSCLC (Quality Measure)
• LNoSurg - Surgery is not the first course of treatment for cN2, M0 lung cases (Quality Measure)

Rectum Measures

• RECRTCT – Preoperative chemotherapy and radiation therapy are administered for clinical AJCC T3N0, T4N0, or Stage III; or Postoperative chemo and radiation are administered within 180 days of diagnosis for clinical AJCC T1-2N0 with pathologic AJCC T3N0, T4N0, or Stage III; or treatment is considered; for patients under the age of 80 receiving surgical resection for rectal cancer (Quality Measure)

Program’s Calculated Performance Rate (95% CI)

Measure	Expected Performance Rate	2013 Programs Calculated Performance Rate	2014 Programs Calculated Performance Rate	2015 Programs Calculated Performance Rate	2016 Programs Calculated Performance Rate
nBx	80%	96%	92%	94%	95%
MASTRT	90%	100%	83%	100%	100%
BCSRT	90%	99%	98%	95%	100%
MAC	NA	100%	82%	90%	93%
HT	90%	92%	88%	84%	89%
ACT	NA	100%	67%	86%	100%
12RLN	85%	100%	88%	90%	94%
G15RLN	80%	25%	NA	83%	75%
LCT	85%	100%	100%	100%	100%
LNoSurg	85%	100%	86%	86%	93%
RECRTCT	85%	100%	71%	83%	83%

 

Each calendar year, the cancer committee designates a physician member to complete an in-depth analysis to assess and verify that cancer program patients are evaluated and treated according to evidence-based national treatment guidelines. Results are presented to the cancer committee and documented in cancer committee minutes.

Study Topic: Verification of Compliance with NCCN guidelines for Bladder Cancer

Leader: Jim Kruse, DO

Objective: To complete an analysis to assess and verify that cancer program patients are evaluated and  treated according to evidence based national treatment guidelines for bladder cancer.

Measurement: Review of 2018 analytic bladder cancer patients

Method: Retrospective chart review and review of cancer registry data

Results: 40 Patients diagnosed with bladder cancer in 2018

Conclusion: In most of the cases patients received full diagnostic. To assure compliance with evidence-based guidelines, periodic reviews of future eligible cases will be performed.