Center Annual Report

2018 Public Reporting of Outcomes

Georgia Cancer Center


2018 Public Reporting of Outcomes Center Annual Report

STANDARD 1.12 Public Reporting of Outcomes

Each calendar year, the Cancer Committee develops and disseminates a report of patient or program outcomes to the public as required by the American College of Surgeons (ACoS) Commission on Cancer (CoC) standards. The content of the report includes outcome information on 1 or more of the following standards:

Standard 4.1 Prevention Programs:

  • 1/2018 Lunch & Learn AU Employees – Fingers, Forks, Feet Obesity & Cancer
  • 2/2018 Historic Spirit Creek Baptist Church & NAACP partnership – Kidney Cancer
  • 3/2018 Richmond Co. Health Dept. In-Service – Tobacco, e-Cigarettes, Cessation
  • 4/2018 Testicular Cancer
  • 4/2018 Earth Day – Skin Cancer, Obesity and Tobacco cessation
  • 5/2018 Sista Strut - Breast Cancer
  • 5/2018 Lunch & Learn – Skin Cancer
  • 5/2018 Breast-Health Education and Self-Exam Training (BEST)
  • 6/2018 Savannah River Site Health Fair
  • 11/2018 Great American Smoke Out

Standard 4.2 Screening Programs

    • Cervical Cancer Screening
    • Colorectal Cancer Screening
    • Lung Cancer Screening Program
    • Mammogram Screenings
    • Head and Neck Cancer Screening

Standard 4.4 Accountability Measures & Standard 4.5 Quality Improvement Measures

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

2012 Programs Calculated Performance Rate

2013 Programs Calculated Performance Rate

2014 Programs Calculated Performance Rate

2015 Programs Calculated Performance Rate

nBx

80%

86%

96%

93%

94%

MASTRT

90%

95%

92%

92%

92%

BCSRT

90%

96%

99%

99%

93%

MAC

NA

91%

100%

81%

89%

HT

90%

96%

92%

92%

95%

ACT

NA

100%

100%

100%

100%

12RLN

85%

87%

100%

88%

90%

G15RLN

80%

NA

NA

NA

NA

LCT

85%

100%

100%

100%

100%

LNoSurg

85%

83%

100%

90%

90%

RECRTCT

85%

100%

100%

100%

100%

Standard 4.6 Monitoring Compliance with Evidence-Based Guidelines

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 Rectal 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 ovarian cancer.

Measurement:

Review of 2017 analytic rectal cancer patients

Method:

Retrospective chart review and review of cancer registry data

Results:

30 Patients diagnosed with rectal cancer in 2017

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.