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:
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
Standard 4.2 Screening Programs
Head and Neck Cancer Screening
Date: April 26, 2019
Outcomes: 34 participants screened. 8 were found to have reason for further evaluation/follow up.
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
Colon Measures
Gastric Measure
Lung Measure
Rectum Measures
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% |
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 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.