1. Cancer Program Annual Outcomes Report 2016

2. National Recognition

3. Vision
Advocate Vision: To be a faith-based system providing the safest environment and best health outcomes, while building lifelong relationships with the people we serve.
Good Samaritan Hospital’s core competency: Building Loyal Relationships

4. Table of Contents:
Quality Measures Studies of Quality Cancer Committee

5. Quality Measures Cancer Program Practice Profile Reports (CP3R) 2014 Outcome Analysis

6. Quality Measures Cancer 2014 CP3R Outcome Analysis
Site
Criteria
Measure
Ratio %
Review
Breast
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)
BCSRT
35/35
100%
  Better than CoC Benchmark of 90%

7. Quality Measures Cancer 2014 CP3R Outcome Analysis
Site
Criteria
Measure
Ratio %
Review
Breast
Tamoxifen or third generation aromatase inhibitor is considered or administered within 1 year (356 days) of diagnosis for women with AJCC T1c or stage IB-III hormone receptor positive breast cancer (Accountability) HT
58/60
96.7%
  Better than CoC Benchmark of 90%

8. Quality Measures Cancer 2014 CP3R Outcome Analysis
Site
Criteria
Measure
Ratio %
Review
Breast
Radiation therapy is recommended or administered following any mastectomy within 1 year of diagnosis of breast cancer for women with ≥ 4 positive regional lymph nodes (Accountability)
MASTRT
6/6
100%
  Better than CoC Benchmark of 90%

9. Quality Measures Cancer 2014 CP3R Outcome Analysis
Site
Criteria
Measure
Ratio %
Review
Breast
Image or palpation-guided needle biopsy (core or FNA) or the primary site is performed to establish diagnosis of breast cancer (Quality Improvement)
nBx
85/87
97.7 %
  Better than CoC Benchmark of 80%

10. Quality Measures Cancer 2014 CP3R Outcome Analysis
Site
Criteria
Measure
Ratio %
Review
Breast
Breast conservation surgery rate for women with AJCC clinical stage 0, I, or II breast cancer (Surveillance)
BCS
66/96
68.8%
CoC has not defined a benchmark 

11. Quality Measures Cancer 2014 CP3R Outcome Analysis
Site
Criteria
Measure
Ratio %
Review
Breast
Combination chemotherapy is considered or administered within 4 months (120) days of diagnosis for women under 70 with AJCC T1cN0 or stage IB-III hormone receptor negative breast cancer (Accountability)
MAC
8/8
100%
  Better than CoC Benchmark of 90%

12. Quality Measures Cancer 2014 CP3R Outcome Analysis
Site
Criteria
Measure
Ratio %
Review
Cervix
Use of brachytherapy in patients treated with primary radiation with curative intent in any stage of cervical cancer (Surveillance)
CBRRT
1/1
100%
 CoC has not defined a benchmark

13. Quality Measures Cancer 2014 CP3R Outcome Analysis
Site
Criteria
Measure
Ratio %
Review
Cervix
Chemotherapy administered to cervical cancer patients who received radiation for stages IB2-IV cancer (group 1) or with positive pelvic nodes, positive surgical margin, and/or positive parametrium (group 2) (Surveillance)
CERCT
1/1
100%
 CoC has not defined a benchmark

14. Quality Measures Cancer 2014 CP3R Outcome Analysis
Site
Criteria
Measure
Ratio %
Review
Cervix
Radiation therapy completed within 60 days of initiation of radiation among women diagnosed with any stage of cervical cancer (Surveillance)
CERRT
No patients
 CoC has not defined a benchmark

15. Quality Measures Cancer 2014 CP3R Outcome Analysis
Site
Criteria
Measure
Ratio %
Review
Bladder
At least 2 lymph nodes are removed in patients under 80 undergoing partial or radical cystectomy (Surveillance)
BL2RLN
No patients
 CoC has not defined a benchmark

16. Quality Measures Cancer 2014 CP3R Outcome Analysis
Site
Criteria
Measure
Ratio %
Review
Colon
At least 12 regional lymph nodes are removed and pathologically examined for resected colon cancer
(Quality Improvement)
12RLN
19/20
95.0%
  Better than CoC Benchmark of 85%

17. Quality Measures Cancer 2014 CP3R Outcome Analysis
Site
Criteria
Measure
Ratio %
Review
Colon
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)
ACT
5/5
100%
  Better than CoC Benchmark of 90%

18. Quality Measures Cancer 2014 CP3R Outcome Analysis
Site
Criteria
Measure
Ratio %
Review
Endo-metrium
Chemotherapy and/or radiation administered to patients with stage IIIC or IV endometrial cancer (Surveillance)
ENDCTRT
No patients
 CoC has not defined a benchmark

19. Quality Measures Cancer 2014 CP3R Outcome Analysis
Site
Criteria
Measure
Ratio %
Review
Endo-metrium
Endoscopic, laproscopic, or robotic performed for all endometrial cancer (excluding sarcoma and lymphoma), for all stages except stage IV (Surveillance)
ENDLRC
8/9
88.9%
 CoC has not defined a benchmark

20. Quality Measures Cancer 2014 CP3R Outcome Analysis
Site
Criteria
Measure
Ratio %
Review
Gastric
At least 15 regional lymph nodes are removed and pathologically examined for resected gastric cancer (Quality Improvement)
G15RLN
No patients
 CoC benchmark is 80%

21. Quality Measures Cancer 2014 CP3R Outcome Analysis
Site
Criteria
Measure
Ratio %
Review
Lung
Systemic chemotherapy is administered within 4 months to day preoperatively or day of surgery to 6 month postoperatively, or it is recommended for surgically resected cases with pathologic lymph node-positive (pN1) and (pN2) NSCLC (Quality Improvement)
LCT
2/2
100%
 Better than CoC benchmark of 85%

22. Better than CoC benchmark of 85%
Program Profile Reports – CP3R Cancer 2014 NCDS Submission Outcome Analysis
Site
Criteria
Measure
Ratio %
Review
Lung
Surgery is not the first course of treatment for cN2,M0 lung cases (Quality Improvement)
LNoSurg
2/2
100%
 Better than CoC benchmark of 85%

23. CoC has not defined a benchmark
Program Profile Reports – CP3R Cancer 2014 NCDS Submission Outcome Analysis
Site
Criteria
Measure
Ratio %
Review
Lung
At least 10 regional lymph nodes are removed and pathologically examined for AJCC stage IA, IB, IIA and IIB resected NSCLC (Surveillance)
10RLN
5/7
71.4%
 CoC has not defined a benchmark

24. Quality Measures Cancer 2014 CP3R Outcome Analysis
Site
Criteria
Measure
Ratio %
Review
Ovary
Salpingo-oophorectomy with omentectomy, debulking/ cytoreductive surgery, or pelvic exenteration in stages I – IIIC ovarian cancer (Surveillance)
OVSAL
3/5
60%
 CoC has not defined a benchmark

25. Quality Measures Cancer 2014 CP3R Outcome Analysis
Site
Criteria
Measure
Ratio %
Review
Rectal
Preoperative chemo and radiation 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 recommended; for patients under the age of 80 receiving resection for rectal cancer (Quality Improvement)
RECRTCT
2/2
100%
 Better than CoC benchmark of 85%

26. Studies of Quality The Cancer Committee at Good Samaritan Hospital designs and completes studies to evaluate whether patients are being evaluated and treated in conformance with evidence-based national treatment guidelines and to review our patient’s outcomes.

27. Colon Cancer Surveillance
Are NCCN colon cancer surveillance guidelines for colonoscopy, CEA and CT being followed for patients diagnosed with Stage II and III (T2 & T3) cancer in 2012 – 2013 who survived without reoccurrence for 3 years past initial diagnosis?
Conclusions:
CEA ordered within 4 months of curative resection for colorectal cancer - GSAM = 97%
CT every 6-12 months - GSAM = 88%
Colonoscopy within 12 months of curative resection or adjuvant chemotherapy – GSAM = 88% (average performance = 14% after 14 months from Oncology Roundtable 2016 Cancer Quality Dashboard pg. 17)

28. Colon Cancer Surveillance Notes
CEA: 1 of 32 non-compliant, did not follow-up with MD (GI)
CT: 4 of 32 non-compliant
2 did not follow-up with MDs (GI & PCP)
1 with 2nd cancer primary under active treatment, CT deferred
1 received treatment at another facility and the facility was unable to provide surveillance information
Colonoscopy: 4 of 32 non-compliant
1 with 2nd cancer primary under active treatment, colonoscopy deferred
1 received treatment at another facility and they were unable to provide surveillance information

29. Use of Deep Breath Hold in Radiation Therapy to Decrease Cardiac Dose
Does the use of deep inspiratory breath hold (DIBH) for L sided breast radiation therapy patients decrease the mean heart dose and Lung V20 scores in comparison to maximum targets established by RTOG and NCCN?
Conclusions:
Patients treated with DIBH in 2014 – 2015 received an average mean heart dose of 108 cGy for 2 fields and cGy for 4 fields, both significantly better than the maximum target dose of 400 cGy.
Patients treated with DIBH in 2014 – 2015 scored 11.9% Lung V20 for 2 fields and 28.7% for 4 fields of treatment, significantly better than the maximum target dose of 35% cGy.

30. Breast and Ovarian Cancer
Are patients diagnosed with breast cancer being referred for cancer genetic counseling in compliance with the NCCN criteria?
Conclusion: patients diagnosed with breast or ovarian cancer in 2014 were reviewed % met the National Comprehensive Cancer Network (NCCN) criteria and were referred for cancer genetic counseling. Based on the Oncology Roundtable Cancer Quality Dashboard, the best observed result nationally is 75%.

31. Safe Administration of Chemotherapy
A 12 month review of near misses and safety events related to chemotherapy concluded: IV pump settings were the most common cause of chemotherapy administration related safety events/near misses. The RN verification process contributed to treatment delays.

32. Safe Administration of Chemotherapy (cont.)
Based on these findings:
the standard RN verification process was modified to include independent review and verification of patient, drug, dose, IV pump settings and IV line reconciliation.
The RN order verification process was revised to occur upon receipt of orders.
Following these improvements, the near miss/safety event rate related to chemotherapy administration decreased from 5/year (2013) to 1/year (2014).

33. Lung Cancer
Are patients diagnosed with non-small cell lung cancer receiving timely treatment?
Conclusion: For patients initially diagnosed with non-small cell lung cancer between July 2012 and June 2013, the average time from diagnosis to treatment was 16.8 days, which places Good Samaritan Hospital in the top quartile of hospitals based on the Oncology Roundtable Cancer Quality Dashboard (mean = 33 days, top quartile = 20 days).

34. Breast Cancer
Are breast cancer patients undergoing mastectomy with four or more positive regional lymph nodes being considered for or receiving radiation therapy within one year of diagnosis?
Conclusion: After reviewing all breast cancer patients undergoing mastectomy with four or more positive regional lymph nodes in 2010 and 2011, 100% were considered for or received radiation therapy within one year of diagnosis.

35. Prostate Cancer
Are prostate patients being screened using an American Urological Association (AUA) approved form to assess urinary, sexual and bowel function prior to initiation of treatment?
Conclusion: For men treated in 2012, 100% were assessed prior to treatment using an AUA approved form.
Are patients at high risk of recurrence who were prescribed adjuvant hormone therapy receiving external beam radiation therapy?
Conclusion: 100% of high risk men treated in 2012 receiving external beam radiation therapy were prescribed adjuvant hormone therapy.

36. Prostate Cancer (cont.)
Are patients a low risk of recurrence who receive interstitial brachytherapy or external beam radiation therapy or radical prostatectomy having a bone scan done after diagnosis? (Note: bone scan is not indicated and results in an unnecessarily exposure to radiation)
Conclusion: 0% of low risk men treated in 2012 were given a bone scan after diagnosis.

37. 2016 Cancer Committee Membership

38. Cancer Committee Membership 2016
Dr. Fari Barhamand
Cancer Committee Chair, Medical Oncologist
Dr. Dennis Azuma
Medical Oncologist, Advocate Good Samaritan Hospital
Clinical Research Coordinator, Cancer Liaison Physician
Dr. Bruce Dillon
Surgeon, Advocate Good Samaritan Hospital
Dr. Susan Fanapour
Diagnostic Radiologist, Advocate Good Samaritan Hospital
Dr. Arpi Thukral
Director of Radiation Oncology, Advocate Good Samaritan Hospital
Dr. William Wilkens
Pathologist, Advocate Good Samaritan Hospital
Cancer Conference Coordinator
Matthew Cross
Director of the Advocate Good Samaritan Cancer Care Center
Jodi Overbeck
Nurse Manager, Oncology & Dialysis
Debbie McCarthy
Cancer Registry Lead Coordinator
Cancer Registry Quality Coordinator

39. Cancer Committee Membership 2016
Kathy Murphy-O’Brien
Social Worker, Inpatient Oncology
Cherry Calalang
Oncology Clinical Nurse Specialist
Theresa Sobol
Quality Improvement Specialist
Quality Improvement Coordinator
Megan Corrigan
Pharmacy
Sheila Erasmus
Oncology Nurse Navigator
Community Outreach Coordinator
Anna Lee Hisey Pierson
Chaplain Mission & Spiritual Care
Deb Oleskowicz
Coordinator, Cancer Genetic Counseling
Pam Welgos
Manager, Radiation Oncology & Clinical Services
Lynette Paver
Manager, Palliative Care, Oncology Nurse Navigation, Cancer Program Quality and Regulatory Compliance & Cancer Genetic Counseling
Psychosocial Services Coordinator
Debbie Fager
American Cancer Society representative

40. Resources
Advocate Good Samaritan Hospital Cancer Registry Statistical Data
National Cancer Database
Cancer Quality Dashboards: Metrics, Definitions, and Benchmarks Spanning the Cancer Care Continuum, 2015 The Advisory Board Company Oncology Roundtable