cervix brachytherapy 2

1. Cancer Program Annual
Outcomes Report 2015
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. Quality Measures
Studies of Quality
Cancer Committee
Table of Contents:

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
Measu
re
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. 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. 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
– 2 did not follow-up with MDs (GI & PCP)
– 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 205.4 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: 125 patients diagnosed with breast or ovarian
cancer in 2014 were reviewed. 54.2% 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. 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
Cancer Committee Membership 2016

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