The cancer committee is a multidisciplinary forum that provides a platform to evaluate care within and across disciplines. This forum allows discussion of processes that work and evaluate how patient care can be improved through evidence-based practice.

The cancer committee is expected to address performance rates that fall below specific thresholds established by the Commission on Cancer (CoC). This is accomplished by reviewing the CoC quality reporting tool, Cancer Program Practice Profile Reports (CP3R). This report looks at 10 cancer sites and is directed toward assuring the completeness of data for each cancer patient.

The CP3R provides a case-by-case review of cancer cases reported to the National Cancer Database. Adhering to these established accountability measures ensure that best practices for patient care are provided.
 
Cancer Program Practice Profile Reports (CP3R) have demonstrated that improvements in data quality and patient care are possible when the entire cancer committee supports system level enhancements to ensure complete and precise documentation.  The CP3R(v3) provides feedback to our programs to:

  • Improve the quality of data across several disease sites;
  • Foster pre-emptive awareness to the importance of charting and coding accuracy;
  • Improve clinical management and coordination of patient care in the multidisciplinary setting. 

The Ellis Fischel Cancer Committee reviews and compares the patient care measures established by the CoC to other cancer centers in our region and throughout the nation. The Ellis Fischel Cancer Center meets or exceeds the standards for the ten cancer types monitored by the CoC. 

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interpreting this report

The estimated performance rates shown below provide your cancer program with an estimate of the proportion of patients concordant with measure criteria by diagnosis year. If appropriate the CoC Standard and benchmark compliance rate is provided. This application provides cancer programs the opportunity to examine data to determine if performance rates are representative of the care provided at the institution and to review and modify case information using the review function for the measure of interest.

Breast Measures Measure Confidence Interval 2016
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 77.3-97.7 87.5
Tamoxifen or third generation aromatase inhibitor is recommended or administered within 1 year (365 days) of diagnosis for women with AJCC T1c or stage IB-III hormone receptor positive breast cancer (Accountability) HT 92.4-100 96.40
Radiation therapy is recommended or administered following any mastectomy within 1 year (365 days) of diagnosis of breast cancer for women with >= 4 positive regional lymph nodes (Accountability) MASTRT 100-100 100.00
Image or palpation-guided needle biopsy to the primary site is performed to establish diagnosis of breast cancer (Quality Improvement) nBx 87.1-96.7 91.90
Breast conservation surgery rate for women with AJCC clinical stage 0, I, or II breast cancer (Surveillance) BCS 46.9-63.9 55.40
Combination chemotherapy is recommended 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 100-100 100.00
Bladder Measures Measure Confidence Interval 2016
At least 2 lymph nodes are removed in patients under 80 undergoing partial or radical cystectomy (Surveillance) BL2RLN 59.8-100 85.7
Radical or partial cystectomy; or tri-modality therapy (Local tumor destruction/excision with chemotherapy and radiation) for clinical T234N0M0 patients with urothelial carcinoma of the bladder, first treatment within 90 days of diagnosis (Surveillance) BLCSTRI 48.3-57.1 66.7
Neo-adjuvant or adjuvant chemotherapy recommended or administered for patients with muscle invasive cancer undergoing radical cystectomy (Surveillance) BLCT 45-100 75
Cervix Measures Measure Confidence Interval 2016
Use of brachytherapy in patients treated with primary radiation with curative intent in any stage of cervical cancer (Surveillance) CBRRT 100-100 100.00
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 100-100 100.00
Radiation therapy completed within 60 days of initiation of radiation among women diagnosed with any stage of cervical cancer (Surveillance) CERRT 100-100 100.00
Colon Measures Measure Confidence Interval 2016
At least 12 regional lymph nodes are removed and pathologically examined for resected colon cancer (Quality Improvement) 12RLN 78.1-99.1 88.6
Adjuvant chemotherapy is recommended, 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 100-100 100.00
Endometrium Measures Measure Confidence Interval 2016
Chemotherapy and/or radiation administered to patients with Stage IIIC or IV Endometrial cancer (Surveillance) ENDCTRT 100-100 100
Endoscopic, laparoscopic, or robotic performed for all Endometrial cancer (excluding sarcoma and lymphoma), for all stages except stage IV (Surveillance) ENDLRC 62.2-90.8 76.5
Gastric Measures Measure Confidence Interval 2016
At least 15 regional lymph nodes are removed and pathologically examined for resected gastric cancer (Quality Improvement) G15RLN   100
Kidney Measures Measure Confidence Interval 2016
At least 1 regional lymph node is removed and pathologically examined for primarily resected unilateral nephroblastoma (Surveillance) PD1RLN Not Applicable no data
Lung Measures Measure Confidence Interval 2016
Systemic chemotherapy is administered within 4 months to day preoperatively or day of surgery to 6 months postoperatively, or it is recommended for surgically resected cases with pathologic lymph node-positive (pN1) and (pN2) NSCLC (Quality Improvement) LCT 100-100 100.00
Surgery is not the first course of treatment for cN2, M0 lung cases (Quality Improvement) LNoSurg 41.6-98.4 70.00
At least 10 regional lymph nodes are removed and pathologically examined for AJCC stage IA, IB, IIA, and IIB resected NSCLC (Surveillance) 10RLN 24.8-55.2 40.00
Ovary Measures Measure Confidence Interval 2016
Salpingo-oophorectomy with omentectomy, debulking/cytoreductive surgery, or pelvic exenteration in Stages I-IIIC Ovarian cancer (Surveillance) OVSAL 29-96 62.50
Rectum Measures Measure Confidence Interval 2016
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 26-96 91.70

 

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