RECTAL CANCER PROJECT

Transcription

1 Canadian Partnership Against Cancer (CPAC) RECTAL CANCER PROJECT PROJECT LEAD WORKBOOK

2 TABLE OF CONTENTS Study Overview Slides.1-9 Communication Infrastructure 10 Contact List 11 Teleconference Meeting Schedule.. 12 Specialty Related Documents 1. Pathology Process Indicators Data Collection Elements.14 Protocol Radiology Process Indicators.17 Data Collection Elements.18 Protocol.19 Synoptic MRI Report Minimum Standard of Resolution Form Radiation Oncology Process Indicators.24 Data Collection Elements Checklist..27 Treatment Summary Surgery Process Indicators.29 Data Collection Elements Checklist MCC Process Indicators.35 Data Collection Elements.36 Synoptic MCC Report Rectal Cancer Project Worksheets

3 CPAC Rectal Cancer Project CPAC Rectal Cancer Project ( ) Funded by Canadian Partnership Against Cancer (CPAC) Quality improvement project 8 centres across Canada Build multidisciplinary community of practice (COP) to share best practices Reduce unwarranted variation Identify gaps in care Implement strategies to close gaps 1

4 This is not QuickSilver! QuickSilver Study Phase II study assessing safety and feasibility of using MRI criteria to identify good prognosis Stage II and Stage III rectal cancer patients eligible for primary surgery 17 centres across Canada Start up meeting June 2013 Recruitment October 2014 to June 2015 Webinar Outline 1. Study Overview 2. Review of process indicators and suggested tools for data capture Pathology Radiology Radiation Oncology Surgery Multidisciplinary Cancer Conference 3. Next Steps and Wrap Up 2

5 Objectives CPAC Rectal Cancer Project To develop a multidisciplinary, pan Canadian Community Of Practice to improve the overall quality of rectal cancer care: 1. Accelerated diffusion implementation: Preoperative staging with MRI Multidisciplinary Cancer Conference (MCC) High quality radiotherapy and surgical care High quality pathologic assessment 2. Select and measure process indicators 3. Identify gaps in care 4. Implement strategies to close existing gaps Year 1 Year 2 Year 3 Apr Mar 2015 Apr 2015 Mar 2016 Apr 2016 Mar 2017 National Workshop (May 23, 2014) Select and finalize process indicators for each quality initiatives Identify areas for knowledge translation AGREE WITH CONCEPT Planning Phase (June 1, 2014 to March 31, 2015) Finalize Project Report Template with final process indicators Develop tool kit to assist centres capture process indicators MRI protocol Synoptic MRI report Radiation Oncology Pre-Treatment Checklist Radiation Oncology Treatment Summary Synoptic OR Report Pathology Protocol Pathology CAP Checklist Develop knowledge translation activities at COP level: Radiology Training Set Radiation Oncology Contouring Webinar Pathology List Serv (EMVI) Study website and database development Hire coordinators at each centre (Jan 2015) Implementation Phase (April 1, 2015 to Dec 31, 2016) Audit and Feedback Measure selected process indicators every 3 months Generate report (total 7 reports) Identify gaps and work towards closing gaps Continue knowledge translation activities on an institutional level FIX THE PROBLEM FOCUS ON DETAILS 3

6 END PRODUCTS A multidisciplinary model to improve quality of care for rectal cancer participating centres will be able to take lead to disseminate model in respective provinces Development of a well coordinated COP Continue to work together on projects including grant capture and trials Selection of Process Indicators Review of pre workshop survey Suggested process indicators were rated scale of 1 5 based on clinical importance National Workshop Attended by 35 Site and Project Leads; representation from all 8 centres Discussion of each specific item Pre meeting survey results Best available evidence Expert opinion Final vote to include/exclude each specific item Anonymous; all specialties 4

7 Selection of Process Indicators Results of the final vote reviewed by Investigative Team and Project Leads Process indicators for which >90% of workshop participants voted to include were kept Final vote results and final process indicators selected were distributed to meeting participants for final feedback Suggested Tools and Strategies for Data Capture of Process Indicators Selected tools and strategies to facilitate data capture based on: Final process indicators selected Multidisciplinary discussion at the national workshop Current best practices at participating centres Expert and consensus opinion 5

8 Suggested Tools and Strategies for Data Capture Introduce tools selected to facilitate data capture of process indicators Suggest how tools may be implemented at each centre Pathology David Driman Radiology Laurent Milot Radiation Oncology Charles Cho Surgery Lara Williams MCC Sender Liberman Each presentation 10 minutes followed by 5 minutes of questions Focus questions on suggested tools and implementation Please direct questions about specific process indicators off line to Site or Project Leads KEEP IN MIND All centres receive $2000/site for project launch All centres encouraged to modify tools or develop new tools to meet their specific institutional needs All centres to start implementing their plan as soon as possible All centres receive $60,000/2 years for a research coordinator All Site Leads will receive a workbook with relevant documents and worksheet to complete (end of November) 6

9 Example Worksheet MSH EXAMPLE What are our group s priorities? Synoptic OR Report (currently narrative) Synoptic MCC Report (currently no report issued) What are our goals? 80% MCC and OR report synoptic How will our group achieve these goals? Review and use OR and MCC synoptic report developed What are the main barriers to Surgeons don t want to dictate MCC implementing this plan? discussion due to time constraints Seem to be ok with synoptic OR report What strategies are required to overcome these barriers? Surgeons seem to be ok with signing a paper copy of synoptic MCC report filled in by MCC chair Surgeons ok using a laminated card with synoptic OR note headings Example Worksheet What is the final implementation strategy? MSH Example MCC chair will complete MCC report on duplicate form for the treating physician to sign and place in chart Distribute laminated cards with synoptic OR report; Site Lead to investigate possibility of developing macro via hospital transcription centre % of reports in synoptic format How will we evaluate if our goals have been met? What resources are required? Synoptic reports, duplicate paper, access to lamination service What is the time line (start date)? Start date is January % 3 months 50% 6 months >80% 12 months 7

10 SUMMARY AND NEXT STEPS Site Leads at each centre to launch project locally ($2000 per site) Review process indicators and best local strategies to ensure capture of the indicators Surgical Site Leads to ensure REB and DSA complete Transfer of $30K (Jan 2015 and Jan 2016) Hire coordinator (consider using pre existing coordinators) SUMMARY AND NEXT STEPS Start to implement initiatives as soon as possible Patient recruitment/data collection begins April 1, 2015 (first report July 2015) Regular teleconference last Tuesday every other month starting January 27 th Newsletter with meeting minutes Website for on site data collection Webinar for research coordinators in March 2015 to review definitions/terms for data collection 8

11 THANK YOU! 1. REB/DSA (Surgical Site Lead) 2. Hire Coordinator for January 2015 (Surgical Site Lead) 3. Project Launch as soon as possible (All Site Leads) 4. Complete Worksheet (All Site Leads) 5. Next teleconference: (All Site and Project Leads) Tuesday January 27 th from 4:30 5:30 pm EST 9

12 10 CPAC Rectal Cancer Project: Communication Infrastructure Investigative Team Erin Kennedy Nancy Baxter Marko Simunovic Robin McLeod Selina Schmocker CPAC Gunita Mitera Surgery Project Leads Lara Williams Carl Brown Pathology Project Leads Richard Kirsch David Driman Radiology Project Leads Laurent Milot Mark Fruitman Blair MacDonald Radiation Oncology Project Leads Charles Cho Raimond Wong Medical Oncology Project Leads Monika Krzyzanowska Ron Burkes MCC Project Lead Sender Liberman Patient Engagement Project Leads Erin Kennedy Nancy Baxter Surgery Site Leads Pathology Site Leads Radiology Site Leads Radiation Oncology Site Leads Medical Oncology Site Leads PFAC Members Knowledge Translation Activities at Individual Sites

13 CPAC Rectal Cancer Project: Site Leads & Project Leads Contact List 11 Province Surgery Site Lead Pathology Site Lead Radiology Site Lead Radiation Oncology Site Lead Medical Oncology Site Lead Province Surgery Site Lead Pathology Site Lead Radiology Site Lead Radiation Oncology Site Lead Vancouver, BC Carl Brown St. Paul s Hospital Doug Filipenko St. Paul s Hospital Patrick Vos St. Paul s Hospital John Hay BC Cancer Agency TBA Vancouver, cbrown@providencehealth.bc.ca BC Carl Brown (St. Paul s) dfilipenko@providencehealth.bc.ca Doug Filipenko (St. Paul s) pvos@providencehealth.bc.ca Patrick Vos (St. Paul s) jhay@bccancer.bc.ca John Hay (BC Cancer Agency) cbrown@providencehealth.bc.ca Wei Xiong dfilipenko@providencehealth.bc.ca pvos@providencehealth.bc.ca jhay@bccancer.bc.ca St. Paul s Hospital X 2660 Calgary, AB Tony MacLean (Foothills Med wxiong@providencehealth.bc.ca Centre) Vincent Falck (Foothills Med Centre) Deepak Bhayana (Foothills Med Centre) Corinne Doll (Tom Baker Cancer Centre) Calgary, Tony MacLean tony.maclean@albertahealthservices.ca Vincent Falck vincent.falck@cls.ab.ca Deepak Bhayana deepak.bhayana@albertahealthservices.ca Corinne Doll corinne.doll@albertahealthservices.ca Patricia Tang AB Foothills Medical Centre Foothills Medical Centre Foothills Medical Centre Tom Baker Cancer Centre Tom Baker Cancer Centre Winnipeg, tony.maclean@albertahealthservices.ca MB David Hochman (St. Boniface) vincent.falck@cls.ab.ca Jose Gomez (St. Boniface) deepak.bhayana@albertahealthservices.ca Iain Kirkpatrick (St. Boniface) corinne.doll@albertahealthservices.ca Shahida Ahmed patricia.tang@albertahealthservices.ca Winnipeg, David Hochman davehochman@hotmail.com Jose Gomez jgomez@dsmanitoba.ca Iain Kirkpatrick IKIRKPATRICK@sbgh.mb.ca Shahida Ahmed (Cancercare Manitoba) TBA MB St. Boniface Hospital davehochman@hotmail.com St. Boniface Hospital jgomez@dsmanitoba.ca St. Boniface Hospital IKIRKPATRICK@sbgh.mb.ca Cancercare Manitoba Shahida.Ahmed@cancercare.mb.ca Shahida.Ahmed@cancercare.mb.ca Toronto, ON Erin Kennedy (Mount Sinai) Richard Kirsch (Mount Sinai) Kartik Jhaveri (UHN) Charles Cho (Southlake Regional) Toronto, Erin Kennedy ekennedy@mtsinai.on.ca Richard Kirsch rkirsch@mtsinai.on.ca Kartik Jhaveri kartik.jhaveri@uhn.ca Charles Cho CCho@southlakeregional.org Monika Krzyzanowska ON Mount Sinai Hospital Mount Sinai Hospital X 6187 University Health Network X 5635 Southlake Regional Health Centre Princess Margaret Cancer Centre ekennedy@mtsinai.on.ca Robin McLeod (Cancer Care rkirsch@mtsinai.on.ca Ontario) Robin McLeod Robin.mcleod@cancercare.on.ca Cancer Care Ontario kartik.jhaveri@uhn.ca Seng Thipphavong (UHN) Seng Thipphavong seng.thipphavong@uhn.ca University Health Network CCho@southlakeregional.org Monika.Krzyzanowska@uhn.ca Ron Burkes Mount Sinai Hospital Toronto, robin.mcleod@cancercare.on.ca ON Nancy Baxter (St. Michael s) Cathy Streutker (St. Michael s) seng.thipphavong@uhn.ca Anish Kirpalani (St. Michael s) Charles Cho (Southlake rburkes@mtsinai.on.ca Regional) Toronto, Nancy Baxter BaxterN@smh.ca Cathy Streutker Streutkerc@smh.ca Anish Kirpalani KirpalaniA@smh.ca Charles Cho CCho@southlakeregional.org Christine Brezden-Masley ON St. Michael s Hospital St. Michael s Hospital X 2363 St. Michael s Hospital Southlake Regional Health Centre St. Michael s Hospital Montreal, BaxterN@smh.ca QUE Sender Liberman (MUHC-Montreal Streutkerc@smh.ca Gen Vicky Marcus (MUHC-Montreal KirpalaniA@smh.ca Gen Caroline Reinhold (MUHC-Montreal CCho@southlakeregional.org Gen Neil Kopek (MUHC-Montreal BrezdenC@smh.ca Gen Hospital) Montreal, Sender Liberman Hospital) Vicky Marcus Hospital) Caroline Reinhold Hospital) Neil Kopek Neil.Kopek@muhc.mcgill.ca Jamil Asselah QUE MUHC-Montreal sender.liberman@mcgill.ca General Hospital MUHC-Montreal victoria.marcus@muhc.mcgill.ca General Hospital MUHC-Montreal caroline.reinhold@muhc.mcgill.ca General Hospital MUHC-Montreal General Hospital MUHC-Montreal General Hospital sender.liberman@mcgill.ca victoria.marcus@muhc.mcgill.ca X caroline.reinhold@muhc.mcgill.ca X Neil.Kopek@muhc.mcgill.ca jamil.asselah@mcgill.ca Giovanni Artho Giovanni Artho (MUHC-Montreal Gen MUHC-Montreal Hospital) General Hospital giovanni.artho@mcgill.ca giovanni.artho@mcgill.ca X Drolet (Hôpital Perigny Martin de Quebec) City, QUE Hôpital St-François D'Assise CHUQ-Hotel-Dieu de Quebec CHUQ-St-Francois d'assise CHUQ-Hotel-Dieu de Quebec QUE D'Assise) de Quebec) d'assise) andre-guy.martin@mail.chuq.qc.ca sebastien.drolet.chx@gmail.com sebastien.drolet.chx@gmail.com martine.perigny@mail.chuq.qc.ca martine.perigny@mail.chuq.qc.ca stanmorin@hotmail.com stanmorin@hotmail.com andre-guy.martin@mail.chuq.qc.ca Quebec Quebec Sébastien City, Drolet Sébastien St-François Martine Perigny Martine (CHUQ-Hotel-Dieu Stanislas Morin Stanislas Morin (CHUQ-St-Francois Andre-Guy Martin Andre-Guy (CHUQ-Hotel-Dieu TBA Halifax, NS Lara Williams Heidi Sapp X Sharon Clarke x Nikhilesh Patil Bruce Colwell Halifax, QE II NS Health Sciences Lara Williams Centre (Queen Elizabeth QE II II Health HSC) Sciences Heidi Centre Sapp (Queen Elizabeth QE II II Health HSC) Sciences Sharon Centre Clarke (Queen Elizabeth Nova II HSC) Scotia Cancer Nikhilesh Centre Patil (Nova Scotia QE II Cancer Health Centre) Sciences Centre Lara.Williams@cdha.nshealth.ca Lara.Williams@cdha.nshealth.ca heidi.sapp@cdha.nshealth.ca heidi.sapp@cdha.nshealth.ca sharon.clarke@dal.ca sharon.clarke@dal.ca Nikhilesh.Patil@cdha.nshealth.ca Nikhilesh.Patil@cdha.nshealth.ca Bruce.colwell@cdha.nshealth.ca Surgery Pathology Radiology Radiation Oncology Medical Oncology Patient Engagement MCC Project Lead CPAC Rectal Cancer Project: Site Leads & Project Leads Project Leads Project Leads Project Leads Project Leads Project Leads Project Leads Carl Brown St. Paul s Hospital cbrown@providencehealth.bc.ca Lara Williams QEII Health Sciences Centre Lara.Williams@cdha.nshealth.ca Richard Kirsch Mount Sinai Hospital rkirsch@mtsinai.on.ca David Driman London Health Sciences Centre david.driman@lhsc.on.ca Laurent Milot Sunnybrook Health Sciences Centre laurent.milot@sunnybrook.ca Mark Fruitman St. Joseph s Health Sciences Centre mark.fruitman@gmail.com Blair MacDonald Ottawa General Hospital blmacdonald@toh.on.ca Charles Cho Southlake Regional Health Centre CCho@southlakeregional.org Raimond Wong Juravinski Cancer Centre raimond.wong@jcc.hhsc.ca Monika Krzyzanowska Princess Margaret Cancer Centre Monika.Krzyzanowska@uhn.ca Ron Burkes Mount Sinai Hospital rburkes@mtsinai.on.ca Erin Kennedy Mount Sinai Hospital ekennedy@mtsinai.on.ca Nancy Baxter St. Michael s Hospital BaxterN@smh.ca Sender Liberman MUHC Montreal General Hospital sender.liberman@mcgill.ca

14 12 Teleconference Meetings Date Time Agenda January 27, :30 to 5:30 EST Update on Project Launch at each Site March 31, :30 to 5:30 EST Update on Tool Implementation at each Site May 26, :30 to 5:30 EST Update on recruitment at each site (recruitment starts April 2015) July 28, :30 to 5:30 EST Review of Report 1 (April May June 3015) September 29, :30 to 5:30 EST Update on implementation initiatives at each site November 24, :30 to 5:30 EST Review of Report 2 (July Aug Sept 2015) January 26, :30 to 5:30 EST Review of Report 3 (Oct Nov Dec 2015) March 29, :30 to 5:30 EST Update on implementation initiatives at each site May 31, :30 to 5:30 EST Review of Report 4 (Jan Feb March 2016) July 26, :30 to 5:30 EST Review of Report 5 (Apr May Jun 2016) Sept 27, :30 to 5:30 EST Update on implementation initiatives at each site November 29, :30 to 5:30 EST Review of Report 6 (July Aug Sept) January 31, :30 to 5:30 EST Review of Report 7 (Oct Nov Dec) March 28, :30 to 5:30 EST FINAL STUDY WRAP UP WEBINAR

15 13 Pathology Process Indicators YOUR CENTRE ALL CENTRES 1 Quirke method used Y/N % Yes 2 3 At least 3 tumour containing blocks with deepest invasion (all including CRM if possible) + 1 additional block of CRM if not included in deepest invasion blocks At least 2 tumour containing blocks with closest serosal surface (where applicable for upper rectal cancers) % Yes % Yes 4 Assessment of TME quality % Yes 5 Documentation of minimum distance of tumour to CRM % Yes 6 Documentation of presence of venous (large vessel) invasion intramural/extramural % Yes 7 Pathology report in synoptic format % Yes 8 Pathology report includes all CAP checklist mandatory elements % Yes

16 14 CPAC Rectal Cancer Project: PATHOLOGY DATA COLLECTION ELEMENTS CLINICAL INFORMATION Outcome Measure Source 1 T category Specify T1/T2/T3/T4 Pathology report 2 # of lymph nodes retrieved [specify number] Pathology report 3 # of positive lymph nodes [specify number] Pathology report 4 N category Specify N0, N1, N2 Pathology report 5 Receipt of pre operative radiation (prert) Y/N Operative report 6 AJCC Tumour Regression Grade (only if prert received) Poor (Grade 3) Pathology report Minimal (Grade 2) Moderate (Grade 1) No residual tumour (Grade 0) 7 Time (in days) from surgery to issue of final pathology report available to all end users [specify number of days] Pathology report PROCESS INDICATORS 1 Quirke method used Tumour fixed with the tumour containing segment unopened, followed by cross sectional slicing when fully fixed 2 At least 3 tumour containing blocks with deepest invasion (all including CRM if possible) + 1 additional block of CRM if not included in deepest invasion blocks 3 At least 2 tumour containing blocks with closest serosal surface (where applicable for upper rectal cancers) Y/N Y/N Y/N Pathology report Pathology report Pathology report 4 Assessment of TME quality Complete, near complete, Pathology report incomplete 5 Documentation of minimum distance of tumour to CRM [specify distance in mm] Pathology report 6 Documentation of presence of venous (large vessel) Invasion intramural Present; Absent Pathology report 7 Documentation of presence of venous (large vessel) Invasion extramural Present; Absent Pathology report 8 Pathology report in synoptic format Y/N Pathology report 9 Pathology report includes all CAP checklist mandatory elements Y/N Pathology report

17 CPAC Pathology Protocol PRE FIXATION 1. Identify anatomical landmarks and location of tumour (by palpation) Peritoneal reflections: The peritoneal reflection is low on the anterior aspect but high on the posterior aspect; the non peritonealized tissue distal to the reflection is the radial resection margin. Serosa and margins: Tumours in the upper/proximal rectum have a serosal covering anteriorly and a radial margin posteriorly; mid to low/distal rectal tumours have a circumferential radial resection margin. 2. Assess the quality of the mesorectal excision. This should be assessed prior to inking and sectioning. Assess the (i) bulk of the mesorectum, (ii) depth of any defects in the mesorectum, (iii) coning and (iv) CRM on transverse sections. The presence or absence of coning for an overall assessment of completeness of the mesorectum according to the table below. The specimen is scored according to the worst area according to the categories below. Complete Near Complete Incomplete Mesorectum Defects Coning intact, smooth moderate bulk, irregular little bulk CRM (on transverse section) no deeper than 5 mm none Intact, smooth no visible muscularis propria (except where levator inserts) down to muscularis propria moderate moderatemarked Mostly smooth with some irregularities Very irregular 3. Measure the distance of tumour(s) from the proximal and distal margins in the fresh state, if possible. 4. Paint the bare area below the peritoneal reflection (black ink posterior; green ink anterior). 5. Open the specimen along the anterior aspect from the top and the bottom, leaving the bowel intact at a level just above and just below the tumour. 6. Place loose gauze (not paper towel) wicks soaked in formalin into the unopened ends of the bowel. 7. Fix all rectal cancer specimens for hours (i.e. 3 4 days) in an adequate volume of clean (nonbloody/contaminated) formalin; dirty formalin may need to be changed. POST FIXATION 1. Photograph intact specimen anterior and posterior views. (OPTIONAL) 2. Slice through the unopened bowel at 3 5 mm intervals and lay slices down on work surface. 3. Photograph the transverse sections overview of all plus close ups of any rings where margin appears threatened or irregular. (OPTIONAL) 15

18 CPAC Pathology Protocol (cont d) PATHOLOGY REPORT REQUIRED ITEMS 1. College of American Pathologists (CAP) Checklist mandatory elements All mandatory data elements of the CAP checklist are REQUIRED 2. CAP Checklist non mandatory elements Assessment of TME quality Treatment effect following neoadjuvant chemoradiotherapy, where applicable (AJCC classification) 3. Non CAP Checklist elements Documentation of Quirke method Documentation of at least 3 tumour containing blocks with deepest invasion (including CRM if possible) +1 additional block of CRM if not included in deepest invasion blocks Documentation of at least 2 tumour containing blocks with closest serosal surface (where applicable for upper rectal cancers) Documentation of minimum distance of tumour to CRM in mm Documentation of presence of venous [large vessel] invasion intramural/extramural 4. Synoptic Format Modified by the CPAC Rectal Cancer Project Group from the Cancer Care Ontario Pathology Working Group For more information, please review the Rectal Cancer Grossing Guideline at: If you have any questions regarding the CPAC pathology protocol and reporting requirements, please contact the Pathology Project Leads: Richard Kirsch (rkirsch@mtsinai.on.ca) or David Driman (david.driman@lhsc.on.ca) 16

19 17 CPAC MRI Process Indicators 1 # Pelvic MRI % Yes YOUR CENTRE ALL CENTRES 2 MRI Protocol meets minimum MERCURY criteria Minimum Resolution Form 3 MRI report in synoptic format % Yes 4 Assessment of T category % Yes 5 Assessment of mesorectal lymph nodes % Yes 6 Assessment of distance to the MRF % Yes 7 Assessment of extramural venous invasion (EMVI) % Yes 8 Assessment of distance of lower extent of relative to tumour to anal verge % Yes 9 Assessment of relationship of tumour to anterior peritoneal reflection % Yes 10 Assessment of distance from the top of the puborectalis sling to the lower extent of tumour % Yes 11 Percent agreement between MRI and pathology for distance to the MRF/CRM (+/ 1 mm) % Yes

20 18 CPAC Rectal Cancer Project: RADIOLOGY DATA COLLECTION ELEMENTS CLINICAL INFORMATION Outcome Measure Source 1 Baseline local staging with MRI Y/N Patient chart 2 Restaging MRI performed Y/N Patient chart 3 Agreement between MRI and pathology for EMVI (primary surgery only) Y/N MRI report/pathology report 4 Agreement between MRi and pathology for T-category (primary surgery only) Y/N 5 Time (in days) to MRI from initial consultation [number of days] Consultation note/mri report 6 Time (in days) from MRI to issue of report (available to all end users) [number of days] MRI report PROCESS INDICATORS Outcome Measure Source 1 Protocol for rectal cancer MRI meets minimum [MERCURY] criteria Y/N Institutional protocol from Radiology Site Lead 2 MRI report in synoptic format Y/N MRI report 3 Assessment of T- category [specify T-category] MRI report 4 Assessment of mesorectal lymph nodes Not suspicious MRI report Suspicious 5 Shortest distance of definite tumour border to the mesorectal fascia (MRF) [specify distance in mm] MRI report 6 Assessment of EMVI Present; Absent; Equivocal MRI report 7 Distance from anal verge to lower extent of tumour Upper (10-15 cm) MRI report Mid (5-10 cm) Low (0-5 cm) 8 Relationship of the tumour to the anterior peritoneal reflection Above; Straddling; Below MRI report 9 Distance from top of the puborectalis sling to lower extent of tumour (cm) [Please report 0 if any component at or below the puborectalis sling] 10 Agreement between MRI and pathology for distance to the CRM (primary surgery only) [specify distance in cm] Y/N MRI report MRI report/pathology report

21 19 CPAC MRI Protocol 1. MRI protocol as per MERCURY 1.5T or 3.0T magnet with phased array coil (NO endorectal coil) Includes four fast spin echo, T2 weighted sequences without fat saturation High resolution, axial oblique T2 sequences REQUIRED (Sequence 3 and 4) Sequence Imaging plane TR/TE FOV (cm) Section thickness (mm) Matrix size ETL NSA 1 Sagittal / x Axial 4000/ x Oblique axial 4000/ x Coronal oblique 4000/ x Optional: T1 sequences and Diffusion Weighted Imaging Gadolinium Bowel preparation Rectal contrast Antiperistaltic agents 3. Synoptic MRI report

22 CPAC Rectal Cancer Study: Synoptic MRI Report 1. MRI PROTOCOL Overall image quality: Adequate Suboptimal Non diagnostic Magnet: 1.5T 3.0T 2. TUMOUR HEIGHT Distance from the anal verge to lower extent of tumour: Low (0 5.0 cm) Mid ( cm) High ( cm) Relationship of the tumour to sacral promontory and anterior peritoneal reflection: Proximal extent of tumour below sacral promontory and distal extent of tumour above or just at peritoneal reflection Proximal extent of tumour below sacral promontory and distal extent of tumour at/below peritoneal reflection Proximal extent of tumour below the peritoneal reflection Distance from the top the of puborectalis sling to distal tumour margin: cm [0 cm if involved and negative integer if below] 3. T CATEGORY T1/early T2* Definite T2 T2/early T3 Definite T3 T3 possible T4* Definite T4* (indicate all involved structures) For low rectal tumours (0 5 cm), please characterize the component at or below the puborectalis sling: [Please note this does not reflect the AJCC staging system] Level 1 Submucosa only, no involvement of the internal sphincter Level 2 Confined to the internal sphincter, no involvement of the intersphincteric fat Level 3 Intersphincteric fat involved INTERSPHINCTERIC PLANE NOT SAFE Level 4 Involves external sphincter or beyond INTERSPHINCTERIC PLANE NOT SAFE 4. DISTANCE TO THE MRF AND EXTRAMURAL DEPTH OF INVASION (EMD) i) Shortest distance of the definitive tumour border to the MRF (not including spiculations) = mm [or unable to estimate] or not applicable (involving the peritonealised portion of the rectum or T4a)] [Record not applicable for T1 and T2 tumours] ii) Extramural depth of invasion (EMD) at most penetrating part of tumour (not including spiculations) = mm [May be at a different location than shortest distance to the MRF. Record 0 mm for T1 and T2 tumours] iii) Are there any spiculations closer to the MRF? No Yes* 20

23 *If yes, please specify distance = mm and location (on clock face) 5. EXTRAMURAL VENOUS INVASION (EMVI) EMVI: Absent Equivocal Present If present, shortest distance of the EMVI to the MRF = mm 6. MESORECTAL LYMPH NODES AND TUMOUR DEPOSITS Any suspicious mesorectal lymph nodes and/or tumour deposits? No Yes* (suspicious = irregular border, mixed signal intensity and/or > 8 mm) *If yes: (please complete a and b) (a) Shortest distance of any suspicious mesorectal lymph node/tumour deposit to MRF = mm (b) Please indicate location of the lymph node/deposit closest to the MRF: At level of tumour; at o clock Above tumour; at o clock Below tumour; at o clock 7. EXTRAMESORECTAL LYMPH NODES Any extramesorectal lymph node(s) with suspicious morphology or signal? No Yes* (suspicious = irregular border, mixed signal intensity and/or > 1 cm) * If yes, please specific location (free text): 8. FREE TEXT/ADDITIONAL COMMENTS If you have any questions regarding the CPAC MRI protocol, synoptic MRI report or Minimum Standard Resolution Form, please contact the Radiology Project Leads: Laurent Milot (laurent.milot@sunnybrook.ca) or Mark Fruitman (mark.fruitman@gmail.com) 21

24 Quicksilver/CPAC MRI Minimum Standard of Resolution For both Quicksilver and the CPAC Rectal Cancer Project the MERCURY protocol will be used as the minimum standard for voxel dimension for MR imaging. In general, studies performed in compliance with the matrix size, FOV and slice thickness specified in the MERCURY protocol will have adequate resolution for Quicksilver and the CPAC Rectal Cancer Project. Sequence Imaging plane TR/TE FOV (cm) Section thickness (mm) Matrix size ETL NSA 1 Sagittal / x Axial 4000/ x Oblique axial 4 Coronal oblique 4000/ x / x (Source: MERCURY Study Group. Extramural depth of tumor invasion at thin section MR in patients with rectal cancer: results of the MERCURY study. Radiology 2007;243:132 9.) At times, however, vendors can use terminology that can be challenging to interpret. For example, a matrix size may be specified as "256 x 128" if there are 128 phaseencoding steps but parallel imaging is used with an acceleration factor of 2. In this scenario, the spatial resolution would be adequate for Quicksilver and CPAC Rectal Cancer Project; however, the spatial resolution implied by the scan parameters would suggest that it does not meet the minimum standard. At a FOV of 160 mm and a matrix of 256 x 256, the in plane resolution is mm/pixel x mm/pixel. The minimum slice thickness is 3 mm with 0 mm intersection gap. In order to ensure that your MRI protocol meets this minimum standard of resolution, we are asking the Radiology Site Lead from each centre to complete the Minimum Standard of Resolution Form (on next page). We encourage you to work with your vendor to verify compliance. Better resolution (i.e. fewer millimeters per pixel) is acceptable provided SNR is adequately preserved. (This will generally be possible on a 3T machine, but harder to accomplish on a 1.5T machine due to time constraints.) 22

25 PLEASE COMPLETE & RETURN BY FAX TO: QuickSilver/CPAC Rectal Cancer Project MRI Minimum Standard of Resolution Form Please work with your vendor to complete the form below If your centre uses both 1.5T and 3.0T magnet please complete one form for each magnet These parameters apply only to axial and coronal oblique high resolution T2 sequences Magnet Strength 1.5T 3.0T Make and Platform Matrix Slice thickness Intersection gap FOV (Field of View) Parallel Imaging NEX X Specify: mm Specify: mm Specify: mm Yes, please specify the acceleration factor: No ETL (Echo Train Length) Sequence Name T1 sequences Diffusion Weight Imaging Gadolinium Antiperistaltic agents Rectal Contrast Bowel Preparation Rou ne Not rou ne Rou ne Not rou ne Rou ne Not rou ne Rou ne Not rou ne Rou ne Not rou ne Rou ne Not rou ne Our centre agrees not to use rectal contrast for the QuickSilver Protocol Confirm As Radiology Site Lead, I confirm that our axial oblique and coronal oblique high resolution T2 sequences meet the minimum resolution requirements (voxel dimensions) specified (page 1) Confirm Name: Signature: 23

26 24 CPAC Radiation Oncology Process Indicators YOUR CENTRE ALL CENTRES 1 # receiving precrt % Yes 2 # receiving post CRT % Yes 3 Institutional protocol available Yes/No 4 Planned target volume (PTV) is peer reviewed % Yes 5 Organs at risk is peer reviewed % Yes 6 Use of blocks and MLC shielding is peer reviewed % Yes 7 Portal imaging at least once per week % Yes 8 Treatment summary documents delivered dose and fractionation % Yes 9 Treatment summary includes technique % Yes 10 Treatment summary includes start date % Yes 11 Treatment summary includes completion date % Yes 12 Treatment summary includes delay/disruption in treatment for any reason % Yes 13 Treatment summary includes length of treatment interruption (total # days) % Yes

27 CPAC Rectal Cancer Project: RADIATION ONCOLOGY DATA COLLECTION ELEMENTS 25 CLINICAL INFORMATION Outcome Measures Source 1 Receiving precrt Y/N Clinical/Operative Note 2 Reason for precrt Clinical Stage II or III Clinical notes/mri Threatened margin Low rectal cancer 3 Receiving postcrt Y/N Clinical Notes 4 Reason for postcrt [do we need to capture reasons for pre op may be hard] Positive nodes Positive margin 5 Technique IMRT 3D Conformal Field based planning Clinical/Path Notes Rad Onc Checklist 6 Dose Fractionation 4500cGy/25fx Rad Onc Checklist 5000cGy/25 fx 2500cGy/5fx Other 7 Boost planned Y/N Rad Onc Checklist 8 Positioning Supine Rad Onc Checklist Prone without belly board Prone with belly board 9 Anal marker at anal verge Y/N Rad Onc Checklist 10 Peer review is completed prior to the start of radiotherapy Y/N Rad Onc Checklist 11 Peer review include medical physicist Y/N Rad Onc Checklist 12 Peer review includes radiation technologist Y/N Rad Onc Checklist 13 Time (in days) from last review session to issue of treatment summary available to all end users [specify time in days] Radiation Oncology Treatment Summary 14 Treatment summary is in a synoptic format Y/N Radiation Oncology Treatment Summary

28 26 PROCESS INDICATORS Outcome Measures Source 1 Institutional protocol available Y/N Radiation Oncology Site Lead (institution based) 2 CT simulator with < 5 mm slice thickness or MRI simulator with < 5 mm slice thickness Y/N Rad Onc Checklist 3 Planned target volume (PTV) is peer reviewed Y/N Rad Onc Checklist 4 Organs at risk (OAR) is peer reviewed Y/N Rad Onc Checklist 5 Hot spots peer reviewed Y/N Rad Onc Checklist 6 Use of blocks and MLC shielding peer reviewed Y/N Rad Onc Checklist 7 Documentation of rationale if PTV or OAR does not meet criteria for institutional dose Y/N Rad Oncology Checklist distribution 8 Frequency of portal imaging Daily Rad Onc Checklist Weekly Other 9 Treatment summary includes delivered dose and fractionation Y/N Rad Onc Treatment Summary 10 Treatment summary includes technique (Field based; 3D conformal or IMRT) Y/N Rad Onc Treatment Summary 11 Treatment summary includes radiotherapy start date Y/N Rad Onc Treatment Summary 12 Treatment summary includes radiotherapy completion date Y/N Rad Onc Treatment Summary 13. Treatment summary documents interruption in treatment for any reason Y/N Rad Onc Treatment Summary 14 Treatment summary documents length of interruption (in days) [specify number of days] Rad Onc Treatment Summary

29 CPAC Radiation Oncology Checklist Comments Technique Dose/Fractionation Boost Planned Positioning Anal marker at anal verge CT or MRI Simulator with < 5 mm slice thickness Planned target volume is peer reviewed Organs at risk (OAR) is peer reviewed Hot spots are peer reviewed Documentation of rationale if PTV or OAR does not meet criteria for institutional dose distribution Use of blocks/mlc shielding is peer reviewed Peer review is completed prior to start of radiotherapy Peer review includes medical physicist Peer review includes radiation technologist Frequency of portal imaging IMRT 3D Conformal Field Based 4500cGy/25 fx 5000cGy/25 fx 2500cGy/5fx Other: Yes No Supine Prone without belly board Prone with belly board Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Daily Weekly Other Radiation Oncologist Signature: Modified for CPAC courtesy of the Department of Radiation Oncology, Juravinski Cancer Centre, McMaster University, Hamilton, Ontario If you have any questions regarding the CPAC Radiation Oncology Checklist, please contact the Radiation Oncology Project Leads: Raimond Wong (raimond.wong@jcc.hhsc.ca) or Charles Cho (CCho@southlakeregional.org) 27

30 RADIATION ONCOLOGY TREATMENT SUMMARY 1. Date of dictation (DD/MM/YYYY): 2. Technique: Field based 3D Conformal IMRT 3. Delivered doses and fractionation: 4500cGy/25fx 5000cGy/25fx 2500cGy/5fx Other (please specify): 4. Chemotherapy: Bolus 5FU Infusional 5FU Capecitabine Other (please specify): 5. Radiotherapy start date (DD/MM/YYYY): 6. Radiotherapy completion date (DD/MM/YYYY): 7. Interruption of radiotherapy for any reason (check all that apply): Diarrhea Nausea Hand foot skin reactions Vomiting Mucositis Perineal desquamation Dehydration Neutropenia Thrombocytopenia Fever Febrile neutropenia Other (specify): 8. Total number of days of interruption break in radiotherapy: < 4 days 4 to 14 days > 14 days Discontinued and not restarted 9. Interruption of chemotherapy for any reason (check all that apply): Diarrhea Nausea Hand foot skin reactions Vomiting Mucositis Perineal desquamation Dehydration Neutropenia Thrombocytopenia Fever Febrile neutropenia Other (specify): 10. Total number of days of interruption break in chemotherapy: < 4 days 4 to 14 days > 14 days Discontinued and not restarted 11. Free text: If you have any questions regarding the CPAC Radiation Oncology Checklist, please contact the Radiation Oncology Project Leads: Raimond Wong (raimond.wong@jcc.hhsc.ca) or Charles Cho (CCho@southlakeregional.org) 28

31 29 Surgery Process Indicators PRE-OPERATIVE ASSESSMENT PROCESS INDICATORS YOUR CENTRE 1 Pre operative CEA % Yes 2 Pre operative CT abdo/pelvis % Yes 3 Pre operative chest imaging (CXR or CT chest) % Yes ALL CENTRES 4 Pre operative endoscopy % Yes 5 Pre operative local staging (MRI or TRUS) % Yes 6 Presentation at MCC % Yes SURGICAL PROCESS INDICATORS YOUR CENTRE 1 Pre operative marking by stoma nurse when applicable % Yes 2 OR Report in Synoptic Format % Yes 3 Documentation of distance from anal verge to lower extent of tumour % Yes 4 Documentation of rationale for APR % Yes 5 Unplanned return to OR within 30 days % Yes ALL CENTRES

32 CPAC Rectal Cancer Project: PRE TREATMENT ASSESSMENT DATA COLLECTION ELEMENTS 30 CLINICAL INFORMATION Outcome Measures Source 1 Pre operative CT chest Y/N Patient chart/radiology report 2 Pre operative CXR Y/N Patient chart/radiology report 3 Pre operative MRI Y/N Patient chart/radiology report 4 Pre operative transrectal ultrasound Y/N Patient chart/radiology report 5 Time (in days) from first treatment (surgery or prert) following initial consultation with surgeon [specify time in days] Patient chart/ Consult note 6 Time (in days) from diagnosis to initial consultation (first contact) with specialist (surgeon or radiation oncologist) [specify time in days] PROCESS INDICATORS Outcomes Measures Source Patient chart/referral form and consult note 1 Pre operative CEA [specify level] Patient chart 2 Pre operative CT abdomen and pelvis Y/N Patient chart/radiology report 3 Pre operative chest imaging (CXR or CT) Y/N Patient chart/radiology report 4 Pre operative endoscopy (flexible sigmoidoscopy for obstructing tumours or colonoscopy for non obstructing tumours) Y/N Patient chart/endoscopy note 5 Pre operative local staging (TRUS or MRI) Y/N Patient chart/radiology report 6 Presentation of case at MCC Y/N Patient chart/mcc report

33 31 CPAC Rectal Cancer Project: SURGERY DATA COLLECTION ELEMENTS CLINICAL INFORMATION Outcome Measures Source 1 Receipt of pre operative radiation Y/N Operative note 2 Reconstructive surgery performed Y/N Operative note 3 Diverting ileostomy performed Y/N Operative note 4 Laparoscopic/laparoscopic assisted Y/N Operative note 5 Laparoscopic/laparoscopic assisted converted to open Y/N Operative note 6 Length of stay (in days) [specify number of days] Discharge summary 7 Time (in days) from date of OR to issue of OR note available to all end users [specify number of days] Operative note 8 Time (in days) from surgery to start of adjuvant therapy [specify number of days] Operative note/medical Oncology Note PROCESS INDICATORS Outcome Measures Source 1 Pre operative assessment and marking by stoma nurse when applicable Y/N Operative note* 2 Documentation of distance from anal verge to lower extent of the tumour (cm) [specify distance in cm] Operative note 3 OR note in synoptic format Y/N Operative note 4 Documentation of rationale for APR [specify reason] Operative note* 5 Unplanned return to the OR within 30 days Y/N Operative note

34 Modified BC Cancer Agency Rectal Cancer Surgery Checklist 1) CLINICAL PREAMBLE Dictate as appropriate 2) SUMMARY REPORT Preoperative Details 1. Preoperative radiotherapy a. None b. Short Course (5 days) c. Long Course (5 weeks) d. Other (specify) e. Unknown 2. Preoperative imaging (include all that apply) a. None b. MRI c. CT abdomen/pelvis d. CXR e. Unknown 3. Preoperative Stage (TMN) Specify T (x, 0, 1 4) Specify N (x, 0, 1 3) Specify M (x, 0, 1) 4. Operative Urgency (include all that apply) a. Elective b. Emergent obstruction c. Emergent bleeding d. Emergent perforation 5. Preoperative Marking by Enterostomal Therapist a. Yes b. No c. Not Applicable d. Unknown Operative Details 6. Procedure a. Subtotal Mesorectal Excision (stme) with Colo rectal Anastomosis b. Total Mesorectal Excision (TME) with Colo Anal Anastomsosis c. Hartmann Procedure with TME and Stapled Anorectal Junction d. Hartmann Procedure with (stme) and Stapled Rectum e. Abdominoperineal Resection with Permanent Colostomy f. Total Proctocolectomy g. Diverting Loop Colostomy (no resection) h. Diverting Loop Ileostomy (no resection) 32

35 7. Rationale for Abdominoperineal Resection (if applicable) a. Involvement of sphincter b. Involvement of levator c. Fecal Incontinence d. Other (specify) 8. Technique a. Laparoscopic (no abdominal incision) b. Laparoscopic Assisted c. Laparoscopy Converted to Open d. Open 9. Diverting Ostomy a. Yes, ileostomy b. Yes, colostomy c. No 10. Distance of Tumour from Anal Verge cm. from anal verge to lower extent of tumour on rigid or flex sig 11. Distance of Anastomosis from Anal Verge cm. from anal verge on rig sig in OR 12. Anastomosis a. None b. Stapled c. Hand sewn 13. Reconstruction a. None b. Straight Anastomosis c. Side to End Anastomosis d. Colonic J Pouch e. Transverse Coloplasty f. Ileal Pouch Anal Anastomosis g. Other (specify) 14. Splenic Flexure Mobilization a. Yes b. No 15. Air Leak Test a. No Leak b. Leak Repaired c. Leak Diverted d. Not done 33

36 16. Multivisceral Resection (include all that apply) a. No b. Bladder c. Ovary, specify (L, R, bilateral) d. Fallopian Tubes, specify (L, R, bilateral) e. Uterus f. Ureter, specify (L, R, bilateral) g. Seminal Vesicles, specify (L, R, bilateral) h. Vagina i. Prostate j. Other (specify) 17. Intra abdominal Adhesions a. None b. Few c. Many/Dense 18. Surgical Specimen a. Not Applicable b. Grade 1 (Poor, incomplete excision of mesorectum, deep clefts in mesorectal fascia that expose rectal muscularis) c. Grade 2 (Fair, complete excision of mesorectum, superficial defects in mesorectal fascia that do not expose rectal muscularis) d. Grade 3 (Good, complete excision of mesorectum, mesorectal fascia intact, no defects) 19. Residual Cancer (include all that apply) a. None b. Local/Regional (unable to clear rectal disease, grossly positive margin) c. Metastatic (obvious distant disease at time of surgery) 20. Blood Transfusion a. Yes, specify units of packed red blood cells (PRBC) b. No 21. Unplanned Events a. None b. Describe (if occurred) 3) NARRATIVE REPORT Dictate your narrative operative report with any additional details. If you have any questions regarding the CPAC surgery checklist, please contact the Surgery Project Leads: Lara Williams (Lara.Williams@cdha.nshealth.ca) or Carl Brown (cbrown@providencehealth.bc.ca) 34

37 35 CPAC MCC Process Indicators YOUR CENTRE 1 # presented at MCC % Yes 2 Imaging based T category % Yes 3 Imaging based N category % Yes 4 # of MCC sessions over 3 months # 5 # of sessions attended by 1 or more surgeons over 3 months # (%) ALL CENTRES 6 # of sessions attended by 1 or more radiologists over 3 months # (%) 7 # of sessions attended by 1 or more medical oncologists over 3 months # (%) 8 # of sessions attended by 1 or more radiation oncologist over 3 months # (%) 9 # of sessions attended by pathology # (%) 10 MCC attended by at least one treating physician (surgery, radiation oncology, medical oncology) % Yes 11 MCC report issued % Yes 12 MCC report dictated by treating physician % Yes 13 MCC report includes attendance by specialty (surgery, radiology, radiation oncology, medical oncology, pathology) % Yes 14 MCC report includes treatment recommendation % Yes 15 MCC report includes rationale for treatment recommendation % Yes

38 CPAC Rectal Cancer Project: MCC DATA COLLECTION ELEMENTS 36 CLINICAL INFORMATION Outcome Source 1 Image based T category T1, T2, T3, T4 MRI/TRUS report 2 Image based N category N0, N1, N2 MRI/TRUS report 3 Case presented at MCC Y/N Patient chart/mcc report 4 MCC coordinator to organize rounds (each site will have a research coordinator who will be able to act as the MCC coordinator) Y/N Reported q 3 months 5 MCC physician chair to promote attendance and facilitate rounds Y/N Reported q 3 months 6 MCC Report in synoptic format Y/N MCC Report (may include free text and narrative) 7 Treatment follows MCC recommendation Y/N MCC Report/Operative Report/Rad Onc Note 8 Time (in days) from MCC to issue of MCC report available to all end users [specify time in days] MCC Report PROCESS INDICATORS Outcome Source 1 # of MCC sessions within 3 month time interval (GI or rectal cancer specific) [specify number] Reported q 3 months 2 # of sessions having representation from surgery [specify number] Reported q 3 months 3 # of sessions having representation from radiology [specify number] Reported q 3 months 4 # of sessions having representation from radiation oncology [specify number] Reported q 3 months 5 # of sessions having representation from pathology [specify number] Reported q 3 months 6 # of sessions having representation from medical oncology [specify number] Reported q 3 months 7 MCC attended by at least one treating physician (surgeon or radiation oncologist) Y/N MCC Report 8 MCC report dictated by treating physician (surgeon or radiation oncologist) Y/N MCC Report 9 MCC report is issued and available on patient chart Y/N Patient Chart/MCC Report 10 MCC report includes attendance by specialty Y/N MCC Report (surgery, radiology, radiation oncology, pathology, medical oncology) 11 MCC report includes treatment recommendation Y/N MCC Report 12 MCC report includes rationale for the treatment recommendation Y/N MCC Report

39 Synoptic MCC Report Date of MCC: Patient Name: Treating Physician: Hospital Number: 1. Case reviewed by treating physician? Yes No 2. Imaging: CT chest or CXR reviewed Yes No Not done CT abdomen/pelvic reviewed Yes No Not done MRI (or TRUS) reviewed Yes No Not done 3. Any new findings or changes on review of imaging? Yes No If yes, please specify: Suspicious mesorectal nodes EMVI Threatened margin Suspicious extramesorectal lymph nodes Metastatic disease: liver lung retroperitoneal lymphadenopathy other (specify): 4. Treatment recommendation: Pre op CRT (long course) followed by surgery (LAR, APR, Hartman) Pre op CRT (long course) followed by restaging MRI and re assessment for surgery Pre op RT (short course) followed by surgery Primary surgery (LAR, APR, Hartmann) Primary surgery (local excision) Chemotherapy Other (specify): 5. Rationale for recommendation: Pre op CRT/RT Primary Surgery Other Threatened CRM T1 Medically unfit Suspicious mesorectal nodes T2/early T3 Patient preference Definite T3/possible T4 Non threatened CRM Metastatic disease Planned APR No suspicious mesorectal nodes Suspicious extramesorectal nodes 6. Attendance: Radiology Surgery Pathology Medical Oncology Radiation Oncology 7. Strength of Recommendation: Strong One superior treatment option Moderate More than one acceptable treatment option; discuss with patient Undecided Further testing required; no treatment recommendation provided 8. Free text: If you have any questions regarding the CPAC Synoptic MCC Report, please contact the MCC Project Lead: Sender Liberman 37

40 CPAC Rectal Cancer Project Worksheet Worksheet Questions What are your group s priorities? Response What are your goals how does your group define success around these priorities (i.e. target bench marks)? What indicators are most important to assess whether your goals have been met? What will assist you to achieve these goals? (described tools/ modified tools/ new tools) What are the barriers to implementation? What strategies will you use to overcome barriers? What is your final implementation strategy? What resources do you require? What is your time-line (start-date)?