2016 Cancer Registry Annual Report

Transcription

1 2016 Cancer Registry Annual Report

2 Cancer Committee Chairman s Report The Cancer Committee at Cancer Treatment Centers of America (CTCA) at Eastern Regional Medical Center (Eastern), established in 2006, is a multidisciplinary committee comprised of physicians from the diagnostic and treatment specialties as well as non-physicians from administrative and supportive services. The Cancer Committee meets regularly throughout the year and is responsible for ensuring the standards of the Commission on Cancer (CoC), a program of the American College of Surgeons, are met and exceeded. Individual members of the committee are appointed to coordinate important aspects of the cancer program. The Cancer Committee has the authority to make recommendations to improve the overall quality of patientcentered cancer care. The Cancer Committee s responsibilities include, but are not limited to, reviewing and evaluating the following: Cancer Registry Activity Clinical and Programmatic Goals Community Outreach Clinic Research and Genetics In 2011, Eastern was initially surveyed by the CoC. The survey evaluates Eastern for compliance with the national standards for cancer care. The facility was awarded a full three-year certification with commendations in all standards, earning the facility the Outstanding Achievement Award, which is given to facilities that exceed standards in all areas of the cancer program that are eligible for commendations. Fernando U. Garcia, MD Pathologist Medical Director of the Department of Pathology and Laboratory Medicine Chairman, Cancer Committee In 2014, Eastern was re-surveyed by the CoC. The CoC found Eastern in compliance with all standards at the time of survey along with eight standard commendations awarding Eastern the Three-Year Commendation Gold Award, their highest award level. In addition, the CoC recognizes this achievement with the Outstanding Achievement Award. The Cancer Committee continues to review and monitor the CoC standards that will be surveyed in The Cancer Committee also has authority over the Breast Committee and monitors the National Accreditation Program for Breast Centers (NAPBC) standards. In 2012, Eastern was awarded an initial certification from the NAPBC and was re-surveyed by the NAPBC on April 1, 2015, at which time Eastern was awarded a full three-year re-certification. The Cancer Committee continues to review and monitor the NAPBC standards that will be reviewed at our next NAPBC survey in 2018.

3 Contents Eastern has also obtained a three-year certificate from the Quality Oncology Practice Initiative (QOPI), an affiliate of the American Society of Clinical Oncology (ASCO). This certificate highlights the commitment to excellence in cancer care. Eastern was invited by the Pennsylvania Health Care Quality Alliance (PHCQA) to share the facility s Cancer Program Practice Profile Reporting (CP3R) results on the PHCQA website. Eastern now makes these outcome results available to the public so that they may review and compare them to other facilities in Pennsylvania. This level of transparency assures the public that they have access to the information to help guide them to make the best-informed decision in choosing a facility for their cancer care. 04 Accreditations, Certifications, Awards and Recognitions 05 Cancer Registry Report 06 Primary Sites The Cancer Committee continues to monitor and review cancer data shared with the CP3R and the Rapid Quality Reporting System as well as the data for appropriate cancer treatment based on National Comprehensive Cancer Network guidelines in order to make recommendations on ways to exceed the standard of care. In 2016, Eastern started the Genomic Tumor Board in collaboration with Foundation One. This specialized tumor board serves as a platform to discuss the next generation of sequencing results from patients in order to determine which targeted therapies will be most effective. The Cancer Committee at Eastern is proud to ensure the care of our patients with cancer is approached in a multidisciplinary fashion that encompasses both physician and non-physician professionals, all committed to providing excellent care to our patients and their families. Fernando U. Garcia, MD Pathologist Chairman, Cancer Committee The information presented throughout the 2016 Cancer Registry Annual Report reflects the data collected from January 1 to December 31, 2015 unless otherwise noted.

4 Accreditations and Certifications Joint Commission Eastern is currently accredited by The Joint Commission with Full Standards Compliance. This accreditation decision is awarded to a health care organization that demonstrates satisfactory compliance with applicable Joint Commission standards in all performance areas. American College of Surgeons Commission on Cancer (CoC) Outstanding Achievement Award (OAA) Eastern is accredited by the Commission on Cancer (CoC), a quality program of the American College of Surgeons (ACS), and received the Outstanding Achievement Award in Quality Oncology Practice Initiative (QOPI) Certification In 2014, Eastern was recognized as meeting the highest standards for quality cancer care by the Quality Oncology Practice Initiative (QOPI ) Certification Program, an affiliate of the American Society of Clinical Oncology (ASCO). The QOPI Certification Program provides a three-year certification for outpatient hematology oncology practices. The QCP seal designates those practices that not only score high on the key QOPI quality measures, but also meet rigorous chemotherapy safety standards established by ASCO and the Oncology Nursing Society (ONS). Eastern is also accredited or certified by the following health care organizations: National Accreditation Program for Breast Centers (NAPBC) Respiratory Care Award from the American Association for Respiratory Care Radiology Accreditation from the American College of Radiology Awards and Recognitions I Am Patient Safety Award, Pennsylvania Patient Safety Authority, 2015, Mashuil Chowdhury, MD Best Places to Work in Philadelphia, Philadelphia Business Journal, 2012, 2013, 2014, 2015 Healthiest Places to Work in Philadelphia, Philadelphia Business Journal, M Award for Excellence in Skin Safety, Wound Ostomy and Continence Nurses Society, 2015 Top Hospital and Health Systems Women Leaders to Know, Becker s Hospital Review, 2016, Nancy Hesse, MSN, RN Top Doctors, Philadelphia Business Journal, 2016, Richard Schmidt, MD; Steven Standiford, MD, FACS; Steven Wagner, MD Top Doctors, Castle Connolly, 2016, Justin Chura, MD; Kevin Kasper, MD; Anthony Perre, MD; Scott Price, MD 4

5 Cancer Registry Report One of the many responsibilities of the Cancer Committee is to track and review Cancer Registry data to ensure patients treated at Eastern receive care according to nationally accepted measures. One standard monitored by the Cancer Committee evaluates processes and how they can be improved to promote evidence-informed practices. Accountability measures promote improvements in care delivery and are the highest standard for measurement. The Cancer Program Practice Profile Report (CP3R) below, is a summary of the CP3R performance grid reporting cases treated at Eastern. We are proud that as of our latest data reporting, our program is exceeding all of the required performance expectations of the Commission on Cancer. Eastern Measures 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) 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) At least 12 regional lymph nodes are removed and pathologically examined for resected colon cancer (Quality Improvement) 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) Measure CoC Std / % BCSRT 4.4 / 90% HT 4.4 / 90% RLN 4.5 / 85% LCT 4.5 / 85%

6 Primary Sites Summary by Body System, Sex, Class and Best CS/AJCC Stage Report Sex Class of Case Stage Distribution - Analytic Cases Only Primary Site Total (%) M F Analy NA Stg 0 Stg I Stg II Stg III Stg IV 88 ORAL CAVITY AND PHARYNX 26 (2.6%) Lip 1 (0.1%) Tongue 10 (1.0%) Salivary Glands 1 (0.1%) Gum and Other Mouth 2 (0.2%) Nasopharynx 2 (0.2%) Tonsil 10 (1.0%) DIGESTIVE SYSTEM 262 (26.7%) Esophagus 1 (0.1%) Stomach 29 (3.0%) Small Intestine 11 (1.1%) Colon Excluding Rectum 73 (7.4%) Cecum Appendix Ascending Colon Splenic Flexure Descending Colon Sigmoid Colon Large Intestine, NOS Rectum and Rectosigmoid 47 (4.8%) Rectosigmoid Junction Rectum Anus, Anal Canal and Anorectum 6 (0.6%) Liver and Intrahepatic Bile Duct 16 (1.6%) Liver Intrahepatic Bile Duct Gallbladder 4 (0.4%) Other Biliary 5 (0.5%) Pancreas 64 (6.5%) Retroperitoneum 1 (0.1%) Peritoneum, Omentum and Mesentery 2 (0.2%) Other Digestive Organs 3 (0.3%) RESPIRATORY SYSTEM 144 (14.6%) Nose, Nasal Cavity and Middle Ear 2 (0.2%) Larynx 2 (0.2%) Lung and Bronchus 140 (14.2%) BONES AND JOINTS 4 (0.4%) SOFT TISSUE (including Heart) 9 (0.9%) SKIN EXCLUDING BASAL AND SQUAMOUS 11 (1.1%) Melanoma Skin 10 (1.0%) Other Non-Epithelial Skin 1 (0.1%)

7 Sex Class of Case Stage Distribution - Analytic Cases Only Primary Site Total (%) M F Analy NA Stg 0 Stg I Stg II Stg III Stg IV 88 BREAST 238 (24.2%) FEMALE GENITAL SYSTEM 73 (7.4%) Cervix Uteri 17 (1.7%) Corpus and Uterus, NOS 27 (2.7%) Corpus Uteri Uterus, NOS Ovary 27 (2.7%) Vulva 1 (0.1%) Other Female Genital Organs 1 (0.1%) MALE GENITAL SYSTEM 73 (7.4%) Prostate 72 (7.3%) Testis 1 (0.1%) URINARY SYSTEM 38 (3.9%) Urinary Bladder 20 (2.0%) Kidney and Renal Pelvis 17 (1.7%) Ureter 1 (0.1%) BRAIN AND OTHER NERVOUS SYSTEM 20 (2.0%) Brain 19 (1.9%) Cranial Nerves Other Nervous System 1 (0.1%) ENDOCRINE SYSTEM 20 (2.0%) Thyroid 19 (1.9%) Other Endocrine including Thymus 1 (0.1%) LYMPHOMA 29 (3.0%) Hodgkin Lymphoma 11 (1.1%) Non-Hodgkin Lymphoma (NHL) 18 (1.8%) NHL Nodal NHL Extranodal MYELOMA 12 (1.2%) LEUKEMIA 12 (1.2%) Lymphocytic Leukemia 5 (0.5%) Acute Lymphocytic Leukemia Chronic Lymphocytic Leukemia Other Lymphocytic Leukemia Myeloid and Monocytic Leukemia 7 (0.7%) Acute Myeloid Leukemia Chronic Myeloid Leukemia MESOTHELIOMA 2 (0.2%) KAPOSI SARCOMA 1 (0.1%) MISCELLANEOUS 9 (0.9%) Total

8 Cancer Treatment Centers of America at Eastern Regional Medical Center 1331 East Wyoming Avenue Philadelphia, Pennsylvania cancercenter.com CTCA 2016 Rising Tide