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Exceptional cancer care, close to home. SAINT JOSEPH HOSPITAL ELGIN

The AMITA Health Saint Joseph Elgin Medical Center Cancer Program is accredited by the American College of Surgeons (ACoS) Commission on Cancer (CoC). The CoC partners with the National Quality Forum, American Society for Clinical Oncology, and the National Comprehensive Cancer Network to provide accredited cancer programs with performance measures and comparison data on an annual basis as a method to assess quality of care. These evidence based quality measures will be used in national accountability programs dedicated to improving the quality of cancer care and have maximal beneficial impact on cancer outcomes in the population. Accountability measures for breast cancer include adjuvant hormone therapy for hormone receptor positive tumors, chemotherapy for hormone negative cancer, radiation after mastectomy if four or more positive lymph nodes, and radiation following lumpectomy. The accountability measure for colon cancer includes adjuvant chemotherapy for Stage III colon cancer. The quality improvement measure for breast cancer includes a needle or palpation guided biopsy for diagnosis. The quality improvement measure for colon and gastric cancers includes removal and examination of at least 12 regional lymph nodes for colon and 15 lymph nodes for gastric. Quality improvement measures for lung cancer include surgery not being the first course of treatment for certain lung cancers and chemotherapy for pathologic lymph node positive lung cancer. The quality improvement measure for rectal cancer is preoperative or postoperative chemotherapy and radiation for certain staged rectal cancers. The following are the most current estimated performance rates reported in 2018 for cancer cases diagnosed in 2016 based on the CoC Cancer Program Practice Profile Report (CP3R). The estimated performance rates shown below indicate the proportion of breast, colon, gastric, lung, and rectal patients treated according to recognized standards of care by diagnosis year. The data in the graphs reflect the most current data provided by the CoC for 2016. Data compares AMITA Health Saint Joseph Elgin Medical Center ( on the chart) to other hospitals in Illinois and all ACoS CoC approved cancer programs. The charts show that the AMITA Health Saint Joseph Elgin Medical Center Cancer Program excels in many of the performance measures.

National Quality Performance Measures Breast Needle Biopsy (nbx) to Establish Diagnosis Prior to Surgical Intervention for Breast Cancer nbx Measure: Image or palpation-guided needle biopsy (core or FNA of the primary site) is performed to establish diagnosis of breast cancer 96.2% is superior to the state (92.7%) and national (90.0%) performance rates when compared with other Breast Conserving Surgery/Radiation Therapy For Breast Cancer (BCS/RT) BCS/RT Measure: Radiation therapy is administered within 1 year (365 days) of diagnosis for women under age 70 receiving breast conserving surgery (lumpectomy) for invasive breast cancer. One year is identified as a measure to allow for medical intervention following surgery. Most often radiation therapy is delivered within one to six months of surgery. Radiation treatment should start as soon as medically feasible. 96.2% 92.7% 90.0% 92.9% is comparable to the state (92.5%) and superior to the national (90.9%) performance rates when compared with other nbx 92.9% 92.5% BCS/RT 90.9% Radiation Therapy Following Mastectomy (MAST/RT) MAST/RT Measure: Radiation therapy is considered or administered following any mastectomy within 1 year (365 days) of diagnosis of breast cancer for women with > = 4 positive regional lymph nodes is superior to the state (89.4%) and national (85.3%) performance rates when compared with other Hormone Therapy (Ht) For Hormone Receptor Positive Breast Cancer HT Measure: Hormone therapy is considered or administered within 1 year (365 days) of diagnosis for women with AJCC T1cN0M0, or Stage II or III hormone receptor positive breast cancer. 89.4% 85.3 % MAST/RT 85.0% is comparable to the state (93.6%) and national (91.5%) performance rates when compared with other HT * 89.4% 85.3 % 85.0% 93.6% 91.5% * Some patients have justified extenuating circumstances that preclude them from taking an aromatase inhibitor.

64.6% National Quality Performance Measures Multi-Agent Chemotherapy (MAC) Treatment For Hormone Receptor Negative Breast Cancer MAC Measure: Multi-agent chemotherapy is considered or administered within 4 months (120 days) of diagnosis for women under 70 with AJCC T1cN0M0, or Stage II or III hormone receptor negative breast cancer. MAC outcomes: performance rate at is superior to the state (96.0%) and national (92.6%) performance rates when compared with other 96.0% 92.6% 96.0% 92.6% Adjuvant Chemotherapy Treatment For Lymph Node Positive Colon Cancer ACT Measure: 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 outcomes: performance rate at is superior to the state (91.1%) and national (87.6%) performance rates when compared with other CoC accredited ACT cancer programs. 91.1% 87.6% 12RLN Pre-op or post-op chemotherapy for certain rectal cancers 93.0% 92.7% REC RTCT Measure: Preoperative chemo and radiation are administered for clinical AJCC T3N0, T4N0, or Stage III; or postoperative chemo and radiation are administered within 180 of diagnosis for clinical AJCC T1-T2N0 with pathologic AJCC T3N0, T4N0, or Stage III; or treatment is recommended; for patients under the age of 80 receiving resection for rectal cancer. LCT Outcomes: performance rate at is superior to the state (85.8%) and national (86.1%) performance rates when compared with other LNoSurg MAC 12 Regional Lymph Nodes Examined For Colon Cancer 96.0% 92.6% 12RLN Measure: At least 12 regional lymph nodes are removed and pathologically examined for resected colon cancer. outcomes: performance rate at is superior to the state (93.0%) and national (92.7%) performance RECRTCT rates when compared with other CoC accredited 12RLNcancer programs. 85.8% 93.0% 86.1% 92.7% ACT A LNoS 1 85.8% 86.1% AHS G15RLN References: N/A LCT American College of Surgeons-Commission on Cancer (ACoS-CoC) National Cancer Data Base (NCDB) Cancer Program Practice Profile Report (CP3R) November 2018 90.0% 85.5% RECRTC 10

LNoSurg Surgery not first treatment for certain lung cancers LNoSurg Measure: Surgery is not first treatment course for cn2, M0 lung cases outcomes: performance rate at is superior to the state (93.0%) and national (92.6%) performance rates when compared with other 15 Regional Lymph Nodes Examined for Gastric Cancer (G15RLN) G15RLN Measure: At least 15 regional lymph nodes are removed and pathologically examined for resected gastric cancer (Quality Improvement) outcomes: performance rate was N/A as no patients fit this criteria for 2016. The state G15RLN was at 60.3% and the national rate was 64.6%. 93.0% 92.6% N/A 60.3% 64.6% Systemic Chemotherapy for certain lung cancers (LCT) LCT Measure: Systemic chemotherapy is administered within 4 months to day preoperatively or day of surgery to 6 months postoperatively, or it is considered for surgically resected cases with pathologic lymph node-positive (pn1) and (pn2) NSCLC outcomes: performance rate at is superior to the state (90.0%) and national (88.5%) performance rates when compared with other 90.0% 85.5% References: American College of Surgeons-Commission on Cancer (ACoS-CoC) National Cancer Data Base (NCDB) Cancer Program Practice Profile Report (CP3R) November 2018

Meadows Regional Cancer Care Center 77 N. Airlite St., Elgin, IL 60123 We know cancer takes a physical toll, but it also impacts every other aspect of life. We partner with you to address all issues of cancer care, body, mind and spirit. We are there to support you throughout your journey with cancer and well into your future. We are thrilled to offer our patients this wonderful center that allows us to provide the most advanced care in a family friendly setting. Here you will find a dedicated team of experts ready to fight cancer side by side with our patients. Call 847.931.5520 to speak with one of our cancer care team members. AMITAhealth.org/stjoseph-elgin SAINT JOSEPH HOSPITAL ELGIN