Outcomes Report: Accountability Measures and Quality Improvements The FH Memorial Medical Center s Cancer Committee ensures that patients with cancer are treated according to the nationally accepted measures. Because we are an accredited cancer program through the Commission on Cancer of the American College of Surgeons, we have the opportunity to participate in the quality reporting systems called Cancer Program Practice Profile Report (CP3R) and Rapid Quality Reporting System (RQRS). These quality measures are standards of care based on evidence-based clinical trials. FH MEMORIAL MEDICAL CENTER 93.0% State of Florida 91.4% Similar COC Accredited Program 93.6% ALL COC Accredited Programs 93.4% FH MEMORIAL MEDICAL CENTER 96.8% State of Florida 89.6% Similar COC Accredited Program 92.3% ALL COC Accredited Programs 92.2% FH MEMORIAL MEDICAL CENTER 100.0% State of Florida 91.2% Similar COC Accredited Program 91.2% ALL COC Accredited Programs 92.0% ACCOUNTABILITY MEASURE: 2015 COLON Adjuvant chemo is recommended, or administered within 4 months (120 days) of diagnosis for patients under the age of 80 with AJCC stage III (LN positive) colon cancer ACCOUNTABILITY MEASURE: 2015 BREAST Radiation is administered within 1 year of diagnosis for women under the age of 70 receiving breast conservation surgery for breast cancer ACCOUNTABILITY MEASURE: 2015 BREAST Tamoxifen or third generation aromatase inhibitor is recommended or administered within 1 years of diagnosis for women with AJCC T1c or Stage IB-III hormone receptor positive breast cancer ACCOUNTABILITY MEASURE: 2015 BREAST Combination chemotherapy is recommended or administered within 45 months (120 days) of diagnosis for women under 70 with AJCC T1c N0 or stage 1B-3 hormone receptor negative breast cancer FH MEMORIAL MEDICAL CENTER 100.0% State of Florida 8.3% Similar COC Accredited Program 88.3% ALL COC Accredited Programs 87.9%
QUALITY IMPROVEMENT MEASURE: 2015 COLON Fewer than 12 LNS are removed and pathologically examined for resected colon cancer FH MEMORIAL MEDICAL CENTER 85.0% State of Florida 90.7% Similar COC Accredited Program 91.9% ALL COC Accredited Programs 92.0% QUALITY IMPROVEMENT MEASURE: 2015 LUNG Surgery is not the first course of treatment for cn2 M0 lung cases FH MEMORIAL MEDICAL CENTER 91.7% State of Florida 86.0% Similar COC Accredited Program 92.8% ALL COC Accredited Programs 92.2% QUALITY IMPROVEMENT MEASURE: 2015 LUNG 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 FH MEMORIAL MEDICAL CENTER 100.0% State of Florida 87.6% Similar COC Accredited Program 89.5% ALL COC Accredited Programs 90.2% The Rapid Quality Reporting System (RQRS) is a quality reporting tool that outlines our current measures of standards within 3 months of diagnosis. Here are some examples of our quality measures. Expected performance should be >90%, unless otherwise noted. BREAST CANCER MEASURES
COLON CANCER MEASURES: Expected Performance > 85% Expected Performance > 90%
2016 CANCER STATISTICS PRIMARY SITE REVIEW PRIMARY SITE GENDER AJCC STAGE TOTAL Analytic Non-Analytic M F 0 I II III IV UNK N/A ALL SITES 1067 832 235 383 449 47 214 103 101 181 98 88 Lung: Non-Small Cell 198 166 32 75 91 0 58 20 26 52 10 0 Breast 155 131 24 4 127 22 56 38 9 1 5 0 Colon 80 64 16 30 34 2 12 16 15 17 2 0 Head & Neck 59 47 12 34 13 2 8 1 3 22 10 1 Pancreas 46 38 8 21 17 0 13 4 2 14 5 0 Lung: Small Cell 48 38 10 19 19 0 5 0 7 24 2 0 Melanoma 44 34 10 28 6 6 8 3 5 7 5 0 Non-Hodgkin's 30 26 4 18 8 0 9 2 6 6 3 0 Brain (Benign) 27 25 2 1 24 0 0 0 0 0 0 25 Rectum 29 24 5 16 8 2 5 2 5 6 4 0 Kidney/Renal Pelvis 33 21 12 11 10 1 8 1 3 4 4 0 Liver 26 20 6 14 6 0 3 2 2 5 2 6 Biliary / Other Digestive 23 20 3 10 10 0 3 0 2 4 5 6 Esophagus 27 18 9 15 3 4 3 1 2 4 4 0 Corpus Uteri 21 18 3 0 18 0 13 0 0 2 3 0 Stomach 18 16 2 12 4 3 1 0 4 4 4 0 Prostate 36 16 20 16 0 0 1 9 1 3 2 0 Thyroid 14 14 0 5 9 0 9 2 0 1 2 0 Brain (Malignant) 19 13 6 10 3 0 0 0 0 0 0 13 Multiple Myeloma 16 11 5 9 2 0 0 0 0 0 0 11 OTHER SITES 118 75 46 37 38 5 5 4 9 10 16 26 During 2016, we provided cancer care for 1067 new cancer patients. Analytic cases represent patients we provide diagnosis and/or treatment for their cancer. In 2016, we treated 832 analytic patients. Non-analytic cases represent patients who were diagnosed and treated elsewhere for their cancer and we provided care for their progression or recurrence. There were 8% more females represented in our 2016 cases. Lung was divided by non-small cell and small cell cancer types for this analysis. Head and Neck is now in our top 5 cancer sites.
Annual Case Volumes: 2012-2016 2016 CANCER STATISTICS Year Analytic Non-Analytic Total 2012 843 270 1113 2013 806 253 1059 2014 857 212 1069 2015 898 145 1043 2016 832 235 1067 Analytic cases represent patients we provide diagnosis and/or treatment for their cancer. Non-analytic cases represent patients who were diagnosed and treated elsewhere for their cancer and we provided care for their progression or recurrence. Our analytic cases have fluctuated over the past 5 years ranging as low as 806 to as high as 898. Our overall total numbers have remained stable over the past 4 years.
2016 CANCER STATISTICS Top 5 Cancer Site Trends: 2012-2016 YEAR LUNG BREAST MELANOMA COLON KIDNEY PANCREAS NH LYMPHOMA 2012 160 170 100 47 25 22 22 2013 171 164 83 46 26 30 32 2014 169 161 81 64 41 33 26 2015 197 169 80 58 26 51 33 2016 204 131 34 64 21 38 26 In 2016 Non-Small Cell Lung Cancer, Breast, Colon, Head & Neck, and Pancreas are the new top 5 sites. Small Cell Lung Cancer and NH Lymphoma are the other two cancers with high volumes. For this review, all lung cancer types were counted in one group. Over the past 2 years, we have seen an increase in lung cancer and a significant decrease in breast and melanoma cases. Colon cancer has increased a slight bit in 2016. Kidney volumes have declined in the past, pancreatic cancer increased significantly in 2015.
Stage at Diagnosis: Top 5 Sites 2016 2016 CANCER STATISTICS SITE Stage 0 Stage 1 Stage 2 Stage 3 Stage 4 Unk Stage Breast (n=131) 16.8% 42.7% 29.0% 6.9% 0.8% 3.8% Lung - Non Small Cell (n=166) 0.0% 34.9% 12.0% 15.7% 31.3% 6.0% Colon (n=64) 3.1% 18.8% 25.0% 23.4% 26.6% 3.1% Melanoma (n=34) 17.6% 23.5% 8.8% 14.7% 20.6% 14.7% Head & Neck (n=47) 4.3% 17.0% 2.1% 6.4% 46.8% 21.3% Pancreas (n=38) 0.0% 34.2% 10.5% 5.3% 36.8% 13.2% During 2016, 59.5% of our breast cancer patients were diagnosed at very early stage (Stages 0-1). Over 88% of our breast cancer patients were diagnosed in early stages 0-2. For our lung patients, nearly 35% were diagnosed as stage 1, however, over 31% were also diagnosed as stage 4. We have a significant number of colon cancer patient (26.6%) found with metastatic disease at diagnosis.
2016 CANCER STATISTICS Cancer Incidence with Comparative Data 2016 Cases Analytic Cases 2016 Cases Analytic Cases FH Memorial Incidence % (n=383) MALE: CANCER TYPE ACS * Incidence % (n=841,390) FH Memorial Incidence % (n=449) FEMALE: CANCER TYPE ACS * Incidence % (n=843,820) 4% Prostate 21% 28% Breast 29% 18% Lung 14% 18% Lung 13% 7% Colon & Rectum 8% 7% Colon & Rectum 8% 2% Bladder 7% 4% Uterine Corpus 7% 7% Melanoma - Skin 6% 2% Thyroid 6% 3% 5% 6% Kidney & Renal Pelvis Non-Hodgkin Lymphoma Oral Cavity& Pharynx 5% 2% 5% 1% 4% 2% Non-Hodgkin Lymphoma Melanoma - Skin Kidney & Renal Pelvis 1% Leukemia 4% 4% Pancreas 3% 4% 3% 3% 4% Liver & Intrahepatic bile duct 3% 1% Leukemia 3% *ACS: American Cancer Society's Cancer Facts and Figures - 2014 For our male population, we have a significantly lower incidence at FHMMC compared to the nation, due to those patients being diagnosed and treated elsewhere in the community. Our incidence of lung melanoma and H&N cancers are higher at FHMMC compared to the national incidence. For our female population, our breast cancer incidence is consistent with and similar to national data. FHMMC has a higher incidence of lung cancer. However, our incidence is lower for uterus, thyroid, lymphoma skin and leukemia.