SIH Cancer Institute Annual Report
Only T R A N S FO R M I NG STAT I ST I C S AND ST UDI E S INTO PAT I E NT CA R E S I H CA N C E R I N ST I T UT E R E P O RT 2 013 Cancer Program Survey 2011 The Cancer Program was surveyed by the American College of Surgeons’ Commission on Cancer in September, 2011. The purpose of the survey was to evaluate the quality of cancer care services, and as a result a three year accreditation with contingency was awarded. The surveyor recognized SIH’s commendation level accomplishments in six particular areas: • Standard 2.11 • Standard 3.7 • Standard 5.2 • Standard 6.2 • Standard 7.2 • Standard 8.2 Outcomes Analysis: “Annual Report each year.” NCDB Quality Criteria: “Very timely submission of NCDB data and error free.” Clinical Trial Accrual: “Very good clinical trial accruals for this community program.” Prevention and Early Detection: “Very active outreach program.” Cancer Education for the Cancer Registry Staff: “CTR attended national meetings.” Cancer Related Quality Improvements: “Good improvements each year.” The Program’s next accreditation survey is scheduled for September, 2014. Working Toward a Stand-Alone Outpatient Cancer Center For almost thirty years, cancer services in Carbondale have been accredited by the Commission on Cancer. The program grows each year and currently sees at least 800 new cancer patients yearly. There is a need for comprehensive outpatient cancer care based on this trend, both regionally and across the USA. Administration believes that specialty physicians, allied health practitioners and technology can be brought together at a comprehensive freestanding outpatient cancer center, and that communities, hospitals, referring physicians and ultimately the cancer patients themselves are best served when cancer care is centrally provided and coordinated. We will have the ability to provide multi-disciplinary clinics in one location to streamline both planning and treatment. The estimated cost is more than $24 million. The cancer center will be centrally located in Carterville near Illinois Route 13. Ground was broken in October 2013 and the intended date to commence service is early 2015. To meet the escalating need, five new oncologists joined SIH Cancer Institute with an additional oncologist arriving in 2014 --- a total of three medical oncologists, one radiation oncologist, and one surgical oncologist. Many cancer related services will be more effectively provided at the new center: medical oncology, radiation oncology, surgery, clinical trials, infusion center, navigation, survivorship, psychosocial support, cancer rehabilitation and data management. Services will be coordinated through a master software system that centralizes all activities on behalf of each patient in a single repository. The center will impart a soothing atmosphere with a light-filled environment, comfortable waiting areas, family and community meeting space, patient library, coffee shop, resource center, healthy cafe and healing gardens. 3 Cancer Registry: data reporting and support for quality measurement Staffed by four Certified Tumor Registrars, the Registry annually abstracts all new cancer cases for the National Cancer Data Base. In addition it makes data available for use by the medical staff and administration for education, research and program development. Abstracted information is continually reviewed for accuracy as required by the Commission on Cancer. During 2012, 866 analytic cases were accessioned by the registry. Top 15 Primary Sites for SIH in 2012 Uterus Esophagus Brain Thyroid Leukemia Pancreas Oral Cavity Kidney Melanoma Bladder Lymphoma Prostate Colorectal Breast Lung 0 50 100 150 200 250 SIH Cancer Stage Distribution vs. All NCDB Hospitals, All Primary Sites Comparison of the stage distributions at diagnosis between SIH and all hospitals which report to the National Cancer Data Base shows close consistency with the national experience. Stage IV Stage III Stage II Stage I Stage 0 0 5 10 15 20 25 NCDB % SIH % 5 SIH Cancer Age Distribution vs. All NCDB Hospitals, All Primary Site Comparison of the age distributions across all cancer types also show little variance from national averages; SIH shows slightly higher percentages of patients within the 60-79 age range. 90 & Over 80 - 89 70 - 79 60 - 69 50 - 59 40 - 49 30 - 39 20 - 29 Under 20 0 5 10 15 20 25 30 All NCDB % SIH % Patient Care Evaluations The registry provided 2012 case information for four patient care evaluations (PCEs) conducted recently. Patient Care Evaluation: Hormonal Therapy in Breast Cancer. The National Cancer Data Base reflected that only sixty percent of 2011 breast cancer patients’ treatment was in compliance with the Commission on Cancer’s HT CP3R. This measure states that ‘tamoxifen or a third generation aromatase inhibitor is considered or administered within 1 year (365 days) of diagnosis for women with AJCC T1cN0M0, or Stage II or III ERA and/or PRA positive breast cancer.’ Physicians were certain that this was incorrect. An audit of every non-concordant case was performed which resulted in the current CP3R data displaying an 85.7% compliance rate for 2011, which meets the CoC benchmark. Patient Care Evaluation: Lung Cancer Disparity Despite falling incidence rates nationally, lung cancer incidence continues to rise in the SIH service area. This relates directly to smoking rates. Location USA Illinois Jackson County Williamson County Franklin County Johnson County Saline County Perry County % Smokers 19 19 26 29 28 22 20 24 Incidence/ 100,000/yr 63 72 66 91 108 99 96 86 Deaths/ 100,000/yr 53 54 53 68 77 64 83 60 7 Stage Distribution Compared to all NCDB Hospitals: Non Small Cell Lung Stage The stage of lung cancer in newly diagnosed SIH patients trends toward more advanced stages in some years. I II III IV Unknown Total Cases SIH % 2011 27 10 24 36 2 124 SIH % 2012 25 4 31 38 2 122 NCDB % 2011 25 10 20 40 5 125137 Age Distribution Compared to all NCDB Hospitals: Non Small Cell Lung Age The age distribution of newly diagnosed SIH patients trends toward younger age. Under 70 70 & Over SIH % 2011 57 43 SIH % 2012 53 47 NCDB % 2011 51 48 Distance Travelled Compared to all NCDB Hospitals: Non Small Cell Lung The distance traveled for treatment is naturally longer than the national averages, given the semi-rural region. Distance < 10 mi 10 - 24 mi 25 - 49 mi > 50 mi SIH % 16 41 34 7 NCDB % 38 27 15 13 First Course Treatment Compared to all NCDB Hospitals: Non Small Cell Lung 16% of local patients had surgery only compared to 20% nationwide. Conversely, more patients opted for definitive radiation therapy here than elsewhere, leaving the totals for single modality first course of treatment approximately equal. A total of 24% of local patients were candidates for curative surgery in 2011, with or without other forms of treatment; this compares to 28% for patients treated nationwide. Similar proportions of patients in the two groups received no treatment at all. First Course Treatment Surgery Only Radiation Only Surgery + Chemotherapy Radiation + Chemotherapy Chemotherapy Only Surgery, Radiation & Chemotherapy No Treatment SIH % 16 17 4 29 12 4 18 NCDB % 20 15 5 21 13 3 20 9 5yr Survival Compared to all NCDB Hospitals: Non Small Cell Lung When survival statistics are compared for local patients and those for all NCDB hospitals as a whole, no statistically significant difference is demonstrated. Due to relatively small case numbers, the confidence intervals for local survival are broad, and they overlap with the confidence intervals for all NCDB hospitals. These data are from the most recent years available. Date Range 1998 - 2002 5yr Survival SIH NCDB 21.5% 16.7% Confidence Interval 15.6 - 27.4 16.5 - 16.8 2003 - 2005 SIH NCDB 18.0% 16.5% 13 - 23 16.3 - 16.6 The information from this Patient Care Evaluation makes our mission clear: the regional smoking rate needs to be addressed with better education, prevention and cessation services. Patients diagnosed with lung cancer do no worse than they do elsewhere, however later stages and distance from the treatment centers presents the challenge of helping patients to be available for prompt and complete treatment. Patient Care Evaluation: Head and Neck Cancer Patient Outmigration Patients diagnosed with head/neck cancer in 2011 and 2012 were classified as to whether they had received all or part of their first course of treatment locally or had gone elsewhere for treatment. Similar numbers of cases - 46 and 44 - were seen, however 21 and 31 were diagnosed locally for 2011 and 2012, representing a 48% increase in one year. 14 and 25 had their surgery done locally, a 78% increase in 2012 over 2011. The number of patients with thyroid cancer having surgery locally doubled from 6 to 12, a 100% increase. These changes are attributed to the successful establishment of two additional otorhinolargyngologists in practice at SIH, both of whom have a special interest in cancer. Patient Care Evaluation: Unknown Stage When the stage is unknown for a given cancer case, then that case is eliminated from most forms of analysis of treatment and outcomes by the National Cancer Data Base. Over the past several years a concerted effort has been made by the Cancer Registry to lower the number of cases reported without definite staging. Clearly this effort has been successful, as the unknown stage rate for SIH is now significantly less than the national average. Cases Reported with Unknown Stage Compared to All NCDB Hospitals SIH NCDB% Year Unknown Stage Unknown Stage 2005 2006 2007 2008 2009 2010 2011 22 19 18 10 5 4 6 10 11 12 9 8 10 9 11 Commission on Cancer Quality Measures The Commission on Cancer reports each participating programâ€™s level of compliance with six accountability and quality improvement measures. These standards of care are either based on high quality clinical trial evidence or demonstrate universally agreed upon good practice. Results are for 2011 cases. 1. Radiation therapy is administered within one year (365 days) of diagnosis for women under age 70 receiving breast conserving surgery for breast cancer. Benchmark is 90%. Radiation Therapy After Breast Conserving Surgery 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Facility Category All NCDB Benchmark 2. Combination chemotherapy is considered or administered within 4 months (120 days) of diagnosis for women under age 70 with AJCC T1cN0M0, or Stage II or III ERA and PRA negative breast cancer. Benchmark is 90%. Chemotherapy for Receptor Negative Breast Cancer 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Facility Category All NCDB Benchmark 3. Tamoxifen or third generation aromatase inhibitor is considered or administered within 1 year (365 days) of diagnosis for women with AJCC T1cN0M0, or Stage II or III ERA and/or PRA positive breast cancer. Benchmark is 90%. Hormone Therapy for Receptor Positive Breast Cancer 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Facility Category All NCDB Benchmark 4. 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. Benchmark is 90%. Chemotherapy for Node Positive Colon Cancer 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Facility Category All NCDB Benchmark 5. At least 12 regional nodes are removed and pathologically examined for resected colon cancer. Benchmark is 80%. 12 Regional Nodes for Resected Colon Cancer 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Facility Category All NCDB Benchmark 6. Radiation therapy is considered or administered within 6 months (180 days of diagnosis for patients under the age of 80 with clinical or pathologic AJCC T4N0M0 or Stage III receiving surgical resection for rectal cancer. Benchmark is 90%. Radiation Therapy for Resectable Rectal Cancer 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Facility Category All NCDB Benchmark 15 Cancer Survival Rates Below are graphical representations of survival data for the most common cancer primary sites seen at SIH, for cases diagnosed from 2003-2006, which is the most recent data available. It is important to note that these charts relate any cause mortality, so that deaths are not purely cancer related. Also, when comparing survival rates between the SIH cancer program and all NCDB hospitals, if the confidence intervals of survival rates overlap, then there is no statistical difference between the two numbers. Finally, overall survival rates can be affected by the stage distribution of cancer at the time of diagnosis. These factors combine to make comparisons complicated. In the less common cancers, SIH case numbers are not sufficient to make meaningful comparisons stage for stage, and so only overall five year survival is presented. Breast Cancer Five Year Survival Overall Survival: SIH 83.0% (79-86.9) All NCDB 85.5% (85.4-85.6) 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Stage 0 Stage I Stage II Stage III Stage IV Overall All NCDB SIH Non Small Cell Lung Cancer Five Year Survival Overall Survival: SIH 16.6% (12.2-20.9) All NCDB 16.7% (16.6-16.8) 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Stage I Stage II All NCDB SIH Stage III Stage IV Overall Overall Five Year Survival by Primary Site, 2003-2006 Site Breast Non Small Cell Lung All Head/Neck All Colorectal All Digestive Lymphoma All Male Genital All Female Genital Urinary SIH % 83.0 (79.0-86.9) 16.6 (12.2-20.9) 50.3 (37.1-63.5) 50.5 (43.1-57.9) 38.6 (32.5-44.6) 63.8 (48.4-79.1) 81.4 (75.2-87.6) 66.5 (51.3-81.8) 43.1 (30.7-55.4) All NCDB % 85.5 (85.4-85.6) 16.7 (16.6-16.8) 53.6 (53.2-54.0) 56.6 (56.4-56.7) 40.8 (40.6-40.9) 63.2 (62.9-63.4) 88.0 (87.9-88.1) 65.1 (64.9-65.4) 62.7 (62.5-62.9) 17 Concordance with NCCN Guidelines 2012 NCCN Guideline Review for Breast Cancer Sample A randomly chosen sample totaling 10% of 2012 breast cancer cases were reviewed for compliance with National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines. These guidelines covered preoperative clinical staging, surgery, chemotherapy, endocrine therapy, radiation therapy and follow-up. 19 of 20 cases accurately applied the guidelines for a 95% concordance rate. The one non-concordant case had more clinical staging imaging than recommended but care was not affected. Four other cases had adjustments made in first course of treatment due to advanced age, refusal of recommended treatment or extensive medical co-morbidity, all of which are permissible and advisable under the guidelines with proper documentation. NCCN Guideline Compliance, Breast Cancer Concordant Nonconcordant 2012 NCCN Review for Colorectal Cancer All colon and rectal cancer cases from 2012 that were treated through SIH, 34 total, were reviewed for concordance with NCCN Clinical Practice Guidelines. Within these two primary sites, cancers of several types were seen: polyp with cancer, cancer appropriate for resection, synchronous metastasis, and recurrence. Within each category, the pretreatment evaluation process and the subsequent course of treatment were assessed. Colorectal Cancer Type 3 1 4 26 Cancer in polyp Cancer appropriate for resection Synchronous Metastasis Recurrance Pretreatment Evaluation 18 16 Concordant Nonconcordant Treatment 4 Concordant Nonconcordant 30 For cases that were scored non-concordant in pretreatment evaluation, it was not possible to locate either preoperative chest imaging, or recommended lab work such as CEA, or both. The four cases that were non-concordant with treatment guidelines all were not referred for medical oncology evaluation when that was indicated due to node negative disease with high risk factors. In summary, pretreatment evaluation non-concordance did not result in treatment errors, and no individual practitioner was primarily responsible. Medical oncology referral is indicated for T3N0 and greater stage tumors. The Programâ€™s corrective action is (1) successful recruitment of specialist colorectal surgeon in 2013 and (2) educational discussion of NCCN CPGs at the monthly multidisciplinary GI Cancer Treatment Planning Conference. 19 Personnel Jennifer Badiu, System Director Dr. Mary Rosenow, Medical Director, SIH Cancer Institute Dr. George Kao, Medical Director, Radiation Oncology Dr. Marsha Ryan, Medical Director, Breast Center Dr. Michael Little, Cancer Liaison Physician Cancer Committee Chair: Dr. Mary Rosenow Quality Improvement Coordinator: Lynn Torres Cancer Registry Quality Coordinator: Christena Vallerga Cancer Conference Coordinator: Amy Behrens Community Outreach Coordinator: Diane Land Psychosocial Coordinator: Dawn Harriett Clinical Research Representative: Mitzie Benns Cancer Liaison Physician: Dr. Michael Little and representatives from: Administration Palliative Care Registry Patient Navigation Radiology Registry Radiation Oncology Medical Oncology Hospice Oncology Nursing Pathology Pastoral Care Surgery Social Services Survivorship Program Cancer Rehabilitation Nutrition Services American Cancer Society Breast Center Only Physicians providing services at and admitting to Memorial Hospital of Carbondale, Herrin Hospital and St. Joseph Memorial Hospital are not employees of the hospital. Physicians exercise their own independent judgement regarding medical care and treatment and the hospital is not responsible for their actions.