5
Diagnosing Cancer

“The key to a continued reduction in mortality is early detection and accurate diagnosis made in a cost-effective manner.”

Breast Cancer Screening and Diagnosis Guidelines

National Comprehensive Cancer Network, 2004

“Decisions regarding adequacy of surgical resection, need for adjuvant therapy, and appropriate surveillance protocols are often predicated on tumor characteristics and propensity for disease recurrence. Ambiguity or underreporting of important pathologic features may adversely influence clinical outcomes.”

Quality of Colon Carcinoma Pathology Reporting: A Process of Care Study

Wei et al., 2004

Whatever Georgia may achieve by expanding cancer screening and early detection could be compromised if the state fails to adequately address the next stages in the continuum of cancer care—diagnosis and treatment. Cancer diagnosis is the critical first step in ascertaining the tumor biology or characteristics and extent of disease, as well as in determining the optimal clinical strategy for combating the disease. Several aspects of the diagnostic process are fundamental to quality cancer care: (1) the timely gathering of appropriate diagnostic and surgical specimens for histological assessment, (2) clear, reliable, and standardized pathology reporting on surgical specimens, and (3) documenting the stage of disease before initiating treatment.

The Institute of Medicine (IOM) committee recommends that the Georgia Cancer Coalition (GCC) adopt 14 quality measures related to



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Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia 5 Diagnosing Cancer “The key to a continued reduction in mortality is early detection and accurate diagnosis made in a cost-effective manner.” Breast Cancer Screening and Diagnosis Guidelines National Comprehensive Cancer Network, 2004 “Decisions regarding adequacy of surgical resection, need for adjuvant therapy, and appropriate surveillance protocols are often predicated on tumor characteristics and propensity for disease recurrence. Ambiguity or underreporting of important pathologic features may adversely influence clinical outcomes.” Quality of Colon Carcinoma Pathology Reporting: A Process of Care Study Wei et al., 2004 Whatever Georgia may achieve by expanding cancer screening and early detection could be compromised if the state fails to adequately address the next stages in the continuum of cancer care—diagnosis and treatment. Cancer diagnosis is the critical first step in ascertaining the tumor biology or characteristics and extent of disease, as well as in determining the optimal clinical strategy for combating the disease. Several aspects of the diagnostic process are fundamental to quality cancer care: (1) the timely gathering of appropriate diagnostic and surgical specimens for histological assessment, (2) clear, reliable, and standardized pathology reporting on surgical specimens, and (3) documenting the stage of disease before initiating treatment. The Institute of Medicine (IOM) committee recommends that the Georgia Cancer Coalition (GCC) adopt 14 quality measures related to

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Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia BOX 5-1 Recommended Measures for Tracking the Quality of Cancer Diagnosis Adequacy of Diagnostic and Surgical Specimens Measure 5-1 Timely breast cancer biopsy Measure 5-2 Use of needle biopsy in breast cancer diagnosis Measure 5-3 Tumor-free surgical margins in breast-conserving surgery Measure 5-4 Appropriate histological assessment of breast cancer Measure 5-5 Appropriate histological assessment of colorectal cancer Adequacy of Pathology Reports on Surgical Specimens Measure 5-6 Pathology laboratories’ compliance with reporting standards for cancer surgical specimens Measure 5-7 Adequacy of pathology reports on breast cancer surgical specimens Measure 5-8 Adequacy of pathology reports on colorectal cancer surgical specimens Measure 5-9 Adequacy of pathology reports on lung cancer surgical specimens Measure 5-10 Adequacy of pathology reports on prostate cancer surgical specimens Documentation of Cancer Pathologic Stage Before Chemotherapy or Radiation Treatment Begins Measure 5-11 Breast cancer stage determined before treatment Measure 5-12 Colorectal cancer stage determined before treatment Measure 5-13 Lung cancer stage determined before treatment Measure 5-14 Prostate cancer stage determined before treatment cancer diagnosis (Box 5-1). The first five measures will help Georgia ensure that adequate diagnostic and surgical specimens are available for timely, pathologic assessment or evaluation of breast and colorectal cancers. The next five measures can be used by Georgia to track the quality of the pathology reports on cancer surgical specimens, which clinicians depend on to assess the extent of the cancer and to advise patients on treatment options. The final set of four measures will help the state ensure adequate treatment planning by monitoring whether health care providers document patients’ cancer stage before initiating chemotherapy or radiation treatment. The 14 recommended quality measures pertaining to cancer diagnosis are discussed further below. For each measure discussed, there is a section providing a brief rationale for the selection of the measure, explanation of the evidence underlying the measure (the “consensus on care”) and a description of what is known about the gap between the evidence and current practice (“knowledge vs. practice”). Also provided near the end of the chapter is a brief section on the potential data sources for measures in

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Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia the diagnostic domain. The chapter concludes with summaries of each quality measure. RECOMMENDED MEASURES FOR TRACKING THE QUALITY OF CANCER DIAGNOSIS Adequacy of Diagnostic and Surgical Specimens Two of the five recommended quality-of-cancer-care measures related to the adequacy of diagnostic and surgical specimens pertain to the use of biopsies in breast cancer diagnosis. During a breast biopsy, either a small sample of suspicious breast tissue (i.e., an incisional core biopsy) or an entire lump or suspicious area is removed (i.e., an excisional biopsy) for histological assessment. When the tissue sample is removed with a needle, the procedure is referred to as a needle biopsy or fine-needle aspiration. To track the timeliness of biopsy after a suspicious, abnormal mammogram and the use of needle biopsy before breast cancer surgery, the committee recommends that Georgia adopt the following measures: Measure 5-1—Timely breast cancer biopsy—the proportion of women who receive a biopsy within 14 days after first documentation of a category 4 or 5 abnormal mammogram. Measure 5-2—Use of needle biopsy in breast cancer diagnosis—the proportion of women who have a needle biopsy of the breast at least 1 day prior to breast cancer surgery. The remaining three measures pertain to the collection and histological assessment or evaluation of surgical specimens taken from patients who undergo surgery for breast or colorectal cancer. To monitor the appropriate collection and histological assessment or evaluation of breast and colorectal cancer surgical specimens, the committee recommends that the GCC adopt the following measures: Measure 5-3—Tumor-free surgical margins in breast-conserving surgery for breast cancer—the proportion of patients undergoing breast-conserving surgery whose surgical margins are free of tumor after the last surgical procedure. Measure 5-4—Appropriate histological assessment of breast cancer—the proportion of Stage I and Stage II breast cancer cases with sentinel node biopsy or with histological assessment of 10 or more axillary lymph nodes. Measure 5-5—Appropriate histological assessment of colorectal cancer—the proportion of colorectal cancer surgery patients with documented histological assessment of 12 or more lymph nodes.

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Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia The rationale for the IOM committee’s decision to recommend each of these measures is discussed further below. Breast Cancer Biopsies The first two recommended quality-of-cancer-care measures pertaining to the adequacy of diagnostic and surgical specimens are the timeliness of biopsy after a suspicious, abnormal mammogram and the use of needle biopsy before breast cancer surgery. A strong evidence base shows that screening mammography reduces breast cancer deaths by finding cancer at an early, treatable stage (USPSTF, 2002).1 Mammography can only improve breast cancer outcomes, however, if follow-up of abnormal findings is timely and appropriate. Screening mammography findings should be documented according to the Breast Imaging and Reporting Data System (BI-RADS) (Box 5-2). Women with abnormalities that are suspicious or suggestive of malignancy—BI-RADS categories 4 and 5—should be followed up with a biopsy according to the National Comprehensive Cancer Network (NCCN) breast screening and diagnosis guidelines (ACR, 2003; NCCN, 2004c). Timely breast cancer biopsy. Consensus on care. There is no consensus on the ideal interval between finding a category 4 or 5 abnormal mammogram and the follow-up biopsy; however, the available evidence suggests that the interval should be brief (Olivotto et al., 2001). The Institute for Clinical Systems Improvement recommends that the biopsy be completed in less than 14 days after first documentation of a category 4 or 5 mammogram; RAND, Inc. recommends no more than 6 weeks (Gifford and Schmidt, 2000; ICSI, 2003). Delayed diagnosis of breast cancer is associated with later stage at diagnosis and poorer prognosis. A recent, multivariate analysis of 4,465 women with invasive breast cancer suggests that 6- to 12-month delays to diagnosis of asymptomatic breast cancer are associated with increased risk of lymph node metastases and larger tumor size (Olivotto et al., 2002). Timeliness is a basic attribute of high-quality health care (IOM, 2001). The IOM committee feels strongly that women with suspicious or highly suggestive abnormal mammograms should not have to wait longer than 14 days for a biopsy. Delays in diagnosis are associated with substantial anxiety and distress for the patient (IOM, 2004). Knowledge vs. practice. The proportion of women who have a needle biopsy before breast cancer surgery is not known. There are only limited 1   See Chapter 4, Detecting Cancer Early, for further discussion of breast cancer screening.

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Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia BOX 5-2 The Breast Imaging and Reporting Data System (BI-RADS) Breast abnormalities that are identified through screening mammography are categorized according to a taxonomy established by the American College of Radiology in collaboration with the Centers for Disease Control and Prevention, the U.S. Food and Drug Administration, the American Medical Association, the American College of Surgeons, and the College of American Pathologists. The six BI-RADS reporting categories represent gradations of the likelihood that a cancer exists, from lowest to highest probability. BI-RADS category BI-RADS assessment Description and recommended follow-up 0 Assessment is incomplete Temporary category; additional imaging evaluation is needed. Most are benign. 1 Negative Breasts appear normal; follow routine screening schedule 2 Benign Negative finding (includes noncancerous lesions such as cysts and calcifications); follow routing screening schedule 3 Probably benign High probability of being benign; follow up with mammography after a short interval 4 Suspicious abnormality Biopsy 5 Highly suggestive of malignancy Biopsy SOURCE: ACR, 2003. Breast Imaging Reporting and Data System. data on the extent of delays in follow-up biopsies after a suspicious mammogram. Studies assessing follow-up of all types of cancer screening indicate that about 25 percent of patients with a suspicious finding do not receive needed follow-up care (Yabroff et al., 2003). Racial and ethnic minorities, as well as uninsured and low-income persons, are especially at risk. A 2001 survey of medical directors of community health centers in 10 states found that about 40 percent of uninsured patients had difficulty getting specialty referrals, including referrals for follow-up of abnormal screening tests (Gusmano et al., 2002).

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Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia Use of needle biopsy in breast cancer diagnosis. Consensus on care. NCCN recommends that breast tissue samples be obtained by needle biopsy if feasible (NCCN, 2004c). Needle biopsy is preferred because it is quick, accurate, and less invasive, and produces a better cosmetic outcome than alternative approaches do (Liberman, 2000; Morrow et al., 2001; Collins et al., 2004; Baxter et al., 2004; NCCN, 2004c). Needle biopsy techniques include core needle biopsy, vacuum-assisted biopsy, or fine-needle aspiration. The biopsy may be performed with or without image guidance depending on the location of the lesion, its visibility at ultrasound, equipment availability, and radiologist’s expertise. For about 10 to 20 percent of women, however, a needle biopsy is not technically feasible because of the location and nature of their breast lesion (NCCN, 2004c). Thus, a standard of 70 to 80 percent rather than 100 percent would be appropriate. Knowledge vs. practice. Data on the use of needle biopsy before breast cancer surgery are not available. Cancer Surgical Specimens Three of the recommended quality measures pertain to the collection and histological assessment or evaluation of surgical specimens taken from patients who undergo surgery for breast or colorectal cancer. One measure is the proportion of breast cancer surgery patients whose surgical margins are free of tumor after the last surgical procedure. The histological assessment of surgical margins is fundamental to cancer diagnosis (Bland et al., 1999; Stocchi et al., 2001; Weir et al., 2002; Trocha and Giuliano, 2003; Le Voyer et al., 2003; Compton, 2003; Krag and Single, 2003; Fitzgibbons et al., 2004). The outer edge of the surgical specimen—referred to as the surgical margin—is considered free of tumor if there is no tumor at the line of resection. If the margin contains cancer or is too small to be fully analyzed, the extent of the patient’s cancer may be underestimated and undertreated. The other two measures pertain to the histological assessment of lymph nodes in patients with breast cancer or colorectal cancer. Lymph node evaluation is central to determining the stage of cancer at diagnosis. About one-third of persons have metastases detected at the time of their first cancer diagnosis (Eyre et al., 2002). If a cancer spreads, the lymph nodes are usually affected. In breast cancer, the axillary (armpit) nodes are the main passageway that cancer cells use to spread to other parts of the body. In colorectal cancer, the regional lymph nodes are the main passageway.

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Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia Consensus on care. Tumor free-breast cancer surgical margins. The goal of breast cancer surgery is to completely remove the tumor and to obtain clear surgical margins. There is extensive evidence that positive surgical margins are associated with significant morbidity and cost, including higher rates of local tumor recurrence and further surgical or medical treatment (Silverstein et al., 1999; Fredriksson et al., 2003; NCCN, 2004b). With lumpectomy, a positive margin often leads to additional surgery with either re-excision of additional tissue at the positive margin, or total mastectomy. If it is not possible to obtain a negative margin with re-excision, then mastectomy is usually required, although it may be appropriate to treat cases with a microscopic focally-positive margin with breast conservation by increasing the dose of a radiation therapy boost (NCCN, 2004b). NCCN guidelines indicate that while margins greater than 1 centimeter are “widely accepted” as negative, such margin width may be excessive causing a less acceptable cosmetic result. Margins less than 1 millimeter are considered inadequate. However, the NCCN guidelines state that data are insufficient to make definitive statements about margins between 1 and 10 mm. Assessment of lymph nodes after breast cancer surgery. Histological assessment of axillary nodes is critical to diagnosing Stage I and II breast cancer and to determining the appropriate course of treatment (Weir et al., 2002; Fitzgibbons et al., 2004; NCCN, 2004b). In Stage I breast cancer, the tumor is less than 2 centimeters in diameter with no spread beyond the breast (axillary nodes are clear). In Stage II, the tumor is 2 to 5 centimeters in size or the tumor has spread to the axillary nodes (Box 5-3). Several studies suggest that examining an insufficient number of lymph nodes leads to poorer survival after breast cancer surgery (Bland et al., 1998; Bland et al., 1999; Weir et al., 2002; Krag and Single, 2003). If too few nodes are removed, the patient’s cancer may be understaged and thus undertreated. NCCN guidelines recommend two options: (1) dissection of 10 or more axillary lymph nodes for histological assessment or (2) sentinel node biopsy for patients with unicentric tumors smaller than 5 centimeters with no prior treatment or large excisions if an experienced sentinel lymph node team is available (NCCN, 2004b). Either procedure may be optional in patients who have particularly favorable tumors, patients for whom the selection of adjuvant systemic therapy is unlikely to be affected, elderly patients, and patients with serious comorbid conditions. Assessment of lymph nodes after colorectal cancer surgery. Most colorectal cancer patients undergo surgical resection—an estimated 92 percent of colon cancer patients and 84 percent of rectal cancer patients (Compton, 2003). Diagnosing the extent of colorectal cancer requires histological assessment of the regional lymph nodes that are retrieved during surgery. There is an extensive literature showing that survival of colorectal

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Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia BOX 5-3 TNM Stages of Breast Cancer Stage 0—Noninvasive; cancer cells remain inside the breast duct and have not invaded the normal adjacent breast tissue. Includes ductal carcinoma in situ or lobular carcinoma in situ. Stage I—Tumor is less than 2 cm in diameter with no spread beyond the breast (lymph nodes are clear). Stage IIA—Includes tumors 2 to 5 cm in diameter without spread to axillary nodes, and tumors less than 2 cm with spread to axillary nodes Stage IIB—Includes tumors 2 to 5 cm in diameter with spread to axillary nodes where the nodes are unattached to each other or other structures, and tumors greater than 5 cm without spread to axillary nodes. Stage IIIA—Locally advanced cancer; includes tumors larger than 5 cm, and tumors less than 5 cm in diameter with spread to the axillary nodes where the nodes are attached to each other or to other structures. Stage IIIB—Locally advanced cancer; includes tumors with spread to the lymph nodes near the breast (skin or chest wall, including the ribs and the muscles in the chest) or inside the chest wall along the breast bone. Stage IV—Metastatic or recurrent carcinoma; tumor has spread beyond the breast and chest wall, such as to liver, bone, or lungs. NOTE: TNM = Tumor, Node, Metastasis. SOURCE: American Joint Committee on Cancer (Greene et al., 2002); NCCN Breast Cancer (NCCN, 2004b). cancer increases with the number of recovered lymph nodes, regardless of the number of positive nodes that are found (Stocchi et al., 2001; Le Voyer et al., 2003; Compton, 2003). While there is no consensus on the specific number of nodes that should be analyzed, the range in the recommendations is small. For example, NCCN advises at least 14 nodes, while the College of American Pathologists (CAP) advises at least 12 nodes and urges that additional techniques such as visual enhancement be considered if fewer than 12 nodes are found (Compton, 2004a, NCCN, 2004f). Knowledge vs. practice. It is difficult to discern from the available research whether shortcomings in pathology data are due to poor documentation

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Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia practices or poor surgical technique. Most research on the collection of breast cancer and colorectal cancer surgical specimens has focused on reporting practices rather than the adequacy of the specimens themselves. However, there is evidence that older women are less likely than younger women to undergo an axillary node dissection despite clinical guidelines to the contrary (Malin et al., 2002). Numerous studies indicate that surgical and pathology reporting practices are of variable quality and, in fact, information on margins and the number and status of nodes is often missing from pathology reports (Weir et al., 2002; Imperato et al., 2002; Compton, 2003; White et al., 2003; Wilkinson et al., 2003; Wei et al., 2004). Stocchi et al. (2001) examined the surgery and pathology reports of 673 patients who were enrolled in a U.S. cooperative group clinical trial for Stage II or III rectal cancer. The researchers found that the operative and pathology notes were poorer than expected; 18 percent of patients had fewer than five lymph nodes examined and 68 percent had fewer than 12 nodes examined. Adequacy of Pathology Reporting on Cancer Surgical Specimens The IOM committee recommends five quality measures to monitor the adequacy of pathology reports on cancer surgical specimens. The first measure tracks pathology laboratories’ compliance with the American College of Surgeons’ Commission on Cancer reporting standards for breast, colorectal, lung, and prostate cancers. Measure 5-6—Pathology laboratories’ compliance with reporting standards for cancer surgical specimens—the proportion of pathology laboratories that report CAP data elements as required by the Commission on Cancer. The remaining four measures track whether pathology reports include the key data elements currently mandated by the Commission on Cancer for breast, colorectal, lung, and prostate cancers: Measure 5-7—Adequacy of pathology reports on breast cancer surgical specimens—the proportion of pathology reports on invasive breast cancer surgical specimens that include CAP data elements as required by the Commission on Cancer. Measure 5-8—Adequacy of pathology reports on colorectal cancer surgical specimens—the proportion of pathology reports on colorectal cancer surgical specimens that include CAP data elements as required by the Commission on Cancer.

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Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia Measure 5-9—Adequacy of pathology reports on lung cancer surgical specimens—the proportion of pathology reports on invasive lung cancer surgical specimens that include CAP data elements as required by the Commission on Cancer. Measure 5-10—Adequacy of pathology reports on prostate cancer surgical specimens—the proportion of pathology reports on prostate cancer surgical specimens that include CAP data elements as required by the Commission on Cancer. The rationale for the IOM committee’s decision to recommend each of these measures is discussed further below. Consensus on Care Pathologists examine surgical specimens to identify the tumor size, histology, and other tumor characteristics—findings that are needed to properly stage the disease, to formulate treatment decisions, and to determine prognosis. The pathology report communicates these findings to the clinician. It is essential that the report is clear and comprehensive. Traditionally, pathologists have used an unstructured, narrative style to complete their reports. Research in the last decade has suggested, however, that standardized reporting templates yield more comprehensive and readable information than free-text pathology reports (Appleton et al., 1998; Cross et al., 1998; Branston et al., 2002). In response, CAP has developed a set of reporting templates, called checklists, for reporting pathology findings for cancer specimens (CAP, 2003). There is a specific checklist for each tumor site and type of surgical specimen. CAP recommends, but does not require, that its certified laboratories use the checklist. As of 2004, the Commission on Cancer, a multidisciplinary program of the American College of Surgeons, has required that pathology laboratories at Commission on Cancer-certified cancer centers report the scientifically validated data elements in the CAP checklists for cancer-directed surgical specimens. The CAP checklist itself is optional. The mandatory data elements include the histologic type and grade, pathologic staging including distant metastasis, margins and lymph nodes, and other cancer-specific data items (Gal et al., 2004; Srigley et al., 2004; Fitzgibbons et al., 2004; Compton, 2004a). Figure 5-1 illustrates the data elements required by the Commission on Cancer in a pathology report on a prostate cancer specimen. Only cancer-directed surgical resection specimens must meet the Commission on Cancer’s requirement to report the scientifically validated data elements in the CAP checklists; cytologic specimens, diagnostic biopsies, and palliative resections are exempt (Paxton, 2004). In 2005, the Commission on Cancer will begin auditing its certified pathology laboratories to ensure that they comply with

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Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia FIGURE 5-1 Pathology report checklist for a prostate cancer surgical specimen, College of American Pathologists

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Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia Key references ACR (American College of Radiology). 1999. ACR Practice Guideline for Communication: Radiation Oncology. [Online] Available: http://www.acr.org/dyna/?doc=departments/stand_accred/standards/standards.html [accessed 2004]. Baxter NN, et al. 2004. Trends in the treatment of ductal carcinoma in situ of the breast. J Natl Cancer Inst. 96(6): 443-8. Commission on Cancer. 2003. Cancer Program Standards 2004. Chicago, IL: American College of Surgeons. [Online] Available: www.facs.org/cancer/coc/cocprogramstandards.pdf. Greene FL, et al. (AJCC). 2002. The AJCC Cancer Staging Manual. 6th Edition. New York: Springer-Verlag. NCCN. 2004. Clinical Practice Guidelines in Oncology-v.1.2004. Breast Cancer.

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Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia MEASURE 5-12: DIAGNOSING CANCER—Colorectal Cancer Stage Determined Before Treatment Description Colorectal cancer cases in which pathologic staging preceded chemotherapy and radiation treatment. Source American College of Radiology; American Society of Clinical Oncology; Commission on Cancer; National Comprehensive Cancer Network Consensus on care Chemotherapy or radiation treatment of colorectal cancer should not be initiated until pathologic stage has been determined and documented in the medical record. Clinical stage is based on what has been learned about a patient’s cancer up to the time of initial definitive treatment. Pathologic stage combines clinical staging information with surgical findings, incorporating pathologic examination of resected primary and regional lymph nodes. Every cancer patient’s treatment regimen should be tailored to his or her stage of disease. Most treatment guidelines cannot be followed until the tumor stage has been determined. Knowledge vs. practice Few studies have reported on documentation of stage of colorectal cancer before treatment. The proportion of Georgians with colorectal cancer that is treated before the stage is determined is not known. Approach to calculating the measure Numerator Number of new colorectal cancer cases with medical chart documentation of pathologic stage before chemotherapy or radiation is initiated Denominator Number of new colorectal cancer cases with chemotherapy or radiation treatment Potential data source(s) Medical records Comments — Limitations — Potential benchmark source(s) Baseline studies of medical records

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Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia Key references ACR (American College of Radiology). 1999. ACR Practice Guideline for Communication: Radiation Oncology. [Online] Available: http://www.acr.org/dyna/?doc=departments/stand_accred/standards/standards.html [accessed 2004]. Commission on Cancer. 2003. Cancer Program Standards 2004. Chicago, IL: American College of Surgeons. [Online] Available: http://www.facs.org/cancer/coc/cocprogramstandards.pdf. Compton CC. 2004. Pathologic staging of colorectal cancer. An advanced users’ guide. Pathology Case Reviews 9(4): 150-62. Greene FL, et al. (AJCC). 2002. AJCC Cancer Staging Manual. 6th Edition. New York: Springer-Verlag. NCCN. 2004. Clinical Practice Guidelines in Oncology-v.2.2004. Colon Cancer.

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Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia MEASURE 5-13: DIAGNOSING CANCER—Lung Cancer Stage Determined Before Treatment Description Lung cancer cases in which pathologic staging preceded chemotherapy and radiation treatment Source American College of Radiology; American Society of Clinical Oncology; Commission on Cancer; National Comprehensive Cancer Network Consensus on care Chemotherapy or radiation treatment of lung cancer should not be initiated until the pathologic stage has been determined and documented in the medical record. Clinical stage is based on what has been learned about a patient’s cancer up to the time of initial definitive treatment. Pathologic stage combines clinical staging information with surgical findings, incorporating pathologic examination of resected primary and regional lymph nodes. Every cancer patient’s treatment regimen should be tailored to his or her stage of disease. Most treatment guidelines cannot be followed until the tumor stage has been determined. Knowledge vs. practice Few studies have reported on documentation of lung cancer stage before treatment. The proportion of Georgians with lung cancer that is treated before the stage is determined is not known. Approach to calculating the measure Numerator Number of new lung cancer cases with medical chart documentation of pathologic stage before chemotherapy or radiation treatment is initiated Denominator Number of new lung cancer cases with chemotherapy or radiation treatment Potential data source(s) Medical records Comments — Limitations — Potential benchmark source(s) Baseline studies of medical records

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Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia Key references ACR. 1999. ACR Practice Guideline for Communication: Radiation Oncology. [Online] Available: http://www.acr.org/dyna/?doc=departments/stand_accred/standards/standards.html [accessed 2004]. Commission on Cancer. 2003. Cancer Program Standards 2004. Chicago, IL: American College of Surgeons. [Online] Available: http://www.facs.org/cancer/coc/cocprogramstandards.pdf. GCCR. 2004. Georgia Cancer Cases by Stage at Diagnosis 1999-2000. Unpublished data. Greene FL, et al. (AJCC). 2002. The AJCC Cancer Staging Manual. 6th Edition. New York: Springer-Verlag. NCCN. 2004. Clinical Practice Guidelines in Oncology-v.1.2004. Non-Small Cell Lung Cancer.

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Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia MEASURE 5-14: DIAGNOSING CANCER—Prostate Cancer Stage Determined Before Treatment Description Prostate cancer cases in which pathologic staging preceded chemotherapy and radiation treatment Source American College of Radiology; American Society of Clinical Oncology; Commission on Cancer; National Comprehensive Cancer Network Consensus on care Chemotherapy and radiation treatment of prostate cancer should not be initiated until the pathologic stage has been determined and documented in the medical record. Clinical stage is based on what has been learned about a patient’s cancer up to the time of initial definitive treatment. Pathologic stage combines clinical staging information with surgical findings, incorporating pathologic examination of resected primary and regional lymph nodes. Every cancer patient’s treatment regimen should be tailored to his or her stage of disease. Most treatment guidelines cannot be followed until the tumor stage has been determined. Knowledge vs. practice Few studies have reported on documentation of prostate cancer stage before treatment. The proportion of Georgians with prostate cancer that is treated before the stage is determined is not known. Approach to calculating the measure Numerator Number of new prostate cancer cases with medical chart documentation of pathologic stage before chemotherapy or radiation treatment is initiated Denominator Number of new prostate cancer cases with chemotherapy or radiation treatment Potential data source(s) Medical records Comments — Limitations — Potential benchmark source(s) Baseline studies of medical records

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Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia Key references ACR. 1999. ACR Practice Guideline for Communication: Radiation Oncology. [Online] Available: http://www.acr.org/dyna/?doc=departments/stand_accred/standards/standards.html [accessed 2004]. Commission on Cancer. 2003. Cancer Program Standards 2004. Chicago, IL: American College of Surgeons. [Online] Available: http://www.facs.org/cancer/coc/cocprogramstandards.pdf. Cooperberg MR, et al. 2004. The contemporary management of prostate cancer in the United States: lessons from the cancer of the prostate strategic urologic research endeavor (CAPSURE), a national disease registry. J Urol. 171:1393-401. NCCN. 2004. Clinical Practice Guidelines in Oncology-v.1.2004. Prostate Cancer.

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