6
Treating Cancer

“… knowledge of treatments with proven efficacy do not translate directly to the optimal delivery of such treatments to patients.”

Developing a System to Assess the Quality of Cancer Care: American Society of Clinical Oncology National Initiative on Cancer Care Quality

Schneider et al., 2004

“More advanced treatment, utilizing cutting-edge technology, will be available at several key medical centers throughout the state, making it unnecessary for Georgians to go elsewhere in the nation. All Georgia cancer providers will become part of the Coalition’s efforts.”

Mobilizing Georgia, Immobilizing Cancer: Annual Report

Georgia Cancer Coalition, 2003

Once cancer is diagnosed, ensuring the best possible treatment is paramount. The Institute of Medicine (IOM) committee recommends that the Georgia Cancer Coalition (GCC) adopt 23 quality measures related to cancer treatment (Box 6-1). Four of the measures will allow Georgia to track cancer patients’ receipt of appropriate primary therapy, focusing on patients’ participation in clinical trials and primary therapy for prostate cancer. Six of the measures will enable the state to track breast and colorectal cancer patients’ receipt of appropriate adjuvant treatment and follow-up. Four other measures will allow the state to assess the extent to which pain management and hospice care are used to minimize cancer patients’ suffering. The final nine measures are routine measures of cancer survival and mortality.



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Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia 6 Treating Cancer “… knowledge of treatments with proven efficacy do not translate directly to the optimal delivery of such treatments to patients.” Developing a System to Assess the Quality of Cancer Care: American Society of Clinical Oncology National Initiative on Cancer Care Quality Schneider et al., 2004 “More advanced treatment, utilizing cutting-edge technology, will be available at several key medical centers throughout the state, making it unnecessary for Georgians to go elsewhere in the nation. All Georgia cancer providers will become part of the Coalition’s efforts.” Mobilizing Georgia, Immobilizing Cancer: Annual Report Georgia Cancer Coalition, 2003 Once cancer is diagnosed, ensuring the best possible treatment is paramount. The Institute of Medicine (IOM) committee recommends that the Georgia Cancer Coalition (GCC) adopt 23 quality measures related to cancer treatment (Box 6-1). Four of the measures will allow Georgia to track cancer patients’ receipt of appropriate primary therapy, focusing on patients’ participation in clinical trials and primary therapy for prostate cancer. Six of the measures will enable the state to track breast and colorectal cancer patients’ receipt of appropriate adjuvant treatment and follow-up. Four other measures will allow the state to assess the extent to which pain management and hospice care are used to minimize cancer patients’ suffering. The final nine measures are routine measures of cancer survival and mortality.

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Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia BOX 6-1 Recommended Measures for Tracking the Quality of Cancer Treatment Receipt of Appropriate Primary Therapy for Cancer Measure 6-1 Cancer patients’ participation in clinical trials Measure 6-2 Inappropriate hormonal therapy before radical prostatectomy Measure 6-3 Appropriate external beam radiation therapy (EBRT) doses for prostate cancer Measure 6-4 Appropriate hormonal therapy with EBRT for prostate cancer Receipt of Appropriate Adjuvant Therapy for Cancer Measure 6-5 Adjuvant radiation after breast-conserving surgery Measure 6-6 Adjuvant hormonal therapy for invasive breast cancer Measure 6-7 Adjuvant combination chemotherapy for breast cancer Measure 6-8 Adjuvant chemotherapy after colon cancer surgery Receipt of Appropriate Follow-Up After Treatment for Cancer Measure 6-9 Follow-up mammography after treatment for breast cancer Measure 6-10 Follow-up colonoscopy after treatment for colorectal cancer Minimization of Cancer Patients’ Suffering Measure 6-11 Cancer pain assessment Measure 6-12 Prevalence of pain among cancer patients Measure 6-13 Cancer deaths in hospice Measure 6-14 Cancer patients’ hospice length of stay Cancer Survival and Mortality Rates Measure 6-15 Breast cancer 5- and 10-year survival rates Measure 6-16 Colorectal cancer 5- and 10-year survival rates Measure 6-17 Lung cancer 5- and 10-year survival rates Measure 6-18 Prostate cancer 5- and 10-year survival rates Measure 6-19 Breast cancer mortality rate Measure 6-20 Colorectal cancer mortality rate Measure 6-21 Lung cancer mortality rate Measure 6-22 Prostate cancer mortality rate Measure 6-23 All cancers mortality rate The 23 recommended quality measures pertaining to cancer treatment are discussed further below, along with the rationale for their selection. Brief explanations of the evidence underlying the measures (the “consensus on care”) and a description of what is known about the gap between the evidence and current practice (“knowledge vs. practice”) are also provided. At the end of the chapter, potential data sources for measures in the treat-

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Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia ment domain are briefly described. Summaries of each quality measure appear at the end of the chapter. RECOMMENDED MEASURES FOR TRACKING THE QUALITY OF CANCER TREATMENT Receipt of Appropriate Primary Therapy for Cancer As noted above, four of the 23 recommended quality-of-cancer-care measures in the cancer treatment domain pertain to cancer patients’ receipt of appropriate primary therapy, focusing on patients’ participation in clinical trials and primary therapy for prostate cancer. The first measure is a measure of cancer patients’ participation in clinical trials: Measure 6-1—Cancer patients’ participation in clinical trials—the proportion of newly diagnosed cancer patients in treatment who are participating in a clinical trial. Expanding clinical trial participation is a principal, strategic goal of GCC (GCC, 2003). Towards this end, GCC has collaborated with many of Georgia’s cancer care providers to establish the Georgia Clinical Oncology Research and Education, Inc., a nonprofit corporation dedicated to developing a statewide cancer clinical trial and research network (GCC, 2004). The IOM committee recommends that GCC monitor the progress of this significant statewide venture by tracking Georgia residents’ enrollment in cancer trials by adopting this quality measure. In the future, GCC should consider expanding its monitoring of clinical trial participation. For example, it will be important to know whether low participation in trials is due to physicians not asking, patients refusing, or lack of appropriate trials even when physicians ask and patients agree. In addition, the IOM committee recommends three quality indicators to track whether Georgia’s prostate cancer patients receive evidence-based care if they opt for surgical or radiation treatment: Measure 6-2—Inappropriate hormonal therapy before radical prostatectomy—the proportion of prostate cancer patients who receive hormonal therapy before undergoing radical prostatectomy. Measure 6-3—Appropriate external beam radiation therapy (EBRT) for prostate cancer—the proportion of intermediate and high-risk prostate cancer patients who undergo external beam radiation and receive central axis doses of at least 75 Grays (Gy).

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Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia Measure 6-4—Appropriate hormonal therapy with EBRT for prostate cancer—the proportion of high-risk prostate cancer patients who are treated with external beam radiation therapy and receive hormonal therapy for at least 2 years. The rationale for the IOM committee’s decision to recommend adoption of these measures is discussed further below. Cancer Patients’ Participation in Clinical Trials The first recommended measure is the proportion of cancer patients in treatment in Georgia who participate in clinical trials. Consensus on care. Clinical trials are essential to developing new cancer therapies and, as a result, they benefit countless numbers of persons with cancer. National Cancer Comprehensive Network (NCCN) guidelines strongly encourage cancer patients to participate in clinical trials (NCCN, 2004a). The conventional wisdom is that trial participants, compared with other cancer patients, have better access to medical professionals, are more closely monitored, and receive more timely interventions when necessary (NCI, 2001; CancerCare, 2003; Scalliet, 2004; Seattle Cancer Care Alliance, 2004). Yet demonstrating a causal relationship between trial participation and improved outcome is difficult (Peppercorn et al., 2004). Recent reviews of the literature have raised some doubts about the true benefit of trial participation largely because the available studies are flawed and data are insufficient to make the case that patients in cancer trials receive better care than other cancer patients (Peppercorn et al., 2004). Knowledge vs. practice. Many cancer patients are not medically eligible to participate in a clinical trial either because of comorbid conditions and other clinical factors or because there are no ongoing trials relevant to their specific disease (Ruckdeschel, 1997). Definitive counts of participants in cancer clinical trials are elusive. GCC estimates that less than 2.0 percent of Georgians with cancer participated in a clinical trial in 2000 (Russell, 2004). Nationally, approximately 1.7 percent of lung, prostate, breast and colorectal cancer patients diagnosed in 2000-2002 enrolled in nonsurgical clinical trials sponsored by National Cancer Institute (NCI) Clinical Trials Cooperative Groups. Clinical trial enrollment is lower among Hispanic and Black persons, and declines with increasing age (Murthy et al., 2004). Estimates of enrollment in non-NCI sponsored trials are not available.

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Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia Primary Therapy for Prostate Cancer Three of the quality measures track whether prostate cancer patients receive evidence-based care. In determining the appropriate course of treatment for prostate cancer, it is essential that the patient’s risk of recurrence be accurately classified. NCCN practice guidelines recommend that clinicians determine each prostate cancer patient’s risk of a recurrence at the time of the individual’s prostate cancer diagnosis (NCCN, 2004f). As shown in Box 6-2, the risk of recurrence is classified into one of four categories—low, intermediate, high, and very high—and is determined by the patient’s tumor stage, Gleason Score (an indicator of tumor grade), and prostate-specific antigen (PSA) level. A man diagnosed with prostate cancer faces an array of possible treatment options (Litwin et al., 2000; Potosky et al., 2000; Spencer et al., 2003). The major therapeutic options include various combinations of radical prostatectomy, external beam radiation therapy, brachytherapy, and hormonal therapy. Evidence on which treatment works best is sparse (Litwin et al., 2000; Potosky et al., 2000). Thus, for many prostate cancer patients, the treatment decision is based to a great extent on the potential side effects and long-term complications of the alternative approaches rather than any demonstrated differences in treatment effectiveness (Potosky et al., 2000; Cooperberg et al., 2004). There is good evidence, however, on the optimal delivery of the alternative treatments for prostate cancer (Litwin et al., 2000; Spencer et al., 2003). The three quality measures related to therapy for prostate cancer, discussed further below, are based on this body of evidence. Inappropriate hormonal therapy before radical prostatectomy. The first recommended measure is the proportion of prostate cancer patients who receive inappropriate hormonal therapy before undergoing radical prostatectomy. Consensus on care. Radical prostatectomy—the removal of the prostate and surrounding tissue—is recommended for localized prostate cancer (NCCN, 2004f). Nationally, it is the most common procedure used to treat prostate cancer and was the primary treatment for approximately 41 percent of men diagnosed with prostate cancer between 1995 and 2003 (Cooperberg et al., 2004). NCCN guidelines do not recommend hormonal therapy before radical prostatectomy (NCCN, 2004f). Yet analyses of recent treatment data indicate that hormonal therapy is sometimes provided to patients undergoing radical prostatectomy in advance of their surgery (Cooperberg et al., 2003; Holzbeierlein et al., 2004). This misuse is worrisome given that several randomized, controlled trials have clearly shown no benefit to this treat-

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Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia BOX 6-2 Determining the Risk of Recurrence in Prostate Cancer Patients Accurate classification of prostate cancer patients’ recurrence risk is essential to determining the appropriate course of treatment. The risk categories are described below: Low recurrence risk—tumor Stage T1-T2a and Gleason score 2-6 and prostate-specific antigen level (PSA) < 10 ng/mL Intermediate recurrence risk—tumor Stage T2b-T2c or Gleason score 7 or PSA 10-20 ng/Ml High—tumor Stage T3a or Gleason score 8-10 or PSA > 20 ng/mL Very high recurrence risk—tumor Stage T3b-T4 or any T and N1 Three clinical variables determine a patient’s risk classification: Tumor stage—based on information from laboratory tests, digital rectal exam, pathology reports, and imaging studies. The TNM staging typology is used; although only the T-values are used for classifying risk. TNM is based on the size and extent of the tumor (T), extent of spread to the lymph nodes (N), and metastasis (M). Higher numbers and letters indicate greater tumor size or more spread to lymph nodes and/or organs. TX: primary tumor cannot be evaluated T0: no evidence of primary tumor T1 a, b, c; T2 a, b, c; T3 a, b; or T4: size and extent of the primary tumor NX: regional lymph nodes were not assessed N0: no regional lymph node metastasis N1: metastasis in regional lymph nodes MX: distant metastasis cannot be assessed M0: no distant metastasis M1: distant metastasis Gleason score—based on microscopic analysis, the Gleason score represents the tumor grade and the likelihood of spread. Scores range from 2 to 10; the higher the value, the higher the risk of spread. Prostate-specific antigen (PSA) level—determined by a blood test that measures the PSA level, a protein produced by the prostate. Men with prostate cancer usually have PSA levels above 4 ng/Ml with values up to 20 ng/ml and higher. Increases in PSA levels are associated with prostate cancer as well as benign prostatic hyperplasia and infection or inflammation of the prostate. SOURCES: NCCN, 2004f; AJCC Staging Manual (Greene et al., 2002).

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Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia ment approach (Schulman et al., 2000; Aus et al., 2002; Soloway et al., 2002; Klotz et al., 2003). Furthermore, there is evidence documenting that hormonal treatment for prostate cancer has serious side effects, including hot flashes, anemia, and fatigue (Holzbeierlein et al., 2004). In addition, presurgical hormonal therapy may unnecessarily delay the tumor’s removal and raise the overall costs of treatment. Knowledge vs. practice. Even though the use of hormonal therapy before radical prostatectomy is inappropriate, the practice appears to be increasing. CaPSURE is a national, longitudinal database documenting the care of prostate cancer patients at 35 academic- and community-based urology practices. A recent CaPSURE study found that hormonal therapy use before radical prostatectomy had risen from 2.9 percent of patients diagnosed in the years 1989-1992 to 7.8 percent of patients diagnosed in the years 1999-2001 (Cooperberg et al., 2003). While this trend may reverse as the trial findings from 2002-2003 become more widely known, monitoring should help end the use of this inappropriate therapy. Appropriate external beam radiation therapy for prostate cancer. The second recommended measure is the proportion of intermediate- and high-risk prostate cancer patients who undergo appropriate external beam radiation and receive central axis doses of at least 75 Gy. Consensus on care. NCCN recommends three-dimensional conformal or intensity-modulated external beam radiation treatment with doses of 75-80 Gy for intermediate- or high-risk prostate cancer patients (NCCN, 2004f). Doses in this range have been shown to be more effective than the former standard dose of 70 Gy. An M.D. Anderson Cancer Center randomized, controlled study, for example, compared the efficacy of 70 Gy vs. 78 Gy in controlling intermediate-and high-risk prostate cancer. The researchers found that the higher radiation dose significantly improved “freedom from failure,” defined as three increases in the patients’ PSA levels (Pollack et al., 2002). After 6 years, 62 percent of patients treated with 78 Gy were “free of treatment failure” compared with only 43 percent of patients treated with 70 Gy. In comparison with the lower dosage group, however, the higher dosage group experienced more rectal complications—a finding that indicates that rectal exposure to radiation treatment should be limited. Preliminary results from another randomized trial, as well as numerous nonrandomized and retrospective studies, similarly support the higher radiation dose in treating prostate cancer patients (Zelefsky et al., 1998, 2001; Lyons et al., 2000; Hanks et al., 2000; Kuban et al., 2003; Kupelian et al., 2004; Zietman et al., 2004). Knowledge vs. practice. Available evidence suggests that a substantial proportion of prostate cancer patients who undergo external beam radia-

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Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia tion therapy receive inadequate doses. A study of 392 patients at 58 radiation facilities, for example, found that only 38 percent of intermediate-risk patients and 60 percent of higher-risk patients received doses above 72 Gy (Zelefsky et al., 2004). Patients treated at academic medical centers were more likely to receive higher doses compared with patients treated at nonacademic centers. Appropriate hormonal therapy with external beam radiation therapy for prostate cancer. The third recommended measure is the proportion of high-risk prostate cancer patients who are treated with appropriate external beam radiation therapy and receive hormonal therapy for at least 2 years. Consensus on care. External beam radiation therapy combined with hormonal therapy is a standard treatment for high-risk prostate cancer patients. NCCN’s prostate cancer guidelines recommend that external beam radiation treatment be accompanied by 2 to 3 years of hormonal therapy for most prostate cancer patients at high recurrence risk (NCCN, 2004f). Randomized trials have demonstrated that high-risk prostate cancer patients who undergo external beam radiation treatment have a substantial survival advantage with long-term hormonal therapy (Pilepich et al., 1997; Bolla et al., 2002; Hanks et al., 2003; Roach, 2003). An analysis of 412 patients in a randomized Phase III trial, for example, found dramatic differences between the patients who had external beam radiation treatment alone compared with the patients who had 3 years of hormonal therapy beginning on the first day of external beam radiation treatment. The hormonal therapy regimen resulted in 5-year, clinical disease-free survival rates of 74 percent, compared to 40 percent when hormonal therapy was not provided (Bolla et al., 2002). It also led to substantial improvements in overall survival and disease-specific survival. Similarly, another Phase III randomized trial compared 2 years vs. 4 months of hormonal treatment with external beam radiation treatment and found marked improvement with the longer-term prostate cancer hormonal therapy (Hanks et al., 2003). Knowledge vs. practice. Analyses of the CaPSURE cohorts indicate that combined use of hormonal therapy with external beam radiation is increasing. Most of the cohort diagnosed between 1999 and 2001, 74 percent of intermediate-risk and 90 percent of high-risk patients, received hormonal therapy before external beam radiation treatment—30 percentage points higher than the 1996-1998 cohort (Cooperberg et al., 2003). By monitoring the use of these prostate cancer treatments, Georgia can help to ensure that prostate cancer patients are receiving treatment that is appropriate to their disease.

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Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia Receipt of Appropriate Adjuvant Therapy for Cancer Surgical resection is the primary course of treatment for most breast and colon cancers (NCCN, 2004b, 2004g). Adjuvant treatments—typically regimens of hormonal therapy, chemotherapy, and/or radiation administered after a cancer is removed surgically—are designed to eradicate or prevent growth of any cancer cells which may not have been surgically removed (Adjuvant therapy, 2000; NCCN, 2004b). When used appropriately, adjuvant therapies reduce the risk of recurrence and improve chances of long-term survival. The IOM committee recommends four quality indicators to monitor the appropriate use of adjuvant therapy for cancer. Three of the measures pertain to adjuvant therapy after surgery for breast cancer: Measure 6-5—Adjuvant radiation after breast-conserving surgery (BCS)—the proportion of selected women who receive radiation treatment within 8 weeks of BCS or after post-BCS chemotherapy, if chemotherapy is given. Measure 6-6—Adjuvant hormonal therapy for invasive breast cancer—the proportion of selected women who receive adjuvant hormonal therapy for hormone-receptor positive invasive breast cancer. Measure 6-7—Adjuvant combination chemotherapy for breast cancer—the proportion of selected women who receive adjuvant combination chemotherapy for hormone-receptor negative Stage I to Stage III breast cancer. The fourth recommended measure pertains to adjuvant therapy for colon cancer: Measure 6-8—Adjuvant chemotherapy after colon cancer surgery—the proportion of Stage III colon cancer patients who receive adjuvant chemotherapy after surgery. The rationale for the IOM committee’s decision to recommend these particular measures is discussed further below. Adjuvant Therapy for Breast Cancer As just noted, three of the recommended measures pertain to adjuvant therapy after surgery for breast cancer. Adjuvant radiation treatment after breast-conserving surgery for breast cancer. The first recommended measure is the proportion of patients under

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Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia age 70 who undergo breast-conserving surgery for invasive cancer and receive adjuvant radiation treatment within 8 weeks of their surgery, or following post-surgery chemotherapy, if chemotherapy is given. Consensus on care. Adjuvant radiation is the standard of care for most women with invasive cancer who undergo breast-conserving surgery (Adjuvant therapy, 2000; NCCN, 2004b). An established, high-level evidence base shows that radiation after breast-conserving surgery markedly reduces the risk of cancer recurrence in the same breast compared with surgery alone (Early Breast Cancer Trialists’ Collaborative Group, 2000; Fisher et al., 2002; Veronesi et al., 2002; Goldhirsch et al., 2003). Recent randomized trial evidence strongly suggests that women, aged 70 and older, may not need adjuvant radiation if they receive a recommended course of hormonal therapy for estrogen-receptor-positive (ER-positive) tumors that are no larger than 2 cm in diameter (see discussion below) (Hughes et al., 2004). Although there is no consensus on how soon radiation treatment should begin after breast-conserving surgery, the available evidence suggests that the interval should be brief. A meta-analysis of 10 retrospective studies involving 7,401 breast cancer patients found that the 5-year local recurrence rate was significantly higher in patients whose adjuvant radiation treatment began more than 8 weeks after surgery (Huang et al., 2003). NCCN recommends radiation after breast-conserving surgery for most Stage I or Stage II breast cancers, as well as for all noninvasive breast cancers (i.e., ductal carcinoma in situ, or DCIS) patients with tumors that are 0.5 cm in diameter or larger (NCCN, 2004b). If the patient also requires adjuvant chemotherapy, the radiation treatments should follow the chemotherapy. Knowledge vs. practice. Breast-conserving surgery has become the most common surgical treatment for women with early-stage breast cancer (Morrow et al., 2002; Singh et al., 2003). In Georgia’s Commission on Cancer-certified hospitals, however, only 51 percent of women with Stage 0 to Stage II breast cancers undergo breast-conserving surgery (NCDB, 2002). Numerous studies have shown that not all women treated with breast-conserving surgery receive radiotherapy as recommended, especially older women, African-American women, women who live longer distances from radiation therapy facilities, and women who did not consult with a radiation oncologist before surgery (Nattinger et al., 2000; Roetzheim et al., 2000; Gilligan et al., 2002; Mandelblatt et al., 2002; Baldwin et al., 2004). Adjuvant hormonal therapy for Stage I and Stage II breast cancer. The second recommended measure is the proportion of Stage I and Stage II breast cancer patients who are hormone-receptor positive and receive adjuvant hormonal therapy after surgery.

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Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia Consensus on care. Adjuvant hormonal therapy is a standard component of early-stage breast cancer treatment for women with cancers that express the estrogen or progesterone receptors (NCCN, 2004b). The objective of hormonal therapy is to prevent estrogen from stimulating further tumor growth. Tumor cells that contain receptors for the hormones are more likely to grow and spread with the presence of the hormones. A cancer is called “ER-positive” if it has receptors for the hormone estrogen and “PR-positive” if it has receptors for the hormone progesterone. Randomized clinical trials have shown that, as the number of ER-positive and PR-positive tumor cells increases, hormonal therapy is more likely to be effective (Adjuvant therapy, 2000; Cole et al., 2001). There is a plethora of evidence showing that adjuvant hormonal therapy reduces the risk of tumor recurrence and significantly improves survival for women with Stage I or Stage II hormone-receptor positive breast cancer (Early Breast Cancer Trialists’ Collaborative Group, 1998; Adjuvant therapy, 2000; Baum et al., 2002; Winer et al., 2002; Goldhirsch et al., 2003). Tamoxifen has long been established as effective adjuvant hormonal therapy for women with ER-positive and PR-positive invasive breast cancer. More recently, aromatase inhibitors such as anastrozole have been shown to be effective at reducing the risk of tumor recurrence, and are now recommended as part of an adjuvant hormonal therapy regimen for postmenopausal women (Baum et al., 2002; Winer et al., 2005). In postmenopausal women, estrogen is no longer produced by the ovaries, but is converted from androgen, another hormone. Aromatase inhibitors inhibit the androgen to estrogen conversion. Knowledge vs. practice. There are numerous reports showing that adjuvant hormone therapy is used less often than well-established clinical guidelines recommend. Failure to undergo hormonal treatment is associated with advancing age as well as age under 45, being nonwhite, and not having seen an oncologist before treatment was initiated (Guadagnoli et al., 1997; Malin et al., 2002; Du et al., 2003). Adjuvant combination chemotherapy after surgery for Stage I to Stage II breast cancer. The third recommended measure is the proportion of Stage I to Stage III breast cancer patients under age 71 who receive adjuvant combination chemotherapy after surgery. Consensus on care. There is an extensive body of research, based on randomized trials, showing that combination chemotherapy—the administration of two or more pharmaceutical agents—substantially increases relapse-free survival and survival overall for women under age 71 with operable breast cancer (Adjuvant therapy, 2000; Cole et al., 2001). NCCN recommends adjuvant combination chemotherapy for women under age 71

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Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia MEASURE 6-21: TREATING CANCER—Lung Cancer Mortality Rate Description Lung cancer deaths per 100,000 persons per year Source National Healthcare Quality Report; Healthy People 2010 Consensus on care Improving the effectiveness of Georgia lung cancer care should ultimately reduce related mortality. Knowledge vs. practice Not applicable Approach to calculating the measure Numerator Number of deaths due to lung cancer (ICD-10 codes C33-34) per year Denominator Total Georgia population Potential data source(s) Georgia Division of Public Health Vital Statistics System Comments Death rate = (Deaths/Population) × 100,000. Data should be age-adjusted to 2000 standard population. Age-adjusted rates are weighted sums of age-specific rates Limitations Substantial time must pass before GCC would have any impact on mortality rates. Potential benchmark source(s) National Healthcare Quality Report; Healthy People 2010; National Vital Statistics System Key references AHRQ. 2003. National Healthcare Quality Report. Rockville, MD: U.S. DHHS. IOM. 2003. Fulfilling the Potential of Cancer Prevention and Early Detection. Washington, DC: The National Academies Press. Martin LM, et al. 2003. Georgia Behavioral Risk Factor Surveillance System, 2001 Report. Atlanta, GA: Georgia Department Human Resources. Publication Number DPH03-069HW. U.S. DHHS. 2000. Healthy People 2010: Understanding and Improving Health. 2nd edition. Chapter 3 Cancer. Washington, DC: U.S. Government Printing Office. [Measure 3-2.]

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Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia MEASURE 6-22: TREATING CANCER—Prostate Cancer Mortality Rate Description Prostate cancer deaths per 100,000 males per year Source National Healthcare Quality Report; Healthy People 2010 Consensus on care Improving the effectiveness of Georgia prostate cancer care should ultimately reduce related mortality. Knowledge vs. practice Not applicable Approach to calculating the measure Numerator Number of deaths due to prostate cancer (ICD-10 code 61) per year Denominator Number of males in Georgia Potential data source(s) Georgia Division of Public Health Vital Statistics System Comments Death rate = (Deaths/Population) × 100,000. Data should be age-adjusted to 2000 standard population. Age-adjusted rates are weighted sums of age-specific rates. Limitations Substantial time must pass before GCC would have any impact on mortality rates. Potential benchmark source(s) National Healthcare Quality Report; Healthy People 2010; National Vital Statistics System Key references AHRQ. 2003. National Healthcare Quality Report. Rockville, MD: U.S. DHHS. GDPH. 2004. OASIS Web Query—Death Statistics. [Online] Available: http://oasis.state.ga.us/webquery/death.html [accessed April 2004-. Jemal A, et al. 2003. Cancer statistics, 2003. CA Cancer J Clin. 53:5-26. U.S. DHHS. 2000. Healthy People 2010: Understanding and Improving Health. 2nd edition. Chapter 3 Cancer. Washington, DC: U.S. Government Printing Office. [Measure 3-7.]

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Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia MEASURE 6-23: TREATING CANCER—All Cancers Mortality Rate Description Cancer deaths (all sites) per 100,000 persons per year Source National Healthcare Quality Report; Healthy People 2010 Consensus on care Improving the effectiveness of Georgia cancer care should ultimately reduce related mortality Knowledge vs. practice Not applicable Approach to calculating the measure Numerator Number of deaths due to cancer (ICD-10 codes C00-C97) per year Denominator Total Georgia population Potential data source(s) Georgia Division of Public Health Vital Statistics System Comments Death rate = (Deaths/Population) × 100,000. Data should be age-adjusted to the year 2000 standard population. Age-adjusted rates are weighted sums of age-specific rates. Limitations Substantial time must pass before GCC would have any impact on mortality rates. Potential benchmark source(s) National Healthcare Quality Report; Healthy People 2010; National Vital Statistics System Key references AHRQ. 2003. National Healthcare Quality Report. Rockville, MD: U.S. DHHS. GDPH. 2004. OASIS Web Query. [Online] Available: http://oasis.state.ga.us/webquery/death.html. NCHS. 2003. Deaths, Age-adjusted Death Rates, and Comparisons by State for Selected Leading Causes of Death. [Online] Available: [http://www.cdc.gov/nchs/releases/03facts/mortalitytables.htm#Georgia] U.S. DHHS. 2000. Healthy People 2010: Understanding and Improving Health. 2nd edition. Chapter 3 Cancer. Washington, DC: U.S. Government Printing Office. [Measure 3-1.]

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