4
Detecting Cancer Early

“Because early detection remains the best guarantee for successful treatment, the Coalition will develop a statewide screening and early detection network of public and private healthcare providers so that every Georgian will have access to cancer screenings.”

Strategic Plan for the Georgia Cancer Coalition, 2001

“In summary, one of the safest, simplest, and most cost-effective ways to reduce cancer morbidity and mortality is to raise the screening rates for selected cancers. There is considerable consensus among experts about high quality screening practices.”

National Healthcare Quality Report,

Agency for Healthcare Research and Quality, 2003

The early detection of cancer refers to the use of screening tests to identify cancer or premalignant disease in persons without signs or symptoms of the disease. It is well established that finding breast cancer and colorectal cancer at an early stage and promptly beginning appropriate treatment—before symptoms develop—improves health outcomes and saves lives (IOM, 2003; NCI, 2004a).

Unfortunately, though, what is known about the potential of early cancer detection is not reflected in current practice (Roetzheim et al., 1999; Breen et al., 2001).

Regular mammography screening for early detection of breast cancer may be a routine in many women’s lives, but far too many women are still



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Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia 4 Detecting Cancer Early “Because early detection remains the best guarantee for successful treatment, the Coalition will develop a statewide screening and early detection network of public and private healthcare providers so that every Georgian will have access to cancer screenings.” Strategic Plan for the Georgia Cancer Coalition, 2001 “In summary, one of the safest, simplest, and most cost-effective ways to reduce cancer morbidity and mortality is to raise the screening rates for selected cancers. There is considerable consensus among experts about high quality screening practices.” National Healthcare Quality Report, Agency for Healthcare Research and Quality, 2003 The early detection of cancer refers to the use of screening tests to identify cancer or premalignant disease in persons without signs or symptoms of the disease. It is well established that finding breast cancer and colorectal cancer at an early stage and promptly beginning appropriate treatment—before symptoms develop—improves health outcomes and saves lives (IOM, 2003; NCI, 2004a). Unfortunately, though, what is known about the potential of early cancer detection is not reflected in current practice (Roetzheim et al., 1999; Breen et al., 2001). Regular mammography screening for early detection of breast cancer may be a routine in many women’s lives, but far too many women are still

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Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia BOX 4-1 Recommended Measures for Tracking the Quality of Early Cancer Detection Use of Cancer Screening Interventions Measure 4-1 Breast cancer screening rate Measure 4-2 Colorectal cancer screening rate Cancer Stage at Diagnosis Measure 4-3 Early-stage breast cancer diagnosis Measure 4-4 Advanced-stage breast cancer diagnosis Measure 4-5 Advanced-stage colorectal cancer diagnosis not screened as recommended (Coughlin et al., 2004).1 Large proportions of low-income and uninsured women are especially at risk of not being screened for breast cancer (Rao et al., 2004; Taplin et al., 2004). Rates of colorectal cancer screening fall far short of recommended levels across the board (Swan et al., 2003). If the Georgia Cancer Coalition (GCC) raises breast and colorectal cancer screening rates in Georgia to recommended levels, the state is likely to experience significant declines in cancer-related morbidity and mortality (assuming newly identified cases are promptly followed with appropriate treatment). The Institute of Medicine (IOM) committee recommends that Georgia adopt five quality indicators to assess the state’s progress in achieving the full potential of early cancer detection (Box 4-1). Two of the indicators would be used to monitor cancer screening rates and three would track cancer stage at diagnosis to gauge the impact of improvements in cancer screening and other means of early detection. The five recommended quality measures pertaining to cancer early detection are discussed further below, along with the rationale for their selection. For each measure discussed, there is a section providing a brief 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”). Potential data sources for measures in the early detection domain are briefly discussed, as 1   See Chapter 7, Crosscutting Issues in Assessing the Quality of Cancer Care, for a discussion about using quality indicators to address disparities in the behaviors and conditions that lead to cancer, as well as in the incidence, diagnosis, treatment, and outcomes of cancer.

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Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia well. Summaries of each recommended quality measure in the early detection domain appear at the end of the chapter. RECOMMENDED MEASURES FOR TRACKING THE QUALITY OF EARLY CANCER DETECTION Use of Cancer Screening Interventions The IOM committee recommends two quality measures to monitor use of screening services for breast cancer and colorectal cancer: Measure 4-1—Breast cancer screening rate—the proportion of women aged 52 to 69 with one or more mammograms in the past 2 years. Measure 4-2—Colorectal cancer screening rate—the proportion of adults aged 52 to 80 who have received either a fecal occult blood test within the past year, flexible sigmoidoscopy within the past 5 years, colonoscopy within the past 10 years, or double-contrast barium enema within the past 5 years. Lung and prostate cancer screening measures are not recommended. A cost-effective screening method for lung cancer has yet to be developed (Mahadevia et al., 2003). Prostate screening is controversial. Although the prostate-specific antigen (PSA) screening test detects very early cancers, some of these cancers might not cause any harm if left untreated and, if treated, might lead to impotence and incontinence (Harris and Lohr, 2002; USPSTF, 2002d; Clark et al., 2003). PSA screening is also associated with false positive results and unnecessary anxiety, biopsies, and follow-up diagnostic procedures (Sirovich et al., 2003). Breast Cancer Screening Rate Early detection of breast cancer saves women’s lives (Fletcher and Elmore, 2003; IOM, 2005; NCI, 2004b). Strong evidence from numerous randomized clinical trials has shown that routine mammography screening, by detecting cancers sufficiently early for curative treatment, cuts the risk of death from breast cancer by as much as 30 percent (USPSTF, 2002b; IOM, 2003). In Georgia, breast cancer is the most commonly diagnosed cancer and the second leading cause of cancer death for women—4,953 women were diagnosed with breast cancer and 996 women died of the disease in 2000 (NCI and CDC, 2004; GDPH, 2004b). The American Cancer Society estimates that 6,080 new cases of breast cancer will be diagnosed in Georgia in 2004 (ACS, 2004).

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Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia The IOM committee recommends that Georgia monitor mammography rates among women aged 50 to 69, with the goal of increasing the rate statewide. The choice of this age group is a pragmatic one. The evidence supporting regular mammography is strongest for women aged 50 to 69 compared with either younger or older women (USPSTF, 2002b). The measure focuses on a starting age of 52, rather than age 50, because it will be applied retrospectively and should allow for the full 2 years to receive recommended screening. This age group is also targeted by the National Committee for Quality Assurance through its HEDIS program (NCQA, 2004). HEDIS, the Health Plan Employer Data and Information Set, is one of the most widely-used, standardized approaches for assessing the quality of health plans, especially with respect to preventive services.2 Consensus on care. Clinical guidelines with respect to the age at which women should begin regular mammography screening vary. One reason is that the risk of developing breast cancer is age-related. Breast cancer is rare among younger women but incidence increases steadily beginning at age 40 and continues to rise until it peaks in women aged 70 to 79. Among Georgia women under age 40, for example, only 14 per 100,000 were diagnosed with breast cancer from 1999 to 2000 (ACS et al., 2003) (Figure 4-1). During the same period, there were 270 breast cancer cases per 100,000 women aged 50 to 59 and 402 breast cancer cases per 100,000 women aged 70 to 79. Although there is a strong consensus that all women should receive mammograms every 1 to 2 years beginning at age 50, some groups urge that screening begin at age 40 (IOM, 2003). Earlier screening is advised for those with an increased risk for the disease. The U.S. Preventive Services Task Force (USPSTF) has concluded that the evidence is strongest for women aged 50 to 69, although many studies also indicate a mortality benefit for women aged 40 to 49 (USPSTF, 2002b). Most groups have not issued specific recommendations for women older than age 70 because so few studies have included this age group (Fletcher and Elmore, 2003). Only two randomized trials have enrolled women over age 69, and no trials have enrolled women over age 74 (Humphrey et al., 2002; USPSTF, 2002b; Fletcher and Elmore, 2003). Knowledge vs. practice. A substantial proportion of Georgia women report having had a mammogram in the past 2 years—81.8 percent of women aged 55 to 64 and 77.5 percent of women over age 64 (Martin et al., 2004). Nevertheless, two vulnerable groups of women—those with lower incomes 2   See Appendix A for additional information on HEDIS.

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Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia FIGURE 4-1 Breast cancer incidence and mortality in Georgia, by age group, 1997-2001. NOTE: Rates are annualized and age-adjusted to the 2000 U.S. standard population. SOURCE: ACS, 2003. and those who report that they did not have health insurance or they were unable to see a doctor “because of cost” in the previous year—are significantly less likely to be screened. In 2002, as shown in Table 4-1, mammography screening rates for women aged 40 and older with incomes under $25,000 were 15 percentage points lower than the rates for women with incomes of at least $35,000 (65.9 percent or lower vs. 81.7 percent or higher) (Martin et al., 2004). Lacking health insurance and difficulties with medical care costs were particularly significant barriers to getting a mammogram. Almost half of Georgia women aged 40 and older (i.e., 49.7 percent) who cited these difficulties with access to care also reported not having been screened for breast cancer. Colorectal Cancer Screening Rate Screening for colorectal cancer substantially improves one’s chances of surviving the disease. It has also been credited with preventing the disease, because when precancerous (referred to as adenomatous) polyps are

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Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia TABLE 4-1 Breast Cancer Screening Rate Among Women over Age 40 in Georgia, by Income and Access to Medical Care, 2002 Population of Women Mammogram in the Past 2 Years (%) All women 75.5 By income group   —Less than $15,000 63.8 —$15,000 to $24,999 65.9 —$25,000 to $34,999 72.8 —$35,000 to $49,999 81.7 —$50,000 to $74,999 82.2 —$75,000 or more 85.6 By access to medical care   —No health insurance or unable to see a doctor “because of cost” 49.7 —All others 79.5   SOURCE: Martin, et al. 2004. detected during screening, they can be removed during the procedure (Mandel et al., 2000; Winawer et al., 2003). More than 80 percent of colorectal cancers begin as adenomatous polyps (USPSTF, 2002c). Colorectal cancer is the second leading cause of cancer death for males and females in the United States. Almost 3,300 Georgians were diagnosed with and 1,260 died of the disease in 2000 (Landis et al., 2004). The risk of developing colorectal cancer increases with age, rising sharply beginning at age 50 (Figure 4-2). The IOM committee recommends that Georgia monitor colorectal screening rates for all adults aged 50 to 80. The measure focuses on adults starting at age 52, rather than age 50, to allow for the first 2-year period during which recommended screening should occur. Consensus on care. USPSTF and most other guidelines recommend that, starting at age 50, all people should be periodically screened for colorectal cancer using one of the available options (USPSTF, 2002b; Winawer et al., 2003; IOM, 2003). As shown in Box 4-2, several types of procedures with different frequency are recommended for colorectal cancer screening: the home fecal occult blood test (FOBT), flexible sigmoidoscopy, the combination of home FOBT and flexible sigmoidoscopy, colonoscopy, and double-

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Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia FIGURE 4-2 Incidence of colorectal cancer by age at diagnosis and sex, United States, 1997-2001. SOURCE: NCI SEER, 2004. contrast barium enema (USPSTF, 2002c). USPSTF has concluded that while there is insufficient evidence to determine which particular screening strategy is best, colorectal cancer screening is likely to be cost-effective regardless of the type of screening method. Knowledge vs. practice. Colorectal cancer screening rates in Georgia fall far short of recommended levels (Figure 4-3). In 2002, 47 percent of men and 51 percent of women, over aged 50, reported ever having a sigmoidoscopy or colonoscopy (Martin et al., 2004). An even smaller proportion of adults were screened via an FOBT. In 2001, about 32 percent of all Georgia adults, over age 50, said they had an FOBT in the past 2 years (Martin et al., 2003). Lacking health insurance and difficulties with medical care costs were important barriers to being screened either by FOBT (21.5 percent) or by sigmoidoscopy/colonoscopy (34.3 percent) (Table 4-2).

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Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia BOX 4-2 Colorectal Cancer Screening Procedures and Recommended Frequency Four types of tests can be used to detect premalignant polyps and early-stage colorectal cancers, as discussed below. Fecal Occult Blood Test (FOBT) An FOBT is used to find occult (i.e., hidden) blood in the stool. Blood vessels at the surface of colorectal polyps, adenomas, or cancers often release a small amount of blood into the stool. For an FOBT, a small sample of stool is applied to a chemically treated card; then a chemical developer solution is added. If the card changes color, there is blood in the stool. Blood in the stool can be caused by cancer, but it may also be due to a number of conditions including hemorrhoids, anal fissures, polyps, peptic ulcers, and ulcerative colitis. Recommended annually. Flexible Sigmoidoscopy Sigmoidoscopy enables the physician to view the lining of the large intestine from the rectum through the last part of the colon, called the sigmoid colon. A sigmoidoscope is a slender, flexible, hollow, lighted 2-foot tube. It is inserted through the rectum into the lower part of the colon and transmits an image via a tiny video camera. Recommended every 5 years. Colonoscopy A colonoscope is a longer version of a sigmoidoscope that provides a complete view of the colon. Colonoscopy not only detects but also prevents colorectal cancer because, during the screening procedure, any identified premalignant polyp can be removed. Recommended every 10 years. Double-Contrast Barium Enema A double-contrast (or air-contrast) barium enema is an X-ray examination of the colon and rectum. Using a tube inserted into the rectum, the colon is filled with a contrast material containing barium and is then drained out, leaving only a thin layer of barium on the wall of the colon. Next, the colon is filled with air, providing a detailed X-ray view of the inner surface of the colon including any small polyps, colorectal cancer, or inflammation. Recommended every 5 years. SOURCE: USPSTF, 2002b.

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Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia FIGURE 4-3 Percentage of adults aged 50 and older in Georgia who ever had a colonoscopy or sigmoidoscopy, by sex, 1993-2002. SOURCE: GDPH, 2004a. TABLE 4-2 Colorectal Cancer Screening Rate Among Adults over Age 50 in Georgia, by Age and Access to Medical Care, 2001 Population FOBT in the Past 2 Years (%) Ever Had a Sigmoidoscopy or Colonoscopy (%) All adults aged 50+ 32.4 48.4 By age     —Aged 50 to 54 NA 34.3 —Aged 55 to 64 NA 47.0 —Aged 65+ NA 59.2 By access to medical care     —No health insurance or unable to see a doctor “because of cost” 21.5 34.3 —All others 33.9 50.4 NOTE: FOBT = fecal occult blood test; NA = not available. SOURCE: Martin et al., 2003.

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Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia TABLE 4-3 Survival of Breast Cancer and Colorectal Cancer in the United States, by Stage at Diagnosis, 1995-2000 Cancer Stage at Diagnosis 5-Year Survival (%) Breast cancer Colorectal cancer All stages 87.7 63.4 By stage     In situ 100.0 NA Localized 97.5 89.9 Regional 80.4 67.3 Distant 25.5 9.6 NOTE: NA = not applicable. SOURCE: Ries et al., 2004. Cancer Stage at Diagnosis Cancer stage describes the extent and severity of an individual’s cancer (NCI, 2005).3 If the cancer has spread, the stage describes how far it has spread from the original site to other parts of the body. As illustrated in Table 4-3, cancer stage at diagnosis determines an individual’s prognosis and chance for cure (Compton, 2003). With expansion of breast and colorectal cancer screening, diagnosis of these two cancers should increasingly occur at an earlier, more treatable stage. In the past, tumor registries typically recorded cancer stage using three different staging systems: (1) Tumor, Regional Lymph Nodes, and Distant Metastasis method (commonly referred to as TNM); (2) Surveillance, Epidemiology, and End Results (SEER) Summary Stage; and (3) SEER Extent of Disease. Each system had a different purpose, data set, and algorithm for translating medical record information into a coded stage. More recently, a unified data set referred to as Collaborative Stage has come into use. Collaborative staging was developed to meet the needs of the three staging systems by combining and standardizing the information needed to assign the stage (AJCC, 2004). NAACCR and SEER registries (including Georgia’s registries) have been required to follow the collaborative method for cases diagnosed from January 2004 forward. Nevertheless, the other staging systems can be derived from the collaborative data elements and they continue to be useful for epidemiological and longitudinal studies. 3   Some cancers, such as acute leukemia, may not be staged.

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Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia The IOM committee recommends that GCC adopt the following three quality measures for tracking cancer stage at diagnosis: Measure 4-3—Early-stage breast cancer diagnosis—the proportion of new breast cancer cases that are diagnosed at an early stage Measure 4-4—Advanced-stage breast cancer diagnosis—the number of newly diagnosed advanced-stage breast cancers per 100,000 women aged 40 and older Measure 4-5—Advanced-stage colorectal cancer diagnosis—the number of newly diagnosed advanced-stage colorectal cancer cases per 100,000 adults aged 50 and older The terms “early stage” and “advanced stage” refer to the SEER summary stage (Box 4-3). SEER summary staging is based on how a cancer grows (Young et al., 2001). Early-stage cancers are noninvasive “in situ” and “localized” tumors that have not spread beyond the organ of origin. BOX 4-3 The SEER Summary Staging System for Cancer The SEER summary stages are described below. Early-Stage Cancers In situ—refers to a malignancy that has not invaded the supporting structure of the organ on which it arose. Also referred to as Stage 0, noninvasive, pre-invasive, and noninfiltrating. Localized—refers to a malignancy that is limited to the organ of origin; it has not spread beyond that organ. The tumor can be invasive and show metastases within the organ. Advanced-Stage Cancers Regional—refers to a malignancy that extends beyond the limits of the organ of origin. A cancer is regional when it has the potential to spread by more than lymphatic or vascular supply route. Distant—refers to a malignancy in which tumor cells have broken away from the primary tumor, traveled to other parts of the body, and begun to grow at the new location. Also referred to as remote, diffuse, disseminated, metastatic, or secondary disease. The liver, lung, brain, and bones are common sites of distant-staged cancer because they receive blood flow from all parts of the body. SOURCE: Young et al., 2001.

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Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia MEASURE 4-2: DETECTING CANCER EARLY—Colorectal Cancer Screening Rate Description Colorectal cancer screening rate Source Health Plan Employer Data and Information Set (HEDIS) Consensus on care Recent studies show an association between colorectal cancer screening and decreased incidence of colorectal cancer. There is also evidence that screening may reduce colorectal cancer mortality. Screening for colorectal cancer is strongly recommended for men and women aged 50 and older (U.S. Preventive Services Task Force category A recommendation). There are several screening options but insufficient evidence on which strategy is best: (1) annual fecal occult blood test (FOBT); (2) flexible sigmoidoscopy every 5 years; (3) annual FOBT plus flexible sigmoidoscopy every 5 years; (4) double-contrast barium enema; and (5) colonoscopy every 10 years. Knowledge vs. practice Screening for colorectal cancer lags far behind screening for other cancers. In 2002, an estimated 49.2 percent of Georgia adults reported having had a sigmoidoscopy or colonoscopy. Approach to calculating the measure Numerator Number of adults aged 52 to 80 who have received either a FOBT within the past year, flexible sigmoidoscopy within the past 5 years, colonoscopy within the past 10 years, or double-contrast barium enema within the past 5 years Denominator Number of adults aged 52 to 80 Potential data source(s) Behavioral Risk Factor Surveillance System (BRFSS); Medicare and Medicaid claims and enrollment files; commercial datasets Comments Although monitoring should begin at age 50, the measure starts at age 52 because it will be applied retrospectively and should allow for the full 2 years to receive recommended screening Limitations HEDIS measures are routinely collected by National Committee for Quality Assurance—accredited managed care organizations; however, HMO enrollment in Georgia is relatively minor outside the Atlanta metropolitan area and minimal among the Medicare population in general. Potential benchmark source(s) HEDIS; BRFSS; Surveillance, Epidemiology and End Results/Medicare dataset

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Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia Key references CDC. 2003. Behavioral Risk Factor Surveillance System, Prevalence Data, Georgia 2002 Colorectal Cancer Screening. [Online] Available: http://www.apps.nccd.cdc.gov/brfss [accessed November 2003]. GDPH. 2004. OASIS Web Query—Death Statistics. [Online] http://oasis.state.ga.us/webquery/death.html [accessed April 2004]. NCQA. 2002. The State of Health Care Quality: 2002. Washington, DC: NCQA. Schneider E, et al. 2003. Screening for Colorectal Cancer. Draft HEDIS measure. USPSTF. 2002. Guide to Clinical Preventive Services. 3rd edition. Rockville, MD: AHRQ.

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Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia MEASURE 4-3: DETECTING CANCER EARLY—Early-Stage Breast Cancer Diagnosis Description Proportion of breast cancer cases diagnosed at an early stage Source Vermont Cancer Center Consensus on care Screening mammography reduces mortality from breast cancer because it detects cancers at an early stage. Five-year relative survival of early-stage, localized breast cancer is 97.5 percent. In contrast, 5-year relative survival of regional-stage breast cancer is 80.4 percent; distant stage is 25.5 percent. Increased breast cancer screening should ultimately increase the proportion of breast cancer cases diagnosed at an early stage. Knowledge vs. practice In Georgia, from 1999-2000, 68.5 percent of breast cancers were diagnosed at an early stage; 31.5 percent at an advanced stage. Approach to calculating the measure Numerator Number of new breast cancer cases diagnosed at an early stage (see comments below) Denominator Number of new breast cancer cases Potential data source(s) Surveillance, Epidemiology, and End Results Program (SEER), Georgia Comprehensive Cancer Registry Comments Early stage refers to SEER summary stage of in situ or localized disease. In situ stage refers to a neoplasm that has not invaded the supporting structure of the organ on which it arose. Localized stage refers to a neoplasm that is limited to the organ of origin; it has not spread beyond that organ. Limitations — Potential benchmark source(s) SEER; U.S. Cancer Statistics publications

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Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia Key references GCCR. 2004. Georgia Cancer Cases by Stage at Diagnosis, 1999-2000. Unpublished data. IOM. 2003. Fulfilling the Potential of Cancer Prevention and Early Detection. Washington, DC: The National Academies Press. Martin LM, et al. 2004. Georgia Behavioral Risk Factor Surveillance System, 2002 Report. Georgia Department of Human Resources. Publication Number DPH04/158HW. Ries LAG, et al. 2004. SEER Cancer Statistics Review 1975-2001. Bethesda, MD: National Cancer Institute. Available: http://seer.cancer.gov/csr/1975_2001/results_merged/topic_survival.pdf. U.S. DHHS. 2000. Healthy People 2010: Understanding and Improving Health. Chapter 3 Cancer. 2nd edition. Washington, DC: U.S. GPO. USPSTF. 2002. Guide to Clinical Preventive Services. 3rd edition. Rockville, MD: AHRQ.

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Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia MEASURE 4-4: DETECTING CANCER EARLY—Advanced-Stage Breast Cancer Diagnosis Description Incidence of advanced-stage breast cancer Source National Healthcare Quality Report; Surveillance, Epidemiology, and End Results Program (SEER) Consensus on care Detection of tumors at an early stage significantly reduces mortality. Five-year relative survival of early-stage, localized breast cancer is 97.5 percent. In contrast, 5-year relative survival of regional-stage breast cancer is 80.4 percent; distant stage is 25.5 percent. Increased breast cancer screening should ultimately reduce the incidence of advanced-stage breast cancer. Knowledge vs. practice The U.S. incidence of advanced-stage breast cancer was 149.7 per 100,000 for women aged 40 and older in 2000. In Georgia, 31.5 percent of breast cancers were diagnosed at an advanced stage from 1999-2000. Approach to calculating the measure Numerator Number of females, aged 40 and older, with new breast cancer diagnosed at advanced-stage (see comments below) Denominator Number of females, aged 40 and older Potential data source(s) SEER; Georgia Comprehensive Cancer Registry Comments Incidence rate = (New advanced-stage breast cancers diagnosed among women aged 40 and older) ÷ (Female population aged 40 and older) x 100,000. Estimate should be age-adjusted to allow comparisons.   Advanced stage refers to SEER summary stage of regional or distant disease. Regional stage refers to a neoplasm that has extended beyond the limits of the organ of origin (i.e., into surrounding organs or tissues or into regional lymph nodes). Distant stage refers to a neoplasm that has spread to parts of the body remote from the primary tumor. Limitations — Potential benchmark source(s) National Healthcare Quality Report; Healthy People 2010; U.S. Cancer Statistics publications

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Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia Key references AHRQ. 2003. National Healthcare Quality Report. Rockville, MD: U.S. DHHS. GCCR. 2004. Georgia Cancer Cases by Stage at Diagnosis, 1999-2000. Unpublished data. IOM. 2003. Fulfilling the Potential of Cancer Prevention and Early Detection. Washington, DC: The National Academies Press. Ries LAG, et al. 2004. SEER Cancer Statistics Review 1975-2001. Bethesda, MD: National Cancer Institute. Available: http://seer.cancer.gov/csr/1975_2001/results_merged/topic_survival.pdf U.S. DHHS. 2000. Healthy People 2010: Understanding and Improving Health. Chapter 3 Cancer. 2nd edition. Washington, DC: U.S. GPO. USPSTF. 2002. Guide to Clinical Preventive Services. 3rd edition. Rockville, MD: AHRQ.

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Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia MEASURE 4-5: DETECTING CANCER EARLY—Advanced-Stage Colorectal Cancer Diagnosis Description Incidence of advanced-stage colorectal cancer Source National Healthcare Quality Report; Surveillance, Epidemiology, and End Results Program (SEER) Consensus on care Colorectal cancer screening detects premalignant polyps and early stage cancers. It can also guide removal of premalignant polyps thus preventing cancer from developing. Detection of tumors at an early stage significantly reduces mortality. Five-year relative survival of localized-stage colorectal cancer is 89.9 percent. In contrast, 5-year relative survival of regional-stage colorectal cancer is 67.3 percent; 9.6 percent, distant stage. Increased colorectal cancer screening should ultimately reduce the incidence of advanced-stage colorectal cancer. Knowledge vs. practice The U.S. incidence of advanced-stage colorectal cancer was 95.6 per 100,000 for adults aged 50 and older in 2000. In Georgia, 58.7 percent of colorectal cancers were diagnosed at an advanced stage from 1999-2000. Approach to calculating the measure Numerator Number of adults, aged 50 and older, with new colorectal cancer diagnosed at an advanced stage (see comments below) Denominator Adult population aged 50 and older Potential data source(s) Georgia Comprehensive Cancer Registry, SEER Comments Incidence rate = (New advanced-stage colorectal cancers diagnosed among adults aged 50 and older) ÷ (Adult population aged 50 and older) × 100,000. Estimate should be age-adjusted to allow comparisons.   Advanced stage refers to SEER summary stage of regional or distant disease. Regional stage refers to a neoplasm that has extended beyond the limits of the organ of origin (i.e., into surrounding organs or tissues or into regional lymph nodes). Distant stage refers to a neoplasm that has spread to parts of the body remote from the primary tumor. Limitations — Potential benchmark source(s) National Healthcare Quality Report; Georgia Comprehensive Cancer Registry; SEER; U.S. Cancer Statistics publications

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Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia Key references AHRQ. 2003. National Healthcare Quality Report. Rockville, MD: U.S. DHHS. GCCR. 2004. Georgia Cancer Cases by Stage at Diagnosis, 1999-2000. Unpublished data. Martin LM, et al. 2003. Georgia Behavioral Risk Factor Surveillance System, 2001 Report. Atlanta, GA: Georgia Department of Human Resources, Publication Number DPH03-069HW. NCI. 2004. SEER Cancer Statistics Review, 1975-2001. Bethesda, MD: National Cancer Institute. Available: http://seer.cancer.gov/csr/1975_2001/results_merged/topic_survival.pdf. U.S. DHHS. 2000. Healthy People 2010: Understanding and Improving Health. 2nd edition. Chapter 3 Cancer. Washington, DC: U.S. GPO. USPSTF. 2002. Guide to Clinical Preventive Services. 3rd edition. Rockville, MD: AHRQ.

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Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia REFERENCES ACS (American Cancer Society). 2003. Breast Cancer Facts & Figures 2003. Atlanta, GA: ACS. ——. 2004. Cancer Facts & Figures 2004. Atlanta, GA: ACS. ACS, University of Georgia Cooperative Extension Service, Georgia Department of Human Resources. 2003. Breast Cancer. [Online] Available: http://www.fcs.uga.edu/pubs/ppt/PPT-43.ppt [accessed July 23, 2004]. AHRQ (Agency for Healthcare Research and Quality). 2003. National Healthcare Quality Report. Rockville, MD: U.S. DHHS. AJCC (American Joint Committee on Cancer). 2004. Collaborative Staging: Introduction. [Online] Available: http://www.cancerstaging.org/cstage/cstageintro.html [accessed January 13, 2005]. Breen N, Wagener DK, Brown ML, Davis WW, Ballard-Barbash R. 2001. Progress in cancer screening over a decade: results of cancer screening from the 1987, 1992, and 1998 National Health Interview Surveys. J Natl Cancer Inst. 93(22): 1704-13. CDC. 2003. Behavioral Risk Factor Surveillance System, Prevalence Data, Georgia 2002 Colorectal Cancer Screening. [Online] Available: http://www.apps.nccd.cdc.gov/brfss [accessed November 2003]. Clark JA, Inui TS, Silliman RA, Bokhour BG, Krasnow SH, Robinson RA, Spaulding M, Talcott JA. 2003. Patients’ perceptions of quality of life after treatment for early prostate cancer. J Clin Oncol. 21(20): 3777-84. Compton CC. 2003. Colorectal carcinoma: diagnostic, prognostic, and molecular features. Mod Pathol. 16(4): 376-88. Coughlin SS, Uhler RJ, Bobo JK, Caplan L. 2004. Breast cancer screening practices among women in the United States, 2000. Cancer Causes Control. 15(2): 159-70. Fletcher SW, Elmore JG. 2003. Clinical practice. Mammographic screening for breast cancer. N Engl J Med. 348(17): 1672-80. Freedman GM, Anderson PR, Goldstein LJ, Hanlon AL, Cianfrocca ME, Millenson MM, von Mehren M, Torosian MH, Boraas MC, Nicolaou N, Patchefsky AS, Evers K. 2003. Routine mammography is associated with earlier stage disease and greater eligibility for breast conservation in breast carcinoma patients age 40 years and older. Cancer. 98(5): 918-25. GCC (Georgia Cancer Coalition). 2001. Strategic Plan. Atlanta, GA: GCC. GCCR (Georgia Comprehensive Cancer Registry). 2004. Georgia Cancer Cases by Stage at Diagnosis, 1999-2000. Unpublished Data. GDPH (Georgia Division of Public Health). 2004a. Georgia Behavioral Risk Factor Surveillance System: Colorectal Cancer Screening. [Online] Available: http://health.state.ga.us/epi/brfss/colorectal.asp [accessed November 26, 2004]. ——. 2004b. OASIS Web Query—Death Statistics. [Online] Available: http://oasis.state.ga.us/webquery/death.html [accessed April 2004]. Ghafoor A, Jemal A, Ward E, Cokkinides V, Smith R, Thun M. 2003. Trends in breast cancer by race and ethnicity. CA Cancer J Clin. 53(6): 342-55. Gwyn K, Bondy ML, Cohen DS, Lund MJ, Liff JM, Flagg EW, Brinton LA, Eley JW, Coates RJ. 2004. Racial differences in diagnosis, treatment, and clinical delays in a population-based study of patients with newly diagnosed breast carcinoma. Cancer. 100(8): 1595-604. Harris R, Lohr KN. 2002. Screening for prostate cancer: an update of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 137(11): 917-29.

OCR for page 79
Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia Humphrey LL, Helfand M, Chan BK, Woolf SH. 2002. Breast cancer screening: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 137(5 Part 1): 347-60. IOM (Institute of Medicine). 2003. Fulfilling the Potential of Cancer Prevention and Early Detection. Curry S, Byers T, Hewitt M, Editors. Washington, DC: The National Academies Press. ——. 2005. Saving Women’s Lives: Strategies for Improving Breast Cancer Detection and Diagnosis. Joy JE, Penhoet EE, Petitti DB, Editors. Washington, DC: The National Academies Press. Landis SH, Steiner CB, Bayakly AR, McNamara C, Powell KE. 2004. Georgia Cancer Data Report, 2000. Atlanta, GA: Georgia Department of Human Resources, Division of Public Health, Cancer Control Section, and the American Cancer Society, Southeast Division. Li CI, Malone KE, Daling JR. 2003. Differences in breast cancer stage, treatment, and survival by race and ethnicity. Arch Intern Med. 163(1): 49-56. Mahadevia PJ, Fleisher LA, Frick KD, Eng J, Goodman SN, Powe NR. 2003. Lung cancer screening with helical computed tomography in older adult smokers: a decision and cost-effectiveness analysis. JAMA. 289(3): 313-22. Martin LM, Chowdhury PP, Powell KE, Clanton J. 2003. Georgia Behavioral Risk Factor Surveillance System, 2001 Report. Atlanta, GA: Georgia Department of Human Resources, Division of Public Health, Chronic Disease, Injury, and Environmental Epidemiology Section. ——. 2004. Georgia Behavioral Risk Factor Surveillance System, 2002 Report. Atlanta, GA: Georgia Department of Human Resources, Division of Public Health, Chronic Disease, Injury, and Environmental Epidemiology Section. NCCN (National Comprehensive Cancer Network). 2003. Clinical Practice Guidelines in Oncology-v.1.2003. Colorectal Screening. [Online] Available: http://www.nccn.org/professionals/physician_gls/PDF/colorectal_screening.pdf [accessed 2004]. ——. 2004. Clinical Practice Guidelines in Oncology-v.1.2004. Breast Cancer Screening and Diagnosis Guidelines. [Online] Available: http://www.nccn.org/professionals/physician_gls/PDF/breast-screening.pdf [accessed 2004]. NCI (National Cancer Institute). 2004a. Cancer Progress Report—2003 Update. [Online] Available: http://progressreport.cancer.gov/ [accessed July 30, 2004]. ——. 2004b. Cancer Progress Report Update—2003. Early Detection: Breast Cancer Screening. [Online] Available: http://progressreport.cancer.gov/doc.asp?pid=1&did=21&chid=10&coid=24&mid=vpco [accessed July 29, 2004]. ——. 2005. Introduction to Collaborative Staging. [Online] Available: http://training.seer.cancer.gov/module_collab_stage/00_cs_home.html [accessed February 1, 2005]. NCI SEER (National Cancer Institute, Surveillance, Epidemiology, and End Results). 2004. Incidence: Colon and Rectum Cancer. SEER*Stat Databases. [Online] Available: http://seer.cancer.gov/faststats/html/inc_colorect.html [accessed February 28, 2005]. NCI and CDC (National Cancer Institute and Centers for Disease Control and Prevention). 2004. State Cancer Profiles. [Online] Available: http://statecancerprofiles.cancer.gov/incidencerates/incidencerates.html [accessed July 9, 2004]. NCQA (National Committee for Quality Assurance). 2002. The State of Health Care Quality: 2002. Washington, DC: NCQA. ——. 2004. The Health Plan Employer Data and Information Set (HEDIS). [Online] Available: http://www.ncqa.org/Programs/HEDIS/index.htm [accessed December 3, 2004]. Rao RS, Graubard BI, Breen N, Gastwirth JL. 2004. Understanding the factors underlying disparities in cancer screening rates using the Peters-Belson approach: results from the 1998 National Health Interview Survey. Med Care. 42(8): 789-800.

OCR for page 79
Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia Ries LAG, Eisner MP, Kosary CL, Hankey BF, Miller BA, Clegg L, Mariotto A, Feuer EJ, Edwards BK, Editors. 2004. SEER Cancer Statistics Review, 1975-2001. Bethesda, MD: NCI. Roetzheim RG, Pal N, Tennant C, Voti L, Ayanian JZ, Schwabe A, Krischer JP. 1999. Effects of health insurance and race on early detection of cancer. J Natl Cancer Inst. 91(16): 1409-15. Schneider E, McGlynn E, and Nadal M. 2003. Screening for Colorectal Cancer. Draft HEDIS measure. Sirovich BE, Schwartz LM, Woloshin S. 2003. Screening men for prostate and colorectal cancer in the United States: does practice reflect the evidence? JAMA. 289(11): 1414-20. Swan J, Breen N, Coates RJ, Rimer BK, Lee NC. 2003. Progress in cancer screening practices in the United States: results from the 2000 National Health Interview Survey. Cancer. 97(6): 1528-40. Taplin SH, Ichikawa L, Yood MU, Manos MM, Geiger AM, Weinmann S, Gilbert J, Mouchawar J, Leyden WA, Altaras R, Beverly RK, Casso D, Westbrook EO, Bischoff K, Zapka JG, Barlow WE. 2004. Reason for late-stage breast cancer: absence of screening or detection, or breakdown in follow-up? J Natl Cancer Inst. 96(20): 1518-27. U.S. DHHS (U.S. Department of Health and Human Services). 2000. Healthy People 2010: Understanding and Improving Health. 2nd edition. Washington, DC: U.S. Government Printing Office. USPSTF (U.S. Preventive Services Task Force). 2002a. Guide to Clinical Preventive Services. 3rd edition. Rockville, MD: AHRQ. ——. 2002b. Screening for Breast Cancer: Recommendations and Rationale. Rockville, MD: U.S. DHHS, AHRQ. ——. 2002c. Screening for Colorectal Cancer: Recommendations and Rationale. Rockville, MD: U.S. DHHS, AHRQ. ——. 2002d. Screening for Prostate Cancer: Recommendations and Rationale. Rockville, MD: U.S. DHHS, AHRQ. Ward E, Jemal A, Cokkinides V, Singh GK, Cardinez C, Ghafoor A, Thun M. 2004. Cancer disparities by race/ethnicity and socioeconomic status. CA Cancer J Clin. 54(2): 78-93. Winawer S, Fletcher R, Rex D, Bond J, Burt R, Ferrucci J, Ganiats T, Levin T, Woolf S, Johnson D, Kirk L, Litin S, Simmang C. 2003. Colorectal cancer screening and surveillance: clinical guidelines and rationale-update based on new evidence. Gastroenterology. 124(2): 544-60. Young JL, Roffers SD, Ries LAG, Fritz AG, Hurlbut AA, Editors. 2001. SEER Summary Staging Manual—2000: Codes and Coding Instructions. Bethesda, MD: NCI