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Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
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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.

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

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-

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

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).

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×
  • 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.

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×
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-

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

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).

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

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-

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

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.

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

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

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

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.

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

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

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

with Stage I, II, or III breast cancer if their tumor is larger than 1 centimeter in diameter and both ER-negative and PR-negative (NCCN, 2004b). The optimal time for initiating chemotherapy is not known (NCI, 2004a). There are insufficient data to either support or discourage adjuvant chemotherapy for women over age 70.

Knowledge vs. practice. There is a clear divergence between consensus recommendations and clinical practice (Harlan et al., 2002; Du et al., 2003). Chemotherapy use declines substantially with increasing age. In addition, older women who undergo chemotherapy are more likely to experience treatment delays and to receive lower than recommended dosages, compared with others (Lyman et al., 2003).

Adjuvant Therapy for Colon Cancer

As noted above, one of the measures recommended is the proportion of Stage III colon cancer patients who receive adjuvant chemotherapy. The rationale for the IOM committee’s decision to recommend this measure is presented below.

Consensus on care. For most colon cancer patients, primary treatment involves surgical removal of the tumor and regional lymph nodes (NCCN, 2003). For patients with Stage III colon cancer—tumors that have spread through the wall of the colon into regional lymph nodes and nearby tissues or organs—adjuvant chemotherapy has been the established standard of care for over a decade (Moore and Haller, 1999). Numerous randomized trials have shown that adjuvant chemotherapy substantially increases disease-free and overall survival of Stage III colon cancer (Moertel et al., 1995; IMPACT Investigators, 1995; Wolmark et al., 1999; Potosky et al., 2002). NCCN specifically recommends 6 months of adjuvant 5-fluorouracil plus leucovorin or FOLFOX1 for all Stage III colon cancer patients (NCCN, 2004g).

Knowledge vs. practice. Despite the well-documented benefits of adjuvant chemotherapy for Stage III colon cancer, numerous reports show that its use varies by a wide range of patient and provider characteristics including patients’ age, race, ethnicity, marital status, health insurance status (i.e., being uninsured) and type of health insurance coverage, Medicaid coverage, hospital volume and individual hospital (Roetzheim et al., 2000; Hodgson et al., 2001; Potosky et al., 2002; Ayanian et al., 2003; Oliveria et al., 2004).

1  

FOLFOX refers to infusional 5-FU/leucovorin/oxaliplatin.

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

Receipt of Appropriate Follow-Up After Treatment for Cancer

After initial cancer treatment, patients are at risk for a recurrence. Mammography after breast cancer and colonoscopy after colorectal cancer are routinely recommended to assure early detection of a recurrence or new cancer (Smith et al., 1999; Benson et al., 2000; NCCN, 2004b, 2004g). The IOM committee recommends two quality indicators to monitor appropriate follow-up of breast and colorectal cancer patients.

  • Measure 6-9—Follow-up mammography after treatment for breast cancer—the proportion of women with Stage 0 to Stage III breast cancer who have a mammogram by 19 months after diagnosis.

  • Measure 6-10—Follow-up colonoscopy after treatment for colorectal cancer—the proportion of patients with Stage I to Stage III colorectal cancer who undergo a colonoscopy within 1 year of surgery.

The rationale underlying the IOM committee’s recommendations is discussed further below.

Follow-Up Mammography After Treatment for Breast Cancer

The first recommended measure is the proportion of women with Stage 0 to Stage III breast cancer who have a mammogram by 19 months after diagnosis.

Consensus on care. Women with a history of breast cancer are at significant risk of recurrence especially if they had breast-conserving surgery without adjuvant radiation. The National Surgical Adjuvant Breast and Bowel Project conducted a 20-year follow-up of women who had breast-conserving surgery and adjuvant radiation. The researchers found that 14.3 percent of the women experienced a recurrent tumor in the same breast; without adjuvant radiation, 39.2 percent of the patients experienced a recurrence (Fisher et al., 2002). Age under 45 years is also a major risk factor for local recurrence of breast cancer (Elkhuizen et al., 1998).

The American Society of Clinical Oncology (ASCO) and NCCN recommend that women treated with breast-conserving therapy have a first post-treatment mammogram of the preserved and contralateral breast approximately 6 to 12 months after radiotherapy is complete and yearly mammograms thereafter (Smith et al., 1999; NCCN, 2004b).

The IOM committee recommends 19 months after diagnosis to allow for a 12-month follow-up period after a 7-month therapeutic period. The goal for this measure may be less than 100 percent to account for those women who refuse follow-up or who undergo bilateral total mastectomies.

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

Knowledge vs. practice. It appears that many women treated for breast cancer—especially women at high-risk of a recurrence—do not get needed follow-up care. Geller and colleagues analyzed 2,503 breast cancer cases in the NCI’s Breast Cancer Surveillance Consortium registries and found that, by 12 months after diagnosis, about half the women had a first follow-up mammogram (Geller et al., 2003). By 30 months, 78 percent of women had returned for a mammogram. Women who did not receive adjuvant radiation after breast-conserving surgery were less likely to return for follow-up despite being at significant risk of recurrence.

Follow-Up Colonoscopy After Treatment for Colorectal Cancer

The second recommended measure—follow-up colonoscopy after treatment for Stage I to Stage III colorectal cancer—is the proportion of Stage I to Stage III colorectal cancer cases who undergo a colonoscopy within 1 year of surgery.

Consensus on care. The recurrence rate after colorectal cancer surgery is not known; estimates of the rate of recurrence range from as low as 2 percent to about 33 percent, at 5 years post-surgery (Green et al., 2002; Fisher et al., 2003). Colonoscopy can detect recurrences, as well as new polyps or new primary cancers. A recent retrospective study of 3,546 Veterans Administration patients strongly supports a mortality benefit for follow-up colonoscopy in patients with a history of nonmetastatic colorectal cancer (Fisher et al., 2003). The researchers compared 5-year mortality rates and found that risk of death was decreased by 43 percent in the group of patients who had at least one follow-up colonoscopy compared with the group of patients who had no follow-up.

NCCN recommends that Stage I to Stage III colorectal cancer patients have a follow-up colonoscopy within 1 year of resection. The colonoscopy should be performed 3 to 6 months after surgery if an obstruction had prevented a preoperative colonoscopy. ASCO guidelines call for a preoperative or perioperative colonoscopy followed by colonoscopy every 3 to 5 years (Benson et al., 2000).

Knowledge vs. practice. The use of colonoscopy to follow up colorectal cancer surgery patients appears to vary with patients’ characteristics and local practice patterns (Cooper et al., 2000; Rulyak et al., 2004). Cooper and colleagues used a national Surveillance, Epidemiology, and End Results (SEER)/Medicare dataset to study the use of endoscopy by 5,716 patients aged 65 and older, following surgery for nonmetastatic colorectal cancer. Colonoscopy was performed in 58 percent of patients who had survived through the end of the 6-year study period. The likelihood of a colonoscopy

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

after surgery was associated with patients’ age, tumor location (colon or rectum), and local provider practice patterns.

Minimization of Cancer Patients’ Suffering

Many cancer patients experience intense pain at some time during the course of their disease (Cleeland et al., 1997; Benedetti, 2001). Furthermore, for many people who ultimately die of cancer, the period before death is characterized by unnecessary pain, distress, nausea, and other physical and psychological symptoms (IOM, 2001). The objective of palliative care is to relieve the symptoms and suffering caused by cancer—starting at diagnosis and continuing through treatment, survivorship, recurrent or advanced disease, and the end of life.

The IOM committee recommends four quality indicators that GCC should use to monitor the quality of palliative care. Two of the recommended measures pertain to the assessment of pain among cancer patients:

  • Measure 6-11—Cancer pain assessment—proportion of cancer patient encounters where patient was assessed for pain.

  • Measure 6-12—Prevalence of pain among cancer patients—proportion of cancer patients who report more than minor pain.

The other two measures track cancer patients’ use of hospice care:

  • Measure 6-13—Cancer deaths in hospice—Rate of cancer deaths in hospice.

  • Measure 6-14—Cancer patients’ hospice length of stay—proportion of hospice cancer patients with a length of stay of at least 7 days.

The rationale underlying each of these measures is discussed further below.

Assessment of Cancer Patients’ Pain

As noted above, the IOM committee recommends two measures pertaining to the assessment of pain among cancer patients: one measure of pain assessment (proportion of cancer patient encounters where patient was assessed for pain) and one measure of the prevalence of pain among cancer patients.

Consensus on care. Regular reassessment of patients’ pain is integral to effective cancer pain management (IOM, 2001; Goudas et al., 2001; ONS, 2002; Balducci, 2003; NCCN, 2004d). The American Pain Society recommends that health providers view pain as the “fifth vital sign”™ so that

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

pain is routinely checked with pulse, blood pressure, core temperature, and respiration in every patient encounter (APS, 1995a).

Several studies have found that the most important predictor of inadequate pain relief is a discrepancy between the patient’s and the physician’s assessment of the severity of pain (Jacox et al., 1994; Reifel, 2000). Consequently, numerous clinical guidelines advise that patients be directly queried regarding their level of pain (Jacox et al., 1994; WHO, 1996; ONS, 2002; National Consensus Project for Quality Palliative Care, 2004; JCAHO, 2004; NCCN, 2004d).

NCCN, for example, recommends that clinicians screen cancer patients for pain every time they are seen and that patients should use one of several available rating scales to quantify their pain (NCCN, 2004d). The Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) has established standards for inpatient pain management including a documentation requirement stipulating that assessed pain be recorded in a way that facilitates appropriate follow-up and reassessment (Center to Advance Palliative Care, 2003). JCAHO, in a recent collaboration with the American Medical Association and the National Committee for Quality Assurance, has also developed a standardized performance measure for tracking the proportion of cancer patients who are assessed for pain (JCAHO, 2004). The IOM committee drew from this effort to develop the measure on the assessment of cancer patients’ pain (Measure 6-11).

The World Health Organization (WHO) has developed an approach to treating cancer pain that is widely endorsed in the United States and around the world (WHO, 1996). WHO outlines a step-by-step algorithm that suggests patients be started on acetaminophen or a nonsteroidal anti-inflammatory drug. If insufficient, the patient should then receive a “weak” opioid, such as codeine, and, if necessary, progress to a “strong” opioid such as morphine.

Knowledge vs. practice. There are no definitive estimates of the prevalence of pain among cancer patients and survivors (Symptom management, 2002). Estimates range from 14 percent to 100 percent. Regardless, the research literature makes clear that severe pain is often characteristic of the cancer experience not only for patients in the advanced stages of disease but also for patients during the course of successful treatment and afterwards (Goudas et al., 2001; Allard et al., 2001; IOM, 2003b). Nevertheless, cancer pain is often untreated or undertreated (Cleeland et al., 1997; Benedetti, 2001; Goudas et al., 2001; IOM, 2001; Symptom management, 2002; IOM, 2003b). Several studies suggest that some groups of cancer patients are more likely to be inadequately treated for pain, especially members of racial or ethnic minorities, women, and elderly persons (Cleeland et al., 1997; Goudas et al., 2001; Green et al., 2003). Cleeland and colleagues

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

(1997) conducted a prospective study of the Eastern Cooperative Oncology Group’s management of outpatients who had pain and recurrent or metastatic cancer. The researchers found poor pain care overall and significant disparities in care; 65 percent of nonwhite and Hispanic patients did not receive guideline-recommended analgesic prescriptions compared with 50 percent of nonminority patients.

Cancer Patients’ Use of Hospice Care

As noted above, the IOM committee recommends two measures pertaining to the cancer patients use of hospice care: one measure of cancer deaths in hospice and one measure of cancer patients’ hospice length of stay.

Consensus on care. Hospice—the gold standard of care for dying persons, their families, and other loved ones—is a home-based or inpatient program of palliative and supportive care services that provides physical, psychological, social, and spiritual care (ASCO, 1998; NCCN, 2004e). NCCN recommends that patients with months to weeks to live be offered palliative or hospice care and that patients with weeks to days to live should be given intensive palliative care—not more anticancer treatments. There is no consensus on how long cancer patients should stay in hospice to receive maximum benefit.

Knowledge vs. practice. Hospice use among cancer patients is increasing. However, most patients are referred to hospice too late to fully benefit from it (MedPAC, 2002; NCCN, 2004e). Some dying cancer patients are not referred at all. Lackan and colleagues analyzed the SEER/Medicare records of more than 170,000 Medicare beneficiaries who had been diagnosed with breast, colorectal, lung, or prostate cancer and died (Lackan et al., 2004). Thirty percent of the study population used hospice services before they died.

The median hospice length of stay for adult cancer patients was 15.4 days in 2000 (AHRQ, 2003). However, a substantial proportion of cancer patients receive hospice care just days before death. An analysis of 28,777 Medicare beneficiaries who died of various cancers found that, among those who ultimately died in hospice, 17.0 percent had exceedingly short stays of only 3 or fewer days (Earle et al., 2004).

Several studies indicate that access to hospice care varies with patient’s age, race and ethnicity, supplemental Medicare coverage, income, urban vs. rural residence, managed care enrollment, and other factors (MedPAC, 2002; Lackan et al., 2004).

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

Cancer Survival and Mortality Rates

Cancer survival and mortality rates are surveillance measures used by epidemiologists to analyze the impact of cancer on a population. Survival rates are generally viewed as indicators of treatment effectiveness while mortality rates may be influenced also by prevention and early detection. If GCC succeeds in narrowing the gap in Georgia between what is known about effective cancer prevention, early detection, and treatment and what is practiced, the change will eventually become evident in survival and mortality rates.

The IOM committee recommends that Georgia track the following cancer survival 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

In addition, the IOM committee recommends that Georgia monitor mortality rates for the state’s four most common cancers and track the mortality rate for all types of cancer as indicators of quality of cancer care:

  • 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 cancer survival and mortality rates recommended as quality measures are discussed further below.

Cancer Survival Rates

Currently, Georgia monitors cancer mortality rates but the state does not track cancer survival rates. The IOM committee recommends that GCC continue to include cancer mortality monitoring in Georgia’s quality-of-cancer-care measurement activities and also build the capacity to track cancer survival trends. Although cancer epidemiologists typically use 5-year survival as the standard statistic for defining when a cancer has been successfully treated, the IOM committee recommends that Georgia plan to track 10-year survival rates as well. Measurable progress will only be apparent over the long-term for most cancers.

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

Cancer survival may be measured in two ways, observed survival and relative survival. Observed survival is the percentage of cancer patients still alive at some specified time after diagnosis, including deaths from cancer and all other causes. Relative survival adjusts the observed rate to account for death due to causes other than cancer. It thus provides a more accurate estimate of the likelihood that a patient will survive the cancer in the specified time period.

There are stark disparities in survival rates by type of cancer; in part, reflecting differences in the availability of early detection methods and effective treatments. Most breast, colorectal, and prostate cancer patients survive 5 years after diagnosis; in Atlanta, 84.6 percent; 61.6 percent; and 97.5 percent, respectively. In contrast, just 16.5 percent of lung cancer patients are living 5 years after diagnosis.

Table 6-1 shows the relative survival rates for breast, colorectal, lung, and prostate cancers in Georgia’s Atlanta SEER registry alone, as well as in the combined U.S. SEER registry areas, including Atlanta, Connecticut, Detroit, Hawaii, Iowa, Los Angeles, New Mexico, San Francisco-Oakland, Seattle-Puget Sound, and Utah.

Cancer survival statistics are subject to bias and should therefore be interpreted with caution. When interpreting cancer survival measures, it is important to keep in mind the potential for lead-time bias and length bias (Box 6-3). Apparent increases in cancer survival rates may reflect advances in early detection rather than true improvements in delivering state-of-the-

TABLE 6-1 Relative Survival Rates for Breast, Colorectal, Lung and Bronchus, and Prostate Cancers

Cancer site

Survival rates (by percent)

Atlanta SEER registry

U.S., SEER registriesa

5 yearsb

5 yearsc

10 yearsd

Breast (female)

84.6

86.8

77.3

Colorectal

61.6

63.7

57.4

Lung and bronchus

16.5

15.2

10.2

Prostate

97.5

98.7

92.1

aIncludes Atlanta, Connecticut, Detroit, Hawaii, Iowa, Los Angeles, New Mexico, San Francisco-Oakland, Seattle-Puget Sound, and Utah.

bCancers diagnosed from 1992-1999.

cCancers diagnosed in 1996.

dCancers diagnosed in 1991.

SOURCE: Ries et al., 2004; Liff, 2004.

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

BOX 6-3
Caveat Emptor: Interpreting Cancer Survival Statistics

Cancer survival measures can sometimes be misleading because of two types of biases in the statistics: lead-time bias and length bias. It is important to keep these in mind when interpreting survival statistics.

Lead-Time Bias

Measured improvements in survival may be due to a statistical artifact called lead-time bias rather than to any deliberate intervention to improve the quality of care. As progress is made in improving early detection of new cancers, cancer diagnosis is pushed back in time. Because of this longer “lead time,” patients can seem to live longer after their diagnosis. Consider a man who is destined to develop prostate cancer symptoms at age 65, to survive 5 years, and to die at age 70. His survival rate can be doubled to 10 years simply by detecting the cancer before symptoms appear, at age 60, even if he still dies from that same cancer at age 70.

Length Bias

Length bias is another statistical artifact that may cause improvements in survival rates to be overestimated for cancers that can be detected early through screening. As early detection becomes more commonplace, relatively more slow-growing cancers are detected. Fast-growing cancers exist in screening populations for a comparably shorter period of time because they tend to lead more hastily to death. Thus, as the proportion of slower-growing cancers increases, the measurable survival period may appear to be lengthening.

SOURCE: Adapted from http://cancer.gov/statistics/glossary.

art cancer treatments to patients. Early cancer detection pushes back the timing of diagnosis—and that, in turn, may artificially lengthen the survival period.

Cancer Mortality Rates

Cancer mortality rates are measured by the number of people who die of cancer within a year, expressed in terms of number of deaths per 100,000 people. Mortality rates are developed from death statistics based on the underlying cause of death—the disease or injury that initiated the sequence of events leading directly to death. Georgia’s mortality rates for the four leading types of cancers and all cancers combined are shown in Figure 6-1 and Figure 6-2.

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

FIGURE 6-1 Mortality rate for each of four leading cancers in Georgia, 1994-2002.

NOTE: Rates are age-adjusted to the year 2000 population.

SOURCE: GDPH, 2004.

FIGURE 6-2 Mortality rate for all cancers in Georgia, 1994-2002.

NOTE: Rates are age-adjusted to the year 2000 population.

SOURCE: GDPH, 2004.

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

DATA SOURCES

The data for treatment-related quality measures may be drawn from a variety of sources (Table 6-2):

  • Georgia Clinical Oncology Research and Education, Inc. will be essential to tracking trends in clinical trial enrollment.

  • Medicare and other claims databases—if linked with tumor registry data—are key to primary and adjuvant treatment quality measures. The linked Medicare claims and SEER dataset is an already available, critical information source. The Georgia Comprehensive Cancer Registry must be upgraded to SEER standards in order to generate survival statistics and conduct analyses of adult populations younger than Medicare age. GCC should explore using and linking commercial claims to registry data for adults under age 65.

  • Medical records will be an essential though costly data source because they contain extensive documentation of patients’ treatments and other important clinical details.

  • Surveys of cancer patients and family members are the best way to capture the patient experience. They will be an indispensable means to assessing the quality of palliative and end-of-life care.

Further information about the strengths and weakness of data sources is presented in Chapter 2, Concepts, Methods, and Data Sources, and Appendixes A and B.

SUMMARY

When a patient is diagnosed with cancer, ensuring the best possible treatment is paramount. Far too often, however, cancer patients do not receive treatments with proven efficacy and their cancer experience is one of unnecessary pain. If Georgia is to meaningfully improve cancer outcomes for state residents, it must encourage the delivery of evidence-based cancer treatment statewide. In this chapter, the IOM committee has recommended four sets of measures to assess the quality of cancer treatment. GCC should use these quality indicators to gauge Georgia’s progress in improving the quality of cancer treatment in the coming years.

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

TABLE 6-2 Potential Data Sources for Recommended Measures of the Quality of Cancer Treatment in Georgiaa

Quality Measures

Potential Georgia-Based Data Sources

Potential National Data Sources for Benchmarking and Comparison

Claims

GA-CORE

GCCR, GA-SEER

GA-SEER/Medicare

Medical records

Patient surveys

Vital statistics

BCSC

NHHCS

NHQR

SEER

SEER/Medicare

Clinical trials

 

 

Primary treatment

 

Adjuvant radiation

 

Adjuvant hormonal therapy

 

 

Adjuvant chemotherapy

 

Treatment follow-up

 

 

 

 

 

Pain assessment and prevalence

 

 

Cancer deaths in hospice

 

 

 

 

 

Hospice length of stay

 

 

 

 

Survival rates

 

 

 

 

Death rates

 

 

 

 

 

 

 

 

 

aSee Chapter 2, Concepts, Methods, and Data Sources, and Appendixes A and B for descriptions of data sources.

NOTE: GCCR = Georgia Comprehensive Cancer Registry; GA-CORE = Georgia Clinical Oncology Research and Education, Inc.; BCSC = Breast Cancer Surveillance Consortium; SEER = Surveillance, Epidemiology, and End Results Program and Patterns of Care Studies; NHQR = National Healthcare Quality Report; NHHCS = National Home and Hospice Care Survey. The symbol ● indicates data are currently available. The symbol indicates that enhancements to current data collection are required.

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

QUALITY MEASURE SPECIFICATIONS: TREATING CANCER

The following section contains summary descriptions of the quality indicators presented in this chapter. These quality indicators were drawn from a variety of clinical practice setting organizations, federal programs, provider groups, and other sources. See Appendix A for descriptions of each of these organizations including their classification schemes for grading clinical recommendations and characterizing evidence.

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 Doses for Prostate Cancer

Measure 6-4.

Appropriate Hormonal Therapy with External Beam Radiation Therapy for Prostate 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

Measure 6-9.

Follow-Up Mammography After Treatment for Breast Cancer

Measure 6-10.

Follow-Up Colonoscopy After Treatment for Colorectal Cancer

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

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

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

MEASURE 6-1: TREATING CANCER—Cancer Patients’ Participation in Clinical Trials

Description

Cancer patients in treatment who participate in clinical trials

Source

National Comprehensive Cancer Network (NCCN); Healthy People 2010

Consensus on care

NCCN encourages participation in clinical trials to ensure the best management of cancer care. Increased participation in clinical trials is a strategic goal of the Georgia Cancer Coalition. It is commonly accepted, although no systemic evidence exists, that participation in clinical trials is associated with excellent medical care as well as improving the standard of care through research.

Knowledge vs. practice

Less than 2 percent of Georgia cancer patients currently participate in clinical trials.

Approach to calculating the measure

Numerator

Number of newly diagnosed cancer patients in treatment participating in clinical trials

Denominator

Number of newly diagnosed cancer patients in treatment

Potential data source(s)

Georgia Center for Oncology Research and Education

Comments

Limitations

Potential benchmark source(s)

Baseline participation rates

Key references

NCCN. 2003. National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology-v.1.2004.

Russell K. 2004. Georgia Clinical Trials. Personal communication to Jill Eden.

U.S. DHHS. 2000. Healthy People 2010: Understanding and Improving Health. 2nd edition. Chapter 3 Cancer. Washington, DC: U.S. Government Printing Office.

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

MEASURE 6-2: TREATING CANCER—Inappropriate Hormonal Therapy Before Radical Prostatectomy

Description

Inappropriate hormonal therapy before radical prostatectomy for prostate cancer

Source

Several prospective randomized trials

Consensus on care

Hormonal therapy should be used infrequently prior to radical prostatectomy. Randomized trials have shown that hormonal therapy prior to radical prostatectomy does not improve progression-free survival. It is an expensive and morbid therapy. Potential side effects include anemia, impotence, fatigue, and hot flashes.

Knowledge vs. practice

A study of 3,439 patients found that use of hormonal therapy before radical prostatectomy increased from 2.9 percent of patients diagnosed in 1989-1992 to 7.8 percent of patients diagnosed in 1999-2001.

Approach to calculating the measure

Numerator

Number of men with prostate cancer undergoing hormonal therapy prior to radical prostatectomy

Denominator

Number of men with prostate cancer undergoing radical prostatectomy

Potential data source(s)

Surveillance, Epidemiology, and End Results (SEER)/ Medicare dataset; medical records

Comments

Limitations

Some patients opt for hormonal therapy while deciding which other therapies to choose.

Potential benchmark source(s)

SEER/Medicare dataset

Key references

Cooperberg MR, et al. 2003. National practice patterns and time trends in androgen ablation for localized prostate cancer. J Natl Cancer Inst. 95(13): 981-9.

Holzbeierlein JM, et al. 2004. Complications of androgen deprivation therapy for prostate cancer. Curr Opin Urol. 14(3): 177-83.

Soloway MS, et al. 2002. Neoadjuvant androgen ablation before radical prostatectomy in cT2bNxMo prostate cancer: 5-year results. J Urol. 167(1): 112-6.

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

MEASURE 6-3: TREATING CANCER—Appropriate External Beam Radiation Therapy Doses for Prostate Cancer

Description

Appropriate doses of external beam radiation therapy (EBRT) for intermediate- and high-risk prostate cancer

Source

National Comprehensive Cancer Network (NCCN)

Consensus on care

NCCN recommends that prostate cancer patients who are at intermediate or high recurrence risk receive EBRT central axis doses of ≥ 75 Gy (Category 2a recommendation). Several studies suggest that doses < 70 Gy are associated with a higher risk of recurrence. An M.D. Anderson randomized trial showed that for patients with prostate-specific antigen (PSA) levels > 10 ng/mL, treatment with 78 Gy resulted in significantly fewer recurrences than a dose of 70 Gy (62 percent vs. 43 percent at 6 years).

Knowledge vs. practice

Limited evidence suggests that many patients are not given appropriate doses of radiation, especially at nonacademic medical centers.

Approach to calculating the measure

Numerator

Number of men with intermediate- or high-risk prostate cancer receiving EBRT central axis doses ≥ 75 Gy

Denominator

Number of men with intermediate- or high-risk prostate cancer receiving EBRT

Potential data source(s)

Surveillance, Epidemiology, and End Results (SEER)/ Medicare dataset, medical records

Comments

Intermediate recurrence risk is defined by the NCCN as tumor Stage T2b-T2c or Gleason score 7 or PSA 10-20 ng/mL. High recurrence risk is defined as tumor Stage T3a or Gleason score 8-10 or PSA > 20 ng/mL.

Limitations

Potential benchmark source(s)

SEER/Medicare dataset

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

Key references

Kupelian PA, et al. 2004. Radical prostatectomy, external beam radiotherapy < or =72 Gy, external beam radiotherapy >72 GY, permanent seed implantation, or combined seeds/external beam radiotherapy for Stage T1-T2 prostate cancer. Int J Radiat Oncol Biol Phys. 58(1): 25-33.

NCCN. 2004. Clinical Practice Guidelines in Oncology-v.1.2004. Prostate Cancer.

Pollack A, et al. 2002. Prostate cancer radiation dose response: results of the M.D. Anderson phase III randomized trial. Int J Radiat Oncol Biol Phys. 53(5): 1097-105.

Zelefsky MJ, et al. 2004. Changing trends in national practice for external beam radiotherapy for clinically localized prostate cancer: 1999 Patterns of Care survey for prostate cancer. Int J Radiat Oncol Biol Phys. 59(4): 1053-61.

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

MEASURE 6-4: TREATING CANCER—Appropriate Hormonal Therapy with External Beam Radiation Therapy for Prostate Cancer

Description

Appropriate hormonal therapy with external beam radiation therapy (EBRT) for high-risk prostate cancer

Source

National Comprehensive Cancer Network (NCCN)

Consensus on care

Randomized trials show high-risk prostate cancer patients have a substantial survival advantage with long-term hormonal therapy. NCCN guidelines recommend EBRT with 2-3 years of hormonal therapy for most high-risk prostate cancer patients (Category 1 recommendation).

Knowledge vs. practice

Use of hormonal therapy combined with external beam radiation is increasing. An analysis of prostate cancer patients diagnosed from 1999-2001 found that 74 percent of intermediate-risk and 90 percent of high-risk patients received adjuvant hormonal therapy with EBRT.

Approach to calculating the measure

Numerator

Number of high-risk prostate cancer patients who are treated with EBRT and receive hormonal therapy for at least 2 years

Denominator

Number of high-risk prostate cancer patients treated with EBRT

Potential data source(s)

Surveillance, Epidemiology, and End Results (SEER)/Medicare dataset; medical records

Comments

High risk is defined as tumor Stage T3a or Gleason score 8-10 or PSA > 20 ng/ml.

Limitations

Some patients may refuse hormonal therapy because of potential side effects such as osteoporosis, anemia, impotence, fatigue, and hot flashes.

Potential benchmark source(s)

SEER/Medicare dataset

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

Key references

Bolla M, et al. 2002. Long-term results with immediate androgen suppression and external irradiation in patients with locally advanced prostate cancer (an EORTC study): a phase III randomized trial. Lancet. 360(9327): 103-8.

Cooperberg, et al. 2003. National practice patterns and time trends in androgen ablation for localized prostate cancer. J Natl Cancer Inst. 95(13): 981-9.

Hanks GE, et al. 2003. Phase III trial of long-term adjuvant androgen deprivation after neoadjuvant hormonal cytoreduction and radiotherapy in locally advanced carcinoma of the prostate: the Radiation Therapy Oncology Group Protocol 92-02. J Clin Oncol. 21(21): 3972-8.

Holzbeierlein JM, et al. 2004. Complications of androgen deprivation therapy for prostate cancer. Curr Opin in Urol. 14(3): 177-83.

NCCN. 2004. Clinical Practice Guidelines in Oncology-v.1.2004. Prostate Cancer.

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

MEASURE 6-5: TREATING CANCER—Adjuvant Radiation After Breast-Conserving Surgery

Description

Adjuvant radiation after breast-conserving surgery (BCS) for women under age 70 with invasive breast cancer

Source

National Comprehensive Cancer Network (NCCN)

Consensus on care

Numerous clinical trials conclude that adjuvant radiation after breast-conserving surgery markedly reduces recurrence. NCCN recommends radiation therapy for patients with negative axillary nodes (category 2A recommendation) or positive nodes (category 1 recommendation). A meta-analysis of 10 studies involving 7,401 cases indicates that recurrence is significantly higher in patients who receive radiation more than 8 weeks after surgery. If the patient also requires chemotherapy, radiation treatment should be given after chemotherapy is completed. Women aged 70 and older who have breast-conserving surgery do not require adjuvant radiation if they have hormonal therapy.

Knowledge vs. practice

Adjuvant radiation for breast cancer is used less often than clinical guidelines recommend. Numerous studies show receipt of adjuvant radiation varies with the patient’s age, health insurance status, geographic access to services, Medicaid coverage, race, ethnicity, and other socioeconomic factors.

Approach to calculating the measure

Numerator

Number of women who undergo radiation treatment within 8 weeks of BCS, or after post-BCS chemotherapy, if chemotherapy is given. Limit to women under age 70 with invasive breast cancer who undergo BCS.

Denominator

Number of women under age 70 with invasive breast cancer who undergo BCS

Potential data source(s)

Special studies of medical records; Surveillance, Epidemiology and End Results (SEER)/Medicare dataset (for 65- to 69-year-olds)

Comments

Limitations

Potential benchmark source(s)

Baseline studies of medical records; SEER/Medicare dataset

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

Key references

Early Breast Cancer Trialists’ Collaborative Group. 2000. Favourable and unfavourable effects on long-term survival of radiotherapy for early breast cancer: an overview of the randomized trials. Lancet. 355(9217): 1757-70.

Fisher B, et al. 2002. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. New Engl J Med. 347:1233-41.

Huang J, et al. 2003. Does delay in starting treatment affect the outcomes of radiotherapy? A systematic review. J Clin Oncol. 21(3): 555-63.

Hughes KS, et al. 2004. Lumpectomy plus Tamoxifen with or without irradiation in women 70 years of age or older with early breast cancer. N Engl J Med. 351(10): 971-7.

NCCN. 2004. Clinical Practice Guidelines in Oncology-v.1.2004. Breast Cancer.

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

MEASURE 6-6: TREATING CANCER—Adjuvant Hormonal Therapy for Invasive Breast Cancer

Description

Adjuvant hormonal therapy for hormone-receptor-positive invasive breast cancer

Source

National Comprehensive Cancer Network (NCCN); American Society of Clinical Oncology; National Institutes of Health Consensus Statement

Consensus on care

NCCN recommends a 5-year course of adjuvant tamoxifen for premenopausal women with hormone-receptor-positive invasive breast cancer followed by 5 years of letrozole (Category 1 recommendation). For postmenopausal women with hormone-receptor-positive invasive breast cancer, NCCN recommends various combinations of aromatase inhibitors and tamoxifen for at least 5 years (Category 1 recommendation). An analysis of 37,000 women in 55 trials found that, after 10 years, 5-year use of adjuvant tamoxifen reduced recurrence and mortality by 47 percent and 26 percent respectively.

Knowledge vs. practice

There are numerous reports showing that adjuvant hormone therapy is used less often than well-established clinical guidelines recommend and that use declines markedly with advancing age.

Approach to calculating the measure

Numerator

Number of women who receive adjuvant hormonal therapy for hormone-receptor-positive invasive breast cancer greater than 1 cm in size

Denominator

Number of women with hormone-receptor-positive invasive breast cancer greater than 1 cm in size

Potential data source(s)

Special studies of medical records

Comments

Hormone-receptor-positive refers to tumors that are estrogen receptor positive or progesterone receptor positive.

Limitations

Potential benchmark source(s)

Baseline studies of medical records

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

Key references

Adjuvant therapy for breast cancer. 2000. NIH Consensus Statement 2000. 17(4): 1-35.

Du XL, et al. 2003. Discrepancy between consensus recommendations and actual community use of adjuvant chemotherapy in women with breast cancer. Ann Intern Med. 138(2): 90-97.

Early Breast Cancer Trialists’ Group. 1998. Tamoxifen for early breast cancer: an overview of the randomized trials. Lancet. 351(9114): 1451-67.

Goldhirsch A, et al. 2003. Meeting highlights: updated international expert consensus on the primary therapy of early breast cancer. J Clin Oncol. 21(17): 3357-65.

Holmes CE, Muss HB. 2003. Diagnosis and treatment of breast cancer in the elderly. CA Cancer J Clin. 53:227-244.

NCCN. 2004. Clinical Practice Guidelines in Oncology-v.1.2004. Breast Cancer.

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

MEASURE 6-7: TREATING CANCER—Adjuvant Combination Chemotherapy for Breast Cancer

Description

Adjuvant combination chemotherapy for women under age 71 with hormone-receptor-negative Stage I to Stage III breast cancer

Source

National Comprehensive Cancer Network (NCCN); National Cancer Institute Consensus Statement

Consensus on care

NCCN recommends that after local surgical treatment, adjuvant combination chemotherapy should be given to all women under age 71 with Stage I, Stage II, or Stage III breast cancer who have hormone-receptor-negative tumors greater than 1 cm (Category 1 recommendation).

Knowledge vs. practice

There are numerous reports showing that combination chemotherapy is used less often than well-established clinical guidelines recommend, especially among older women.

Approach to calculating the measure

Numerator

Number of women under age 71 who receive combination chemotherapy after surgery for a hormone-receptor-negative Stage I to Stage III breast cancer

Denominator

Number of women under age 71 who undergo surgery for hormone-receptor-negative Stage I to Stage III breast cancer

Potential data source(s)

Special studies of medical records; Surveillance, Epidemiology, and End Results (SEER)/Medicare dataset

Comments

For Stage I cancers, include only those cases with tumors larger than 1 cm. Hormone-receptor-negative refers to tumors that are both estrogen-receptor-negative and progesterone-receptor-negative.

Limitations

Potential benchmark source(s)

Baseline studies of medical records; SEER/Medicare dataset

Key references

Cole BF, et al. 2001. Polychemotherapy for early breast cancer: an overview of the randomized clinical trials with quality-adjusted survival analysis. Lancet. 358(9278): 277-86.

Goldhirsch A, et al. 2003. Meeting highlights: updated international expert consensus on the primary therapy of early breast cancer. J Clin Oncol. 21(17): 3357-65.

Harlan LC, et al. 2002. Adjuvant therapy for breast cancer: practice patterns of community physicians. J Clin Oncol. 20(7): 1809-17.

NCCN. 2004. Clinical Practice Guidelines in Oncology-v.1.2004. Breast Cancer.

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

MEASURE 6-8: TREATING CANCER—Adjuvant Chemotherapy After Colon Cancer Surgery

Description

Adjuvant chemotherapy after surgery for Stage III colon cancer

Source

National Comprehensive Cancer Network (NCCN)

Consensus on care

NCCN guidelines recommend 6 months of adjuvant chemotherapy for patients with node-positive colon carcinoma (Category 1 recommendation). There is evidence from randomized clinical trials that adjuvant chemotherapy decreases colon cancer mortality by about one-third.

Knowledge vs. practice

Numerous studies indicate that older patients are less likely to receive recommended adjuvant chemotherapy despite evidence that chemotherapy is well tolerated by older patients. Race, marital status, hospital volume, and individual hospitals are also associated with receipt of adjuvant chemotherapy.

Approach to calculating the measure

Numerator

Number of patients with Stage III colon cancer who receive a full course of adjuvant chemotherapy after surgery

Denominator

Number of patients with Stage III colon cancer who undergo surgery

Potential data source(s)

Surveillance, Epidemiology and End Results (SEER)/Medicare dataset; special studies of medical records

Comments

Stage III colon cancer refers to tumors that have spread through the wall of the colon or rectum into 1 to 4 regional lymph nodes and nearby tissues or organs. The current standard for chemotherapy is a 6-month course.

Limitations

Potential benchmark source(s)

SEER/Medicare dataset; baseline studies of medical records

Key references

Ayanian JZ, et al. 2003. Use of adjuvant chemotherapy and radiation therapy for colorectal cancer in a population-based cohort. J Clin Oncol. 21(7): 1293-300.

Moore HC, Haller DG. 1999. Adjuvant therapy of colon cancer. Semin Oncol. 26:545-55.

NCCN. 2004. Clinical Practice Guidelines in Oncology-v.2.2004. Colon Cancer.

Neugut AI, et al. 2002. Use of adjuvant chemotherapy and radiation therapy for rectal cancer among the elderly: a population-based study. J Clin Oncol. 20(11): 2643-50.

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

MEASURE 6-9: TREATING CANCER—Follow-Up Mammography After Treatment for Breast Cancer

Description

Follow-up mammography after treatment for Stage 0 to Stage III breast cancer

Source

American Society of Clinical Oncology (ASCO); National Comprehensive Cancer Network (NCCN)

Consensus on care

ASCO and NCCN recommend that women treated with breast-conserving therapy have a first post-treatment mammogram about 6 months after radiotherapy is complete (ASCO Level of evidence I, Grade of recommendation A; NCCN Category 2a recommendation). Women treated for breast cancer are at risk of recurrence. The 20-year findings of the National Surgical Adjuvant Breast and Bowel Project indicate that 14.3 percent of women experienced a recurrent tumor in the same breast after lumpectomy and adjuvant radiation. Recurrence was 39.2 percent among women with no adjuvant radiation.

Knowledge vs. practice

An analysis of data from the national Breast Cancer Surveillance Consortium found that 78 percent of women had returned for a mammogram 30 months following a breast cancer diagnosis. Within 12 months of diagnosis, about half the women had a first follow-up mammogram. Women who did not receive radiation treatment after breast-conserving surgery were less likely to return for follow-up despite being at significant risk of recurrence.

Approach to calculating the measure

Numerator

Number of women with a return mammogram by 19 months after a Stage 0 to Stage III breast cancer diagnosis

Denominator

Number of women with Stage 0 to Stage III breast cancer

Potential data source(s)

Georgia Comprehensive Cancer Registry (with enhancements); Surveillance, Epidemiology, and End Results (SEER)/Medicare dataset, special studies medical records; mammography registry (if available).

Comments

The 19-month period in the numerator is based on a 12-month follow-up period after a 7-month therapeutic period. The goal for this measure should be less than 100 percent to account for those women who undergo bilateral total mastectomies.

Limitations

Potential benchmark source(s)

Breast Cancer Surveillance Consortium; SEER/Medicare dataset; baseline studies of medical records

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

Key references

Fisher, B et al. 2002. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. New Eng J Med. 347(16): 1233-41.

Geller BM, et al. 2003. Mammography surveillance following breast cancer. Breast Cancer Res Treat. 81(2): 107-15.

NCCN. 2004. Clinical Practice Guidelines in Oncology-v.1.2004. Breast Cancer.

Smith, et al. 1999. American Society of Clinical Oncology 1998 update of recommended breast cancer surveillance guidelines. J Clin Oncol. 17(3): 1080-2.

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

MEASURE 6-10: TREATING CANCER—Follow-Up Colonoscopy After Treatment for Colorectal Cancer

Description

Follow-up colonoscopy after treatment for Stage I to Stage III colorectal cancer

Source

National Comprehensive Cancer Network (NCCN)

Consensus on care

NCCN recommends that Stage I to III colorectal cancer patients have a follow-up colonoscopy by 1 year after resection (Category 2A recommendation). A study of 3,546 VA patients strongly supports a mortality benefit for follow-up colonoscopy in patients with nonmetastatic colorectal cancer. The researchers compared 5-year mortality rates and found that risk of death was decreased by 43 percent in the group of patients who had at least one follow-up colonoscopy compared with the group of patients who had no follow-up.

Knowledge vs. practice

Use of endoscopic procedures after potentially curative resection for local- or regional-stage colorectal cancer varies with patient-related factors and local practice patterns.

Approach to calculating the measure

Numerator

Number of Stage I to Stage III colorectal cancer cases with a colonoscopy within 1 year of surgery

Denominator

Number of Stage I to Stage III colorectal cancer cases

Potential data source(s)

Surveillance, Epidemiology, and End Results (SEER)/Medicare dataset; special studies of medical records

Comments

Limitations

Potential benchmark source(s)

SEER/Medicare dataset; baseline studies of medical records

Key references

Cooper GS, et al. 2000. Patterns of endoscopic follow-up after surgery for nonmetastatic colorectal cancer. Gastrointest Endosc. 52(1): 33-8.

Fisher DA, et al. 2003. Mortality and follow-up colonoscopy after colorectal cancer. Am J of Gastroenterol. 98(4): 901-6.

NCCN. 2004. Clinical Practice Guidelines in Oncology-v.2.2004. Colon Cancer.

Rulyak SJ, et al. 2004. Clinical and sociodemographic factors associated with colon surveillance among patients with a history of colorectal cancer. Gastrointest Endosc. 59(2): 239-47.

Winawer S, et al. 2003. Colorectal cancer screening and surveillance: clinical guidelines and rationale-update based on new evidence. Gastroenterology. 124(2): 544–60.

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

MEASURE 6-11: TREATING CANCER—Cancer Pain Assessment

Description

Cancer patients who are regularly assessed for pain

Source

National Comprehensive Cancer Network (NCCN); Joint Commission on Accreditation of Healthcare Organizations, (JCAHO); Oncology Nursing Society; American Pain Society (APS)

Consensus on care

Cancer patients—at all stages of the disease—frequently experience severe pain. Regular reassessment of patients’ pain is integral to effective cancer pain treatment. Patients (or family members) should be directly queried regarding their level of pain. Several studies indicate that an important predictor of inadequate pain relief is a discrepancy between the patient’s and physician’s assessment of the severity of pain. NCCN advises clinicians to screen cancer patients for pain every time they are seen and that patients should use a rating scale to quantify their pain (Category 2A recommendation). APS encourages health providers to view pain as “the fifth vital sign” so that patients’ pain is routinely checked with pulse, blood pressure, core temperature, and respiration in every patient encounter.

Knowledge vs. practice

The proportion of cancer patients who receive routine pain assessments is not known. Cancer pain is often untreated or undertreated. Several studies suggest that some groups of cancer patients are more likely to be inadequately treated for pain, especially racial or ethnic minorities, women, and elderly persons.

Approach to calculating the measure

Numerator

Number of cancer patient encounters where patient was assessed for pain

Denominator

Number of cancer patient encounters

Potential data source(s)

Special patient surveys; studies of medical records

Comments

This measure should be used in all health care settings (hospital, physician office, nursing homes, hospice, etc.) for all patients who are not comatose. It will require different sampling and monitoring approaches depending on the health care setting.

Limitations

Potential benchmark source(s)

Baseline patient surveys and studies of medical records; JCAHO

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

Key references

APS. 1995. Pain: The Fifth Vital SignTM. [Online] Available: http://www.ampainsoc.org/advocacy/fifth.htm [accesseed November 30, 2004].

JCAHO. 2004. Pain Management Performance Measurement Final Report, JCAHO Inpatient Cancer Pain Management Measures. A collaboration of the American Medical Association, JCAHO, and the National Committee on Quality Assurance. Unpublished.

NCCN. 2004. Clinical Practice Guidelines in Oncology-v.1.2004. Cancer Pain.

ONS. 2002. [ONS Position]. Cancer Pain Management. Pittsburgh, PA: ONS. [Online] Available: http://www.ons.org/Positions/Cancer_Pain.pdf.

Symptom management in cancer: pain, depression, and fatigue. 2002. NIH Consens State Sci Statements. 19(4):1-29.

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

MEASURE 6-12: TREATING CANCER—Prevalence of Pain Among Cancer Patients

Description

Prevalence of more than minor pain among cancer patients

Source of measure

National Comprehensive Cancer Network; Joint Commission on Accreditation of Healthcare Organizations; Oncology Nursing Society; American Pain Society

Consensus on care

Unrelieved pain has debilitating adverse physical and psychological effects. Regular reassessment of patients’ pain is integral to effective cancer pain treatment. Most cancer pain can be treated safely and effectively. The World Health Organization (WHO) has developed an approach to treating cancer pain that is widely endorsed in the United States and around the world. WHO outlines a step by step algorithm that suggests patients be started on acetaminophen or a nonsteroidal anti-inflammatory drug. If insufficient, the patient should then receive a “weak” opioid, such as codeine, and, if necessary, progress to a “strong” opioid such as morphine.

Knowledge vs. practice

Cancer pain frequently goes untreated or undertreated. There are no definitive estimates of the prevalence of pain among cancer patients and survivors; estimates range from 14 percent to 100 percent.

Approach to calculating the measure

Numerator

Number of cancer patients who report being in more than minor pain

Denominator

Number of cancer patients who are not comatose

Potential data source(s)

Special patient surveys; studies of medical records

Comments

This measure should be used in all health care settings (hospitals, physician offices, nursing homes, hospice, etc.). It will require different sampling and monitoring approaches depending on the health care setting. A validated pain scale that defines “minor pain” must be used in each care setting. The threshold for minor pain should be reported along with the measure.

Limitations

Low prevalence estimates may be due to poor medical record documentation.

Potential benchmark source(s)

Baseline patient surveys and studies of medical records

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

Key references

APS. 1995. Quality improvement guidelines for the treatment of acute pan and cancer pain. JAMA. 274(23): 1874-80.

Goudas J, et al. 2001. Management of Cancer Pain: Volume 1. Evidence Report/Technology Assessment Number 35. AHRQ Publication Number 02-E002. Rockville, MD: AHRQ.

NCCN. 2004. Clinical Practice Guidelines in Oncology-v.1.2004. Cancer Pain.

ONS. 2002. Cancer Pain Management [ONS Position]. Pittsburgh, PA: ONS. Available: http://www.ons.org/publications/positions/CancerPainManagement.shtml.

Symptom management in cancer: pain, depression, and fatigue. 2002. NIH Consens State Sci Statements. 19(4):1-29.

WHO. 1996. Cancer Pain Relief. 2nd edition. Geneva: WHO.

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

MEASURE 6-13: TREATING CANCER—Cancer Deaths in Hospice

Description

Cancer deaths in hospice per 100 cancer deaths

Source of measure

National Healthcare Quality Report

Consensus on care

Hospice is the gold standard of care for dying persons, their families, and other loved ones. NCCN recommends that patients with months to weeks to live be offered palliative or hospice care and that patients with weeks to days to live should be given intensive palliative care—not more anticancer treatments (Category 2A recommendation).

Knowledge vs. practice

Hospice use among cancer patients is increasing although substantial numbers of dying cancer patients are not referred at all. In one study of more than 170,000 Medicare beneficiaries who had breast, colorectal, lung, or prostate cancer and had died, only 30 percent of the study population had used hospice services before they died. Several studies indicate that access to hospice care varies with patient’s age, race and ethnicity, supplemental Medicare coverage, income, and other socioeconomic factors.

Approach to calculating the measure

Numerator

Number of adults discharged (disposition = dead) from hospice care with cancer as the underlying cause of death (see comment below)

Denominator

Number of deaths where cancer is the underlying cause of death (see comment below)

Potential data source(s)

Surveillance, Epidemiology and End Results (SEER)/ Medicare dataset; vital statistics (mortality)

Comments

Rate = (Cancers deaths in hospice/All cancer deaths) × 100. Estimate should be age-adjusted to allow comparisons. Cancer diagnoses include ICD-10 codes C00-C97, ICD-9 codes 140-208.

Limitations

Potential benchmark source(s)

National Healthcare Quality Report; National Home and Hospice Care Survey; Outcome and Assessment Information Set.

Key references

AHRQ. 2003. National Healthcare Quality Report. Rockville, MD: U.S. DHHS.

Lackan NA, et al. 2004. Decreasing variation in the use of hospice among older adults with breast, colorectal, lung, and prostate cancer. Med Care. 42(2):116-22.

NCCN. 2004. Clinical Practice Guidelines in Oncology-v.1.2004. Palliative Care.

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

MEASURE 6-14: TREATING CANCER—Cancer Patients’ Hospice Length of Stay

Description

Cancer patients who receive hospice care for at least 7 days

Source

National Healthcare Quality Report; National Comprehensive Cancer Network (NCCN) (Category 2a recommendation)

Consensus on care

Hospice is the gold standard of care for dying persons, their families, and other loved ones. NCCN recommends that patients with months to weeks to live be offered palliative or hospice care and that patients with weeks to days to live should be given intensive palliative care—not more anticancer treatments. There is no consensus on how long cancer patients should stay in hospice to receive maximum benefit.

Knowledge vs. practice

A substantial proportion of cancer patients who receive hospice care, receive it just days before death. An analysis of 28,777 Medicare beneficiaries who died of breast cancer, lung cancer, or colorectal or other gastrointestinal cancers found that, among those who died in hospice, 17 percent had exceedingly short stays of only 3 or fewer days. Several studies indicate that access to hospice care varies with patient’s age, race and ethnicity, supplemental Medicare coverage, income, and other socioeconomic factors.

Approach to calculating the measure

Numerator

Number of adults who are discharged from hospice (disposition = dead) with cancer listed as the underlying cause of death with a length of stay of at least 7 days

Denominator

Number of adults with a cancer diagnosis who are discharged from hospice (disposition = dead) with cancer listed as the underlying cause of death

Potential data source(s)

Surveillance, Epidemiology and End Results (SEER)/Medicare dataset

Comments

Cancer diagnoses include ICD-10 codes C00-C97, ICD-9 codes 140-208. Because hospice length of stay differs depending on the care setting, separate rates should be reported for inpatient and outpatient settings.

Limitations

Potential benchmark source(s)

SEER/Medicare dataset

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

Key references

AHRQ. 2003. National Healthcare Quality Report. Rockville, MD: U.S. DHHS.

Earle CC, et al. 2004. Trends in the aggressiveness of cancer care near the end of life. J Clin Oncol. 22(2): 315-21.

Lackan NA, et al. 2004. Decreasing variation in the use of hospice among older adults with breast, colorectal, lung, and prostate cancer. Med Care. 42(2): 116-22.

NCCN. 2004. Clinical Practice Guidelines in Oncology-v.1.2004. Palliative Care.

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

MEASURE 6-15: TREATING CANCER—Breast Cancer 5- and 10-Year Survival Rates

Description

Breast cancer 5- and 10-year relative survival rates (females)

Source

Surveillance, Epidemiology, and End Results Program (SEER)

Consensus on care

Not applicable

Knowledge vs. practice

Early detection, improved quality of care, and better access to care should increase breast cancer survival. Many studies show consistently poorer breast cancer survival rates among lower-income women and women without health insurance. The 5-year relative breast cancer survival rate in metropolitan Atlanta was 84.6 percent for cancers diagnosed from 1992 to 1999.

Approach to calculating the measure

Numerator

Proportion of women diagnosed with breast cancer in the past 5 (or 10) years who are still alive (see comments below)

Denominator

Proportion of women from the general population of comparable age to those diagnosed with breast cancer expected to be alive (based on mortality rates from all causes)

Potential data source(s)

SEER; Georgia Comprehensive Cancer Registry (with enhancements)

Comments

Relative survival adjusts for causes of death besides cancer. It is the ratio of the number of cancer patients alive at a point in time to the number of people expected to be alive from a comparable, cancer-free population. Georgia should also consider monitoring stage-specific breast cancer survival rates.

Limitations

Breast cancer survival rates are subject to lead-time bias and length bias, and should be interpreted with caution. Early cancer detection pushes back the timing of diagnosis which can artificially lengthen the survival period.

Potential benchmark source(s)

SEER

Key references

Bradley CJ, et al. 2002. Race, socioeconomic status, and breast cancer treatment and survival. J Natl Cancer Inst. 94(7): 490-6.

Liff J (Georgia Center for Cancer Statistics). 2004. Unpublished data.

Ries LAG, et al., Editors. 2004. SEER Cancer Statistics Review, 1975-2000. Bethesda, MD: NCI. [Online] Available: http://seer.cancer.gov/csr/1975_2000.

Singh GH, et al. 2003. Area Socioeconomic Variations in U.S. Cancer Incidence, Mortality, Stage, Treatment, and Survival, 1975-1999. NCI Cancer Surveillance Monograph Series, Number 4. NIH Publication Number 03-5417. Bethesda, MD: NCI.

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

MEASURE 6-16: TREATING CANCER—Colorectal Cancer 5- and 10-Year Survival Rates

Description

Colorectal cancer 5- and 10-year relative survival rates

Source

Surveillance, Epidemiology, and End Results Program (SEER)

Consensus on care

Not applicable

Knowledge vs. practice

Early detection, improved quality of care, and better access to care should increase colorectal cancer survival. Many studies show consistently poorer colorectal cancer survival rates among lower-income patients and people without health insurance. The 5-year relative colorectal cancer survival rate in metropolitan Atlanta was 61.6 percent for cancers diagnosed from 1992-1999.

Approach to calculating the measure

Numerator

Proportion of adults diagnosed with colorectal cancer in the past 5 (or 10) years who are still alive (see comments below)

Denominator

Proportion of adults from the general population of comparable age to those diagnosed with colorectal cancer expected to be alive (based on mortality rates from all causes)

Potential data source(s)

SEER; Georgia Comprehensive Cancer Registry (with enhancements)

Comments

Relative survival adjusts for causes of death besides cancer. It is the ratio of the number of cancer patients alive at a point in time to the number of people expected to be alive from a comparable cancer-free population. Georgia should also consider monitoring stage-specific colorectal cancer survival rates.

Limitations

Colorectal cancer survival rates are subject to lead-time bias and length bias and should be interpreted with caution. Early cancer detection pushes back the timing of diagnosis and can thereby artificially lengthen the survival period.

Potential benchmark source(s)

SEER

 

Liff J (Georgia Center for Cancer Statistics). 2004. Unpublished data.

Ries LAG, et al., Editors. 2004. SEER Cancer Statistics Review, 1975-2000. Bethesda, MD: NCI. [Online] Available: http://seer.cancer.gov/csr/1975_2000.

Singh GH, et al. 2003. Area Socioeconomic Variations in U.S. Cancer Incidence, Mortality, Stage, Treatment, and Survival, 1975-1999. NCI Cancer Surveillance Monograph Series, Number 4. NIH Publication Number 03-5417. Bethesda, MD: NCI.

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

MEASURE 6-17: TREATING CANCER—Lung Cancer 5- and 10-Year Survival Rates

Description

Lung cancer 5- and 10-year relative survival rates

Source

Surveillance, Epidemiology and End Results Program (SEER)

Consensus on care

Not applicable

Knowledge vs. practice

Early detection, improved quality of care, and better access to care should increase lung cancer survival. Many studies show consistently poorer lung cancer survival rates among lower income patients and people without health insurance. The 5-year relative lung cancer survival rate in metropolitan Atlanta was 16.5 percent for cancers diagnosed from 1992 to 1999.

Approach to calculating the measure

Numerator

Proportion of adults who were diagnosed with lung cancer in the past 5 (or 10) years and are currently alive (see comments below)

Denominator

Proportion of adults from the general population of comparable age to those diagnosed with lung cancer expected to be alive (based on mortality rates from all causes)

Potential data source(s)

SEER; Georgia Comprehensive Cancer Registry (with enhancements)

Comments

Relative survival adjusts for causes of death besides cancer. It is the ratio of the number of cancer patients alive at a point in time to the number of people expected to be alive from a comparable cancer-free population. Georgia should also consider monitoring stage-specific lung cancer survival rates.

Limitations

Potential benchmark source(s)

SEER

Key references

Liff J (Georgia Center for Cancer Statistics). 2004. Unpublished data.

Ries LAG, et al., Editors. 2004. SEER Cancer Statistics Review, 1975-2000. Bethesda, MD: NCI. [Online] Available: http://seer.cancer.gov/csr/1975_2000.

Singh GH, et al. 2003. Area Socioeconomic Variations in U.S. Cancer Incidence, Mortality, Stage, Treatment, and Survival, 1975-1999. NCI Cancer Surveillance Monograph Series, Number 4. NIH Publication Number 03-5417. Bethesda, MD: NCI.

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

MEASURE 6-18: TREATING CANCER—Prostate Cancer 5- and 10-Year Survival Rates

Description

Prostate cancer 5- and 10-year relative survival rates

Source

Surveillance, Epidemiology, and End Results Program (SEER)

Consensus on care

Not applicable

Knowledge vs. practice

Early detection, improved quality of care, and better access to care should increase prostate cancer survival. Uninsured, low-income, and African-American men are at greater risk for delayed diagnosis and death from prostate cancer. The 5-year relative prostate cancer survival rate in metropolitan Atlanta was 97.5 percent for cancers diagnosed from 1992-1999.

Approach to calculating the measure

Numerator

Proportion of men diagnosed with prostate cancer in the past 5 (or 10) years who are still alive (see comments below)

Denominator

Proportion of men from the general population of comparable age to those diagnosed with prostate cancer expected to be alive (based on mortality rates from all causes)

Potential data source(s)

SEER; Georgia Comprehensive Cancer Registry (with enhancements)

Comments

Relative survival adjusts for causes of death besides cancer. It is the ratio of the number of cancer patients alive at a point in time to the number of people expected to be alive from a comparable cancer-free population. Georgia should also consider monitoring stage-prostate cancer survival rates.

Limitations

Prostate cancer survival rates are subject to lead-time bias and length bias and should be interpreted with caution. Early cancer detection pushes back the timing of diagnosis which can artificially lengthen the survival period.

Potential benchmark source(s)

SEER

Key references

Clegg LX, et al. 2002. Cancer survival among US whites and minorities. Arch Intern Med. 162(17): 1985-93.

Liff J (Georgia Center for Cancer Statistics). 2004. Unpublished data.

Ries LAG, et al., Editors. 2004. SEER Cancer Statistics Review, 1975-2000. Bethesda, MD: NCI. [Online] Available: http://seer.cancer.gov/csr/1975_2000.

Singh GH, et al. 2003. Area Socioeconomic Variations in U.S. Cancer Incidence, Mortality, Stage, Treatment, and Survival, 1975-1999. NCI Cancer Surveillance Monograph Series, Number 4. NIH Publication Number 03-5417. Bethesda, MD: NCI.

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

MEASURE 6-19: TREATING CANCER—Breast Cancer Mortality Rate

Description

Breast cancer deaths per 100,000 females per year

Source

National Healthcare Quality Report; Healthy People 2010

Consensus on care

Improving the effectiveness of Georgia breast cancer care should ultimately reduce related mortality.

Knowledge vs. practice

Not applicable

Approach to calculating the measure

Numerator

Number of female deaths due to breast cancer (ICD-10 code C50) per year

Denominator

Number of females 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].

IOM. 2003. Fulfilling the Potential of Cancer Prevention and Early Detection. Washington, DC: The National Academies Press.

U.S. DHHS. 2000. Healthy People 2010: Understanding and Improving Health. 2nd edition. Chapter 3 Cancer. Washington, DC: U.S. Government Printing Office. [Measure 3-5.]

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

MEASURE 6-20: TREATING CANCER—Colorectal Cancer Mortality Rate

Description

Colorectal cancer deaths per 100,000 persons per year

Source

National Healthcare Quality Report; Healthy People 2010

Consensus on care

Improving the effectiveness of Georgia colorectal cancer care should ultimately reduce related mortality.

Knowledge vs. practice

Not applicable

Approach to calculating the measure

Numerator

Number of deaths due to colorectal cancer (ICD-10 codes C18-C21) 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 could 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.

CDC. 2004. Behavioral Risk Factor Surveillance System, Prevalence Data: Georgia 2002 Colorectal Cancer Screening. [Online] Available: http://apps.nccd.cdc.gov/brfss/display.asp?cat=CC&yr=2002&qkey=7400&state=GA [accessed November 26, 2004].

GDPH. 2004. OASIS Web Query. [Online] http://oasis.state.ga.us/webquery/death.html.

IOM. 2003. Fulfilling the Potential of Cancer Prevention and Early Detection. Washington, DC: The National Academies Press.

U.S. DHHS. 2000. Healthy People 2010: Understanding and Improving Health. 2nd edition. Chapter 3 Cancer. Washington, DC: U.S. Government Printing Office. [Measure 3-5.]

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

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.]

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

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.]

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

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.]

Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

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Suggested Citation:"6 Treating Cancer." Institute of Medicine and National Research Council. 2005. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. Washington, DC: The National Academies Press. doi: 10.17226/11244.
×

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Shortly after 1998, leading members of Georgia's government, medical community, and public-spirited citizenry began considering ways in which some of Georgia's almost $5 billion, 25-year settlement from the tobacco industry's Master Settlement Agreement with the 50 states could be used to benefit Georgia residents. Given tobacco's role in causing cancer, they decided to create an entity and program with the mission of making Georgia a national leader in cancer prevention, treatment, and research. This new entity--called the Georgia Cancer Coalition, Inc. (GCC)-- and the state of Georgia subsequently began implementing a far-reaching state cancer initiative that includes five strategic goals: (1) preventing cancer and detecting existing cancers earlier; (2) improving access to quality care for all state residents with cancer; (3) saving more lives in the future; (4) training future cancer researchers and caregivers; and (5) turning the eradication of cancer into economic growth for Georgia.

Assessing the Quality of Cancer Care identifies a set of measures that could be used to gauge Georgia's progress in improving the quality of its cancer services and in reducing cancer-related morbidity and mortality.

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