Assessing the Quality of Cancer Care An Approach to Measurement in Georgia (2005) / Chapter Skim
Currently Skimming:
6 Treating Cancer
6 Treating Cancer
Pages 160-222
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 160... ...
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.
|
From page 161... ...
At the end of the chapter, potential data sources for measures in the treat
|
From page 162... ...
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)
|
From page 163... ...
. 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)
|
From page 164... ...
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.
|
From page 165... ...
· 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 repre sents the tumor grade and the likelihood of spread. Scores range from 2 to 10; the higher the value, the higher the risk of spread.
|
From page 166... ...
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.
|
From page 167... ...
Appropriate hormonal therapy with external beam radiation therapy for prostate cancer. The third recommended measure is the proportion of highrisk prostate cancer patients who are treated with appropriate external beam radiation therapy and receive hormonal therapy for at least 2 years.
|
From page 168... ...
· 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.
|
From page 169... ...
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.
|
From page 170... ...
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.
|
From page 171... ...
. 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.
|
From page 172... ...
· 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.
|
From page 173... ...
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.
|
From page 174... ...
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.
|
From page 175... ...
. 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)
|
From page 176... ...
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.
|
From page 177... ...
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.
|
From page 178... ...
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.
|
From page 179... ...
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.
|
From page 180... ...
SOURCE: GDPH, 2004. 250 240 230 220 people 210 100,000 200 per 190 180 Deaths 170 160 150 1994 1995 1996 1997 1998 1999 2000 2001 2002 Year FIGURE 6-2 Mortality rate for all cancers in Georgia, 1994-2002.
|
From page 181... ...
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.
|
From page 182... ...
and Epidemiology, and are GA- SEER/ Medicare Recommended Registry; Home Sources, for collection Cancer Surveillance, GCCR, GA- SEER Data = National data and = Sources SEER Georgia-Based GA- CORE current Data to Sources Methods, Comprehensive NHHCS Potential Data Claims Consortium; Report; Georgia Potential Concepts, = 2, enhancements 6-2 Quality Measures trials deaths length rates that prevalence rates GCCR Surveillance assessment hospice stay Chapter treatment radiation hormonal therapy chemotherapy follow-up and in of TABLE Quality Clinical Primary Adjuvant Adjuvant Adjuvant Treatment Pain Cancer Hospice Survival Death See a NOTE: Cancer Healthcare indicates
|
From page 183... ...
Cancer Patients' Participation in Clinical Trials Measure 6-2. Inappropriate Hormonal Therapy Before Radical Prostatectomy Measure 6-3.
|
From page 184... ...
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 Baseline participation rates source(s)
|
From page 185... ...
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)
|
From page 186... ...
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)
|
From page 187... ...
2004. Changing trends in national practice for external beam radiotherapy for clinically localized prostate cancer: 1999 Patterns of Care survey for prostate cancer.
|
From page 188... ...
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.
|
From page 189... ...
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.
|
From page 190... ...
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)
|
From page 191... ...
2002. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer.
|
From page 192... ...
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.
|
From page 193... ...
1998. Tamoxifen for early breast cancer: an overview of the randomized trials.
|
From page 194... ...
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)
|
From page 195... ...
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)
|
From page 196... ...
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)
|
From page 197... ...
2002. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer.
|
From page 198... ...
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)
|
From page 199... ...
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.)
|
From page 200... ...
2004. Pain Management Performance Measurement Final Report, JCAHO Inpatient Cancer Pain Management Measures.
|
From page 201... ...
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.)
|
From page 202... ...
2002. Cancer Pain Management [ONS Position]
|
From page 203... ...
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.
|
From page 204... ...
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.
|
From page 205... ...
2003. National Healthcare Quality Report.
|
From page 206... ...
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.
|
From page 207... ...
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.
|
From page 208... ...
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.
|
From page 209... ...
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.
|
From page 210... ...
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)
|
From page 211... ...
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)
|
From page 212... ...
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 National Healthcare Quality Report; Healthy People 2010; source(s)
|
From page 213... ...
Potential benchmark National Healthcare Quality Report; Healthy People 2010; source(s) National Vital Statistics System Key references AHRQ.
|
From page 214... ...
Potential benchmark National Healthcare Quality Report; Healthy People 2010; source(s) National Vital Statistics System Key references AHRQ.
|
From page 215... ...
2002. Three-month neoadjuvant hormonal therapy before radical prostatectomy: a 7-year follow-up of a randomized controlled trial.
|
From page 216... ...
2001. Polychemotherapy for early breast cancer: an overview of the randomised clinical trials with quality-adjusted sur vival analysis.
|
From page 217... ...
2002. Adjuvant therapy for breast cancer: practice patterns of community physicians.
|
From page 218... ...
2002. Quality of breast cancer care: what do we know?
|
From page 219... ...
2004a. Breast Cancer PDQ: Treatment.
|
From page 220... ...
2004. Comparison of outcomes in cancer patients treated within and outside clinical trials: conceptual framework and structured review.
|
From page 221... ...
2005. American Society of Clinical Oncology Technology Assessment on the use of aromatase inhibitors as adjuvant therapy for postmenopausal women with hormone receptor-positive breast cancer: status report 2004.
|
From page 222... ...
2004. Changing trends in national practice for external beam radiotherapy for clinically localized pros tate cancer: 1999 Patterns of Care survey for prostate cancer.
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.