2015-16 Cancer Network Annual Report

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2013 Quality Measures Data

To earn voluntary accreditation, a cancer program must be evaluated every three years and meet or exceed quality standards established by the Commission on Cancer. A new standard now requires accredited programs to reach specific performance levels on measuring quality for treating patients with breast, colon, and rectal cancers. These quality measures are defined by the Commission on Cancer and endorsed by the National Quality Forum. The Sentara Cancer Network tracked and monitored these measures before they were required by the Commission on Cancer. Multi-year performance is shared here.

Breast

Radiation therapy is administered within 1 year of diagnosis for women under the age of 70 receiving breast conservation surgery for breast cancer

Combination chemotherapy is considered or administered within 4 months of diagnosis for women under 70 with T1cN0M0, or Stage II or III hormone receptor negative breast cancer

Tamoxifen Administration
Tamoxifen or third generation aromatase inhibitor is considered or administered within 1 year of diagnosis for women with T1cN0M0, or Stage II or III hormone receptor positive breast cancer

Radiation Therapy Administration Following Mastectomy
Radiation therapy is considered or administered following any mastectomy within 1 year (365 days) of diagnosis of breast cancer
for women with >= 4 positive regional lymph nodes

Colorectal

At least 12 regional lymph nodes are removed and pathologically examined for resected colon cancer

Adjuvant chemotherapy is considered or administered within4 months of diagnosis for patients under the age of 80 with Stage III (lymph node positive) colon cancer

Lobectomy Mortality*

Sentara Cancer Network vs. Society of Thoracic Surgeons (STS) National Database Benchmark 2010-2014

Sentara CarePlex Hospital, Sentara Leigh Hospital, Sentara Norfolk General Hospital, Sentara Obici Hospital, Sentara Virginia Beach General Hospital, Sentara Williamsburg Regional Medical Center
Chart-Lobectomy-Mortality

 

Pancreatic Resection Mortality*

Sentara Cancer Network consistently meets or exceeds the data presented in the Journal of the National Cancer Institute.

Sentara CarePlex Hospital, Sentara Leigh Hospital, Sentara Norfolk General Hospital, Sentara Virginia Beach General Hospital
Chart-Pancreatic-Resection-Mortality

Breast Re-Excision Rate*

A national study of breast cancer patients established a benchmark that no more than 25.7% of women undergoing breast surgery had to have a “re-excision” or second surgery. In the Sentara Cancer Network, our teams have worked hard to reduce that number to 14% in 2014, giving more women the advantage of having all cancer removed during the first surgery.


2013 NAPBC Quality Measures Data

In compliance with Standard 6.1 of the National Accreditation Program for Breast Centers, the Sentara Cancer Network conducts and shares studies to measure quality and outcomes. The breast program leadership communicates the findings and discusses the outcomes and importance with the breast center staff, participants of the interdisciplinary conferences and the network steering committee.

Breast Conservation Rate for Women with AJCC Stage 0, I or II Breast Cancer

Sentara exceeds the NAPBC goal of at least 50% of cases.
Chart-Breast-Conservation-Rate

Needle Biopsy Performed Prior to Surgical Treatment of Breast Cancer

Sentara exceeds the NAPBC goal of at least 80% of cases.Chart-Needle-Biobsy