2016-17 Cancer Network Annual Report

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Quality and Outcomes

Our quality measures

Every three years, the American College of Surgeons’ Commission on Cancer surveys the Sentara Cancer Network to evaluate the effectiveness of the services provided, the utilization of Sentara Martha Jefferson Hospital multidisciplinary care, clinical quality, and the institution’s commitment to community outreach. As part of these standards, the Commission on Cancer reviews clinical quality metrics to ensure the cancer program is in compliance and identifying any opportunities for improvement.

Multi-year performance is shown below with the US and VA data acquired from the American College of Surgeons’ National Cancer Data Base (NCDB).

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 concerned 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 within 4 months of diagnosis for patients under the age of 80 with Stage III (lymph node positive) colon cancer.

Rectal

Peroperative chemo and radiation are administered for clinical AJCC T3N0, T4N0, or Stage III; or postoperative chemo and radiation are administered within 180 days of diagnosis for clinical AJCC T1-2N0 with pathologic AJCC T3N0, T4N0, or Stage III; or treatment is recommended for patients under the age of 80 receiving resection for rectal cancer.

Gastric

At least 15 lymph nodes are removed and pathologically examined for resected gastric cancer.

Lung

Systemic chemotherapy is administered within 4 months to day preoperatively or day of surgery to 6 months postoperatively, or it is recommended for surgically resected cases with pathologic lymph node-positive.

Surgery is not the first course of treatment for cN2, M0 lung cases.