2018-19 Cancer Network Annual Report

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Differentiated Orthopedic Care at Sentara

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 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.

Quality Breast1

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.

Quality Breast2

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 more than 4 positive regional lymph nodes.

Quality Breast3

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.

Quality Breast4

NBX

Image or palpation-guided needle biopsy to the primary site is performed to establish diagnosis of breast cancer.

Quality NBX

Colorectal

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

Quality Colorectal1

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.

Quality Colorectal2

Gastric

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

Quality Gastric

Rectal

Preoperative 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.

Quality Rectal

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.

Quality Lung1

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

Quality Lung2