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and Research > 2022 Quality & Outcomes

2022 Quality & Outcomes

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 Southeast region data acquired from the American College of Surgeons’ National Cancer Data Base (NCDB).



Radiation therapy is administered within 1 year of diagnosis for women under the age of 70 receiving breast conservation surgery for 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 IB-III hormone receptor positive breast cancer.

Radiation Therapy Administration Following Mastectomy

Radiation is recommended or administered following any mastectomy within 1 year (365 days) of diagnosis of breast cancer for women with 4 or more positive regional nodes.


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

BCSdx (First Therapeutic Breast Surgery)

First therapeutic breast surgery in a non-neoadjuvant setting is performed within 60 days of diagnosis for patients with AJCC clinical stage I-III breast cancer.

MAC (Combination Chemotherapy or Chemo-Immunotherapy)

Combination chemotherapy or chemo-immunotherapy (ifHER2 positive) is recommended or administered within 4 months (120 days) of diagnosis for women under 70 with AJCC T1cN0M0, or stage IB-III hormone receptor negative breast cancer.


Colorectal Lymph Node Removal

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

Adjuvant Chemotherapy

Adjuvant chemotherapy is recommended or administered within 4 months (120 days) of diagnosis for patients under the age of 80 with AJCC Stage III (lymph node positive) colon cancer.


Gastric Lymph Node Removal

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

Neoadjuvant Chemotherapy

Neoadjuvant chemotherapy and/or chemo-radiation is administered within 120 days preoperatively for patients with AJCC cT2+ or cN1+, cM0 for gastric carcinoma; or (cT2 and poor differentiation) or cT3+ or cN1+, cM0 for esophageal junction carcinoma; age 18-79



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 (pN1) and (pN2) NSCLC.

Rectal Resections

Circumferential Margin is greater than 1mm from the tumor to the inked, non-serosalized resection margin for Rectal Resections

Head and Neck

Time to initiation of postoperative radiation therapy less than 6 weeks for patients with surgically-managed head and neck squamous cell carcinoma


Melanoma adjuvant systemic therapy was administered within 6 months of surgery or recommended for eligible patients with Stage IIIB-D resected melanoma

Sentara Cancer Network Top 20 Tumor Sites 2023

Sentara Cancer Network Primary Site Tables

We collect data on cases diagnosed and treated at each facility in our network.

This table’s data is collected by the Sentara Cancer Network Registry Subcommittee from
the Hampton Roads region and other regional registrars.