Cancer program annual report 2010 - Evangelical Community Hospital

EVANGELICAL COMMUNITY HOSPITAL
CANCER PROGRAM ANNUAL REPORT 2010
2

EVANGELICAL COMMUNITY HOSPITAL CANCER ANNUAL REPORT 2010
table of contents
A Letter from the Chair.............................................. 1
Cancer Liaison Report................................................. 2
Cancer Conferences..................................................... 3
Community Outreach Program Report.................... 4
Quality Initiatives........................................................ 6
Cancer Registry............................................................ 7
Lewisburg Cancer Center, Radiation Oncology...... 7
Primary Site Tabulation for 2009 Cases.................... 8
2009 Colorectal Cancer Data Analysis for
Evangelical Community Hospital.............................10
Evangelical Community Hospital’s Cancer Committee
Commission on Cancer CP3R
Quality Measure for Colorectal Cancers................. 13
Front Row, left to right: Vice President-Nursing Paul Tarves, RN, Director of the Thyra M. Humphreys Center for
Breast Health Andrea Bertram, breast health specialist Beth Jordan, CRNP, breast health specialist Billie Jo Day, RN, and
cancer registrar Cynthia Miller.
Back Row, left to right: Vice President-Operations Kendra Aucker, Chief Compliance Officer Matthew Hoeger,
Medical Director of the Thyra M. Humphreys Center for Breast Health John F. Turner, MD, FACS, radiation oncologist
Peter Whitcopf, MD, social worker Mary Pahl. Not pictured are Pathology Services Medical Director John Kryston, DO,
Committee Chairman Bradley Mudge, DO, FACS, ACS representative Karen Maurer, Community Health Education
Director Nichole Hockenbrock, recording secretary Alicia Smith, Mayur Patel, MD, James O’Brien, MD, and survivorship
coordinator Michael Hayes, PhD.

A LETTER FROM THE CHAIR
Dear Friends and Colleagues:
“The ‘Paint the Valley
Pink’ campaign in
October 2010 resulted in
a significant increase in
scheduled procedures.”
Bradley Mudge, DO, FACS
I
The CoC’s Accreditations Program
offers many notable benefits that
will enhance a cancer program and
its quality of patient care. One of the
steps in the survey process involves
participating in a consultative
evaluation of the program performed
by a CoC-trained independent
cancer program consultant. This
consultative evaluation determines
the cancer program’s readiness for
the Accreditations Program survey.
am proud to present the 2010 Annual Report for the Cancer Program at Evangelical
Community Hospital. The Cancer Committee’s focus is not only on meeting and
serving the needs of our patients and community, but also to earn accreditation
through the American College of Surgeons Commission on Cancer (CoC).
On October 5, 2010, we were
evaluated by an independent
consultant; I am pleased to report we
had a successful evaluation. I would like
to thank the Hospital’s Administration,
Cancer Committee members and all
support staff for their hard work and
dedication to make this possible. Our
Cancer Program will be surveyed by
CoC’s Accreditations Program in 2011.
For our patients and the community,
the quality standards established by
the CoC ensure the following:
• Comprehensive care including a
complete range of state-of-the-art
services and equipment
• A multidisciplinary team approach
to coordinate the best available
treatment options
• Information about evidence-based
national treatment guidelines
• Access to prevention and early
detection programs, cancer
education and support services
• A cancer registry that offers
lifelong patient follow-up
• Ongoing monitoring and
improvements in cancer care
• Quality care in our community
In addition to 2009 statistical data
regarding the number of patients
and the types of cancer encountered,
this report offers insight into our
clinical care, education and support
programs. Our area of focus for this
report is colorectal cancer. The annual
report reflects our activities for 2010
and our commitment to providing
our patients with compassionate,
high-quality care.
Sincerely,
Bradley Mudge
Bradley Mudge, DO, FACS
Chair, Cancer Committee
Evangelical Community Hospital
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cancer liaison report
The year 2010 has been marked by many accomplishments for the Cancer Committee at
Evangelical Community Hospital. For the first time on a consistent basis, Continuing Medical
Education (CME) credits are available for physician participants and Continuing Education
Units are available for all other participants in cancer conferences (Tumor Board).
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“Many thanks are due to
Cynthia Miller, CTR, for
her diligence in collecting
the Tumor Registry
data and in readying us
for the upcoming CoC
accreditation survey.”
John F. Turner, MD, FACS
We are seeing increased primary care
participation in cancer conferences
and continue to work towards even
greater participation. Care for our
patients has been positively impacted
by the involvement of their primary
care providers in these conferences.
Currently, all cases presented at the
weekly breast Virtual Tumor Board
and the majority of cases presented at
the monthly General Tumor Board are
presented prospectively (during the
active decision-making process, prior to
definitive therapy).
We once again had a very successful
Mammathon, making more than 4,000
calls and speaking with more than
1,600 women. Close to 900 committed
to have their mammogram and 164
scheduled their mammogram that day
for a positive outcome of 53 percent.
We served more than 100 women at
the annual Women’s Health Screening
event.
As our tumor registry continues to
grow, we are receiving valuable data,
which influence the organization and
procedures of our cancer programs
and are utilized in analyzing the quality
of cancer care. Gary Ayers, DO, and
the director of the Gastrointestinal
Malignancy Clinic, will be discussing
the registry’s colon cancer statistics
elsewhere in this report.
Below are the data from the registry
entered into the American College of
Surgeons Commission on Cancer (CoC)
CP3R quality measures for breast cancer
study:
1. Radiation therapy is administered
within one year (365 days) of
diagnosis for women under age 70
receiving breast-conserving surgery
for breast cancer.
• 100 percent compliance
2. Combination chemotherapy is
considered or administered within
four months (120 days) of diagnosis
for women under age 70 with
American Joint Committee on Cancer
(AJCC) T1CN0M0, or Stage II or III
hormone receptor negative breast
cancer.
• 100 percent compliance
3. Tamoxifen or third-generation
aromatase inhibitor is considered or
administered within one year (365 days)
of diagnosis for women with AJCC
T1CN0M0, or Stage II or III hormone
receptor positive breast cancer.
• 27/28 patients met this criterion
(96 percent)
• One patient had hormonal
treatment delay due to
complications during
chemotherapy treatment
Additionally, the surgeons at the Thyra
M. Humphreys Center for Breast Health
participated in the Mastery of Breast
Surgery quality measure database, and
our results compared quite favorably
with breast surgeons across the nation
in relation to three quality measures.
Sincerely,
John F. Turner
John F. Turner, MD, FACS
Cancer Liaison Physician, Breast Surgeon
Evangelical Community Hospital

Cancer conferences
Cancer conferences, also known as tumor boards, are essential forums
to provide multidisciplinary consultative services for patients, and
offer education to physicians and healthcare providers. Cancer conferences
are a requirement for an accredited program by the CoC.
The number of cases presented each year
is based on a percentage of annual analytic
cases added to the cancer registry database.
The CoC requires that at least 10 percent of
the annual analytic cases be presented, and
75 percent of the cases discussed need to
be presented prospectively with appropriate
stage documented for the five major sites
seen at our facility. Nationally recognized
treatment guidelines such as those outlined
by the National Comprehensive Cancer
Center Network need to be considered when
discussing treatment options.
In 2010, there were 11 multidisciplinary
cancer conferences held at Evangelical.
Primary sites presented were colorectal, lung,
prostate, small bowel, lymphoma, thyroid,
endometrial, pancreas, bladder, testis,
thymus, salivary gland and esophagus. A
site-specific conference is held every Tuesday
that includes all breast cases. Diagnosis and
treatment recommendations are discussed.
Primary care physician participation is
encouraged for all cancer conferences and
was a clinical goal the Cancer Committee
achieved in 2010.
David Hicks, MD, from the University of
Rochester, presented Her2-positive Breast
Cancer/Diagnostic Tools and Challenges to
the Medical Staff in March. This educational
activity was in addition to the multidisciplinary
cancer conference; CME credits were
provided to the attendees. In April, the
Cancer Committee offered educational
sessions to the Medical Staff and allied health
professionals on AJCC staging for breast,
colon, lung and thyroid cancer.
Beginning in March 2010, Evangelical
partnered with Geisinger Medical Center,
and CME credits were granted to Tumor
Board/cancer conference attendees.
In 2010, there were
11 multidisciplinary
cancer conferences
held at Evangelical.
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Community outreach 2010 Program report
subcommittee Members: Mayur Patel, MD (Co-Chair), Nichole Hockenbrock (Acting Co-Chair), Billie Jo Day, RN, Cynthia Miller, Karen Maurer (American
Cancer Society), Chuck Stahl (Community member), Carol Yost (Community member)
Key: ACS–American Cancer Society, CBH–Evangelical Community Hospital’s Thyra M. Humphreys Center for Breast Health, EASC–Evangelical Ambulatory
Surgical Center, MCR–Middleburg Community Room, CHC–Community Health Education Center, SVM–Susquehanna Valley Mall, POB–Professional Office Building
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Supportive Services
Look Good …Feel Better—a partnership with an
American Cancer Society Program in CHC
Cancer Support Group held in conjunction with
Cancer Care of Central PA
Cancer Support Group—community members
meet in our community conference room for
group meetings in MCR
*Mammogram Screening—under- and
un-insured women (CBH) funded by the
Northeastern Pennsylvania Affiliate of Susan G.
Kommen for the Cure
Health Screening for the underand
un-insured
Prevention & Early Detection Programs
Tobacco/Smoking Education (employee program)
at T-Ross Brothers Construction
Date
Presented
Held every
month
Second
Wednesday of
most months
Held every
other month
Throughout
the 2010
calendar year
Outcomes/Findings
Date of Cancer
Committee Review
Actions Recommended
Average monthly attendance = 1-2 women 9/21/2010 Continue collaboration
with ACS
Average monthly attendance = 5-7 participants 9/21/2010 Work with marketing
to aid in the promotion
of the group/conduct a
survey of participants
Average monthly attendance = 10 participants
209 screenings to date. Findings: 180 normal screening results, 29
required additional imaging, 7 required biopsy (6 biopsies were
benign to date), 14 required 6-month follow-up.
1/22/2010 54 persons in attendance, 17 self-breast exams, 3 referred for
additional testing
Date
Outcomes/Findings
Presented
3/4/2010 33 participants
Sun Safety Education at Turbotville Preschool 4/7/2010 12 participants
Mammathon with CBH held at the SVM 4/14/2010 6,426 calls were made, spoke to 1,930 women, left 1,758
messages about early detection, commitments from 1,116
women to schedule their mammograms, 197 mammograms
were scheduled during the event.
Skin Cancer Educational Program at
4/20/2010 15 participants
TPA worksite
Clear the Air sm — tobacco cessation program 4/26/2010 2 participants
(Highmark) with CHC
Men’s Health Screening—screening for prostate,
skin, oral and colorectal cancer at POB
6/5/2010 54 participants, 9 men required follow-up for suspicious lesions.
1 positive occult blood for follow-up. 1 elevated PSA required
follow-up.
Date of Cancer
Committee Review
Actions Recommended
7/20/2010 Continue annual event

Prevention & Early Detection Programs
Sun Safety Education Program held for
CONCERN employees
Clear the Air sm —Tobacco Cessation Program
(Highmark) with CHC
Evangelical Community Hospital
Employee Health Fair
Women’s Health Screening and *Mammogram
Screening (CBH) skin, breast, colorectal and
cervical cancer
Life After Loss Bereavement Support Group, held
in conjunction with Evangelical Hospice
“Paint the Valley Pink” Marketing Initiative for
Breast Cancer Awareness
Breast Cancer Education in partnership with the
ACS at Northumberland National Bank Health Fair
I Can Cope Program for the Breast Cancer
Survivor (CBH)—support program for patients
and family members
Clear the Air sm —Tobacco Cessation Program
(Highmark) with CHC
AIRS (Area Invitation and Recall System)—phone
calls are made to non-compliant women
encouraging them to schedule a mammogram
Date
Presented
7/8/2010 18 participants
7/26/2010 3 participants
Outcomes/Findings
9/8/2010 Education on Breast, American Cancer Society Resources,
prevention and early detection information and Smoking
Cessation was provided for more than 250 employees and
family members.
9/11/2010 73 women screened for colon cancer, 2 positive results; 73
women screened for cervical cancer, 0 follow-ups; 45 women
screened for breast cancer, 2 women required follow-up; 84
women screened for skin cancer, 4 required follow-up.
September- 8 participants
October 2010
October 2010 This was part of the comprehensive breast cancer awareness
program—radio, newspaper advertising and outdoor
billboards. The “Paint the Valley Pink” Web site had
18,000 visitors. Approximately 75,000 listeners per day,
which included four radio stations. Newspapers reached
approximately 25,000 persons. Results included a significant
increase in scheduled procedures.
October 2010 90 participants
October 2010
10/25/2010
June 2009-
April 2010
30 participants
1,378 phone calls were made, 195 women committed to
scheduling a mammogram, 259 had their mammograms,
256 messages were left, 179 mammograms were scheduled
during the phone call, 208 did not schedule.
Date of Cancer
Committee Review
Actions Recommended
9/21/2010 Continue annually
OTHER: The ACS tracks referrals made to them from the Evangelical network. Evangelical Community Hospital network made 42 referrals to the American Cancer Society, 62 from
Cancer Care of Central PA and 3 referrals from Central Penn Gastroenterology Associates. Evangelical Community Hospital employees participated in the American Cancer Society Relay
events, and the Hospital, along with Central Susquehanna Surgical Specialists, PC, sponsored area Relays. Evangelical was a site for the American Cancer Society Daffodil Days.
*2010 Mammogram Screening Results
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quality initiatives
The Tumor Board model
ensures that quality is
built into the care process.
Tumor Boards
General Tumor Boards are at the center of the Cancer Committee’s quality initiatives at Evangelical Community
Hospital and integral to its efforts to offer a comprehensive approach to patient care that involves a wide
range of disciplines. Monthly meetings to discuss prospective cases routinely include surgeons, pathologists,
oncologists, primary care physicians, patient navigators and various other support personnel.
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By prospectively discussing the case details among personnel with varying
perspectives, the group can come to a consensus on a treatment plan that
offers the patient the greatest opportunity for success, which is based on
National Comprehensive Cancer Network (NCCN) evidence-based guidelines.
The Cancer Committee believes that this model ensures that quality is built
into the care process.
Quality Initiatives
Because this is a relatively new program for the Hospital, the quality
initiatives were undertaken on an ad hoc basis as the program developed
but were consistently focused on maintaining the quality of the database as
it is the foundation for not only the Cancer Committee’s work here at the
Hospital but across the entire Registry. The Cancer Committee began with
a focus on educating physicians on the proper staging of primary sites and
the associated documentation. Members also realized the need to be able
to survey patients undergoing surgical interventions as part of their cancer
treatment separately from patients utilizing other surgical services. The
Cancer Committee is now able to more specifically survey those patients,
which will help gain a better understanding of how they perceived their care
experience. This information will help to identify future quality improvement
efforts. Finally, the Cancer Committee will continually benchmark key care
indicators against national standards and follow generally accepted and
scientifically proven methods related to care processes.

lewisburg cancer care, radiation oncology
Cancer Registry
The cancer registry is a source of statistics
and data for research, presentations, quality
improvement opportunities, productivity
measures and protocol applications. The cancer
registry at Evangelical utilizes Electronic Registry
Systems to collect, manage and analyze data
on oncology patients. The American College
of Surgeons Commission on Cancer (CoC)
requires registries in approved programs to
access, abstract and conduct follow-up activities
for required tumors diagnosed and/or initially
treated at the abstracting facility. The tumors
must meet the criteria for analytic cases
(classes of case 00-22), and pathologically and
clinically diagnosed inpatients and outpatients
must be included. All abstracting is performed
using the CoC Facility Oncology Registry Data
Standards and the Pennsylvania Cancer Registry
requirements.
The registry at Evangelical is managed by a
Certified Tumor Registrar, who is an active
member of the National Cancer Registrar
Association and Pennsylvania Association of
Cancer Registrars.
Sincerely,
Cynthia Miller
Cynthia Miller, CTR
Cancer Registry Coordinator
Evangelical Community Hospital
In October 2009, Peter Whitcopf, MD, joined the staff of Cancer Care of Central Pennsylvania
as the radiation oncologist at Lewisburg Cancer Care. Dr. Whitcopf trained at the
University of Virginia and worked at the Ephrata Cancer Center and Reading Hospital
prior to moving to Selinsgrove. This year, the radiation oncology department has treated
patients mostly for breast, prostate and lung cancer.
The treatment unit at Lewisburg Cancer Care is capable
of Intensity-Modulated Radiation Therapy (IMRT), which is
used for nearly all prostate cancer patients and for many
other types of cancer as well. In many situations, IMRT is
better than conventional radiation therapy techniques at
protecting normal tissues from the damaging effects of
radiation while effectively treating the cancer.
Most breast cancer patients receive six to seven weeks of
external-beam radiation therapy, but some patients were
treated with Accelerated Partial Breast Irradiation (APBI),
which is given over just one week, with High Dose-Rate
(HDR) brachytherapy using the Contura balloon catheter.
APBI is an option available for some, but not all, women
with early-stage breast cancer, available through the
Thyra M. Humphreys Center for Breast Health. In selected
patients, the balloon catheter is placed in the tumor cavity
by either John Turner, MD, or Bradley Mudge, DO, and the
patient goes to Lewisburg Cancer Care to receive radiation
therapy twice a day for five days.
Additionally, prostate brachytherapy (also known as “seed
implant”) is being offered by urologist Anuj Chopra, MD.
Dr. Chopra performed brachytherapy in Hazleton previously
and now brings his expertise to Evangelical Community
Hospital. The procedure is performed as One-Day Surgery
in selected patients with early prostate cancer. Drs.
Chopra and Whitcopf use an ultrasound-guided, real-time
planning technique to precisely place radioactive “seeds”
containing Iodine-125 to irradiate prostate cancers from
within. Many of these patients also receive a course of
hormone-blocking therapy (i.e., Lupron) from Dr. Chopra,
depending on the size of the prostate gland and grade
of the cancer. Thus far, 11 patients have undergone this
procedure since April 6, 2010.
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Primary Site Tabulation for 2009 Cases
PRIMARY SITE TOTAL CLASS SEX CS STAGE GROUP
A N/A M F 0 I II III IV UNK N/A
ALL SITES 585 270 315 271 314 58 96 76 48 96 156 55
ORAL CAVITY 4 1 3 2 2 0 1 0 1 1 1 0
LIP 1 1 0 0 1 0 0 0 1 0 0 0
TONGUE 1 0 1 1 0 0 1 0 0 0 0 0
OROPHARYNX 0 0 0 0 0 0 0 0 0 0 0 0
HYPOPHARYNX 0 0 0 0 0 0 0 0 0 0 0 0
OTHER 2 0 2 1 1 0 0 0 0 1 1 0
DIGESTIVE SYSTEM 115 64 51 69 46 14 11 10 14 29 33 4
ESOPHAGUS 10 6 4 7 3 0 0 0 1 4 5 0
STOMACH 10 5 5 8 2 0 0 0 1 3 5 1
COLON 51 30 21 30 21 11 4 8 9 14 5 0
RECTUM 21 12 9 14 7 3 7 2 2 1 6 0
ANUS/ANAL CANAL 0 0 0 0 0 0 0 0 0 0 0 0
LIVER 3 2 1 2 1 0 0 0 0 0 3 0
PANCREAS 15 6 9 5 10 0 0 0 0 7 7 1
OTHER 5 3 2 3 2 0 0 0 1 0 2 2
RESPIRATORY SYSTEM 62 37 25 33 29 0 6 1 12 31 11 1
NASAL/SINUS 0 0 0 0 0 0 0 0 0 0 0 0
LARYNX 0 0 0 0 0 0 0 0 0 0 0 0
LUNG/BRONCHUS 61 36 25 33 28 0 6 1 12 30 11 1
OTHER 1 1 0 0 1 0 0 0 0 1 0 0
BLOOD & BONE MARROW 33 12 21 17 16 0 0 0 0 0 0 33
LEUKEMIA 13 3 10 9 4 0 0 0 0 0 0 13
MULTIPLE MYELOMA 4 0 4 2 2 0 0 0 0 0 0 4
OTHER 16 9 7 6 10 0 0 0 0 0 0 16
BONE 0 0 0 0 0 0 0 0 0 0 0 0
CONNECT/SOFT TISSUE 3 1 2 3 0 0 1 0 0 0 2 0
SKIN 25 6 19 11 14 1 2 2 1 1 18 0
MELANOMA 23 5 18 11 12 1 1 2 1 1 17 0
OTHER 2 1 1 0 2 0 1 0 0 0 1 0
BREAST 123 67 56 1 122 20 37 32 13 9 11 1
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Primary Site Tabulation for 2009 Cases (cont.)
PRIMARY SITE TOTAL CLASS SEX CS STAGE GROUP
A N/A M F 0 I II III IV UNK N/A
FEMALE GENITAL 45 16 29 0 45 1 12 0 2 6 24 0
CERVIX UTERI 3 2 1 0 3 0 2 0 0 0 1 0
CORPUS UTERI 22 9 13 0 22 0 10 0 0 1 11 0
OVARY 15 5 10 0 15 0 0 0 2 5 8 0
VULVA 4 0 4 0 4 1 0 0 0 0 3 0
OTHER 1 0 1 0 1 0 0 0 0 0 1 0
MALE GENITAL 82 17 65 82 0 0 4 22 1 7 47 1
PROSTATE 78 13 65 78 0 0 0 22 1 7 47 1
TESTIS 3 3 0 3 0 0 3 0 0 0 0 0
OTHER 1 1 0 1 0 0 1 0 0 0 0 0
URINARY SYSTEM 46 18 28 36 10 22 8 7 0 5 2 2
BLADDER 37 12 25 29 8 22 3 7 0 4 1 0
KIDNEY/RENAL 6 5 1 5 1 0 4 0 0 1 1 0
OTHER 3 1 2 2 1 0 1 0 0 0 0 2
BRAIN & CNS 3 1 2 2 1 0 0 0 0 0 0 3
BRAIN (BENIGN) 0 0 0 0 0 0 0 0 0 0 0 0
BRAIN (MALIGNANT) 0 0 0 0 0 0 0 0 0 0 0 0
OTHER 3 1 2 2 1 0 0 0 0 0 0 3
ENDOCRINE 16 14 2 2 14 0 12 0 1 2 1 0
THYROID 16 14 2 2 14 0 12 0 1 2 1 0
OTHER 0 0 0 0 0 0 0 0 0 0 0 0
LYMPHATIC SYSTEM 18 7 11 7 11 0 2 2 3 5 6 0
HODGKIN’S DISEASE 2 1 1 1 1 0 0 0 0 1 1 0
NON-HODGKIN’S 16 6 10 6 10 0 2 2 3 4 5 0
UNKNOWN PRIMARY 9 9 0 5 4 0 0 0 0 0 0 9
OTHER/ILL-DEFINED 1 0 1 1 0 0 0 0 0 0 0 1
Number of cases excluded: 3
This report EXCLUDES CA in-situ cervix cases, squamous and basal cell skin cases, and intraepithelial neoplasia cases.
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2009 Colorectal Cancer Data Analysis for Evangelical Community Hospital
The Cancer Committee at Evangelical Community Hospital,
as part of the Hospital’s ongoing effort to improve
cancer care, performs annual analyses of cancer-specific
data to assess the effectiveness of treatments provided.
Such analyses are strongly advocated by the American College
of Surgeons Commission on Cancer (CoC) so that the institution
can objectively compare its outcomes with nationally recognized
benchmarks. The goal of this undertaking is to demonstrate both
strengths and weaknesses in the institution’s treatment processes
in an effort to improve patient care and survival outcomes.
With respect to colorectal cancer,
the CoC has developed three quality
measures that have been documented in
the medical literature to improve survival
outcomes for colon and rectal cancer:
1. At least 12 regional lymph nodes are
removed and pathologically examined
for resected colon cancer.
2. Adjuvant chemotherapy is considered
or administered within four months
(120 days) of diagnosis for patients
under the age of 80 with American
Joint Committee on Cancer (AJCC)
Stage III (lymph node positive) colon
cancer.
3. Radiation therapy is considered or
administered within six months (180
days) of diagnosis to patients under the
age of 80 who have been diagnosed
with AJCC T4N0M0 or Stage III rectal
cancer and who are receiving surgical
therapy for said cancer.
The following data analysis targets the
above numbered quality measures and
also presents a broad overview of the
spectrum of colon and rectal cancer
treated at Evangelical during 2009.
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Number of Patients
10
8
6
4
2
0
Figure 1
20-29
30-39
40-49
50-59
60-69
Age Range
70-79
80-89
Female
Male
90-99
Overview
At Evangelical, 41 cases of colorectal cancer were treated during
2009. Of those, 59 percent were male and 41 percent were female.
Average age distributions at the time of diagnosis were higher for
males (70-79 years of age) when compared with the female cohort
(60-69 years of age), (see Figure 1).
Stage at Diagnosis
With respect to the stage of disease present at the time of diagnosis,
no real trend is apparent insofar as comparative analysis to statewide
data is concerned. It does appear, however, that a significantly higher
number of Stage 0 cancers were surgically treated at Evangelical
when compared with the rest of the state (see Figure 2).
The bulk of cancers treated at Evangelical comprised early stage
cancer, i.e., Stage 0 and I colon cancers. Further illustration of the
stage at the time of diagnosis can be found in Figure 3.
30
25
Evangelical
PA
19.51%
20
21.95%
Percent
15
10
17.07%
5
5.00%
0
0 I II III IV Unknown
9.76%
14.63%
Figure 2
Stage
Figure 3
12.20%
0 I IV IIA IIIB IIIC IIIA
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Quality Measure Analysis
Lymph node harvest:
Regarding the first of the aforementioned quality
measures—harvest and analysis of at least 12 lymph
nodes in the resected specimen—Evangelical shows
room for improvement: Of all cancers resected at
Evangelical, 32 percent were found to have at least 12
lymph nodes in the specimen. The above data include
Stage 0 cancers, which, in essence, represent incidental
findings of carcinoma in polyps
resected endoscopically, which
then go on to oncologic
resection secondary to an
inability to assess for complete
excision on the colonoscopically
resected specimen. One can
argue that such scenarios
should be excluded as there is
no residual carcinoma identified
on the final pathology;
disregarding the Stage 0
resections, however, results in only nominal elevation
of percentage of specimens removed with the requisite
number of lymph nodes: 43 percent.
Lymph node harvests in
excess of 12 nodes have
been shown to increase
survival as a result of
their staging properties.
The author of this report undertook analysis of the
data available insofar as the impact of the surgeon,
pathologist and site of the primary tumor was concerned
regarding lymph node harvest. The data demonstrated
no clear trend with respect to the impact of the surgeon
or the pathologist in question. Regarding the site of
the primary tumor, sigmoid resections demonstrated
the largest lymph node harvest with an average of 23
lymph nodes per specimen; this was followed closely by
right colectomies, which demonstrated an average of
14 lymph nodes per specimen.
Discussions have ensued regarding the handling of
pathologic specimens by the pathologists, and it has
been determined that measures are in place to ensure
maximal nodal harvest from the surgical specimen,
namely that of de-fatting protocols to assist in the
identification of mesenteric lymph nodes.
Per the guidelines of the National Comprehensive
Cancer Network (NCCN), lymph node harvests in excess
of 12 nodes have been shown to increase survival
as a result of their staging
properties; counter-arguments
would state that adequate
lymph node harvest acts as a
surrogate marker for adequate
resection and, accordingly,
inadequate nodal harvest
reflects inadequate oncologic
resection, thereby leading to
inferior outcomes insofar as
survival is concerned. While it
is a fine point to argue, current
guidelines do recommend for adjuvant chemotherapy in
patients resected with inadequate nodal harvests; this,
in essence, is an argument as to whether or not to treat
Stage II cancers with fewer than 12 lymph nodes in the
resected specimen.
With the advent of novel assays such as the Oncotype
dx colon cancer genomic assay, one could argue the
value of lymph node harvest for Stage II colon cancers.
In essence, the Oncotype dx colon cancer assay is
a genomic assay that assesses the propensity of
recurrence of the primary tumor following resection. A
score is generated based on the assay results, and this
score predicts the probability of local recurrence within
a 36-month period. A lower score portends a lower
likelihood of recurrence. This assay has been utilized by
the author of this report to help determine the utility of
adjuvant chemotherapy in Stage II colon cancers with
a great degree of success (admittedly, though, with
a very small cohort of patients). The advocacy of the
NCCN insofar as KRAS mutation and mismatch repair
gene testing is concerned pays homage to the potential
significance of genetic markers and their impact on
colon cancer treatment.
Adjuvant chemotherapy for Stage III cancer:
Eight patients under the age of 80 were surgically resected
for Stage III disease and 100 percent of these patients
were referred for evaluation by Medical Oncology for
the consideration of adjuvant chemotherapy. Complete
compliance in this regard is enthusiastically endorsed
by the author, accompanied by an insatiable desire to
report identical results in the ensuing years.
Radiation therapy for rectal cancer:
Zero out of one cases that fulfill the requirements of
this benchmark were referred for radiation therapy. The
precise details of the situation in question are unknown
to the author, so insight into this clinical scenario is
obscure. The benefit of neoadjuvant therapy in rectal
cancer as it pertains to reductions in local recurrence has
been unabashedly endorsed in the medical literature,
and one would be hard pressed to argue against it; that
12

eing said, mitigating circumstances could be present
insofar as reasons against radiation oncology referral are
concerned in this particular case.
Summary and Conclusion
In essence, 41 cases of colorectal carcinoma were
treated at Evangelical in 2009. The patient distributions
of age and sex were, essentially, in accordance with
national guidelines. It appears as though there was an
exceptionally high number of early-grade carcinomas of
the colon treated at Evangelical. This is likely indicative
of enhanced screening protocols put in place by the
primary care physicians.
The utilization of adjuvant chemotherapy in patients
with Stage III adenocarcinoma was found to be in
100 percent compliance. The utility of radiation in the
context of rectal cancer was sorely understated in the
given study; one could argue the validity of such results
given a patient population of one.
The primary point of contention in the current study is
that of lymph node harvest. Disregarding the Stage 0
carcinomas, the percentage of cases in which 12 or more
lymph nodes were harvested is woefully inadequate.
Analysis of the surgeon and pathologist data failed
to reveal any clear-cut correlation to the analysis in
question. Ultimately, the data presented indicate
that an increase in aggressive surgical intervention is
indicated as it pertains to colorectal surgery. One could
argue that an anticipated increase in vascular injury
might be anticipated as one pursues more aggressive
resections in the context of colorectal cancer, but this
remains to be seen. A counter-argument would be
that of incorporating genomic assays into the staging
of colorectal cancers, which could serve to enhance
staging criteria and potentially lead to a situation in
which aggressive surgical resection is unnecessary.
Commission on Cancer CP3R
Quality Measure for Colorectal Cancers
• At least 12 regional lymph nodes are removed and
pathologically examined for resected colon cancer.
• Adjuvant chemotherapy is considered or administered
within four months (120 days) of diagnosis for
patients under the age of 80 with American Joint
Committee on Cancer (AJCC) Stage III (lymph node
positive) colon cancer.
• Radiation therapy is considered or administered
within six months (180 days) of diagnosis for patients
under the age of 80 with clinical or pathologic AJCC
T4N0M0 or Stage III and who are receiving surgical
resection for rectal cancer.
Evangelical resected colon cases 2009
• Total number of surgical colon cases: 37 (9 cases Stage 0)
• Twelve cases: >12 lymph nodes removed
Evangelical Stage III colon cases 2009— patients under the age of 80—
considered or administered chemotherapy within four months (120 days)
• Total number of Stage III colon cases-patient under the age
of 80: 8 of 8 (100 percent)
• All eight cases met this criterion
Radiation therapy is considered or administered to patients under the age of 80 with clinical or
pathologic AJCC T4N0M0 or Stage III rectal cancer.
Evangelical had one rectal case in 2009 where the patient was under 80, pathologic Stage IIIB, surgically
resected and received chemotherapy per Cancer Care; there is no documentation that the patient was
seen or considered for radiation.
Prepared by Cynthia Miller, CTR
Source: Evangelical Community Hospital Tumor Registry
2009 colorectal cancer cases
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www.evanhospital.com