Cancer program annual report 2010 - Evangelical Community Hospital

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
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