2015 Cancer Program

Performance Outcomes

Introduction

Saint Agnes Medical Center has proudly maintained a American College of Surgeons’ Commission on Cancer (CoC) approved cancer program since 1986, providing service to our community, cancer patients and their families as well as physicians, researchers and the State of California Cancer Registry.

As part of our CoC accredited status we also participate in the National Cancer Data Base (NCDB) which offers us the opportunity to compare our cancer program’s performance to nationally recognized standards of care. To that end, we continuously monitor all twenty currently available CoC/NCDB quality measures to insure that Saint Agnes Cancer Program consistently provides the highest level of quality patient care.

The following Commission on Cancer Accountability and Quality Improvement measures are deemed by the CoC/NCDB to be the most significant to share with our community:

Breast measures:

BCSRT: Radiation therapy is administered within 1 year (365 days) of diagnosis for women under age 70 receiving breast conserving surgery for breast cancer.

MASTRT: Radiation therapy is considered or administered following any mastectomy within 1 year (365 days) of diagnosis of breast cancer with =/> 4 positive regional lymph nodes.

MAC: Combination chemotherapy is considered or administered within 4 months (120 days) of diagnosis for women under age 70 with AJCC T1cN0M0, or stage IB – III hormone receptor negative breast cancer.

HT: Tamoxifen or third generation aromatase inhibitor is considered or administered within 1 year (365 days) of diagnosis for women with AJCC T1cN0M0, or stage IB - III hormone receptor positive breast cancer.

nBx: Image or palpation guided needle biopsy (core of FNA) is performed to establish the diagnosis of breast cancer.

cont.

Colon measures

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

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

Since the inception of NCDB Cancer Program Performance Ratings (CP3R) our designated Comprehensive Community Cancer Program (CCCP) has met and/or exceeded compliance for each of these important quality measures.

For your inspection, the following slide display our CoC performance ratings.

***Please note, to insure that measures with low volume can be appropriately gauged, the Commission on Cancer provides a ‘percentage rating’ and indicates whether the facility's percentage rating falls within a 95% confidence interval range to determine compliance.

Saint Agnes Medical Center’s Cancer Program Performance Ratings

COMPLIANCE ACHIEVED ALL YEARSAll ratings within 95% Confidence Interval Range

& Comparable to CoC program type CCCP

CoCMeasure

2011 2012 2013Rating

all years

COMPLIANCE

MASTRT 100% 86% 100% 93%

BCSRT 100% 90% 100% 97%

MAC 89% 100% 100% 95%

HT 95% 100% 100% 98%

nBx 91% 88% 86% 88%

ACT 86% 67% 100% 81%

12RLN 88% 85% 84% 86%