Coordination of Cancer Care in the State of Maine: Review of Breast

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Coordination of Cancer Care in the State of
MaineReview of Breast Colon Cancer Projects

• Maine Chapter of the
• American College of Surgeons
• June 8th, 2008
• Paige Teller MD

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Problem
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Patient
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Population
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Starting point
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State of Maine - Demographics

• Population in 2000 1,274,923
• Counties 16
• Land Area 30,862 sq miles
• Persons per sq mile 41.3
• Largest city population Portland

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State of Maine Hospitals treatingcancer
patients
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State of Maine - Counties Hospitals

• Androscoggin
• Central Maine Medical Center
• St. Marys Regional Medical Center
• Aroostook
• Cary Medical Center
• Northern Maine Medical Center
• Houlton Regional Hospital
• Aroostook Medical Center
• Cumberland
• Bridgton Hospital
• Mid Coast Hospital
• Park View Adventist Medical Center
• Maine Medical Center
• Mercy Hospital
• Franklin
• Franklin Memorial Hospital
• Hancock
• Mt. Desert Island Hospital
• Blue Hill Memorial Hospital

• Lincoln
• St. Andrews Hospital
• Penobscot Valley Hospital
• Oxford
• Stephens Memorial Hospital
• Rumford Hospital
• Penobscot
• EMMC
• St. Joseph Hospital
• Millinocket Regional Hospital
• Piscataquis
• Mayo Regional Hospital.
• Sagadahoc
• Somerset
• Sebasticook Valley Hospital
• Redington-Fairview General Hospital
• Waldo
• Waldo County General Hospital
• Washington

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Annual Cancer Incidence for Maine1-Year Average
Tumor Site Counts by County
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State of Maine Cancer Care in 2000

• Limited hospital infrastructure
• No statewide network
• Lack of national affiliations
• NCI National Cancer Institute
• ACoS American College of Surgeons
• ACS American Cancer Society
• COC Commission on Cancer

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Building a foundation
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Maine Cancer Consortium

• Formed in 1999 to identify priorities for cancer
  prevention, control, and care
• 2001 2005 Maine Cancer Consortium raised over
  6,000,000 for implementation of the Maine Cancer
  Plan
• Funding 75 of the Maine Care Plan initiatives

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The Maine Cancer Plan
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Increase the use of national treatment guidelines
among health care professionals in Maine
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• Maine Cancer Consortium
• www.mainecancerconsortium.org
• Maine Central Registry
• http//www.maine.gov/dhhs/bohdcfh/mcr
• American Cancer Society
• www.cancer.org

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Treatment Workgroup

• State tumor registrars, ACS staff and OIS
  specialist
• Quarterly meeting
• Sponsor American Cancer Society
• Established guidelines for retrospective data
  collection at each hospital

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Treatment Workgroup Goals

• Analyze collected data
• Derive focused inquiries
• Draw conclusions from the data inquiries
• Compare results to national benchmarks
• Develop strategies to improve care in identified
  areas
• Advance cancer care statewide

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Treatment of Stage IIB and III Colon Cancer How
does Maine compare?

• Annual Meeting
• New England Surgical Society
• October 2007
• Paige Teller, MD

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Data Inquiries

• Stage at diagnosis
• Nodal staging
• Lymph node positivity
• Chemotherapy administration
• Chemotherapeutic agents

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Data Inquiries

• Stage at diagnosis
• Nodal staging
• Lymph node positivity
• Chemotherapy administration
• Chemotherapeutic agents

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Nodal Staging

• 12 nodes is the standard for adequate lymph node
  staging
• Stage IIB node negative disease
• Stage III node positive disease

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Number of nodes examined in Stage III Colon
Cancer Cases
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Nodal Status in Stage IIB
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Conclusions Nodal Staging

• Standard for nodal staging 12 nodes
• Stage III
• 31 cases lt 12 nodes
• Stage IIb
• 50 cases lt 12 nodes

Improved nodal staging is needed, half of Stage
IIb lesions were at risk of being under-staged
and under-treated
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The Treatment of Breast Cancer in Maine

• Commission on Cancer State Chair Meeting
• American College of Surgeons Annual Meeting
• New Orleans
• October 2007
• Paige Teller MD

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Data Inquiries

• Stage at diagnosis
• Lumpectomy vs. Mastectomy
• Post-lumpectomy Radiation Therapy
• Sentinel vs. Regional Node Biopsy
• Hormone therapy

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Data Inquiries

• Stage at diagnosis
• Lumpectomy vs. Mastectomy
• Post-lumpectomy Radiation Therapy
• Sentinel vs. Regional Node Biopsy
• Hormone therapy

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Post-lumpectomy Radiation

• Cases treated with lumpectomy should receive
  radiation therapy
• EXCEPTIONS
• Age gt70 lt1cm tumors ER positive
• Contraindication to radiation
• Early pregnancy
• Prior radiation
• Connective tissue disorders, Scleroderma

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Radiation Status Overall(lumpectomy cases)
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Radiation Status by Stage
83
78
60
68
48
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Radiation by ACS Regions
?
?
74.5
?
Androscoggin Kennebec
Aroostook Washington
Cumberland York Sagadahoc Lincoln
Somerset Franklin Oxford
Piscataquis Hancock Knox Waldo Penobscot
?? statistically significant
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Maine Hospitals by ACS Region Radiation
Therapy Centers
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Post-lumpectomy Radiation Standards

• Benchmark
• Stage 0 95
• Stage 1 100
• Best Practice
• Stage 0 91
• Stage 1 85
• Maine
• Stage 0 60 (subtracted gt70 yo 71)
• Stage 1 83
• Stage 2 78

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Post-lumpectomy Radiation Therapy

• Adjuvant Radiation
• Access
• Increase radiation centers
• Improve center and county relationship
• Health care policy
• Inconvenience
• Partial Breast Radiation
• Mammosite 5 vs. 33 days of treatment
• Cosmesis
• Mammosite

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MaineHealth Oncology Workgroup
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MaineHealth Oncology Workgroup Quality GOALS

• The five most prevalent cancers
• adopt evidence-based clinical care guidelines
• identify quality metrics reporting methodology
• provide a range of educational supports to
  promote consistent use of guidelines

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MaineHealth Oncology Workgroup Infrastructure
GOALS

• Improve the Network Registry to support increased
  access and data review for outcomes and quality
  metrics.
• Coordinate services regionally to provide access
  to care (i.e. improve access to specialists.)
• Increasing access to clinical trials.

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Northern New England Clinical Oncology Society
(NNECOS)
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Collaboration with Northern New England Clinical
Oncology Society (NNECOS)

• Oncology Care in Rural Northern New England
• Maine Treatment Workgroup will assist NH and VT
  in completing the colon and breast studies
• Data from 3 states will be used to assess the
  needs of cancer patients in rural areas

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NNECOS Outcome Goals

• Review cancer outcomes data
• Initiate a collaborative process among state
  cancer plans (ME,NH,VT), using the clinical
  expertise of NNECOS physicians
• Pool resources to reduce the burden of cancer
  through
• cancer risk reduction
• early detection
• improve treatment
• Enhance survivorship across all three states

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Grant Funding

• Local
• MMCPHO MMC Physician Hospital Organization
• National
• COC Commission on Cancer
• Best Practice
• NCI National Cancer Institute
• CCOP

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(No Transcript)
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Commission on Cancer Best Practice Award
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Community Clinical Oncology Program (CCOP)

• Established 1983
• Division of Cancer Prevention of the National
  Cancer Institute (NCI)
• Develop conduct state-of-the-art cancer
  prevention, control and treatment clinical trials
  with significant involvement of community
  oncologists and populations they serve

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Community Clinical Oncology Program (CCOP)

• Mission
• accelerate development of interventions to
  prevent and treat cancer and its symptoms by
  increasing accrual to studies
• foster quality care in the community through
  adoption of results from clinical trials
• increase the involvement of minority and
  underserved patient/participant populations in
  cancer clinical trials and associated research

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Community Clinical Oncology Program (CCOP)

• 10.9 million in total costs in FY 2008
• 17 CCOP group awards
• CCOP group award shared award amongst
  hospitals and/or private practices applying
  together
• Grant submission committee in Maine

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Future 2015
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Goals

• Create regional algorithms for care
• Expand hospital national accreditation
• Embrace e-QuIP i.e. government standards

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Goals

• Create regional algorithms for care
• Expand hospital national accreditation
• Embrace e-QuIP

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Workgroups

• Treatment Workgroup
• Apply data review model to other cancers
• Re-apply model to assess for improvement in care
• MaineHealth Oncology Workgroup
• Treatment
• Patient process
• Palliation
• Northern New England Clinical Oncology Society

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Goals

• Create regional algorithms for care
• Expand hospital national accreditation
• Embrace e-QUIP

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Increase by 3 the number of hospitals in Maine
accredited by Commission on Cancer (COC)
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Commission on Cancer (CoC)

• American College of Surgeons (ACoS) and American
  Cancer Society (ACS) founded in 1913
• CoC established in 1922 as a cooperative venture
• CoC receives financial support from the American
  Cancer Society
• National Cancer Database (NCDB)
• Cancer Liaison Program (CLP)

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Commission on Cancer Mission Statement

• The CoC is a consortium of professional
  organizations dedicated to improving survival and
  quality of life for cancer patients through
  standard-setting, prevention, research,
  education, and the monitoring of comprehensive
  quality care.

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CoC Objectives

• Setting standards for quality multidisciplinary
  cancer care delivered primarily in hospital
  settings
• Surveying facilities to assess compliance with
  those standards
• Collecting standardized, high quality data from
  CoC-accredited healthcare settings to measure
  cancer care quality
• Using data to support cancer control and clinical
  surveillance activities that monitor treatment
  patterns and outcomes and
• Developing effective educational interventions to
  improve cancer prevention, early detection, and
  the quality of cancer care delivery

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Distribution of CoC Approved Cancer Programs by
State (1,400)
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Cancer Programs in United States Hospitals
Treated elsewhere
Hospitals w/ approval
20
25
80
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Dx and treated in approved programs
Hospitals w/o approval
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Commission on Cancer

• Frederick L. Greene, MD, FACS
• Chair
• Stephen B. Edge, MD, FACS
• Chair-Elect

• David P. Winchester, MD, FACS Medical Director,
  Cancer Programs
• Clifford Ko, MD, FACS Medical Director,
  National Cancer Data Base Director, Division of
  Research and Optimal Patient Care
• Connie Bura Administrative Director, Cancer
  Programs

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CoC Accreditation

• Survey
• scope, organization, activity of a cancer
  program
• web-enabled Survey Application Record (SAR)
• Conducted every 3 years
• Trained physician surveyor
• 36 standards
• CoC Cancer Program Standards
• Data collection standards
• Facility Oncology Registry Data Standards (FORDS)
  
• Independent review
• Multi-disciplinary Program Review Subcommittee

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CoC Accreditation
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Benefits from CoC Accreditation

• Program
• National Recognition
• Organized Care
• Quality Improvement Measures
• Data Analysis
• Public Awareness

• Patient Community
• Comprehensive care
• Multidisciplinary team approach
• Clinical trials new treatment options
• Prevention early detection programs, cancer
  education support services
• Cancer registry
• Quality care, close to home

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National Accreditation Program for Breast Centers
(NAPBC)
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National Accreditation Program for Breast Centers
(NAPBC)
WHAT?
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National Accreditation Program for Breast Centers
(NAPBC)

• A program to identify and recognize breast
  centers in the United States
• Improve the quality care monitoring of patients
  with breast disease

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National Accreditation Program for Breast Centers
(NAPBC)
WHO?
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National Accreditation Program for Breast Centers
(NAPBC)

• Board of Regents of the ACoS
• 2005 proposal
• Consortium
• 18 national professional organizations
• 10 pilot sites
• gt100 interested centers

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National Accreditation Program for Breast Centers
(NAPBC)
HOW?
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National Accreditation Program for Breast Centers
(NAPBC)

• Recognized breast center categories
• Clinical Breast Center (CBC)
• Breast Evaluation and Management Center (EMC)
• Comprehensive Breast Evaluation and Management
  Center (CEMC)
• Breast Imaging Centers of Excellence
• (BI-COE)

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NAPBCSummary of Components Requirements
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National Accreditation Program for Breast Centers
(NAPBC)
WHY?
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National Accreditation Program for Breast Centers
(NAPBC)

• Numerous breast centers
• No single model for delivery of care
• Physician-
• multidisciplinary care
• evidence-based standards
• Patient/Payer-
• accredited programs
• documented outcomes
• meet/exceed national standards

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Goals

• Create regional algorithms for care
• Expand hospital national accreditation
• Embrace eQuIP

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Electronic Quality Improvement Packet (eQuIP)

• Commission on Cancer (CoC) with the National
  Quality Forum establish quality of care
  indicators for breast and colorectal cancer
• Reviewed annually by the Cancer Committee and by
  the CoC during site survey
• CoC plans to roll out eQuIP for additional tumor
  sites