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The Value of Clinical Staging in Cancer

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The Value of Clinical Staging in Cancer Timothy Wm. Mullett, MD Chairman, Cancer Committee UKHealthCare ITEM 4: Patient Care Issues and Policies A random sampling of ... – PowerPoint PPT presentation

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Title: The Value of Clinical Staging in Cancer


1
The Value of Clinical Staging in Cancer
  • Timothy Wm. Mullett, MD
  • Chairman, Cancer Committee
  • UKHealthCare

2
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3
TLO(Terminal Learning Objectives)
  • 1.  Understand the definition of clinical stage
    in cancer
  • 2.  Learn the components of clinical stage
  • 3.  Recognize the importance of pre-treatment
    recording of clinical stage in the medical record
  • 4. Really have a hard time NOT thinking about
    summertime.

4
Definition of Clinical Stage
  • The extent of disease that can be determined from
  • history and physical,
  • biopsy procedure,
  • imaging studies,
  • endoscopy, and
  • exploration prior to initial treatment.
  • Expressed as TNM and stage group, as possible.

5
Primary Tumor (T)
  • TX Primary tumor cannot be evaluated
  • T0 No evidence of primary tumor
  • Tis Carcinoma in situ
  • T1, T2, T3, T4 Size and/or extent of the primary
    tumor

6
Regional Lymph Nodes (N)
  • NX Regional lymph nodes cannot be evaluated
  • N0 No regional lymph node involvement
  • N1, N2, N3 Involvement of regional lymph nodes
    (number and/or extent of spread)

7
Distant Metastasis (M)
  • MX Distant metastasis cannot be evaluated
  • M0 No distant metastasis
  • M1 Distant metastasis (cancer has spread to
    distant parts of the body)

8
TNM data provides Stage
9
Why do we need Clinical Staging?
  • Staging helps plan a persons treatment.
  • The stage can be used to estimate the persons
    prognosis
  • We all need to have hope in this diagnosis of
    cancer
  • We all need to have realistic expectations of our
    predicted course
  • Knowing the stage is important in identifying
    clinical trials that may be suitable for a
    particular patient.

10
The IASLC Lung Cancer Database
Summary of Cases Contributed to Project
Updated from Goldstraw P, Crowley JJ. The
International Association for the Study of Lung
Cancer International staging project on lung
cancer. J Thorac Oncol 2006 1 281-286.
11
The IASLC Lung Cancer Database
Treatment Modalities 81,495 Cases
From Goldstraw P, Crowley JJ. The International
Association for the Study of Lung Cancer
International staging project on lung cancer. J
Thorac Oncol 2006 1 281-286.
12
The IASLC Lung Cancer Database
Types of Contributing Groups 81,495 Cases
13
The IASLC Lung Cancer Database
Stage Distribution, Non-small Cell Lung
Cancer 67,725 Cases with Clinical Stage,
Pathological Stage, or Both
14
T-Descriptors Size of Primary Tumor
Size of Primary Tumor, cT1-3, N0 NSCLC
From Rami-Porta R, Ball D, Crowley J et al. The
IASLC lung cancer staging project proposals for
the revision of the T descriptors in the
forthcoming (seventh) edition of the TNM
classification for lung cancer. J Thorac Oncol
2007 2 593-602.
15
T-Descriptors Size of Primary Tumor
Size of Primary Tumor, pT1-3, N0 NSCLC
From Rami-Porta R, Ball D, Crowley J et al. The
IASLC lung cancer staging project proposals for
the revision of the T descriptors in the
forthcoming (seventh) edition of the TNM
classification for lung cancer. J Thorac Oncol
2007 2 593-602
16
N-Descriptors
Surgically Managed Patients
From Rusch VW, Crowley J, Giroux DJ et al. The
IASLC lung cancer project proposals for the
revision of the N descriptors in the forthcoming
seventh edition of the TNM classification for
lung cancer. J Thorac Oncol 2007 2 603-612
17
TNM Stage Category
Pathological Stage v. 6 and Proposed v. 7
pTNM 6th Edition
From Goldstraw P, Crowley J, Chansky K et al.
The IASLC lung cancer project proposals for the
revision of the TNM stage groupings in the
forthcoming (seventh) edition of the TNM
classification of malignant tumours. J Thorac
Oncol 2007 2 706-714
18
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19
Clinical Staging Liabilities
  • Relies on imaging
  • Subject to false positives and false negatives
  • Subject to false negative bias by less invasive
    testing
  • Needle biopsy vs. Core vs. Tissue biopsy
  • Subject to incomplete staging
  • Dont sample as many nodes as we can
    pathologically
  • But, with guideline based approach
  • We will capture most data with less risk

20
NCCN The National Comprehensive Cancer Network
  • www.nccn.org
  • Enroll for access
  • Look for the Clinical Practice Guidelines in
    Oncology
  • Search for your site of disease

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27
  • The CoC provides accreditation to most hospitals
    caring for cancer patients

Failure to secure accreditation leads to loss of
access to Clinical Trials, can have a negative
impact on approved providers and can limit
referral access
28
  • Monitor all aspects of cancer care
  • Prevention
  • Early Diagnosis
  • Pretreatment
  • Evaluation
  • Staging
  • Best Practices/Treatment

29
Good news!
30
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31
But we are at risk!
  • We will be reviewed again in 2011
  • Internal and external monitoring has indicated
    that we have a chronic deficiency in our
    DOCUMENTATION of staging.
  • This will be a focus of the next review.

32
How do we do, at UK?
  • Began to collect data
  • Focused on multidisciplinary cancer conferences
  • Established minimum participation criteria
  • Collected data for participation and staging
  • Began last yearbad data
  • tip-toed around the problem

33
Cancer Committee ReportMarch 2009
  • Gathered data
  • Presented with anonymous labels
  • Tried to gather support for improving the
    institutional data collection
  • Too soft.

34
ITEM 4 Patient Care Issues and Policies
  • A random sampling of 10 patient records was
    pulled from each of these services
  • Breast
  • GI
  • GU
  • Gyn Onc
  • Head and Neck
  • Lung

35
Clinical Stage DocumentedMarkey Cancer Center
Target for 2008 Standards
Mean of all Services
10 charts/svc paper and EMR survey ANY
documentation of required elements Pre-treatment
T N M Stage Group Attending Physician
Signature
36
ITEM 4 Patient Care Issues and Policies
37
2010 Initiative - More Precision - Better
Performance
  • Abandon anonymity!
  • Present the collected data
  • in real time
  • Identifiable
  • Accountability
  • Opportunity to defend the data and make
    corrections
  • Giving up on trying to protect the sensitive
    feelings of physicians

38
Malignant Hematology/Bone Marrow Transplant
           
39
Lung Cancer Program
       
   
40
Genitourinary Program
   
41
Head and Neck Oncology Program
       
42
GI Cancer Program
         
43
Next Steps
  • Collect data on clinical trial consideration
  • Considered?
  • Eligible?
  • Enrolled?
  • Collect data outside the confines of the
    Multidisciplinary Cancer Conferences
  • Enterprise wide
  • Capture data on other important aspects of cancer
    care
  • Palliative Care
  • Rehabilitative Services
  • Nutrition Services
  • Track Timing of Care

44
Cancer Monitor
  • Ongoing audit of our care
  • Images reviewed at UK
  • Pathology reviewed at UK
  • Smoking status/Cessation Counseling
  • Appropriate referrals to treatment specialists
  • Med/Onc RT Surgery Genetic Counseling
  • Timing of care
  • Initiated in prostate in 2009, lung in 2010

45
We need your help
  • For all cancer patients
  • DOCUMENT the following information in EVERY note
  • Clinical diagnosis
  • e.g. suspect lung cancer OR Poorly
    Differentiated Adenocarcinoma of Transverse Colon
  • Stage
  • Clinical cT1bN0M0
  • Need Source document (CT Scan/PET Scan/MRI)
  • Pathologic pT2aN1M0
  • Date of Diagnosis
  • Date of Surgery (if applicable)
  • Sign the document

46
Our Goals for 2010
  • Achieve 90 Clinical Staging Documentation
  • We DO thiswe need to get credit for it
  • See patients within 2 weeks of referral
  • Clinical Staging within 2 weeks of initial visit
  • Treatment initiation within one month
  • Our cancer patients have a TREMENDOUS sense of
    urgency
  • We need to demonstrate the same

47
Thank you.
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