National Quality Forum Endorsed Commission on Cancer Measures for Quality of Cancer Care for Breast and Colorectal Cancers

American College of Surgeons Press Release

First Posted: April 12, 2007

Last Updated: May 14, 2007

Background

The Commission on Cancer (CoC) of the American College of Surgeons (ACoS) submitted quality of care measures for breast and colorectal cancer to the National Quality Forum (NQF) in response to its call for proposed breast measures in late 2004 and colorectal measures in early 2005.  Measures were reviewed by the CoC’s breast and colorectal disease site teams prior to their submission to the NQF for consideration. 

A NQF Steering Committee for quality of cancer care measures was charged with assuring that pertinent stakeholders had appropriate opportunity review and provide input on the measures under consideration.  Two Technical Panels assembled by the NQF made up of breast and colorectal experts in the areas of surgery, radiotherapy, medical oncology, health care consumers, and health services research provided technical evaluation of the proposed measures.  The NQF Steering Committee and Technical panels reviewed measures using four criteria:

• importance: the extent to which a measure reflects variation that has the potential for improvement;
• scientific acceptability: that a measure is reliable, valid, precise, and adaptable to patient preference;
• usability: information produced as part of the measure could be used to make decisions and/or take actions, and that reported performance levels were statistically, and clinically meaningful;
• feasibility: that data can be obtained within the normal flow of clinical care and that implementation of the measure was achievable.

Development

Eight measures proposed by the CoC (four breast cancer, three colon cancer, and one rectal cancer) were reviewed by the NQF.  In response to specific comments from the NQF, the CoC examined additional data and made revisions to the originally proposed measures.  Five measures were determined to meet the evaluation criteria established by the NQF and are specified in the following tables.

Cancer registry data elements are nationally standardized and considered open source.  Each of these measures was developed by the CoC with the expectation that cancer registries would be used to collect the necessary data to assess and monitor concordance with the measures.  Extensive assessment and validation of the measures was performed using cancer registry data reported to the National Cancer Data Base (NCDB).

All measures are designed to assess performance at the hospital or systems-level, and are not intended for application to individual physician performance.

Four measures were endorsed by the NQF as accountability measures, meaning that these measures can be used for such purposes as public reporting, payment incentive programs, and the selection of providers by consumers, health plans, or purchasers.  Quality improvement measures are intended to be used for internal monitoring of performance within an organization or group so that analyses and subsequent remedial actions can be taken, as appropriate. 

Through a parallel process the American Society for Clinical Oncology (ASCO) and the National Comprehensive Cancer Network (NCCN) developed a similar set of measures for breast and colorectal cancer.  Facilitated by the NQF, the CoC, ASCO, and NCCN agreed to synchronize their developed measures to ensure that a unified set were put forth to the public. 

Breast Cancer Measures submitted by the CoC to the National Quality Forum (NQF) and endorsed by the NQF in April 2007. Through a collaborative process, the CoC, ASCO and NCCN have agreed upon common specifications of the measures below.
Radiation therapy is administered within 1 year (365 days) of diagnosis for women under age 70 receiving breast conserving surgery for breast cancer.
Application	Type	Denominator	Numerator
Hospital or systems-level performance	Accountability	Women Age 18-69 at time of diagnosis Known or assumed first or only cancer diagnosis Primary tumors of the breast Epithelial invasive malignancy only AJCC Stage I, II, or III Surgically treated by breast conservation surgery (surgical excision less than mastectomy) All or part of first course of treatment performed at the reporting facility Known to be alive within 1 year (365 days) of diagnosis	Radiation therapy to the breast initiated within 1 year (365 days) of date of diagnosis
Combination chemotherapy is considered or administered within 4 months (120 days) of diagnosis for women under 70 with AJCC T1cN0M0, or Stage II or III hormone receptor negative breast cancer.
Application	Type	Denominator	Numerator
Hospital or systems-level performance	Accountability	Women Age 18-69 at time of diagnosis Known or assumed first or only cancer diagnosis Primary tumors of the breast Epithelial invasive malignancy only AJCC T1cN0M0, or Stage II or III Primary tumor is estrogen receptor negative and progesterone receptor negative All or part of first course of treatment performed at the reporting facility Known to be alive within 4 months (120 days) of diagnosis	Consideration or administration of multi-agent chemotherapy initiated within 4 months (120 days) of date of diagnosis
Tamoxifen or third generation aromatase inhibitor is considered or administered within 1 year (365 days) of diagnosis for women with AJCC T1cN0M0, or Stage II or III hormone receptor positive breast cancer.
Application	Type	Denominator	Numerator
Hospital or systems-level performance	Accountability	Women Age >=18 at time of diagnosis Known or assumed first or only cancer diagnosis Epithelial invasive malignancy only AJCC T1cN0M0, or Stage II or III Primary tumor is estrogen receptor positive or progesterone receptor positive All or part of first course of treatment performed at the reporting facility Known to be alive within 1 year (365 days) of diagnosis	Consideration or administration of tamoxifen or third generation aromatase inhibitor initiated within 1 year (365 days) of  date of diagnosis

 

Colon Cancer Measure submitted by the CoC to the National Quality Forum (NQF) and endorsed by the NQF in April 2007. Through a collaborative process, the CoC, ASCO and NCCN have agreed upon common specifications of the measures below.
Adjuvant chemotherapy is considered or administered within 4 months (120 days)  of diagnosis for patients under the age of 80 with AJCC Stage III (lymph node positive) colon cancer.
Application	Type	Denominator	Numerator
Hospital or systems-level performance	Accountability	Age 18-79 at time of diagnosis Known or assumed to be first or only cancer diagnosis Primary tumors of the colon Epithelial invasive malignancy only AJCC Stage III All or part of first course of treatment performed at the reporting facility Known to be alive within 4 months (120 days) of diagnosis	Consideration or administration of chemotherapy  initiated within 4 months (120 days) of date of diagnosis
At least 12 regional lymph nodes are removed and pathologically examined for resected colon cancer.
Application	Type	Denominator	Numerator
Hospital or systems-level performance	Quality Improvement	Age >=18 at time of diagnosis Known or assumed to be first or only cancer diagnosis Primary tumors of the colon Epithelial invasive malignancy only AJCC Stage I, II, or III Surgical resection performed at the reporting facility	>=12 regional lymph nodes pathologically examined

Current Activities

The Cancer Program Practice Profile Reports (CP³R) for Stage III colon cancer released in January 2005, and Electronic Quality Improvement Packets (e-QuIP) for breast and colorectal cancers, released in October 2006 and March 2007 respectively, have demonstrated that improvements in data quality can demonstrate the quality of patient care when the entire cancer committee supports system-level enhancements to ensure complete and precise documentation.  Specifically, the e-QuIP reports provide CoC-Approved Cancer Programs with a preliminary examination of program-specific breast and colorectal cancer care practices and promote quality improvement activities in anticipation of the endorsement by the NQF of the measures documented here.

Next Steps

The CoC has begun development of reporting templates for each of these measures using data reported by cancer registries from CoC-Approved Cancer Programs.  All three organizations (CoC, ASCO, and NCCN) have agreed that implementation of these measures necessitates reporting concordance rates for administered therapy, considered therapy, and an aggregate rate.  This approach will facilitate the identification of hospitals or systems that report disproportionately high rates of performance outside the recommended considered therapy regimens, potentially promoting educational interventions and improving care at the local level. 

The measures will be updated regularly to reflect changes in evidence-based findings in consultation with ASCO and NCCN.

Collaboration with other Organizations

The specifications of each of the five CoC measures endorsed by the NQF have been commonly agreed upon with ASCO and NCCN, and are expected to facilitate broad acceptance and implementation of the measures.

In addition to the measures endorsed by the NQF, the CoC, ASCO, and the NCCN have developed and agreed upon specifications for an additional rectal cancer measure that appears in the following table.

Surveillance measures can be used at the community, regional, and/or national level to monitor patterns and trends of care in order to guide policymaking and resource allocation.

Rectal Cancer Measures developed independently by the CoC and ASCO/NCCN. Through a collaborative process, the CoC, ASCO and NCCN have agreed upon common specifications of the measures below.
Radiation therapy is considered or administered within 6 months (180 days)  of diagnosis for patients under the age of 80 of  with clinical or pathologic AJCC T4N0M0 or Stage III receiving surgical resection for rectal cancer.
Application	Type	Denominator	Numerator
Hospital or systems-level performance	Surveillance	Age 18-79 at time of diagnosis Known or assumed to be first or only cancer diagnosis Primary tumors of the rectum Epithelial invasive malignancy only AJCC clinical or pathologic AJCC T4N0M0 or Stage III All or part of first course of treatment performed at the reporting facility Known to be alive within 6 months (180 days) of diagnosis	Consideration or administration of radiation therapy initiated within 6 months (180 days) of date of diagnosis

The National Quality Forum

The National Quality Forum (NQF) is a not-for-profit membership organization that develops and implements national strategies for health care quality measurement and reporting. Membership in the NQF has broad public and private participation, including but not limited to health care consumers, purchasers (both private and public), employers, health care professionals, health plans and organizations involved in health care research or quality improvement.  The members of the NQF work to promote common approaches to measuring health care quality and promoting quality improvement.  Funding support for the development of the National Voluntary Consensus Standards for Diagnosis and Treatment of Breast and Colon Cancer was provided by the following Federal agencies: Agency for Healthcare Research and Quality (AHRQ), the National Cancer Institute (NCI), the Centers for Medicare and Medicaid Services (CMS), and the Centers for Disease Control and Prevention (CDC).

Dedication

Dr. Rodger Winn passed away April 4^th, 2007 following a battle with esophageal cancer.  The CoC is indebted to Dr. Winn who was instrumental in his role as Director of the National Quality Forum’s Quality of Cancer Care Project as he steered the consensus process through the delicate and daunting prospect of balancing the realities of real-world feasibility with the demands of scientific rigor.  Dr. Winn enjoyed a long and successful career in both private and academic medicine, and is widely recognized as one of the leading figures responsible for the establishment of the NCCN Clinical Practice Guidelines in Oncology.

For questions related to the release of these quality measures, please contact the NCDB at ncdb@facs.org or call 312-202-5111.

 

Revised May 14, 2007

NCDB