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Palos Cancer Program Profile Report

The American College of Surgeons' Commission on Cancer requires all accredited Cancer Programs to participate in the Cancer Program Practice Profile Report (CP3R). Palos Health refers to this report to compare our facility’s treatment for Breast, Colon, Gastric, Lung, Rectal, Ovarian, Endometrium, Cervical, Bladder and Kidney cancer to that of state and national levels.

2016  Breast Cancer Measures for First Course Treatment

Treatment Measure Definition PCH Illinois National
BCS Breast conservation surgery rate for women with AJCC clinical stage 0, 1 or 2 breast cancer (Surveillance) 64.7% 69.6% 67.2%
nBx Image or palpation-guided needle biopsy of the primary site is performed to establish diagnosis of breast cancer (Quality Improvement) 100.0% 92.9% 90.3%
MASTRT Radiation therapy is recommended or administered following any mastectomy within 1 year (365 days) of diagnosis of breast cancer for women with >=4 positive regional lymph nodes (Accountability) 100% 89.7% 85.8%
BCSRT Radiation is administered within 1 year (365 days) of diagnosis for women under the age of 70 receiving breast conservation surgery for breast cancer (Accountability) 93.8% 92.7% 91.1%
MAC Combination chemotherapy is recommended or administered within 4 months (120 days) of diagnosis for women under 70 with AJCC T1N0, or stage IB-III negative breast cancer (Accountability) 57.7% 96.5% 92.7%
HT Tamoxifen or third generation aromotase inhibitor is recommended or administered within 1 year (365 days) of diagnosis for women with AJCC T1c, or stage IB-III hormone receptor positive breast cancer (Accountability) 97.4% 93.8% 91.7%

2016 Colon Cancer Measures for First Course Treatment

Treatment Measure Definition PCH Illinois National
ACT Adjuvant chemotherapy is considered or administered within 4 months (120 days) of diagnosis for patients under the age of 80 with AJCC Stage 3 (lymph node positive) Colon cancer (Accountability) 100% 91.0% 87.8%
12RLN At least 12 regional lymph nodes are removed and pathologically examined for resected colon cancer(Quality Improvement) 93.0% 93.3% 92.7%

2016 Gastric Cancer Measures for First Course Treatment

Treatment Measure Definition PCH Illinois National
15RLN At least 15 regional lymph nodes are removed and pathologically examined for resected gastric cancer (Quality Improvement) 50% 59.4% 64.7%

2016 Lung Cancer Measures for First Course Treatment

Treatment Measure Definition PCH Illinois National
10RLN

At least 10 regional lymph nodes are removed and pathologically examined for AJCC stage IA, IB, IIA, and IIB resected NSCLC (Surveillance)

58.6% 53.3% 49.0%
LCT Systemic chemotherapy is administered within 4 months to day preoperatively or day of surgery to 6 months postoperatively, or it is recommended for surgically resected cases with pathologic lymph node positive (pN1) and (pN2) NSCLS (Quality Improvement) 100.0% 91.0% 89.2%
LNoSurg Surgery is not the first course of treatment for cN2, MO lung cases (Quality Improvement) 66.7% 93.2% 92.7%

2016 Rectal Cancer Measures for First Course Treatment

Treatment Measure Definition PCH Illinois National
RECRT Perioperative chemo and radiation are administered for AJCC T3N0, T4N0, or Stage III; or Postoperative chemo and radiation are administered within 180 days of diagnosis for clinical AJCC T1-2N0 with pathologic AJCC T3N0, T4N0, or Stage III; or treatment is recommended ; for patients under the age of 80 receiving resection for rectal cancer (Quality Improvement) No data 86.6% 86.6%

2016 Ovarian Cancer Measures for First Course Treatment

Treatment Measure Definition PCH Illinois National
OVSAL Salpingo-oophorectomy with omentectomy, debulking/cytoreductive surgery, or pelvic exenteration in Stages I-IIIC Ovarian cancer (Surveillance) 0.0% 65.6% 67.2%

2016 Endometrium Cancer Measures for First Course Treatment

Treatment Measure Definition PCH Illinois National
ENDCTRT Chemotherapy and/or radiation administered to patients with Stage IIIC or IV Endometrial cancer (Surveillance) no data 83.3% 83.5%
ENDLRC Endoscopic laparoscopic, or robotic performed for all Endometrial cancer (excluding sarcoma and lymphoma), for all stages except stage IV (Surveillance) 62.5% 76.3% 80.0%

2016 Bladder Cancer Measures for First Course Treatment

Treatment Measure Definition PCH Illinois National
BL2RLN At least 2 lymph nodes are removed in patients under 80 undergoing partial or radical cystectomy(Surveillance) no data 93.8% 92.4%
BLCSTRI Radical or partial cystectomy; or tri-modality therapy (Local tumor destruction/excision with chemotherapy and radiation) for clinical T234NOMO patients with urothelial carcinoma of the  bladder, first treatment within 90 days of diagnosis (Surveillance) 0.0% 58.9% 53.4%
BLCT Neo-adjuvant or adjuvant chemotherapy recommended or administered for patients with muscle invasive cancer undergoing radical cystectomy (Surveillance) no data 57.6%

64.1%

2016 Cervical Cancer Measures for First Course Treatment (new measure)

Treatment Measure Definition PCH Illinois National
CERRT Radiation therapy completed within 60 days of initiation of radiation among women diagnosed with any stage of cervical cancer (Surveillance) no data 82.8% 81.2%
CERCT Chemotherapy administered to cervical cancer patients who received radiation for stages IB2-IV cancer (Group 1) or with positive pelvic nodes, positive surgical margin, and/or positive parametrium (Group 2) (Surveillance) no data 87.4% 88.9%
CBRRT Use of brachytherapy in patients treated with primary radiation with curative intent in any stage of cervical cancer (Surveillance) no data 77.2%

68.5%

2016 Kidney Cancer Measures for First Course Treatment

Treatment Measure Definition PCH Illinois National
PD1RLN At least 1 regional lymph node is removed and pathologically examined for primarily resected unilateral nephroblastoma (Surveillance) no data no data 89.3%