Meeting American College of Surgeons’ Commission on Cancer Standards

The American College of Surgeons' Commission on Cancer, the professional organization that accredits hospital cancer programs including Rose Medical Center, requires that all accredited facilities meet rigorous standards every year. Below, please learn about how our program met some of these standards in 2018, all designed to fulfill community needs:

Standard 4.1 - Prevention Programs

Each year, the Rose cancer program provides at least one cancer prevention program designed to reduce the incidence of a specific cancer type.

In March of 2018, during Colon Cancer Awareness Month, Rose colorectal surgeon Dr. David Longcope presented colonoscopy screening information, high-risk cancer education and colon cancer prevention strategies at Denver Water. Dr. Longcope also has made a series of educational videos with regard to colonoscopy and colon screening guidelines. Dr. Daniel Donato, Rose gynecologic oncology surgeon, was part of a series of videos on gynecologic screenings and the HPV vaccine. In May, Rose was part of an event at Kavod Senior Living where breast cancer education and screening information was provided. In October, Rose Medical Center held an event at Rose community partner Temple Emanuel where fertility experts Dr. Laxmi Kondapalli snd Dr. Mandy Katz-Jaffe provided education and a Q&A session about Jewish genetic diseases, screening technology, infertility awareness and education, and the role of genetics for the Jewish population.

Standard 4.2 - Screening Programs

Each year, the cancer center provides at least one cancer screening program targeted to decrease the number of patients with late-stage disease.

In May of 2018, the Rose Breast Center had a walk-in breast cancer screening event for Rose staff. Thirty-five employees had mammograms; zero staff had positive results.

Standard 4.6 - Monitoring Compliance with Evidence-Based Guidelines

Each year, a cancer center physician performs a study to assess whether patients in a specific program are evaluated and treated according to evidence-based national treatment guidelines.

In 2018, Rose radiation oncologist Dr. Paige Dorn assessed the breast re-excision rate at Rose Medical Center for 2017 compared to national guidelines. In 2017, Rose had 108 patients who underwent lumpectomies. Of those 108 patients, 16 had re-excision lumpectomies or mastectomies, and 19 had re-excision surgeries. Of those 19 re-excision surgeries, 10 were performed for positive margins (53%), and 9 were performed for < 2mm DCIS margin (47%). Rose Medical Center was found to be 100% compliant with national guidelines on re-excision surgeries.

Standard 4.7 - Studies of Quality

Each year, under the guidance of the quality improvement coordinator, the committee develops, analyzes and documents the required studies that measure quality of care and outcomes for cancer patients.

IORT (intraoperative radiation treatment) has been in use at Rose Medical Center in the setting of a prospective trial for more than 6 years. Data from this institutional study is maturing with longer term follow-up available for the initial two cohorts. International data is accumulating and guidelines have been published with regard to IORT. Per Dr. Paige Dorn, the purpose of this study is to compare Rose Medical Center recurrence rates in the initial two IORT cohorts with national results. The mean follow-up is 55 months. There were 184 breast cancer patients that received IORT, and 10 of them, or 5.4%, have had recurrences. The recurrence rate in patients with grade 3 invasive disease was 19%, as opposed to grade 2 invasive disease which was 2.0%, and grade 1 invasive disease which was 1.4%. The recurrence rate in patients with grade 3 DCIS was 11.1%, versus grade 2 DCIS which was 7.1%, and grade 1 DCIS for which there were no recurrences. By studying this recurrence data, the physicians are now better able to counsel patients as to whether IORT is best option for therapy or if patients should pursue other treatment.

Standard 4.8 - Quality Improvements

The quality improvement coordinator implements two patient care improvements annually. One improvement is based on results of a study that measures quality of can and outcomes while the other can be from another source or another completed study.

In 2018, a study was completed to determine if there is benefit to patients having acupuncture while they are undergoing chemotherapy. Rose partner program Medicine Hands completed 474 appointments with patients from Rose Cancer Center. The team assessed primary outcomes during pre and post session interviews using a verbal numeric self-rating scale from 0 to 10. Based on patient self-assessment, the following outcomes improved from before treatment to after treatment: pain (67%), anxiety (68%), nausea (65%), fatigue (37%), neurologic/balance (54%), comfort/support (58%), and muscle tension (47%). As evidenced by this study, acupuncture has the potential to greatly improve the quality of life in cancer patients.

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