rectal cancer - from a to naprc 6.11€¦ · 6/11/2020 3 objectives •to familiarize participants...

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Rectal Cancer-From A to NAPRC

June 11, 2020

Presented by Christi Cox, CTR-Manager of Education

Confidential and proprietary. © ERS 2020. All rights reserved.

Confidential Information and Disclaimer

• The information provided in this presentation and accompanying documentation is confidential and proprietary and may not be reproduced or distributed without the express consent of Electronic Registry Systems, Inc. © Copyright 2020. Unauthorized use may violate copyright and trademark laws.

• The information provided in this presentation is done as a service to ERS clients. The objective of the information provided is to provide information about Rectal Cancer Care and how to collect and report data in a manner that supports your cancer program and NAPRC accreditation goals and is not intended to be a webinar on coding rules.

• At the time this presentation was created, the links provided were the most current links from various standard setters and manuals. It is ultimately the client’s responsibility to ensure the use of the proper resources for coding.


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Having Trouble Hearing Me?

• If you are listening through your computer speakers, please turn up the volume on your computer. If that does not work, please dial in on the telephone.

• If you are listening through the telephone, crank up the volume on your phone, or if that does not work try listening through your speakers.


Housekeeping

• Handouts were distributed to the email address you provided for registration prior to this meeting.

• Handouts are also available during this webinar. They are located under the handouts pane. Just click and download.

• The webinar will be approximately 1 hour in length.

• CE Certificates will be sent later this week to the email address you provided during registration for this webinar.


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Objectives

• To familiarize participants with clinical aspects of Rectal Cancer including customary diagnostics, surgeries and other treatment modalities

• To explore anatomy related to rectal surgery recommendations from Operative Standards for Cancer Care

• To highlight data collection enhancements for NAPRC accreditation efforts


Rectal Cancer- History and Trends

Difficult to separate “Colorectal” stats into Colon and Rectum

In USA 2019

• 44,180 new Rectal cancer cases

• 101,420 new Colon cancer cases

• Combined deaths 51,020


Rates are age adjusted to the

2000 US standard population

and are adjusted for reporting

delays.

Source: Incidence – SEER

Program, National Cancer

Institute, 2016. Mortality –

National Center for Health

Statistics, Centers for Disease

Control and Prevention, 2016.

©2017 American Cancer

Society, Inc., Surveillance

Research

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Rectal Cancer- History and Trends


Rectal Cancer Screening Recommendations

• Screening should be instigated at age 45 for average risk individuals

• Colonoscopy remains “Gold Standard”• Requires prep, typically includes sedation, most reliable screening

• Less invasive screening methods now available• CT Colonography

• Stool DNA test

• Guaiac-based fecal occult blood test (gFOBT)

• Fecal immunochemical test (FIT)

• If any yield abnormal results, colonoscopy still needs to be done


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The future of screening?


Diagnosis of Rectal Cancer

• Non-symptomatic disease commonly dx by screening colonoscopy and polypectomy or biopsy

• Symptomatic disease also frequently leads to partial or full colonoscopy and either polypectomy or biopsy for diagnosis

• DRE- Somewhat primitive, somewhat controversial..

• Pathologic examination and tumor markers

• Histologic type and grade

• MSI/MMR- Indicators of Lynch Syndrome

• Genetic markers- KRAS, NRAS, BRAF


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Rectal Cancer Markers

• MSI- Microsatellite Instability

• MMR or MMRP- Mis-Match Repair Proteins

• MLH1, MSH2, MSH6 and PMS2

• KRAS

• NRAS

• BRAF

• Her2


Rectal Cancer Surgery- Transanal

• Transanal Local Excision

• Small tumor (<3 cm)

• <30% circumferential

• Distal lesion (within 8 cm of anal verge)

• No LVI or PNI

• Well- Mod diff

• T1 only

• Full-thickness excision feasible


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Diagnostic/ Staging- IMAGING

• MRI is preferred for

rectal/pelvic imaging

• Rectal EUS if not eligible for MRI

• CT or PET/CT of C/A/P

to rule out mets


This image reproduced for educational purposes with permission from the Radiology Assistant

Rectal MRI Synoptic Reports

• Standardized reporting for Rectal MRI

• NAPRC Standard 2.3-• For MRI staging to be effective, the technique of acquiring and interpreting the

images must be uniform and the results must be reported in a standardized report. Without standardized reporting, less than 40 percent of MRI reports contain all of the necessary information to make treatment decisions.

• Minimum elements to be included on report are defined in the Cancer Care Ontario template

• https://www.cancercareontario.ca/en/guidelines-advice/treatment-modality/surgery/quality-improvement-resources


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Rectal MRI Standardized Report Template


Rectal Cancer Surgery

• New CoC standard for Total Mesorectal Excision (TME)

• CoC Standard 5.7 (phase-in)

• Applies to all Low and Mid rectal cancers treated with curative intent surgery


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Rectal Cancer Surgery- Op Report

• NAPRC Standard for Surgical resection AND Synoptic Op reports

• Specialization of surgeons

• ASCRS rectal cancer checklist was used as a guide to developing the standardized synoptic Op report

• Minimum required elements are in Table 1 of NAPRC appendix


Confidential and proprietary. © ERS 2020. All rights reserved

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Announced Today 6/11/2020:


NAPRC Standards- Chapter 1

• 1.1 - CoC accreditation

• 1.2 - Establish RCMDT• Physician disciplines include surgery, pathology,

radiology, medical onc and radiation onc

• 1.3 - Each member 50% attendance

• 1.4 - Meet twice each calendar month

• 1.5 - Appoint RCMDT director• Internal Audit Responsibilities

• Liaison between CoC and RCMDT

• Data Interpretation Responsibilities

• 1.6 - Appoint Program Coordinator

• 1.7 - Complete NAPRC Education


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NAPRC Standards- Chapter 2


NAPRC Standard 2.1

• The RCP must confirm the dx of rectal cancer before the initiation of tx at the accredited RCP

• If diagnosed elsewhere, RCP must review outside slides

• If slides cannot be obtained, reportsmust be reviewed

• If slides and reports are unavailable, the pt must be re-biopsied by the RCP

• Review of outside pathology must be documented in EMR


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NAPRC Standard 2.2

• Previously untreated patients must have staging imaging

• Systemic staging with CT C/A/P or PET/CT C/A/P

• Local Staging with MRI of the pelvis• Exception for patients with documented contraindications to CT or MRI


NAPRC Standard 2.3

• MRI with Rectal Protocol

• Uniformity in technique & interpretation

• Standardized Synoptic report


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NAPRC Standard 2.4

• CEA level is obtained before definitive treatment begins

• Recorded in the EMR

• 75% compliance required


NAPRC Standard 2.5Treatment planning discussion must include:

Review of diagnostic and staging studies

• Colonoscopy report (location of primary tumor and synchronous lesions) if present/available

• Biopsies of primary rectal cancer and metastases if present/available (Standard 2.1)

• CT scan or PET/CT of chest, abdomen, and pelvis (Standard 2.2)

• Rectal Cancer MRI (Standard 2.2)

• Pretreatment CEA level (Standard 2.4)

Assignment of clinical stage

• Clinical stage according to the AJCC

Creation of individualized treatment plan

• Neoadjuvant therapy regimen, when indicated

• Anticipated surgical procedure

• Referral to radiation oncology, when indicated

• Referral to medical oncology, when indicated

• Palliative care, when indicated


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NAPRC Standard 2.6The physician who presents the patient to the RC-MDT is responsible for

ensuring communication and presentation of the evaluation and treatment

recommendation summary to the patient’s PCP and/or referring physician.

The standardized evaluation and treatment recommendation summary includes,

but is not limited to:

• Tumor location in the rectum

• Indication of sphincter involvement

• Pretreatment (clinical) AJCC stage

• Pretreatment CRM status

• CEA level

• Neoadjuvant therapy recommendation

• Type and duration of neoadjuvant therapy recommended

• Anticipated date and type of surgical procedure

• Clinical research study eligibility and/or enrollment


NAPRC Standard 2.7

Accredited rectal cancer programs must ensure that 80 percent of previously untreated patients begin definitive treatment within 60 days of the patient’s initial clinical evaluation for rectal cancer at the accredited RCP. The treatment plan is documented in the patient’s medical record.


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NAPRC Standard 2.8

• Specialized surgeons

• Members of the RC-MDT

• TME performed

• Standardized Op report

• Checklist fromNAPRC appendix1 is utilized


Photos from the free pages of the Operative Standards for Cancer Care downloaded from the CoC section of facs.org

NAPRC Standard 2.9

• Path reports must include all CAP Rectal Cancer Protocol elements• Includes an evaluation of the completeness of the mesorectal excision, the

status of the circumferential margin, and the response of the tumor to neoadjuvant therapy (Tumor Regression Grade)

• Standardized Synoptic format

• Path report complete within 2 weeks of the definitive surgicalresection


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NAPRC Standard 2.10

• Minimum of 65 percent of rectal cancer specimens are photographed to document the quality of the mesorectum and include anterior, posterior, and lateral views.

• These images are shown and discussed at RC-MDT meetings and are electronically stored with a patient identifier.

• If the specimen is photographed but not presented and discussed at an RC-MDT meeting, then it does not qualify for the 65 percent required for compliance with this standard.


NAPRC Standard 2.11

The four primary components of the

treatment outcome discussion* for

rectal cancer patients are:

1. Presurgical Evaluation and Treatment

2. Review of the outcome of the surgery

3. Review of the final pathology report and stage

4. Recommendation for adjuvant treatment


*The treatment outcome discussion

must happen within 4 weeks of the

patient’s definitive surgery, and the

discussion must be documented in the

EMR

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NAPRC Standard 2.12

The treatment summary must include, but is not limited to, the following information:

• Pretreatment (clinical) stage according to AJCC

• Pretreatment CEA level

• Neoadjuvant therapy before surgery

• Type of neoadjuvant therapy

• Neoadjuvant therapy date of completion

• Surgical procedure

• Date of surgery

• Final pathological stage according to AJCC

• Tumor Regression Grade

• Microsatellite instability status

• Circumferential Resection Margin

• Distal Resection Margin

• Mesorectal Grade

• Recommendation for adjuvant therapy (if applicable)

• Recommendation for adjuvant therapy regimen (if applicable)


NAPRC Standard 2.13

• NCCN Guidelines • Clinical or Pathologic Stage II and III

• 5-FU based systemic therapy

• Overall and disease free survival improved

• Initiate within 8 weeks after surgery• Document reasons for delays


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NAPRC Chapter 3

Standard 3.1

• Submit all eligible rectal cancer cases to RQRS

• Submit within 3 months ofdiagnosis

Standard 3.2

• Review your program’s EPR (Estimated Performance Rate)

• Develop and execute plans for improving compliance


NAPRC Benefits

• Ensures specialized care for all Rectal Cancer Program patients

• Provides structure for treatment decisions through multidisciplinary discussions

• Provides timeline for milestones of care so delays are avoided

• Empowers patients through improved communication with Care Team

• Improves communication and accountability between Rectal Cancer Program members


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NAPRC Data Collection




Std 2.1

Std 2.2

Std 2.3

Std 2.4

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Std 2.5

Std 2.6

Std 2.7

Std 2.8

Std 2.9

Std 2.10

Std 2.11

Std 2.12

Std 2.13


• Five User-defined fields to capture further details or non-NAPRC standard info

• Text area to record information about treatment delays, or use as a tracking tool for upcoming due dates for treatment start, outcome discussion, etc.


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NAPRC Registry Reporting


NAPRC Registry Reporting


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Thank you for participating!


rectal cancer - from a to naprc 6.11€¦ · 6/11/2020 3 objectives •to familiarize participants...

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