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Oncology Roundtable

Tumor Site Dashboards: Colorectal Cancer Volume, Financial, and Clinical Benchmarks Essential for Strategic Planning 2014

©2014 The Advisory Board Company advisory.com 2

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Oncology Roundtable

Project Analyst

Contributing Consultant

Practice Manager

Hanna Kemeny

Deirdre Fuller

Lindsay Conway


Table of Contents

Introduction……………………………………………………………………………………….4

Market Demographics…………………………………………………………………………...5

Treatment Patterns………………………………………………………………………………7

Volumes and Finances………………………………………………………………………….9

Colorectal Cancer Forecast………………………………………………………………… 13

Creating a Center of Excellence……………………………………………………………...15

Clinical Quality Dashboard……………………………………………………………………16

ICD Codes and DRGs……………………………………………………………………… …12


Introduction

Developing a tumor site strategic plan requires cancer administrators to synthesize a broad range of disease site-specific clinical and financial information. To help these efforts, the Oncology Roundtable has developed a series of tumor site dashboards for breast, colorectal, lung, and prostate cancer. Each dashboard includes tumor site-level data for patient population demographics and size, primary treatment modality by stage, and business unit-level finances. In addition, to aid in business planning, a tumor site-specific resource grid and clinical quality dashboard are included. These dashboards are living documents and will be updated as newer information, both clinical and financial, becomes available. If you have questions please contact Deirdre Fuller at 202-568-7863 or [email protected], or Lindsay Conway at 202-266-5845 or [email protected].

mailto:[email protected]

mailto:[email protected]


Rectal Cancer Population Slightly Younger than Colon Cancer Population

Market Demographics

Source: National Cancer Data Base; Surveillance Epidemiology and End Results (SEER) Cancer Statistics; Oncology Roundtable analysis.

Colorectal cancer is comprised of two distinct diseases, colon and rectal cancers, and is considered one of the top four cancers effecting the US population with about 136,830 new colon and rectal cancer diagnoses expected in 2014. Many colon cancer cases are diagnosed at stage II, yet a sizable portion continue to be diagnosed in later stages of the disease despite an increased focus on early detection. Rectal cancer, however, is often caught at stage I and is typically diagnosed in a slightly younger population than colon cancer. Overall, from 2007-2011, the number of new colon and rectal cancer cases was 43.7 per 100,000 men and women per year, while the number of deaths each year was 16.4 per 100,000 men and women.

Colon Cancer

Stage at Diagnosis Diagnosed in 2011

Age at Diagnosis Diagnosed in 2011

Stage at Diagnosis Diagnosed in 2011

Age at Diagnosis Diagnosed in 2011

Rectal Cancer

6%

20%

24% 25%

19%

0%

6%

0 I II III IV N/A Unknown

0% 1% 2%

7%

17%

24% 25%

20%

4%

<20 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90+

6%

29%

19% 22%

14%

0%

9%

0 I II III IV N/A Unknown

0% 1% 3%

11%

25% 26%

20%

12%

2%

<20 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90+


Colorectal Cancer Incidence Highest in Older Males

Market Demographics

Source: National Cancer Data Base; Surveillance Epidemiology and End Results (SEER) Cancer Statistics; Oncology Roundtable analysis.

1) Relative survival rate is calculated by comparing observed survival of cancer patients with expected survival from a comparable population without cancer.

Between 2002 and 2011, rates of new colorectal cancer cases fell 3.1% on average each year, and survival rates have continued to improve. Rectal cancer patients accounting for approximately 28% of the total colorectal cancer population. The incidence for colorectal cancer is much greater in older populations, especially those 65 and older, and affects African Americans at a higher incidence rate than other races or ethnicities.

Colorectal Cancer Population

Percent Incidence by Age (2007-2011)

Incidence by Race (2007-2011) Per 100,000 of a Specified Race

0.1% 1% 4%

14%

21% 24% 23%

12%

<20 20-34 35-44 45-54 55-64 65-74 75-84 85+

51 50

62

43 46 45 51

38 37

48

32 36

31

39

All Races White Black Asian/PacificIslander

AmericanIndian/Alaskan

Hispanic Non-Hispanic

Male Female


Surgery Remains the Predominant Treatment Option for Colon Cancer

Treatment Patterns

Source: National Cancer Data Base; Oncology Roundtable analysis. 1) First course of treatment by stage. Due to rounding, percentages by row may not sum to

100.

While colon and rectal cancers share similar biology in that both usually develop slowly over a period of years, management of the two diseases differs dramatically. The primary treatment modality for patients diagnosed with colon cancer is surgery; 60% of patients receive stand-alone surgery and an additional 26% in combination with chemotherapy. While increased penetration of colon cancer screening should increase the number of patients diagnosed with early stage disease, it will likely have limited impact on the services utilized given the limited variation in treatment across stages.

Colon Cancer Treatment Modality by Stage1

Colon Cancer Patients Diagnosed in 2011

Stage Surgery Surgery + Chemo Other No Primary Treatment

0 89% 1% 2% 8%

I 92% 2% 2% 4%

II 79% 15% 5% 1%

III 36% 59% 4% 1%

IV 19% 37% 26% 18%

N/A 36% 8% 22% 34%

Unknown 38% 9% 11% 42%

Total 58% 26% 8% 8%


Surgery and Multimodal Therapy Both Used to Treat Rectal Cancer

Treatment Patterns

1) First course of treatment by stage. Due to rounding, percentages by row may now sum to 100. 2) Radiation therapy.

Unlike colon cancer, where treatment is centered primarily around surgery, multimodal therapy is the treatment of choice for later stage rectal cancer patients. This typically encompasses a combination of surgery, radiation therapy, and chemotherapy. In fact, 56% of stage II and 63% of stage III patients receive all three modalities. That said, because a significant volume of patients are diagnosed with early stage disease, stand-alone surgery is the primary treatment for 74% of all rectal cancer patients.

Rectal Cancer Treatment Modality by Stage1

Rectal Cancer Patients Diagnosed in 2011

Stage Surgery Surgery + Chemo

RT2 + Chemo

Surgery + RT + Chemo Other No Primary

Treatment

0 74% 1% 1% 15% 2% 8%

I 59% 1% 3% 27% 4% 5%

II 16% 4% 13% 56% 7% 4%

III 10% 9% 12% 60% 6% 3%

IV 4% 10% 21% 15% 34% 16%

N/A 40% 2% 3% 2% 41% 12%

Unknown 31% 1% 11% 10% 12% 35%

Total 74% 1% 1% 15% 2% 8%

Source: Advisory Board Data and Analytics Group analysis; Oncology Roundtable analysis.

Clinical Innovations in Colorectal Cancer

• Molecular Diagnostics

• Magnetic Resonance Colonography

• Intraoperative Radiation Therapy

• Proton Beam Therapy

• Hyperthermic Intraperitoneal Chemotherapy

• Transanal Endoscopic Microsurgery

• Laparoscopic Colectomy

• Targeted Therapy


Colorectal Surgery Accounts for a Large Portion of Inpatient Surgeries

Volumes and Finances

1) All calculations based on hospital outpatient data. 2) Chemotherapy and radiation therapy volumes represent patients, not visits. 3) Includes procedural diagnosis (e.g. biopsies). 4) Medical diagnostics.

Due to the fact that surgery is the most common form of treatment for colorectal cancer, it accounts for 14% of inpatient oncology revenue and 14% of inpatient oncology contribution profit. However, colorectal cancer patients’ financial contribution to inpatient medical oncology is limited, only accounting for 5% of total oncology contribution profit.

On the outpatient side, chemotherapy for colorectal cancer contributes significantly to outpatient oncology revenue and contribution profit. Procedures contribute to 10% of all outpatient oncology business. Despite radiation therapy’s pivotal role in rectal cancer treatment, it contributes little to the total radiation therapy business primarily due to a relatively small patient population.

Colorectal Cancer Share of Hospital Inpatient Oncology Business

Total Imaging Chemo2 RT2 Procedures3 Lab Medical Dx4

Share of OP Oncology Volume 17% 3% 14% 3% 55% 18% 2%

Share of OP Oncology Revenue 21% 8% 26% 2% 8% 18% 20%

Share of OP Oncology Contribution Profit

22% 8% 26% 2% 10% 18% 8%

Colorectal Cancer Share of Hospital Outpatient Oncology Business1

Total Inpatient Inpatient Medical Inpatient Surgical

Share of IP Oncology Volume 11% 6% 14%

Share of IP Oncology Revenue 14% 5% 18%

Share of IP Oncology Contribution Profit 14% 5% 18%



Oncology Services Shifting to Outpatient Setting


1) 2013 all-payer data.

The table below illustrates both the inpatient and outpatient share of the colorectal cancer market. Not surprisingly, the majority of colorectal cancer business takes place in the outpatient setting, accounting for 97% of volume and 67% of both colorectal revenues and contribution profit.

Inpatient and Outpatient Share of Colorectal Cancer Market1

Volume Revenue Contribution Profit

Inpatient Share of Colorectal Market 3% 33% 33%

Outpatient Share of Colorectal Market 97% 67% 67%



Inpatient Surgery Outpacing Inpatient Medical


1) 2013 all-payer data. 2) All calculations based on HOPD data. 3) Chemotherapy and radiation therapy financials are per patient, not per visit. 4) Chemotherapy per patient financials are on average across tumor sites, tumor site-specific data not available. 5) Includes procedural diagnostics (e.g. biopsies). 6) Medical diagnostics.

The table below shows hospital-based volumes, revenues, and profits generated by colorectal cancer patients nationally. Not surprisingly, inpatient surgical volumes drive the majority of colorectal cancer revenue and profit; the typical colorectal cancer surgery generates $8,202 in contribution profit per patient.

On the outpatient side, imaging and outpatient procedures account for a total of 93% of colorectal contribution profit, which is driven primarily by colonoscopies.

Unbundling Hospital Inpatient Colorectal Finances1

Unbundling Hospital Outpatient Colorectal Finances1,2

Inpatient Medical Inpatient Surgical

Inpatient Share of Colorectal Market Total Volume % of Total Colorectal Volume

31,748 18%

146,538

82%

Revenue Total Revenue (Millions) Revenue per Case % of Total Colorectal Revenue

$270

$8,519 9%

$2586

$17,650 90%

Contribution Profit (CP) Total CP (Millions) CP per Case % of Total Colorectal CP

$132

$4,186 10%

$1,202 $8,202 90%

Contribution Margin 49% 46%

Imaging Chemo3,4 RT3 Procedures5 Lab Medical Dx6

Volume Total Volume (Thousands) % of Total Colorectal Volume

616 9%

33 0%

17 0%

5,314 79%

719 11%

65 1%

Revenue Total Revenue (Millions) Revenue per Scan/Procedure % of Total Colorectal Revenue

$553 $898 9%

$251

$7,664 4%

$144

$8,577 2%

$4,751 $894 81%

$122 $170 2%

$47

$730 1%

Contribution Profit (CP) Total CP (Millions) CP per Scan/Procedure % of Total Colorectal CP

$307 $498 11%

$23

$696 1%

$67

$3,991 2%

$2,231 $420 82%

$89

$124 3%

$18

$281 1%

Contribution Margin 56% 9% 47% 47% 73% 39%



ICD Codes and DRGs

1) ICD-10 codes not finalized at time of writing.

Colorectal Cancer ICD-9 and ICD-10 Codes1

Top 10 Colorectal DRGs (2013)

DRG Description MED/SURG Percent of Total

330 MAJOR SMALL & LARGE BOWEL PROCEDURES W CC SURG 35%

331 MAJOR SMALL & LARGE BOWEL PROCEDURES W/O CC/MCC SURG 22%

329 MAJOR SMALL & LARGE BOWEL PROCEDURES W MCC SURG 12%

375 DIGESTIVE MALIGNANCY W CC MED 10%

333 RECTAL RESECTION W CC SURG 5%

374 DIGESTIVE MALIGNANCY W MCC MED 4%

334 RECTAL RESECTION W/O CC/MCC SURG 3%

376 DIGESTIVE MALIGNANCY W/O CC/MCC MED 3%

394 OTHER DIGESTIVE SYSTEM DIAGNOSES W CC MED 2%

332 RECTAL RESECTION W MCC SURG 1%

ICD-9 Code Description Tentative ICD-10 Code ICD-9 Code Description Tentative

ICD-10 Code

153 Mal Neo Hepatic Flexure C183 153.9

Mal Neo Colon Nos C189

153.1 Man Neo Transverse Colon C184 154

Mal Neo Rectosigmoid Jct C19

153.2 Mal Neo Descend Colon C186 154.1

Mal Neo Rectum C20

153.3 Mal Neo Sigmoid Colon C187 154.8

Mal Neo Rectum/Anus Nec C218

153.4 Mal Neo Cecum

C180 197.5 Sec Malig Neo Large Bowel C785

153.5 Mal Neo Appendix

C181 211.3 Benign Neo Large Bowel D120

153.6 Mal Neo Ascend Colon C182 211.4

Benign Neo Rectum/Anus D127

153.7 Mal Neo Splenic Flexure C185 230.3

Ca In Situ Colon D010

153.8 Mal Neo Colon Nec C188 230.4

Ca In Situ Rectum D011



Inpatient Medical and Surgical Volumes on the Rise

Colorectal Cancer Forecast

1) Forecasts are for all providers including hospital-based and freestanding providers. 2) Volumes represent visits, not individual patients.

Inpatient medical and surgical volumes will continue to increase over the next ten years, driven largely increasing incidence. Outpatient volumes will also increase concurrently.

Inpatient Medical Volumes 2013-2023

Inpatient Surgical Volumes 2013-2023

Outpatient Chemotherapy Volumes1,2

2013-2023

Outpatient Radiation Therapy Volumes1,2

2013-2023

71,376

76,867

82,361

2013 2018 2023

Change 2013-2023: 15%

389,516

452,303

525,815

2013 2018 2023

Change 2013-2023: 35%

1,005,066 1,047,829

1,164,966

2013 2018 2023

371,081 390,701

452,230

2013 2018 2023

Change 2013-2023: 22% Change 2013-2023: 21%



Colorectal Cancer Forecast

1) Forecasts are for all providers including hospital-based and freestanding providers.

Outpatient Imaging Volumes1

2013-2023

970,928 1,063,849

1,172,110

2013 2018 2023

Change 2013-2023: 21%

Additional Forecasting Data Available For forecasts by tumor site at the procedural level customized to your market, please see the Oncology Outpatient Market Estimator, available at www.advisory.com



Creating a Center of Excellence

Source: Oncology Roundtable interviews and analysis.

The colorectal program resource grid presented below provides guidance on the resources required to develop basic, intermediate, and advanced colorectal programs. It also provides additional detail on how resources are tiered according to program features. Access the full grid at www.advisory.com/or/tumorsitegrids.

Program Design Guidance • Many hospitals encompass colorectal under the GI umbrella given the ability to share staff, technology, and

treatment resources, which allows them to serve a larger patient population.

• Colorectal programs are well suited for the flexibility of a virtual model given the range of patient disease sites and treatment complexity; this is particularly true for colorectal programs in a larger GI cancer program.

• Colorectal programs are more likely to be offered at community hospitals as patients are less resource-intensive and follow a relatively straightforward treatment path; GI programs are more likely to be offered at AMCs as patients are more resource-intensive and follow relatively complex treatment paths.

http://www.advisory.com/or/tumorsitegrids


Colorectal Cancer Clinical Quality Dashboard


The clinical quality dashboard presented below contains indicators specific to colon and rectal cancer care. While not every program can track all 27 indicators, the Roundtable recommends programs track a core set of indicators to increase self-awareness on quality and to prepare for future nationally-mandated quality initiatives.

Measure Definition Benchmark Endorsed By

Process – Risk Assessment

Presence or absence of cancer in first-degree blood relatives documented for patients with colorectal cancer

Percent of patients with colorectal cancer for whom presence or absence of cancer in first-degree relative was documented

Ideal Benchmark: 100% ASCO/QOPI Test Measure1

Presence or absence of cancer in second-degree blood relatives documented for patients with colorectal cancer

Percent of patients with colorectal cancer for whom presence or absence of cancer in second-degree relative was documented


Age at diagnosis documented for each blood relative diagnosed with cancer

Percent of patients with colorectal cancer for whom age at diagnosis of blood relative with cancer was documented


Patients with invasive colorectal cancer referred for or received genetic testing

Percent of patients with invasive colorectal cancer who were referred for or received genetic testing

Ideal Benchmark: 100% ACoS/CoC4, ASCO/QOPI5

Patients with increased hereditary risk referred for or received genetic testing

Percent of patients with invasive colorectal cancer with increased hereditary risk for colon cancer who were referred for or received genetic testing

Ideal Benchmark: 100% ACoS/CoC6, ASCO/QOPI7

Process – Appropriateness of Care

Colon: Lymph node sampling Percent of surgical patients for which least 12 regional lymph nodes are removed and pathologically examined for resected colon cancer

National Average: 12 or more lymph nodes sampled in 41%8-44%9 of cases, Best Observed: 85%10; ACoS/CoC CP3R Required Performance Rate: >80%, Ideal Benchmark: >90%11

ACoS/RQRS12, AMA-PCPI, ASCO/QOPI13, NCCN14, NQF #022515, PCHQR

KRAS testing prior to administration of anti-EGFR MoAb therapy

Percent of patients with metastatic colorectal cancer tested for KRAS mutation prior to administration of anti-EGFR MoAb therapy

30%-40% of metastatic colorectal cancers carry KRAS mutation16; Ideal Benchmark: 100%

ASCO/QOPI17

Anti‐EGFR MoAb therapy received by patients with KRAS mutation

Percent of patients with KRAS mutation who receive anti-EGFR MoAb therapy

Ideal Benchmark: 0% ASCO/QOPI Measure18

Rectal: Adjuvant chemotherapy Percent of patients, <80 years of age, with stage II or III rectal cancer for whom post-operative adjuvant chemotherapy was considered or administered

Ideal Benchmark: 100% of eligible patients

ASCO/QOPI19, NCCN20

Rectal: Post-operative radiation therapy Percent of patients, <80 years of age, with clinical or pathologic T4N0M0 or stage III rectal cancer receiving surgical resection for whom radiation therapy was considered or administered

Ideal Benchmark:100% of eligible patients

ACoS/RQRS21, ASCO22, NCCN23





Process – Appropriateness of Care

Rate of sphincter-sparing surgery Percent of rectal cancer patients receiving sphincter-sparing surgery

National Average: 60.5% overall24, Best observed in rectal cancers in lower third - 46.5%25, middle - 73%, upper third - 94%26; Ideal benchmark: >70% overall

Multimodal therapy for rectal cancer Percent of stage II and III rectal cancer patients who received surgery, chemotherapy, and radiation

NCDB Average: Stage II 55.8%, Stage III 61.3%27

ASCO28, NCCN29

CEA within 4 months of curative resection for colorectal cancer

Percent of patients receiving CEA monitoring within 4 months of curative colorectal cancer resection


Colon: Adjuvant chemotherapy Percent of patients with stage III lymph node positive colon cancer, <80 years of age, for whom adjuvant chemotherapy was considered or administered within 4 months (120 days) of surgery

National Average: 59%31; Ideal Benchmark: 100% of eligible patients32

ACoS/RQRS33, AMA-PCPI, ASCO/QOPI34, NCCN35, NQF #022336, PCHQR, PQRS

Follow-up: Surveillance for cancer recurrence Percent of patients receiving colonoscopy within 6 months of curative colorectal cancer resection or adjuvant chemotherapy

Average Performance: 49% after 14 months37; Ideal Benchmark: >90%

AGSE38, ASCO/QOPI39, NCCN

Enrollment in clinical trials Percent of patients enrolled in clinical trials OR Percent of physicians referring one or more patients to trials per year

Only 6% of colorectal cancer patients were aware that clinical trials existed40. Average percent of physicians referring one or more patients to a clinical trial: medical oncology - 88%, radiation oncology - 66%, surgical oncology - 35%41; CoC Requirement: 4% of all analytic cases across all tumor sites, Ideal Benchmark for patient enrollment: >10% enrollment, Ideal Benchmark for physician participation: 100% of physicians refer 1 or more patients

ACoS/CoC42

Process – Patient-Centered Care

Pre-test genetic counseling Percent of patients with invasive colorectal cancer who were referred for or received pre-test genetic counseling

Ideal Benchmark: 100% as per ACoS/CoC 2012 Standards43

ACoS/CoC44

Post-test genetic counseling Percent of patients with invasive colorectal cancer who were referred for or received post-test genetic counseling

Ideal Benchmark: 100% as per ACoS/CoC 2012 Standards45

ACoS/CoC46, ASCO/QOPI47





Process – Patient-Centered Care

Shared decision-making Percent of patients sharing in decision-making regarding surgical options

Reported Average: 34%48; Ideal Benchmark: 100% of patients who desire an active role in decision-making

Process – Documentation Completeness

Colorectal: Pathology report completeness Percent of pathology reports containing all data elements specified by CAP surgical case summary

CAP Quality Probe average: 65.7% of colorectal pathology reports complete49; ACoS/CoC Requirement: 90% of pathology reports include required data elements as per CAP protocol50, Ideal benchmark: 100%

ACoS/CoC51, ASCO/QOPI52, CAP53

Colorectal: Staging completeness Percent of patients with complete TNM staging documented in the medical record

Reported Averages: 38%-73% TNM staging completeness54; ACoS/CoC Requirement: 90% of pathology reports include required data elements as per CAP protocol (staging included)55, Ideal benchmark: 100%

ACoS/CoC56, ASCO/QOPI57, CAP58

Outcome

Rectal: Surgical margin positivity rate Percent of rectal cancer patients with positive surgical margins

Upper middle rectal: 12.6%59, Low rectal overall: 20%60-26.5%61, Low rectal abdominalperineal excision: 30.4%62-31.9%63, Low rectal anterior resection 10.7%64-12%65; Ideal Benchmark: <11%66

Colon: Surgical margin positivity rate Percent of colon cancer patients with positive surgical margins

Best Observed: 11%67

Anastomotic leaks Percent of surgical patients experiencing anastomotic leak

Average: Rectal 3%68-10%69, Colon 3%70; Ideal Benchmark: Rectal <5%, Colon <3%

Local recurrence rate Percent of patients with locally recurrent cancer within 5-years

Average: Colon cancer 18% depending on stage and therapy71, Rectal cancer: 2-30% depending on stage and therapy (e.g. Local recurrence after mesorectal excision and radiotherapy: 2.4%, Mesorectal excision alone: 8.2%)72





Outcome

Survival rate: Colon Five-year survival rate by stage at diagnosis

All stages – 63.6% Localized – 90.8% Regional – 70.0% Distant – 11.7% Unstaged – 27.4% By Stage: Stage I - 74% Stage IIA - 67% Stage IIB - 59% Stage IIC - 37% Stage IIIA - 73% Stage IIIB - 46% Stage IIIC - 28% Stave IV - 6%73

ASCO/QOPI74

Survival rate: Rectal Five-year survival rate by stage at diagnosis

All stages – 66.2% Localized – 88.0% Regional – 68.5% Distant – 12.7% Unstaged – 45.4% By Stage: Stage I - 74% Stage IIA - 65% Stage IIB - 52% Stage IIC - 32% Stage IIIA - 74% Stage IIIB - 45% Stage IIIC - 33%75

ASCO/QOPI76




Colorectal Cancer Clinical Quality Dashboard Sources

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15. National Quality Forum, NQF Endorsed Measure #0225, “At least 12 regional lymph nodes are removed and pathologically examined for resected colon cancer,” available at: http://www.qualityforum.org/QPS/, last accessed: June 20, 2012 16. College of American Pathologists. "KRAS mutation testing for colorectal cancer (CRC)," 2010, published online at: http://www.cap.org/apps/cap.portal?_nfpb=true&cntvwrPtlt_actionOverride=%2Fportlets%2FcontentViewer%2Fshow&_windowLabel=cntvwrPtlt&cntvwrPtlt%7BactionForm.contentReference%7D=committees%2Ftechnology%2FKRAS_Mutation.html&_state=maximized&_pageLabel=cntvwr 17,18. Allegra CJ, et al., "American society of clinical oncology provisional clinical opinion: Testing for KRAS gene mutations in patients with metastatic colorectal carcinoma to predict response to anti-epidermal growth factor receptor monoclonal antibody therapy," Journal of Clinical Oncology, 2009, 27(12): 2091-2096.; Brand TM, Wheeler DL, "KRAS mutant colorectal tumors: Past and present,” Small GTPases, 2012, 3(1): 34-9. 20,23. National Comprehensive Cancer Network, “National comprehensive cancer network clinical practice guidelines: Rectal cancer,” 2010, available at: Http://www.nccn.org/, last accessed August, 2012. 24. Paquette IM, et al., "Patient and hospital factors associated with use of

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