## Measures of Cancer Population 2006:

Organizations implementing planned cancer screening across all their
facilities need to adopt measures across all the teams within those
facilities in order to track progress and provide a focus fro planning.
Each cancer team is required to track the core national measures
(measures 1-6). along with registry size. In addition, it is recommended
that [all teams]{.underline} select at least one of the additional
recommended cancer measures (measures 7-16).

**[It is critically important to establish the entire size of the target
population, and the denominator of the screening measures at the start
of work in order to interpret and reinforce progress.]{.smallcaps}**

+----------+-----------------+------------------+---+-----------------+
| ### R    |                 |                  |   |                 |
| EQUIRED  |                 |                  |   |                 |
| MEASURES |                 |                  |   |                 |
+----------+-----------------+------------------+---+-----------------+
| **M      | **Definition**  | **Data Gathering | * | #### Notes/Comm |
| easure** |                 | Plan**           | * | ents/References |
|          |                 |                  | G |                 |
|          |                 |                  | o |                 |
|          |                 |                  | a |                 |
|          |                 |                  | l |                 |
|          |                 |                  | * |                 |
|          |                 |                  | * |                 |
+----------+-----------------+------------------+---+-----------------+
| 1.       | Number of       | On the last      | \ | "Shared         |
|  Percent | patients (women | workday of the   | > | decision        |
|     of   | ≥21 years of    | month, find all  | 7 | making"         |
|          | age and men     | patients (women  | 0 | includes three  |
| patients | ≥51) in the     | ≥18 years of age | % | elements:       |
|          | registry who    | and men ≥50) who |   |                 |
|   having | have            | have had at      |   | 1.  Asking      |
|          | documentation   | least one visit  |   |                 |
|    docum | of              | in the prior     |   | 2.              |
| entation | self-management | three years.     |   | Telling/sharing |
|     of   | goal setting    |                  |   |     information |
|          | *(Self          | Within this      |   |                 |
|  self-ma | management goal | population       |   | 3.  Identifying |
| nagement | setting can and | identify those   |   |     a plan      |
|     goal | is recommended  | women            |   |                 |
|     se   | to include      | [\               |   | Self-management |
| tting.\* | documented      | >]{.underline}21 |   | support for     |
|          | shared          | and those men    |   | health and      |
|          | de              | \>51 with        |   | specific        |
|          | cision-making\* | documentation of |   | conditions is a |
|          | discussion      | self-management  |   | general         |
|          | about cancer    | goal setting. At |   | process.^1^ The |
|          | screening and   | the same time,   |   | discussion of   |
|          | follow-up when  | count the number |   | cancer          |
|          | appropriate)*   | of women         |   | screening is    |
|          | in the last 12  | [\               |   | undertaken      |
|          | months divided  | >]{.underline}21 |   | within the      |
|          | by the total    | years of age and |   | context of this |
|          | number women    | the number of    |   | general process |
|          | ≥21 years of    | men              |   | but occurs      |
|          | age and the     | [\>              |   | through         |
|          | number of men   | ]{.underline}51. |   | shared-decision |
|          | ≥51 in the      |                  |   | making.^1^      |
|          | registry.       |                  |   |                 |
|          | Multiply by 100 |                  |   |                 |
|          | to get          |                  |   |                 |
|          | percentage.     |                  |   |                 |
+----------+-----------------+------------------+---+-----------------+
| 2.       | Number of women | On the last      | \ | Humphrey et     |
|  Percent | [\>             | workday of the   | > | al,^2^          |
|     of   | ]{.underline}42 | month, the       | 7 |                 |
|          | years of age    | registry will be | 0 | The measure     |
|    women | who have had a  | searched for all | % | begins at 42 to |
|     [\   | mammogram in    | women            |   | allow time for  |
| >]{.unde | the previous 2  | [\               |   | the first       |
| rline}42 | years divided   | >]{.underline}42 |   | mammogram. The  |
|          | by the total    | years of age who |   | USPSTF review   |
|    years | number of women | have had a       |   | states there is |
|     of   | [\>             | mammogram in the |   | no clear        |
|     age  | ]{.underline}42 | previous 2 years |   | evidence upon   |
|     who  | years of age in | At the same time |   | which to        |
|     have | the registry.   | the total number |   | recommend one   |
|     had  | Multiply by 100 | of women ≥42     |   | vs. two years.  |
|     a    | to get          | years of age in  |   |                 |
|     m    | percentage.     | the registry     |   | General US      |
| ammogram |                 | will be counted. |   | Population:     |
|     in   |                 |                  |   | 70%^3^          |
|     the  |                 |                  |   |                 |
|          |                 |                  |   | Low Income      |
| previous |                 |                  |   | Population:     |
|     2    |                 |                  |   | 58%^4^          |
|          |                 |                  |   |                 |
|    years |                 |                  |   |                 |
+----------+-----------------+------------------+---+-----------------+
| 3.       | Number of women | On the last      | \ | Saslow et al,   |
|  Percent | age ≥21 who     | workday of the   | > | ^4^             |
|     of   | have had a Pap  | month count the  | 9 |                 |
|          | smear within    | number of women  | 0 | The             |
|    women | the prior *3*   | age ≥21 who have | % | recommendations |
|     age  | years divided   | had a pap smear  |   | for cervical    |
|     ≥21  | by the total    | within the prior |   | cancer          |
|     who  | number of women | 3 years. At the  |   | screening       |
|     have | ages ≥21.       | same time, count |   | reflect the     |
|     had  | Multiply by 100 | the number women |   | realization     |
|     a    | to get          | age ≥21 in the   |   | that            |
|     Pap  | percentage.     | registry.        |   | overtreatment   |
|          |                 |                  |   | of early        |
|    smear |                 |                  |   | lesions occurs  |
|          |                 |                  |   | with earlier    |
|   within |                 |                  |   | screening.      |
|     the  |                 |                  |   |                 |
|          |                 |                  |   | General US      |
|    prior |                 |                  |   | Population:     |
|     *3*  |                 |                  |   | 82%^3^ (women   |
|          |                 |                  |   | [\>]            |
|    years |                 |                  |   | {.underline}25) |
|          |                 |                  |   |                 |
|          |                 |                  |   | Low Income      |
|          |                 |                  |   | Population:     |
|          |                 |                  |   | 69%^4^ (women   |
|          |                 |                  |   | [\>             |
|          |                 |                  |   | ]{.underline}18 |
|          |                 |                  |   | within 2 years) |
+----------+-----------------+------------------+---+-----------------+
| 4.       | Number of       | On the last      | \ | Pignone et      |
|  Percent | adults ages     | workday of the   | > | al,^6^          |
|     of   | [\>             | month, the       | 5 |                 |
|          | ]{.underline}51 | registry will be | 0 | Whether         |
|   adults | have been       | searched for all | % | colonoscopy is  |
|     age  | screened with   | adults           |   | the standard of |
|     [\   | at least one of | [\               |   | practice often  |
| >]{.unde | the following:  | >]{.underline}51 |   | comes up and it |
| rline}51 |                 | who have been    |   | is clearly not. |
|     who  | --FOBT within   | screened with at |   | Any of the      |
|     have | one year        | least one of the |   | three screening |
|     been |                 | following:       |   | tests is        |
|          | --Sigmoidoscopy |                  |   | acceptable and  |
|    appro | within 5 years  | --FOBT within    |   | the best        |
| priately |                 | one year         |   | evidence for    |
|          | --Colonoscopy   |                  |   | efficacy exists |
| screened | within 10 years | --Sigmoidoscopy  |   | for hemoccult   |
|     for  | divided by the  | within 5 years   |   | screening.      |
|          | total number of |                  |   | Randomized      |
|    colon | adults ages     | --Colonoscopy    |   | trial data      |
|          | [\>]            | within 10 years. |   | exists for      |
|   cancer | {.underline}51. | At the same      |   | hemoccult       |
|          | Multiply by 100 | time, count the  |   | screening.      |
|          | to get          | total number of  |   |                 |
|          | percentage.     | adults           |   | Levels of       |
|          |                 | [\               |   | Screening:      |
|          |                 | >]{.underline}51 |   |                 |
|          |                 | years of age in  |   | General US      |
|          |                 | the registry.    |   | population:     |
|          |                 |                  |   |                 |
|          |                 |                  |   | Either an FOBT  |
|          |                 |                  |   | w/in the past   |
|          |                 |                  |   | year or         |
|          |                 |                  |   | colorectal      |
|          |                 |                  |   | endoscopy w/in  |
|          |                 |                  |   | the *past 5     |
|          |                 |                  |   | years*          |
|          |                 |                  |   |                 |
|          |                 |                  |   | Men: 41.0%      |
|          |                 |                  |   |                 |
|          |                 |                  |   | Women: 37.5%^3^ |
|          |                 |                  |   |                 |
|          |                 |                  |   | []{.mark}       |
|          |                 |                  |   |                 |
|          |                 |                  |   | Either FOBT or  |
|          |                 |                  |   | endoscopy       |
|          |                 |                  |   | within          |
|          |                 |                  |   | recommended     |
|          |                 |                  |   | time-frame      |
|          |                 |                  |   |                 |
|          |                 |                  |   | Men 44.5%       |
|          |                 |                  |   |                 |
|          |                 |                  |   | Women 41.0%^7^  |
|          |                 |                  |   |                 |
|          |                 |                  |   | Uninsured       |
|          |                 |                  |   |                 |
|          |                 |                  |   | Either an FOBT  |
|          |                 |                  |   | w/in the past   |
|          |                 |                  |   | year or         |
|          |                 |                  |   | colorectal      |
|          |                 |                  |   | endoscopy w/in  |
|          |                 |                  |   | the *past 5     |
|          |                 |                  |   | years*          |
|          |                 |                  |   |                 |
|          |                 |                  |   | Men: 19.8%      |
|          |                 |                  |   |                 |
|          |                 |                  |   | Women: 18.0%^6^ |
|          |                 |                  |   |                 |
|          |                 |                  |   | Either FOBT or  |
|          |                 |                  |   | endoscopy       |
|          |                 |                  |   | within          |
|          |                 |                  |   | recommended     |
|          |                 |                  |   | time-frame      |
|          |                 |                  |   |                 |
|          |                 |                  |   | Both genders    |
|          |                 |                  |   | 18.1%^7^        |
+----------+-----------------+------------------+---+-----------------+
| 5.       | The number of   | On the last      | \ | Federal         |
|  Percent | women (age ≥42) | workday of the   | > | regulation,     |
|     of   | having          | month, the       | 9 | Mammography     |
|          | documented      | registry will be | 0 | Quality         |
| patients | notification of | searched for all | % | Standard Ac,    |
|          | mammogram       | women (age ≥42)  |   | requires that   |
|   having | results within  | having           |   | all women be    |
|     do   | 30 days of test | documented       |   | notified of     |
| cumented | c               | notification of  |   | their mammogram |
|     noti | ompletion\*\*\* | mammogram        |   | results.        |
| fication | plus the number | results within   |   | Radiology       |
|     of   | of women        | 30 days and      |   | facilities are  |
|     ma   | [\>             | women            |   | responsible for |
| mmogram, | ]{.underline}21 | [\               |   | this            |
|     PAP  | having          | >]{.underline}21 |   | no              |
|     and  | documented      | having           |   | tification.^8,^ |
|          | notification of | documented       |   |                 |
|    colon | PAP smear       | notification of  |   | While similar   |
|          | results within  | PAP smear        |   | standards of    |
|   cancer | 30 days of test | results within   |   | notification    |
|     s    | completion plus | 30 days of test  |   | are not         |
| creening | the number of   | completion and   |   | established for |
|          | adults age      | the number of    |   | cervical        |
|  results | [\>             | adults age       |   | pathology,      |
|          | ]{.underline}51 | [\               |   | there are some  |
|   within | having          | >]{.underline}51 |   | benchmarks for  |
|     30   | documented      | having           |   | reporting       |
|     days | notification of | documented       |   | results.^9,10^  |
|          | colon cancer    | notification of  |   |                 |
|          | screening       | colon cancer     |   |                 |
|          | results within  | screening        |   |                 |
|          | 30 days of test | results within   |   |                 |
|          | completion      | 30 days of test  |   |                 |
|          | \[these counts  | completion       |   |                 |
|          | are for         | \[these counts   |   |                 |
|          | screenings that | are for          |   |                 |
|          | have occurred   | screenings that  |   |                 |
|          | in the last 12  | have occurred in |   |                 |
|          | months\],       | the last 12      |   |                 |
|          | divided by the  | months\]. At the |   |                 |
|          | total number of | same time, count |   |                 |
|          | women age ≥42   | the number of    |   |                 |
|          | having a        | women (age ≥42)  |   |                 |
|          | mammogram plus  | having a         |   |                 |
|          | the total       | mammogram, women |   |                 |
|          | number of women | [\               |   |                 |
|          | [\>             | >]{.underline}21 |   |                 |
|          | ]{.underline}21 | having PAP, and  |   |                 |
|          | having PAP plus | adults           |   |                 |
|          | the total       | [\               |   |                 |
|          | number of       | >]{.underline}51 |   |                 |
|          | adults          | having colon     |   |                 |
|          | [\>             | cancer screening |   |                 |
|          | ]{.underline}51 | within the last  |   |                 |
|          | having colon    | 12 months.       |   |                 |
|          | cancer          |                  |   |                 |
|          | screening.      |                  |   |                 |
|          | \[These counts  |                  |   |                 |
|          | are for         |                  |   |                 |
|          | screenings that |                  |   |                 |
|          | have occurred   |                  |   |                 |
|          | in the last 12  |                  |   |                 |
|          | months\]        |                  |   |                 |
|          |                 |                  |   |                 |
|          | Multiply each   |                  |   |                 |
|          | by 100 to get   |                  |   |                 |
|          | percentage.     |                  |   |                 |
+----------+-----------------+------------------+---+-----------------+
| 6.       | Number of women | On the last      | \ | There is no     |
|  Percent | [\>             | workday of the   | > | "standard of    |
|     of   | ]{.underline}42 | month, find all  | 9 | care" across    |
|          | years of age    | women \>42 years | 0 | all three       |
| patients | having          | of age who have  | % | cancers. The    |
|     r    | additional      | documented       |   | measure         |
| equiring | required        | required         |   | reflects        |
|     ad   | evaluation      | additional       |   | prudent care    |
| ditional | (imaging,       | evaluation       |   | and a simple    |
|     ev   | biopsy,         | (imaging,        |   | target that     |
| aluation | clinical)       | biopsy,          |   | expert opinion  |
|          | within 60 days  | clinical) within |   | thought should  |
|   and/or | of the date of  | 60 days of the   |   | be attainable   |
|     t    | abnormal        | date of abnormal |   | for all three   |
| reatment | mammogram plus  | mammogram. At    |   | cancers. As     |
|     co   | the number of   | the same time,   |   | noted below,    |
| mpleting | adults (age     | the number of    |   | there are       |
|     that | ≥51) with       | women \>42 years |   | cancer specific |
|     asse | positive fecal  | of age who have  |   | measures that   |
| ssment/t | occult blood    | had an abnormal  |   | sites may use   |
| reatment | testing having  | mammogram will   |   | to provide more |
|          | colonoscopy (or | be counted. On   |   | specific        |
|   within | sigmoidoscopy   | the last workday |   | insight into    |
|     app  | and BE) within  | of the month     |   | the processes   |
| ropriate | 60 days of the  | count the number |   | of care for     |
|     time | date of the     | of women(age     |   | their site.     |
|          | positive result | [\>]{.underline} |   |                 |
|   frame. | plus the number | 42) with         |   |                 |
|          | of women (age   | invasive cancer  |   |                 |
|          | [               | or ductal        |   |                 |
|          | \>]{.underline} | carcinoma in     |   |                 |
|          | 42)with         | situ having      |   |                 |
|          | invasive cancer | initial          |   |                 |
|          | or ductal       | treatment        |   |                 |
|          | carcinoma in    | documented       |   |                 |
|          | situ having     | within 90 days   |   |                 |
|          | initial         | of diagnosis. At |   |                 |
|          | treatment       | the same time,   |   |                 |
|          | documented      | count the number |   |                 |
|          | within 90 days  | of women(age     |   |                 |
|          | of diagnosis    | [\>]{.underline} |   |                 |
|          | plus the number | 42) with         |   |                 |
|          | of women (age   | invasive cancer  |   |                 |
|          | [\>]            | or ductal        |   |                 |
|          | {.underline}21) | carcinoma in     |   |                 |
|          | who require     | situ in the      |   |                 |
|          | colposcopy\*\*  | registry.        |   |                 |
|          | having been     | Documentation    |   |                 |
|          | evaluated       | could include    |   |                 |
|          | within 90 days  | Type of surgery  |   |                 |
|          | of the date of  | (lumpectomy,     |   |                 |
|          | the abnormal    | mastectomy,      |   |                 |
|          | test plus the   | other), use of   |   |                 |
|          | number of women | chemotherapy     |   |                 |
|          | (age            | (yes, no),       |   |                 |
|          | [\>]            | radiation        |   |                 |
|          | {.underline}21) | therapy (yes,    |   |                 |
|          | with CIN 2 & 3  | no), hormonal    |   |                 |
|          | or invasive     | therapy (yes,    |   |                 |
|          | cervical cancer | no). Refusal of  |   |                 |
|          | having initial  | care should be   |   |                 |
|          | treatment       | documented as    |   |                 |
|          | documented      | well with        |   |                 |
|          | within 90 days  | reasons for      |   |                 |
|          | of diagnosis    | refusal.         |   |                 |
|          | plus the number |                  |   |                 |
|          | of adults (age  | On the last      |   |                 |
|          | ≥51) with polyp | workday of the   |   |                 |
|          | or colon cancer | month count the  |   |                 |
|          | having initial  | number of women  |   |                 |
|          | treatment       | (age ≥21) who    |   |                 |
|          | documented      | require          |   |                 |
|          | within 90 days  | colposcopy\*\*   |   |                 |
|          | of lab          | and have been    |   |                 |
|          | confirmation of | evaluated within |   |                 |
|          | the diagnosis   | 90 days of the   |   |                 |
|          | \[these counts  | date of the      |   |                 |
|          | are for         | abnormal test.   |   |                 |
|          | screenings and  | At the same time |   |                 |
|          | diagnoses that  | count the total  |   |                 |
|          | have occurred   | number of women  |   |                 |
|          | in the last 12  | (age             |   |                 |
|          | months\]        | [\>              |   |                 |
|          | divided by the  | ]{.underline}21) |   |                 |
|          | total number of | requiring        |   |                 |
|          | women           | colposcopy\*\*.  |   |                 |
|          | [\>             |                  |   |                 |
|          | ]{.underline}42 | On the last      |   |                 |
|          | years of age    | workday of the   |   |                 |
|          | with an         | month count the  |   |                 |
|          | abnormal        | number of women  |   |                 |
|          | mammogram plus  | (age             |   |                 |
|          | the total       | [\>              |   |                 |
|          | number of       | ]{.underline}21) |   |                 |
|          | adults          | with CIN 2 & 3   |   |                 |
|          | ([              | or invasive      |   |                 |
|          | \>]{.underline} | cervical cancer  |   |                 |
|          | 51) having      | who have their   |   |                 |
|          | positive fecal  | initial          |   |                 |
|          | occult blood    | treatment        |   |                 |
|          | testing plus    | documented       |   |                 |
|          | the total       | within 90 days   |   |                 |
|          | number of women | of diagnosis. At |   |                 |
|          | (age            | the same time    |   |                 |
|          | [\>]            | count the number |   |                 |
|          | {.underline}42) | of women (age    |   |                 |
|          | with invasive   | [\>              |   |                 |
|          | cancer or       | ]{.underline}21) |   |                 |
|          | ductal          | with CIN 2 & 3   |   |                 |
|          | carcinoma in    | or invasive      |   |                 |
|          | situ plus the   | cervical cancer. |   |                 |
|          | total number of |                  |   |                 |
|          | women (age      | On the last      |   |                 |
|          | [\>]            | workday of the   |   |                 |
|          | {.underline}21) | month, the       |   |                 |
|          | requiring       | registry will be |   |                 |
|          | colposcopy\*\*  | searched for the |   |                 |
|          | plus the total  | number of adults |   |                 |
|          | number of women | (age ≥51) with   |   |                 |
|          | (age            | positive fecal   |   |                 |
|          | [\>]            | occult blood     |   |                 |
|          | {.underline}21) | testing having   |   |                 |
|          | with CIN 2 & 3  | colonoscopy (or  |   |                 |
|          | or invasive     | sigmoidoscopy    |   |                 |
|          | cervical cancer | and BE) within 8 |   |                 |
|          | plus the total  | weeks of the     |   |                 |
|          | number of       | date of the      |   |                 |
|          | adults          | positive FOBT.   |   |                 |
|          | (age\>=51) with | At the same      |   |                 |
|          | polyp or colon  | time, count the  |   |                 |
|          | cancer \[these  | number of adults |   |                 |
|          | counts are for  | (age             |   |                 |
|          | screenings and  | [\>              |   |                 |
|          | diagnoses that  | ]{.underline}51) |   |                 |
|          | have occurred   | who have had a   |   |                 |
|          | in the last 12  | positive FOBT.   |   |                 |
|          | months\].       |                  |   |                 |
|          | Multiply by 100 | On the last      |   |                 |
|          | to get          | workday of the   |   |                 |
|          | percentage.     | month, the       |   |                 |
|          |                 | registry will be |   |                 |
|          |                 | searched for the |   |                 |
|          |                 | number of adults |   |                 |
|          |                 | (age ≥51) with   |   |                 |
|          |                 | polyp or colon   |   |                 |
|          |                 | cancer who have  |   |                 |
|          |                 | their initial    |   |                 |
|          |                 | treatment        |   |                 |
|          |                 | documented       |   |                 |
|          |                 | within 90 days   |   |                 |
|          |                 | of lab           |   |                 |
|          |                 | confirmation of  |   |                 |
|          |                 | the diagnosis.   |   |                 |
|          |                 | At the same      |   |                 |
|          |                 | time, count the  |   |                 |
|          |                 | number of adults |   |                 |
|          |                 | (age ≥51) with   |   |                 |
|          |                 | polyp or colon   |   |                 |
|          |                 | cancer. \[These  |   |                 |
|          |                 | counts are for   |   |                 |
|          |                 | screenings and   |   |                 |
|          |                 | diagnoses that   |   |                 |
|          |                 | have occurred in |   |                 |
|          |                 | the last 12      |   |                 |
|          |                 | months\]         |   |                 |
+----------+-----------------+------------------+---+-----------------+

+----------+-----------------+------------------+---+-----------------+
| ### AD   |                 |                  |   |                 |
| DITIONAL |                 |                  |   |                 |
|  RECOMME |                 |                  |   |                 |
| NDED MEA |                 |                  |   |                 |
| SURES: Y |                 |                  |   |                 |
| our team |                 |                  |   |                 |
|  must ch |                 |                  |   |                 |
| oose at  |                 |                  |   |                 |
| least on |                 |                  |   |                 |
| e of the |                 |                  |   |                 |
| se to tr |                 |                  |   |                 |
| ack and  |                 |                  |   |                 |
| report o |                 |                  |   |                 |
| n. *You  |                 |                  |   |                 |
| will fin |                 |                  |   |                 |
| d that t |                 |                  |   |                 |
| hey can  |                 |                  |   |                 |
| be used  |                 |                  |   |                 |
| to enhan |                 |                  |   |                 |
| ce care  |                 |                  |   |                 |
| and incr |                 |                  |   |                 |
| ease the |                 |                  |   |                 |
|  ability |                 |                  |   |                 |
|  to achi |                 |                  |   |                 |
| eve the  |                 |                  |   |                 |
| required |                 |                  |   |                 |
|  measure |                 |                  |   |                 |
| s above* |                 |                  |   |                 |
+----------+-----------------+------------------+---+-----------------+
| **M      | **Definition**  | **Data Gathering | * | **N             |
| easure** |                 | Plan**           | * | otes/Comments** |
|          |                 |                  | G |                 |
|          |                 |                  | o |                 |
|          |                 |                  | a |                 |
|          |                 |                  | l |                 |
|          |                 |                  | * |                 |
|          |                 |                  | * |                 |
+----------+-----------------+------------------+---+-----------------+
| 7.       | Number of       | On the last      | \ | "Shared         |
|  Percent | patients (women | workday of the   | > | decision        |
|     of   | [\>             | month, find all  | 7 | making"         |
|          | ]{.underline}21 | patients (women  | 0 | includes three  |
| patients | and men         | [\>]{.underline} | % | elements:       |
|          | [               | 21 and men       |   |                 |
|   having | \>]{.underline} | [\>]{.underline} |   | 1.  Asking      |
|     do   | 51) in the      | 51) who have a   |   |                 |
| cumented | registry who    | documented       |   | 2.              |
|          | have documented | shared           |   | Telling/sharing |
|   shared | shared          | d                |   |     information |
|     d    | decision-making | ecision-making\* |   |                 |
| ecision- | discussion of   | discussion about |   | 3.  Identifying |
| making\* | cancer          | cancer screening |   |     a plan      |
|     di   | screening and   | and follow-up.   |   |                 |
| scussion | its follow-up   | At the same      |   |                 |
|          | in the last 12  | time, count the  |   |                 |
|    about | months divided  | number of women  |   |                 |
|          | by the total    | [\               |   |                 |
|   cancer | number women    | >]{.underline}21 |   |                 |
|     s    | ≥21 years of    | years of age and |   |                 |
| creening | age and the     | the number of    |   |                 |
|     and  | number of men   | men              |   |                 |
|     f    | ≥51 in the      | [\>              |   |                 |
| ollow-up | registry.       | ]{.underline}51. |   |                 |
|          | Multiply by 100 |                  |   |                 |
|          | to get          |                  |   |                 |
|          | percentage.     |                  |   |                 |
+----------+-----------------+------------------+---+-----------------+
| 8.       | Number of women | On the last      | \ |                 |
|  Percent | (age ≥42)       | workday of the   | > |                 |
|     of   | having          | month count the  | 9 |                 |
|          | documented      | number of women  | 5 |                 |
|    women | notification of | (age\>=42) with  | % |                 |
|     (age | mammogram       | documented       |   |                 |
|     ≥42) | results within  | notification of  |   |                 |
|          | 30 days of      | mammogram        |   |                 |
|   having | mammogram date, | results within   |   |                 |
|     do   | divided by the  | 30 days of the   |   |                 |
| cumented | total number of | mammogram date   |   |                 |
|     noti | women (age ≥42) | \[these counts   |   |                 |
| fication | having a        | are for          |   |                 |
|     of   | mammogram       | mammograms that  |   |                 |
|     m    | \[these counts  | have occurred in |   |                 |
| ammogram | are for         | the last 12      |   |                 |
|          | mammograms that | months\]. At the |   |                 |
|  results | have occurred   | same time, count |   |                 |
|          | in the last 12  | the number of    |   |                 |
|   within | months\].       | women (age ≥42)  |   |                 |
|     30   | Multiply by 100 | who have had a   |   |                 |
|     days | to get          | mammogram within |   |                 |
|          | percentage.     | the last 12      |   |                 |
|          |                 | months.          |   |                 |
+----------+-----------------+------------------+---+-----------------+
| 9.       | Number of women | On the last      | \ | See Schofield   |
|  Percent | (age ≥21)       | workday of the   | > | et al ^11^      |
|     of   | having          | month count the  | 9 |                 |
|          | documented      | number of women  | 5 |                 |
|    women | notification of | age ≥21 with     | % |                 |
|     (age | Pap smear       | documented       |   |                 |
|          | results within  | notification of  |   |                 |
|  \>= 21) | 30 days of lab  | Pap smear        |   |                 |
|          | date, divided   | results within   |   |                 |
|   having | by the total    | 30 days of the   |   |                 |
|     do   | number of women | lab date \[these |   |                 |
| cumented | (age ≥21)       | counts are for   |   |                 |
|     noti | having Pap      | pap smears that  |   |                 |
| fication | smears \[these  | have occurred in |   |                 |
|     of   | counts are for  | the last 12      |   |                 |
|     Pap  | pap smears that | months\]. At the |   |                 |
|          | have occurred   | same time, count |   |                 |
|    smear | in the last 12  | the number of    |   |                 |
|          | months\].       | women age ≥21    |   |                 |
|  results | Multiply by 100 | who have had Pap |   |                 |
|          | to get          | smears within    |   |                 |
|   within | percentage.     | the last 12      |   |                 |
|     30   |                 | months.          |   |                 |
|     days |                 |                  |   |                 |
+----------+-----------------+------------------+---+-----------------+
| 10.      | Number of       | On the last      | \ |                 |
|  Percent | adults age      | workday of the   | > |                 |
|          | [\>             | month, the       | 9 |                 |
|   adults | ]{.underline}51 | registry will be | 5 |                 |
|     (age | having          | searched for the | % |                 |
|     ≥51) | documented      | number of adults |   |                 |
|          | notification of | age              |   |                 |
| screened | colon cancer    | [\               |   |                 |
|     for  | screening       | >]{.underline}51 |   |                 |
|          | results within  | who have had     |   |                 |
|    colon | 30 days of      | colon cancer     |   |                 |
|          | screening date  | screening and    |   |                 |
|   cancer | divided by the  | have received    |   |                 |
|          | total number of | documented       |   |                 |
|   having | adults (age     | notification of  |   |                 |
|     do   | [\>]            | colon cancer     |   |                 |
| cumented | {.underline}51) | screening        |   |                 |
|     noti | having          | results within   |   |                 |
| fication | screening       | 30 days of       |   |                 |
|     of   | \[these counts  | screening date   |   |                 |
|          | are for         | \[these counts   |   |                 |
|  results | screenings that | are for          |   |                 |
|          | have occurred   | screenings that  |   |                 |
|   within | in the last 12  | have occurred in |   |                 |
|     30   | months\].       | the last 12      |   |                 |
|     days | Multiply by 100 | months\]. At the |   |                 |
|     of   | to get          | same time, count |   |                 |
|     s    | percentage.     | the number of    |   |                 |
| creening |                 | adults age       |   |                 |
|          |                 | [\               |   |                 |
|          |                 | >]{.underline}51 |   |                 |
|          |                 | who have         |   |                 |
|          |                 | received colon   |   |                 |
|          |                 | cancer screening |   |                 |
|          |                 | within the last  |   |                 |
|          |                 | 12 months.       |   |                 |
+----------+-----------------+------------------+---+-----------------+
| 11.      | Number of women | On the last      | \ |                 |
|  Percent | [\>             | workday of the   | > |                 |
|     of   | ]{.underline}42 | month, find all  | 9 |                 |
|          | years of age    | women            | 5 |                 |
|    women | having          | [\               | % |                 |
|     (age | additional      | >]{.underline}42 |   |                 |
|     [\>] | required        | years of age who |   |                 |
| {.underl | evaluation      | have documented  |   |                 |
| ine} 42) | (imaging,       | required         |   |                 |
|     r    | biopsy,         | additional       |   |                 |
| equiring | clinical)       | evaluation       |   |                 |
|     ad   | within 60 days  | (imaging,        |   |                 |
| ditional | of the date of  | biopsy,          |   |                 |
|     ev   | abnormal        | clinical) within |   |                 |
| aluation | mammogram       | 60 days of the   |   |                 |
|          | divided by the  | date of abnormal |   |                 |
|   having | total number of | mammogram, which |   |                 |
|     it   | women           | occurred within  |   |                 |
|     c    | [\>             | the last 12      |   |                 |
| ompleted | ]{.underline}42 | months. At the   |   |                 |
|          | years of age    | same time, the   |   |                 |
|   within | with an         | number of women  |   |                 |
|     60   | abnormal        | [\               |   |                 |
|     days | mammogram       | >]{.underline}42 |   |                 |
|     of   | within the last | years of age who |   |                 |
|     the  | 12 months.      | have had an      |   |                 |
|          | Multiply by 100 | abnormal         |   |                 |
| abnormal | to get          | mammogram within |   |                 |
|     m    | percentage.     | the last 12      |   |                 |
| ammogram |                 | months will be   |   |                 |
|          |                 | counted.         |   |                 |
+----------+-----------------+------------------+---+-----------------+
| 12.      | Number of women | On the last      | \ |                 |
|  Percent | (age            | workday of the   | > |                 |
|     of   | [\>]            | month count the  | 9 |                 |
|          | {.underline}42) | number of women  | 5 |                 |
|    women | with invasive   | ages             | % |                 |
|     (age | breast cancer   | [\               |   |                 |
|          | or ductal       | >]{.underline}42 |   |                 |
|   \>=42) | carcinoma in    | with invasive    |   |                 |
|     with | situ            | breast cancer or |   |                 |
|          | \[diagnosed     | ductal carcinoma |   |                 |
| invasive | within the last | in situ          |   |                 |
|          | 12 months\]     | \[diagnosed      |   |                 |
|   breast | having initial  | within the last  |   |                 |
|          | treatment       | 12 months\]      |   |                 |
|   cancer | documented      | having initial   |   |                 |
|     or   | within 90 days  | treatment        |   |                 |
|          | of diagnosis    | documented       |   |                 |
|   ductal | divided by the  | within 90 days   |   |                 |
|     c    | total number of | of diagnosis. At |   |                 |
| arcinoma | women (age      | the same time,   |   |                 |
|     in   | [\>]{.un        | count the number |   |                 |
|     situ | derline}42)with | of women ages    |   |                 |
|          | invasive cancer | [\>]{.           |   |                 |
|   having | or ductal       | underline}42with |   |                 |
|          | carcinoma in    | invasive breast  |   |                 |
|  initial | situ            | cancer or ductal |   |                 |
|     t    | \[diagnosed     | carcinoma in     |   |                 |
| reatment | within the last | situ \[diagnosed |   |                 |
|     do   | 12 months\].    | within the last  |   |                 |
| cumented | Multiply by 100 | 12 months\].     |   |                 |
|          | to get          | Documentation    |   |                 |
|   within | percentage.     | could include    |   |                 |
|     90   |                 | type of surgery  |   |                 |
|     days |                 | (lumpectomy,     |   |                 |
|     of   |                 | mastectomy,      |   |                 |
|     di   |                 | other), use of   |   |                 |
| agnosis. |                 | chemotherapy     |   |                 |
|          |                 | (yes, no),       |   |                 |
|          |                 | radiation        |   |                 |
|          |                 | therapy (yes,    |   |                 |
|          |                 | no), hormonal    |   |                 |
|          |                 | therapy (yes,    |   |                 |
|          |                 | no). Refusal of  |   |                 |
|          |                 | care should be   |   |                 |
|          |                 | documented as    |   |                 |
|          |                 | well the reasons |   |                 |
|          |                 | for refusal.     |   |                 |
+----------+-----------------+------------------+---+-----------------+
| 13.      | Number of women | On the last      | \ | See 12-15       |
|  Percent | (age            | workday of the   | > |                 |
|     of   | [\>]            | month count the  | 8 |                 |
|          | {.underline}21) | number of women  | 0 |                 |
|    women | who require     | ages             | % |                 |
|     (age | colposcopy\*\*  | [\>]{            |   |                 |
|     [\>  | \[need          | .underline}21who |   |                 |
| ]{.under | determined      | require          |   |                 |
| line}21) | within the last | colposcopy\*\*   |   |                 |
|     r    | 12 months\]     | \[need           |   |                 |
| equiring | having been     | determined       |   |                 |
|          | evaluated       | within the last  |   |                 |
|   colpos | within 90 days  | 12 months\] and  |   |                 |
| copy\*\* | of the date of  | have been        |   |                 |
|          | the abnormal    | evaluated within |   |                 |
|   having | test divided by | 90 days of the   |   |                 |
|     ev   | the total       | date of the      |   |                 |
| aluation | number of women | abnormal test.   |   |                 |
|          | (age            | At the same time |   |                 |
|   within | [\>]{.underlin  | count the total  |   |                 |
|     3    | e}=21)requiring | number of women  |   |                 |
|          | colposcopy\*\*  | ages             |   |                 |
|   months | \[need          | [\>]{.underline} |   |                 |
|     of   | determined      | 21requiring      |   |                 |
|     the  | within the last | colposcopy\*\*   |   |                 |
|          | 12 months\].    | \[need           |   |                 |
| abnormal | Multiply by 100 | determined       |   |                 |
|     Pap  | to get          | within the last  |   |                 |
|          | percentage.     | 12 months\].     |   |                 |
|    Smear |                 |                  |   |                 |
+----------+-----------------+------------------+---+-----------------+
| 14.      | Number of women | On the last      | \ |                 |
|  Percent | (age            | workday of the   | > |                 |
|     of   | [\>]{.un        | month count the  | 9 |                 |
|          | derline}21)with | number of women  | 5 |                 |
|    women | CIN 2 & 3 or    | ages             | % |                 |
|     (    | invasive        | [\>]{.underline} |   |                 |
|          | cervical cancer | 21with CIN 2 & 3 |   |                 |
|   age[\> | \[diagnosed     | or invasive      |   |                 |
| ]{.under | within the last | cervical cancer  |   |                 |
| line}21) | 12 months\]     | \[diagnosed      |   |                 |
|     with | having initial  | within the last  |   |                 |
|     CIN  | treatment       | 12 months\] who  |   |                 |
|     2 &  | documented      | have their       |   |                 |
|     3,   | within 90 days  | initial          |   |                 |
|     [or  | of diagnosis    | treatment        |   |                 |
|          | divided by the  | documented       |   |                 |
| invasive | total number of | within 90 days   |   |                 |
|          | women (age      | of diagnosis. At |   |                 |
| cervical | [\>]            | the same time    |   |                 |
|          | {.underline}21) | count the number |   |                 |
|   cancer | with CIN 2 & 3  | of women (age    |   |                 |
| ]{.mark} | or invasive     | [\>              |   |                 |
|          | cervical cancer | ]{.underline}21) |   |                 |
|   having | \[diagnosed     | with CIN 2 & 3   |   |                 |
|          | within the last | or invasive      |   |                 |
|  initial | 12 months\].    | cervical cancer  |   |                 |
|     t    | Multiply by 100 | \[diagnosed      |   |                 |
| reatment | to get          | within the last  |   |                 |
|     do   | percentage.     | 12 months\].     |   |                 |
| cumented |                 |                  |   |                 |
|          |                 |                  |   |                 |
|   within |                 |                  |   |                 |
|     90   |                 |                  |   |                 |
|     days |                 |                  |   |                 |
|     of   |                 |                  |   |                 |
|     d    |                 |                  |   |                 |
| iagnosis |                 |                  |   |                 |
+----------+-----------------+------------------+---+-----------------+
| 15.      | Number of       | On the last      | \ |                 |
|  Percent | adults (age     | workday of the   | > |                 |
|     of   | ≥51) with       | month, the       | 9 |                 |
|          | positive fecal  | registry will be | 0 |                 |
|   adults | occult blood    | searched for the | % |                 |
|     (age | testing, within | number of adults |   |                 |
|     ≥51) | the last 12     | (age ≥51) with   |   |                 |
|     with | months, having  | positive fecal   |   |                 |
|          | colonoscopy (or | occult blood     |   |                 |
| positive | sigmoidoscopy   | testing \[within |   |                 |
|          | and BE) within  | the last 12      |   |                 |
|   occult | 8 weeks of the  | months\] having  |   |                 |
|          | date of the     | colonoscopy (or  |   |                 |
|    blood | positive result | sigmoidoscopy    |   |                 |
|          | divided by the  | and BE) within 8 |   |                 |
|  testing | total number of | weeks of the     |   |                 |
|          | adults (age     | date of the      |   |                 |
|   having | [\>]            | positive FOBT.   |   |                 |
|     col  | {.underline}51) | At the same      |   |                 |
| onoscopy | having positive | time, count the  |   |                 |
|     (or  | fecal occult    | number of adults |   |                 |
|          | blood testing,  | (age             |   |                 |
|    sigmo | within the last | [\>              |   |                 |
| idoscopy | 12 months.      | ]{.underline}51) |   |                 |
|     and  | Multiply by 100 | who have had a   |   |                 |
|     BE)  | to get          | positive FOBT    |   |                 |
|          | percentage.     | within the last  |   |                 |
|   within |                 | 12 months.       |   |                 |
|     8    |                 |                  |   |                 |
|          |                 |                  |   |                 |
|    weeks |                 |                  |   |                 |
|     of   |                 |                  |   |                 |
|          |                 |                  |   |                 |
| positive |                 |                  |   |                 |
|          |                 |                  |   |                 |
|  testing |                 |                  |   |                 |
+----------+-----------------+------------------+---+-----------------+
| 16.      | Percent of      | On the last      | \ |                 |
|  Percent | adults (age     | workday of the   | > |                 |
|     of   | ≥51) with polyp | month, the       | 9 |                 |
|          | or colon cancer | registry will be | 5 |                 |
|   adults | \[diagnosed     | searched for the | % |                 |
|     (age | within the last | number of adults |   |                 |
|     ≥51) | 12 months\]     | (age ≥51) with   |   |                 |
|     with | having initial  | polyp or colon   |   |                 |
|          | treatment       | cancer           |   |                 |
|    polyp | documented      | \[diagnosed      |   |                 |
|     or   | within 90 days  | within the last  |   |                 |
|          | of lab          | 12 months\] who  |   |                 |
|    colon | confirmation of | have their       |   |                 |
|          | the diagnosis,  | initial          |   |                 |
|   cancer | divided by the  | treatment        |   |                 |
|          | total number of | documented       |   |                 |
|   having | adults          | within 90 days   |   |                 |
|          | (age\>=51) with | of lab           |   |                 |
|  initial | polyp or colon  | confirmation of  |   |                 |
|     t    | cancer          | the diagnosis.   |   |                 |
| reatment | \[diagnosed     | At the same      |   |                 |
|     do   | within the last | time, count the  |   |                 |
| cumented | 12 months\].    | number of adults |   |                 |
|          | Multiply by 100 | (age ≥51) with   |   |                 |
|   within | to get          | polyp or colon   |   |                 |
|     90   | percentage.     | cancer           |   |                 |
|     days |                 | \[diagnosed      |   |                 |
|     of   |                 | within the last  |   |                 |
|     lab  |                 | 12 months\].     |   |                 |
|     conf |                 |                  |   |                 |
| irmation |                 |                  |   |                 |
|     of   |                 |                  |   |                 |
|     the  |                 |                  |   |                 |
|     d    |                 |                  |   |                 |
| iagnosis |                 |                  |   |                 |
+----------+-----------------+------------------+---+-----------------+

£ Individuals who choose not to be screened, or are inappropriate for
screening (eg an 83 yo woman with Alzheimer's disease) should be
excluded from the denominator after a documented discussion with the
person or responsible guardian.(ref)

\* "Shared decision making" includes three elements (Asking,
Tell/sharing information, identifying a plan). Information systems may
document the occurrence of counseling but it is rare that the type of
counseling is documented. We therefore encourage documentation of the
general process of self-management support. If teams want to document
the specific process of shared decision making regarding cancer this is
recommended as an additional measure (#7).

\*\* Women requiring colposcopy:

-   All LSIL HSIL, AGUS, cancer

-   ASCUS should be colpo\'d if HPV positive or result found twice in
    two years after q 6 month repeat

\*\*\* Federal regulation, Mammography Quality Standard Act

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.