Albert J. and Judith A. Dunlap Cancer Center at Mayo Clinic Health ...

Albert J. and Judith A. Dunlap Cancer Center at Mayo Clinic Health System in Eau Claire
2011–2012 CANCER ANNUAL AND OUTCOMES REPORT
We bring the knowledge of hundreds of Mayo Clinic cancer specialists — and the experience of treating more
than a million patients — to your community.
The Albert J. and Judith A. Dunlap Cancer Center at Mayo Clinic Health System in Eau Claire offers a full
range of comprehensive medical and surgical specialists who are board certified in medical, surgical and
radiation oncology. Working in collaboration, they bring personalized, patient-centered, high-quality care to
patients.
Clinicians treating the same patient consult one another, review test results and work in partnership on treatment
plans. Regular cancer conferences are held to exchange information on complex and common diagnoses.
Together, our specialized medical professionals create optimum patient care plans and coordinate care and
treatment plans with Mayo Clinic. Cancer therapies are designed using the most advanced treatments, research,
clinical trials and support resources. Our multidisciplinary team approach integrates services by understanding
the emotional and physical effects of cancer and focuses on the whole person, not just the disease.
In addition, Mayo Clinic Health System’s strong support teams augment the cancer team. They are comprised of
specialists from pain management, palliative medicine, behavioral medicine, nutrition, physical therapy,
emotional and spiritual guidance, social services and nationally certified oncology nurses.
In fall 2012, Mayo Clinic Health System, along with Daniel Burns, M.D., and Sandeep Basu, M.D., welcomed
Mary Misischia, M.D., board certified in medical oncology, to the facility.
On July 9, 2010, the cancer program at Mayo Clinic Health System in Eau Claire received the American College
of Surgeons’ Commission on Cancer Accreditation Award. The program was awarded a Three Year
Accreditation with Commendation. On June 7, 2011, the HERS Breast Center at Mayo Clinic Health System in
Eau Claire was awarded a Three-Year Full Accreditation through the National Accreditation Program for Breast
Centers. The cancer program also participates in treatment and clinical trials, cancer education and support
while providing quality care close to home with Mayo Clinic expertise.
REPORT CONTENTS
• About The Albert J. and Judith A. Dunlap Cancer Center at Mayo Clinic Health System in Eau
Claire
• Breast Cancer Outcome Analysis & Comparative Data Report — 2012
• Cancer Program Year in Review
o Community Outreach

o Research/Clinical Trials
o Support Groups
• MCHS Cancer Registry
o Annual Analytic Case Report
o The Function of the Mayo Clinic Health System Cancer Registry
o 2011 Analytic Cases by Site, Gender and Stage
• Contact Information
o Cancer Committee
• Commission on Cancer (CoC) Survey: Spring 2013
• 2012 Membership
Breast Cancer Outcome Analysis & Comparative Data Report — 2012
The American College of Surgeons’ Commission on Cancer (CoC) and National Accreditation Program for
Breast Centers (NAPBC) requires annual performance rates to be reported for six quality measures identified by
the NAPBC. Performance and outcomes for these measures are evaluated annually by Mayo Clinic Health
System in Eau Claire and breast program leadership. Breast cancer data evaluated for this report is from the
Mayo Clinic Health System in Eau Claire Cancer Registry’s 2011 analytic caseload.
1. Basic epidemiology.
In 2012, it is estimated that among U.S. women there will be 226,870 new cases of invasive breast cancer
(includes new cases of primary breast cancer among survivors, but not recurrence of original breast cancer
among survivors). Also, there will be 63,300 new cases of in situ breast cancer (includes ductal carcinoma in
situ (DCIS) and lobular carcinoma in situ (LCIS), of which about 85 percent will be DCIS. DCIS is a
noninvasive breast cancer, and LCIS is a condition that increases the risk of invasive breast cancer. There will
be 39,510 women who die of breast cancer.
2. Local epidemiology as to cases within our group.
Within 2011, Mayo Clinic Health System in Eau Claire diagnosed and/or provided first-course treatments, often
referred to as the analytic caseload to 127 breast patients per the Mayo Clinic Health System in Eau Claire
Cancer Registry. The most commonly used method of disease distribution for studies, and in compliance with
national guidelines, is the American Joint Committee on Cancer (AJCC) staging, the process that describes the
extent or severity of an individual’s cancer based on the extent of the original (primary) and the extent of spread
in the body. The 2011 breakdown is as follows:
Mayo Clinic Health System in Eau Claire 2011 Analytic Breast Cases by AJCC Stage
AJCC
Stage
TOTAL 0 I II III IV UNK N/A
BREAST 127 21 53 33 10 5 3 2
The stage at which the cancer is diagnosed is the best predictor of a woman’s chance of surviving the disease.
Early stage, Stage 0–II requires less aggressive, life-interrupting treatments to ensure surviving the diagnosis.
Twenty-one cases were Stage 0, 53 cases were Stage I and 33 cases were Stage II. Thus, over 80 percent of the

cases were detected at a highly curable stage. This high percent of early stage cases is also a marker of the
clinic’s efforts to promote screening and accuracy of early detection methods such as mammography.
3. Quality of breast cancer care at Mayo Clinic Health System in Eau Claire.
We reviewed 80 consecutive cases diagnosed and treated by our group in 2010–2011. They were reviewed for
the care they received and how they matched up to recognized measures of high-quality breast cancer care. The
following summarizes this review.
A. The pattern of care in the CP3R data reports — These reports track the long-term trends in the
group’s efforts in key survival enhancing measures. These are national measures and felt by many
groups, including the ACS CoC, NCCN, ASCO and others, to demonstrate the quality of a group’s
cancer program.
Cancer Program Practice Profile Reports (CP 3 R)
for Breast Cancers Diagnosed 2004 - 2010
Mayo Clinic Health System, Eau Claire, Wis.
FACILITY SELECTION ALL MEASURES SUMMARY THIS MEASURE SUMMARY
Combination chemotherapy is considered or
administered within four months (120 days) of diagnosis
for women under 70 with AJCC T1cN0M0, or Stage II
or III hormone receptor negative breast cancer. [MAC]
Diagnosis Year: 2010
(Last Update: Dec 10, 2012 11:12:16 PM CST)
Perf. Rate 95% CI Cases #Prog.
My Cancer Program 100 % (100 - 100) 7
My State (WI) 98.2 % (96.6 - 99.8) 271 32
My ACS Division (Mid-West) 97.1 % (95.8 - 98.4) 654 69
My Census Region (Greatlakes) 92.9 % (91.9 - 93.9) 2482 253
My CoC Program Type (COMP) 91.9 % (91.3 - 92.5) 6821 560
All CoC Approved Programs (ALL) 90.7 % (90.2 - 91.2) 13670 1283
Interpreting this table: The estimated performance rates shown in this table provide your cancer program with an
indication of the proportion of women under 70 with advanced, mid-stage HR-breast cancer treated or considered for
multiagent chemotherapy according to recognized standards of care. These rates are computed based on data directly
reported from CoC approved registries to the NCDB using specifications endorsed by the NQF.
The CP3R provides cancer programs with the opportunity to examine data to determine if these performance rates are
representative of the care provided at the institution. This application provides the ability to review and modify cases
using this application. Simply click on the cell of underlined cases of interest to view a detailed case listing.
Displayed performance rates are immediately updated once modifications via the CP3R are completed by cancer
program staff. Note, any modifications made online should be reflected at the local cancer registry, and cancer
programs are encouraged to resubmit data to the NCDB.

CANCER PROGRAM PRACTICE PROFILE REPORTS (CP3R) FOR BREAST
LUTHER MIDELFORT - MAYO HEALTH SYSTEM, EAU CLAIRE, WI
2004 2005 2006 2007 2008 2009 2010
Radiation therapy is administered within 1 ye
(365 days) of diagnosis for women under ag
70 receiving breast conserving surgery for
breast cancer. [BCS/RT] N/A N/A N/A N/A 100% 100% 100%
Combination chemotherapy is considered or
administered within 4 months (120 days) of
diagnosis for women under 70 with AJCC T1
N0 M0, or Stage II or III ERA and PRA nega
breast cancer. [MAC] N/A N/A N/A N/A 90.90% 100% 100%
Tamoxifen or third generation aromatase
inhibitor is considered or administered within
year (365 days) of diagnosis for women with
AJCC T1c N0 M0, or Stage II or III ERA and
PRA positive breast cancer. [HT] N/A N/A N/A N/A 100% 97.10% 94.60%
B. The American Society of Clinical Oncology (ASCO) has launched a Quality Oncology Practice
Initiative (QOPI). This tracks additional measures as markers of quality for ensuring the best longterm
outcomes for cancer patients. Included are Mayo Clinic Health System’s breast cancer results
on the 80 cases reviewed.
4. Additional quality efforts involving breast cancer care at Mayo Clinic Health System in Eau Claire are
included in the list below.
A. American College of Cancer accreditation.
B. NAPBC accreditation.
C. Number of quality improvement projects involving specific patient-related activities. This is a list of
some, but not all, of the projects completed.
i. Tracking and assuring the time to the starting of postoperative treatments are within the number
of days or sooner than best practices recommended.
ii. Reviewing and documenting the completeness of the consults we provide to women on genetic
risks of breast cancer related issues.
iii. Pathology handling and sample orientation of surgical samples to ensure accurate
documentation of surgical margins.
5. Summary.
This summary indicates that Mayo Clinic Health System in Eau Claire meets or exceeds current
standards of care for the breast cancer patients cared for in this area. We also go beyond national
standards by having a robust system to determine which of our patients may be at high risk of
developing breast cancer and provide comprehensive management of that risk. This process has been
improved by a plan to review quality improvement project. The surgical and pathology departments
have coordinated specimen handling to ease and further guarantee accurate margin determination of
breast specimens. We, as a group, understand the importance of timeliness in the diagnosis and
treatment implementation for breast cancer patients. We have stated goals and tracked the number of
days from an abnormal mammogram to a surgery consult and from surgery to initiation of definitive
post-surgery therapy.
6. Action plan.
We will continue to track these critical measures as we reapply for the American College of Surgeons’
CoC and NAPBC accreditations in the coming two years. We will develop annual plans to review
projects involving breast cancer care as specific clinic departments and the cancer committee determines
the need. We are currently formulating a timeline for accreditation by the American Society of Clinical
Oncology (ASCO) and Quality Oncology Practice Initiative (QOPI). This will give us feedback on how
we compare to nationwide outcomes.

Daniel Burns, M.D., Cancer Committee Chair, 12/12/12
Cancer Program Year in Review
Community Outreach
Mayo Clinic Health System collaborates with other agencies in bringing cancer awareness to the community
through a series of activities. The facility offers multiple prevention and screening programs and multiple
support groups to support our patients as well as the whole community.
• Coaches vs. Cancer UW-Eau Claire Girls Basketball Game
• American Cancer Society and Mayo Clinic Health System’s collaborative agreement
• Digestive Health Event — Colon cancer prevention and information
• Presentation: Mohs Skin Cancer Treatment and the Role of Mohs Micrographic Surgery
• Spa Night
• Cancer Awareness, Resources & Education (CARE) Fair
• Lymphedema Health Talk: Learn about symptoms, causes and how to manage the condition
• Tobacco Free class
• WIAC Volleyball Game and Breast Cancer Awareness Event sponsorship
• Health Break: Put Your Breast to the Test. Will You Pass? Discuss the latest developments in
diagnosing breast cancer.
• Making Strides Against Breast Cancer — Walk to raise money for the American Cancer Society’s
breast cancer programs
• Women Rock — Breast cancer awareness event
Mayo Clinic Health System and the American Cancer Society Patient and Family Support Groups
• Caregivers Support Group
• Let’s Talk: Breast Cancer Support Group
• US TOO Prostate Cancer Support Group
• Myeloma Support Group
• Sharing the Cancer Journey Support Group
• Lymphedema: Laugh and Learn Support Group
• General Support Group
For further information, click here.
Cancer Resource Center
• Hope Lodge
• I Can Cope: Nutrition and Cancer; Relieving Cancer Pain; Communicating the Cancer Experience
• Lodging Services
• Look Good Feel Better
• Man to Man (prostate cancer)
• Patient Navigator
• Reach to Recovery (breast cancer)
• Road to Recovery
• Transportation Services

To find an American Cancer Society office near you, visit cancer.org.
Research/Clinical Trials
When you participate in clinical research, you become part of the Mayo Clinic team. Clinical studies help bridge
research and patient care by evaluating therapies, drugs, diagnostic tools and patient care practices.
Types of clinical studies:
• Observational Study
• Clinical Trial
• Medical Records Research
For the most current open and pending clinical trials, click here.
Cancer Registry
Mayo Clinic Health System Cancer Registry Annual Analytic Case Report
(Eau Claire, Northland, Chippewa Valley and Oakridge)
2011 Case Totals (Eau Claire, Total Base Index Since 2008
Northland, Chippewa Valley and
Oakridge)
All Cases: 907
All Cases: 3413
Analytic: 689
Follow-up: 2649
Expired: 135
Expired: 764
• 2012 case totals unavailable pending six-month data collection process.
The Function of the Mayo Clinic Health System Cancer Registry
The most important element in cancer care is the patient. At Mayo Clinic Health System, we treat the “whole”
patient considering all the factors that may influence the patient’s treatment outcomes. This is why clear and
accurate data becomes one of the most effective tools we have to fight cancer with.
The cancer registry tells the patient’s story, from the onset of disease, continuing with update of information
with lifelong follow-up. A certified tumor registrar interprets and integrates clinical and all aspects of medical
information into a database. It’s an organized process that documents cancer occurrence (incidence), type of
cancer (site), extent of diagnosis at onset (stage) and treatment received with results (survival).
The Mayo Clinic Health System cancer registry is operated in conjunction with CHAMPS Oncology, a
professional registry management company that specializes in accuracy, program certifications and data
reporting.
The Commission on Cancer (CoC) states, “That the treatment of cancer is complex and the patient care process
continually changes and grows with the introduction of new cancer treatment, delivery methods, clinical trials,
and additional program accreditations. High-quality cancer registry data are essential to accurately assess
treatment outcomes and patient survival.”

At CHAMPS Oncology, the emphasis is on high-quality data and not quantity. The certified tumor registrar is
continually educated and evaluated to provide accurate clinical documentation. The true function of any cancer
registry is to integrate each patient’s disease diagnosis and course into an abstract summary. The abstract will be
used by local, state and national organizations to construct patterns and outcomes. Physicians use the data to
develop treatment strategies and identify care inconsistencies. The information is used to generate data for
studies and provide a historical base for the best possible reporting results. Cancer statistics must be reliable and
useful on all levels — for clinics, hospitals, governmental and other health agencies.
Our medical abstractors at Mayo Clinic Health System are educated in medical and oncology practices and use a
standard data set and coding instructions to collect and interpret cancer information. The data complies with
federal and state reporting mandates.
By request, Mayo Clinic Health System medical abstractors have added facility-specific fields to the database
and expanded the information possibilities. Physicians and administrators have customized the information they
want collected and rely on the certified tumor registrar to provide useful reporting methods. Physicians at Mayo
Clinic Health System in Eau Claire use the cancer registry limitlessly. To date, the facility is participating in
three cancer care programs: COC, NAPBC and QOPI. Multiple studies have been developed and continue to be
a vital part of cancer care planning. Medical oncology has studies available on lung, breast, colorectal, prostate
and bladder cancers. Mayo Clinic Health System in Eau Claire is a shining example of how to fully benefit from
cancer registry data.
Over the years, cancer registries nationwide have served to identify environmental influences, financial-related
treatment connections, cultural treatment barriers and identified less invasive treatment options. A cancer
registry provides accurate data that overall saves the patient and facility unwarranted medical costs. Ultimately,
a cancer registry helps facilities to raise the bar for standard of care.
The Mayo Clinic Health System/CHAMPS Oncology cancer registry is part of a combined effort to offer cancer
patients the best optimum care and treatment outcomes.
2011 Analytic Cases by Site, Gender and Stage
Mayo Clinic Health System in Eau Claire 2011 Analytic Cases by Site, Gender and Stage
PRIMARY SITES SEX AJCC STAGE
TOTAL M F 0 I II III IV UNK N/A
ALL SITES 732 363 369 57 220 118 111 135 12 79
BASE OF TONGUE 2 1 1 0 0 0 0 2 0 0
OTHER PARTS OF TONGUE 4 3 1 0 1 0 3 0 0 0
GUM 2 1 1 0 0 0 0 1 1 0
FLOOR OF MOUTH 2 2 0 0 1 1 0 0 0 0
PAROTID GLAND 3 1 2 0 2 1 0 0 0 0
TONSIL 5 3 2 0 1 0 1 3 0 0
OROPHARYNX 3 1 2 0 0 1 0 2 0 0
ESOPHAGUS 13 10 3 0 1 3 5 4 0 0
STOMACH 10 6 4 0 3 1 2 4 0 0
SMALL INTESTINE 4 2 2 0 2 1 1 0 0 0
COLON 44 20 24 1 11 14 10 7 1 0

RECTOSIGMOID JUNCTION 2 1 1 0 0 2 0 0 0 0
RECTUM 11 5 6 0 3 2 4 2 0 0
ANUS & ANAL CANAL 1 1 0 0 0 0 1 0 0 0
LIVER & BILE DUCTS 8 5 3 0 2 0 2 3 0 1
GALL BLADDER 3 2 1 1 0 2 0 0 0 0
OTHER BILIARY TRACT 3 2 1 0 0 0 0 0 0 3
PANCREAS 29 10 19 0 6 4 3 16 0 0
ACCESSORY SINUSES 1 1 0 0 0 0 0 1 0 0
LARYNX 7 6 1 1 4 0 1 0 0 1
BRONCHUS & LUNG 99 60 39 1 25 7 25 38 2 1
HEART MEDIASTINUM PLEURA 2 2 0 0 0 0 1 0 0 1
BLOOD & BONE MARROW 35 23 12 0 0 0 0 1 0 34
SKIN 55 33 22 11 34 5 2 1 2 0
PERIPHERAL NERVES & AUTONOMIC NERVOUS SYSTEM 1 1 0 0 1 0 0 0 0 0
RETROPERITONEUM & PERITONEUM 1 0 1 0 0 0 0 1 0 0
CONNECTIVE SUBCUTANEOUS OTHER SOFT TISSUE 1 1 0 0 0 0 1 0 0 0
BREAST 127 1 126 21 53 33 10 5 3 2
VULVA 2 0 2 0 1 0 0 1 0 0
CERVIX UTERI 1 0 1 0 1 0 0 0 0 0
CORPUS UTERI 16 0 16 0 11 0 3 1 1 0
UTERUS NOS 1 0 1 0 0 0 0 1 0 0
OVARY 8 0 8 0 3 0 3 2 0 0
OTH FM. GENITAL ORGN. 1 0 1 0 1 0 0 0 0 0
PENIS 1 1 0 0 0 1 0 0 0 0
PROSTATE GLAND 65 65 0 0 17 28 8 12 0 0
TESTIS 3 3 0 0 3 0 0 0 0 0
KIDNEY 24 12 12 0 16 1 4 3 0 0
KIDNEY, RENAL PELVIS 4 4 0 2 0 0 1 1 0 0
URINARY BLADDER 42 37 5 19 6 7 2 7 1 0
MENINGES 6 3 3 0 0 0 0 0 0 6
BRAIN 14 7 7 0 1 0 0 0 0 13
OTHER NERVOUS SYSTEM 2 1 1 0 0 0 0 0 0 2
THYROID GLAND 17 2 15 0 5 2 6 3 1 0
OTHER ENDOCRINE GLANDS 3 1 2 0 0 0 0 0 0 3
LYMPH NODES 32 17 15 0 5 2 12 13 0 0
UNK PRIMARY 12 6 6 0 0 0 0 0 0 12

Mayo Clinic Health System in Eau Claire Cancer Committee 2012
Commission on Cancer (CoC) Survey: Spring 2013
It’s hard to believe survey time is approaching, but it’s coming soon! We surveyed for the first time on July 9,
2010, and will be surveyed again in spring 2013. The Commission on Cancer (CoC) program approval process
began in 1930. Currently, there are more than 1,500 CoC-accredited cancer programs in the United States and
Puerto Rico.
Every three years, a facility volunteers to a rigorous survey that enables a cancer program to offer better cancer
care by pursuing requirements that monitor and evaluate the quality of their program. Each year, the facility
completes a survey application record, referred to as the SAR.
Mayo Clinic Health System in Eau Claire, Wis., is an accredited program and agrees with the basis of the CoC
program: To consider the “whole” patient when implementing a care plan and to be concerned with the patient’s
full continuum of cancer from prevention through hospice and end-of-life care or survivorship and quality of
life.
To meet the program requirements, the facility depends on an effective cancer committee. The Cancer
Committee is a group of committed people who work continually to plan and execute all the activities in the
cancer program. They are dedicated to the cancer patient and representing the full scope of the patient’s cancer
care.
To view the CoC’s cancer program standards, click here.
2012 Mayo Clinic Health System in Eau Claire Cancer Committee Membership
Pathologist .......................................................................................... Vipul A. Trivedi, M.D.
Surgeon .............................................................................................. Chris D. Hower, M.D.
Medical Oncologist (Cancer Liaison) ................................................ Daniel Burns, M.D.
Radiation Oncologist ........................................................................... Larry R. Past, M.D.
Cancer Liaison Physician ................................................................... Daniel Burns, M.D.
Cancer Program Administrator .......................................................... Barbara Eidahl, R.N., Director
Oncology Nurse ................................................................................. Corey Moneyhan, R.N.
Oncology Nurse .................................................................................. Vicki Wolf, R.N.
Social/Psychosocial ............................................................................ Sarah Lewis, M.S.W., A.P.S.W.
Certified Tumor Registrar .................................................................. Loretta (Lori)Travers, R.H.I.T., C.T.R.
Certified Tumor Registrar .................................................................. Mary Marshall, C.T.R.
Performance Improvement/Quality Management Representative ..... Janel Wittrock
Palliative Care Team Member ............................................................ Mary Thelen, R.N.
Cancer Conference Coordinator * ....................................................... Daniel Burns, M.D.
Quality Improvement Coordinator* ................................................... Janel Wittrock
Cancer Registry Quality Coordinator* ................................................ Loretta (Lori)Travers, R.H.I.T., C.T.R.
Community Outreach* ........................................................................ Jennifer Blaskowski

Clinical Research ............................................................................... Dawn Mrozinski
Rehab Representative .......................................................................... Mary Beth Clark, C.C.C. - S.L.P.
American Cancer Society ................................................................... Jill McCarthy, M.S.W.
American Cancer Society .................................................................... Katie Sarver
*Redesignate 4 coordinators Standard 2.3
2011-2012 Cancer Annual and Outcomes Report was prepared and provided by Mayo Clinic Health System in
Eau Claire and CHAMPS Oncology Cancer Specialists.