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George L. Jackson, Leah L. Zullig, S. Yousuf Zafar, Adam A. Powell, Diana L. Ordin, Ziad F. Gellad, David Abbott, James M. Schlosser, Janis Hersh and Dawn Provenzale

Clinical practice guidelines can be used to help develop measures of quality of cancer care. This article describes the use of a Cancer Care Quality Measurement System (CCQMS) to monitor these measures for colorectal cancer in the Veterans Health Administration (VHA). The CCQMS assessed practice guideline concordance primarily based on colon (14 indicators) and rectal (11 indicators) cancer care guidelines of the NCCN. Indicators were developed with input from VHA stakeholders with the goal of examining the continuum of diagnosis, neoadjuvant therapy, surgery, adjuvant therapy, and survivorship surveillance and/or end-of-life care. In addition, 9 measures of timeliness of cancer care were developed. The measures/indicators formed the basis of a computerized data abstraction tool that produced reports on quality of care in real-time as data were entered. The tool was developed for a 28-facility learning collaborative, the Colorectal Cancer Care Collaborative (C4), aimed at improving colorectal cancer (CRC) care quality. Data on 1373 incident stage I–IV CRC cases were entered over approximately 18 months and were used to target and monitor quality improvement activities. The primary opportunity for improvement involved surveillance colonoscopy and services in patients after curative-intent treatment. NCCN Clinical Practice Guidelines in Oncology were successfully used to develop a measurement system for a VHA research–operations quality improvement partnership.

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Dawn Provenzale, Samir Gupta, Dennis J. Ahnen, Travis Bray, Jamie A. Cannon, Gregory Cooper, Donald S. David, Dayna S. Early, Deborah Erwin, James M. Ford, Francis M. Giardiello, William Grady, Amy L. Halverson, Stanley R. Hamilton, Heather Hampel, Mohammad K. Ismail, Jason B. Klapman, David W. Larson, Audrey J. Lazenby, Patrick M. Lynch, Robert J. Mayer, Reid M. Ness, Scott E. Regenbogen, Niloy Jewel Samadder, Moshe Shike, Gideon Steinbach, David Weinberg, Mary Dwyer and Susan Darlow

This is a focused update highlighting the most current NCCN Guidelines for diagnosis and management of Lynch syndrome. Lynch syndrome is the most common cause of hereditary colorectal cancer, usually resulting from a germline mutation in 1 of 4 DNA mismatch repair genes (MLH1, MSH2, MSH6, or PMS2), or deletions in the EPCAM promoter. Patients with Lynch syndrome are at an increased lifetime risk, compared with the general population, for colorectal cancer, endometrial cancer, and other cancers, including of the stomach and ovary. As of 2016, the panel recommends screening all patients with colorectal cancer for Lynch syndrome and provides recommendations for surveillance for early detection and prevention of Lynch syndrome-associated cancers.

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Randall W. Burt, Jamie A. Cannon, Donald S. David, Dayna S. Early, James M. Ford, Francis M. Giardiello, Amy L. Halverson, Stanley R. Hamilton, Heather Hampel, Mohammad K. Ismail, Kory Jasperson, Jason B. Klapman, Audrey J. Lazenby, Patrick M. Lynch, Robert J. Mayer, Reid M. Ness, Dawn Provenzale, M. Sambasiva Rao, Moshe Shike, Gideon Steinbach, Jonathan P. Terdiman, David Weinberg, Mary Dwyer and Deborah Freedman-Cass

Mortality from colorectal cancer can be reduced by early diagnosis and by cancer prevention through polypectomy. These NCCN Guidelines for Colorectal Cancer Screening describe various colorectal screening modalities and recommended screening schedules for patients at average or increased risk of developing colorectal cancer. In addition, the guidelines provide recommendations for the management of patients with high-risk colorectal cancer syndromes, including Lynch syndrome. Screening approaches for Lynch syndrome are also described.

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Randall W. Burt, James S. Barthel, Kelli Bullard Dunn, Donald S. David, Ernesto Drelichman, James M. Ford, Francis M. Giardiello, Stephen B. Gruber, Amy L. Halverson, Stanley R. Hamilton, Mohammad K. Ismail, Kory Jasperson, Audrey J. Lazenby, Patrick M. Lynch, Edward W. Martin Jr., Robert J. Mayer, Reid M. Ness, Dawn Provenzale, M. Sambasiva Rao, Moshe Shike, Gideon Steinbach, Jonathan P. Terdiman and David Weinberg

OverviewColorectal cancer (CRC) is the third most frequently diagnosed cancer in men and women in the United States. In 2009, an estimated 106,100 new cases of colon cancer and 40,870 new cases of rectal cancer will occur in the United States, and 49,920 people will die of colon and rectal cancers. Patients with lo-calized colon cancer have a 90% 5-year survival rate.CRC mortality can be reduced through early diagnosis and cancer prevention with polypectomy. Therefore, the goal of CRC screening is to detect cancer at an early, curable stage and to detect and remove clinically significant adenomas. Screening tests that can detect both early cancer and adenomatous polyps are encouraged, although the panel recognizes that patient preference and resource accessibility play a large role in test selection.Curent technology falls into 2 broad categories: structural and stool/fecal-based tests. Although some techniques are better established than others, panelists agreed that any screening is better than none.Structural Screening TestsStructural tests are able to detect both early cancer and adenomatous polyps using endoscopic or radiologic imaging. These have several limitations, including their relative invasiveness, the need for dietary preparation and bowel cleansing, and the time dedicated to the examination (typically a day). Endoscopic examinations require informed consent and sedation, and have related risks, including perforation and bleeding. Recently, a large cohort study of 53,220 Medicare patients between ages 66 and 95 years showed that risk for adverse events after colonoscopy increases with age.ColonoscopyColonoscopy is the most complete...
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Dawn Provenzale, Samir Gupta, Dennis J. Ahnen, Arnold J. Markowitz, Daniel C. Chung, Robert J. Mayer, Scott E. Regenbogen, Amie M. Blanco, Travis Bray, Gregory Cooper, Dayna S. Early, James M. Ford, Francis M. Giardiello, William Grady, Michael J. Hall, Amy L. Halverson, Stanley R. Hamilton, Heather Hampel, Jason B. Klapman, David W. Larson, Audrey J. Lazenby, Xavier Llor, Patrick M. Lynch, June Mikkelson, Reid M. Ness, Thomas P. Slavin Jr, Shajanpeter Sugandha, Jennifer M. Weiss, Mary A. Dwyer and Ndiya Ogba

The NCCN Guidelines for Colorectal Cancer (CRC) Screening outline various screening modalities as well as recommended screening strategies for individuals at average or increased-risk of developing sporadic CRC. The NCCN panel meets at least annually to review comments from reviewers within their institutions, examine relevant data, and reevaluate and update their recommendations. These NCCN Guidelines Insights summarize 2018 updates to the NCCN Guidelines, with a primary focus on modalities used to screen individuals at average-risk for CRC.

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Dawn Provenzale, Kory Jasperson, Dennis J. Ahnen, Harry Aslanian, Travis Bray, Jamie A. Cannon, Donald S. David, Dayna S. Early, Deborah Erwin, James M. Ford, Francis M. Giardiello, Samir Gupta, Amy L. Halverson, Stanley R. Hamilton, Heather Hampel, Mohammad K. Ismail, Jason B. Klapman, David W. Larson, Audrey J. Lazenby, Patrick M. Lynch, Robert J. Mayer, Reid M. Ness, M. Sambasiva Rao, Scott E. Regenbogen, Moshe Shike, Gideon Steinbach, David Weinberg, Mary A. Dwyer, Deborah A. Freedman-Cass and Susan Darlow

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Colorectal Cancer Screening provide recommendations for selecting individuals for colorectal cancer screening, and for evaluation and follow-up of colon polyps. These NCCN Guidelines Insights summarize major discussion points of the 2015 NCCN Colorectal Cancer Screening panel meeting. Major discussion topics this year were the state of evidence for CT colonography and stool DNA testing, bowel preparation procedures for colonoscopy, and guidelines for patients with a positive family history of colorectal cancer.

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Samir Gupta, Dawn Provenzale, Scott E. Regenbogen, Heather Hampel, Thomas P. Slavin Jr, Michael J. Hall, Xavier Llor, Daniel C. Chung, Dennis J. Ahnen, Travis Bray, Gregory Cooper, Dayna S. Early, James M. Ford, Francis M. Giardiello, William Grady, Amy L. Halverson, Stanley R. Hamilton, Jason B. Klapman, David W. Larson, Audrey J. Lazenby, Patrick M. Lynch, Arnold J. Markowitz, Robert J. Mayer, Reid M. Ness, Niloy Jewel Samadder, Moshe Shike, Shajanpeter Sugandha, Jennifer M. Weiss, Mary A. Dwyer and Ndiya Ogba

The NCCN Guidelines for Genetic/Familial High-Risk Assessment: Colorectal provide recommendations for the management of patients with high-risk syndromes associated with an increased risk of colorectal cancer (CRC). The NCCN Panel for Genetic/Familial High-Risk Assessment: Colorectal meets at least annually to assess comments from reviewers within their institutions, examine relevant data, and reevaluate and update their recommendations. These NCCN Guidelines Insights focus on genes newly associated with CRC risk on multigene panels, the associated evidence, and currently recommended management strategies.

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Samir Gupta, Dawn Provenzale, Xavier Llor, Amy L. Halverson, William Grady, Daniel C. Chung, Sigurdis Haraldsdottir, Arnold J. Markowitz, Thomas P. Slavin Jr, Heather Hampel, CGC, Reid M. Ness, Jennifer M. Weiss, Dennis J. Ahnen, Lee-may Chen, Gregory Cooper, Dayna S. Early, Francis M. Giardiello, Michael J. Hall, Stanley R. Hamilton, Priyanka Kanth, Jason B. Klapman, Audrey J. Lazenby, Patrick M. Lynch, Robert J. Mayer, June Mikkelson, CGC, Shajan Peter, Scott E. Regenbogen, Mary A. Dwyer, CGC and Ndiya Ogba

Identifying individuals with hereditary syndromes allows for improved cancer surveillance, risk reduction, and optimized management. Establishing criteria for assessment allows for the identification of individuals who are carriers of pathogenic genetic variants. The NCCN Guidelines for Genetic/Familial High-Risk Assessment: Colorectal provide recommendations for the assessment and management of patients with high-risk colorectal cancer syndromes. These NCCN Guidelines Insights focus on criteria for the evaluation of Lynch syndrome and considerations for use of multigene testing in the assessment of hereditary colorectal cancer syndromes.