(v.4) 05-06-11
Cancer Case Conferences
CME Program Application
Please Note: Throughout this document, endnotes are used to provide you with additional
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endnote.
Information available to person completing the application:
 Instructions:i
 Deadlines:ii
o Caution related to the months the Advisory Board does not meetiii
o Regularly Scheduled Series for which Educational Grants are being soughtiv
 Contact Informationv
Type of Activity
Prospective Cancer Conferencevi
Retrospective Cancer Conferencevii
1. What type of activity is this?
Activity Information
2. Proposed Activity Name:
3. Proposed Start and End Dates:
4. Activity’s proposed beginning and
ending time:
5. Rotational frequency of the program:
Frequency
Semi Annually
Quarterly
Bi monthly (6 meetings per year)
Monthly
Bi-weekly (25 meetings per year)
Weekly
Day of the Week
Monday
Tuesday
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East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education, 2010
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Wednesday
Thursday
Friday
Week of the Month
First Week
Second Week
Third Week
Fourth Week
Other:
6. Proposed number of contact hours per
scheduled event:
7. Location:
Facility:
City:
8. What is the name of the sponsoring
organization?
9. Has this activity been accredited in the
past by the ETSU Office of CME?
No
Yes
when?
Target Audience
10. Who is your target audience?
11. How many professionals typically
attend on any given week?
12. Is your cancer conference restricted,
primarily, to members of your
organization’s medical staff?
2
Medical Oncologists
Radiation Oncologists
Surgical Oncologists/Surgeons
Pathologist
Radiologists
Primary Care Physicians
Oncology Nurses
Tumor Registrar
Residents, Fellows
Other: Please List:
Physicians :
(excluding residents)
NP/PAs:
Non Physicians:
(including residents)
Yes
No. Please explain:
East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education, 2010
(v.4) 05-06-11
Statement of Need and Learning Gap
13. Please read the following “Statement
of Need” and related “Educational
Gap” for Cancer Conferences.
Yes, this description adequately reflects our
Statement of Need and Educational Gap
No, we would like to substitute the following:
“There is a wide range of evidence
based treatment options for patients
with newly diagnosed or newly
recurrent cancer. The plan of care and
its sequencing is dictated by multiple
factors, and spans the expertise of
multiple medical disciplines.”
“Cancer Conferences are integral to
improving the care of cancer patients
by contributing to the patient
management process and outcomes
and providing education to physicians
and other staff in attendance.”
“Consultative services are optimal
when physician representatives from
diagnostic radiology, pathology,
surgery, medical oncology and
radiation oncology participate in
facility-wide or network wide cancer
conferences.”
“The type, format, frequency of cancer
conferences and required attendance
are driven by the case profile of the
organization, and all are determined
by the Cancer Committee.”
“Learning Gap: “Because of new and
emerging technology and treatment
protocols, without an opportunity for
regular multidisciplinary
collaboration, our physicians are not
providing the most advanced,
focused, integrated, timely and
appropriately sequenced care “
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East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education, 2010
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Educational Format
14. Educational Format: Which of the
following typically occurs at your case
conference? (Check all that apply)
Presentation and review of
How patient first presented
Patient’s pertinent history
Presentation. viewing of and discussion of:
Radiologic and imaging studies
Pathology studies, including
Margins and staging
Consideration, discussions of and recommendations
for:
Medical options
Radiation options
Surgical options
Other therapeutic options
Palliative options
Sequencing
Other. Please describe:
Learning Objectives and Outcomes
15. Please read the following learning
objectives which are typically
associated with cancer case
conferences.
Prospective Cancer Conferences:


Obtain multidisciplinary input into the diagnosis and
treatment options for the presented patient
Determine an overall plan of care for the patient
Yes, we accept these learning objectives.
No, we would like to propose the following
alternative objectives:
Retrospective Cancer Conferences:



In a multidisciplinary format, retrospectively examine
diagnosis, treatment and rationale of recently
identified cancer cases
Interpret radiology and pathology findings, and how
they lead to optimal treatment plans
Describe how multidisciplinary collaboration enhances
patient outcomes
Yes, we accept these learning objectives.
No, we would like to propose the following
alternative objectives:
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16. Does you cancer program have, or are
you currently preparing for
accreditation?
17. Has your Cancer Conference been
commissioned by your organization’s
Cancer Committee?
18. Answer this question ONLY if you are
accredited or seeking accreditation of
your Oncology Program from COC or
NCI
No
I don’t know
Yes. With which accrediting body?
Commission on Cancer (COC)
NCI
Other/ Please Describe:
No
I don’t know
Yes. Is your cancer conference’s compliance with
cancer conference accreditation criteria reported
back to cancer committee at least yearly?
No
I don’t know
Yes. Please describe the
frequency, and typically which
months of the year.
Part A: Which of your multidisciplinary team of
physicians are required to attend the case
conference? (Your Tumor Registrar Knows)
Medical Oncologist
Surgeon/Surgical Oncologist
Radiation Oncologist
Pathologist
Radiologist
Tumor Registrar
Other. Please list:
Part B: What is the percent of multidisciplinary
attendance required by your Cancer
Committee?
% (Your Tumor Registrar Knows)
Please Note: Based on your answers to the questions in this section, your CME Planner will
describe for you how your activity’s outcomes will be measured.
Financial Support
19. Do you intend to seek commercial
support for this activity?
No
Yes. Please explain:
Activity Director Information
20. Activity
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Directorviii
East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education, 2010
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21. Title
22. Specialty
23. Organization Name / College /
Department
24. Address
25. E-mail Address
26. Phone
27. Fax
Planning Committeeix
Name and Title
Specialty
Phone Number
E-mail Address
Contact Information
Contact Person Name
Title
Organization
Address
Phone Number
Fax Number
E-Mail
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East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education, 2010
(v.4) 05-06-11
Is this person the
individual who is
responsible for the day
to day support of this
activity?
Yes
No. If no, who is that person and what is their contact information?
For Office Use Only
Prospective
Educational need is “Performance”
Retrospective
“Performance” outcomes will be measured as follows:
 Annual Compliance with National Standards of the ACOS
Commission on Cancer’s “Cancer Case Conference Criteria” 2.6 – 2.9
 Quarterly Evaluation as outlined below
Educational need is “Competency”
“Competency” outcomes will be measured as follows:
 Quarterly Evaluation to measure the extent to which the activity has
met its educational objectives and to determine how, as a result of
this activity, the participants have changed their practice.
Next Steps
You may call the Office of Continuing Medical Education during business hours to
receive assistance with completing this application, or to discuss anything related to
your potential activity. Our number is 423-439-8081.
Return this form along with required attachment via e-mail (PREFERRED) to
johnsonc@etsu.edu or fax to Office of CME at 423 439 8040. Within a few days one
of our educational planners will give you a call.
Required Attachments
1) You must provide the following documents with your application:
a) A “Required Signatures” form that includes the Activity Director’s Conflict of
Interest Disclosure and his or her signature accepting responsibility for the
program. Click this link to access this form: Required Signature Form
b) The Activity Director’s CV
2) Additional documents required before the CME Advisory Board Meeting (1st
Thursday of each month)
a) A “Conflict of Interest Disclosure” completed by each member of the Planning
Committee. Send this link to each member of the planning committee:
Planning Committee Member Conflict of Interest Disclosure Statement
b) The CV of each member of the Planning Committee
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Footnotes
i
Instructions:
 This application is in MS Word, and is a form. To complete, put your cursor in a grey shadowed area and start
typing. It is difficult to spell check in a Word Form, so be aware that this is not a problem to us if your spelling is not
perfect. If you are the person completing this application, it is important that you have significant information on
the need, focus and expected outcomes of the proposed activity.
 If this is the first time you have completed one of our applications, we do not expect you to complete this
application flawlessly. However, you must complete it thoughtfully. Once we have received it, our planners will
assist you in further refining your application until it is ready for the Advisory Board’s review. This consultation
process is what makes it necessary for the application to be submitted according to the deadlines.
 You may contact us at any time if you need clarification on the application or the process.
 Once the application is complete, you may either e-mail (preferred) or fax it to the Office of Continuing Medical
Education. The contact information is listed at the end of the application.
ii
Deadlines:
All applications and their supporting documentation receive a thorough internal review before they are submitted
to the Advisory Board. Deadlines are set to accommodate that internal review, and to provide the best opportunity
for the activity to be approved.
 Advisory Board meetings are the first week of the month. Applications for a Regularly Scheduled Series must be
received by the 10th day of the month that PRECEEDS submission to the Advisory Board. For example, an
application that is going to be reviewed by the board the first week of May must be submitted to the Office of
Continuing Medical Education by April 10.

iii
The Advisory Board does not meet in January or July. Applications which would ordinarily be submitted for January or
July review, will need to be reviewed at the December or June meetings respectively. This shortens your application
deadline by an additional month. Contact us by phone if you are caught by this unawares.
iv
Commercial support is rarely sought for Regularly Scheduled Series. Please discuss this with your CME Planner, and be
aware that NO commercial support can be requested or received by any party to the activity except the Office of
Continuing Medical Education.
v
Office of Continuing Medical Education
James H. Quillen College of Medicine
East Tennessee State University
Box 70572
Johnson City, TN 37614-1708
Phone: 423-439-8081
Fax: 423-439-8040
Email: johnsonc@etsu.edu
Website: http://www.etsu.edu/com/cme/
vi
“Prospective Cancer Case Conferences”, also called Tumor Boards and Working Case Conferences are typically
conducted to determine the optimal plan of care for a newly diagnose or newly presenting cancer patient. Members of
the multidisciplinary team are brought together to review the diagnostic findings, the optimal course of treatment, the
sequencing, and to determine the best method to proceed with the patient.
“Retrospective Cancer Case Conferences” examine retrospectively the patient’s presentation, diagnosis, care and
outcome, are conducted primarily for their educational value, and are not typically used to plan or manage the patient’s
ongoing case.
vii
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(v.4) 05-06-11
viii
The Activity Director must be a physician or nurse practitioner. The Activity Director must have direct involvement in
the planning of the activity, and will need to be in a position to collaborate with the Office of Continuing Medical
Education as the planning unfolds.
ix
EXAMPLE: Medical Staff Grand Rounds e.g.:
 Activity Director (former Chief of Staff or Director of Med Ed)
 Members of the Medical Executive Committee
 VP Medical Affairs or Chief Operating Office
 QI Representative
EXAMPLE: Cancer Case Conference, e.g.:
 Activity Director (Physician)
 Physicians representing other specialties involved (Radiology, Pathology etc.)
 Other representatives, if on staff:
o Tumor Registrar
o Nurse Coordinator
o Educational Coordinator
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East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education, 2010