Mission...3. Chairman s Report...4. Program Achievements...5. The Cancer Committee Facts and Figures...8. Infusion Center Update...

Transcription

1 WE RE ALL IN THIS TOGETHER. CANCER PROGRAM ACHIEVEMENTS

2 TABLE OF CONTENTS Mission...3 Chairman s Report...4 Program Achievements...5 The Cancer Committee Facts and Figures...8 Infusion Center Update...15 A View from the Other Side of Cancer...16 Community Outreach: Cervical Cancer Prevention...18 Research Report Dr. Fornalik...20 List of Services & Locations WE RE ALL IN THIS TOGETHER.

3 MISSION VALUES The mission of Goshen Health is to improve the health of our communities by providing innovative, outstanding care and services through exceptional people doing exceptional work. COMPASSION and commitment to serve with empathy. ACCOUNTABILITY with integrity and action. RESPECT through treating others as you with to be treated. EXCELLENCE in all we do. WE RE ALL IN THIS TOGETHER. 3

4 CHAIRMAN S REPORT Interdisciplinary cancer care and collaboration are part of our DNA at Goshen Center for Cancer Care at Goshen Hospital. We bring together clinicians from all specialties to discuss the best approach for every case. Whether it s a difficult, complex case or an early stage, localized one, we believe each patient deserves this personalized level of care. It s how we limit side effects, improve outcomes and give patients the best experience possible. More than 1,230 new patients chose our cancer center for diagnosis or treatment in Nearly one out of four traveled more than 20 miles or out of state for care. We provided specialized care for breast, lung, gastrointestinal and gynecologic cancers as well as other tumor types. Daniel Bruetman, MD, MMM Chairman, Cancer Committee As our case volume expands, we continue to assess ways to ensure our facilities meet current and future patient needs. This thoughtful process led to the opening of the Alice A. and Rex Martin Infusion Center in Its well-planned, spacious design gives us a better way to provide life-changing therapies, privacy and support at a time when our patients need it most. We are grateful for the generosity of the Rex and Alice A. Martin Foundation in support of this project. Clinical research has always been a key component of our cancer program. Our active participation in these trials gives patients access to potentially new, life-saving therapies. We continue to refer patients for clinical studies for many types of cancer. Our collaborative model of care continues to attract board certified, fellowship trained oncologists. These clinicians broaden our integrated program to give referring providers and patients more options for high quality care in one location. We look forward to continued focus on our mission under the leadership of our new medical director, Leonard Henry, MD, MBA, FACS. As we approach 2019, we anticipate a highly successful outcome of our upcoming accreditation survey by the Commission on Cancer. This quality program of the American College of Surgeons has always acknowledged excellence in the cancer care we deliver. In this report, we highlight recent quality data and achievements for Goshen Center for Cancer Care. We also introduce you to patients and their families who bring strength, determination and courage to their challenge with cancer. Their spirit forms a powerful source of energy and healing. It also inspires us to surround them with the resources they need to face each phase of a diagnosis and treatment. 4 WE RE ALL IN THIS TOGETHER.

5 CANCER PROGRAM ACHIEVEMENTS Key quality measures and accreditations place us among the leading cancer centers in our region. Recent highlights include: Expansion of our Infusion Center that allows personalized cancer therapies with the latest infusion technology Reaccreditation by the American College of Radiology (ACR) for radiation oncology practice Extension of our free lung screening program to firefighters who are at higher risk for respiratory disease, including lung cancer Introduction of a modified surgical position for high-risk gynecologic patients during robotic surgery Consistent achievement of patient satisfaction scores above the 90th percentile WE RE ALL IN THIS TOGETHER. 5

6 CANCER COMMITTEE Sachin Agarwal, MD Rachelle Anthony Ingrid Bowser, MSN, ANP-BC, AOCNP Medical Oncologist Goshen Center for Cancer Care American Cancer Society Representative American Cancer Society Palliative Care Representative Goshen Center for Cancer Care Hollie Carlson, MS, Ed Fiona Denham, MD Daniel Diener, MD, FACS Susan Franger, MHA Community Outreach Coordinator Goshen Retreat Women s Health Center Surgical Oncologist & Genetics Professional Goshen Retreat Women s Health Center Cancer Liaison Physician Gerig Surgical Services Cancer Program Administrator Goshen Center for Cancer Care Juliet Leamon, BSN, RN, NE-BC Beth Otto, CTR, CMA Tracy Paulus, CTR Helen Sivicek, RN Oncology Nurse Goshen Hospital Cancer Conference Coordinator Goshen Hospital/Center for Cancer Care Certified Tumor Registrar & Cancer Registry Quality Coordinator Goshen Hospital/Center for Cancer Care Clinical Research Coordinator Goshen Center for Cancer Care

7 COMMITTEE RESPONSIBILITIES Michael Brendle, MD Daniel Bruetman, MD, MMM Develop and evaluate the annual goals and objectives for the clinical, educational and programmatic activities related to cancer. Diagnostic Radiologist Radiology Inc. Cancer Committee Chairman & Medical Oncologist Goshen Center for Cancer Care Promote a coordinated, multidisciplinary approach to patient management. Ensure that educational and consultative cancer conferences cover all major sites and related issues. Ensure that an active, supportive care system is in place for patients, families and Colleagues. Promote clinical research. Monitor quality management and improvement through completion of quality management studies that focus on quality, access to care and outcomes. Rita Gingrich, LSCW, OSW-C Social Worker & Psychosocial Services Coordinator Goshen Center for Cancer Care Rhonda Griffin, RN, BSN Quality Improvement Coordinator Goshen Center for Cancer Care Supervise the cancer registry and ensure accurate and timely abstracting, staging and follow-up reporting. Perform quality control of registry data. Encourage data usage and regular reporting. Ensure content of the annual report meets requirements. Publish the annual report. Uphold medical ethical standards. James Wheeler, PhD Min Yan, MD Radiation Oncologist Goshen Center for Cancer Care Pathologist Goshen Hospital WE RE ALL IN THIS TOGETHER. 7

8 2017 FACTS AND FIGURES CANCER REGISTRY REPORT The Cancer Registry Department at Goshen Hospital/Goshen Center for Cancer Care is a hospital-based cancer information center. Under the guidance of the Clinical Quality and Data Manager, our certified tumor registrars collect, interpret, and record a wide range of demographic, diagnostic, and treatment information on all cancer patients while adhering to all regulations and guidelines set by state and national statutes. Since 2004, the Goshen Cancer Program has been accredited by the American College of Surgeons (ACoS) Commission on Cancer (CoC) and designated as a Community Hospital Comprehensive Cancer Center. A detailed abstract for each case of malignant disease seen at our facility, as well as benign brain and related CNS tumors as required, is submitted to the Indiana State Cancer Registry, as well as the National Cancer Database (NCDB). Comparisons are frequently performed to analyze state and national trends and benchmarking statistics. Quality of registry data is paramount. For this reason, quality assurance procedures, periodic audits from the Indiana State Department of Health, and internal quality assurance practices are performed to ensure that Cancer Registry data are complete and accurate. Since our reference year of 1999, there have been over 9,500 patients entered into the cancer registry database. In 2017, a total of 858 cancer cases were added to the database: 775 were analytic cases (diagnosed and/or received first course of treatment at Goshen) and 83 were non-analytic. Approximately 5,000 patients are followed to ensure that continued medical surveillance is being completed. We maintained a follow-up rate of 91.63% on patients diagnosed since our reference year (80% required by the Commission on Cancer) and a follow-up rate of 96.17% for patients diagnosed within the last five years (90% required by the Commission on Cancer). Successful follow-up must be accomplished to determine outcomes of treatment and to provide accurate survival data. 8 WE RE ALL IN THIS TOGETHER.

9 TOP SEVEN SITES STATE AND COUNTY DISTRIBUTION 14% 9% 7% NATIONAL** 26% Breast 255,180 Lung & Bronchus 222,500 Uterine 61,380 Prostate 161,360 Colon & Rectum 135,430 Melanoma 87,110 NH Lymphoma 72,240 16% 22% St. Joseph 2.45% Marshall 2.97% Elkhart 53.16% Kosciusko 16.52% LaGrange 6.32% Noble 4.90% Steuben.90% Allen 1.03% Other Indiana Counties 5.95% Out-of-State 5.80% 6% 14% 8% 16% 7% 7% STATE** Breast 5,140 Lung & Bronchus 5,540 Uterine 1,370 Prostate 3,410 Colon & Rectum 3,080 Melanoma 1,730 NH Lymphoma 1,560 6% 6% 24% 25% GOSHEN HOSPITAL S MOST FREQUENT DIAGNOSES (analytic patients only) NUMBER OF PATIENTS % 10% GOSHEN HOSPITAL* Breast 165 Lung & Bronchus 107 Uterine 52 Prostate 50 Colon & Rectum 45 Melanoma 33 NH Lymphoma 28 35% Breast Lung Prostate Colon/ Rectum Melanoma Non-Hodgkin Lymphoma Pancreas Uterine 11% 22% * Goshen Hospital Registry total patients ** Cancer Facts & Figures 2017, Estimated Numbers of New Cases for Selected Cancers by State, US, 2017 (American Cancer Society, 2017) WE RE ALL IN THIS TOGETHER. 9

10 PRIMARY SITE TABLE Primary Site Total Male Female Analytic Non Analytic 0 I II III IV NA UNK ORAL CAVITY, PHARYNX Lip Tongue Salivary Gland Gum, Other Mouth Tonsil Other Oral Cavity and Pharynx DIGESTIVE SYSTEM Esophagus Stomach Small Intestine Colon, Rectum, Anus Liver Gallbladder Intrahepatic Bile Duct Other Biliary Pancreas Retroperitoneum Peritoneum, Omentum, Mesentery RESPIRATORY SYSTEM Nose Larynx Lung and Bronchus - Non-Small Cell Lung and Bronchus - Small Cell Lung and Bronchus - Other Lung Mediastinum, Other Resp SOFT TISSUE INCLUDING HEART SKIN Skin: Melanoma Other Non-Epithelial BREAST WE RE ALL IN THIS TOGETHER. GENDER CLASS OF CASE AJCC STAGING GENDER Primary Site Total Male Female Analytic CLASS OF CASE Non Analytic AJCC STAGING 0 I II III IV NA UNK FEMALE GENITAL SYSTEM Cervix Uteri Uterus Ovary Vagina Vulva Other Female Genital Organs MALE GENITAL SYSTEM Prostate Testis Penis URINARY SYSTEM Urinary Bladder Kidney Renal Pelvis Ureter BRAIN, OTHER NERVOUS SYSTEM Brain: Malignant Cranial Nerves, Other Nervous System Brain-CNS: Benign, Borderline ENDOCRINE SYSTEM Thyroid Adrenal Gland Endocrine: Benign, Borderline LYMPHOMA Hodgkin Nodal Non-Hodgkin Lymphoma - Nodal Non-Hodgkin Lymphoma - Extranodal MYELOMA LEUKEMIA Acute Lymphocytic Leukemia Chronic Lymphocytic Leukemia Acute Myeloid Leukemia Acute Monocytic Leukemia Chronic Myeloid Leukemia Other Acute Leukemia Aleukemic, subleukemic and NOS MESOTHELIOMA MISCELLANEOUS TOTALS

11 WE RE ALL IN THIS TOGETHER. Ebenezer Kio, MD Medical Oncologist, with patient, Karen

12 12 WE RE ALL IN THIS TOGETHER.

13 Alice A. and Rex Martin Infusion Center Opened September 2018 WE RE ALL IN THIS TOGETHER. 13

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15 UNSURPASSED LEVEL OF CARE FOR PATIENTS IN NEW INFUSION CENTER We expanded patient access to personalized cancer therapies with the opening of the Alice A. and Rex Martin Infusion Center in The new wing enhances privacy, support and care for patients undergoing infusion therapy or injections. It also has increased our capacity by 15% percent. Large, private bays offer plenty of room for friends and family to lend patient support during infusion sessions. Wide pathways give care teams ample room to guide infusion equipment into place for treatment. Individual comfort controls allow patients to control lighting, sound, temperature and entertainment options in their bays. Open seven days a week, the center offers outpatient infusion and injection services, including antibiotics, diuretics, transfusions, hydration and supplements. Patients also can receive routine blood work, PICC line care and other phlebotomy services at the center. Highlights of the Alice A. and Rex Martin Infusion Center Expanded treatment access with 18 infusion chairs Improved privacy for patients, family and caregivers Safe, accessible blood work in on-site phlebotomy room Patient-centered care though enhanced nursing model Enhanced patient support through integrated workspace This support for the infusion center comes from our hearts as personal expressions of gratitude, but also from a deep desire to strengthen the ability of the Goshen Center for Cancer Care to continue to treat others on their cancer journey. Alice A. Martin, Community Philanthropist, Goshen Center for Cancer Care patient WE RE ALL IN THIS TOGETHER. 15

16 A VIEW FROM THE OTHER SIDE OF CANCER Few people see inside as many cancer centers as Jeff Schneider, MD, did before choosing one for his oncology treatment. In the past two decades, the radiation oncologist has walked the hallways of 20 to 30 treatment facilities in more than six states. He travels from center to center as a locum tenens a physician hired temporarily by a medical center. Jeff looked at Goshen Center for Cancer Care with different eyes in March 2018 when he needed treatment himself. While filling in at the center s Radiation Oncology unit, Jeff saw first-hand the collaborative process that s a hallmark of the center s practice model. He participated in weekly tumor boards with other oncologists, nurses, integrative providers and support staff. I understood the nature of the medical conferencing program, said Jeff. I was impressed with how entire team comes together to discuss new patient cases and coordinate treatment plans. The collaborative approach proved a turning point when he sought a diagnosis for himself. WHEN THE DOCTOR BECOMES THE PATIENT Jeff suspected blood he had seen in his stools was a sign of colorectal disease. He had plenty of choices where he could go for diagnosis and treatment. Only Goshen seemed the right fit for him. He knew the oncology team would work together to sequence treatment, based on clinical evidence and outcomes. Cancer treatment can be very complicated, explained Radiation Oncologist Houman Vaghefi, MS, MD, PhD. We bring providers from multiple disciplines together for a cohesive plan of treatment that s best for the patient. Not only does the team discuss the type of cancer and its stage, the group reviews medical data about previous treatments. Providers also consider the patient s overall health and risk factors. And they discuss the patient s mental and emotional health. Family support also plays an important role in the discussion. Cancer care today can take several months to complete. A patient may have surgery, followed by months of chemotherapy. Then the patient may go through weeks of radiation. It takes collaboration not only with the medical team but the patient and family to get through treatment, said Dr. Vaghefi. You can have the most sophisticated care in the world, but if patients don t connect with you or you don t have families on board, that s a missed opportunity to deliver the best care. 16 WE RE ALL IN THIS TOGETHER. HOLISTIC APPROACH CANTERS AROUND THE PATIENT Other cancer centers where Jeff had worked followed a more fragmented delivery of care. Typically, patients traveled from one facility to another for appointments, biopsies, surgeries, infusions, doctor appointments and follow-up care. Jeff appreciated the convenience of going to one location at the Goshen Health campus. As soon as he talked with Dr. Vaghefi about his symptoms, the two brought Surgical Oncologist Leonard Henry, MD, MBA, FACS, into the discussion. They quickly decided Jeff needed a colonoscopy first and scheduled an appointment with Goshen Gastroenterologist Sadat Rashid, MD. I was able to schedule my colonoscopy on a Thursday when I was able to take a day off from covering at the clinic, Jeff said. That made it convenient for me, since I was already in the area filling in at the Cancer Center. Biopsy results on polyps were negative. However, the rectal tumor came back positive for adenocarcinoma, a common type of colorectal cancer in the lining of the organ. That s when Jeff s team expanded to include Medical Oncologist Daniel Bruetman, MD, MMM. TREATMENT TAILORED TO THE PATIENT As the patient, not the doctor, Jeff no longer participated in weekly medical conferences. Yet he was fully involved with decisions about treatment options and sequence of therapies. Part of Jeff s medical history includes a bout with prostate cancer. In 2003, Jeff chose brachytherapy, a form of internal radiation therapy at a cancer center in Seattle. Oncologists implanted radioactive seeds into the prostate gland. The seeds remain in place permanently, releasing a low level of radiation for several months. Given his medical history and clinical evidence, Jeff and his team chose an aggressive approach to treat his rectal cancer. The strategy started with a combination of chemotherapy pills and radiation therapy. It placed surgery at the end of the treatment cycle. If the drugs and radiation worked, Jeff could avoid an abdominal perineal resection (APR) to remove his rectum and place a colostomy.

17 ONE LOCATION FOR DIAGNOSIS, TREATMENT AND FOLLOW-UP Jeff made the daily hour-an-a-half commute from his home in Fort Wayne to Goshen Center for Cancer Care 33 times. He appreciated the support of his entire cancer team. Nurses were always available to answer his questions. A dietitian explained how combinations of foods, vitamins and probiotics could help with side effects. Jeff used naturopathic medicines on his skin to relieve symptoms from radiation. The care and quality of support was at the highest level, he said. Everyone was attentive to the details and shared what was going on with me. Three months after treatment, Jeff had a follow-up MRI and PET CT scan at the Cancer Center that showed no new sites of disease. The diagnostic scans indicated the pelvic lymph node had shrunk and was less intense. Results from an endoscopic ultrasound (EUS) and biopsy a month later showed tumor cells remained in the rectal area. That diagnosis led Jeff s team to stage a limited resection of the tumor in October. The tumor was resected with negative margins. Follow-up evaluations will determine if Jeff s pelvic disease is considered to have completely responded to his organ preserving treatment. I tell people, based on my experience, Goshen Health is the best place in the state for treatment of cancers they specialize in, he said. The care and outcomes are as good or better than anywhere else you could go. The care and outcomes are as good or better than anywhere else you could go. Dr. Schneider, Patient at Goshen Center for Cancer Care A MERGER OF CAREER PATHS Oncology wasn t Jeff s first choice for a career path. The native of Philadelphia had received a bachelor s degree in physics from Saint Joseph s University in his hometown. While working in a cooperative program with General Electric s Missile and Space Division, Jeff pursued a master s degree in systems engineering. He worked as an aerospace consultant in Washington, DC, where he met his wife, Sharon, and started a family. That career path didn t keep his attention for long. With encouragement from Sharon, Jeff followed a different passion medicine and started night school to complete his prerequisites. Eventually, Jeff graduated from the University of Alabama with his Doctor of Medicine. He chose radiation oncology as his specialty and moved his family to New England for a residency at Harvard University. His experience as an oncologist and as a patient with prostate cancer brought Jeff and Sharon to Fort Wayne in He served as Medical Director of the Prostate Cancer Center, which is owned by Northeast Indiana Urology and part of the Dupont Hospital campus. Jeff also served as Director of the center for three years. Today, Jeff considers himself semi-retired. He continues to work about a week a month, on average, as a locum doctor. Locum tenens positions take him primarily to centers in Indiana and Massachusetts. He also maintains his medical license in Alabama, Arkansas, Mississippi and New York. When he s not working, Jeff divides his time between homes in Florida and Fort Wayne. Grandchildren in Birmingham, Ala., Atlanta and New York City also keep him on the move. 17

18 COMMUNITY OUTREACH FOCUSES ON CERVICAL CANCER PREVENTION Each year, we take a close look at our community s needs for cancer prevention programs. The annual assessment reveals ways we can help people take steps to prevent cancer before it starts. We chose an initiative in 2018 to raise awareness about a vaccine for HPV, or human papillomavirus, that prevents cervical cancer. HPV immunization rates in Elkhart County ranked in the bottom 25 percent of state counties, according to a 2017 American Cancer Society assessment. One in five adolescents in the county had received HPV immunization. Statewide, vaccination rates fell below 35 percent in 2017 in an Indiana HPV profile by the Centers for Disease Control and Prevention. RISK FACTORS FOR CERVICAL CANCER Clinical evidence has clearly established a link between HPV and cervical cancer. Studies show the virus causes virtually all cervical squamous cell cancer cases. Two HPV types (16 and 18) are responsible for 70 percent of all cases. Nearly 12,000 women in the U.S. receive a diagnosis of invasive cervical cancers each year. A third die from the disease, even with screening and treatment. Thousands more are diagnosed with cervical pre-cancers. OUTREACH PROGRAM EFFORTS We participated in a local high school athletic event to educate our community about the importance of the HPV vaccine. Connected directly with athletes, parents and fans about the HPV vaccine and cancer prevention Provided take-away materials with facts about the vaccine and its effectiveness in preventing cancer SURVEY RESULTS: 100% aware of HPV 100% aware of HPV vaccine 50% felt well informed 100% learned new information 44% had child vaccinated 44% plan to have child vaccinated 4% do not plan to have child vaccinated 8% did not respond regarding current or future vaccinations Conducted surveys to gauge awareness about HPV, its connection to cancer and who should get vaccinated The HPV vaccine is over 97 percent effective at preventing infection, according to the American Cancer Society. 18 WE RE ALL IN THIS TOGETHER.

19 PREVENTION, DETECTION AND TREATMENT OPTIONS COMMUNITY-BASED PROGRAM SPREADS CANCER PREVENTION EDUCATION A primary care physician or OB/GYN can help determine if HPV testing or the HPV vaccine is right for a woman or adolescent. Treatment options for women with cervical cancer vary, depending on the type and progression of the disease. The gynecology oncology team at Goshen Center for Cancer Care specializes in minimally invasive robotic surgery. Led by Gynecologic Oncologist Hubert Fornalik, MD, FACOG, the team performs 90 percent of major cases robotically, compared to a 65 percent specialty average. Robotic surgeries offer shorter hospital stays and quicker recovery than traditional open surgeries. An interdisciplinary approach that combines surgery with chemotherapy and radiation offers a unique approach to patients with recurrent cancers. The cancer center has also found that natural therapies and supportive services help improve health and wellbeing throughout a cancer journey. When found early, precancerous lesions can be treated before they develop into cancer. Cervical cancer also is highly treatable if detected early. One woman s crusade to raise awareness about HPV inspired our outreach program in Lizzi (Bartosik) Haas knew nothing about HPV in her early 20s. That s when she first tested positive for the virus. She also did not know her strain of HPV put her at high risk for cervical cancer. Two months after the birth of her son, doctors diagnosed the 30-year-old with stage 1b1 invasive cervical cancer. She immediately began an aggressive treatment plan at a cancer center in Oregon. Her regimen included external radiation, chemotherapy and internal brachytherapy radiation. Although treatment was working, Lizzi became immunosuppressed from chemotherapy. Her body could not heal from an infection that took her life in Lizzi used social media to speak up about HPV and cancer prevention. Her heartfelt message lives on in her 2016 video posted online at HPV16and18.com. LIZZI S STORY More than 160 friends and fans attended a girls softball game to honor Lizzi in The game matched Lizzi s high school alma mater, Penn High School, against crosstown rival Concord High School. Goshen Center for Cancer Care took part in the event to educate the community on cancer prevention, early detection and screening guidelines. Awareness about HPV and its link to cervical cancer scored high at a community outreach event for Goshen Center for Cancer Care. It s important to know about HPV and know if you are at risk for this preventable disease. Lizzi (Bartosik) Hass 19

20 A DIFFERENT ANGLE TO GYNECOLOGIC SURGERY High-risk women with cancers in the reproductive system are now candidates for robot-assisted hysterectomies, thanks to a surgical modification introduced at Goshen Center for Cancer Care. Our gynecologic oncology team uses a 25-degree pelvic tilt for selected obese women during surgery to lower the risk for optic nerve damage. It replaces the standard robotic surgery position, called the Trendelenburg position. Hubert Fornalik, MD, FACOG Goshen Center for Cancer Care, Board Certified Gynecologic Oncologist Practice standards recommend surgeons use the Trendelenburg position in robotic surgeries to improve exposure of the pelvic organs. It places the patient up to a 40-degree angle with the pelvis higher than the head. However, patients with obesity-related comorbidities, including diabetes and glaucoma, are particularly susceptible to intraocular pressure (IOP) fluctuations when they are in an inverted position.

21 MODIFIED POSITION LEADS TO UNCOMPLICATED SURGERY BETTER QUALITY STAGING WITH MINIMALLY INVASIVE SURGICAL APPROACH A case demonstration of a robotic hysterectomy and pelvic lymphadenectomy without Trendelenburg position 1 concluded that the surgery can be performed safely in selected candidates. The surgery was led by Hubert Fornalik, MD, FACOG, Gynecologic Oncologist at Goshen Center for Cancer Care, with his wife, Physician Assistant Nicole Fornalik, PA-C. It marks the first reported robotic pelvic surgery performed using an alternative angle to the standard approach. Robotic surgery allows us to do more precise work in the anatomical area than open surgery, said Dr. Fornalik. Surgery may take longer, but we see fewer intraoperative complications. Patients recover faster with a shorter stay in the hospital. Gynecologists widely use robot technology for hysterectomy and malignancy staging. Its advantages include reduced surgical trauma, less post-operative pain, shorter hospital stay and better cosmetic outcome compared to traditional, open surgery. However, obesity poses substantial surgical risk. Obese patients commonly have comorbid conditions, such as high blood pressure or diabetes, that can complicate intraoperative and postoperative care. 2 More than 40 percent of women in the U.S. are considered obese with a BMI 30 kg/m2. Nearly 10 percent are extremely obese with BMI 40 kg/m2. The case report presented a 76-year old female with grade 2 endometrial cancer. She had a body mass index (BMI) of 36 kg/m2. Her medical history included type 2 diabetes and severe open angle glaucoma. Optic nerve damage had resulted in visual field loss. Her ophthalmologist was concerned that surgery with the traditional Trendelenburg position could lead to further damage and worsening of vision. After considering her condition, we decided to proceed with roboticassisted surgery without the use of Trendelenburg position, said Nicole Fornalik. Instead, we used a 25-degree pelvic tilt. 1 Robotic hysterectomy and pelvic lymphadenectomy without Trendelenburg position (BMI 36), Hubert Fornalik, Nicole Fornalik, Goshen Center for Cancer Care, 2 Can Teamwork and High-Volume Experience Overcome Challenges of Lymphadenectomy in Morbidly Obese Patients (Body Mass Index of 40 kg/ m2 or Greater) with Endometrial Cancer? Int J Gynecol Cancer Jun; 28(5): WE RE ALL IN THIS TOGETHER. 21

22 TEAMWORK APPROACH FORMS CORNERSTONE OF TECHNIQUE GYNECOLOGIC ONCOLOGY Robotic-assisted surgery part of interdisciplinary approach The conclusion of the case demonstration identified key factors that affect outcomes. They include an experienced team, use of modifications, two bedside assistants and the pelvic tilt. The case was considered difficult even for our experienced team, said Nicole Fornalik. Dr. Fornalik had performed more than 1,100 robotic surgery cases. Nicole Fornalik had assisted with more than 1,300 robotic cases. The certified surgical first assistant had performed more than 100 robotic cases. Other studies led by Dr. Fornalik have demonstrated favorable outcomes for morbidly obese patients who undergo robotic surgeries 3. Results rely on surgeries at centers with high-volume surgeons and a multidisciplinary approach, according to the authors. A skilled team of professionals can troubleshoot complex and overlapping problems and implement remedial strategies. A broad group of cancers affect a woman s reproductive organs, called gynecologic cancer. Types of cancers include cervical, ovarian, uterine, vaginal and vulvar cancer. No woman is without risk, and a woman s risk increases with age. Nearly 100,000 new cases of these cancers are diagnosed each year. Approximately 30,000 women will die of one of these cancers. Goshen Center for Cancer Care offers a full range of treatment options for gynecologic cancer, including surgery, chemotherapy and radiation. Gynecologic Oncologist Hubert Fornalik, MD, FACOG, leads the gynecologic program at Goshen Center for Cancer Care. He specializes in robotic-assisted surgery for tumor removal and other benign gynecological conditions. Referring high-risk surgeries to centers that specialize in robotic surgeries improves outcomes. We are pleased to bring this practice to our community to provide better care for our patients. Hubert Fornalik, MD, FACOG 22 WE RE ALL IN THIS TOGETHER. 3 Ibid. Int J Gynecol Cancer Jun; 28(5): Hubert Fornalik and Nicole Fornalik with the Da Vinci Si HD Surgical System Dr. Fornalik performs 90 percent of his major cases robotically, compared to an average among specialists of 65 percent. The fellowship-trained gynecologic oncologist has focused his clinical and research interests on the effects of obesity on prognosis and surgical outcomes. As part of his research in new robotic-assisted surgical approaches, he has introduced the first report of robotic handassisted surgery to stage ovarian and high-risk uterine cancers.

23 LOCATIONS & SERVICES GOSHEN CENTER FOR CANCER CARE 200 High Park Drive, Goshen, IN (South of Goshen Hospital s main entrance) GoshenCancerCare.org (888) 492-HOPE Services available at our primary facility: Medical oncology Surgical oncology Radiation oncology Integrative therapies Cancer screenings Support regimens Educational services GOSHEN CENTER FOR CANCER CARE AT WARSAW 2938 Frontage Road, Warsaw, IN (866) Services available at our primary facility: Medical oncology Consultations Chemotherapy infusions (low to moderate risk) Support regimens Educational services GOSHEN RETREAT WOMEN S HEALTH CENTER GOSHEN CANCER PROGRAM ACCREDITATIONS 1135 Professional Drive, Goshen, IN (574) Services available at our primary facility: Diagnostic services Cancer services High risk breast cancer program Naturopathic consultation Educational services WE RE ALL IN THIS TOGETHER. 23

24 CANCER PROGRAM ACHIEVEMENTS High Park Ave. Goshen, Indiana (574) (888) 492-HOPE