2012 Cancer Program Public Report

Transcription

1 2012 Cancer Program Public Report 2012 I CANCER PROGRAM PUBLIC REPORT I 1

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3 Message from the Medical Director Bachar Dergham, MD Best Cancer Care, Close to Home. Our cancer team at Marymount Hospital is dedicated to offering the best in cancer care. The Commission on Cancer of the American College of Surgeons has recognized our cancer program as offering the best in cancer care. We received full accreditation with six commendations from the Commission on Cancer [CoC] following a survey on September 12, It is recognition of the quality of our comprehensive, interdisciplinary patient care. We are very proud to have the very best in cancer treatment close to your home. Bridges to Better Care. Our cancer program integrates with the Cleveland Clinic system and services to provide our patients with state-of-the art care. Our alliances with the American College of Surgeons Commission on Cancer, the American Cancer Society, Cleveland Clinic Taussig Cancer Institute and our community physicians allow us to deliver better and safer care, function with efficiency, build system accountability and incorporate innovation into our practice. The collaboration provides the platform to appropriately apply medical advances to our cancer patients. How the Best Get Better. Every year, I look forward to our cancer site-specific review. Evaluating adherence to evidence based treatment guidelines and comparing our performance against CoC accredited programs is a way of determining quality. This year, we reviewed colon cancer care and outcomes. Colon cancer is the second most common cancer diagnosed at Marymount Hospital. We looked closely at our Stage II colon cancer cases because we want to apply the best treatment available to decrease the risk of recurrence. Our completed review demonstrates concordance with national guidelines. Our 5-year survival outcomes for colon cancer cases are comparable to other community cancer programs. I am privileged to lead our cancer care team. I am proud to share a snap shot of our work and progress made in our cancer program. I hope you will find this information useful. We have great hope for advancements in cancer care and look forward to bringing our community the very best in cancer treatment close to your home. Bachar Dergham, MD Chairperson, Cancer Committee I CANCER PROGRAM PUBLIC REPORT I 3

4 Best Cancer Care, Close to Home: 2012 Commission on Cancer Accreditation Marymount Hospital was awarded a threeyear accreditation by the American College of Surgeons Commission on Cancer (CoC). Accreditation was awarded following a successful program survey conducted by the CoC in September, Marymount Hospital has been an accredited Community Hospital Cancer Program since Marymount s cancer program provided evidence of compliance to standards that represent the full scope of our community cancer program: cancer committee leadership cancer data management clinical services research community outreach quality improvement In recognition of our program s delivery of quality cancer care, Marymount s cancer program earned the highest level designation bestowed by the CoC, Three-Year Accreditation with Commendation. In addition to complying with each of the 36 CoC standards, the program received commendation rating for the following standards: outcomes analysis published in an annual report abstracting timeliness for cancer cases accurate and timely submission of data to the NCDB adherence to Clinical and Anatomic Pathology guidelines delivery of prevention and early detection programs to our community cancer-related quality improvements For the patient and the community, an accredited cancer Community Hospital Cancer Program ensures: comprehensive care, a team approach to coordinate the best available treatment options, information about and access to on-going clinical trials and new treatment options access to prevention and early detection programs, cancer education and support services, a cancer registry services that offers lifelong patient follow-up and on-going monitoring and improvements in cancer care. We are proud of our accreditation because we know we bring to our community quality care, close to home. 4 I CANCER PROGRAM PUBLIC REPORT I 2012

5 New Surgery Center at Marymount Hospital Improves Diagnostic Capability for Breast Cancer Patients Marymount hospital celebrated the opening of the new Surgery Center and entranceway. The three-story, 45,000-square-foot addition features seven operating rooms, which are 50 percent larger to allow for the use of state-of-the-art technologies. For cancer patients, this means new wireless lymph node probes that allow the surgeon to have real time imaging and greater sensitivity in the operating room. The devices improve the sentinel lymph node technique and allow the surgeon to visualize and reach even the most hidden and deep hot nodes in cancer diagnostic procedures. In addition to the new Surgery Center, the Marymount expansion features a new entranceway and surgical waiting area. The new surgery center will make things more convenient, accessible and comfortable for our patients, said Joanne Zeroske, President and CEO of Marymount Hospital. Every detail of the new space was chosen to improve patient care. The new areas feature open spaces with large windows to provide natural light and straight corridors to make it easy for patients to get around. Evidence-based research shows that everything in a care-giving environment affects healing, said Pete Flauto, Director of Perioperative Services. That is why we focused on making everything from our waiting rooms to the recovery areas more inviting for patients. The healing nature of the environment can only benefit our cancer patients and their families I CANCER PROGRAM PUBLIC REPORT I 5

6 Colon Cancer Treatment at Marymount Hospital William O Brien, M.D Byron Coffman, M.D. Study assistants: Tracy Funk, RHIA, CTR Ricci Grosick, RHIT, CTR Rosemary B. Field, MS, RN, AOCNS Overview Colon cancer remains one of the top five cancer sites diagnosed at Marymount Hospital. Of the 411 cancer cases diagnosed at Marymount Hospital, colon cancer [n=62] is the second most common cancer diagnosed, accounting for 15% of cancer cases. The review includes the following elements for colon cancer cases diagnosed at MMH. Demographic changes for 2011 and 2007 Marymount Hospital (MMH) patient population diagnosed with colon cancer. Differences and similarities of treatment used for Stage I, II, III and IV colon cancer patients diagnosed at Marymount Hospital with appropriate NCDB populations. Differences and similarities between Marymount Hospital & NCDB survival data for patients diagnosed with colon cancer. Demographics. For the period between 2007 and 2011, there was a 7% increase in the number of colon cases diagnosed at MMH. Over a five-year period there was one notable difference in the age distribution of patients diagnosed with colon cancer at Marymount Hospital. The age group increased by 53% which reflects the aging population of the our service area. Table 1. Table 1. Demographics: Colon Cancer Cases Diagnosed at Marymount Hospital Colon Cancer Age at Diagnosis Age TOTAL I CANCER PROGRAM PUBLIC REPORT I 2012

7 Stage at Diagnosis For the period between 2007 and 2011, there was an increase in the number of colon cases diagnosed at earlier stages at MMH. Over a five-year period there were more patients diagnosed with early stage cancer despite a 14% increase in the >60 year old age group. During that time period, there was a 22% increase in the number of Stage 0 and I cases diagnosed at Marymount Hospital. Of note is the small number of unknown stage for colon cancer which remains unchanged during the time period. These findings may be a result of improved screening and better staging information. (Figure 1) Figure 1: A Comparison of Stage at Diagnosis: Colon Cancer Comparing Marymount Hospital Cancer Program to NCDB Reporting Hospitals The National Cancer Data Base (NCDB), a joint program of the Commission on Cancer and the American Cancer Society, is a nationwide oncology outcomes database for more than 1,500 CoC-accredited cancer programs in the United States and Puerto Rico, capturing approximately 70 percent of all newly diagnosed cases of cancer annually. Started in 1989, the NCDB contains approximately 25 million case records. Data collected include patient characteristics, tumor staging and histology characteristics, type of first course treatment administered, disease recurrence, and survival information. This data is used to explore trends in cancer care, create regional and state benchmarks for participating hospitals, and to serve as the basis for quality improvement 2012 I CANCER PROGRAM PUBLIC REPORT I 7

8 Stage and Age at Diagnosis The age group, which makes up 17% of NCDB and 15% of MMH cases, has a similar distribution of stage at diagnosis except for stage IV disease. MMH has a greater proportion of patients in this age group diagnosed with stage IV disease. The age group, which makes up 21% of NCDB and 33% of MMH cases, has differences in distribution of stage at diagnosis. MMH has a greater proportion of patients in this age group that have early stage disease when compared to NCDB and a greater proportion of patients in this age group with stage IV disease. Overall, regardless of age group, more patients at MMH have stage IV disease than the NCDB comparison group. (Table 2) Table 2: Differences and Similarities: A Comparison of Marymount Hospital and NCDB Cases by Stage and Age at Diagnosis Cases Stage 0 Stage I Stage II Stage III Stage IV Unknown Stage Age vs. Stage NCDB MMH NCDB MMH NCDB MMH NCDB MMH NCDB MMH NCDB MMH NCDB MMH % 0% 0% 0% 0% 0% 0% 3% 0% 0% 0% 0% % 0% 1% 0% 0% 0% 1% 0% 1% 0% 0% 0% , % 0% 1% 0% 2% 0% 2% 3% 3% 0% 1% 0% , % 10% 6% 7% 6% 8% 8% 0% 10% 5% 5% 0% , % 0% 17% 14% 14% 12% 17% 14% 19% 24% 14% 14% , % 20% 24% 25% 22% 0% 24% 14% 25% 14% 19% 0% , % 60% 27% 21% 27% 35% 25% 29% 22% 33% 24% 14% , % 10% 21% 29% 25% 42% 20% 31% 17% 24% 26% 71% 90+ 2, % 0% 3% 4% 5% 4% 3% 6% 3% 0% 9% 0% Overall Totals 71, % 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% * Marymount Incology Data Services Data *2010 NCDB Data Stage and Treatment at Diagnosis Decision making regarding initial treatment choice is often shared between clinician and patient, taking into consideration adverse effect profiles of treatment, co-morbid disease and other factors. Life expectancy should be the foremost component of the discussion. Table 3 compares the treatment patterns for the colon cancer cases at Marymount Hospital with NCDB data for all stages. Marymount Hospital had the same proportion of patients who underwent surgical resection as the only course of treatment for Stage 0, I and II colon cancer. For Stage I and II colon cancer, Marymount Hospital had a slightly higher proportion of patients who received surgery and chemotherapy. A closer evaluation of findings for the treatment of Stage II colon cancer is completed in the 2012 patient care 8 I CANCER PROGRAM PUBLIC REPORT I 2012

9 evaluation study for colon cancer. For Stage III colon cancer, Marymount Hospital had a lower proportion of patients who received surgery and chemotherapy. For Stage IV colon cancer, Marymount Hospital had a higher proportion of patients who received surgery and chemotherapy and a smaller number of patients who did not receive a first course of treatment for stage IV disease. These findings may be explained by a smaller sample size and by the larger number of Marymount cases in the age group when compared to NCDB data. Table 3. Differences and Similarities Colon Cancer: A Comparison of Marymount Hospital and NCDB Cases by Stage and Treatment at Diagnosis Cases Stage 0 Stage I Stage II Stage III Stage IV Unknown Stage Treatment NCDB MMH NCDB MMH NCDB MMH NCDB MMH NCDB MMH NCDB MMH NCDB MMH Surgery 41, % 90% 92% 96% 80% 81% 37% 51% 20% 14% 43% 57% Surgery & Chemo 18, % 0% 2% 4% 15% 19% 58% 46% 38% 71% 10% 0% Chemo Only 0 2 0% 0% 0% 0% 0% 0% 0% 3% 0% 10% 0% 0% Other Specified Treatment No 1st Course Treatment 5, % 0% 2% 0% 4% 0% 4% 0% 24% 0% 9% 0% 5, % 10% 4% 0% 1% 0% 1% 0% 18% 5% 38% 43% Overall Totals 71, % 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% * Marymount Incology Data Services Data *2010 NCDB Data Outcomes: Five-Year Survival Report The populations used for comparison of observed survival were Marymount Hospital colon cancer cases diagnosed between [107 cases ] and from the 477 NCDB Community Hospital Cancer Programs in all states [161, 883 cases]. At the 5-year survival mark, Marymount colon cases had higher survival rates when compared to NCDB data for all stages of colon cancer. Figure I CANCER PROGRAM PUBLIC REPORT I 9

10 Figure 2. Comparison of Marymount Hospital and NCDB Colon Cases: Survival Rate at 5-Years 10 I CANCER PROGRAM PUBLIC REPORT I 2012

11 Stage II Colon Cancer: An Evaluation of Concordance with National Comprehensive Cancer Network [NCCN] Guidelines William O Brien, M.D Byron Coffman, M.D. Study assistants: Tracy Funk, RHIA, CTR Ricci Grosick, RHIT, CTR Rosemary B. Field, MS, RN, AOCNS Overview Adherence to national treatment guidelines is integral to quality and outcomes evaluation of cancer treatment. A retrospective review of Stage II colon cancer 2011 data from the Marymount Hospital cancer registry was completed to determine whether patients within the program are evaluated and treated according to NCCN guidelines. The study determines that the diagnostic evaluation is adequate, prognostic indicators are reviewed, and the treatment plan is concordant with the referenced guideline. Colon cancer is the second most frequently diagnosed cancer at Marymount Hospital. Stage II colon cancer is frequently curable depending on features of the cancer, resulting in 60-75% of patients cured without evidence of cancer recurrence following treatment with surgery alone. Despite a favorable cure rate for Stage II colon cancer, 25-40% of patients with Stage IIB and IIC are likely to experience recurrence of their cancer. The study site was selected because: (1) for 2011 cancer cases [n=68], Stage II colon was the second most common sub-type of colon cancer, 22%[ 15/68 cases], and (2) delivering effective, evidence based care to Stage IIB and IIC may eliminate and improve outcomes to that sub-type of Stage II colon cancer patient. Method Colon cancer Stage II cases [n=15] abstracted for year 2011 were reviewed. Cases were reviewed for: adequacy of diagnostic work-up, accuracy of AJCC staging, evaluation of prognostic indicators and utilization of evidence based national treatment guidelines. NCCN guidelines (NCCN 2012 v.3) for the treatment of Stage II colon cancer was used to determine concordance with evidence base treatment guidelines. [Attachment A: Physician Colon Cancer Data Collection Tool] 2012 I CANCER PROGRAM PUBLIC REPORT I 11

12 Results Demographics. Median age of patients included in the review was 83 years old [range: 42-94] years old]. There was only 1 patient without co-morbid disease. Patients included in the review generally had more than 2 co-morbid diseases. Greater than 12 lymph nodes were resected in 14/15 cases [average= 18; range: 8-35]. Diagnostic Work-up. Pre-operative evaluation included: colonoscopy [14/15]; CT of the chest, abdomen and pelvis [12/15], CEA determination [11/15] and CBC, platelet and LFT evaluation [15/15]. Complete pre-operative evaluation based on NCCN guidelines occurred 87% of the time. Findings may be due to: clinical presentation at the time of diagnosis [one patient presented in the emergency department with an obstruction, another patient presented with GI bleeding and colon cancer was an incidental finding postoperatively]; the lack of specificity and sensitivity to tumor markers associated with colon cancer and inability to access medical records for review. Primary Treatment. Surgical resection was used as the primary treatment for 100% of cases reviewed. The surgical procedures used included colectomy with enbloc removal of the regional lymph nodes, laparoscopic colectomy, and resection with diversion. 14/15 cases had >12 lymph nodes resected. The AJCC and College of American Pathologist recommend an examination of a minimum of 12 lymph nodes to accurately identify Stage II colon cancers; however the literature lacks consensus as to the minimal number to accurately identify stage II cancer. 1/15 cases classified as Stage II disease had <12 nodes resected. Closer review of the case revealed that only 8 nodes were resected because the patient had a history of Stage IV colon cancer, S/P sigmoid colon resection followed by 4 cycles of capecitabine, hepatic lobectomy with adjuvant capecitabine in 14 months prior to discovery of a new colonic mass requiring resection. Staging. AJCC staging for 18/18 cases were accurate based on a review of the pathology report and AJCC stage assigned. Pathology reports for the cases reviewed reported standard elements for TNM staging, evaluation of lymphovascular or perineural invasion and findings suggestive of MSI. Routine testing for Mismatched Repair [MMR] protein to determine microsatellite instability [MSI] was completed in 2/15 cases with Stage II disease. The patient who was <50 years old was tested for MMR protein. 12 I CANCER PROGRAM PUBLIC REPORT I 2012

13 Risk Assessment for Stage II Disease and Adjuvant Treatment. High risk characteristics that influenced physician recommendation for adjuvant therapy after primary treatment with surgical resection included: number of lymph nodes analyzed after surgery [<12]; poor prognostic features such as poorly differentiated histology, lymphatic/vascular invasion; obstruction and/or perforation, indeterminate or positive margins, assessment of co-morbidities and anticipated life expectancy, and microsatellite instability [MSI]. Four of the 15 patients [27%] received adjuvant treatment for Stage II colon cancer; one patient was offered treatment, but the patient s guardian refused. Two of the 4 patients received adjuvant treatment because they were upstaged to Stage IV after additional staging work-up was completed post-operatively. One of the 4 patients who received adjuvant treatment was less than 50 years old with T4aN0 M0. Analysis The completed review determined concordance with the NCCN guidelines for diagnostic work-up, AJCC staging, and evaluation of prognostic factors to determine next steps for primary and adjuvant treatment. MMR protein testing was completed for the one patient included in the evaluation who was less than 50 years old. Risk and benefits of adjuvant treatment were reviewed for all patients who presented with high risk features. Looking forward Because of the many advances in cancer research (molecular biology, genetics, biologics, etc.), the understanding of the complexity underlying the diseases of cancer has grown exponentially over the past decade. In parallel, advances in diagnostics and treatments for colon cancer have led to better outcomes and higher standards of what outcomes are expected. These new understandings and treatments have raised multiple new questions and issues with regard to the decisions on the appropriate treatment of stage II colon cancer patients. In the years ahead, the Marymount Hospital cancer program will continue to monitor the quality of care provided to colon cancer patients by reviewing new NCCN or ASCO guidelines for implementation and compliance with attention to: 1. Biomarker evaluation which are increasingly recognized and applied for guidance in diagnosis, prognosis and treatment decisions and evaluation I CANCER PROGRAM PUBLIC REPORT I 13

14 Starting in 2013, regional pathology for the Cleveland Clinic Health System will start routine testing of MSI for all resected colon cancer patients. 2. The clinical application of biologics and newer cancer treatments, which are enabling the possibility for new combined treatment modalities in earlier stage disease 3. The methods used to systematically and consistently evaluate performance status, which are important factors influencing treatment decisions 4. Participation in comparative effectiveness evaluation endeavors which is becoming an expectation across all treatments and diseases, and will prove difficult to accomplish within the complexity of cancer diseases. Reference: NCCN Guidelines Version : Colon Cancer, accessed Marymount Hospital Practice Profile Reports (CP3R) For Breast, Colon and Rectal Cancers The Web-based Cancer Program Practice Profile Reports (CP3R) offer Marymount Hospital cancer care providers comparative information to assess adherence to and consideration of standard of care therapies for major cancers. This reporting tool is reviewed at Cancer Committee providing a platform to have discussion that promotes continuous practice improvement to improve quality of patient care. Reports are used to identify problems in practice and delivery and to implement best practices that will diminish disparities in care across CoC-accredited cancer programs. It is important to start treatment in a timely manner after a diagnosis of breast cancer. A thorough review to determine factors contributing to treatment delay was completed for the cases that fell out. Findings revealed appropriate therapy was planned and recommended; however, patient-related issues such as refusal and illness contribute to the findings. Overall, adherence to the six published guidelines for breast, colon and rectal cancer was achieved. Continued evaluation of the CP3R reports will be a standing agenda item for the cancer committee. 14 I CANCER PROGRAM PUBLIC REPORT I 2012

15 Table 1. Cancer Program Practice Profile Reports (CP3R): Marymount Hospital Site Measures Marymount Ohio NCDB Marymount Data 2010 Data 2010 Radiation therapy is administered within 1 year (365 days) of diagnosis for women under age 70 receiving breast conserving surgery for breast cancer. [BCS/RT] 90.9% 94.3% 90.6% 100% Combination chemotherapy 75% 94.0% 91.5% 80% is considered or administered within 4 months (120 days) of diagnosis for women under Breast 70 with AJCC T1c N0 Cancer M0, or Stage II or III ERA and PRA negative breast cancer. [MAC] Tamoxifen or third generation aromatase inhibitor is considered or administered within 1 year (365 days) of diagnosis for women with AJCC T1c N0 M0, or Stage II or III ERA and/or PRA positive breast cancer. [HT] 96.3% 93.5% 87.3% 100% Colon Cancer RECTUM Adjuvant chemotherapy is considered or administered within 4 months (120 days) of diagnosis for patients under the age of 80 with AJCC Stage III (lymph node positive) colon cancer. [ACT] At least 12 regional lymph nodes are removed and pathologically examined for resected colon cancer. [12RLN Radiation therapy is considered or administered within 6 months (180 days) of diagnosis for patients under the age of 80 of with clinical or pathologic AJCC T4N0M0 or Stage III receiving surgical resection for rectal cancer. [AdjRT] 100% 96.6% 92.2% 100% 91.7% 87.8% 86.6% 94.6% 100% 93.1% 92.3% 100% 2012 I CANCER PROGRAM PUBLIC REPORT I 15

16 Eliminating Central Line Associated Bloodstream Infections We know that always using the best-practice central line maintenance care can reduce central line-associated bloodstream infection [CLABSI] rates in hospitalized oncology patients. Studies have shown repeatedly that meticulous daily care of the central line can cut the number of bloodstream infections in critically ill patients. For our cancer patients, using the best-practice central line care means: Meticulous hand-hygiene by staff caring for central lines Thorough antisepsis procedures when accessing the central line or changing dressings Optimal catheter site selection Careful evaluation of the on-going need of the central line In 2012, there was only one reported CLABSI in a patient with a cancer diagnosis. We continue towards zero by building on the following practice improvements put into place: education and training of nursing staff; unit-based project on 4E to improve tubing labeling; timely removal of femoral lines, with close attention to central line insertion; and site selection practices in the ICU. 16 I CANCER PROGRAM PUBLIC REPORT I 2012

17 Community Outreach Cancer care reaches beyond the confines of the hospital. Marymount Hospital reaches out into the community to provide programs and services that help families and friends. Serving our community means improving access to screening services and providing information about cancer prevention and early detection through health fairs and community education programs. Cancer Screening: Key to catching cancer early A frican American Women N urturing and G iving E ach Other L ife Leveraging partnerships can only improve the community s access to breast cancer screening. Marymount Hospital partnered with The ANGEL Network program to improve breast health for uninsured, minority women in the surrounding communities of Marymount and South Pointe Hospitals. The ANGEL Network s program mission is to eradicate breast cancer as a life threatening disease for African American women. The program s goal is to spread the word about good breast health practices through education, dispelling the myths and breaking down any barriers to service. ANGEL, which stands for African American Women Nurturing and Giving Each Other Life, is based at South Pointe Hospital, and works in collaboration with Euclid and Marymount Hospitals, all Cleveland Clinic hospitals. The ANGEL Network receives its grant funding from the Susan G. Komen foundation. In 2012, the ANGEL Network had a display booth at 4 health fairs sponsored by MMH community outreach. The program provided screening services to 6 women. To learn more about the ANGEL Network call Promoting Risk Reduction Behaviors through Health Education: Leveraging Partnerships Three health education events promoting American Cancer Society guidelines for reducing colon, breast, lung and prostate cancer risk were provided. Two programs focused on decreasing risk and promoting early detection of cancer in women [Ladies Night Out program, with 225 participants and Women s Health Talk, with 8 participants]. A third program was offered featuring information 2012 I CANCER PROGRAM PUBLIC REPORT I 17

18 about risk reduction and early detection practices for men and women [Maple Heights Health and Wellness Fair, Sept. 29, 2012, with 110 participants at Zion Lutheran Church, 5780 Dunham Road. Marymount Hospital Program Growth 18 I CANCER PROGRAM PUBLIC REPORT I 2012

19 Cancer Program Leadership B. Dergham, MD Chairperson and Cancer Conference Coordinator L. Rabinowitz, MD Pathology, Co-Chair W. O Brien, MD General Surgery T. Mostriani, MD Radiation Oncology B. Coffman, MD Hematology/Oncology, Cancer Physician Liaison M. Kyei, MD Hematology/Oncology Community Outreach Coordinator A. Thomas, MD Radiology T. Funk, RHIA, CTR Cancer Registry P. Shell, RN Quality Improvement Coordinator R. Field, MS, RN, AOCNS Oncology Clinical Nurse Specialist S. Conard-Scott, RN Nurse Manager R. McBride, RN Clinical Trials Clinical Research Coordinator B. Zinner, RN, MSN Chief Nursing Officer Cancer Program Administrator L. Bernstien, MD Urology D. Waite, MD Cardiothoracic Surgery N. Scuggs American Cancer Society M. Douglas Rehab Services A. Almasy Nutrition Services J. Michael, PharmD Pharmacy L. Zimmerman Community Outreach R. Grosick, RHIT, CTR Tumor Registry B. Gulick Director Pastoral Care A. Blaha, MSW Case Management Psychosocial Services Coordinator 2012 I CANCER PROGRAM PUBLIC REPORT I 19

20 12300 McCracken Road Garfield Heights, OH