John R. Marsh Cancer Center

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1 John R. Marsh Cancer Center Lung Program Overview: Initiatives Lung CT Screening Dr. Gregory Zimmerman In cooperation with The Lung Cancer Steering Committee, Diagnostic Imaging Services at the Robinwood Medical Campus has instituted a Low Dose CT (LDCT) lung cancer screening program and has received recognition by the American College of Radiology as an ACR designated lung cancer screening center. To participate in the program, patients must be between 55 and 77 years of age, currently smoking or quit within 15 years, 30+ pack year smoking history and no lung cancer diagnosis. Those who meet these criteria may be scheduled for low dose chest CT screening which is a non-contrast chest CT with scanning parameters optimized for detection of pulmonary nodules while significantly reducing the patients radiation exposure. The low dose chest CT examinations are supervised and interpreted on site by board certified Radiologists utilizing LungRads Criteria established by the American College of Radiology. A dedicated nurse navigator is available to organize follow up of detected pulmonary nodules and facilitate further diagnosis and treatment of positive patients in coordination with the referring physician. Lung Navigation Desirae Rosensteel, B.S.N., RN As the nurse navigator for the lung navigation program, my job is ensure that patients with abnormal imaging of their lungs continue to get the follow up care that they need and do not get lost within the system. I can begin to work with a patient after they have abnormal imaging completed in the emergency room or after a referral from their physician. If the nodule that is found measures less than 4mm, I follow along with the patient and his or her primary care physician providing them both with reminders when their next radiographic study needs to be completed according to the Fleischner Criteria. However, if the nodule is larger than 4mm it is suggested that the patient be seen by a pulmonologist. Throughout each step of the process I contact the patient, as well as the primary care physician to make them aware of the need for further follow up. I continue to work with the patient throughout this process to assist them with any barrier of care. Generally, a nodule is monitored for two years. If there are no changes within that time frame no further monitoring is needed. However, if there are changes that lead to a cancer diagnosis. I continue to work with the patient, meeting them first at biopsy and then frequently at their oncology office visits and treatment appointments. I continue to be an advocate and support system for each patient throughout their entire journey. At the end of this journey, they will be given a survivorship care plan. This care plan presents all of the information regarding their diagnosis, treatment, contact numbers, and the outline for follow up care in one document. Navigational Bronchoscopy Dr. John Alencherry In the past, to effectively diagnose most lung lesions, doctors had to rely on traditional bronchoscopy which is only effective in the top portion of the lungs or a needle biopsy, which may result in a collapsed lung. Some patients even had to undergo traditional open surgery, which requires a large incision, broken ribs and a long recovery time just to find out if the lesion was cancerous or not. But now, as part of the Meritus Health comprehensive lung health program, patients have the option of a minimally invasive procedure which can aid in earlier diagnosis of lung lesions, so those with cancer can get treated as soon as possible and patients with benign conditions can potentially avoid surgery. These Electromagnetic Navigation Bronchoscopy procedures, also known as ENB procedures, which are performed with a device known as the superdimension navigation system with LungGPS technology, allow the physician to navigate and access difficult-to-reach areas of the lung from the inside. The superdimension navigation system, with GPS-like technology, is a significant advance for aiding in the diagnosis of lung cancer and overcomes limitations of traditional diagnostic approaches including bronchoscopy, needle biopsy and surgery, said Dr Jonny Alencherry, MD, Pulmonologist. By guiding us through the complicated web of pathways inside the lungs, we re able to access and sample target tissue throughout the entire lung without surgical needle biopsy. With this technology, we re able to get anywhere in the lung to acquire a biopsy or tissue sample, stage the lymph nodes and prepare for future treatment all in one procedure. With the superdimension system, the CT scan images are used to create a roadmap of the thousands of tiny pathways inside the lungs. The LungGPS technology then provides a

2 roadmap that allows physicians to guide tiny tools through the lung pathways so they can take tissue samples of the lesion and place markers. This technology prevents patients from undergoing multiple procedures. Medical Oncology Advances Dr. Alan Wan Immune Based treatments in Medical Oncology has been under study and development for quite some time. Most recently with the FDA approval of multiple medications including Yervoy, Opdivo, Keytruda, the reality has been realized. These are exciting new medications with a very new way of approaching cancer treatment. In the approved settings of non-small cell lung cancer in the advanced metastatic setting. PD-inhibitors have produced excellent and durable remissive responses to therapy. These medications work up by activating the T Cell within one s own body to increase the immune system to fight cancer. These medications are tolerated very well when given appropriately. As newer data emerges, the wave of future lies within harnessing the power of the immune system to help attack cancer. These medications are now available here at John Marsh Cancer Center. SITE BY AJCC STAGE TABULATION FOR LUNG CASES 2014 Bronchus & Lung Total Number of Cases: % 22% 20% 11% 1% Stage 0 Stage I Stage II Stage III Stage IV Stage UNK %

3 SITE BY AJCC STAGE TABULATION FOR 2014-ANALYTIC-CASELOAD SITE NAME NUMBER STG STG STG STG STG STG N/A CASES 0 I II III IV UNKOWN Oral Cavity Base Of Tongue Floor Of Mouth Palate Other/Unspecified Parts Of Mouth Parotid Gland Tonsil Oropharynx Nasopharynx Digestive System Esophagus Stomach Small Intestine Colon Rectosigmoid Junction Rectum Liver & Bile Ducts Other Biliary Tract Pancreas Respiratory System Nasal Cavity & Middle Ear Larynx Bronchus & Lung Heart Mediastinum Pleura Blood & Bone Marrow Skin Retroperitoneum & Peritoneum Connective Subcutaneous Other Soft Tissue Breast

4 SITE BY AJCC STAGE TABULATION FOR 2014-ANALYTIC-CASELOAD (continued) SITE NAME NUMBER STG STG STG STG STG STG N/A CASES 0 I II III IV UNKOWN Female Genital Vulva Vagina Cervix Uteri Corpus Uteri Ovary Oth Fm. Genital Orgn Male Genital Prostate Gland Testis Urinary System Kidney Kidney, Renal Pelvis Ureter Urinary Bladder Brain Orbit, Nos And Overlapping Lesion Brain Other Nervous System Endocrine Thyroid Gland Lymphatic System Lymph Nodes Unknown Primary Overall Totals Number of cases excluded: 17 This report EXCLUDES CA in-situ cervix cases, squamous and basal cell skin cases, and intraepithelial neoplasia cases.

5 Top 10 Sites at Meritus Medical Center 2014 SITE NAME NBR-CASES MMC % MALE % FEMALE % Breast Bronchus & Lung Prostate Gland Colon Corpus Uteri Blood & Bone Marrow Lymph Nodes Skin Unk Primary Thyroid Gland Urinary Bladder Top 10 Sites at Meritus Medical Center - National Comparison 2014 SITE NAME Washington County % of Cases (and surrounding region) National % of Cases Breast Bronchus & Lung Prostate Gland 9 26 Colon 6 8 Corpus Uteri 5 7 Blood & Bone Marrow 5 4 Lymph Nodes 4 5 Skin 4 6 Unk Primary 2 Thyroid Gland 2 6 Urinary Bladder 2 7

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