Oncology Services 2013 ANNUAL REPORT

Transcription

1 Oncology Services 2013 ANNUAL REPORT

2 Oncology Services 2013 ANNUAL REPORT 4... President s Report 6... Medical Director s Report 6... Cancer Liaison Report 8... Baptist Cancer Committee Cancer Conferences M&S Radiology Baptist Cancer Registry BHS Pathology Services Breast Center overview Oncology nursing at BHS Palliative Care Social Service/Case Management Community Outreach Quality Study: Atypical Ductal Hyperplasia and Papillomas Quality Study: Pathology Review of Papilloma Reports for Core Biopsy Baptist Cancer Registry 2013 Statistical Summary Baptist Cancer Committee 2 ONCOLOGY SERVICES 2013 ANNUAL REPORT

3 President s Report CANCER: IT S PERSONAL GRAHAM REEVE President & Chief Executive Officer Baptist Health System Perhaps more than any other disease or condition we treat in the five hospitals and many clinics of the Baptist Health System, cancer care is personal. Cancers that strike women s ability to bear children are personal. Cancers that steal the breath from a man are personal. Cancers that attack the brain and the bones are personal in the way they sap one s mind and strength. Cancer is personal, and here in the Baptist Health System we take the treatment of cancer personally. Our patients are inspiring. They each have their own story and their own fight. Some are young, some are old. Some have a short and very successful treatment, while others battle for survival for years. I want each patient, as well as their family and circle of friends, to know we value you, and we will do all we can to serve you better. Our affiliated physicians are some of the finest men and women I know. Baptist will continue to support their efforts, as we ve done in the development of the Baptist Breast Centers, the GI Cancer Center, and most recently the South Texas Lung Institute. I am proud that an increasing number of our nurses are becoming certified in oncology nursing. Similarly, our patient navigators are certified, as are our genetic counselors. These caregivers take their professions personally and act on their commitment by deepening their skills. Our entire oncology team pledges to build and improve cancer services at Baptist Health System ANNUAL REPORT ONCOLOGY SERVICES 3

4 Medical Director s Report SUCCESSFUL 2013 ACTIVITIES SUPPORT PATIENTS FACING BREAST, GI AND LUNG CANCERS On behalf of the Baptist Cancer Center, it is a pleasure and privilege to provide this annual update that serves as an overview of the extensive cancer activities that were conducted in These activities were consistent with our mission to provide state-of-the-art services to inpatients and outpatients faced with the diagnosis of cancer. MORTAN KAHLENBERG, M.D., FACS Medical Director, Baptist Cancer Center and Cancer Services 2013 was replete with activities and programmatic growth that exemplify Baptist Health System s commitment to providing comprehensive, compassionate cancer care and to be recognized as our community s premier cancer care destination. We have committed to providing the San Antonio and South Texas community with the finest organ site specific programs in addition to overall excellence in general cancer care. Our National Accreditation Program for Breast Centers (NAPBC) accredited Baptist Breast Center Network continued its growth and maturation. Our physician participation expanded and we opened new Breast Center sites. Nurse navigation services and genetic counseling and testing are now provided at multiple points of access. A high risk breast clinic was established in order to identify patients at increased risk for the development of breast cancer and importantly, introduce these patients to various options for breast cancer prevention. All the requisite components for breast cancer treatment and prevention are provided in 4 ONCOLOGY SERVICES 2013 ANNUAL REPORT

5 the Network and it is transforming the way breast cancer care is provided in South Texas. The Gastrointestinal Cancer Clinic (GICC) was also initiated to provide patients at risk for or those already diagnosed with upper gastrointestinal cancers (esophagus, stomach, pancreas, liver, and bile ducts) the opportunity to obtain state-of-the-art multidisciplinary care, nurse navigation and genetic counseling. These are very complex cancers that require sophisticated technology for both diagnosis and treatment AND physicians who are trained and have extensive experience caring for these patients. This model was developed in 2013 and has seen significant initial success. The formation of the South Texas Lung Institute (STLI) also began in 2013, focused around similar principles of higher level cancer care including a multidisciplinary team of physicians, sophisticated surgical technique, nurse navigation and genetic counseling. We look forward to taking this program to new heights in the years to come was markedly successful and we look forward to 2014 as an opportunity to continue to develop our cancer program and provide our community with the finest in cancer care. Thank you for your continued support ANNUAL REPORT ONCOLOGY SERVICES 5

6 CANCER LIAISON REPORT Cancer Liaison Annual Report for 2013 BY DENNIS ROUSSEAU JR., M.D., Ph.D., FACS Cancer Liaison Physician The year 2013 continued the development and focus of cancer treatment in the Baptist Health System with regard to the organization and delivery of cancer care to our patients. With the success of the breast program, we began to examine the quality and outcomes of care for several of the more complex GI cancers treated in the hospital system. Quality and outcome audits for Gastric Cancer revealed some disparity in the care and outcomes across the system, seen at both an individual provider and individual hospital level. With the lower incidence of this type of cancer, the volume/outcome relationship was significant. With this in mind, the Baptist Health System pushed forward with the development of the Gastrointestinal Cancer Center or GICC. The GICC will focus on the treatment of complex upper GI cancers with a participating membership of highly trained physicians encompassing the disciplines of Surgery, Medical Oncology, Radiation Oncology, Gastroenterology, and Interventional Radiology. The focus of the center is to provide a destination for expert multidisciplinary care in the Baptist Health System for the treatment of patients with complex upper GI malignancy. Nurse navigation and genetic counseling will 6 ONCOLOGY SERVICES 2013 ANNUAL REPORT

7 also be members of the GICC team. A system for quality audits and outcome reporting is in development to provide feedback and continuous quality improvements for the program. The Center will be located at Northeast Baptist Hospital. With the continued development of the GICC in 2014, we will expect to see an improvement in the treatment and outcome of the patients with upper GI cancers entrusted to our care at the Baptist Health System. With the success of the breast program, we began to examine the quality and outcomes of care for several of the more complex GI cancers treated in the hospital system ANNUAL REPORT ONCOLOGY SERVICES 7

8 Baptist Cancer Committee As a result... the High-Risk Clinic was implemented targeting young women with a lifetime risk of 20% or greater of developing breast cancer. The Cancer Committee has the administrative oversight of the Baptist Cancer Program (BCP). The Committee oversees the cancer care delivered within the Baptist Health System and reports to the Baptist Medical Executive Board. The Cancer Committee monitors oncology-related activities in accordance with the American College of Surgeons Commission on Cancer (ACoS/CoC) standards of accreditation. Monitoring includes, but is not limited to: Physician credentialing Cancer Committee membership and attendance Cancer Program goals Cancer Registry data collection and quality program Cancer Conference activity Community Outreach (including screening and prevention programs) Clinical Trials Clinical Education Program College of American Pathologists Cancer Protocols Oncology Nursing Care Risk Assessment and Genetic Counseling Palliative Care Services Patient Navigation Psychosocial Distress Screening Survivorship Program Accountability and Quality Improvement Measures Quality Studies and Quality Improvements 8 ONCOLOGY SERVICES 2013 ANNUAL REPORT

9 With so many activities to be monitored, the Cancer Committee Chair appoints members of the Cancer Committee to coordinate various areas and report to the Committee. These are: Cancer Liaison Physician: Serves as a liaison between the BCP and ACoS/CoC. Monitors the accountability and quality improvement measures. Conducts studies to ensure compliance with evidence-based guidelines. Cancer Conference Coordinator: Monitors the cancer conference activity. Quality Improvement Coordinator: Monitors the quality improvement program. Cancer Registry Quality Coordinator: Monitors the quality of registry data. Community Outreach Coordinator: Monitors the outreach activities. Clinical Research Coordinator: Responsible for tracking patients enrolled in clinical trials from within the program and/or patients referred for enrollment in clinical trials at other facilities or physician offices. Psychosocial Services Coordinator: Works collaboratively with other departments and community organizations to provide, improve and expand the range of psychosocial services. The Cancer Committee meets every other month for a total of six (6) meetings per year. All meetings are video conferenced to each BHS facility for ease of membership attendance. Much of the focus during 2013 was in further delineating and developing the Oncology Service Line. Two primary goals were targeted: Clinical Goal: To develop a high-risk clinic at the Baptist Breast Center Programmatic Goal: To develop the infrastructure for the development of a GI Cancer Clinic at Northeast Baptist Hospital that will offer access to skilled endoscopists performing (EUS) and other advanced endoscopic procedures. As a result of the above efforts, the High-Risk Clinic was implemented targeting young women with a lifetime risk of 20% or greater of developing breast cancer. The program will consist of a team of seven (7) surgeons and four (4) medical oncologists as well as genetic counselors, nursing, and nutrition counseling. Efforts for the GI Cancer Clinic goal resulted in its launch in October Patients have access to the aforementioned services ANNUAL REPORT ONCOLOGY SERVICES 9

10 Cancer Conferences MULTIDISCIPLINARY FORUMS BRING TOGETHER PROVIDERS, SUPPORT STAFF AND ADMINISTATORS TO IMPROVE CARE FOR OUR PATIENTS The Cancer Conference Program of the Baptist Health System (BHS) provides multidisciplinary forums bringing together providers, support staff, and administrators involved in the diagnosis and management of malignancy. Attendance includes (but is not limited to) radiologists, pathologists, surgeons, medical oncologists and radiation oncologists with the aim of providing multidisciplinary collaborative consultation pertaining to management of cancer patients while promoting awareness to clinicians of the state of the art regarding cancer prevention, screening, diagnosis and treatment methodologies (to include surgical management, radiation therapy, and systemic therapy to include chemotherapy, endocrine therapy, and immunotherapy). Each case discussion includes medical history, radiologic and pathologic findings, staging, prognostic indicators, discussion of national treatment guidelines, treatment planning, possible clinical trial availability and psychosocial issues. The Cancer Conferences are accredited to provide CME credit and physician participants receive 1 AMA PRA Category 1 Credit for each conference attended. The Cancer Conferences meet as follows: General Cancer Conferences: each Wednesday at 7 a.m. Breast Cancer Conferences: 1st, 3rd and 5th Fridays at 7 a.m. The meetings are available via video conferencing at each Baptist facility. Participants are welcome to attend via any of the following locations: NBH - Classroom 1 10 ONCOLOGY SERVICES 2013 ANNUAL REPORT

11 NCBH - Garrett Room BMC - Café C SLBH - Boardroom MTBH - Command Center The following is a summary of the 2013 Cancer Conference Program: Conference Criteria General Breast Total Total Conferences Scheduled Total Case Presentation Number Total Cases Presented Prospective Case Presentation Number of Prospective % Prospective Cases (must be >80%) 92% 94% 93% Multidisciplinary Attendance Surgeon present (must be >80%) 94% 100% 96% Hem/Onc present (must be >80%) 77% 100% 85% Radiation Onc present (must be >80%) 79% 100% 86% Pathologist present (must be >80%) 100% 100% 100% Radiologist present (must be >80%) 98% 100% 99% 2013 ANNUAL REPORT ONCOLOGY SERVICES 11

12 M&S Radiology Improving access to quality care in 2013 BY PHILLIP FORTENBERRY, M.D. M&S Radiology Appropriate cancer treatment begins with accurate imaging diagnosis. M&S Radiology is a physician group that provides radiology coverage of the Baptist Health System hospitals. It jointly owns Baptist M&S Imaging Centers with Baptist. M&S helps lay the groundwork for success by providing accurate and timely diagnostic imaging reports and the highest levels of patient care in our Interventional Radiology program. Baptist Breast Network Baptist M&S Imaging Centers improved access to high quality breast cancer screening services by opening two additional full service breast centers in the Westover and downtown areas. These sites offer a full spectrum of breast screening services from screening mammogram to biopsy. Baptist M&S Imaging Centers brought 3D mammography to San Antonio by opening a Breast Tomosynthesis service at the North Central Baptist Breast Center. Tomosynthesis adds value by reducing callbacks for additional imaging and has become an important tool in the breast screening program. M&S also welcomed our two newest fellowship-trained breast imagers, Drs. Joseph Sutcliffe and Nina Patel. 12 ONCOLOGY SERVICES 2013 ANNUAL REPORT

13 GI Cancer Center M&S expanded its Interventional Oncology program by developing expertise using Y-90 intraarterial embolization to treat solid organ tumors with minimally-invasive methods. Y-90 is one of many tools used by the Interventional Radiologists of M&S to improve the lives of Baptist patients. South Texas Lung Institute M&S participated in the planning phase for San Antonio s first lung cancer screening program using Low-Dose CT scans offered through the Baptist M&S Imaging Centers. Low dose CT screening for lung cancer reduces rates of mortality from lung cancer and reduces the overall cost of lung cancer care. Baptist M&S Imaging Centers Baptist M&S Imaging Centers became the only San Antonio facility to offer PET- CT examinations on Saturdays. PET-CT offers incredible clarity in staging cancer and assessing tumor response to therapy. San Antonio patients now have more convenient access to this invaluable technology. Baptist M&S Imaging Centers improved access to imaging results by offering Synapse Mobility. Mobility allows Physicians to easily access their patients images and reports through any web-accessible smart phone, tablet, laptop, or desktop computer. Physicians now have complete access to their patients imaging any time and any place with no software incompatibilities ANNUAL REPORT ONCOLOGY SERVICES 13

14 Baptist Cancer Registry The Cancer Registry is a systemic collection of cancer or tumor data. The data is collected by certified tumor registrars (CTRs); highly trained and skilled professionals in cancer coding and abstracting. With a primary goal of helping to improve cancer treatment, the CTRs complete an abstract on every patient coming through the Baptist Health System with a new diagnosis of a reportable tumor and/or treatment for tumor. The data collected includes detailed information regarding diagnosis and treatment. All data collected follows stringent cancer reporting guidelines and coding standards. Another important function of the Cancer Registry is to provide life-time surveillance to Baptist cancer patients. Surveillance or followup can promote optimal patient care while providing patient outcomes through ongoing monitoring of health status. Follow-up helps to ensure Baptist cancer patients continue with medical surveillance to monitor cancer status, identify additional tumors and address treatment interventions. Outcome or survival data helps our physicians determine the effectiveness of treatment. The Cancer Registry further supports the Baptist Cancer Program by providing administrative support to the Cancer Conference Program, the Cancer Committee and the Breast Program Leadership Committee. During 2013 the Cancer Registry underwent 14 ONCOLOGY SERVICES 2013 ANNUAL REPORT

15 a dramatic change as abstracting was moved to outsourcing. Cancer Registry management and follow-up services will continue to be maintained by Baptist. All data collected follows stringent cancer reporting guidelines and coding standards ANNUAL REPORT ONCOLOGY SERVICES 15

16 BHS Pathology Services PROVIDING CONTINUING LEADERSHIP AND GUIDANCE OF INTERDISCIPLINARY CANCER CARE BY JOSEPH P. PULCINI, M.D. Cancer Conference Coordinator As a Cancer Center accredited by the American College of Surgeons Commission on Cancer, the Baptist Health System provides a true interdisciplinary approach to cancer care. The BHS pathology team is aggressively integrated within this multidisciplinary team, serving in planning and leadership roles in addition to providing diagnostic expertise. In 2013, the BHS pathology services accomplished the following: SERVICE The BHS pathology services evaluated more than 34,000 cases in 2013, encompassing almost 100,000 individual specimens. A significant proportion of these were related to malignant disease, to include more than 1,200 definitive cancer resection specimens. A BHS pathologist serves as the coordinator of the BHS Cancer Conference program, and pathology is represented at 100% of all tumor conferences. QUALITY BHS pathologists provide medical directorship for the BHS laboratories, which maintain prestigious accreditation by the College of American Pathologists (CAP). A BHS pathologist sits on the CAP Board of Governors, and multiple BHS pathologists are certified as CAP inspectors and inspection team leaders. Our pathology service maintains near-perfect compliance with CAP reporting 16 ONCOLOGY SERVICES 2013 ANNUAL REPORT

17 guidelines, and BHS pathologists have been instrumental in terms of maintaining state of the art molecular testing in support of cancer care. To this end, in 2013 the guidelines for reflex molecular testing pertaining to various malignancies were revamped in accordance with latest ASCO/NCCN guidelines. Additionally, coordination of the integration of the genetics team into the care of patients with hereditary colorectal cancer syndromes was spearheaded by pathology. GROWTH A BHS pathologist serves as a part of the GI program leadership team, which in 2013 brought to fruition the establishment of an advanced endoscopy service integrated with a GI Center Center, complete with navigation services coordinating diagnostic and therapeutic care, a dedicated GI cancer conference, and ancillary services. BHS pathologists provide in-room support of advanced endoscopy. Likewise, a BHS pathologist served as a part of the team establishing a Lung Cancer Center of Excellence to include establishment of a dedicated lung cancer conference in early BHS pathologists have been intimately associated with the establishment and growth of the BHS Breast Centers ANNUAL REPORT ONCOLOGY SERVICES 17

18 Breast Center overview PROVIDING PATIENTS WITH BREAST CANCER ANSWERS AND ACTION, FAST A multidisciplinary approach to breast cancer diagnosis and treatment has enabled our five Baptist Breast Centers to give women in South Texas what they desperately seek when given a diagnosis of breast cancer: answers and action, fast. LESLIE BUCHEIT, M.S., CGC Certified Genetic Counselor ANDREA KASSEM, R.N., OCN, CBCN, CBPN-IC Breast Care Nurse Navigator Our patients are at the center of this multidisciplinary approach, and the linchpin is the Nurse Navigator. Once a patient is diagnosed, she (sometimes he!) is immediately contacted by a Nurse Navigator, who mobilizes the entire team. This team of radiologists, surgeons, plastic surgeons, medical and radiation oncologists, pathologists, genetic counselors, navigators and others, work together to develop and provide a personalized plan of care tailored to the individual patient. Traditional treatment was linear and segmented, with weeks between each step. Our vision in creating the Baptist Breast Center was to systematically streamline each step by working more closely together for the good of our patient. As a result, we ve decreased the number of days from diagnosis to first specialist consultation from more than 30 (the national average) to an average of 10 days. Our patient satisfaction rating is consistently at or above the 98th percentile at all five Baptist Breast Center sites. 18 ONCOLOGY SERVICES 2013 ANNUAL REPORT

19 During 2013, our multidisciplinary team achieved the following: GROWTH We expanded from one center to five, located throughout San Antonio for the convenience of our patients. We navigated more than 1,200 patients through their cancer treatment journey. We increased our mammography volume by 2 percent and our biopsies by 46 percent. Our specialist surgeons performed 12 percent more procedures in Baptist facilities. We provided genetic counseling to more than 500 patients to identify and reduce their risk. QUALITY: We maintained our NAPBC accreditation through continual quality monitoring and 2013 ANNUAL REPORT ONCOLOGY SERVICES 19

20 adherence to national guidelines. We ensure that every member of our multidisciplinary team participates in annual continuing education specific to breast cancer care. SERVICE Created the Whole Life Wellness program to support patients and their caregivers undergoing treatment, through treatment completion and into survivorship. Started a pre-operative education class for anyone preparing to undergo breast surgery. Maintained active outreach to the community to increase awareness and provide education. ACHIEVEMENT Vanguard Vision Award. 20 ONCOLOGY SERVICES 2013 ANNUAL REPORT

21 Baptist Emergency Hospital 24 hours 2013 ANNUAL REPORT ONCOLOGY SERVICES 21

22 Oncology nursing at BHS BY SUSAN LAKE AHUMADA, R.N., M.S., OCN Oncology nurses in the Baptist Health System take pride in the care they deliver to their patients. The focus of oncology nursing practice is centered upon providing high quality patient care, support, and resources for patients and families living with cancer. Our highly qualified and compassionate oncology nurses are active members of the cancer program s multidisciplinary healthcare team. In our patient-centered care environment the team includes oncology nurses, physicians, social workers, genetic counselors, case managers, dietitians, physical therapists, nurse navigators and pharmacists all working together to ensure that our patients will receive the well-coordinated, quality care and treatment for their specific needs. Oncology nurses at the Baptist Health System promote an environment that respects dignity and enhances quality of life. Our exceptional oncology nursing staff has received specialized training in the art and science of oncology nursing. They are provided with the most comprehensive, up-to-date training and education to ensure the delivery of competent and compassionate care. Our patients and their families will be provided with comprehensive information on cancer, symptom control, illness prevention and follow-up care. The nursing staff is committed to maintaining 22 ONCOLOGY SERVICES 2013 ANNUAL REPORT

23 the highest standards of patient care through evidence based research and the national standards set by the National Comprehensive Cancer Network, and the Oncology Nursing Society. The Baptist Health System promotes and supports the professional development of our nurses by providing continuing education to achieve and maintain their national Oncology Nursing Certification, Chemotherapy Administration Competency, and the most current guidelines to manage side effects and symptoms associated with cancer and cancer treatment ANNUAL REPORT ONCOLOGY SERVICES 23

24 Palliative care offers patients experienced support BY ROSEMARY CHACKO, M.D., FACP, FABQAURP, FAAHPM Interim Medical Director, BHS Palliative Care Services In January 2013, the pilot palliative care team opened at St Luke s Baptist Hospital followed by palliative care teams at Northeast Baptist Hospital, Baptist Medical Center, Mission Trail and North Central Baptist Hospital. The palliative care teams have full-time dedicated palliative care nurses who act as the fulcrum of the teams which consist of a palliative medicine physician or nurse practitioner, spiritual care coordinator or chaplain, social worker or other interdisciplinary professionals as needed. The palliative care teams see patients with serious illness or cancer anywhere along the trajectory of their illness. The palliative care teams work with the medical team and with the patients providing specialized interdisciplinary care for physical, psychosocial and spiritual distress as well as education and counseling. These interventions assist patients and families with knowledge and understanding for informed decision making within the context of patient centered goals. Also, palliative care teams fill a gap of improving transitions when curative treatments are not possible and hospital treatments become burdensome. 24 ONCOLOGY SERVICES 2013 ANNUAL REPORT

25 Social Services/Case Management help patients during and after hospitalization BY CATHERINE McKEOWN, LMSW, CCM Every patient s needs may differ and we assist each patient individually. The social services/case management departments at the five Baptist Health System hospitals play an important role in the care of our oncology patients both in the hospital and as they are discharged. Social workers and nurse case managers help our oncology patients by offering support, assisting with discharge planning, as well as connecting them to community resources. When people have a new cancer diagnosis or a change in their condition, the situation can be overwhelming. Every patient s needs may differ and we assist each patient individually. Patients may have financial concerns, home assistance needs, legal paperwork needs, placement needs, etc. We are available to connect the patients/families with the appropriate resources based on their needs and concerns. Often patients are connected with the American Cancer Society which offers many programs to assist Oncology patients after discharge from the hospital (i.e Look Good Feel Better, Road to Recovery, etc). The Social Services/Case Management team played an important role in developing a psychosocial distress tool for oncology patients admitted to a Baptist Health System hospital. The tool was created in 2013 and it is being piloted in ANNUAL REPORT ONCOLOGY SERVICES 25

26 Community Outreach Date Type of Program Company/Event Name Team Member Participants CME? 01/16/13 Health and Wellness Fair - Booth Northeast Baptist Hospital Kathy 01/17/13 Community EducationPresentation - Family history & Genetics BHS-CRM Kali Chatham 01/30/13 Community Education Presentation - Family history & Genetics BHS- CRM Leslie Bucheit 02/16/13 Community Event - Booth BHS Cancer Update Conference 03/06/13 Community Education Presentation - wellness Cox Construction Andrea Kassem 03/06/13 Community Education Presentation - wellness Cox Construction Andrea Kassem 03/19/13 Community Education Presentation - genetics, breast health Junior League San Antonio Kali Chatham 04/06/13 Commuity Event - Sponsor and Booth Komen S.A. - Race for the Cure All 04/12/13 CME Presentation/Event - Breast Cancer Surgery in 2013 Bexar County Medical Society All 04/19/13 Community Event - Booth Fiesta Forum education to rural nurses Kali, Laurie 04/23/13 Community Education Presentation - Breast Health Trinity University Kali 04/23/13 Presentation - Breast Health Awareness Breast and Ovarian Health 101 Kali 05/30/13 Community Education Presentation - Family history & Genetics The Capital Group Companies Leslie 05/30/13 Community Education Presentation - Family history & Genetics to The Capital Group Companies Leslie 7/18/13 Presentation: Sleep and Health The Westin Group Andrea Kassem 50 N 7/20/13 Experiential Outreach for High Risk Women Bright Pink San Antonio Kali Chatham 15 N 8/7/13 Community Education Presentation - Wellness Cox Construction Andrea Kassem N 8/7/13 Community Education Presentation - Wellness Cox Construction Andrea Kassem N 8/7/13 Nutrition & Cancer Lymphedema Support Group Andrea Kassem, Kathy F. N 8/8/13 Network CME Event Baptist Breast Center Sharon Wilks/Team 25 CME - 1 hour 09/08/13 Health and Wellness Fair -- Booth Warriors at Heart 5K Run/Walk 09/12/13 Health and Wellness Fair -- Booth Girls Night Out with Tanji Patton 9/12/13 BHS Health Fair Weston Group Andrea, Kathy, Leslie N 9/12/13 Community Education Presentation - Beating Cancer to the Punch Community (NCBH CRM) Andrea Kassem N CRM 9/14/13 Community Event - Booth/Sponsor Alamo City Cancer Council - Annual Update Event Kali, Kathy, Leslie, Bianca N ThinkPink Campaign 09/15/13 Attendee/Sponsor Texas Indo-American Physicians Society 4th Annual Chairty Gala 09/16/13 Community Event - Booth San Antonio Scorpions vs. Carolina RailHawks 9/18/13 Community Education Presentation - Breast Health 101 Northwest Lakeview Comm College Kali Chatham N 9/18/13 Community Education Presentation - 10 tips to Victory PRMA Support Group Andrea Kassem N 09/19/13 Community Event - Booth Stone Oak Business Association Expo and Pep Rally 09/19/13 Community Event - Sponsor ACS Ranch Chic Fashion Show 9/19/13 Attendee/Sponsor - ACS Ranch Chic Fashion Show American Cancer Society Andrea, Kathy, Bianca N ThinkPink Campaign 9/21/13 Attendee/Sponsor - WINGS gala WINGS Kali, Kathy N ThinkPink Campaign 09/23/13 Attendee/Sponsor Fiestas Patrias Celebration 9/26/13 Community Education Presentation - Genetic Counseling Reagan HS Leslie Bucheit 40 N 9/26/13 Communty Wellness Fair (table) Stone Oak Business Assoc Kathy, Bianca N 09/29/13 Attendee/Sponsor WINGS Annual Gala 10/2/13 Holiday Ole (table) Junior League San Antonio Kali, Kathy N 26 ONCOLOGY SERVICES 2013 ANNUAL REPORT

27 Date Type of Program Company/Event Name Team Member Participants CME? ThinkPink Campaign 10/3/13 Holiday Ole (table) Junior League San Antonio Kali Chatham, Bianca Rodriguez N ThinkPink Campaign 10/5/13 CME Event - Breast Cancer NCCN Guideline Symposia BBC/Community (Providers) Leslie Bucheit, Andrea Kassem 40 CME HRs 10/5/13 Scorpions Breast Cancer Awareness Night WINGS Leslie Bucheit, Kali Chatham N ThinkPink Campaign 10/06/13 Health Fair - Booth San Fernando Safety & Health Fair 10/10/13 Girls Night Out WIML, NCBH, BBC Kali Chatham, Bianca, Kathy F. N ThinkPink Campaign 10/10/13 Bras for a Cause? Kristen Shock N ThinkPink Campaign 10/11/13 Community Event - Booth Girls Night Out with NCBH 10/13/13 Community Event - Booth Alamo City Breast Council Cancer Update 10/13/13 Community Event - Booth Madison HS vs. Reagan HS Football Game 10/15/13 BrightenUp! Texas Lutheran University Kali Chatham N 10/19/13 Paint the Parkway Pink WIML, NCBH, BBC Kali, Leslie, Kathy, Bianca N ThinkPink Campaign 10/20/13 Health and Wellness Fair - Booth Paint the Parkway Pink 5K 10/20/13 Attendee/Sponsor Cattle Baron s Gala 10/21/13 Community Presentation - ThinkPink! Know your risk BHS - MTBH Kali, Leslie N 10/22/13 Community Presentation - ThinkPink! Know your risk BHS - NCBH (session 1) Kali, Leslie 10/22/13 Community Presentation - ThinkPink! Know your risk BHS - NCBH (session 2) Kali, Leslie N 10/23/13 Community Presentation - Breast Health Talk Community (SLBH CRM) Dr. McKay, Kathy N ThinkPink Campaign, CRM 10/23/13 Community Presentation - ThinkPink! Know your risk BHS-SLBH Kali, Leslie N 10/24/13 Community Event - Booth Junior League SA Holiday Ole 10/24/13 Community Presentation - ThinkPink! Know your risk BHS - NBH Kali, Leslie N 10/25/13 Community Presentation - ThinkPink! Know your risk BHS - BMC Kali, Leslie N 10/26/13 Attendee/Sponsor -Cattle Baron s Gala American Cancer Society BHS Execs N 10/28/13 Community Presentation - ThinkPink! Know your risk Aveda Beauty Institute Andrea, Kathy N 10/29/13 Health and Wellness Fair - Booth A Touch of Wellness Health Fair 10/30/13 Community Event - Host ThinkPink Celebration Party 10/30/13 Community Presentation - ThinkPink! Know your risk Aveda Beauty Institute Andrea, Kathy N 11/07/13 Presentation - Breast Health Awareness Breast and Ovarian Health 101 to Texas Lutheran University 11/12/13 Family History & Cancer Risk BHS CRM Leslie 15 N 12/11/13 Family History & Cancer Risk BHS CRM Kali 15 N 12/12/13 Presentation - Breast Health Awareness YMCA in Castroville Date Type of Program Company/Event Name Team Member Participants CME? 10/28/13 Screening Event - Massages & Mammograms Community Screening Event - PET All Nt 10/28/13 Screening Event - Massages & Mammograms Community Screening Event - WH All Nt 10/29/13 Screening Event - Massages & Mammograms Community Screening Event - BIC All N 10/29/13 Screening Event - Massages & Mammograms Community Screening Event - MTBH All N 10/30/13 Screening Event - Massages & Mammograms Community Screening Event - NCBH All N 2013 ANNUAL REPORT ONCOLOGY SERVICES 27

28 Atypical Ductal Hyperplasia and Papillomas: A Comparison of Ultrasound Guided Breast Biopsy and Stereotactic Guided Breast Biopsy BY POLLY HANSEN, M.D. Breast Cancer is the most common cancer diagnosed in women in the United States, excluding skin cancer. The American Cancer Society (ACS) has reported that the lifetime probability of a woman developing breast cancer is 1 in 8. The good news is that mortality has decreased by 34% since 1990 [1]. The decline in mortality has been attributed to improvements in treatment and early detection. An important tool in the early identification of breast cancer is minimally invasive needle core breast biopsy. Core needle breast biopsy can be performed under stereotactic or ultrasound guidance. These procedures are highly accurate for the diagnosis of breast carcinoma. Findings can be categorized as malignant, benign, or high risk. High risk lesions include atypical ductal hyperplasia (ADH), lobular carcinoma in situ (LCIS), papillomas, radial scars, and fibroepithelial lesions. High risk lesions either confer increased risk to the patient for development of carcinoma and/or are associated with the presence of carcinoma on subsequent excisional biopsy. There is general consensus that ADH has a sufficiently high risk of adjacent malignancy (approximately 18% risk of DCIS or IDC) that excision is warranted. The data is not as clear for other lesions. Recent literature on papillomas reveals a range of 1% to 18% upgrade to malignancy. In addition, there are conflicting recommendations for managing patients who are found to have papillomas. Some authors recommend imaging follow up and others recommend surgical excision [2]. 28 ONCOLOGY SERVICES 2013 ANNUAL REPORT

29 OBJECTIVE The purpose of the study is to determine our upgrade rates for Atypical Ductal Hyperplasia (ADH) and papillomas identified by core needle biopsy with ultrasound or stereotactic methods. METHODS 1ST STUDY: STEREOTACTIC GUIDED Two-hundred forty-eight (248) stereotactic guided breast biopsies were reviewed. Sixty (24.2%) cancers were detected and one-hundred forty-nine (60%) benign lesions identified. Thirty-nine (15.7%) of the procedures were recommended to undergo repeat/excisional biopsy or surgical consult due to high-risk pathology. Thirty (30) of the cases were described as cellular atypia, including twenty-two (22) cases of ADH. In addition, there were five (5) cases of papilloma. RESULTS Twenty (20) of the twenty-two (22) cases of ADH were excised and four (4) patients (18%) were found to have DCIS. No cases of invasive ductal carcinoma (IDC) were found. Two (2) cases of ADH were not excised. Follow-up showed that one (1) case remained stable at one year all calcifications had been removed. The other case of ADH has no follow up despite phone calls, two letters to the patient and one letter to doctor. All five of the papilloma cases identified at stereotactic biopsy were excised and confirmed as benign, resulting in a 0% upgrade rate. The stereotactic results are likely related to nearly complete sampling of most calcifications and the use of a 7 or 11g needle size typically used for large core vacuum assisted biopsy. The 18% upgrade rate for ADH is in line with published results. The papillomas biopsied under stereotactic guidance all presented as small clusters of calcifications which were completely removed at the time of biopsy. This suggests that these were small intraductal papillomas which were thoroughly sampled. 2nd STUDY: ULTRASOUND GUIDED Four-hundred sixty-nine (469) U.S. guided breast biopsies were reviewed. One ANNUAL REPORT ONCOLOGY SERVICES 29

30 hundred forty-seven (31.3%) cancers were detected. Two-hundred seventy-five (58.6%) benign lesions identified. Forty-seven (10%) of the procedures were recommended to undergo excisional biopsy or surgical consult due to high-risk (46) or discordant (1) results. Four (4) of the 47 were categorized as ADH at biopsy with two (2) subsequently upgraded to DCIS/IDC. The other two ADH cases were benign at excision. The one discordant lesion was excised with benign histology. Additionally, twenty-nine (29) of the forty-seven (47) cases or (62%) were categorized as papillomas. Eighteen (18) were benign at excision, and six (6) cancers were identified. Five (5) of the cases were changed to follow-up by referring physician. These patients have all received reminder phone calls at six months along with reminder letters but had not returned for follow up by the time of this review. In addition, their referring physicians were reminded with a letter. RESULTS The results showed a 50% upgrade rate for the ADH diagnosed with the ultrasound-guided core needle biopsy. ADH does not present as a mass. These core results could be considered discordant with the imaging findings, but since ADH is high-risk and usually excised, these results were not categorized as such by the radiologist. All ADH lesions were appropriately recommended for excision. For the papillomas diagnosed by ultrasound guided core needle biopsy, there was a 21% upgrade rate to malignancy. This is higher than expected. There are several possible explanations for this. Our radiologists predominantly use fourteen (14) gauge core biopsy needles for ultrasound guided procedures. The smaller needle results in an inherent sampling error as the whole lesion is not removed. Papillomas are heterogeneous lesions, so the larger the lesion is with respect to the needle, the more significant this effect will be. Also, the lesions biopsied under ultrasound guidance were significantly larger than the papillomas biopsied under stereotactic guidance. CONCLUSION This study revealed a 21% (6 out of 29) upgrade rate for U.S. guided core needle biopsy for papillomas. As a comparison, stereotactic core needle biopsy for 30 ONCOLOGY SERVICES 2013 ANNUAL REPORT

31 papillomas produced a 0% (0 out of 5) upgrade rate. This information is important for the breast imager to keep in mind when performing the radiologic pathologic correlation following the biopsy. The radiologist needs to adequately convey to the referring physician the probability that the lesion will be upgraded to a malignancy. For ultrasound detected lesions which are larger and have suspicious ultrasound characteristics, greater emphasis should be placed on the recommendation for subsequent excision. Close communication with the pathologist is also necessary. The unexpectedly high upgrade of ADH to malignancy on ultrasound was an important finding. As previously noted, ADH should probably be handled as a discordant biopsy result by the radiologist, unless there is some other pathologic lesion to explain the ultrasound finding, in which case ADH would be an incidental high risk lesion. In either case, the lesion should be excised, due to the high rate of associated/adjacent malignancy. Limitations of the study include sample size, retrospective review and limi ted details about this patient group. RECOMMENDATIONS Surgeons should be made aware of the study and the results. The radiologists and pathologists should be encouraged to communicate with each other regarding the level of concern for papilloma upgrades based on imaging and histologic findings, and include the management recommendations in both reports. Jill Uecker, M.D., Pathologist at the BBC will analyze the papilloma data and pathologists reports for a companion study. Careful radiologic-pathologic correlation, physician education and improved communication are key elements which should be stressed throughout the Baptist Breast Network. References 1. American Cancer Society. Breast Cancer Facts & Figures Atlanta: Americ an Cancer Society, Inc. 2. Yu-Mee Sohn, MD, PhD & So Hyun Park, MD. Comparison of Sonographically Guided Core Needle Biopsy and Excision in Breast Papilloma. J Ultrasound Med 2013; 32: ANNUAL REPORT ONCOLOGY SERVICES 31

32 Pathology Review of Papilloma Reports for Core Biopsy BY JILL UECKER, M.D. AND JOSEPH PUCINI, M.D. A retrospective study of biopsies performed at the Baptist Breast Center (BBC) was conducted during 2012 to compare the upgrade rates for ultrasound-guided versus stereotactic-guided biopsies with high risk pathology on core biopsy. The 21% upgrade rate to malignancy for papillomas diagnosed by ultrasound guided core needle biopsy was higher than reported in the literature. This was attributed to heterogeneity of the papillomas and increased size of the lesions biopsied by ultrasound compared to the smaller lesions biopsied under stereotactic guidance. Appropriate follow up of patients with papillomas depends on careful radiologic/pathologic correlation. Jill Uecker, M.D., Pathologist at the BBC reviewed the pathology reports and slides for papillomas/ papillary lesions identified in the 2012 study to assess appropriateness of recommendations. OBJECTIVE The purpose of this study is to determine the appropriateness of the pathology reports and management recommendations in pathology reports for papillomas/papillary lesions. STUDY AND RESULTS Thirty-six (36) patients had a surgical excision following a radiology biopsy diagnosis of papilloma or papillary lesion. This study revealed that eight (8) of these cases were upgraded to DCIS and/or invasive carcinoma (22%) which corresponds with the earlier study performed. Of that, seven (7) were diagnosed 32 ONCOLOGY SERVICES 2013 ANNUAL REPORT

33 as papillary lesion on the initial biopsy with a comment in the pathology report recommending excision. The eighth case had two biopsies of same breast, one with papilloma and second with invasive cancer. None of the lesions upgraded were called benign papillomas by pathologist on initial biopsy. In addition, each of these cases had a specific recommendation for subsequent excision from the pathologist or a standard comment regarding papillary lesions. The standard comment used by the pathologists is shown below: The histologic findings are those of an intraductal papilloma. Intraductal papillary processes may be heterogeneous (may contain areas of atypia or in situ carcinoma). Excisional biopsy is recommended to ensure complete removal and to confirm a benign diagnosis. Six (6) of the thirty-six (36) that received subsequent excision were called papilloma by the pathologist on the radiology core biopsy and did not have the standard comment or a recommendation for excision. Only two (2) of the six (6) lesions had the papilloma completely excised by the radiologist at the time of core biopsy. All six cases had benign findings on subsequent excision. Review of the biopsy slides confirmed the incomplete excision of the papilloma in four of the six cases. The pathology log also identified five (5) cases where the radiology specimen was diagnosed as papilloma by the pathologist and there was no subsequent excision. Slides from these five cases were also reviewed. Of the five (5), only one (1) was completed excised by the radiologist. The remaining four (4) were called papilloma and one of these was described as having ductal epithelial atypia by the pathologist in the microscopic description. In these four cases the entire lesion was not examined and no standard disclaimer was included on the reports. Dr. Polly Hansen, Radiology, performed additional follow-up on these five (5) cases. One (1) case had later excision which revealed an intraductal papilloma with ADH. The finding of ADH is considered benign when found on excisional biopsy, so this lesion is not considered an upgrade; but the patient is now considered to be at higher risk for developing cancer in the future. Two (2) papillomas are stable at one year and are being followed. The papilloma from the fourth patient had focal ductal epithelial atypia but was stable at 6 months. However, this patient developed an interval cancer (invasive lobular cancer) in another part of the same 2013 ANNUAL REPORT ONCOLOGY SERVICES 33

34 breast. The fifth case was completely excised at core biopsy and has not returned for follow up mammography as yet. The remaining fifteen (15) cases contained the recommended comment for papillomas/papillary lesions in the pathology report and were benign on excision. CONCLUSION All of the papillary lesions found on core biopsy that were upgraded to carcinoma at excision were correctly recommended for excision by the pathologist. There were five (5) cases called papilloma that did not have a recommendation for excision by the pathologist. None of these went to excision initially, but one underwent excision at a later time and was found to have ADH and a second patient was subsequently found to have invasive lobular carcinoma in a different area of the same breast. Review of the radiologic and pathologic data from 2012 demonstrates that approximately one (1) in five (5) patients has an upgraded lesion on excision. This demonstrates the importance of the pathologist s recommendations in guiding patient management. 34 ONCOLOGY SERVICES 2013 ANNUAL REPORT

35 Baptist Cancer Registry 2013 STATISTICAL SUMMARY The American Cancer Society (ACS) estimates that in 2012 there were 1,638,910 cancer cases diagnosed in the United States; 110,470 of those here in Texas. These estimates do not include carcinoma in-situ (non-invasive cancer) of any site except urinary bladder and does not include basal and squamous cell skin cancers which are not required to be reported by the Cancer Registry. As with other states, cancer is a reportable disease in the state of Texas. Cancer reporting to the Texas Cancer Registry (TCR) is mandated by the Texas Cancer Incidence Reporting Act, Chapter 82, Texas Health and Safety Code. The TCR is a division of the Department of State Health Services and maintains a cancer incidence data base. The Baptist Cancer Program (BCP) is accredited by the American College of Surgeons Commission on Cancer (ACoS/CoC). A requirement of ACoS/CoC accreditation is submission of cancer data to the National Cancer Data Base (NCDB). The NCDB is a joint program of ACoS/CoC and the American Cancer Society (ACS) with more than 1,500 CoC-accredited cancer programs in the United States and Puerto Rico. NCDB maintains a cancer outcomes database. In addition to survival data, NCDB tracks and maintains National Quality Forum (NQF) quality measures by which the BCP can compare and 2013 ANNUAL REPORT ONCOLOGY SERVICES 35

36 evaluate the cancer care delivered to its patients. The following is a brief snapshot of the statistical cancer experience of the Baptist Health System (BHS) as seen through the data collection of the Cancer Registry. The following facilities are represented: Baptist Medical Center (BMC) Mission Trail Baptist Hospital (MTBH) North Central Baptist Hospital (NCBH) Northeast Baptist Hospital (NBH) St. Luke s Baptist Hospital (SLBH) Baptist Breast Centers Data analysis and comparison is based on Analytic cases: First diagnosed and treated at BHS First diagnosed at BHS, but treated elsewhere First diagnosed elsewhere, but treated at BHS On the next page is a depiction of the cancer caseload for BHS between the years of 2006 and A steady increase was seen from 2006 to 2009, but then a slight decline followed by an upward move. Throughout the years we have seen cancer care shift from the hospital setting to the physician office. With advances in healthcare, cancers such as prostate cancer and melanoma have seen a shift to physician offices. Chemotherapy long ago moved to physician cancer clinics and private offices. However, with Medicare payments for chemotherapy administered in the outpatient hospital setting increasing but substantially decreasing for physician community cancer clinics, a paradigm shift is once again occurring. As the BHS further develops its cancer program, we see greater engagement with physicians and an increase in patient volumes. Note: Non-Analytic: cases are required to be reported to the Texas Cancer Registry Analytic: cases are required to be reported to the Texas Cancer Registry and the National Cancer Data Base 36 ONCOLOGY SERVICES 2013 ANNUAL REPORT

37 Baptist Caseload Number of Cases Non-Analytic Analytic Non-Analytic: cases are required to be reported to the Texas Cancer Registry. Analytic: cases are required to be reported to the Texas Cancer Registry and the National Cancer Data Base 2013 ANNUAL REPORT ONCOLOGY SERVICES 37

38 Case year 2012 PRIMARY SITE TABLE (ANALYTICS) The distribution by primary site of cancer is depicted below. We see that for 2012 the major cancer sites are: colon and rectum, lung, breast, corpus uteri and prostate. Females make up 57% of the population while males constitute 43%. PRIMARY SITE TOTAL SEX CS STAGE GROUP M F 0 I II III IV UNK N/A ALL SITES ORAL CAVITY LIP TONGUE OROPHARYNX HYPOPHARYNX OTHER DIGESTIVE SYSTEM ESOPHAGUS STOMACH COLON RECTUM ANUS/ANAL CANAL LIVER PANCREAS OTHER RESPIRATORY SYSTEM NASAL/SINUS LARYNX LUNG/BRONCHUS OTHER BLOOD & BONE MARROW LEUKEMIA MULTIPLE MYELOMA OTHER BONE CONNECT/SOFT TISSUE SKIN MELANOMA OTHER BREAST ONCOLOGY SERVICES 2013 ANNUAL REPORT

39 PRIMARY SITE TOTAL SEX CS STAGE GROUP M F 0 I II III IV UNK N/A FEMALE GENITAL CERVIX UTERI CORPUS UTERI OVARY VULVA OTHER MALE GENITAL PROSTATE TESTIS OTHER URINARY SYSTEM BLADDER KIDNEY/RENAL OTHER BRAIN & CNS BRAIN (BENIGN) BRAIN (MALIGNANT) OTHER ENDOCRINE THYROID OTHER LYMPHATIC SYSTEM HODGKIN S DISEASE NON-HODGKIN S UNKNOWN PRIMARY OTHER/ILL-DEFINED Number of cases excluded: 3 This report EXCLUDES CA in-situ cervix cases, squamous and basal cell skin cases, and intraepithelial neoplasia cases 2013 ANNUAL REPORT ONCOLOGY SERVICES 39

40 In comparison of BHS data to estimated cases for both the United States and Texas, we see a higher percentage of female breast cancer at BHS. This finding is attributed to the excellent work of the Baptist Breast Center. The lower percentages of cases seen at BHS for melanoma of the skin, prostate cancer and urinary bladder are attributed to the shift to private physician offices. Of interest, however, is the higher percentage of corpus uteri seen in the BHS. Comparison of Select Cancer Sites UNITED STATES VS. TEXAS VS. BAPTIST U.S. Texas Baptist Female Breast 14% 14% 16% Uterine Cervix 1% 1% 1% Colon & Rectum 9% 9% 10% Corpus Uteri 3% 2% 6% Leukemia 3% 3% 2% Lung 14% 13% 12% Melanoma of Skin 5% 4% 1% Non-Hodgkins Lymphoma 4% 4% 4% Prostate 15% 14% 12% Urinary Bladder 4% 4% 3% 40 ONCOLOGY SERVICES 2013 ANNUAL REPORT

41 A look at the BHS caseload in comparison to ACS estimates by gender we see that prostate cancer is the top site for males while breast cancer remains the top cancer site for females. Lung cancer is the seconding leading cancer site for both males and females Top Cancer Sites by Gender MALE SITE ACS BAPTIST Prostate 29% 26% Lung 14% 13% Colon & Rectum 9% 12% Urinary Bladder 7% 5% Melanoma of Skin 5% 1% Kidney & Renal Pelvis 5% 7% Non-Hodgkin s Lymphoma 4% 4% Oral Cavity & Pharynx 3% 2% Leukemia 3% 3% Pancreas 3% 2% FEMALE SITE ACS BAPTIST Breast 29% 29% Lung 14% 11% Colon & Rectum 9% 8% Corpus Uteri 6% 11% Thyroid 5% 4% Melanoma of Skin 4% 1% Non-Hodgkin Lymphoma 4% 3% Kidney & Renal Pelvis 3% 4% Ovary 3% 4% Pancreas 3% 2% 2013 ANNUAL REPORT ONCOLOGY SERVICES 41