Cancer Program. Annual Report 2017 (Data from 2016) ST. VINCENT S MEDICAL CENTER RIVERSIDE CANCER COMMITTEE

Transcription

1 MEDICAL CENTER RIVERSIDE CANCER COMMITTEE Cancer Program Annual Report 2017 (Data from 2016) INCLUDES ONLY INCIDENCE DATA FOR SOUTHSIDE AND CLAY COUNTY

2 Table Of Contents Acknowledgements ACKNOWLEDGEMENTS 1 MISSION AND CORE VALUES 2 We would like to acknowledge with much appreciation the crucial role of St. Vincent s Riverside Cancer Program Team and the Oncology Support Services (Cancer Registry) department who made this report possible. In particular, we acknowledge the support and contribution from of the following: CANCER COMMITTEE CHAIR S MESSAGE 3 ACCREDITATIONS 4 ACCOMPLISHMENTS 5 Overall report compiled by: Data Analyses, Statistical Summary, Tables and Figures by: Barbara Dearmon, BS, CTR Barbara Dearmon, BS, CTR MAYO CLINIC CANCER CENTER RIVERSIDE 6-7 RIVERSIDE CANCER COMMITTEE 8 Cancer Committee Membership Annual Study of Quality by: Cancer Committee Chair Message by: Susmitha Vaka, MD Paul Ossi, MD CANCER PANEL/ CANCER CONFERENCES 10 St. Vincent s Riverside Summary of Cancer Panel (Jan-Dec 2016) 10 RIVERSIDE ACCOMPLISHMENTS FOR CANCER SERVICES CANCER REGISTRY MANAGER S REPORT 13 CANCER DATA STATISTICS FOR RIVERSIDE TOTAL CANCER DIAGNOSES - RIVERSIDE CANCER INCIDENCES AND ANALYSES FOR RIVERSIDE 17 COMMUNITY OUTREACH ACTIVITIES COMPLETED IN CANCER CASES DIAGNOSED IN ACCOUNTABILITY AND QUALITY IMPROVEMENT MEASURES HEALTHCARE PREVENTION PROGRAM ANNUAL STUDY MONITORING EVIDENCE-BASED GUIDELINES ON AML REFERENCES AND DEFINITION OF TERMS 26 HEALTHCARE LOCATIONS AND CONTACT INFORMATION 28 St. Vincent's Riverside has been home to a comprehensive cancer program since For decades the program has provided compassionate, holistic care by treating the physical, emotional, social and spiritual needs of patients. In 2016, St. Vincent s expanded its oncology services by partnering with the Mayo Clinic. In October, we opened a Mayo Clinic Cancer Center on our Riverside campus. Mayo Clinic physicians work alongside St. Vincent s nurses and medical staff to deliver world class care in a beautiful setting along the St. Johns River. In addition, patients at this new clinic have access to some of the most advanced and innovative cancer research through Mayo clinical trials. Together, St. Vincent s and Mayo focus on providing patients personalized healthcare. Nurse navigators guide patients through their appointments and the cancer journey. All treatment planning is centered on evidence-based guidelines. Additional services include genetic assessment and counseling as well as palliative and survivorship care and patient tracking through the Cancer Registry. St. Vincent s Medical Center Riverside Cancer Committee Cancer Program Annual Report

3 Mission and Core Values Cancer Committee Chair s Message ABOUT HEALTHCARE HISTORY St. Vincent s HealthCare is a faith-based, not-forprofit health system that has served the people of Jacksonville and the surrounding communities since Today, St. Vincent s is a member of Ascension, the nation s largest non-profit health system. In 1633, the Daughters of Charity were founded in Paris, France, by St. Vincent de Paul and St. Louise de Marillac. Deeply concerned with the poverty and suffering surrounding them, they brought together a group of young women who shared their dedication to helping the poor and the sick. In the 19th century, inspired by the work of these original Daughters, St. Elizabeth Ann Seton founded a community of Sisters in the United States that later joined with the Daughters of Charity in France. From the beginning, people recognized the good works of the sisters in America. Many requested their services to the poor and needy. To answer these requests for help, the sisters moved throughout the U.S. serving those in need. On May 1, 1916, three Daughters of Charity arrived in Jacksonville in response to a request by a group of local physicians and community leaders to operate the DeSoto Sanatorium, located in Springfield. At the time, the 42-bed sanatorium was understaffed and debt-ridden. The Sisters began their ministry in Jacksonville, operating under the philosophy of Christ centered care based upon the teachings of the Gospel and a mission of service to the poor. Two months later, the Sisters renamed their facility St. Vincent s Hospital. St. Luke s Hospital, now St. Vincent s Medical Center Southside, was started by three women who saw the need for medical care in the community. Founded in 1873, it stands as Florida s oldest private hospital. OUR MISSION Rooted in the loving ministry of Jesus as healer, we commit ourselves to serving all persons with special attention to those who are poor and vulnerable. Our Catholic health ministry is dedicated to spiritually centered, holistic care which sustains and improves the health of individuals and communities. We are advocates for a compassionate and just society through our actions and our words. VISION We envision a strong, vibrant Catholic health ministry in the United States that leads healthcare s transformation. We will ensure service that is committed to health and well-being for our communities while meeting the needs of individuals throughout their lives. We will expand the role of laity, in both leadership and sponsorship, to ensure a Catholic health ministry in the future OUR CORE VALUES We are called to: Service of the Poor: Generosity of spirit, especially for persons most in need Reverence: Respect and compassion for the dignity and diversity of life Integrity: Inspiring trust through personal leadership Wisdom: Integrating excellence and stewardship Creativity: Courageous innovation Dedication: Affirming the hope and joy of our ministry DEAR FRIENDS, I am honored to address St. Vincent s administration, physicians, supporting staff, and patients to highlight many of the successful programs and achievements that our cancer program has made as we continue to improve on patients experience at all three of the hospital s campuses. Being a comprehensive cancer program for more than 60 years, in addition to being accredited by the National Programs for Breast Health Centers, exemplifies St. Vincent s commitment to our patients in providing the most complete, up to date cancer care in Jacksonville. Our cancer program has seen significant growth in our patient support services through the expanded roll of our social workers, patient advocates, survivorship navigator, genetic counselor, oncology dietitian, research, breast and thoracic navigators. They have become a very integral part of the comprehensive and holistic attitude that St. Vincent s embraces for all patients. One of the longest successful programs in Jacksonville is St. Vincent s cancer panel conferences. The multidisciplinary team approach meets 10 times a month to formulate a unified effective treatment plan for our cancer patients. It is made up of physicians, nurses, tumor registry, and all support services. This coordination of care is just one more commitment that we have made to provide the most comprehensive cancer care in Jacksonville. Continuing to improve and expand our cancer care, St Vincent s has partnered with the Mayo Clinic. This collaboration gives St. Vincent s patients access to the most advanced cancer care available from Mayo Clinic Oncologists at St. Vincent s Riverside. The partnership has been in effect for over one year and has proven to be very successful as the program continues to grow. I have only touched upon a few of the many accomplishments regarding St. Vincent s cancer program that are well documented in the annual report. We continue to be the leaders in cancer healthcare, while not losing our core values of service to the poor, reverence, integrity, wisdom and creativity. Sincerely, Paul Ossi, MD Cancer Committee Chairman St. Vincent s Riverside 02 St. Vincent s Medical Center Riverside Cancer Committee Cancer Program Annual Report

4 Accreditations Cancer Program Accomplishments St. Vincent s Cancer Program is voluntarily accredited by the American College of Surgeons Commission (ACoS) per the Commission on Cancer (CoC) Standards as a Comprehensive Community Cancer Program (CCCP). The program assesses more than 1500 newly diagnosed cancer cases each year, provides a full range of diagnostic and comprehensive treatment services as noted below, either on-site or by referral, as well as participates in cancer-related clinical research and cancer-related clinical trials, per CoC Standards. Additionally, St. Vincent s Cancer Program is also voluntarily accredited by the National Accreditation Program for Breast Centers (NAPBC) and the Joint Commission. The NAPBC holds organizations to the highest standards of care for patients with diseases of the breast. St. Vincent s promoted, continued to offer the following services, sponsored and/or participated in following community outreach activities: Mayo Clinic Cancer Center located at St. Vincent s Riverside opened Oct 2016 Successfully received 3 year re-accreditation from the Commission on Cancer and the National Program of Breast Center and was nominated for best practices on patient services in patient navigation, survivorship, and genetics Cancer Registry received Florida Cancer Data Systems Jean Byers Award for excellence in Cancer Reporting for meeting or exceeding the national quality standards for timeliness and completeness of cancer reporting to the Florida Department of Health and Pat Strait Award for excellence in Cancer Abstracting Barbara Dearmon, BS, CTR, Manager, Oncology Support Services was nominated and elected to serve as President-Elect/Secretary for NCRA, She will assume the role of President in 2017 Continued participation in Rapid Quality Reporting System for tracking breast and colorectal national treatment measures Promoted Community Hospice Center for Caring at St. Vincent s Riverside on 4th floor Promoted the Lung Cancer Institute Continued to offer Kids Together Against Cancer (KTAC) a cancer support group for families who have a parent with cancer Promoted St. Vincent s Spine and Brain Institute Continued to offer free Yoga Classes for Cancer Survivors and Care Givers in conjunction with the Christina Phipps Foundation Hosted Candid Conversations about Breast Cancer a support group for women diagnosed with breast cancer Continued membership and participation in Association of Community Cancer Centers (ACCC) Continued to partner with American Cancer Society Board and Committees, and programs such as Road to Recovery, patient referral services Promoted smoking cessation with I Quit Smart program, formalized program of AHEC 622 referrals made to I Quit AHEC smoking cessation program in 2016 Participated in & provided leadership for the American Cancer Society s Making Strides Against Breast Cancer events Promoted Survivorship Program Promoted physicians use of the AJCC TNM Staging and clinical documentation in pretreatment planning Continued to monitor quality treatment measures covering 9 cancer sites against the estimated performance rate set by the Commission on Cancer for accredited programs Continued to maintain compliance with the National Programs for Breast Health Centers performance rate set by Commission on Cancer Continued to participate in the NCDB Annual Call for Data Promoted the CT Lung Screening Program Enrolled 53 patients in clinical trials 04 St. Vincent s Medical Center Riverside Cancer Committee Cancer Program Annual Report

5 Mayo Clinic Cancer Center Riverside St. Vincent s partnered with Mayo Clinic to offer Cancer Services on our Riverside campus. This agreement enables Mayo Clinic to bring the highest quality of cancer care to even more patients in our area. By joining forces we will strengthen the delivery and quality of care in this region. Mayo Clinic Cancer Center opened in October of Patients will be seen in a newly renovated 11,500 sq. ft. medical suite in the DePaul Building and have access to the latest in cancer care and clinical trials from nationally and internationally respected Mayo Clinic oncologists. This collaboration is all about providing the people of our community access to the most advanced cancer care available anywhere, right here at home, said Tom VanOsdol, Chief Operating Officer of St. Vincent s HealthCare. At the Mayo Clinic Cancer Center located at St. Vincent s Riverside, patients will receive the best of both worlds: Worldrenowned cancer care delivered by Mayo physicians in the holistic compassionate tradition of St. Vincent s in our beautiful setting along the St. Johns River. CLINIC SPECIFICS STATISTICS Specialized care for cancer Chemotherapy, Immunotherapy Innovative clinical trials Comprehensive cancer care Full-time, onsite Mayo Clinic specialists will work with subspecialists rotating from the Mayo Clinic Campus. BENEFIT TO PATIENTS Nationally and internationally renowned board-certified experts Patients seen inside the Mayo Clinic Cancer Center located at St. Vincent s Riverside will benefit from Mayo Clinic clinical expertise in the compassionate setting of St. Vincent s Patients billed through St. Vincent s. We accept the following insurance plans: BCBS Medicare Medicaid (FL & GA) Aetna Cigna UHC Coventry PHCS/Multiplan/Beech Street Sunshine Wellcare Carelink Patients and referring doctors will have access to the knowledge and care of physicians in the Mayo Clinic Medical Oncology Division Clinical trials offered by Mayo Clinic will be available Free dedicated parking spots in the DePaul garage PROVIDING COMPREHENSIVE CANCER SERVICES The Josephine H. Bryan Breast Health Center Imaging Services Surgical Services Medical Oncology Radiation Oncology Gynecologic Oncology Rehabilitation Services Cytology and pathology Plastic and Reconstructive Surgery Neurologic Oncology Oncology Pharmacy Cancer Treatment Panel Cancer Committee Approved Cancer Program National Accreditation of Breast Programs Oncology Support Services (Cancer Registry) Multidisciplinary Breast Clinic YOUR CANCER PROGRAM TEAM The Cancer Committee is an official St. Vincent s Hospital Medical Staff committee with multidisciplinary representation and is accountable for goal setting, planning, initiating, implementing and improving all cancer related activities for the health system. The Cancer Committee is responsible for monitoring, assessing and identifying changes to cancer services provided to patients onsite or by referral annually. Its composition, as required by the Commission on Cancer, includes board-certified physicians from Surgery, Medical Oncology, Radiation Oncology, Diagnostic Radiology, and Pathology, along with the Cancer Liaison Physician, Clinical Research Manager, Palliative Care Specialist, and representatives from Hospital Administration, Nursing, Pharmacy, Psycho-social services, Cancer registry, and Quality Improvement. 06 St. Vincent s Medical Center Riverside Cancer Committee Cancer Program Annual Report

6 Cancer Committee Membership 2016 PHYSICIAN MEMBERSHIP William Sumner, III, MD Cancer Committee Chair Anne Bernstein, MD Brett Cantrell, MD Jennifer Contin, MD Michael Donohue, MD Michael Fallucco, MD Leann Fox, MD Javier Herrera, MD, COC Physician Liaison Ali Lankarani, MD Paul Ossi, MD Donald Smitha, DDS Jose Soto-Soto, MD NON-PHYSICIAN MEMBERSHIP Tina Calloway Robin Bettman, RPH, BCOP Kate Bodden, DPT Sue Kreichelt, RN, BSN, MSH Lauren Lane LCSW Kristin Lothman, MSW, LCSW, OSW-C Lisa Heath, MSN, RN-BC Barbara Dearmon, BS, CTR Alanna Eubanks, RD, CSO Thomas Keith, Ph.D Veena Ganesh, MS, CGC, MS Biotech Maureen McGuinn Wendy Holt, RN, MSN, OCN Abby Hart, RN, BSN, CPHON Sue Kreichelt, RN, BSN, MSH Cathy Lane, RN, BSN, OCN John Lee, MBA, BSN, RN Jenny Lehman, MSW Melissa Mackoul, RN Ray Miller, PT Jill Nelson, RT Marlynn Townsend, RT Mary Moore Marketing Oncology-Certified Pharmacist Rehabilitative Services Spine/Brain and Thoracic Nurse Navigator Manager, Palliative Care Social Worker Oncology Nursing Manager, Oncology Support Services Oncology-Certified Dietitian Oncology Service Line Director Genetic Counselor ACS Representative Clinical, Manager, Cancer Services Research Manager Nurse Navigator Radiation Oncology Nurse Nurse Survivorship Navigator Social Worker Nurse Navigator Manager, Rehabilitative Therapy Manager, Medical Imaging Cancer Patient Navigator Chaplin, Pastoral Care PROGRAM COORDINATORS Quality Improvement Coordinator Education/Outreach Coordinator Cancer Conference Coordinator Cancer Registry Coordinator Palliative Care Coordinator Research Coordinator Psychosocial Services Coordinator Veena Ganesh, MS, CGC, MS Biotech (Leann Fox, MD - co-coordinator) Anna Peterson, RN Anne Bernstein, MD Barbara Dearmon, BS, CTR Jennifer Contin, MD Abby Hart, RN, BSN, CHPON Kristin Lothman, LCSW 08

7 Cancer Panel Conferences Cancer Services The Cancer Panel Conference at St. Vincent s Riverside is an integral part of the hospital s cancer program. The Cancer Panel Conference is a multidisciplinary forum which provides consultative services for patients to formulate an effective treatment planning and improve the monitoring of care of patients. The Cancer Committee annually monitors and evaluates the conference activities outlined in summary below. The conference offers continuing education to physicians and allied health professionals. Conferences are held weekly from 7:00 am 8:00 am. Oncology Support Services (Cancer Registry) coordinates the meetings and preparation of agendas. A combination of top cancer sites are discussed at each meeting. In 2016, the average physician attendance was 10 physicians per conference and a 100% attendance in the conference by all five required physician specialties. SUMMARY OF CANCER PANEL (CONFERENCES) FOR 2016 BELOW St. Vincent s goal is to provide holistic care. This means treating your physical, emotional, social and spiritual needs. Recognized since 1956 as a Comprehensive Community Cancer Program we provide you: Quality care close to home Comprehensive care A multidisciplinary team approach Care monitoring and quality improvement Treatment planning based on evidence-based national treatment guidelines Clinical trials and new treatment options Follow-up care including a survivorship care plan Patient tracking through the cancer data system Information and education Conference meetings are held bi-weekly (Tues & Fri) Breast cases are presented 7:00 am to 7:30 am and all other sites from 7:30 am to 8:00 am. Thoracic Panel meets on the 2nd, 4th and 5th Thurs of month from 7:00 am 8:00 am. Patient-centered services Genetic assessment and counseling, and palliative care services 10 St. Vincent s Medical Center Riverside Cancer Committee Cancer Program Annual Report

8 Cancer Services Cancer Registry Report St. Vincent s goal is to provide holistic care. This means treating your physical, emotional, social and spiritual needs. Recognized since 1956 as a Comprehensive Community Cancer Program we provide you: Quality care close to home Comprehensive care A multidisciplinary team approach Information and education Patient-centered services Genetic assessment and counseling, and palliative care services Care monitoring and quality improvement Treatment planning based on evidence-based national treatment guidelines Clinical trials and new treatment options Follow-up care including a survivorship care plan Cancer risk assessment, genetic counseling and Patient tracking through the cancer data system genetic testing services are provided to patients either on site or by referral seen by a board YOUR SUPPORT TEAM certified genetic counselor or professional. Total cases screened 427 for Patient and nurse navigation Survivorship nurse navigator Psychosocial and Distress Screening services Certified Genetic counseling 500 patients screened which is approximately Research nurse 49% of population served. Physical Therapy and Rehabilitative services Certified oncology dietitian St. Vincent s Riverside promoted clinical research Palliative care and accrued 53 patients on cancer related clinical Imaging research which included patient registry studies Cancer support groups and pharmaceutical trials conducted through the Surgical services medical oncology private practices. In 2016, St. Radiation therapy Vincent s Riverside enrolled 5% of the analytic Medical oncology population diagnosed and treated on clinical Pathology trials. Our accrual percentage rate exceeds the Lymphedema therapist requirement set forth by the American College of Pastoral Care Surgeons Commission on Cancer. For information Pharmacy about cancer research studies contact the Cancer Radiologists Research office at St. Vincent s Oncology Support Services (Cancer Registry) is a hospital-based disease specific registry designed to collect the complete history, diagnosis, staging, treatment and prognostics indicators on patients with diagnosis of cancer, precancerous condition and benign CNS tumor diagnosed or treated at St. Vincent s Healthcare. A wide range of information is collected to monitor quality care and outcomes. In 2016, we accessioned 2,751 cancer cases Cancer registry data collection helps organizations system wide into the registry database and and public health officials to monitor quality of 1,833 were initially diagnosed and treated at our care and progress in prevention, screening and facilities. A total of 36,442 cancer cases have been treating cancer based on which is one of the entered in the registry since January 1, 1995 to leading causes of death in United States. December 31, The cancer registry provided information for To ensure the accuracy of collection of data, The several administrative data requests throughout Cancer Committee Chair and physician members the year to assist with monitoring cancer performed quality review on registry data. In 2016, volume, examine patients navigated through 10% of Riverside analytical cases were reviewed hospital, support the NAPBC program and to for accuracy on data collection. The cancer registry support Ascension Oncology Service line quality control policy is reviewed annually by the initiatives and goals. Cancer Registry Coordinator and Cancer Committee to evaluate the quality of data collection. Oncology Support Services is responsible for maintaining compliance with the following Annual lifetime follow-up of former patients is regulatory agencies: a very important part of the program. This is accomplished through letters to the attending Florida Cancer Data Systems, Department of physicians or by letters to patients and their Health for cancer incidence reporting. family members. Occasionally phone calls will be made to patients in order to capture follow-up American College of Surgeons, Commission on information including the patient s current contact Cancer for accredited comprehensive program information and health status. This contact serves and monitoring quality treatment measures as a reminder to our former patients to continue covering 9 cancer sites their follow-up exams with physicians. Currently, National Cancer Database Call for Data St. Vincent s Riverside has approximately 10,366 Rapid Quality Reporting Systems patients in active follow-up. St. Vincent s Riverside National Accreditation Program for cancer program maintains or exceeds an 80% Breast Centers follow up rate on all cases in database since reference year January 1st, 1995 and 90% on all patients diagnosed within the past five years. 12 St. Vincent s Medical Center Riverside Cancer Committee Cancer Program Annual Report

9 Total Cancer Diagnoses AT HEATHCARE IN 2016 BY FLORIDA COUNTY AND FACILITY Only cases diagnosed and treated at St. Vincent s HealthCare are included in the analysis by county, race, gender, primary site and quality measures. DIAGNOSIS COUNTY RIVERSIDE NUMBER OF CASES PERCENT SOUTHSIDE NUMBER OF CASES PERCENT CLAY COUNTY NUMBER OF CASES PERCENT DUVAL CLAY OUT-OF-STATE NASSAU BAKER ST. JOHNS BRADFORD PUTNAM TOTAL Total Cancer Diagnoses AT HEATHCARE IN 2016 BY PRIMARY SITE AND FACILITY Only cases diagnosed and treated at St. Vincent s HealthCare are included in the analysis by county, race, gender, primary site and quality measures. PRIMARY SITE RIVERSIDE NUMBER OF CASES SOUTHSIDE NUMBER OF CASES CLAY COUNTY NUMBER OF CASES BREAST LUNG COLORECTAL BLADDER MELANOMA ENDOMETRIUM LYMPHATIC SYSTEM BLOOD DISEASE PANCREATIC BRAIN & CNS ALL OTHER TOTAL Total Cancer Diagnoses AT HEATHCARE IN 2016 BY GENDER AND FACILITY Only cases diagnosed and treated at St. Vincent s HealthCare are included in the analysis by county, race, gender, primary site and quality measures. GENDER RIVERSIDE NUMBER OF CASES SOUTHSIDE NUMBER OF CASES CLAY COUNTY NUMBER OF CASES MALE FEMALE TOTAL St. Vincent s Medical Center Riverside Cancer Committee Cancer Program Annual Report

10 Total Cancer Diagnoses AT HEATHCARE IN 2016 BY RACE AND FACILITY St. Vincent s Riverside Cancer Cases DIAGNOSED IN 2016 RACE RIVERSIDE NUMBER OF CASES PERCENT SOUTHSIDE NUMBER OF CASES PERCENT CLAY COUNTY NUMBER OF CASES PERCENT *NATIONAL COMPARISON OF SELECTED CANCER SITES *ESTIMATED NUMBERS OF NEW CASES FROM: THE AMERICAN CANCER SOCIETY CANCER FACTS & FIGURES 2016 EXCLUDES 48 CASES WHITE BLACK OTHER ASIAN AMERICAN INDIAN ALEUT ESKIMO OTHER TOTAL RIVERSIDE FLORIDA NATIONAL PRIMARY SITE CASES PERCENT CASES PERCENT CASES PERCENT BREAST , , LUNG , , PROSTATE , , COLORECTAL , ,490 8 BLADDER , , NH LYMPHOMA , , CORPUS UTERI , , MELANOMA , , LEUKEMIA , , CERVIX , , ALL OTHERS , , TOTAL CASES , ,685, NOTE: Florida and national data are based on estimated numbers of new cancer cases from the American Cancer Society s Cancer Facts & Figures (2016). The comparison analysis excludes basal and squamous cell skin cancers and 48 non-invasive carcinomas except urinary bladder. It is estimated that about 61,000 carcinoma-in-situ of the female breast and 68,480 melanoma-in-situ cases will be diagnosed in the U.S in Only cases that were diagnosed and/or treated at St. Vincent s Riverside were included in this analysis 16 St. Vincent s Medical Center Riverside Cancer Committee Cancer Program Annual Report

11 Community Outreach Activities COMPLETED IN 2016 AT HEATHCARE St. Vincent s HealthCare HOSTED AND PARTICIPATED IN THE FOLLOWING COMMUNITY OUTREACH ACTIVITIES IDENTIFIED AREA OF COMMUNITY NEED SPECIFIC COMMUNITY OUTREACH ACTIVITIES PERFORMED: PREVENTION PROGRAMS SUMMARY OF EFFECTIVENESS BREAST CANCER The Mobile Mammography unit s patient exam totals from 1/ /31/2016 = 1,660 Our mobile mammogram unit is offered community side to local businesses, physician s offices, community sites and Winn Dixie. We serve the insured, uninsured and underinsured. Individuals can call to schedule their visit so they can be preregistered and screened for any financial assistance needed. This is for screening mammograms only. LUNG CANCER I Quit with AHEC (Annually): St. Vincent s uses Northeast Florida Area Health Education Center (AHEC) to assist patients in kicking the habit of smoking. Patients are provided several options to increase their chances of quitting (nicotine replacement, individual phone counseling, web services and in person classes). One of the major priorities of The Northeast Florida AHEC in partnership with Tobacco Free Florida is to provide tobacco cessation opportunities throughout the State and train current and future healthcare professionals on how to assist tobacco-using patients. Tobacco cessation classes are offered throughout the North Florida area. These classes provide tobacco users with the information, resources, and support they need to quit smoking now. A total of 622 referrals were made from St. Vincent s Medical Center all campuses to I Quit AHEC smoking cessation program in The Navigators continue to refer patients to the Stop Smoking Programs. AHEC tracks the number of patients referred and the outcome of those referrals. We know patients have a hard time quitting the first time, especially during a stressful time. If a patient does not succeed the first time, they can repeat the program over till they reach their goal of quitting. AHEC has a 32.4% success rate is assisting patients to quit smoking ACS Making Strides Against Breast Cancer October 22, 2016): There were over 10,000 people in attendance. This includes survivors, caregivers, walkers, and supporters. 365 teams and 2,389 registered participants American Lung Association Walk Community Health Fair: Greater Church of God by Faith (November 12, 2016): Melissa Mackoul, Breast Nurse Navigator and Willie Roberts, Community Nurse Coordinator St. Vincent s promoted breast cancer awareness and services available and provided informational resources to participants. There were 117 women served. Breast Reconstruction Awareness Day (October 19, 2016) Florida Plastic Surgery Group collaborated with St. Vincent s to raise the level of knowledge about reconstruction options and offer to the Jacksonville community. 64 registered, 53 attended. Free to Breathe 5k Walk Lung Force Walk ACS Collaboration and Patient Referrals KTAC Yoga for Survivors Survivorship Event Candid Conversations About Breast Cancer Mind-Body Cancer Recovery Support Group Spring into Wellness Annual Clinical Update for Philippine Nurses Association for NE FL 18 St. Vincent s Medical Center Riverside Cancer Committee Cancer Program Annual Report

12 Cancer Cases Diagnosed In 2016 AT CLAY COUNTY BY AGE AND GENDER Cancer Cases Diagnosed In 2016 AT RIVERSIDE BY AGE AND GENDER MALE FEMALE MALE FEMALE Cancer Cases Diagnosed In 2016 AT SOUTHSIDE BY AGE AND GENDER Accountability and Quality Improvement Measures AT RIVERSIDE IN MALE FEMALE The St. Vincent s Riverside Cancer Committee ensures that patients with cancer are treated according to nationally evidenced based guidelines. Services are measured in compliance with retrospective and real-time CoC quality reporting tools, such as the Rapid Quality Reporting System (RQRS) and Cancer Program Practice Profile Reports (CP3R). These programs utilize quality measures endorsed by the National Quality Forum (NQF). TYPES OF MEASURES Accountability measures are high level of evidence which supports the measure, including multiple randomized control trials and quality Improvement are evidence from experimental studies, not randomized control trials that supports the measure which are intended for internal monitoring of performance within an organization. Below are St. Vincent s Riverside cancer program estimated performance rates on proportion of patients concordant with national treatment measures for This report reflects continuous improvement in quality of care and compliance with national treatment guidelines endorsed by the NQF. 20 St. Vincent s Medical Center Riverside Cancer Committee Cancer Program Annual Report

13 Accountability and Quality Improvement Measures AT RIVERSIDE IN 2016 RIVERSIDE 2016 CANCER PROGRAM QUALITY MEASURES RECTUM COC EPR% SVR RIVERSIDE 2016 CANCER PROGRAM QUALITY MEASURES COC EPR% SVR Preoperative chemo and radiation are administered for clinical AJCC T3N0, T4N0, or Stage III; or Postoperative chemo and radiation are administered within 180 days of diagnosis for clinical AJCC T1-2N0 with pathologic AJCC T3N0, T4N0, or Stage III; or treatment is recommended; for patients under the age of 80 receiving resection for rectal cancer. RECRTCT (Quality Improvement) 85% 100% BREAST (NQF #219) Radiation therapy is administered within 1 year (365 days) of diagnosis for women under age 70 receiving breast conserving surgery for breast cancer. BCSRT (Accountability) (NQF #0220) Tamoxifen or third generation aromatase inhibitor is recommended or administered within 1 year (365 days) of diagnosis for women with AJCC T1cN0M0, or stage IB - III hormone receptor positive breast cancer.ht (Accountability) Radiation therapy is recommended or administered following any mastectomy within 1 year (365 days) of diagnosis of breast cancer for women with > 4 positive regional lymph nodes.mastrt (Accountability) Image or palpation-guided needle biopsy to the primary site is performed to establish diagnosis of breast cancer. NBX. (Quality Improvement) COLON (NQF #0225) At least 12 regional lymph nodes are removed and pathologically examined for resected colon cancer. 12RLN (Quality Improvement) GASTRIC At least 15 regional lymph nodes are removed and pathologically examined for resected gastric cancer. G15RLN (Quality Improvement) NON SMALL CELL LUNG Systemic chemotherapy is administered within 4 months to day preoperatively or day of surgery to 6 months postoperatively, or it is recommended for surgically resected cases with pathologic, lymph node-positive (pn1) and (pn2) NSCLC. LCT (Quality Improvement) Surgery is not the first course of treatment for cn2, M0 lung cases. LN0Surg (Quality Improvement) 90% 90% 90% 80% 85% 80% 85% 85% 93.06% 90.48% 100% 94% 89.13% 50% 100% 83.33% St. Vincent s Healthcare Prevention Program 2016 MOBILE MAMMOGRAPHY SUMMARY NEEDS ASSESSMENT A screening mammogram is used to assess the presence of breast disease in patients without symptoms. Screening mammograms are usually first performed in patients without a family history or other risk factors between 35 to 40 years of age and then annually in patients over 40 years of age. A diagnostic mammogram is performed in patients with symptoms such as a palpable mass, skin changes, or nipple discharge or as a follow up for an abnormal screening mammogram. Nine out of 10 (90%) patients who have an abnormal screening mammogram and are scheduled for a follow up diagnostic mammogram do not have breast cancer. Approximately 0.2 to 0.4% of screening mammograms lead to a diagnosis of breast cancer. OBJECTIVES Provide convenient screening mammography to the community. Provide screening mammography to corporate locations for employees Increase accessibility to screening mammography to the community. SITUATION ANALYSIS Each year more than 2,000 patients receive their screening mammograms through the Mobile Mammography Unit. The mobile unit is easily accessible to patients. It allows screening mammograms to be performed in convenient locations throughout the community including shopping malls, places of employment, etc. Additionally, St Vincent s HealthCare has programs to assist uninsured patients who cannot afford the expense of a screening mammogram. The Josephine H. Bryan Breast Health Center has long been a hallmark of coordinated, compassionate care at St. Vincent s HealthCare Riverside Campus. Providing breast imaging services for over 40 years, St Vincent s performs digital mammography, breast ultrasound, 22 St. Vincent s Medical Center Riverside Cancer Committee Cancer Program Annual Report

14 St. Vincent s Healthcare Prevention Program 2016 MOBILE MAMMOGRAPHY SUMMARY (Continued) St. Vincent s Riverside ANNUAL STUDY MONITORING EVIDENCE-BASED GUIDELINES ON ACUTE MYELOID LEUKEMIA (AML) BY DR. SUSMITHA VAKA, M.D. minimally invasive biopsies, breast MRI, and bone densitometry. A library with Internet access is If a biopsy is recommended and performed, the Radiologist discusses the results with TOPIC available on site. The program is accredited by the Mammography Quality Standards Act and the American College of Radiology as a Breast Center of Excellence. It is certified by the Food and Drug Administration. Every mammogram is read by a board certified or board eligible Radiologist using the same stateof-the-art technology found at the St Vincent s the patients and recommends any additional treatment. NATIONAL GUIDELINES Recommendations by the American College of Radiology and the Society of Breast Imaging: The earlier breast cancer is found, the better This study aims to evaluate if patients diagnosed with AML are treated based on evidence based guidelines. An in-depth analysis will be conducted to assess and verify patients diagnosed with AML are treated according to NCCN guidelines and will include cases from Cancer Registry database diagnosed or treated at St. Vincent s Riverside 1/1/2012 thru 6/30/2016. hospital location. RESULTS The Mobile Mammography unit s patient exam totals from 1/ /2016 =1660 the prognosis for the patient. Our shared goal is to save the most lives possible from breast cancer, the American College of Radiology (ACR) and Society of Breast Imaging (SBI) continue to recommend that women get yearly mammograms starting at age 40. CRITERIA FOR EVALUATION Patients who have been diagnosed with Acute Myeloid Leukemia at St. Vincent s Riverside 1/1/2012 thru 6/30/2016. Further treatment recommendations: Follow up at one of the St Vincent s HealthCare Medical Center locations (Riverside, Southside or Clay) Results: All results are documented at each AUDIENCES General Community (Duval, Clay, Nassau, Data from the following sources was utilized in this study: St. Vincent s Cancer Registry Database Medical Center location. St Johns, Baker, Flagler Counties) BACKGROUND FOR STUDY DIAGNOSTIC CONFIRMATION FOLLOW-UP PLAN Patients with an abnormal screening mammogram are contacted and directed to either the St Vincent s Riverside, Southside or Clay locations to receive a diagnostic mammogram. At the time of the diagnostic mammogram, the patient meets with a Radiologist to discuss results and recommendations. ADVERTISING Florida Times Union St. Vincent s HealthCare Intranet Printed Flyers in physicians offices and corporate locations. NEW FOR D Screening Mammography will be installed on the mobile unit for those who are interested in this Leukemia is cancer of the blood cells and occurs most often in adults older than 55 years, but it is also the most common cancer in children younger than 15 years. Leukemia can be either acute or chronic. Acute leukemia is a fast-growing cancer that usually gets worse quickly. Chronic leukemia is a slower-growing cancer that gets worse slowly over time. The treatment and prognosis for leukemia depend on the type of blood cell affected and whether the leukemia is acute or chronic. National guidelines for evaluation of Acute Leukemia include a Bone Marrow Biopsy and Aspiration with Cytogenetics and Molecular Analyses, Immunophenotyping and Flow cytometry is also recommended. 7 out of 45 had Flow Cytometry to confirm diagnosis Two cases had No Pathology or Flow Cytometry 36 cases had Bone Marrow Aspirate confirmation new technology. 24 St. Vincent s Medical Center Riverside Cancer Committee Cancer Program Annual Report

15 St. Vincent s Medical Center Riverside 2017 STUDY MONITORING COMPLIANCE WITH EVIDENCE-BASED GUIDELINES FOR AML BY DR. SUSMITHA VAKA, M.D. (Continued) MOST COMMON TYPES CHEMOTHERAPY MULTIPLE AGENTS ADMINISTERED 33 out of 45 had the following chemotherapies HIDAC HIDAC-GLEEVAC CYTARABINE IDA-ARA TREANDA-RITUXAN DECITABINE 1 DOSE ONLY VIDAZIA ANALYSIS & SUMMARY A total of 45 cases who were treated at St.Vincent s Riverside from 1/1/2012 thru 6/30/2016 were identified to be included in study.. Different age group patients were treated, from age years of age. 26 male and 19 female patients were treated. 43 out of 45 AML cases were diagnosed per NCCN guidelines. 33 out of 45 patients were treated with different chemotherapy regimens. 32 out of 33 patients received chemotherapy per NCCN guidelines. REFERENCES NCCN GUIDELINES VERSION AML 1. Döhner H, Estey EH, Amadori S, et al. Diagnosis and management of acute myeloid leukemia in adults: recommendations from an international expert panel, on behalf of the European LeukemiaNet. Blood 2010; 115:453. SOURCE ST VINCENT S CANCER REGISTRY References & Definitions of Terms St. Vincent s Oncology Support Services database American Cancer Society, Cancer Facts and Figures National Cancer Database Commission on Cancer benchmark reports DEFINITION OF TERMS ACS American Cancer Society AJCC American Joint Committee on Cancer A Analytic NCDB National Cancer Database NCCN National Comprehensive Cancer Network 26

16 St. Vincent s Healthcare Locations 1 Shircliff Way Jacksonville, FL Phone: Belfort Road Jacksonville, FL Phone: St. Vincent s Way Middleburg, FL Phone: For more information or to schedule an appointment with St. Vincent s Mary Virginia Terry Cancer Center Call at