A Year in Review. September 30 and October 1, 2017 were the dates for the expanded

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1 December 29, 2017 Annual Report By any standard 2017 was an eventful year for the Cancer Centers of Southwest Oklahoma (CCSO). There were new clinical programs, the renewal of an important accreditation, our management of the 2017 Spirit of Survival, physician loss and gain, expansion to another city and the continued growth of support by all of Southwest Oklahoma. Under the direction of CCSO s radiation oncologists, Dr. LeAnn Smith and Dr. Michael Kerley, CCSO expanded the brachytherapy program to include not only breast cancer treatments but gynecological brachytherapy as well. This involved extensive training and the development of new competencies by the staff. The program is offered to women who in the past had no choice but to have the treatment provided in Oklahoma City. A Year in Review The American College of Surgeons (Commission on Cancer) surveyed our cancer program in April and for the fourth consecutive survey, we received the highest level of accreditation given by CoC. This means that for twelve consecutive years our cancer program has ranked among the top 10% of cancer programs in the United States. Congratulations and thanks to Cancer Program Manager Alison Green and physician liaison Dr. Carol Dittmann for their leadership in achieving this. Ours is the only cancer program to have achieved this level of accreditation for this many years. September 30 and October 1, 2017 were the dates for the expanded 12th annual Spirit of Survival, which was for the first time, directed solely by the staff of CCSO. This year s event saw the addition of four bike tours ranging from miles. Just over 200 riders of all ages participated. They were joined by 3,100 runners and walkers on Sunday, October 1. This event is the largest tourist event in Southwest Oklahoma with participants coming from numerous By Lane Hooton, COO, Cancer Centers of Southwest Oklahoma states and many cities within Oklahoma. In July, medical oncologist Dr. Aman Garsa relocated to Oklahoma City and is now working for CCSO in our newest facility in Chickasha, Oklahoma. While no longer working in Lawton, she remains an integral part of the CSSO medical staff. Her position in Lawton was filled in August by Dr. Narender Gorukanti, who came to us from Ft. Smith, Arkansas. In August, we lost the services of Dr. Mahakit Inklab, who due to family illness, moved back to Thailand. As of this writing, his position has not been filled. The annual screenings for skin, prostate and head and neck cancer brought in over 1,000 patients through our three centers. Specialists from all communities assisted in these events. Also, we had the help of 10 physicians from the CCMH Residency Program to help with the screenings. Many thanks to these young doctors. Continued on Pg.7 Pg. 2 Quality Measures Pg.4 Achievements pg. 8 Screenings

2 Page 2 Quality, Accountability, and Surveillance Measures By: Carol Dittmann, M.D., Cancer Liaison Physician These standards require performance levels be met annually according to the specified accountability and quality improvement measures defined by the CoC. As the Cancer Liaison Physician it is my responsibility to provide leadership and direction to monitor, maintain, and improve quality within the cancer program. A part of the monitoring process includes evaluating, interpreting and reporting the programs performance using the National Cancer Data Base (NCDB) data as well as monitoring the performance status of our program via the Cancer Program Practice Profile Reports (CP3R). It is the cancer committee s responsibility to ensure that patients with cancer are treated according to nationally accepted measures by (in part) compliance with Commission on Cancer (CoC) quality reporting tools, such as the Cancer Program Practice Profile Reports (CP3R). These standards enable CoC-accredited programs to demonstrate that patients receive care that is consistent with standards of care and good clinical practice thereby promoting a better outcome for the patients with cancer who are treated at Comanche County Memorial Hospital (CCMH) and The Cancer Centers of Southwest Oklahoma. Expected Estimated Performance Rates (EPR) for accountability and quality measures assessed with Commission on Cancer (CoC) Standards 4.4 and 4.5 are established based on the year of survey. When reviewing the most recent reported data I found CCMH to be within the confidence interval set by the CoC for all measures. I have recommended that a list of all measures be distributed to the medical staff so that any physician who is caring for cancer patients will have the most recent information from the Commission on Cancer. Current CP3R measures are as follows: Bladder: BL2RLN- At least two lymph nodes are removed in patients under 80 undergoing partial or radical cystectomy BLCSTRI- Radical or partial cystectomy; or Trimodality therapy (Local tumor destruction/ excision with chemotherapy and radiation) for clinical T234N0M0 patients, first treatment within 90 days of diagnosis BLCT- Neo-adjuvant or adjuvant chemotherapy offered or administered for patients with muscle invasive cancer undergoing radical cystectomy Breast: BCSRT- Radiation therapy is administered within 1 year (365 days) of diagnosis for women under age 70 receiving breast conserving surgery for breast cancer (Accountability) MAC- Combination chemotherapy is recommended or administered within 4 months (120 days) of diagnosis for women under 70 with AJCC T1cN0M0, or stage IB III hormone receptor negative breast cancer (Accountability) HT- Tamoxifen or third generation aromatase inhib-

3 Page 3 itor 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 (Accountability) MASRT- 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 (Accountability) NBx- Image or palpation-guided needle biopsy to the primary site is performed to establish diagnosis of breast cancer (Quality Improvement) BCS- Breast conservation surgery rate for women with AJCC clinical stage 0, I, or II breast cancer Gastric: G15RLN- At least 15 regional lymph nodes are removed and pathologically examined for resected gastric cancer (Quality Improvement) Cervix: CBRRT- Use of brachytherapy in patients treated with primary radiation with curative intent in any stage of cervical cancer CERRT- Radiation therapy completed within 60 days of initiation of radiation among women diagnosed with any stage of cervical cancer CERCT- Chemotherapy administered to cervical cancer patients who received radiation for stages IB2-IV cancer (Group 1) or with positive pelvic nodes, positive surgical margin, and/or positive parametrium (Group 2) Colon: ACT- Adjuvant chemotherapy is recommended or administered within 4 months (120 days) of diagnosis for patients under the age of 80 with AJCC Stage III (lymph node positive) colon cancer (Accountability) 12RLN- At least 12 regional lymph nodes are removed and pathologically examined for resected colon cancer (Quality Improvement) Endometrium: ENDCTRT- Chemotherapy and/or radiation administered to patients with Stage IIIC or IV Endometrial cancer ENDLRC- Endoscopic, laparoscopic, or robotic surgery performed for all endometrial cancer (excluding sarcoma and lymphoma), for all stages except stage IV Kidney: PD1RLN- Pediatric measure: At least 1 regional lymph node is removed and pathologically examined for primarily resected unilateral nephroblastoma (Quality Improvement) Non-Small Cell Lung: 10RLN- At least 10 regional lymph nodes are removed and pathologically examined for AJCC stage IA, IB, IIA, and IIB resected NSCLC LCT- 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 nodepositive (pn1) and (pn2) NSCLC (Quality Improvement) LNoSurg- Surgery is not the first course of treatment for cn2, M0 lung cases (Quality Improvement) Ovary: OVSAL- Salpingo-oophorectomy with omentectomy, debulking; cytoreductive surgery, or pelvic exenteration in Stages I- IIIC Ovarian cancer Rectum: RECRTCT- 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 (Quality Improvement)

4 Page 4 Achievements Over the course of the year, many outstanding clinical staff have added to their credentials. We would like to take this opportunity to shine the spotlight on those professionals, who take the initiative and go above and beyond to provide the best care Right Here at Home. Congratulations to Anita Moss RN-BC, OCN at our Duncan facility. She successfully passed the Oncology Certified Nurse exam December 11, She also has a certification in Gerontology. Fantastic work, Anita! Congratulations to Jayne Gallimore, RN, OCN at our Lawton facility. She successfully passed the Oncology Certified Nurse exam November 29, Fantastic job, Jayne! The Cancer Centers of Southwest Oklahoma are pleased to congratulate Stephanie Stewart, RN, OCN at our Duncan facility for obtaining her OCN certification December 27, Excellent job, Stephanie! Congratulations to James Puckett RN, OCN at our Lawton facility. He successfully passed the Oncology Certified Nurse exam December 5, Fabulous work, James! Congratulations to Lily Alvarado RN, OCN at our Duncan facility as she has passed her Oncology Certified Nurse exam November 14, Great job, Lily! Janada Jenkins, RN, OCN, CBCN, at our Duncan facility has passed her Certified Breast Care Nurse exam on November 13. Congratulations Janada! Congratulations to Susie McCoy BSN, RN, OCN, CBCN, for passing her ONS breast certification test on December 2 to become a Certified Breast Care Nurse. Way to go, Susie! Morgan Johns, APRN-CNS, OCN, at our Altus facility has passed her Oncology Certified Nurse exam on November 11, Excellent work, Morgan!

5 Page 5 Achievements continued... The Cancer Centers of Southwest Oklahoma are pleased to congratulate Vonda Williams, RN, OCN, CBCN, Nurse Manager in Duncan for becoming our first Certified Breast Care Nurse. She passed this rigorous exam on October 26, Congratulations and job well done! Tori Hazel, RN, BSN, OCN, CMC, ONN-CG, Nurse Manager in Altus, passed her Oncology Certified Nurse exam on October 27, She is also a certified Case Manager and has tested and obtained the Oncology Nurse Navigator-Certified Generalist certification. Fantastic work, Tori! Congratulations to Diandra Stewart, BS, CCRP, the newest Certified Clinical Research Professional for the Cancer Centers of Southwest Oklahoma. Diandra passed this difficult test from the Society of Clinical Research Associates on October 11th. Awesome job, Diandra! The Cancer Centers of Southwest Oklahoma would like to congratulate Robyn Lewis, RN, OCN, CBCN, Nurse Manager in Lawton, for passing her Certified Breast Care Nurse exam on December 29. Congratulations, Robyn! Congratulations to Brody Barker, CMD for passing the certification exam of the Medical Dosimetrist Certification Board. Amazing job, Brody! The Cancer Centers of Southwest Oklahoma are pleased to congratulate Monica Rhodes, APRN, AGCNS-BC, OCN upon graduating from The University of Oklahoma Health Sciences Center and passing her ANCC board certification as an Advanced Practice Registered Nurse Clinical Nurse Specialist Adult/Gerontology in July of Congratulations Monica! Congratulations to Robert Darnell, RN, OCN, Director of Nursing for Cancer Centers of Southwest Oklahoma, as he has passed the Certified Breast Care Nurse exam given by the Oncology Nursing Society on November 14, Way to go, Robert!

6 Page 6 A Beloved Driver says Farewell Not many people can say that they have been part of something from its inception. But Francis Sheets can. Francis Sheets, AKA Pillowcase, has touched many lives over the past eight years. Francis has been volunteering with the Cancer Centers Transportation program since day one in September of And what an exciting first day he had! On his way back from Duncan, Francis had an unexpected encounter. A deer darted in front of the brand new van and left an impression on the van and an impression on Francis. Over the past 8 years, Francis has left an impression on patients and staff members alike. He has a great sense of humor and a heart of gold. Francis is one of several drivers who are cancer survivors. That has not slowed him down one bit. In his spare time, Francis enjoys working with stained glass and woodworking. He has also volunteered with Habitat for Humanity. He shares 4 sons, 7 grandchildren and 8 greatgrandchildren with his wife Vera.

7 DAISY award presented to Jayne Gallimore Amazing nurses go to great lengths each day to ensure that their patients receive the best care possible. The Daisy award is an award given to recognize the efforts of a nurse who has gone above and beyond in patient care. What happens when that patient is also a coworker? Tammy Hardman was tired after physical therapy on August 28th but didn t think anything of it. As she was preparing to go home, she developed a sharp pain across her chest that proceeded to get worse. She ran down the hall looking for Jayne Gallimore, her friend and colleague who has worked as a nurse at the Cancer Centers and the cath lab. She knew that Tammy was having a heart attack. Jayne proceeded to put Tammy in a wheelchair and took her down to the ER. Jayne helped the nurses once she got to the ER but didn t stop there. She alerted Tammy s family to the fact that she was having a heart attack and needed emergency surgery. When Tammy was facing incredible pain, Jayne pushed her to stay awake for her family that needs her. She made sure that Tammy wasn t alone and that her family was aware of the situation. Tammy credits Jayne with saving her life. Jayne s heroic actions and quick thinking that day are just one example of the incredible nurse and person that Jayne Gallimore is. Congratulations, Jayne! Page 7 A Year in Review Continued... CCSO nurses created their own headlines in At the start of the year, we were very pleased that 38% (8 of 21) of our nurses had taken and passed the rigorous certification test (OCN) for oncology nurses. This is not an easy exam and generally takes years of experience before a practicing nurse can expect to pass it. In my previous position in Dallas, less than 10% of our nurses were OCN certified. However, as of December 31, 2017, we are very proud to report that 71% (15 of 21) of our nurses have achieved this high level of certification. Furthermore, five of our nurses are now certified in breast cancer care, two more hold certificates in gerontology and nurse navigation and we have two Advanced Practice Nurses on staff. This speaks volumes of the professionalism of the staff. Because of the physician leadership of Dr. Manal Robin-Hanna, our Medical Director, Principal Research Investigator, Dr. Eugenio Najera, and the rest of the physicians and staff, CCSO stands tall in the oncology/hematology field in Oklahoma. Our statewide reputation for quality and access has been strong for years but even more so now. The paragraphs above show that we had an eventful year but they do not tell you that in 2017 the three cancer centers of CCSO welcomed over 1,600 new patients and performed over 60,000 procedures. We feel very comfortable in saying that because of you, the patients and families of Southwest Oklahoma, we are making a difference-right Here at Home.

8 Page 8 Detection is the Best Prevention 2017 Cancer Screenings By: Alison Green, Cancer Program Manager & Sandy Foster, Community Outreach Coordinator The Colon Cancer Screening was held the entire month of March IFOB Fecal Occult tests distributed to the public at the Cancer Centers of Southwest Oklahoma in Lawton, Duncan, and Altus. This year, approximately 179 IFOB tests were distributed with 7 positive results requiring further testing, 102 negative results, 4 inconclusive results, and 66 not returned. The Just Say Ahh Oral Cancer Screening was held at the Leah M. Fitch Cancer Center in Lawton on Saturday April 8, We had 202 participants this year with 107 requiring further evaluation and 2 needing immediate follow up for suspected neoplasm. The Skin Cancer Screenings in Altus were held at the Cancer Centers of Southwest Oklahoma on Saturday June 17, There were a total of 81 participants, 13 requiring follow up and 12 requiring a biopsy. The Skin Cancer Screening in Lawton were held at the Leah M. Fitch Cancer Center on Saturday May 6, 2017 There were a total of 251 participants with 73 requiring follow up and 73 requiring a biopsy. The Skin Cancer Screening in Duncan were held at the Taylor Le Norman/McCasland Cancer Center on Saturday April 22, There were a total of 116 participants, with 55 requiring follow up. The Prostate Cancer Screening in Lawton was held at the Leah M. Fitch Cancer Center on Saturday September 9, We had 364 participants with 12 Abnormal DRE s and 90 with enlarged or BPH. The Prostate Cancer Screening in Duncan was held at the Taylor Le Norman/McCasland Cancer Center on Friday September 22, We had 40 participants with 2 Abnormal DRE s. The participants of each prostate screening were each given a copy of their DRE Exam at the screening and instructed to provide this information to their PCP or Urologist. A letter was mailed with the PSA result also instructing the participants to take the lab result to their PCP/Urologist and have them interpret it in accordance to their history and compare to previous PSA s. Low Dose CT lung screenings are available year round to individuals who meet the established highrisk criteria. This year 221 patients were scanned in Lawton with 190 negative results, 2 positive results and 29 abnormal results in need of a follow-up. In 2017, 74 patients were scanned in Altus with 60 negative results, 0 positive results and 14 abnormal results in need of a follow-up.