2016 Annual Report BON SECOURS CANCER INSTITUTE Bon Secours Maryview Medical Center

Transcription

1 2016 Annual Report BON SECOURS CANCER INSTITUTE Bon Secours Maryview Medical Center

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3 Mission: The mission of the Bon Secours Health System is to bring compassion to health care and to be Good Help to Those in Need, especially those who are poor and dying. As a system of caregivers, we commit ourselves to help bring people and communities to health and wholeness as part of the healing ministry of Jesus Christ and the Catholic Church.

4 2016 Cancer Committee Membership Chair... Jeffrey Riblet, MD Diagnostic Radiologist... Susan McKenzie, MD Pathologist... David Cummings, MD Medical Oncologist... Lloyd Shabazz, MD Radiation Oncologist... Judith Blevins, MD CLP... Charles Williams, MD Administrative Director, Oncology Services... Marylou Anton, MSN, RN, OCN Oncology Nurse... Kimberly Kennedy, RN, OCN Social Worker/Case Manager... Kristina Cartwright CTR... Theresa Johnlouis, CTR Palliative Care Professional... Juanita Smith, MD Quality Improvement Coordinator... Cheryl Hewlett, PhD, MBA, MSN, RN, CNEA-BC Psychosocial Services Coordinator... Debra Peters, MSW Community Outreach Coordinator... Robin Boothe, RN Clinical Research Coordinator... Wendy Crawford Cancer Conference Coordinator... Theresa Johnlouis, CTR Cancer Survivorship Program... Donna Talbott, MSN, RN, AOCN ACS... Mary Beth Taylor Radiation Therapy... Crystal C. Branch RT(R)(T) Breast Program Coordinator/Nurse Navigator... Laurie Jesz, RN, BSN OPIC Manager... Sheena Smith, RN, BSN PI/Quality... Cheryl Hewlett, PhD, MBA, MSN, RN, CNEA-BC Rehab... Renee Cone, PT, DPT, MS

5 2016 Cancer Program Goals and Objectives CLINICAL GOALS Enhance breast cancer program to include a hereditary cancer risk assessment program as recommended by the NAPBC. Developed a formal policy and process to identify and evaluate patients with high risk for breast cancer, educate and refer for appropriate follow-up per NCCN guidelines. April 2016: presented to breast leadership committee and approved. Submit COPN for SRS/SBRT for Bon Secours Harbour View radiation oncology department. Have a COPN approved by state to provide SRS/SBRT as a treatment option for patients. PROGRAM GOALS Track patients from the cancer conference who have been recommended for a medical oncology or radiation oncology consult. (Patients who have had a consult for either service before the cancer conference are not included in the tracking.) January 2016: Changed cancer conference template to accommodate notes related to needed consultation. January 2016: Developed tracking spreadsheet and new format for cancer conference documentation. Review January to September Patients recommended for treatment from the conferences: 85. Patients advised to seek medical oncology consult: patients had consults with Virginia Oncology Associates. 14 patients had consults with Dr. Shabazz. 3 patients had consults with Riverside Cancer Care Center. 1 patient had a consult with Dr. McCann. 1 patient was referred to Duke Cancer Center. 2 patients expired. Patients advised to seek radiation oncology consult: patients had treatment at Bon Secours Maryview Medical Center. 2 patients had treatment at Sentara Obici Hospital. 1 patient had treatment at Riverside Cancer Care Center. 1 patient referred to Johns Hopkins. 1 patient had treatment at Chesapeake Regional Medical Center. 1 patient was referred to Duke Cancer Center. 1 patient was referred to VCU. 2 patients expired. Review October to December Patients recommended for treatment from the conferences: 38. Patients advised to seek medical oncology consult: patients had consults with Virginia Oncology Associates. 7 patients had consults with Dr. Shabazz. 1 patient had a consult with Dr. McCann. 1 patient had treatment at Johns Hopkins. Patients advised to seek radiation oncology consult: patients had treatment at Bon Secours Maryview Medical Center. 1 patient had a consult at Johns Hopkins. 1 patient had a consult at Proton Center. Collaboration with Bon Secours In Motion Physical Therapy to develop a Cancer Rehabilitation Program November 2016: In Motion staff members completed four-day program for education and certification. Marketing plan developed and program implemented for 2017 rollout. Member of the cancer rehab team is now a member of Cancer Committee. Cancer rehab program integrated into Bon Secours oncology practices as an important part of cancer survivorship.

6 Who We Serve Bon Secours cancer program serves the needs of our community and surrounding areas. Cancer Occurrence Summary by Site and Sex, 2016, MMC The chart below shows all cancer cases diagnosed in 2016 by disease site and sex. FEMALE TOTAL CASES: 308 Thyroid: 7 (0.6%) Lung & Bronchus: 49 (15.9%) Breast: 132 (42.9%) Kidney & Renal Pelvis: 9 (2.9%) Ovary: 10 (3.2%) Uterine Corpus: 18 (5.8%) Colon & Rectum: 26 (8.4%) Non-Hodgkin Lymphoma: 9 (2.9%) Melanoma of the Skin: 2 (0.6%) Leukemia: 0 (0%) Female Male Oral Cavity & Pharynx 1 (0.3%) 5 (1.9%) Digestive System 45 (14.6%) 38 (14.8%) Respiratory System 52 (16.9%) 63 (24.5%) Bones & Joints 1 (0.3%) 1 (0.4%) Soft Tissue 2 (0.6%) 2 (0.8%) Skin, Excluding Basal & Squamous 2 (0.6%) 4 (1.6%) Breast 132 (42.9%) 7 (2.7%) Female Genital System 34 (11.0%) 0 (0.0%) Male Genital System 0 (0.0%) 79 (30.7%) Urinary System 16 (5.2%) 36 (14.0%) Brain & Other Nervous System 0 (0.0%) 1 (0.4%) Endocrine System 7 (2.3%) 1 (0.4%) Lymphoma 10 (3.2%) 11 (4.3%) Myeloma 2 (0.6%) 1 (0.4%) Leukemia 0 (0.0%) 2 (0.8%) Mesothelioma 0 (0.0%) 2 (0.8%) Miscellaneous 4 (1.3%) 4 (1.6%) TOTAL CASES: 565 MALE TOTAL CASES: 257 Oral Cavity & Pharynx: 5 (1.9%) Lung & Bronchus: 56 (21.8%) Pancreas: 3 (1.2%) Kidney & Renal Pelvis: 13 (5.1%) Urinary Bladder: 22 (8.6%) Colon & Rectum: 15 (5.8%) Prostate: 74 (28.8%) Non-Hodgkin Lymphoma: 10 (3.9%) Melanoma of the Skin: 4 (1.6%) Leukemia: 2 (0.8%)

7 Top Five Sites, Analytic Cases, , MMC The chart to the right shows the numbers and disease sites from 2012 to 2016 at Bon Secours Maryview Medical Center Colorectal Lung & Bronchus Breast Prostate Gland Bladder All Cancer Cases, Female vs. Male, , MMC The chart to the right depicts gender distribution from 2012 to 2016 at Bon Secours Maryview Medical Center Total Female Male Cancer Occurrence Top Sites, Total # of Cases by Sex, 2016, MMC The top five sites diagnosed at Bon Secours Maryview Medical Center by sex are depicted in the chart to the right Female Colorectal Male Lung & Bronchus Breast Prostate Gland Bladder

8 American College of Surgeons (ACS) National Cancer Database (NCDB) Cancer Program Practice Profile Reports for Breast, Colon and Rectal Cancers (CP3R) Comparison: Bon Secours Maryview Medical Center to Virginia to National Statistics The charts below represent data available for the most recent three years. ONCOLOGY METRIC: The ACS Cancer has defined six Cancer Program Practice Profile Reports (CP3R) that must be evaluated and publicly reported for commendation. BREAST Radiation Radiation therapy is administered within one year (365 days) of diagnosis for women under the age of 70 receiving breast-conserving surgery for breast cancer. MMC 86% 91% 95% Virginia 94% 94% 93% National 93% 93% 91% >=90% BREAST Combination Chemotherapy Combination chemotherapy is considered or administered within four months (120 days) of diagnosis for women under 70 with AJCC T1cN0M0, or Stage II or III hormone receptor-positive breast cancer. MMC 70% 58% 87% Virginia 96% 92% 94% National 93% 93% 93% Not applicable BREAST Tamoxifen or Third-Generation Aromatase Inhibitor Tamoxifen, or third-generation aromatase inhibitor, is considered or administered within one year (365 days) of diagnosis for women with AJCC T1cN0M0, or Stage II or III hormone receptor-positive breast cancer. MMC 97% 98% 92% Virginia 94% 95% 93% National 93% 92% 91% >=90% BREAST Needle Biopsy Versus Open Biopsy Image- or palpation-guided needle biopsy to the primary site is performed to establish diagnosis of breast cancer (Quality Improvement). MMC 91% 83% 88% Virginia 93% 94% 93% National 91% 92% 91% >=80%

9 BREAST Breast Conservation Surgery Breast conservation surgery rate for women with AJCC clinical stage 0, I or II breast cancer (Surveillance). MMC 54% 55% 56% Virginia 60% 62% 65% National 63% 64% 66% Not applicable BREAST Post-Mastectomy Care Radiation therapy is recommended or administered following any mastectomy within one year (365 days) of diagnosis of breast cancer for women with >= 4 positive regional lymph nodes (Accountability). Breast conservation surgery rate for women with AJCC clinical stage 0, I or II breast cancer (Surveillance). MMC 86% 91% 67% Virginia 92% 90% 94% National 90% 88% 87% >=90% COLON Lymph Nodes Removed and Pathologically Examined At least 12 regional lymph nodes are removed and pathologically examined for resected colon cancer. MMC 79% 95% 91% Virginia 91% 91% 91% National 90% 91% 92% >=85% COLON Adjuvant Chemotherapy Adjuvant chemotherapy is considered or administered within four months (120 days) of diagnosis for patients under the age of 80 with clinical or pathological AJCC T4N0M0 or Stage III receiving surgical resection for early rectal cancer. MMC 86% 100% 100% Virginia 94% 95% 93% National 91% 89% 88% Not applicable RECTUM Chemotherapy and Radiation Preoperative chemo and radiation are administered for clinical AJCC T3N0, or Stage III; or postoperative chemo and radiation are administered within 180 days of diagnosis for clinical AJCC T1-T2N0 with pathologic AJCC T3N0, T4N0, or Stage III; or treatment is recommended for patients under the age of 80 receiving resection for rectal cancer. MMC 67% 100% 100% Virginia 93% 93% 88% National 88% 88% 87% >=85%

10 2016 Community Outreach Cancer Awareness, Prevention and Screening In 2016, Bon Secours Maryview Medical Center engaged in a range of outreach activities to educate our community about preventing cancer and the importance of early screening for this disease. Breast Cancer Support Group January 25, 2016 Topic: Image Recovery February 22, 2016 Topic: Asking for Help April 25, 2016 Topic: Surviving Breast Cancer/Missionary Work The Pink Ride Leather & Lace Ball February 13, 2016 (150 participants) Breast cancer awareness and fundraising Bon Secours Weight Loss Support Group March 9, 2016 (35 participants) Topic: Colon Cancer Awareness and Prevention March 11, 2016 (49 participants) Topic: Colon Cancer Awareness and Prevention Colorectal Cancer Roundtable March 15, 2016 Topic: Colorectal Cancer Screening Sponsored by the Cancer Action Coalition of Virginia Bon Secours Colon Cancer Awareness 5K & 1-Mile Fun Run April 2, 2016 (374 participants) Raise colorectal cancer awareness The Sweet Truth About Metabolism and Weight Loss/Health Exhibits April 12, 2016 (100 participants) Oncology services information table Community Skin Cancer Screening (Jointly with EVMS) April 30, 2016 (123 participants) Bon Secours Aging Forum May 19, 2016 (481 participants) Topic: Colon, Prostate and Breast Cancer Awareness Suffolk Coders Association May 19, 2016 (24 participants) Topic: Colon Cancer Awareness and Prevention The Pink Ride Golf Tournament June 1, 2016 (100 participants) Breast cancer awareness and fundraising City of Portsmouth Employees Wellness Fair June 15, 2016 (145 participants) Topic: Breast, colon, skin and prostate cancer prevention and screening The Pink Ride Cornhole Tournament June 25, 2016 (100 participants) Breast cancer awareness and fundraising Portsmouth Public Schools Health Fair September 1, 2016 (1,300 participants) Oncology services information table Radio Promotion September 1-30, 2016 Topic: Prostate Cancer Awareness and Prevention Cancer Support Group October 18, 2016 Topic: Cancer Support ACS Making Strides Against Breast Cancer Walk October 22, 2016 (1,000 participants) Flagship sponsor Oncology services information table 2016 ZERO Prostate Cancer Run/Walk November 12, 2016 (400 participants) Oncology services information table

11 Varian TrueBeam Linear Accelerator at Maryview Medical Center Department of Radiation Oncology Bon Secours Cancer Institute Center at Harbour View

12 Bon Secours Maryview Medical Center 3636 High St., Portsmouth, VA 23707