SOMC Cancer Services. Annual Report. SOMC Cancer Center 1121 Kinneys Lane Portsmouth, OH (740)

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1 SOMC Cancer Services Annual Report 2015 SOMC Cancer Center 1121 Kinneys Lane Portsmouth, OH (740)

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3 the somc cancer services 2015 Annual Report SOMC Cancer Center 1121 Kinneys Lane Portsmouth, OH Contents SOMC Cancer Services Highlights & Happenings A Message from Cancer Registry Cancer Committee Members 2015 SOMC Case Accession Summary for Combined Calendar Years 2012, 2013, and 2014 SOMC Site Distribution Data Illustration for Diagnosis Years 2012, 2013, and 2014 Results that Demonstrate Quality Care Lung Cancer Special Report

4 1 SOMC Cancer Services Southern Ohio Medical Center (SOMC) is committed to providing quality cancer care in our region. We honor our commitment by offering a state-of-the-art center; innovative cancer screenings and prevention strategies; experienced, credentialed staff, physicians, and providers; top-notch cancer-fighting technology and procedures, National Cancer Institute clinical trials, and dynamic patient-centered relationships. The cancer program s connection to SOMC enables the team with a full complement of support services including nutrition counseling, genetic counseling and testing, patient navigation, survivorship care planning, palliative and hospice care, social work, rehabilitation, complementary medicine, behavioral health, and inpatient care. The excellent care provided is recognized through American College of Radiology (ACR) accreditation in radiation oncology, American College of Surgeons Commission on Cancer (ACoS) accreditation with commendations, SOMC s Joint Commission accreditation, and participation in the National Community Oncology Research Program (NCORP) that provides patients access to National Cancer Institute clinical trials. Highlights & Happenings Over the years the SOMC Cancer program has grown and changed. In the fall of 2015, the team welcomed Elliot Navo, MD to Radiation Oncology. Dr. Navo received his medical degree at the State University of New York: Downstate Medical Center College of Medicine in Brooklyn, NY. He completed his residency in Radiation Oncology at SUNY Downstate Medical Center in Brooklyn, NY. Additionally, SOMC Cancer Services added a fourth provider to complement the team, John Harcha, PA-C. John received a bachelor of science from Shawnee State University and his Master of Science in Physician Assistant Studies at Marietta College in Marietta, Ohio. John will participate in the management of cancer patients and cancer care and will further develop the process through which patients receive chemotherapy education, immediate acute-care visits, and survivorship care. Lastly, our cancer program has expended much effort in the further development of lung care, adding a lung navigator, Jennifer Woodyard, RRT, CPFT and introducing a lung nodule clinic. The lung navigator has a role along continuum of lung care through: Elliot Navo, MD + + Referring high-risk patients for early detection low-dose CT screening + + Analyzing information and taking action to facilitate patient wellness and healing + + Collaborating with the patient and the patient s family to ensure they are receiving the best care possible + + Facilitating provider recommendations for patient care to ensure understanding and compliance + + Helping patients with financial needs find resources for assistance + + Providing educational and emotional support + + Coordinating patient care between specialties John Harcha, PA-C Still, the SOMC cancer program is probably best known for extensive involvement in the region promoting cancer prevention strategies such as idon t.iwon t, cancer screenings and education, and healthy lifestyle education and programming. The SOMC Compassion Fund is extended to patients undergoing active cancer care. The SOMC Compassion Fund is widely supported by the region and every year access to assistance for the cancer patient population in our community grows. Jennifer Woodyard, RRT, CPFT

5 2 A Message from Cancer Registry The SOMC Cancer Registry Department supports all cancer activities within SOMC. The registrar oversees collection, quality assurance, lifetime follow-up, and analysis of data from patients diagnosed with cancer who receive all or part of their care at SOMC and those deemed reportable. Local, state and national cancer agencies use registry data in defined areas to make important health decisions that maximize the effectiveness of limited public health funds, such as the placement of screening programs. This contribution of information advances cancer knowledge and ultimately impacts cancer patient care. The primary responsibility of the cancer registrar is to ensure that timely, accurate, and complete data is incorporated and maintained on all types of cancer diagnosed and/or treated within SOMC. The ultimate goal is to learn from the data and reduce cancer death and illness nationwide. Collection and reporting of the data is of utmost importance. Registry data also serves as an ongoing resource to the cancer committee in determining the most effective allocation of resources, in determining community education and outreach initiatives, and monitoring program quality. The realm of a cancer registrar is ever changing, and seems to be changing even faster with the advancement of computers and the ability to capture data and report the data similarly for comparisons. In an effort to ensure SOMC s data is comparable to those collected at other programs around the country, the registrar adheres to established data rules. Keeping up with these changes is challenging, but the SOMC Cancer Registry department understands the significance of this work and is committed to continuously raising the bar SOMC Cancer Committee Members Thomas Summers, DO, FACOI Medical Oncology/Hematology Cancer Committee Chair Quality Improvement Coordinator Ben Gill, MBA Administration Vincent Scarpinato, MD, FACS, MBA General Surgeon/Breast Cancer Surgeon Cancer Liaison Physician Scott Logan, MD Diagnostic Radiology Janan Alkilidar, MD Diagnostic Radiology Bambi Overacre, RT(R)(MR)(CT) Medical Imaging Donna Corcoran, RT(R)(CT)(M) Breast Imaging Stephanie Hale, BSN, RN, CN-BN Breast Navigation Melissa Hutchens, BS, RT (R), RDMS Medical Imaging Christopher Shiepis, DO Urology Meghan Sexton American Cancer Society Rachelle Collins, RN, BSN, OCN Outpatient Oncology Community Outreach Coordinator Brooke Coriell Outpatient Rehabilitation Valerie DeCamp, RN, BSN, MHA, NE-BC Inpatient Nursing Ann Fankell, LSW, MSW, NADIII Cancer Center Social Work Psychosocial Services Coordinator Kristi Coleman, BS, CTR Cancer Registrar Linda Horner, RN, BSN, OCN, PCCN Inpatient Oncology Nursing Jamie Arnett, RN, OCN Clinical Research Representative Aubrey Roy Community Relations Debbie Daniels Physician Liaison Wendi Waugh, R.T. (R) (T) CMD, CTR, BS Administrator Cancer Services Cancer Registry Quality Control Chair Vincent Randaisi, DO, FACP Pathology Jill Preston, RN, MSN Community Health & Wellness Kimberlee Richendollar, RN, BSN, OCN Nurse Navigation Jennifer Woodyard, RRT, CPFT Lung Navigation Chad Lore, MS, NP-C Hospice and Palliative Care Jenny Smathers, RN, BSN, CHPN Palliative Care Elie Saab, MD Pulmonology Yinong Liu, MD, PhD Medical Oncology/Hematology Cancer Conference Chair Elliot Navo, MD Radiation Oncology Jessica Suber, MD Plastic Surgery George Shahade, DO ENT, Otolaryngology Andrea Barger Pulmonology Office

6 3 SOMC Case Accession Summary for Combined Calendar Years 2012, 2013, & 2014 Total % Male % Female % Oral Cavity & Pharynx Tongue Salivary Glands Gum & Other Mouth Nasopharynx Tonsil Oropharynx Other Oral Cavity & Pharynx Digestive System Esophagus Stomach Small Intestine Colon Excluding Rectum Cecum Ascending Colon Hepatic Flexure Appendix Splenic Flexure Descending Colon Sigmoid Colon Large Intestine, NOS Rectum & Rectosigmoid Rectosigmoid Junction Rectum Anus, Anal Canal & Anorectum Liver & Intrahepatic Bile Duct Gallbladder Peritoneum, Omentum, Mesentery Pancreas Respiratory System Larynx Lung & Bronchus Trachea, Mediastinum & Other Respiratory Organs

7 4 SOMC Case Accession Summary for Combined Calendar Years 2012, 2013, & 2014 Soft Tissue Skin Excluding Basal & Squamous Melanoma -- Skin Other Non-Epithelial Skin Breast Female Genital System Cervix Uteri Corpus & Uterus, NOS Ovary Vagina Vulva Male Genital System Prostate Testis Penis and Other Urinary System Urinary Bladder Kidney, Renal Pelvis & Ureter Brain & Other Nervous System Endocrine System Thyroid Other Endocrine including Thymus LYMPHOMA Hodgkin Lymphoma Non-Hodgkin Lymphoma Myeloma Leukemia Lymphocytic Leukemia Myeloid &Monocytic Leukemia Other Leukemia Mesothelioma Kaposi Sarcoma Miscellaneous Total 1,

8 5 SOMC Site Distribution Data Illustration for Diagnosis Years 2012, 2013, & 2014 Oral Cavity & Pharynx 18 (4%) Lung & Bronchus (30%) Thyroid - 22 (3%) Lung & Bronchus (19%) Breast - 271(41%) Pancreas - 11 (2%) Kidney & Renal Pelvis - 5 (<1%) Urinary Bladder - 29(6%) Prostate - 60 (12%) Colon & Rectum - 69 (14%) Kidney & Renal Pelvis - 3 (<1%) Ovary - 6 (<1%) Uterine Corpus 31 (5%) Colon & Rectum - 58 (9%) Non-Hodgkin Lymphoma - 20 (4%) Melanoma of the Skin - 24 (5%) Leukemia - 14 (3%) Non-Hodgkin Lymphoma - 28 (4%) Melanoma of the Skin - 24 (4%) Leukemia - 12 (2%) All Other Sites - 98 (20%) All Other Sites - 88 (13%) *** The number next to the site represents the number of cases diagnosed at SOMC diagnosis years 2012, 2013 and 2014 combined and the number in parenthesis represents the percentage this cancer site represents at SOMC for those same diagnosis years.

9 6 Results that Demonstrate Quality of Care Our accreditation by the American College of Surgeons Commission on Cancer allows the center to compare treatment standards and quality of care. The Commission on Cancer partners with the National Quality Forum (NQF), the American Society for Clinical Oncology (ASCO), and the National Comprehensive Cancer Network (NCCN). These organizations have identified quality cancer measures. The following graphs demonstrate the results of SOMC Cancer Care team compared to all approved East Central ACS, all approved programs with a similar type of accreditation as we hold-community Hospital Cancer Program-(CHCP), and all Commission on Cancer (CoC) approved programs for the CoC Accountability measures. We are very proud of our results. These results represent the latest published data, calendar year Radiation Therapy is Considered or Administered following Mastectomy for Women with 4 + Nodes 2013 Performance Radiation is Administered within 1 Year of Diagnosis for Women Receiving Breast Conserving Surgery 2013 Performance SOMC East Central ACS CoC Community Cancer Centers All Approved CoC Programs 80 SOMC East Central ACS CoC Community Cancer Centers All Approved CoC Programs Combination Chemotherapy is Considered or Administered within 4 months for AJCC T1cNO, or Stage IB-III Hormone Receptor Positive Breast Cancer 2013 Performance Aromatase Inhibitor is Considered or Administered within 1 year of Diagnosis for AJCC T1c or IB-III Hormone Receptor + Breast Cancer 2013 Performance SOMC East Central ACS CoC Community Cancer Centers All Approved CoC Programs 80 SOMC East Central ACS CoC Community Cancer Centers All Approved CoC Programs Adjuvant Chemotherapy is Considered or Administered within 4 months for AJCC III Colon Cancer 2013 Performance SOMC East Central ACS CoC Community Cancer Centers All Approved CoC Programs

10 7 Lung Cancer Special Report Thomas Summers DO, FACOI Medical Director Hematology/Oncology Elie Saab, MD Medical Director Pulmonology Cancer is the second leading cause of death in Ohio and in the United States. In 2015, 65,010 persons in Ohio are expected to be diagnosed with cancer of which about 10,000 cases will be lung cancer (fig 1). Figure 1. Number of New Invasive Cancer Cases for the Leading Cancers in Ohio, 2012 Lung and Bronchus Breast Prostate Colon and Rectum Bladder Melanoma of Skin Non-Hidgkin Lymphoma Kidney and Renal Pelvis Uterus Pancreas Thyroid New Cases Cancer is the second most common cause of death in Ohio and the United States, accounting for nearly one of every four deaths. Cancer claimed the lives of more than 25,000 Ohioans in 2012, at a rate (182.0 per 100,000) 9 percent higher than the U.S. rate (166.5 per 100,000). Figure 2 Cancer mortality rates in Ohio varied by county in Scioto County had an age-adjusted cancer mortality rate of (212 per 100,000) higher than the US Rate of 165 per 100,000 (Figure 2). The majority of counties with the highest cancer mortality rates were located in the Appalachian and/or southern regions of Ohio. Lung and bronchus cancer was the leading cause of cancer death in Ohio in 2012, representing 29.8 percent of all cancer deaths. The National Cancer Institute at the National Institutes of Health estimates that, in 2015, approximately 221,200 new cases of lung cancer will be diagnosed in the United States and that the disease will claim about 158,000 lives annually more than breast, prostate, ovarian, colon and lymph cancers combined (Figure 3). (740)

11 8 Figure 3 Estimated New Cases in ,200 % of All New Cancer Cases 13.3% Estimated Deaths in ,040 number per 100,000 persons New Cases Deaths Percent Surviving 5 Years 17.4% % of All Cancer Deaths year Lung cancer is more common in men than women, particularly African American men. The number of new cases of lung and bronchus cancer was 58.7 per 100,000 men and women per year based on cases (Figure 4). The median age at diagnosis is 70 (Figure 5). Figure 4 Number of New Cases per 100,000 Persons by Race/Ethnicity & Sex: Lung and Bronchus Cancer male female 70.1 All Races White Black Asian Pacific Islander American Indian Alaska Native Hispanic Non-Hispanic 53.5 Figure 5 Percent of New Cases by Age Group: Lung and Bronchus Cancer Percent of New Cases % < % 27.6% 21.4% 8.4% 9.1% 0.3% 1.2% >84 age Lung and bronchus cancer is most frequently diagnosed among people aged Median Age At Diagnosis 70 Lung cancer is the leading cause of cancer deaths in both men and women. This should not be the case, as lung cancer is also one of the most preventable cancers. It is generally accepted that more than 60% of all cancers are related to personal lifestyle or environmental factors, such as smoking and diet, and are therefore preventable. According to the 2014 Surgeon General s Report, 87% of lung cancer deaths are preventable. Other factors such as age, gender and family history of cancer are also associated with the development of cancer and aid in the identification of people at high risk. Early detection is stressed, but for some cancers, prevention is much more beneficial. Lung cancer is a disease that takes many years to develop and often spreads

12 9 to other parts of the body before it is detected. Early detection options have been limited and routine radiographic screening for specific patients may be helpful. In response to this, the National Institute of Health conducted the National Lung Cancer Screening Trial (NSLT). The trial included 50,000 patients and demonstrated a reduction of all-cause of mortality by 6.7% and lung cancer relative death risk rate reduction of 20% (NEJM). The United States Preventative Task Force [USPSTF) subsequently recommended the use of low-dose CT scans for screening for patients with high-risk criteria: to 77 years of age + + Tobacco smoking history of at least 30-pack-years + + Either a current smoker or one who has quit smoking within the last 15 years + + No diagnostic CT of chest in the past 18 months + + No prior history of lung cancer + + No active signs or symptoms In November of 2014 the Centers for Medicare and Medicaid released a coverage decision providing payment under the Accountable Care Act. This coverage will extend to an estimated 4 million people, many of whom are at greatest risk for the disease. Scans would cost recipients nothing; the coverage would apply to beneficiaries that meet the established criteria. Under the Affordable Care Act, private insurers must also cover such screenings. SOMC responded to the coverage decision and is leading the way in our community with the development of a robust lung cancer screening program coupled with smoking cessation teaching and intervention strategies. A task force comprised of radiology, pulmonology, surgery, oncology nursing, and respiratory therapy disciplines has built upon our Lungs for Life program. Under this program, patients with high-risk criteria were enrolled and received CT scan provided by SOMC, Radiologists, and the Scioto Foundation. Additions to the program in 2015 include the introduction of a dedicated pulmonary nodule clinic, shared decision-making provider visits, and lung navigation. SOMC also recently purchased a software program to maintain data and report results to the ACR registry. The screening program is certified by the ACR (American College of Radiology) as an accredited center for lung cancer screening. Much like the breast cancer registry the lung registry data will be entered and referred to the ACR by CMS. It is our desire to meet the need of patients in a timely fashion while maintaining a high standard of detection and management according to the latest evidence-based guidelines. It is important to highlight that smoking cessation is an integral part of this program. Nearly 50% of the scans will have an abnormality, 96% of which will be false positive meaning that patients most likely will be observed with serial CT scans. Patients should talk with their healthcare providers about the benefits, limitations and potential harm of lung cancer screening. Screening should only be done at facilities like SOMC through which ACR accreditation has been achieved and the center has met all the criteria to perform the screening exams. Smoking is the leading cause of preventable death in the United States and is by far the leading risk factor for developing lung cancer. It is estimated 80% of lung cancers and 30% of other types of cancer result from smoking. Smokers exposed to radon and asbestos are at even higher risk. Cigar and pipe smoking are almost as likely to cause lung cancer as cigarette smoking. Nonsmokers who breathe in second-hand smoke are also at a 20% increased risk. Air pollution and increased age are factors, and women who smoke seem at greater risk for developing cancer than men who smoke. Stopping smoking at any age lowers the subsequent risk of developing lung cancer. Smoking kills more people than alcohol, AIDS, automobile accidents, illegal drugs, murders and suicides combined. Figure 6 graphically shows 70% of the lung cancer patients diagnosed at SOMC resided in Scioto County. Surrounding Ohio counties and neighboring counties in Kentucky represent

13 10 the other 30% of the diagnoses. Last year, SOMC diagnosed 52 female and 45 male patients. The majority of female patients were diagnosed within the age group of while the male patient majority was diagnosed in the age group. The average age at diagnosis nationally for both genders is the age group (Figure 7) County Distribution of Lung Cancer Accessioned by SOMC Scioto Pike Adams Figure 6 Brown Depending on how cells appear when examined Highland Figure 7 SOMC 2014 Lung Cancer Cases Age at Diagnosis Kentucky Women Men under a microscope, lung cancer is divided into two main categories: small cell/neuroendocrine/ carcinoid (nationally 20% of the diagnoses) or non-small cell (NSCLC) (80%). The treatment courses are very different based on the histology. Small cell occurs almost exclusively in smokers and non-small cell encompasses several similar sub-types: adenocarcinoma, squamous cell carcinoma and large cell carcinoma. Figure 8 shows the national distribution compared to the 2014 SOMC distribution All NSCLC specimens are processed for Figure 8 National Lung Cancer Histology SOMC 2014 Histology Small Cell Squamous Non-small cell-not specified Adenocarcinoma Other Small Cell Squamous Adenocarcinoma Carcinoid Acinar All Other molecular testing. Identifying targeted therapies and applying them when appropriate is proving beneficial. Patients are also enrolled in clinical trials when appropriate. The interventional bronchoscopy lab is equipped with the latest tools available for less invasive techniques. The staff is skilled in computerized navigational bronchoscopy, peripheral bronchoscopy and central airway bronchoscopy. Central airway bronchoscopy is mainly used to obtain specimens from lymph nodes surrounding the tracheobronchial tree and is an essential tool for staging. Patients with lymph node involvement around the trachea should undergo a nonsurgical therapeutic approach. The interventional radiology staff complements the team obtaining percutaneous aspirates when required. Rapid on-site (ROSE) cytology specimens are analyzed real-time to help guide sampling. The cytopathologist assists in the bronchoscopy suite to provide feedback to the sampling bronchoscopist. SOMC encourages a multidisciplinary approach to the diagnoses of lung cancer and the following therapeutic interventions. The yield of the SOMC bronchoscopy lab specimens is higher than the national average. In fact, with our approach SOMC diagnoses more patients in earlier stage than nationwide in both NSCLC and small cell lung cancers (Figure 9 & Figure 10).

14 Percentage Surviving 11 SOMC Compared to NCDB NSCLC Stage at Diagnosis Data SOMC Compared to NCDB Small Cell Lung Cancer Stage at Diagnosis Data Figure 9 Figure Stage I NCDB Stage II SOMC Stage III Stage IV Stage I NCDB Stage II SOMC Stage III Stage IV Figure SOMC Lung Cancer First Course of Treatment D D, R, C D, C D, P S D=Diagnostic Biopsy D, R R=Radiation D, S C=Chemotherapy D, S, R, C P=Palliative R S, C S=Surgery Other Based on type and stage of cancer, treatments include surgery, radiation therapy, chemotherapy and targeted therapies. Early stage cancer may be treated only with surgery, and later stage cancer usually is treated with several modalities. The SOMC first course of treatment combinations are pictured below (Figure 11). The national one-year relative survival for all lung cancers combined increased from 34 percent in to approximately 51 percent in , largely due to improvements in surgical techniques and combined therapies. Figure 12 reflects the one-year survival (all stages combined) for analytic cases diagnosed at SOMC compared to NCDB. The national five-year survival rate is 54% for cases detected when the disease is still localized, 26% for patients with regional disease and 4% for patients with distant-stage disease. SEER data shows reflecting the national five-year survival rates. The graph below compares SOMC (solid line) to NCDB (dashed line) five-year survival by Stage using AJCC Staging Manual 6th Edition for Analytic NSCLC patients (Figure 13). All Stages One-Year Observed Survival Analysis Cases of NSCLC Comparing SOMC to NCDB SOMC NDCB Figure 12 Figure 13 Observed 5-Year Survival for SOMC Analytical NSCLC Compared to NCDB Number of Months Stage I Stage II Stage III Stage IV Stage I NDCB Stage II NDCB Stage III NDCB Stage IV NDCB

15 12 As displayed there are some differences in survival especially in the early stages. Several factors may explain the differences and several strategies have been implemented to lessen the gap such as ebus, navigational bronchoscopy, better staging techniques, better targeted treatment techniques and lastly management of the entry points into the comprehensive lung navigation program. As illustrated in Figure 14 below, pulmonary nodules identified through screening or diagnostic CTs lead to expected next steps and a diagnosis of lung cancer if applicable. Upon diagnosis, the tumor board committee meets again to discuss options and therapeutic recommendations. These discussions are documented and the recommendation can be found in the patient s medical record. Consideration of the functional capacity, physiological determinants, radiographic analysis, and clinical stage drive the patient s treatment recommendations. The final AJCC stage, pathology, and molecular characteristics are important in determining what therapeutic modalities are recommended. Stage I and stage II lung cancers are evaluated for lung resection or stereotactic ablative radiation therapy. The SOMC Cancer Committee has adopted NCCN guidelines as guiding principles in both management and recommendations for all stages of lung cancer diagnosed in the institution. Figure 14 Screening CT Diagnostic CT Pulmonary Nodule LR1 /LR2 Return Subsequent Year for Repeat Screen LR3 Pulmonary Visit for FUP Discussion pulmonary visit LR4 or Higher tumor board diagnostic surgical procedure or pet The Cancer Committee also monitors detection to diagnosis, diagnosis to treatment, and other indicators of surgical resection specimen adequacy as required by the national guidelines SOMC Performance Data Indicator Average detection to diagnosis elapsed Average report to biopsy Average pathology turnaround Average diagnosis to treatment Performance 29 days 27 days 2 days 45 days At least 10 regional lymph odes are removed for resected AJCC IA to IIB NSCLC 11% Systemic chemotherapy is administered within 4 months pre-op or 6 months post-op when appropriate 100% (740)

16 13 The SOMC Cancer Committee is focused on decreasing detection to diagnosis and detection to treatment elapsed days. In addition SOMC Cancer Committee has issued a Standard of Care for both Lung Surgery and Lung Screening. These Standards of Care are aimed to educate and hold staff increasingly accountable for these important standards (Figure 15 and Figure 16). There is an abundant need for further work in the field of lung cancer. Our team is dedicated and proud of the accomplishments and even more excited about the work underway. Figure 15 Figure 16 (740)

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20 SOMC Cancer Center 1121 Kinneys Lane Portsmouth, OH (740)