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1 2014 Annual Report

2 From the Cancer Committee Chair 2014 was a busy year for the Cancer Center at EAMC. First and foremost, I would like to recognize our official approval from the Commission on Cancer. We were last surveyed on October 22, 2013, by Dr. Marvin Jose Lopez. At that time, we were granted a three-year approval award with contingencies. Through the hard work of our dedicated staff, we were able to successfully satisfy all contingencies, and now have full approval for three years, with commendations in five of eight areas. While quite satisfying, we continue to aim to improve. Our goal for the 2016 survey remains the same full approval with commendations in every area possible. Thus far, we are on track! Dr. Peggy Howland and Chelsea Kroll, LGSW, have started a new initiative called From Cancer to Health, a stress management and coping intervention for new cancer patients. The program includes 16 weekly sessions and monthly follow-up sessions for 8 months to provide continued support. This is a no-cost service for EAMC patients. Additionally, the program has a clinical trial component which will help the Cancer Center fulfill Commission on Cancer standards. We are also excited to report that Lee Pathology has joined the EAMC family, which should help us to further streamline services and pathology reporting, as well as standardize pathology reports. Our pathologists, as well as other specialists including radiology, radiation oncology, and surgery, continue to serve voluntarily on the Cancer Committee. Their commitment to excellence and service is just one of the many things that help our Cancer Center excel. The Infusion Center Extension (ICE) was recently expanded, giving us more than 100% improvement of space and patient capacity. This translates to more efficiency, and more availability for our transfusion and iron-requiring patients. Our main infusion room continues to thrive, and we very soon will need to explore options to expand our services. The robust program in radiation oncology continues. Growth options are being explored including the addition of a physician assistant, nurse practitioner, or an additional radiation oncologist. Two new initiatives for 2015 are the addition of low dose chest CT scans for early detection of lung cancer in high risk patients, and adding SIRTEX a radioisotope used to treat metastatic lesions of the liver. This would also entail interventional radiology, again demonstrating our multi-disciplinary approach. Other goals for 2015 have been outlined, and include: Initiate collaborative opportunities with other institutions to expand clinical research at EAMC Strive to meet 8/8 areas of commendation in the 2016 Commission on Cancer survey Find additional ways to streamline our processes to improve patient care and safety Our entire staff remains dedicated to providing quality, patient-centered care. While we believe we are already an excellent Cancer Center, there is always room for improvement. We look forward to 2015! Brandon Johnson, M.D. 2 The Cancer Center of East Alabama 2014 Annual Report

3 Cancer Committee Members (2014) Brandon Johnson, MD Medical Oncology, Committee Chair Njideka Obiekwe, MD Gynecology, Cancer Liaison Physician John Cabelka, MD Radiation Oncology Cancer Conference Coordinator Katrin Klemm, MD Pathology Johnathan Hadley, MD Radiology Allen Foster, MD Surgery Chris Clark, Asst. VP Clinical Services Cancer Committee Attendees Linda Farmer, MD Medical Oncology Edith Graves, MD Medical Oncology Kressida Cain Benson, MD Pathology Michael Johnson, MD Pathology Clay Harper, MD Surgery Justin Phillpott, MD Radiology Jeanie Mann American Cancer Society Beth Butz, Pharm.D., BCPS Pharmacy John Faircloth, MMSc Medical Physicist/Director, Radiation Oncology Gabe Hedges, CMD Dosimetrist Kathe Briggs Disease Mgmt./Wellness Services Mandy Levins, RN Inpatient Oncology Kathy Clanton, RN Inpatient Oncology Jody Shields, OTR/L, CLT Rehabilitation Services Noelle Stewart, RD, LD Clinical Dietitian Services Jody Kirkley, RN Hospice Services Trevis Hawkins, RN, BSN Director, Medical Oncology Wendy Richardson, CTR Cancer Registry Coordinator Colleen Alsobrook, RN Breast Health Navigator, Community Outreach Coordinator Amber Davis, RN Clinical Research Coordinator, Cancer Registry Chelsea Kroll, MSW, LGSW, OSW-C Social Work Services, Psychosocial Services Coordinator Andrea Davis, RN Quality Improvement Coordinator Jayme Gardner, RN, BSN Patient Safety Services Laura Grill Exec. VP/Administrator, Patient Care Services Sheila Grant, CTR Cancer Registry Michelle Holloway, RN Cancer Center Linda Parker, RN Cancer Center Stephanie Duran, MSW Cancer Center Susan Fitzwater, RN Cancer Center Tanya Rice, RN Performance Improvement The Cancer Center of East Alabama 2014 Annual Report 3

4 Cancer Registry Report The Cancer Registry collects data on all cancer patients who were diagnosed and/or treated at East Alabama Medical Center. Diagnostic, therapeutic and outcome statistics are collected and evaluated in a database which provides easy access to information. The Cancer Registry is supervised by the Cancer Committee to ensure compliance with the American College of Surgeons Commission on Cancer for the Comprehensive Community Hospital Cancer Program. The Cancer Registry participates with the National Cancer Wendy Richardson, CTR Cancer Registry Coordinator Data Base and submits to the Alabama Statewide Cancer Registry for Cancer Statistics. The Cancer Registry continues to provide lifetime followup on all cancer patients accessioned into the registry. The current 5-year follow-up rate is 90.09% and reference year follow-up rate is 84.05%. The information, including disease status, treatment and mortality information, keeps the cancer care team informed on the status of their patients. Cancer Conferences 2013 East Alabama Medical Center cancer conferences are multidisciplinary conferences held bi-monthly. The conference includes individual cancer presentations and is open to the entire medical staff and allied care professionals. The medical, surgical, and radiation oncology perspectives of each case are reviewed and correlated with its radiologic and pathologic findings. Cancer conferences are integral to improving the care of cancer patients by contributing to the patient management process, monitoring outcomes and providing education to physicians and other staff. In 2013, 24 cancer conferences were held and 110 patient case presentations were made. The following table gives a summary of the cases presented. EAMC s Mission, Vision and Values MISSION High quality, compassionate health care VISION To be a national leader in quality, cost and service VALUES Excellence Integrity Compassion Respect Teamwork Site Cases Presented Head and Neck 11 Digestive System 17 Respiratory System 23 Breast 13 Soft Tissue 3 Skin Excluding Basal/Squamous cell 2 Female Genital System 4 Male Genital System 8 Urinary System 2 Brain/Nervous System 1 Endocrine System 6 Lymphomas 10 Myeloma 3 Leukemia 1 Unknown Primary 6 TOTAL FOR ALL SITES 110 The Cancer Center of East Alabama 2014 Annual Report 4

5 2013 Distribution of Cases The East Alabama Medical Center Cancer Registry accessioned 735 cancer cases for This total includes both analytic and non-analytic cases with analytic cases totalling 702. A brief overview of the distribution of new cancer cases that were diagnosed and/or treated (analytic cases) at East Alabama Medical Center follows. Of the 702 analytic cases accessioned, 357 (51%) were male and 345 (49%) were female. Of these patients, 49.15% of patients reside in Lee County while 48.3% reside in other counties of Alabama, and 2.55% reside within other states. The top 5 major sites of cancer seen at this institution were breast, prostate, lung, colon, and hematopoietic. 160 Age at Diagnosis by Gender 140 Clay 1 Randolph Male Female Autauga 1 Coosa 4 Elmore 6 Montgomery 3 Tallapoosa 55 Macon 40 Bullock 7 Chambers 154 Lee 345 Russell 31 Troup 7 Harris 7 Muscogee Pike 1 Barbour Best AJCC * Stage by Gender Male Female 60 AL-County Unk - 1 CO-Moffat - 1 FL-Manatee - 1 GA-Crawford - 1 GA-Crisp - 1 ZZ-County Unk Stg 0 Stg I Stg II Stg III Stg IV 88 Unk Class of Case Report Analytic Data *American Joint Committee on Cancer Cancer Cases Diagnosed/Treated by Race and Gender Race Male Female Total White Black American Indian, Aleutian, Eskimo Chinese Japanese Vietnamese Other Asian, Asian/Oriental Other Total The Cancer Center of East Alabama 2014 Annual Report

6 Prostate Cancer: To treat or not to treat is just as important as how to treat By John Cabelka, M.D. It is difficult to appreciate the whirlwind of events associated with a diagnosis of cancer. It is assumed that the first decision fork in the road after a cancer diagnosis is how to treat the cancer. This is not necessarily the case, in particular with prostate cancer a cancer that is often slow growing/ well behaved. Prostate cancer is most often diagnosed in men greater than 60 years of age. Men at this age often have other illnesses, many of which are more life threatening than prostate cancer. Therefore, many men will die with it rather than of it. In keeping with the healthcare mandate to first do no harm, we would like to spare men who do not need or who would not benefit from treatment the potential side effects related to such. In addition, considering a larger scope, the decision to treat or not has implications on society. The cost of healthcare in America is at an alarmingly high level and rising. The reasons are multiple, and all facets need to be reviewed. Cancer care is expensive. Over-utilization is a catchall term that includes over-treatment. In the cancer arena, over-treatment is essentially treatment rendered but not effective. Take, for example, a patient with cancer X. After surgery, the cure rate with no further treatment is 80% but increases to 90% with chemotherapy. If 100 patients with cancer X receive chemotherapy, we know 80 will not benefit because they were cured following surgery. We also know that 10 patients will die even though they receive chemotherapy; therefore, 9 out of 10 patients will not benefit from chemotherapy (they were cured already or they were doomed to die of the disease). Only 10 out of the 100 patients (1 out of every 10 patients treated) will benefit from chemotherapy. Said another way, 9 of 10 patients receiving treatment will only experience the side effects of treatment (no benefit) and an enormous amount of healthcare money is wasted ( a double whammy ). So over-treatment includes therapy for (1) someone who is doomed to die of disease no matter the treatment, (2) someone who is already cured and does not require treatment and, (3) someone who will die of something other than the disease, i.e. die with it rather than of it. This leads back to prostate cancer, a disease where some 30% of all men in their 50s, and as many as 70% of all men in their 80s will have cancer in their prostate at autopsy (they died not of prostate cancer). The question to treat is further complicated by not only considering whether someone will die of the disease, but whether the disease will become symptomatic in that patient s lifetime without aggressive treatment. Prostate cancer likes to spread to bone causing bone pain and a subsequent decrease in quality of life. Men can live many years even when prostate cancer has spread. The Cancer Center of East Alabama 2014 Annual Report 6

7 PSA screening has led to an increase in prostate cancer diagnoses usually at an earlier stage. Ideally, treatment would be delivered (1) to cure men who would 20 otherwise die of prostate 16.6 cancer or (2) to prevent 15 symptoms in those where untreated cancer will cause 5 such. Prostate cancer in general is a slow-growing 0 cancer. Even the more aggressive prostate cancers are not anywhere near as aggressive as pancreas and lung cancers. Patients rarely die soon after a diagnosis of prostate cancer they can 8 8 live many years even when 6 4 no treatment is rendered. 2 So, the first decision fork 0 in the road is to consider the overall health of the patient. Does he have a good chance of living 5 years? If not, then curative treatment is rarely indicated (in fact PSA testing was probably not indicated, but who should we screen for prostate cancer is another discussion). In fact, a patient should have a good chance of living another 10 years before offering aggressive therapy. The National Comprehensive Cancer Network, which supplies recommended guidelines for cancer treatment, has an older adult oncology guideline. A component is the comprehensive geriatric assessment, a tool that can help predict a person s remaining lifetime Years Years and thus the need for cancer treatment. Here is a portion of a life expectancy chart based on age: Upper, Middle and Lower QuarAles of Life Expectancy for Women at Selected Stages* Upper, Middle and Lower QuarAles of Life Expectancy for Men at Selected Stages* Age Age *Data from the Life Tables of the United States See the life expectancy tables in the National Vital Statistics Reports at httg:// /nvsr gdf Genetic evaluation of prostate cancer, on a case by case basis to determine the aggressiveness, is on the horizon. This type of evaluation is used in breast cancer indicating who will and won t benefit from treatment. I have just been diagnosed with cancer and you recommend no treatment? When discussing prostate cancer with patients, no treatment is often lumped in with different forms of prostate cancer therapy. Patients are told of surgery, radiation, or hormone treatment Top 25th Percen5le 50th Percen5le Lowest 25th Percen5le 4.6 Top 25th Percen7le 50th Percen7le Lowest 25th Percen7le The Cancer Center of East Alabama 2014 Annual Report

8 options as well as doing nothing where nothing can be watching, active surveillance, waiting, etc. Nothing from the patient s perspective often means letting it grow. This is when physicians need to spend time educating and reassuring patients and their families. We need to have the treatment versus no treatment discussion with men more frequently. Moreover, this needs to be done prior to the what type of treatment is available discussion. The following graph shows 5-year survival rates for patients treated with curative intent at EAMC. The data is in good accordance with national survival rates. Since it is unlikely for a man diagnosed with non-metastatic prostate cancer (i.e. prostate cancer that has not spread) to die of the disease within 5 years, this graph serves to show how well patients are chosen for curative treatment. For example, if the graph shows a significant number of deaths, it is likely those deaths were due to other causes and that prostate cancer treatment was not necessary. In essence, physicians would like to know who is going to die with, rather than of, prostate cancer, and secondly, who is destined to die of the disease despite treatment. The remaining patients would benefit from treatment (and thus should be offered curative treatment). It is reasonable to assume that if a man dies within 5 years of receiving curative prostate cancer treatment, (1) he likely did not die of prostate cancer and (2) probably would not have died of the cancer without treatment and (3) therefore did not require therapy. In fact, with newer treatment options, if a patient dies within 10 years of his curative prostate treatment, he may not have actually required such. These are discussion points that I have with each and every one of my prostate cancer patients, ensuring their understanding before we even start to discuss possible curative treatment options. Putting a diagnosis of prostate cancer in perspective and considering no treatment is an important discussion, one that all too often goes unsaid. East Alabama Medical Center Observed Survival by Best CS/AJCC Stage The Cancer Center of East Alabama 2014 Annual Report 8

9 P rimary Site Table Status Sex Class of Case Stage Distribution - Analytic Cases O Primary Site Total (%) M F Analy NA Alive Exp Stg 0 Stg I Stg II Stg III Stg IV 88 Unk ORAL CAVITY & PHARYNX 33 (4.5%) Tongue 6 (0.8%) Salivary Glands 1 (0.1%) Floor of Mouth 3 (0.4%) Gum & Other Mouth 5 (0.7%) Nasopharynx 1 (0.1%) Tonsil 12 (1.6%) Oropharynx 3 (0.4%) Hypopharynx 2 (0.3%) DIGESTIVE SYSTEM 127 (17.3%) Esophagus 9 (1.2%) Stomach 10 (1.4%) Small Intestine 6 (0.8%) Colon Excluding Rectum 63 (8.6%) Cecum Ascending Colon Hepatic Flexure Transverse Colon Splenic Flexure Descending Colon Sigmoid Colon Large Intestine, NOS Rectum & Rectosigmoid 18 (2.4%) Rectosigmoid Junction Rectum Anus, Anal Canal & Anorectum 3 (0.4%) Liver & Intrahepatic Bile Duct 7 (1.0%) Gallbladder 1 (0.1%) Other Biliary 4 (0.5%) Pancreas 5 (0.7%) Peritoneum, Omentum & Mesentery 1 (0.1%) RESPIRATORY SYSTEM 104 (14.1%) Nose, Nasal Cavity & Middle Ear 4 (0.5%) Larynx 10 (1.4%) Lung & Bronchus 90 (12.2%) BONES & JOINTS 1 (0.1%) Bones & Joints 1 (0.1%) SOFT TISSUE 4 (0.5%) Soft Tissue (including Heart) 4 (0.5%) SKIN EXCLUDING BASAL & SQUAMOUS 11 (1.5%) Melanoma -- Skin 10 (1.4%) Other Non-Epithelial Skin 1 (0.1%) BASAL & SQUAMOUS SKIN 2 (0.3%) Basal/Squamous cell carcinomas of Skin 2 (0.3%) BREAST 151 (20.5%) Breast 151 (20.5%) FEMALE GENITAL SYSTEM 40 (5.4%) Cervix Uteri 9 (1.2%) Corpus & Uterus, NOS 14 (1.9%) Ovary 14 (1.9%) Vulva 2 (0.3%) Other Female Genital Organs 1 (0.1%) MALE GENITAL SYSTEM 108 (14.7%) Prostate 104 (14.1%) Testis 3 (0.4%) Penis 1 (0.1%) URINARY SYSTEM 47 (6.4%) Urinary Bladder 23 (3.1%) Kidney & Renal Pelvis 23 (3.1%) Ureter 1 (0.1%) EYE & ORBIT 1 (0.1%) Eye & Orbit 1 (0.1%) BRAIN & OTHER NERVOUS SYSTEM 7 (1.0%) Brain 6 (0.8%) Cranial Nerves Other Nervous System 1 (0.1%) ENDOCRINE SYSTEM 14 (1.9%) Thyroid 13 (1.8%) Other Endocrine including Thymus 1 (0.1%) LYMPHOMA 37 (5.0%) Hodgkin Lymphoma 6 (0.8%) Non-Hodgkin Lymphoma 31 (4.2%) NHL - Nodal NHL - Extranodal MYELOMA 8 (1.1%) Myeloma 8 (1.1%) LEUKEMIA 20 (2.7%) Lymphocytic Leukemia 10 (1.4%) Myeloid & Monocytic Leukemia 10 (1.4%) Acute Myeloid Leukemia Chronic Myeloid Leukemia Other Myeloid/Monocytic Leukemia MESOTHELIOMA 1 (0.1%) Mesothelioma 1 (0.1%) MISCELLANEOUS 19 (2.6%) Miscellaneous 19 (2.6%) Total