Download 2014 CANCER TREATMENT PROGRAM

2014
CANCER TREATMENT PROGRAM
Comprehensive Care, Close to Home
Cancer Care Service Line
Mary Gunkel, RN, Oncology Service Line Director
Contents
2014 Cancer Treatment Program at Confluence Health
3 Cancer Care Service Line
12 2014 Accomplishments
4 Our Cancer Program
13 Comparative Data
5 Mammography Screening
13 Quarterly Results for Cancer Care
8 Non-Hodgkin’s Lymphoma
15 2014 Cancer Committee
Our Approach
The Cancer Program at Confluence Health
offers a full range of medical services along
with a multidisciplinary team approach to
patient care.
Our program and treatment center is
affiliated with the Seattle Cancer Care
Alliance and accredited by the Commission
on Cancer, which sets stringent guidelines
to improve patient outcomes and promotes
consultation among surgeons, medical and
radiation oncologists, pathologists and other
cancer specialists.
Comprehensive Care
ACS CoC Accreditation
In 2014 Confluence Health launched its
Cancer Care Service Line. The structure and
leadership were defined by the administrative
leadership of Confluence Health who worked
with consultants and looked at models in other
prominent healthcare systems. This brings the
comprehensive oncology services and care that
occurs in Confluence Health under the same
leadership moving in a common direction. It
allows the Confluence Health Cancer Program
to evaluate and direct patient care across the
continuum at all locations it is received. This
enables the leadership to develop a strategic
plan that has priorities based on needs of the
communities and patients it serves.
The Confluence Health Cancer Program was
awarded full accreditation by the American
College of Surgeons Commission on Cancer
with several areas of commendations in 2014.
The areas of commendation were in:
Our Priorities
We provide state-of-the-art pretreatment
evaluation, staging, treatment and clinical
follow-up for many hundreds of patients each
year. The following report is an analysis of
our program in 2014 and includes statistical
data abstracted from the previous year.
We recognize that cancer is a complex group
of diseases and that each diagnosis is a lifechanging event for every patient. And this
is why we firmly believe that setting goals,
monitoring activity and evaluating our
services are critical components to improve
patient care.
Our present areas of focus and priorities were
based on a community needs assessment that
was done in our region and a patient survey.
The assessment and patient survey pointed us to
areas where gaps existed and by filling in those
gaps we could improve the care for our patients.
Our present priorities and focus are:
•Development and implementation of an
•Clinical Trial Accrual
•Nursing Care
•Public Reporting of our outcomes
•Adherence to the College of American
Pathologist Protocols
•Accuracy of our data
•Education of Cancer Registry Staff
•Participation in Rapid Quality Reporting
System
We were also noted to have best practices
in the areas of survivorship care, palliative
care, and nurse navigation. The surveyor
from the Commission on Cancer noted that
the development and implementation of our
cancer care service line was a notable advance
that would allow continual improvement in
the care of our patients.
oncology nursing role that navigates the
patient across the continuum of care
•Improving the social navigation and support
for cancer patients
•Improving the financial navigation for
cancer patients
Wenatchee, WA
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Our Cancer
Program
Ancillary Services
Financial Services, Nutrition
Services, Behavioral Health
Services, Physical and
Occupational Health Services,
Rehabilitation Services,
Pharmacy Services, Social
Services, Palliative Care, and
referrals to Genetic Counselors
and Pastoral Care.
Cancer Board
A weekly multidisciplinary
conference that includes Medical
and Radiation Oncologists,
Primary Care Physicians,
Specialists, Surgeons,
Radiologists, Pathologists,
Palliative Care, Nurse Navigation
and Tumor Registrars to approach
case consultation from different
perspectives.
Cancer Committee
Provides leadership over
operations and continually
evaluates cancer program.
Cancer Registry
Provides collection of data
through abstraction on all
patients diagnosed with
and/or treated for cancer at
Confluence Health into an
electronic database.
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Screening Mammograms
Julie Smith, MD, Medical Oncology and Randal Moseley, MD, Quality Department
Inpatient Services
Palliative Care
Inpatient care of oncology
patients happens at both
Central Washington Hospital and
Wenatchee Valley Hospital. Both
hospitals provide surgery and post
surgical care for oncology patients.
Central Washington Hospital
provides inpatient oncology care
which includes chemotherapy
administration by chemotherapy
trained nursing staff.
Palliative care is provided by a
multidisciplinary team in both the
inpatient and outpatient settings
to improve a patients quality
of life by providing specialized
medical knowledge and an extra
layer of support. This team can
manage pain and symptoms,
assist patients and families to
navigate the healthcare system
and make informed decisions
about their care.
Medical Staff
A complete range of Medical,
Surgical and Radiation specialty
departments involved in the care
of cancer patients. Our core of
board-certified specialists includes
Medical Oncologists, Radiation
Oncologists, Hematologists, General
Surgeons, Radiologists, Breast
Imaging Specialists, Pathologists
and Nurse Practitioners.
Oncology Certified
Nursing
Nurse Navigation, Case
Management and Infusion Nurse
Services available to patients
throughout their cancer care.
Outreach
Treatment provided by Medical
Oncologists, Nurse Practitioners,
and Oncology Certified Nurses at
Confluence Health’s Moses Lake
Clinic and Omak Clinic. Infusion
services are also provided at both
Moses Lake and Omak.
Research
Access to promising
investigational and innovative
therapies through participation
in national and institutional
trials, including trials through our
affiliation with the Seattle Cancer
Care Alliance.
Support Services
Seattle Cancer Care Alliance,
American Cancer Society,
Wellness Place and Resource
Center, Support Groups, Exercise
Programs, Housing Assistance
Services and other community
resources to help with cancer
prevention and early detection.
Survivorship
Program
A special program to enhance
the care for our cancer survivors
and augment communication
with the providers who care for
cancer survivors.
Breast Cancer is one of the most common
cancers among women. All major health professional
organizations recommend routine screening
mammograms for women between the ages of
50-74. However, there is wide variation among
these same organizations regarding use of screening
mammograms in women under age 50 and over age
75. There is also controversy regarding how often to
have mammography between the ages of 50-74.
Balancing Benefits with Harms
The reason for all this variation and controversy
relates to the limitations and potential harms of all
cancer screening tests. These limitations include
not finding a cancer that is actually present as
well as triggering further tests when the results are
uncertain. Perhaps most concerning is the potential
harm of “over-diagnosis”. Some cancers found
by screening mammograms will never cause any
health problems in the future. This is especially true
in Ductal Carcinoma in Situ, or DCIS. It is not
currently possible to predict which cancers found by
mammogram will never become a problem, so all
cancers found are generally treated. The challenge
is balancing the benefits vs. harms of screening on
an individual basis. Useful patient information
regarding these controversies and variable
recommendations seems scarce.
Physician Support
Confluence Health is dedicated to improving our
patients’ health by providing safe, high-quality care
in a compassionate and cost-effective manner. The
physicians felt it important to develop guidelines
for our patients addressing the wide variation in
recommendations for screening mammograms. These
guidelines are meant to empower women and their
health care providers to discuss on an individualized
basis their personal risk of breast cancer, the benefit
and harms of screening tests for cancer, and give tools
to address these issues.
Under the oversight of the Quality Department
at Confluence Health, a multi-specialty group of
physicians was formed to create these new guidelines.
This group includes primary care physicians,
continued p. 6
Staging of Breast
Cancer Based on
Tumor Size*
* For cancers that
have not spread to the
lymph nodes
blueberry
cherry
walnut
Stage I
lime
Stage II
Tonasket, WA
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Mammography Screening
Mammography Screening
physicians specializing in women’s healthcare, physicians
specializing in radiology, and physicians specializing in
the treatment of Breast Cancer. Participating Confluence
Health physicians on this multidisciplinary workgroup are:
• Randal Moseley, MD
Quality Department
• Adrienne Hansen, MD
Radiology
• Julie Smith, MD
Medical Oncology
• Galen Sorom, MD
Internal Medicine
• Gail Feinman, MD
Internal Medicine
• Bethany Lynn, MD
Family Practice,
Wenatchee
• Richard Hourigan, MD
Family Practice,
Moses Lake Clinic
• Rob Justus, MD
Family Practice,
Omak Clinic
• Rita Hsu, MD
OB/GYN
Unadjusted 5-Year Breast Cancer
Survival Rates by Stage 2003-2006*
Confluence Health (CH)*
National
90.2%
Stage 0
95.6%
97.2%
Stage I
92.2%
• Linda Strand, MD
Radiology
• Malcolm Butler, MD
Columbia Valley
Community Health
95.8%
Stage II
Stage III
85.4%
Too few cases
66.7%
The guidelines developed by this group include
information to enable women to assess their personal
risks of breast cancer as well as their own potential
benefits and harms from screening mammograms.
New Mammogram Guidelines
For women ages 40-49, deciding whether to obtain
screening mammograms is especially challenging.
We recommend a baseline mammogram at age 40,
as well as a review of risk factors to help determine a
woman’s individual risk. For women in this age group
with average risk for breast cancer, potential harms of
screening mammograms may outweigh the benefits.
Confluence Health does not recommend regular
screening mammograms for these women without
first discussing these potential harms and benefits
with their primary care provider. Confluence Health
does highly recommend an assessment of individual
risk, since women at higher than average risk likely
benefit from screening mammograms. If a woman
has a greater than average risk for breast cancer we
recommend routine screening mammography starting
in the 40s. Factors that may increase a woman’s
risk of breast cancer include: a first degree relative
(mother, sister, child) who has had breast cancer, a
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Stage IV
Too few cases
21.1%
previous breast biopsy with normal result or showing
atypia, dense breast tissue on mammogram, and
previous radiation treatments to the chest. Confluence
Health endorses a Breast Cancer Risk Assessment Tool
available through the National Cancer Institute to
determine personal risk:
www.cancer.gov/bcrisktool
For women ages 50-74 of average risk, Confluence
Health recommends a screening mammogram at
least once every two years. For those women with
higher than average risk in this age group, yearly
mammography should be considered.
For women ages 75 and older, there is not agreement
among expert national groups whether to continue
screening mammograms. Taken as a group, the life
saving benefit of screening mammography seems small
for women of this age. The dots in the box below
represent 1000 women. The orange dots in the diagram
below show the number of women in that 1000 who
will die of breast cancer in the next 5 years. Out of
1000 women, 1 less woman may die of breast cancer in
this age group who choose to continue mammograms.
However, there may be wide variation for benefit among
individual women. Confluence Health supports patientcentered care, and we want to encourage an open dialogue
between a woman and her healthcare provider regarding
her underlying health, chronic medical illnesses, and
personal risk of breast cancer to determine if she should
continue screening mammograms.
Your Decision
In summary, Confluence Health is dedicated to
personalized care for all our patients. Confluence Health
recommends that baseline screening mammography
be performed at age 40, as well as a review of risk
factors to help determine a woman’s individual risk
between the ages of 40-49. For women ages 50-74
with an average risk of breast cancer, routine screening
mammograms are recommended at a minimum of
once every two years, with yearly mammography for
women with increased risk. For women age 75 and older
screening mammography is not felt to impact overall
life expectancy, but the decision to continue screening
mammograms in this group should be based upon
personal risk and informed decision making with the
individual’s health care provider.
All Stages
CH 89.1%
Number of Women aged 75 and Older Who Will Die
of Breast Cancer in the Next 5 Years in the U.S.
All women
Breast cancer deaths
Stage of Breast Cancer
Diagnosed in 2000-2012
Confluence Health
Other Hospitals
26%
26%
19%
20%
National 85.5%
Stage 0
37%
39%
*Includes patients of all ages, deaths from all
causes, and there has been no adjustment for
co-morbidity or other risk factors. If no result is
shown, too few cases were submitted. Survival
not calculated if less than 30 cases.
Stage II
Stage III
*Confluence Health statistics for all graphs in
this report include cancer data obtained from
the National Cancer Data Base from both
Wenatchee Valley Hospital and Clinics, and
Central Washington Hospital and Clinics.
10%
8%
3%
4%
Stage I
Stage IV
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Non-Hodgkin’s Lymphoma
Non-Hodgkin’s Lymphoma
Julie Smith, MD, Medical Oncology and Thomas Tucker, MD, Medical Oncology
31.3%
Small Lymphocytic Lymphoma
21.9%
Diffuse Large B Cell Lymphoma
Follicular Lymphoma
Overview and General Statistics
Lymphoma and specifically Non-Hodgkin’s
Lymphoma (NHL) is one of the most common
types of cancer diagnosed and treated at
Confluence Health, and also in the United
States. NHL is a diverse group of cancers which
originate from cells of the lymphatic system, with
many different subtypes. The National Cancer
Institute estimates from SEER data (Surveillance,
Epidemiology, and End Results) that in 2014 there
will be approximately 70,800 new cases of NHL
diagnosis within the United States, accounting
for 4.3% of all new cases of cancer for 2014, with
an estimated 18,900 deaths due to NHL in 2014.
The overall survival in patients diagnosed with
NHL has improved over the past 30 years, from
45% 5-year survival to of 70% 5-year survival. It is
estimated that 2.1 percent of men and women will
be diagnosed with NHL during their lifetime.
Our data from Confluence Health Tumor Registry
shows 67 new cases of Lymphoma diagnosed in
2013, with 64 (95.5%) being NHL cases. There
were 3 cases of Hodgkin’s Lymphoma. There are
multiple subtypes of NHL, each with unique
characteristics and behavior. The most common
types of NHL diagnosed within Confluence Health
in 2013 include Diffuse Large B Cell Lymphoma,
Follicular Lymphoma, Small Lymphocytic
Lymphoma, Marginal Zone Lymphoma, Burkitt’s
Lymphoma, Waldenstrom’s Macroglobulinemia,
T-Cell Lymphoma, NHL not otherwise specified,
and Hairy Cell Leukemia.
Marginal Zone Lymphoma
Waldenstrom’s Macroglobulinemia
Lymphatic System
Right (lymphatic) duct
Left (thoracic) duct
Heart
Spleen
Thoracic duct
Pelvic lymph nodes
Inguinal lymph nodes
Distance Traveled of NHL - Nodal
Cancer Diagnosed in 2000-2012
Types of NHL Diagnosed at
Confluence Health in 2013
12.5%
9.4%
4.7%
NHL not otherwise specified
4.7%
Hairy Cell Leukemia
3.1%
1.6%
Diagnosis of NHL
NHL is diagnosed by obtaining tissue for analysis. This may
include lymph node biopsy, bone marrow biopsy, peripheral
blood analysis, or pathologic analysis of other involved tissue or
organs. The staging of NHL is important, in that treatment is
personalized for the patient dependent on the subtype of NHL,
the stage (reflecting overall disease burden within the body),
the clinical behavior of the lymphoma, and also the patient’s
underlying health and co-morbidities.
Risk Factors and Prevention of NHL
Lymph vessels and
nodes of lower limbs
5%
50-99 miles
10.9%
T-Cell Lymphoma
Burkitt’s Lymphoma
100+ miles
Most patients that develop NHL have no other risk factors
other than age. Some infections have been associated with the
development of NHL in some patients, including HIV infection
(the virus that causes AIDS), and H.Pylori (a bacterium that
may infect the stomach). Patients with a weakened immune
system, or those receiving immunosuppressive treatments for
other disorders, may also be at increased risk of developing
NHL. Prevention of NHL includes stopping the spread of HIV,
treatment with anti-HIV drugs if infected, and maintenance of a
healthy weight and lifestyle.
25-49 miles
7%
10-24 miles
11%
13%
5-9 miles
< 5 miles
13%
2%
17%
20%
21%
22%
29%
Confluence Health
Other Hospitals
36%
Where there is a substantial difference in our patient
population diagnosed and treated within Confluence
Health for NHL involves the distance traveled by
patient to receive their treatment and follow up.
Many of our patients travel a distance of greater than
50-100 miles one way, to receive care. This is due
to the wide geographical area for which we provide
care in this region. Outreach Oncology services
including infusion and chemotherapy, and oversight
and follow up of patients with NHL occur both in
Moses Lake Clinic, and Omak Clinic.
Omak, WA
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Non-Hodgkin’s Lymphoma
Staging of NHL
Age Group of NHL - Nodal Cancer
Diagnosed in 2000-2012
Younger than 20
0%
2%
20-29
1%
2%
30-39
1%
4%
Confluence Health
Other Hospitals
9%
10%
40-49
17%
18%
50-59
60-69
24%
23%
70-79
30%
24%
15%
15%
80-89
3%
2%
90 and older
Stage of NHL - Nodal Cancer
Diagnosed in 2000-2012
Confluence Health = outer circle
Other Hospitals = inner circle
Stage I
Stage IV
Stage II
N/A
Stage III
Unknown
10%
1%
14%
0%
15%
17%
15%
34%
40%
10
19%
18%
16%
Stage I disease includes disease confined to one
lymph node group. Stage II disease involves two
or more nodal groups on the same side of the
diaphragm. Stage III disease involves nodal groups
on both side of the diaphragm, and stage IV disease
involves distant organs, including bone marrow,
liver, lung, and central nervous system. When NHL
involves tissues that are not classically felt to be
lymphatic tissue, this is known as extra-nodal disease
(skin and gut for example). When constitutional
symptoms such as drenching night sweats, fevers,
and weight loss are present, the patient is assigned
a clinical “B” category. When no constitutional
symptoms are present, the patient is assigned a
clinical “A” category.
Treatment of NHL
The treatment of NHL is personalized to the
individual patient, their tumor characteristics, their
stage, but more importantly their underlying health
including co-morbidities and performance status.
The treatment of NHL for many patients with
indolent asymptomatic disease consists of a watchfulwaiting approach. For patients with symptomatic
disease there are many treatment options, including
but not limited to chemotherapy, radiation therapy,
immunotherapy, biologic targeted therapy, stem cell
transplantation, and clinical trials.
2014
Accomplishments
for OUR CANCER COMMITTEE
Accreditation
Palliative Care Expansion
Received accreditation with commendation
for both Central Washington Hospital and
Wenatchee Valley Hospital cancer programs
from American College of Surgeons
Commission on Cancer.
Palliative Care Program experienced
significant growth in the outpatient area.
Referrals and consult visits increased by
41% for oncology patients.
Oncology Service Line
Launched the Confluence Health Oncology
Service Line.
Mammogram Guidelines
Beacon
Medical Oncology and Infusion implemented
Beacon: Epic’s oncology module.
Remodel in Moses Lake
Developed mammogram guidelines for
Confluence Health.
Moses Lake Oncology and Infusion area was
remodeled to improve patient safety and
care experience.
Research in NHL
Nurse Navigation
Pilot Project: Choosing Wisely
The treatment of many cancers, including NHL, has
greatly evolved over time due to the development of
novel therapies and clinical trials. Confluence Health
Cancer Program has received commendation during
our recent Commission on Cancer 2014 Survey for
our participation in clinical trials. We partner with
regional institutions (including but not limited to
Fred Hutch Cancer Research Center and the Seattle
Cancer Care Alliance) national groups (including
but not limited to US Oncology, National Cancer
Center Network, South West Oncology Group), and
various pharmaceutical groups to offer clinical trials
for many cancers. The Confluence Health Oncology
Research Program is proud to provide patients
in North Central Washington access to the most
current and novel treatment options for patients with
NHL through our clinical trial program.
Developed and began implementation of
new oncology nursing role that navigates
patients through their whole cancer journey.
Confluence Health Cancer Program became
one of the SCCA network sites to participate
in Choosing Wisely Pilot Project with HICOR
(Hutchinson Institute for Cancer Outcomes
Research) which will help develop a system
to monitor adherence to the national
Choosing Wisely recommendations.
New Rounds
Radiation Oncology implemented weekly
chart rounds. M&M rounds implemented for
medical and radiation oncology as a team.
Real Time Data
Spread the Rapid Quality Reporting System
across the top 5 diseases in both CWH and
WVH programs which gives us real time
data from the registry.
Hospice Support
Hospice added 5 respite beds at Wenatchee
Valley Hospital which adds support for
caregivers and patients who are on hospice.
11
Comparative
Data to
National
24%
34%
6%
8%
14%
11%
18%
24-49
10-24
5-9
2% 3%
20-29
30-39
22% 22%
12% 13% 13%
12%
15%
9% 8%
7%
1% 1%
25%
20%
10%
19%
100+ 50-99
23%
14%
28%
1%
Confluence Health
Other Hospitals
10% 9% 11%
8%
2% 2%
40-49
60-69
50-59
70-79
80-89
90 +
0
I
II
III
Age (Years)
<5
IV
N/A Unknown
Stage
Distance (miles)
to
Oc
to
Oc
Oc
ly
100%
100%
100% 86%
86%
100%
100%
100%
90%
100%
90%
100%
100% 98%
Ap
u
ly
100% 100%
Ap
ril
Ap
100%
100%
ril
100%
100%
80%
ril
ril
ril
98%
Jan
r
y
ly
100%
be
Ju
Ap
100%
97% 99%
Percentage of time adjunctive
chemotherapy is considered or
administered within 4 months of
diagnosis for patients age <80 with
stage III node positive Colon Cancer
ar
90%
100%
u
y
ly
Jan
r
100%
100%
Ju
Ap
be
100%
100%
Ju
94%
75%
90%
91%
77%
100%
95%
96%
Ju
Ju
ly
85%
80%
90%
u
ar
96%
2014
94%
92%
Jan
r
100%
98%
95%
79%
98%
96% 95%
be
y
97%
85%
2013
96%
85%
u
ar
75%
Jan
r
y
y
96%
be
ar
ar
98%
2012
u
Oc
Jan
r
Percentage of time combination
Percentage of time Tamoxifen or third
chemotherapy is considered or administered generation AI considered or administered
witih 4 months of diagnosis for women <70,
within 1 year of diagnosis for women
stage 1C - Stage III Hormone Receptor
with Stage 1C- Stage III hormone
Negative Breast Cancer
receptor Positive Breast Cancer
to
XRT administered within
1 year of diagnosis for women
ages <70 receiving breast conserving
surgery for Breast Cancer
be
Oncology
Oc
>12 Regional LNs removed and
pathologically examined for resected
Colon Cancer - CWH&C surgery
analytical for WVH&C
to
ROTC
to
Surgery
Legend
12
20%
20%
21%
Legend
Wenatchee Valley Hospital & Clinics
for Years 2012-2014
Stage of All Sites Cancer Diagnosed
in 2000-2012
28% 27% 27%
14%
Wenatchee Valley Hospital &
Clinics vs. All Types Hospitals
(1,613) in All States
Quarterly
Results for
Cancer Care
Age Group (Years) of All Sites Cancer
Diagnosed in 2000-2012
Distance Traveled of All Sites Cancer
Diagnosed in 2000-2012
13
2014 Cancer
Committee
First Row
Second Row
left to right
left to right
Jeanine Allen, RN
CWH Inpatient Medical/
Oncology/Surgical
Director
Keta Evans
Practice Manager
Radiation Oncology,
Outreach Coordinator
Jennifer Jorgensen, MD
Gastroenterology
John Register, MD
Radiation Oncology
Tracey Kasnic, RN
Chief Nursing Officer
Thomas Tucker, MD
Medical Oncology
Cici Asplund, MD
Family Practice
Anna Hansen, MD
Diagnostic Imaging
Katie Kemble, DNP
Survivorship Program
Susie Ball, CGC
Genetic Counseling
Program
Ginny Heinitz, RN
Palliative Care
Daniel Kerr, MD
Pathology
Kelli Van Wagner, RN
Practice Manager
Oncology Outpatient
Services, Nurse
Navigation
Darren Hess, MD
General Surgery,
CoC Physician Liaison
Kate Kraemer, RN
Quality Coordinator
Rachelle Boyd, CTR
Tumor Registry
Thomas Carlson, MD
Radiation Oncology
Sharmen Dye, CTR
Tumor Registry,
Cancer Conference
Coordinator
Susan Howell, LICSW
Behavioral Health,
Psychosocial Coordinator
Kristine Mathison, RN
Respecting Choices
Coordinator
Deb Vedder, RN
Moses Lake Outreach,
Oncology
Deric Weiss, MD
Palliative Care
Ladonna Muscatell, RN
Oncology Research
Jody O’Conner
ACS Representative
Cindy Phillippi, RN
Hospice
Above, left to right: Mary Gunkel, RN Oncology Service Line Director, TR QC Coordinator | Julie Smith, MD Medical Oncology
Cancer Committee Chair | Richard Bennett, RN Senior Vice President, Quality and Service Lines
Moses Lake, WA
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