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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 2 3 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. 4 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 5 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 6 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 7 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 8 9 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 14 15