Cancer Committee Chairman Report 2013

Building on our Strong Foundation In 2013 the Gwinnett Medical Center Cancer Institute made several advancements. We developed a three year plan for our program growth and implemented several steps this year. Chief among our goals completed was the launch of a Certified Oncology Rehabilitation Program. The Massachusetts-based Oncology Rehab Partners, experts in the field of survivorship care, awarded this designation to GMC. STAR Program Certification is a conventional medicine and evidence-based standardized model of oncology rehabilitation service delivery. We also enhanced our services provided to patients undergoing diagnostic testing for breast cancer by adding a diagnostic breast navigator and establishing a Breast Clinic. At the Breast Clinic, patients who have undergone a minimally invasive breast biopsy (MIBB) are offered appointments within 48 hours with Gwinnett Medical Center’s network of breast interventional radiologists. Here patients learn about their results and receive education, support and coordination of surgical appointments. A Thoracic Oncology Steering Committee was formed this year to begin working on establishing a comprehensive approach to lung and thorax cancer, from prevention to screening to diagnosis, treatment and survivorship. We have launched a low-dose CT screening program to identify lung cancer at earlier stage of disease and we have hired a thoracic nurse navigator to assist patients and families with the complexities of dealing with a diagnosis of lung or thorax cancer. An oncology social worker was hired this year to start a psychosocial oncology program geared to foster coping and mobilize community resources in order to support patients and families. We continued the strong relationship between the physicians at Suburban Hematology-Oncology Associates and GMC through the success of the Center for Cancer Care where our team of 8 medical oncologists not only provide the latest in medical oncology and hematologic care, but also provided medical directorship to help launch many of the goals and improvements achieved this year. On behalf of the Cancer Committee, our sincere thanks go out to the skilled and compassionate staff and physicians at GMC who have provided outstanding care this year. I can’t wait to see what 2014 brings! Alexander Saker, Jr, MD Medical Oncologist/Hematologist Chairman, Cancer Committee

Oncology Annual Report 2013

Studies of Quality – Anthony Landis, DO Medical Oncologist/Hematologist, GMC Oncology Services Medical Director Quality Improvement is a core aspect of the Cancer Institute and we conducted two studies this year to help us improve our quality of care delivered to patients.

Time-to-Treatment for all Lung Cancer Patients Using 2011 Data

The Quality Subcommittee reviewed the Time-to-Treatment (elapsed time, in days, between a patient’s diagnosis and the date on which first treatment was reported to have started) for our top five cancer sites compared to Georgia and the U.S using reports available through the National Cancer Database (NCDB) and our Oncology Data Center. For a subset of lung cancer patients, non small cell lung cancer (NSCLC), we learned that more patients in our program experience time from diagnosis to treatment that exceeds 64 days (a benchmark put forth by the NCDB) and this was identified as an opportunity for improvement.

For cases in 2011 examined in our study we found:

• Total number of cases 164 (135 – NSCLC; 29 – SCLC) • Total that had treatment was 123 (22 SCLC had treatment. 100 - NSCLC • 13 (NCSLC) out of 100 (13%) time-to-treatment greater than 64 days (NCSLC) • All SCLC (22) were under 64 days

Of the 13 cases of NCSLC which time to treatment was greater than 64 days, the reasons for delays vary; patient preference, delays getting to surgery and delays in the diagnostic process.

As a result of this study, a Thoracic Oncology Steering Committee was formed to develop a comprehensive thoracic oncology program within the Cancer Institute. Program development is ongoing but includes the establishment of a lung cancer screening program to help identify cancer at earlier stages and the establishment of a thoracic nurse navigator position to assist patients in the process of diagnosis and treatment. Pain Assessment at the Center for Cancer Care

This year the Center for Cancer Care and the physicians of Suburban Hematology-Oncology Participated in the American Society of Clinical Oncologists’ Quality Oncology Practice Initiative (QOPI®). QOPI's goal is to promote excellence in cancer care by helping practices create a culture of self-examination and improvement.

Through examining our data and comparing ourselves to other practices throughout the country, we saw an opportunity to improve our documentation of pain assessment for patients seen at our practice.

Our score showed that only 18.18% of our charts indicated that we had assessed and addressed pain. While this does not mean that our physicians weren’t asking about pain and addressing it, the truth is we weren’t documenting this well and that is an opportunity to improve in our care.

As a result of the study, we modified our oncology EMR to include the NCCN pain scale every time we take vital signs. We also educated our providers on the NCCN guidelines for Adult Cancer Pain on Pain Intensity Rating along with the categorical scale and renewed our efforts to be sure that we are documenting our plan. I am happy to report that our most recent scores improved by 25% and are still climbing.

Cancer Liaison Physician Report Miles Mason, III, MD, FACS, Surgeon GMC and NCDB (U.S.) 5 year survival rate comparison The survival data for GMC and the US remain similar this year, an indication that patients treated at the Cancer Institute are receiving quality care in keeping with evidence-based standards. The chart below was generated as part of our special analysis of lung cancer outcomes and depicts GMC’s survival rates for our lung cancer.

In late 2012, GMC received a rating of compliant with the following National Quality Forum endorsed measures (2013 rating pending): Radiation therapy is administered within 1 year (365 days) of diagnosis for women under age 70 receiving breast conserving surgery for breast cancer. Year GMC Comprehensive Cancer

Programs 2009 79.1% 91.1% 2010 87.5% 93% 2011 91.2% 91.6% Combination chemotherapy is considered or administered within 4 months (120 days) of diagnosis for women under 70 with AJCC T1c N0 M0, or Stage II or III ERA and PRA negative breast cancer. Year GMC Comprehensive Cancer

Programs 2009 100% 91.6% 2010 100% 93% 2011 84.6% 91.1% Note: The two cases in 2011 that did not receive treatment were actually lost to follow up (patient moved out of the area/received care elsewhere and we have no information). Tamoxifen or third generation aromatase inhibitor is considered or administered within 1 year (365 days) of diagnosis for women with AJCC T1c N0 M0, or Stage II or III ERA and/or PRA positive breast cancer. Year GMC Comprehensive Cancer

Programs 2009 88.3% 87.7% 2010 89.3% 90.9% 2011 93.2% 88.7% Adjuvant chemotherapy is considered or administered within 4 months (120 days) of diagnosis for patients under the age of 80 with AJCC Stage III (lymph node positive) colon cancer. Year GMC Comprehensive Cancer

Programs 2009 92.3% 87.7% 2010 89.3% 90.9% 2011 93.2% 88.7% At least 12 regional lymph nodes are removed and pathologically examined for resected colon cancer. Year GMC Comprehensive Cancer

Programs 2009 78.4% 85.1%

Community Outreach at GMC

In addition to offering high quality treatment options in the region, GMC is proud to be part of prevention, screening, early detection and community outreach activities aimed at decreasing the burden of cancer in our community.

• The Cancer Navigators made close to 3,000 patient contacts with patients seeking support, assistance or resources

• Over 1,300 low cost or free screenings were offered for breast, colorectal and prostate cancer

• Over 100,000 individuals reached through community awareness events and activities aimed at prostate cancer, lung cancer and breast cancer

• More than 500 contacts made with individuals seeking assistance to quit smoking. • More than 500 individuals attended health and wellness programs such as yoga, tai chi,

cardio dance and health risk assessments  

Navigation Evaluation

This year an evaluation of our patient navigation services was conducted. The purpose of this evaluation was to achieve the baseline assessment of the patient navigation programs’ processes and to set up goals and benchmarks for ongoing improvement. The National Cancer Institute Community Cancer Centers Program (NCCCP) Navigation Assessment Tool was used to evaluate the patient navigation services and processes at Gwinnett Medical Center. As a result of our evaluation, we have established the following areas of focus for 2014:

1. Explore the current hospital processes for financial clearance, counseling etc. for patients outside of the Center for Cancer Care.

2. Establish an acuity tool for use with navigators to help prioritize workload. 3. Integrate the new positions of Thoracic Nurse Navigator and Oncology Social worker as

well as Oncology Dietician into our full spectrum of navigation and support services. 4. Continue to work at identifying areas and populations within our service area that may need

additional outreach due to later stage diagnosis.

 

2010 80% 86.4% 2011 76.7% 87.4%

Quality Improvements Katie S. Michaud, MPA, Director of Oncology In 2013 a number of quality improvements and program advancements were made within the Cancer Institute that positively impact the care of patients. Some of these changes are large and others were smaller in scale but they all add up to a very successful year of collaborations and innovations. I am proud to share the following quality improvement highlights in this report: Genetics/Pathology

• Initiation of routine testing of squamous cell carcinomas of the base of tongue and tonsil for p16 immunohistochemistry as a surrogate marker of HPV status

• Improved quality and ordering process for bone marrow biopsies • Initiated IHC tumor tissue testing on all patients with colon cancer under the age of 70yrs

Center for Cancer Care • Initiated participation in Quality Improvement practice Initiative (QOPI) • 25% improvement in documentation of pain addressed appropriately (baseline spring

2013: 18.18% of charts, Fall 2013: 43.40% of charts) • Introduced and integrated an Oncology Pharmacy at our office locations in Duluth,

Snellville and Lawrenceville Breast Program

• Implementation of Post Biopsy Breast Clinic in Duluth and Lawrenceville • Doubled breast nurse navigator capacity • Decreased overall percentage of breast biopsies that are image-guided needle biopsy as

the initial approach from baseline of 60% to 30% (goal 10%). • Developed an algorithm for management of benign and malignant breast cases

Outpatient Treatment Center • Increased patient satisfaction with explanations given by staff from the 39th percentile to

the 56th percentile • Improved documentation of dating on oncology flow sheet from 85% to 98%

Oncology Program/Rehabilitation Services/Imaging Services • Achieved Oncology Rehabilitation Certification • Hired an Oncology Social Worker • Established a Thoracic Oncology Steering Committee • Established a low dose CT lung cancer screening program • Hired a Thoracic Nurse Navigator

Oncology Data Center Report Debra Fortier, RHIA, CTR The Oncology Data Center (ODC) information system is designed for the collection, management and analysis of data of persons with the diagnosis of malignant (or neoplastic disease) and benign brain tumors. The information maintained in the GMC the tumor registry includes demographic information, medical history, diagnostic findings, cancer findings (including primary site, histology cell type and extent of disease and/or stage), cancer therapy (including surgery, radiation therapy, chemotherapy and/or immunotherapy to name a few) and follow-up (annual information concerning additional treatment, recurrences and patient status). In 2012, the ODC processed 1,429 analytic cases, an increase of 3% over prior year. These cases represent patients who were diagnosed and/or received all of the first course of treatment at GMC or were diagnosed elsewhere and received all or part of the first course of therapy at GMC. Additionally there were 414 non-analytic cases, representing patients diagnosed elsewhere and receiving all of the first course of treatment elsewhere and seen at GMC now with active disease.

The top five cancers for women were Breast, Lung, Colon, Thyroid Gland and Corpus Uteri cancers. The top five cancers for men were Prostate, Lung, Colon, Lymphoma and Urinary Bladder.

All of our abstractors in the registry are Certified Tumor Registrars. The ODC collects the required data items mandated by the American College of Surgeons, Commission on Cancer, Georgia Comprehensive Cancer Registry and SEER (Surveillance Epidemiology and End Results), while maintaining strict patient confidentiality. The ODC reports monthly to the Georgia Center for Cancer Statistics and the American College of Surgeons Rapid Quality Reporting System (RQRS) and yearly to the National Cancer Data Base.

2013 Cancer Committee

Alexander Saker, Jr. MD Cancer Committee Chair Medical Oncologist/Hematologist

Cancer Conference Coordinator Murtaza Cassoobhoy, MD Hospitalist/Palliative Care Ken Dixon, MD General and Oncologic Surgeon Kimberley Hutcherson, MD Breast Interventional Radiologist Miles Mason III, MD, FACS Surgeon, Cancer Liaison Physician Community Outreach Coordinator Leela Maxa, MD Radiation Oncologist Cancer Registry Quality Coordinator Julie McGill, MD General Surgery Philip Shrake, MD Radiation Oncologist Robert Siegel, MD Pathologist Jamila Brown, CHES Health Education Specialist Samantha Cannon, MSOT/L-CLT Lymphodema Therapist Chuck Christie, M.Div., BCC Chaplain, Psychosocial Services Coordinator Kathy Vance, RN, ONS, Oncology Nurse Sheila Forman, RN Palliative Care Debra Fortier, RHIA, CTR Certified Tumor Registrar Holly Richards Director, Office of Research, Clinical Research

Representative Katie Michaud, MPA Director, Oncology Services Rachel Joiner, American Cancer Society Jennifer Griffin American Cancer Society Patient Resource Navigator Amy McEachin, RN, OCN Outpatient Treatment Center Supervisor Rita Michael, RN, BS, CPHQ Performance Improvement Representative Mark Mullin Director of Planning Deidre Robinson, MSW Oncology Social Worker Sharon Smallwood Clinical Manager, Inpatient Oncology Tina Smith, RN, BSN, TNCC Nurse Clinician Cindy Snyder, APNG, FNP-C CBCN Genetics Professional Donna Stoudenmire, RN, CBPN-IC Breast Health Nurse Navigator Gretchen Hayward, RN, CBPN-IC Breast Health Nurse Navigator Amy Tella, MS, RD, CNSC Clinical Nutrition Manager Michael Naughton, Pharm. D Director of Pharmacy Robert Fritz, MD Thoracic Surgeon Brandon Kang, MD Radiologist Anthony Landis, DO Medical Director, Medical Oncologist/Hematologist Robert McGann, MD Pulmonologist Mary Cooper, RN, BSN, FCN Nurse Navigator, Faith Community Nursing