A Year of Patient Care ImprovementsThe Gwinnett Medical Center Cancer Institute has quite a bit to be

proud of this year. The Cancer Support Center (CSC) was opened in Lawrenceville at 631 Professional Drive, Suite 210 providing a central location for patients and family members to receive supportive care such as patient navigation services, nutrition counseling, oncology social work services, hereditary cancer risk assessment and survivorship education. Within the CSC, we launched an oncology nutrition program with our own oncology registered dietitian to begin providing crucial medical nutrition therapy for our patients under cancer treatment to help them maintain good nutritional status.

Also within the CSC, we began screening all of our new patients at the Center for Cancer Care for emotional distress and linking them with our oncology social worker to provide emotional support and other needed services. The Cancer Transitions ® class series for survivors was launched offering an evidence based approach to survivorship education around topics such as nutrition, exercise and emotional wellbeing. Three new support groups were added to our very successful women’s cancer support group; Men to Men (for all cancer types); a Spanish women’s support group and a caregiver support group.

Our lung cancer program received recognition as a Lung Cancer Screening Center of Excellence through the Lung Cancer Alliance and we were proud to host one of 200 Shine a Light on Lung Cancer events nationwide at the Gwinnett County Historic Courthouse to call attention to the need for increased research and funding to help improve survival rates for people with lung cancer.

We also focused efforts to support our talented staff so that they can continue to provide excellent service to our patients. An oncology nurse clinician role was established to provide oversight and support for oncology nurse practice in all of our locations and we developed a robust safe-handling program for all of our caregivers who come in contact with potentially hazardous drugs such as chemotherapy.

As you read our 2014 annual report, I know that you will be as impressed as I am with all that we have accomplished this year. It will be a hard year to top, but we’ve already got some exciting new initiatives in motion for 2015!

Alexander Saker Jr., MDMedical Oncologist/Hematologist & Chairman, Cancer Committee

Cancer Committee Chairman Report 2014

Community Outreachat GMC

A number of offerings aimed at education, early detection, screening and prevention were enjoyed this year by the community.

• The cancer navigators made over 4,000 patient contacts with patients seeking support, assistance or resources – an increase of 1,000 contacts from 2013

• More than 300 free colorectal screening kits were provided to the community

• Nearly 100 people received low cost, low dose CT Lung Cancer Screenings

• Over 1,400 people received low cost mammograms through our Care-a-Van mobile mammography unit

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

• More than 300 contacts were 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

• Over 500 GMC Guides to Cancer Screening were provided at community events

Oncology Annual Report 2014

CANCER INSTITUTE

Studies of Quality – Anthony Landis, DOMedical Oncologist/Hematologist, GMC Oncology Services Medical Director

Quality Study Report: Continuity of Care for Patients Receiving PEG TubesA PEG (percutaneous endoscopic gastrostomy) is a safe and effective way to provide food, liquids and medications (when appropriate) directly into the stomach. The procedure is done for patients who are having difficulty swallowing. The GMC Clinical Dietary staff raised concerns about a potential gap in care for patients who receive PEG tubes and may not consistently receive adequate education from the dietitians and/or have home health care set up for care of the PEG and feedings. A total of 43 patient charts were reviewed whose PEGs were placed in endoscopy and interventional radiology and a Cancer Committee workgroup convened to review the findings. Several observations were made:

• 6 patients didn’t receive a consult with a registered dietician before discharge and/or home health care• If the patient had the PEG placed, there were a variety of order forms being used and some weren’t using the specific forms for PEG

placement at all• Some of the forms included home health care and an assessment by a registered dietitian and others didn’t

The workgroup established goals to have each patient assessed by a registered dietitian and have home health care set up before they leave the hospital, decrease readmits for PEG problems and have the patients well satisfied with their discharge plan.

Strategies implemented to achieve the goals:• The standard PEG post-op orders are used on each patient in endoscopy in Lawrenceville and Duluth. This order set has a registered

dietician consult for tube feeding, as well as a consult for home health care.• A similar order set was developed to be used in interventional radiology which allows the registered dietician and home health care to

be consulted before being discharged. • The final piece of the puzzle was looping in outpatient oncology registered dietician services. The inpatient registered dieticians have

referral forms for the new Cancer Support Center oncology dietician and have these filled out and signed for these patients to follow up on an outpatient basis. Upon discharge, the inpatient registered dietician contacts the oncology dietician to let them know that they have made a referral.

Quality Study Report: Breast Biopsy Pain After hearing feedback that some patients experienced pain during their breast biopsy, the Gwinnett Breast Center undertook a study to examine this issue and identify potential strategies to make the experience better. The study included 134 patients from Lawrenceville and Duluth. Data was collected post procedure by a registered nurse in an interview and the study had three sections including: pre-procedure pain assessment, intra-procedure and post-procedure pain assessments.

Prior to a breast imaging procedure, patients are encouraged to take Tylenol, are offered PO Xanax and have their pre-procedure pain assessed and scored on the Wong-Baker Pain Scale (1-10).

Pre-Procedure Results• 11% (15/134) reported pre-existing pain, scores ranged from 1-8 on the pain scale• 13% (18/134) self-medicated for pain/anxiety medication the morning of their procedure• 17% (23/134) were given Xanax prior to the procedure

Intra-Procedure Results (five elements were studied)• Pain due to positioning: 25% (34/134)• Pain due to injection of local anesthetic: 50% (68/134)• Pain due to procedure: 24% (33/134)• Pain due to post-procedure compression: 20% (28/134)• Pain due to post-procedure mammogram: 31% (42/134)

Actions Taken to Address Pain• More local anesthetic given: 68• Repositioning: 15• Reassurance: 2

Post-Procedure Results• 11% (12/134) patients reported an increase pain score post procedure compared to their baseline pain score• Seven patients went from 0 to 1, two patients went from 0 to 2, two patients went from 0-4, one patient went from 0-6• 8/12 received Xanax prior to procedure

Individual physicians are reviewing their results and the Gwinnett Breast Center team will be making adjustments in their processes. The cancer committee and breast leadership committees agreed that the results overall look acceptable, however, would like to keep monitoring this as a quality improvement area of focus. The plan is to repeat the study in the next year after gaining this insight into the patient experience around pain during biopsy.

Quality Study Report: Chemoprevention Education In an effort to ensure that patients with atypical findings were given the opportunity for chemoprevention or risk reduction medications, our breast program leadership committee undertook a quality improvement study. We worked with area surgeons to review charts of 58 patients with atypical findings who had been seen between 12/2013 and 5/2014. Of the 58 charts, 13 of these patients were subsequently upgraded in their diagnosis and no longer qualified to be part of the study. Of the 45 charts remaining, 37 or 87% were found to have documentation that chemoprevention education was provided or that a referral was made. Surgeons participating in the study were very receptive to the study efforts. The breast program leadership committee agreed that while our performance was acceptable for a baseline study, 100% should be our target for evidence that a discussion or referral was made for chemoprevention. Our target is to have 90% of patients who have documentation of follow through after a referral made. The study will be repeated in 2015.

Cancer Liaison Physician Report – Miles Mason, III, MD, FACPSurgeon

In 2014, GMC received a rating of compliance from the American College of Surgeons; Commission on Cancer for 2012 submitted data for the following national quality forum endorsed quality measures:

Radiation therapy is administered within one year (365 days) of diagnosis for women under age 70 receiving breast conserving surgery for breast cancer. Year 2012 GMC – 84.9% Comprehensive Cancer Programs – 85.7%

Combination chemotherapy is considered or administered within four 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 2012 GMC – 83.3% Comprehensive Cancer Programs – 86.8%

Tamoxifen or third generation aromatase inhibitor is considered or administered within one 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 2012 GMC – 94.4% Comprehensive Cancer Programs – 78.8%

Adjuvant chemotherapy is considered or administered within four months (120 days) of diagnosis for patients under the age of 80 with AJCC Stage III (lymph node positive) colon cancer. Year 2012 GMC – 100% Comprehensive Cancer Programs – 80.3%

At least 12 regional lymph nodes are removed and pathologically examined for resected colon cancer.Year 2012 GMC – 80% Comprehensive Cancer Programs – 87.7%

NEW Measures established by the Commission on Cancer this year:

Breast conservation surgery rate for women with AJCC clinical stage 0, I or II breast cancer (surveillance)Year 2012 GMC – 58.8% Comprehensive Cancer Programs – 62.9% Image or palpation-guided needle biopsy (core or FNA) is performed to establish diagnosis of breast cancer (quality improvement)Year 2012 GMC – 88.8% Comprehensive Cancer Programs – 86.1%

At least 15 regional lymph nodes are removed and pathologically examined for resected gastric cancer (quality improvement)Year 2012 GMC – 25% Comprehensive Cancer Programs – 52.4%

At least 10 regional lymph nodes are removed and pathologically examined for AJCC stage IA, IB, IIA and IIB resected NSCLC (surveillance)Year 2012 GMC – 13.3% Comprehensive Cancer Programs – 39.2%

Systemic chemotherapy is administered within four months to day preoperatively or day of surgery to six months postoperatively, or it is considered for surgically resected cases with pathologic lymph node-positive (pN1) and (pN2) NSCLC (quality improvement)Year 2012 GMC – 100% Comprehensive Cancer Programs – 81.9%

Radiation therapy is considered or administered within six months (180 days) of diagnosis for patients under the age of 80 with clinical or pathologic AJCC T4N0M0 or stage III receiving surgical resection for rectal cancer (surveillance)

Year 2012 GMC – 66.7% Comprehensive Cancer Programs – 87.8%

Left: Medical Oncologist Mohan Krishnamachary, MD, Nancy McCormick, RN, BSN Thoracic Nurse Navigator, Georgia State House Representative Brooks Coleman and Radiation Oncologist Gary Stillwagon, PhD, MD, FACR, at the Shine a Light on Lung Cancer event.

Right: First graduates of the Cancer Transitions ® class at the Cancer Support Center.

2014 Quality Improvements – Katie S. Michaud MPADirector of Oncology

The span of quality improvements that have been made this year for cancer patients throughout GMC is impressive. Our cancer committee and breast program leadership committee take pride in the attention paid to not only clinical improvements but also improvements in the patient experience. Below are examples of quality improvements made this year:

Center for Cancer Care• Expanded patient financial navigation/counseling services

• Improved safety of chemotherapy administration by instituting safety needles, spiros and changing to single use gown along with double gloving and double checking the chemotherapy rate of the pumps

• Increased patient satisfaction with ability to reach office by phone as measured by Press Ganey patient surveys

The following are improvements noted through our Quality Oncology Practice Initiative (QOPI) national benchmarking participation:

• Improved the percent of patients in need of hospice care enrolled more than seven days before death

• Improved assuring that patient performance status (patient functioning indicator) is documented for patients with initial AJCC stage of IV of distant metastatic non-small cell lung cancer improved

• Continued improvement in assurance that pain assessment and intervention is well documented

Interventional Radiology and Endoscopy• Implemented PEG tube home healthcare and nutrition order sets and improved inpatient to outpatient coordination of

care improves the service provided to patients who receive feeding tubes

Radiology• Achieved Center of Excellence Status for Lung Cancer Screening

• Decreased time from screening to diagnostic mammogram by 65% (21 days to 7 days)

• Began offering Xofigo treatments, an injection used to treat prostate cancer that is resistant to medical or surgical treatments

• Increased Care-a-Van access to affordable screening mammography and population of underserved patients: (10% increase in sites visited from last year; 7% increase in mammograms provided from last year; 4% increase in population unable to pay for screening from last year)

Cancer Committee• Improved access to tumor conferences via Webex providing more opportunities for the multidisciplinary treatment team

to participate from their offices and receive valuable input into the care of patients with cancer.

• Increased Road to Recovery volunteer drivers by more than 60%, providing more access to free transportation for patients undergoing cancer treatment.

Pastoral Care• Implemented oncology chaplain services including rounding in chemotherapy infusion areas

Cancer Support Center• Implemented thoracic (lung) cancer navigation services and increased timeliness of care from diagnosis to treatment for

lung cancer

• Implemented oncology nutrition program for high risk patients to help maintain optimal nutritional status during treatment

• Implemented evidence-based Cancer Transitions® Program for survivorship care

• Implemented oncology social work program and psychosocial distress screening for all new patients of the Center for Cancer Care

• Expanded support groups including a new men’s support group, caregivers support group and Spanish women’s support group

• Implemented hereditary risk assessment services and increased genetic counseling visits

• Implemented a volunteer program including cancer resource volunteers providing support and information to cancer patients various care locations as well as appearance services

• Now offering a free Yoga class for breast cancer patients

• Initiated On a Good Note, a newsletter for patients and the community to inform them of services and events offered by the Cancer Institute

Oncology Data Center Report – Theresa Vallerand, BGS CTRInterim Manager

The Oncology Data Center (ODC) information system is designed for the collection, management and analysis of data of persons with the diagnosis of malignant disease (cancer) and benign brain tumors. The information maintained in the GMC ODC Database includes demographic information, diagnostic testing, cancer findings (including primary site, histology or cell type and extent of disease and/or stage), initial treatment modalities (surgery, radiation therapy, chemotherapy and combinations thereof) and annual surveillance information such as vital and disease status. The collection of this data is a process called cancer registry abstraction or abstracting.

The ODC collects the 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 to the Georgia Center for Cancer Statistics monthly and to the National Cancer Database annually. This data is also used internally for assessing community need, appropriate treatment and services, and maintaining the highest quality of care and support for our cancer patients.

All abstractors in the ODC are certified tumor registrars, the national credential for these medical professionals. The ODC staff also includes an administrative assistant.

The ODC abstracted 1,586 analytic cases on patients first seen for their disease at GMC in 2013, an increase of 1.1% over 2012. These cases represent patients who were seen at GMC for initial diagnosis and/or initial treatment for cancer or benign brain tumors. Additionally there were 306 patients first seen at GMC after initial treatment and having residual, progressive, recurrent or metastatic disease.

The five most prevalent cancers seen in GMC female patients were breast, lung, colon-rectal, thyroid gland and uterus/endometrium cancers. The five most prevalent cancers seen in GMC male patients were colon-rectal, prostate, lung, lymphoma/myeloma and urinary bladder.

This year has been a year of transition in the ODC. The staff structure has changed and processes and procedures have been and are continuing to be revised and fined tuned. This transition will position the ODC for future growth and development.

Oral Cavity & Pharynx - 27 (4%) Lung & Bronchus - 107 (16%) Pancreas - 22 (3%) Kidney & Renal Pelvis - 17 (3%) Urinary Bladder - 50 (7%) Colon & Rectum - 80 (12%) Prostate - 114 (17%) Non-Hodgkin Lymphoma - 26 (4%) Melanoma of the Skin - 7 (1%) Leukemia - 23 (3%) All Other Sites - 195 (29%)

Thyroid - 61 (7%) Lung & Bronchus - 87 (9%) Breast - 397 (43%) Kidney & Renal Pelvis - 7 (1%) Ovary - 17 (2%) Uterine Corpus - 48 (5%)

Colon & Rectum - 62 (7%)

Non-Hodgkin Lymphoma - 22 (2%)

Melanoma of the Skin - 3 (0%)

Leukemia - 17 (2%)

All Other Sites - 197 (21%)

Males Females

GMC 2013 Analytic Cancer Cases

Images reprinted by the permission of the American Cancer Society, Inc. from www.cancer.org. All rights reserved.

Summary by Body System and Sex ReportGMC 2013 Analytic Cancer Cases Primary Site Total % Male % Female %

ORAL CAVITY & PHARYNX 35 2.2% 27 4.0% 8 0.9%Lip 2 0.1% 1 0.1% 1 0.1%Tongue 12 0.8% 10 1.5% 2 0.2%Salivary Glands 1 0.1% 1 0.1% 0 0.0%Floor of Mouth 1 0.1% 1 0.1% 0 0.0%Gum & Other Mouth 3 0.2% 3 0.4% 0 0.0%Nasopharynx 3 0.2% 2 0.3% 1 0.1%Tonsil 8 0.5% 6 0.9% 2 0.2%Oropharynx 1 0.1% 0 0.0% 1 0.1%Hypopharynx 4 0.3% 3 0.4% 1 0.1%

DIGESTIVE SYSTEM 312 19.7% 176 26.3% 136 14.8%Esophagus 18 1.1% 16 2.4% 2 0.2%Stomach 35 2.2% 24 3.6% 11 1.2%Small Intestine 13 0.8% 5 0.7% 8 0.9%Colon Excluding Rectum 101 6.4% 54 8.1% 47 5.1%Rectum & Rectosigmoid 41 2.6% 26 3.9% 15 1.6%Anus, Anal Canal & Anorectum 9 0.6% 4 0.6% 5 0.5%Liver & Intrahepatic Bile Duct 30 1.9% 17 2.5% 13 1.4%Gallbladder 8 0.5% 3 0.4% 5 0.5%Other Biliary 6 0.4% 4 0.6% 2 0.2%Pancreas 46 2.9% 22 3.3% 24 2.6%Retroperitoneum 1 0.1% 1 0.1% 0 0.0%Peritoneum, Omentum & Mesentery 4 0.3% 0 0.0% 4 0.4%

RESPIRATORY SYSTEM 207 13.1% 116 17.4% 91 9.9%Nose, Nasal Cavity & Middle Ear 2 0.1% 2 0.3% 0 0.0%Larynx 10 0.6% 7 1.0% 3 0.3%Lung & Bronchus 194 12.2% 107 16.0% 87 9.5%Trachea, Mediastinum & Other 1 0.1% 0 0.0% 1 0.1%

BONES & JOINTS 1 0.1% 1 0.1% 0 0.0%Bones & Joints 1 0.1% 1 0.1% 0 0.0%

SOFT TISSUE 9 0.6% 6 0.9% 3 0.3%Soft Tissue 9 0.6% 6 0.9% 3 0.3%

SKIN EXCLUDING BASAL & SQUAMOUS 13 0.8% 8 1.2% 5 0.5%Melanoma - Skin 10 0.6% 7 1.0% 3 0.3%Other Non-Epithelial Skin 3 0.2% 1 0.1% 2 0.2%

BREAST 399 25.2% 2 0.3% 397 43.2%Breast 399 25.2% 2 0.3% 397 43.2%

FEMALE GENITAL SYSTEM 83 5.2% 0 0.0% 83 9.0%Cervix Uteri 10 0.6% 0 0.0% 10 1.1%Corpus & Uterus, NOS 48 3.0% 0 0.0% 48 5.2%Ovary 17 1.1% 0 0.0% 17 1.9%Vulva 8 0.5% 0 0.0% 8 0.9%

MALE GENITAL SYSTEM 124 7.8% 124 18.6% 0 0.0%Prostate 114 7.2% 114 17.1% 0 0.0%Testis 9 0.6% 9 1.3% 0 0.0%Penis 1 0.1% 1 0.1% 0 0.0%

URINARY SYSTEM 84 5.3% 69 10.3% 15 1.6%Urinary Bladder 57 3.6% 50 7.5% 7 0.8%Kidney & Renal Pelvis 24 1.5% 17 2.5% 7 0.8%Ureter 1 0.1% 0 0.0% 1 0.1%Other Urinary Organs 2 0.1% 2 0.3% 0 0.0%

BRAIN & OTHER NERVOUS SYSTEM 55 3.5% 20 3.0% 35 3.8%Brain 31 2.0% 14 2.1% 17 1.9%Other Nervous System 24 1.5% 6 0.9% 18 2.0%

ENDOCRINE SYSTEM 83 5.2% 17 2.5% 66 7.2%Thyroid 73 4.6% 12 1.8% 61 6.6%Other Endocrine 10 0.6% 5 0.7% 5 0.5%

LYMPHOMA 59 3.7% 31 4.6% 28 3.1%Hodgkin Lymphoma 11 0.7% 5 0.7% 6 0.7%Non-Hodgkin Lymphoma 48 3.0% 26 3.9% 22 2.4%

MYELOMA 34 2.1% 21 3.1% 13 1.4%Myeloma 34 2.1% 21 3.1% 13 1.4%

LEUKEMIA 40 2.5% 23 3.4% 17 1.9%Lymphocytic Leukemia 22 1.4% 14 2.1% 8 0.9%Myeloid & Monocytic Leukemia 13 0.8% 5 0.7% 8 0.9%Other Leukemia 5 0.3% 4 0.6% 1 0.1%

MESOTHELIOMA 2 0.1% 2 0.3% 0 0.0% Mesothelioma 2 0.1% 2 0.3% 0 0.0%

KAPOSI SARCOMA 2 0.1% 2 0.3% 0 0.0% Kaposi Sarcoma 2 0.1% 2 0.3% 0 0.0%

MISCELLANEOUS 44 2.8% 23 3.4% 21 2.3% Miscellaneous 44 2.8% 23 3.4% 21 2.3%

TOTAL 1,586 668 918

Christopher Hagenstad, MD, Medical Oncologist and

Kimberly Hutcherson, MD, Breast Interventional Radiologist, share a

moment with an attendee at GMC’s Cancer Survivor Celebration.

Cancer Survivor Celebration participant enjoying a free

foot massage.

New Cancer Support Center

Alexander Saker Jr., MD Cancer Committee Chair

Medical Oncologist/Hematologist

Cancer Conference Coordinator

Murtaza Cassoobhoy, MD Hospitalist/Palliative Care

Kimberly 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 Surgeon

Jean-Claude Schwartz, MD, PhD Surgeon

Philip Shrake, MD Radiation Oncologist

Robert Siegel, MD Pathologist

Jamila Brown, CHES Health Education Specialist

Brad Humphrey, PT Director of Rehabilitation

Chuck Christie, M.Div., BCC Chaplain, Psychosocial Services Coordinator

Kathy Vance, RN, ONS Oncology Nurse Manager

Terry Vallerand, BGS, CTR Certified Tumor Registrar/Manager

Holly Richards Director, Office of Research,

Clinical Research Rep.

Donna Hedger, HT Pathology Manager

Katie Michaud, MPA Director, Oncology Services, Quality Coordinator

Rachel Joiner American Cancer Society

Jennifer Griffin American Cancer Society Patient

Resource Navigator

Amy McEachin, RN, OCN Oncology Nurse Clinician

Rita Michael, RN, BS, CPHQ Performance Improvement Representative

Mark Mullin Director of Planning

Kim Petty Senior Planning Analyst

Karen Kubik R.T. (R) Imaging Director

Deidre Robinson, MSW Oncology Social Worker, Psychosocial

Services Coordinator

Cindy Snyder, APNG, FNP-C CBCN Genetics Professional

Amy Trammell, RN, OCN Breast Health Nurse Navigator

Gretchen Hayward, RN, CBPN-IC Breast Health Nurse Navigator

Nancy McCormick, BSN Thoracic Nurse Navigator

Amy Tella, MS, RD, CNSC Clinical Nutrition Manager

Thelema Martin, MS, RDN, LD Oncology Nutritionist

Michael Naughton, Pharm. D Director of Pharmacy

Kevin Peacock, MD Medical Oncologist

Mohan Krishnamachary, MD Medical Oncologist

Brandon Kang, MD Radiologist

Anthony Landis, DO Medical Director, Medical Oncologist/Hematologist

2014 Cancer Committee