Oncology Report FY2016

Oncology FY 2016 REPORT

Our advanced technologies and treatment options, along with our multidisciplinary approach, have earned Carilion Clinic the reputation as the regional leader in cancer care. We provide comprehensive services for diagnosis, treatment, rehabilitation and survivorship for adult and pediatric cancer patients in the Roanoke Valley, southwest Virginia and beyond. From highly developed therapy options such as CyberKnifeŽ stereotactic radiosurgery to the area’s only dedicated inpatient medical oncology unit, we are committed to providing the highest quality care for cancer patients and their families.

In addition to our cancer center, we have a number of support facilities. These include 22 private inpatient rooms located within Carilion Roanoke Memorial Hospital, an ambulatory infusion center at 1 Riverside and the Carilion Breast Care Center, which continues to be a regional pillar for women’s health in the Roanoke Valley for all women.

With our commitment to excellence in all areas of cancer care, as well as our strong partnership with the Virginia Tech Carilion School of Medicine and Research Institute, Carilion has earned the Commission on Cancer (CoC) accreditation by the American College of Surgeons as an Academic Comprehensive Cancer Center. The CoC accreditation recognizes cancer care programs for their commitment to providing comprehensive, high-quality and multidisciplinary patient-centered care.

We are pleased to share information about our services and latest achievements here and we invite you to join us in commending the hard work of the many oncology professionals that it represents. We are especially grateful to the physicians and staff of Blue Ridge Cancer Care and the American Cancer Society, whose partnership is essential in making this high level of care possible for patients in our region.

Steven Arner President and CEO, Carilion Medical Center

David Buck, M.D. Cancer Committee Chair

The cancer program at Carilion Clinic is directed by a multidisciplinary committee of physician and non-physician members who are dedicated to the quality care of cancer patients and their families.

The American College of Surgeons Commission on Cancer (ACoSCoC) has set forth mandatory standards for the programs that bear the ACoSCoC accreditation. Our cancer committee follows the program standards set forth by the ACoS and the structure for the cancer program at Carilion Clinic. There are five key areas that define a quality cancer program according to ACoSCoC standards:

Clinical services that provide state-of-the-art pretreatment, staging, treatment and follow-up care at the facility for primary and ongoing care or end-of-life care

A cancer committee that leads the program with goal setting and also maintains activity, monitors patient outcomes and improves care

Cancer conferences, which used to be called Tumor Boards, that provide a platform for patient consultation and physician education

A quality improvement program that is in place to provide a mechanism for evaluating and improving patient outcomes

The cancer program maintains a hospital cancer registry and database to maintain quality of care

Each area of the cancer program at Carilion Clinic has a significant role in the quality of care of our patients.

THE STRENGTH OF OUR CLINIC IS THAT

each part is a part of a whole.

OUR CANCER TREATMENT PROGRAMS

at Carilion, in collaboration with the physicians of Blue Ridge Cancer Care, provide the full range of cancer treatments on both an inpatient and an outpatient basis. All types of adult and pediatric cancers are treated, and comprehensive cancer prevention and screening programs are available.

EXPERTISE IN CHEMOTHERAPY ADMINISTRATION Our highly trained nursing staff in the medical/surgical oncology unit provide care to patients who have complex needs related to their diagnoses or side effects of treatment.

INPATIENT CLINICAL SERVICES INPATIENT ONCOLOGY The area’s only medical/surgical oncology unit that is dedicated to the treatment of adults is located in the south tower of Carilion Roanoke Memorial Hospital. The unit has 22 private rooms and highly trained nurses with expertise in chemotherapy and biotherapy administration and care for the oncology patient. Evidence-based nursing care is provided to medical and surgical patients with complex needs. We have the ability to treat all kinds of blood disorders and cancers; patients needing acute leukemia induction therapies can stay close to home for their treatment needs. Patients are also treated for related complications and side effects of treatment such as neutropenic fever, anemia, wound care and symptom and pain management. Ancillary support services include dietitians, therapists, social services, case management, pharmacy and chaplain services. Padmaja Mallidi, M.D., serves the inpatient oncology unit as our medical director.

SURGICAL ONCOLOGY Because surgery is among the most effective treatments for many types of cancer, we offer our patients access to a team of highly skilled, specialized and experienced surgeons who treat many forms of cancer, including gastrointestinal, gynecologic, thoracic, head and neck, breast, skin, prostate and other cancers.

One specialized tool that our surgeons have available is the da Vinci® Surgical System. As part of our mission to deliver the latest, most innovative, state-of-the-art technology to our patients, da Vinci® is often used to perform a variety of surgical procedures, both cancerous and noncancerous, including removal of gynecologic cancers and cancers around male reproductive organs such as prostate, bladder and kidney cancers.

“We take pride in developing a unique care plan for each patient that establishes the correct diagnosis, removes the tumor in the least invasive fashion and returns our patients to their loved ones free from disease.”

- David Luyimbazi, M.D.

INPATIENT CLINICAL

PALLIATIVE CARE Palliative care is specialized care of seriously ill patients with the goal of improving pain and symptom management while assisting the patient and family with establishing goals of care. The palliative care team consists of nurses, advanced practice nurses (C.N.S., N.P.), bereavement counselors, fellows, residents and physicians. This team is augmented by chaplaincy, dietary, social work, case management and pharmacy services. These disciplines participate in daily interdisciplinary unit rounds. Common diagnoses include advanced cancer, cardiac, pulmonary, renal, liver and neurological conditions/diseases. The palliative care team provides comprehensive management of patients’ physical, psychological, social and spiritual needs while supporting their families/caregivers. Additionally, bereavement services are provided to families for up to a year after the loss of their loved one.

INPATIENT CLINICAL

PHARMACEUTICAL Our oncology pharmacists maintain a clinical practice by working with medical and nursing personnel to optimize the pharmacotherapeutic aspects of patient care. This includes optimal selection of pharmacologic agents to maximize therapeutic benefit and minimize toxicity along with ongoing daily follow-up on the clinical effects of the regimen, with adjustment as necessary to achieve desired outcomes. Pharmacokinetics dosing or monitoring occurs for all patients where therapeutic levels are reported. Drug and clinical information is provided to other health care professionals in response to specific questions regarding new or evolving issues related to the care of patients with cancer. The IV Admixture Center is staffed with highly trained pharmacists and pharmacy technicians who carefully and accurately make all IV chemotherapy preparations and other medications. Prepared inside a biological safety cabinet designed for chemotherapy, the sterile environment and techniques assure each dose is provided to ensure quality patient care.

OUTPATIENT CLINICAL SERVICES MEDICAL ONCOLOGY Carilion offers a full range of medical oncology services in the inpatient and outpatient settings, partnering with the physicians of Blue Ridge Cancer Care to provide comprehensive cancer treatment to oncology patients in Virginia. Patients are offered the latest in chemotherapy, biologic therapy, immunotherapy and experimental drugs through clinical trials.

RADIATION ONCOLOGY The state-of-the-art radiation oncology treatment opportunities offered at Carilion are unmatched anywhere in the region. The technology of the CyberKnife® and other, more traditional radiation therapies continue to offer patients more treatment options from a radiation oncology team that is highly trained and passionate about the patient-centered care they provide.

Some of the radiation therapy options include: »» Intensity modulated radiation therapy (IMRT) »» Image-guided radiation therapy (IGRT) »» High-dose rate brachytherapy (HDR) »» Prostate seed implant »» Stereotactic radiosurgery (CyberKnife®) Our experienced radiation team consists of radiation oncologists, physicists, nurses and radiation therapists who offer personalized care to each and every patient. David Buck, M.D., serves as our medical director.

GENETICS

GENETICS Cancer has a variety of causes, including genetic, and Carilion Clinic recognizes the importance of genetics in the care and planning for our patients. Carilion Clinic has partnered with the InformedDNA genetics program. InformedDNA is committed to assisting our patients and their family members to understand the risks of hereditary cancer and to develop a plan of action to reduce their risk or prevent cancer altogether.

Patients may be referred by a provider or self-referred. They are able to speak to a board-certified genetics specialist during day, evening or weekend appointments in a setting of their choosing.

We typically refer patients who have: »» An unusual pattern of cancer in the family »» O nset of cancer at an unusually young age among family members »» Family members with the same kind or related types of cancer »» Family members with more than one kind of cancer »» Rare forms of cancer among family members Our services include: »» Education about cancer risks »» G uidelines for cancer screening and prevention »» Referrals to resources and support groups »» Coordination of genetic testing and related insurance issues »» I dentification and enrollment of eligible patients in cancer research studies

OUTPATIENT CLINICAL

AMBULATORY INFUSION CENTER Our Infusion Center, located on the third floor of Riverside 1, provides administration of intravenous chemotherapy, biotherapy and subcutaneous injections for our patient population. The chemotherapy biotherapy course offered by the Oncology Nursing Society (ONS) provides education and training for each Infusion Center nurse to provide safe, quality and evidence-based patient care through the use of chemotherapy and biologic medications.

The Infusion Center is equipped with 10 patient care chairs and staffed by five registered nurses. We serve various patient populations, including gynecologic oncology, rheumatology, gastroenterology, neurology and endocrinology. Our infusion nursing staff uses their specialized knowledge of medications to care for rheumatology patients with conditions such as rheumatoid arthritis, psoriatic arthropathy, ankylosing spondylitis, vasculitis and lupus, as well as gastrointestinal conditions such as ulcerative colitis and Crohn’s disease. We provide infusions and injections both for neurology patients with conditions such as multiple sclerosis and for endocrinology patients with conditions such as osteoporosis. The nursing staff administers intraperitoneal and intravenous chemotherapy to gynecologic oncology patients with GYN cancers such as endometrial, cervical, ovarian or peritoneal cancers. Janet Osborne, M.D., serves as the medical director for the Infusion Center.

HOSPICE Carilion Clinic Hospice is a unique provider in the continuum of care, providing end-of-life services and support to the patient and family, while maintaining dignity and comfort.

Hospice care has been a service for over 40 years and is 100 percent covered by Medicare. Medicaid and most private insurances also provide these benefits to patients, with little to no co-pay. Our hospice staff consists of an interdisciplinary team that provides skilled nursing services, medical social workers, volunteers, chaplains, certified nursing assistants, massage therapists, music therapists, pet therapists, grief counselors and medical directorship. All of these staff members make visits to the patient’s home, nursing home or hospital for care, a service that our team is honored to provide. Bereavement services are available for the family and caregivers free of charge and last for up to 13 months after the passing of a loved one.

Carilion Clinic Hospice holds several grief support groups throughout the year for anyone that has experienced a loss. Soul Survivors is a grief support group open to grieving children and their families.

Soul Survivors provides a caring and safe environment where participants are free to explore their feelings and concerns.

“My wife died last year and I attend Soul Survivors with our son. I came because of my son’s needs but quickly realized that I too could learn and share with other parents.”

- Soul Survivors participant

INPATIENT AND OUTPATIENT CLINICAL SERVICES GYN-ONCOLOGY Carilion provides comprehensive care for all patients with gynecologic malignancies.

Through inpatient and outpatient care, we are committed to providing the highest quality of services using the latest treatment options and procedures, including the da Vinci® Surgical System. GYN-oncology services include GYN surgery for malignant diseases, administration of chemotherapy, cancer screenings, genetic counseling, palliative care and the opportunity for clinical trial participation through National Research Group.

BREAST PROGRAM Our Breast Care Center is a national leader in breast cancer screening, diagnosis and treatment. We believe in an interdisciplinary approach to the treatment of breast cancer. Our skilled and compassionate integrated care team provides: »» A weekly cancer treatment planning conference so every woman receives an individual review of her care plan from the combined expertise of a team of specialists »» L arge-format pathology, a more accurate pathology approach that may lower the rate of breast cancer recurrence »» Breast MRI, an advanced technology that allows for more precisely targeted breast cancer treatment »» Nurse navigation to provide individualized care, support and education throughout the cancer treatment journey »» A bimonthly support group to help newly diagnosed patients gain support and information from others going through similar circumstances »» An annual overnight retreat for breast cancer survivors to broaden their support systems and learn relaxation techniques

COMPASSION Our skilled and kindhearted care team uses an interdisciplinary approach to the treatment of breast cancer.

INPATIENT AND OUTPATIENT

IMAGING Carilion Clinic is committed to staying at the forefront of imaging technology and quality of care by supporting our providers and staff with the most innovative and advanced equipment available. This focus ensures that our patients have access to the highest quality care.

We have advanced equipment in computed tomography (CT) and all high-field-strength MRI scanners and multiple wide-bore scanners. The high field strength provides greatest tissue discrimination for characterization and diagnosis. Carilion uses a host of additional sophisticated imaging tools for the diagnosis and treatment of malignancies.

Our radiologists are all certified by the American Board of Radiology; 25 of our 35 radiologists are fellowship trained in the following subspecialty areas: body imaging, interventional radiology, cardiovascular, musculoskeletal, pediatric, neuroradiology, breast imaging, neurointerventional surgery and neurovascular. Our registered nurses, physician assistants and radiologic technologists carefully guide you through every step of our imaging process.

Carilion is dedicated to making your experience with us as comfortable as possible. We will do our best to schedule appointments around your busy schedule. When you have worries or concerns, we are here to answer your questions about current treatments and explore other possible imaging options.

Our interventional radiology services include: »» Diagnostic radiology & fluoroscopy (X-rays)

»» MRI »» Nuclear medicine/molecular imaging

»» B one density testing

»» Interventional radiology

»» Ultrasound

»» Advanced imaging

»» C T

»» Mammography

»» PET/SPECT CT scanning Our oncology-related imaging services include: »» Biopsies

»» Radiofrequency ablation

»» Port placement

»» Cryoablation

»» Port removal

»» Microwave ablation

»» Chemoembolization »» Radio embolization

»» T horacentesis, paracentesis, PleurX catheter placement

»» Radioimmunotherapy

»» PICCU/vascular access teams

REHABILITATION SERVICES Cancer rehabilitation services and treatments help patients cope with activities of daily living affected by the cancer experience and enable them to resume normal activities. Rehabilitation helps cancer patients and survivors improve functional status and quality of life.

The Carilion Clinic cancer program is pleased to offer a full range of rehabilitation services for the oncology patient. Services include: »» Physical, occupational and speech therapy »» Lymphedema management »» Pelvic floor rehabilitation »» Therapeutic exercise and strengthening »» Cancer-related fatigue management »» Vestibular rehabilitation »» Dysphagia treatment »» Communication methods following laryngectomy »» Tracheo-esophageal prosthesis and follow-up management »» Motor speech and cognition treatment

INPATIENT AND OUTPATIENT

PEDIATRIC HEMATOLOGY/ONCOLOGY At Carilion Children’s Pediatric Hematology/Oncology, parents whose children have a pediatric blood disorder or cancer don’t ever have to feel they must make a choice between expert treatment and warm, supportive care—we emphasize both. We know that a child’s cancer or blood disorder can present extraordinary physical, emotional and social challenges not just for the patient but for the whole family.

We are with you every step of the way. Our specialists work collaboratively to provide a variety of services and treatments in a child-friendly, family-centered environment. It’s our mission to provide your child with compassionate and coordinated care—including state-of-the-art treatment delivered by a team that consists of physicians, nurses, nurse practitioners, psychologists, child life specialists, dietitians, social workers, chaplains, pharmacists, case managers and volunteers. The pediatric unit has 14 private rooms and five semi-private rooms and is staffed by highly trained nurses with expertise in chemotherapy administration and care for the pediatric oncology patient.

Our integrated approach also provides access to many of our pediatric sub-specialty areas for coordination of treatments and services. Carilion Children’s physicians work collaboratively with our specialists in Pediatric Hematology/Oncology to treat children with blood disorders and cancer from infancy through the teenage years.

Conditions we treat: »» Anemia

»» Hemophilia

»» Neuroblastoma

»» Bone and soft-tissue cancers

»» Leukemia

»» Platelet problems

»» Brain tumors

»» Lymphoma

»» Sickle cell disease

»» Clotting disorders

»» Musculoskeletal tumors

»» Solid tumors

»» Hematologic malignancies

»» Myelodysplastic syndromes

PAIN MANAGEMENT Carilion Clinic’s pain management team offers many safe treatment options to reduce pain. The comprehensive pain management team includes Don Bivins, M.D., Director of the Comprehensive Pain Team; Rachel Huddleston, R.N.-B.C., B.S.N., M.S.N.; Tendai Ushe, R.N.-B.C., B.S.N.; and Lisa Simpson, R.N.-B.C., B.S.N., M.S.N., F.N.P.-C. Dr. Bivins is board certified in hospice and palliative medicine and the nursing team is board certified in pain management. The team is trained in and embraces several modalities of pain management with the goal of helping individuals manage their pain and return to their daily activities.

Our team provides services in all areas of need such as the intensive care unit, the pediatric intensive care unit or the medical and surgical units and sees approximately 1,000 consults per year. Patients may be referred for interventional treatments such as massage therapy, acupuncture, Reiki, water aerobics and pet therapy to identify and treat the individual’s pain. Our team is very involved in education and research and provides resources for the pain resource nurse program and the biannual pain conference held at Carilion Clinic.

PATHOLOGY Ten board-certified pathologists with subspecialty expertise in surgical pathology, gastrointestinal and hepatic pathology, dermatopathology, hematopathology, cytopathology and forensic pathology provide diagnostic pathology services for our oncology patients. These services include intraoperative consultation, gross examination of patient specimens obtained at surgery and microscopic examination of surgical specimens, biopsies, and cytologic specimens.

All pathology reports are rendered using College of American Pathology synoptic formats developed in cooperation with the oncology community. These formats ensure completeness of reporting and ease of access to information for patient management.

Our pathologists are often called on to review cancer diagnoses from other institutions and they provide 32 hours each month to patient care conferences.

SUPPORT SERVICES ONCOLOGY NUTRITION An oncology-certified registered dietitian/ nutritionist provides nutrition services to our oncology inpatients and outpatients.

The services include performing nutritional assessments and developing and implementing nutritional care plans, as well as providing nutritional counseling. Counseling covers education on modified diets, symptom and weight management, nurition support therapies, complementary nutritional approaches and optimizing wellness for cancer survivorship.

All inpatients are evaluated and monitored for nutrition care and management per hospital policy. Inpatients are screened for nutrition risk by nursing at the time of admission. Patients are referred to the dietitian for a nutritional assessment if they have significant unplanned weight loss, have decreased oral intake related to difficulty chewing or swallowing, are admitted with tube feedings, parenteral nutrition or wounds, or are surgical patients over 65 years of age.

Radiation oncology outpatients are screened for nutritional risk by nursing using the patient-generated subjective global assessment, a validated tool for oncology.

Patients generating an increased risk score are referred to our registered dietitian for assessment. Additionally, all patients with feeding tubes, TPN or those with head and neck, esophageal or primary gastrointestinal tumors are also referred to the dietitian for evaluation. Staff members also refer any patient who is experiencing significant difficulties through the course of treatments. All other oncology outpatients are referred to a registered dietitian as needed.

SUPPORT SERVICES

SOCIAL WORK AND CASE MANAGEMENT Oncology social workers and case managers provide specialized services to individuals undergoing cancer treatment and their family members. These services are available at Carilion Roanoke Memorial Hospital’s inpatient oncology and palliative care units as well as the Radiation Oncology Outpatient Clinic.

Our oncology social workers meet with individuals and their family members to address practical problems such as transportation and financial concerns. They are knowledgeable about local and national resources and can make appropriate referrals as needed. They can provide guidance, education and problem-solving strategies to address quality of life issues related to the cancer diagnosis and treatment.

Our team of social workers also helps individuals prepare for important conversations with family members and cope with possible reactions. They can help our acute hospital inpatients review availability of alternative placement options when a return to prior living arrangements may be difficult for the individual.

Inpatient case managers work in collaboration with oncology social workers and are available at Carilion Roanoke Memorial Hospital. A case manager evaluates each individual after admission for specific discharge needs, such as referrals for home health/hospice services, physical/ occupational therapy, medical equipment, home oxygen and medication assistance.

Healing Emotions Through Art Providing the very best patient care means treating more than just physical symptoms. We address the emotional needs of patients and families by integrating literary, performing and visual art experiences into the healing process. The result is a more inspirational, supportive and restorative environment for patients, visitors and caregivers of Carilion Clinic.

Activities have included: »» Live music weekly in radiation oncology »» B edside and public area activities by artists-in-residence, including painting, pottery and creative writing »» Journaling »» V isual art exhibitions »» Free poetry brochures available for patients and visitors in waiting areas

SUPPORT SERVICES

PASTORAL CARE Carilion’s chaplains provide emotional and spiritual support for patients and families of all faiths as they experience illness, healing, suffering and death. Services include pastoral counseling, reflective listening, prayer and pastoral presence.

Our chaplains offer support and therapeutic care in situations of crisis and grief, and help resolve conflicts and promote communication between patients, families and staff concerning religious and cultural traditions that may affect health care decisions.

“As Director of Chaplaincy Services, I’m grateful that we can support and enhance the faith of our patients and their families during hospitalizations. The chaplain’s role in the healing process ensures that we are caring for the entire person in mind, body and spirit.”

- Richard Brown

CLINICAL TRIALS AND RESEARCH By taking part in clinical trials and innovative cancer research, we are able to stay on the forefront of cancer treatment. Our patients can be assured that physicians who are involved in clinical trials are staying up-to-date on the latest treatment options and will provide the best possible care right here at home.

Carilion Clinic’s gynecologic oncology program attracts significant funding each year for research which conducts progressive research trials through the NRG Oncology Group and the National Cancer Institute. Our program conducts 15 to 20 studies at any given time and continues to grow.

Carilion Children’s childhood cancer program conducts clinical research trials through its association with the Children’s Oncology Group. We see approximately 15 to 20 new oncology patients per year. The only board-certified pediatric hematologist/oncologists in southwest Virginia and southeastern West Virginia are on our team. This enables us to offer cutting-edge cancer treatment to pediatric patients and their families.

Carilion has partnered with Blue Ridge Cancer Care to offer patients access to cutting-edge medical and radiation oncology clinical trials. The radiation clinical trial program gives cancer patients a chance to participate in the development of future treatments while providing access to the very latest therapies that can potentially increase survival while improving quality of life. The trials are a collaborative effort among Blue Ridge Cancer Care, Carilion Clinic, US Oncology Research and NRG Oncology.

In addition to radiation clinical trials, medical oncology clinical trials have been an integral part of our efforts to provide cancer patients access to the latest therapies and treatment options for many years. Blue Ridge Cancer Care offers 25 to 30 medical oncology clinical trials at any given time, including breast cancer, lymphoma, lung cancer, gastrointestinal cancer, hematological malignancies and many more. The trials are offered via a collaborative effort from US Oncology Research and/or pharmaceutical companies that sponsor the clinical trials.

CARILION CANCER COMMITTEE The Carilion Cancer Committee is a multidisciplinary committee comprised of physician and non-physician members according to guidelines established by the American College of Surgeons Commission on Cancer. It is the responsibility of the committee to establish and evaluate annual goals related to cancer care for the program, to establish cancer conference frequency, maintain quality and to provide for oncology education for medical and allied health professional staff at the facility. The American College of Surgeons (ACoS) has designated a position on the committee entitled the Cancer Liaison Physician (CLP) to act as a liaison between the committee and the ACoS. During 2016, the committee was chaired by David A. Buck, M.D., of Radiation Oncology.

David Luyimbazi, M.D., our surgical oncologist, served as the CLP for the committee.

The committee functions under the leadership of six coordinators. For 2016, these coordinators were: Catherine Hagan, M.S.N., C.B.N.®, community outreach coordinator; Natasha Holt, C.C.R.P., clinical research coordinator; Padmaja Malidi, M.D., cancer conference coordinator; Leta Vess, B.A., C.T.R., cancer registry quality coordinator; Jean Westervelt, L.S.W., psychosocial services coordinator; and Lisa Mitchell, quality improvement coordinator.

CANCER CONFERENCES Multidisciplinary cancer conferences provide opportunities for physicians to present patient cases in a collaborative setting with physician specialists and other health care team members at Carilion Clinic in order to offer patients the most thorough and up-to-date oncology treatment options. Conference attendees include medical oncologists, radiation oncologists, radiologists, pathologists, surgeons and specialists in the conference discipline. Attendees also include nurses, advanced care providers, allied health professionals, medical students and residents. Conferences offer patients the opportunity for multi-disciplinary care and offer medical professionals ongoing education opportunities. Carilion is a regional leader in cancer conference offerings. Currently over 20 individual monthly conferences are held in the following specialty areas:

»» Thoracic oncology

»» Breast pre-treatment planning

»» Pediatric oncology

»» General oncology

»» GYN oncology

»» Head and neck oncology

»» GI oncology

»» Neuro-oncology

GYNECOLOGICAL ONCOLOGY CONFERENCE On October 15, 2015, Carilion Clinic sponsored a gynecological oncology conference for the purpose of presenting pertinent and up-to-date information about multidisciplinary approaches to the diagnosis and treatment of gynecological cancers, treatment options, genetic testing and survivorship care to primary care physicians and allied health professionals in the community. The conference was held at the Hotel Roanoke and Conference Center and was attended by over 80 health professionals from Roanoke and surrounding areas. Presenters included gynecologic oncologists, gynecologists, a pathologist, a radiation oncologist, medical oncologists, a genetics counselor, a certified registered dietitian and a gynecologic oncology nurse. The symposium, uniquely designed in a multidisciplinary case presentation format, offered medical professionals continuing medical hours of professional credit. Topics included: »» Multidisciplinary management of endometrial cancer »» Surgical and systemic therapy options for ovarian cancer »» Multidisciplinary approach to cervical cancer »» Survivorship and supportive care issues »» Genetics

PREVENTION AND SCREENING PROGRAMS The Carilion Cancer Committee monitors community outreach activity through the work of the Community Outreach Coordinator. The committee continues its extensive community outreach efforts to educate the community about cancer.

Working in conjunction with various community partners (American Cancer Society, Susan G. Komen, New Horizons Healthcare, Bradley Free Clinic), our team of health care providers and educators develop cancer awareness programs that teach preventive measures and lifestyle changes—such as smoking cessation, dietary modifications and exercise—that aid in reducing incidence of cancer.

Outreach is also conducted through lectures, broadcast and web-based media, health fairs and screenings, brochures and other written media. In addition, Carilion sponsors and facilitates access to support groups for cancer patients and their families. We continually assess the needs of our community and design programs and strategies to address those needs.

»» Community Health Needs Assessment Carilion Clinic and Healthy Roanoke Valley partnered to conduct the 2015 Roanoke Valley Community Health Needs Assessment (CHNA). The service area included the counties of Botetourt, Craig, Franklin and Roanoke and the cities of Roanoke and Salem. An emphasis was placed on those living in the city of Roanoke, especially those living in the two medically underserved areas of the city.

The CHNA revealed distinct disparities, especially for those living in the city of Roanoke. Poverty rates were higher, academic attainment rates were lower and unemployment rates continue to be greater than statewide averages impacting the social determinants of health. Many survey respondents and focus group participants, whether insured or uninsured, noted that the cost of services keeps them from accessing preventive care and services. There is a need to develop a culture of wellness with an emphasis on health education, access to healthy foods and increased physical activity. The Roanoke Valley is rich in resources for underserved populations but respondents stated that strengthening coordination of care could significantly improve current access to services.

For 2016, highlighted priorities reinforced our ongoing need to remain focused on screening prevention and education related to breast, colorectal, prostate and skin cancers as these are four of the top five cancers in our region. It was also reemphasized that nutritional education and prevention programs related to cancer prevention are still very important and targeted as a need for those served in our community.

»» Fiscal Year (FY) 2016 Cancer Awareness/Carilion Events • Wear Red Day – scheduled 300 mammograms for Carilion Clinic employees • Breast Cancer Survivor Soirée – 250 attendees • Komen Race for the Cure – 300 attendees • H ollins Health Fair – scheduled mammograms and drove awareness; 200 participants • Eat Right Be Fit events – 210 total attendees • ACS Relay for Life – educational materials provided to 150 participants • Smoking Cessation Programs – 3 total attendees • D iet and Colon Cancer Prevention Web-X for Virginia Cooperative Extension – 34 employees attended • Healthy Happy Hour events – scheduled 59 total mammograms • S isters’ Night Out Breast Cancer Awareness Event – targeted underinsured AfricanAmerican women; 300 attendees • Promise Breast Cancer Awareness Luncheon – 300 attendees • Positively Pink Parade Breast Cancer Event – 200 attendees • Poker Run Breast Cancer Awareness Event – 100 attendees • Harvester Performance Center Breast Cancer Awareness Event – 250 attendees • B reast Health Educational Seminars at Hollins University – two events, 200 total attendees • Komen Worship in Pink program – 3,325 participants reached • Pajama Jam Breast Cancer Awareness Event – 300 reached • Climb to Conquer Cancer Event with American Cancer Society – 350 reached • F resh Food Rx program – two sessions focusing on cancer prevention, 17 total attendees

»» S creening Programs

Early detection is the key to finding cancer in an early stage, thus providing a better chance for cure. Screenings can detect cancers in early stages, before symptoms would prompt a physician office visit. The cancer committee provided the following screenings in FY 2016: • H eld a skin cancer screening in December 2015 at Morningside Manor Development where 19 participants were screened by Carilion Clinic Dermatologists • E nrolled 460 women for screening mammograms into the Every Woman’s Life Program, resulting in 33 breast cancer diagnoses • Provided pap screenings through Every Woman’s Life, diagnosing 50 cervical cancers

QUALITY STUDIES AND IMPROVEMENTS The annual evaluation of the care of Carilion’s cancer patients provides a baseline to measure quality and an opportunity to enhance care and quality outcomes. Quality cancer care is our goal, and measuring quality patient outcomes has been a hallmark of the Carilion cancer program since its inception. The following are outstanding examples from among the many studies and improvements constantly underway at Carilion. Fiscal year 2016 studies included:

A Study Assessing Clinical Impact of Enhanced Recovery After Surgery (ERAS): Evidence-Based Practice for Colon Cancer Patients Carilion Clinic Department of Surgery Sandy Fogel, M.D., surgeon Deborah Copening, senior director, Surgery Description ERAS protocols have proven successful in adult populations with reduced length of stay (LOS) and overall speeding recovery from surgery. With a regimen of fluid management, reduced narcotics and enhanced epidural approach, healing time is quicker with less infection, as demonstrated in the literature. The study is designed to measure the impact of ERAS protocols in oncologic patient population and report outcomes associated with ERAS over standard protocols.

Summary Evidence-based practice demonstrates preparation for surgery specific to nutrition, exercise, prevention of complications through perioperative care protocol and following surgery through ERAS clinical guidelines will improve outcomes.

Results Seventy-four colon cancer patients were reviewed from calendar year 2015. »» M ean LOS reduction from 7.08 days to 5.2 days with ERAS patients »» Reduction in LOS was 1.8 days with ERAS »» Readmissions improved from 19 percent to 13 percent with ERAS patients »» Reductions were seen across all patients over three years (2013-2015) in mortality, surgical site infection (SSI), sepsis and return to operating room (ROR)

QUALITY IMPROVEMENT

Time Study for Wire Needle Localization for Breast Cancer Surgery Carilion Clinic Breast Care Program Catherine Hagan-Aylor, B.A., B.S.N., M.S.N., C.B.C.N. Carilion Clinic Breast Care Center Description This study will retrospectively measure the timeliness of wire needle localization (WNL) for breast cancer at Carilion Clinic Breast Care Center. The study will include time from start to completion of WNL procedure, cost of procedures/processes involved and allocation of resources necessary.

The Need WNL is currently the most common method for surgical localization (done under imaging guidance) for breast-conserving therapy for those diagnosed with breast cancer. Throughout the literature, it is noted that this process does not come without significant challenges for the radiologist, surgeon and patient. The most commonly reported challenges include issues with scheduling, time management, cost and resource allocation (M.D. and technologists, transportation).

Measure »» T ime patient spends at Carilion Clinic Breast Care Center for localization process »» Clinical time necessary with patient for localization process »» Technical and transportation costs for localization process »» Number of procedures that can be completed on a monthly basis Opportunities Identified to Improve »» N eed for patient to have WNL performed on day of surgery »» Need for transport to hospital on day of surgery »» Ease of localization procedure for patient »» Increase in workflow for radiologists and technologists »» Flexibility in surgical scheduling for patients Results »» Average cost: $385 per needle localization; total cost: $8,855 »» Average time per procedure: 1 hour, 23 minutes »» Average transportation time from Breast Care Center to hospital: 23 minutes

HOSPITAL CANCER REGISTRY The cancer registry at Carilion Roanoke Memorial Hospital has a reference date of January 1, 1985 and has over 74,000 patients listed. The five-year follow-up rate is 94 percent and the overall follow-up rate is 89 percent, which far exceeds the CoC standards. The registry employs a manager and five full-time, highly qualified and trained professionals who also provide support to physicians presenting at cancer conferences and to the Cancer Committee. The staff members abstract cases not only for Carilion Roanoke Memorial Hospital, but also for all of Carilion’s six additional hospitals and ambulatory physician practices. The registry ensures that the data of all the cancer cases diagnosed or treated at all Carilion facilities are maintained accurately. The data are collected in a strict accordance with HIPAA regulations and are used for measuring outcomes and quality improvement, providing follow-up information, allocating resources, developing educational programs for health care providers and reporting cancer incidence at the state and national levels.

RAPID QUALITY REPORTING SYSTEM Carilion’s cancer program is a voluntary participant in the American College of Surgeons Commission on Cancer’s Rapid Quality Reporting System (RQRS), which monitors the real-time reporting of breast and colorectal cancer cases at Carilion Roanoke Memorial Hospital. The purpose of RQRS is to improve patient outcomes of care by allowing better monitoring of patient treatment. Monthly reports are sent to the American College of Surgeons and monitored by the Carilion Clinic Cancer Committee for compliance with national treatment guidelines. Patients who are in need of timely treatment can be quickly evaluated, with recommendations made to the managing physician. This allows for higher quality patient care.

CANCER STATISTICS 2015 data from Carilion Facilities

750

MOST COMMON CANCERS BY PRIMARY SITE

720

700 650 600 550 500

476

450 400

398 Breast Lung & Bronchus

350 300 250

Colorectal 265

Prostate 243

Skin - Melanoma Brain & CNS

181

200

130

150 100

Uterus 121

108

99

Non-Hodgkins Lymphoma 72

Urinary Bladder Pancreas

50

All Other

0

CANCER NUMBERS BY RACE Total: 2,813

White 90.50% | 2,546

Other African-American 8.80% | 249

including Chinese, Japanese, Filipino, Korean, Vietnamese, Asian Indian or Pakistani

0.70% | 18

CANCER NUMBERS BY GENDER Total: 2,254

500

Females 54.84% 1,236

Males 45.16% 1,018

477

450

TOP FIVE FEMALE CANCERS

400 350

Breast

300

Lung & Bronchus

250

Colorectal

188

200

125

150

Uterus

119 82

100

Skin - Melanoma

50 0

250

243 212

TOP FIVE MALE CANCERS

200 Prostate 150

Lung & Bronchus

131

Colorectal

111

83

100

Melanoma - Skin Urinary Bladder

50 0

CLASS OF CANCER CASE

Total: 2,254

Analytic/new dx 89.44% | 2,016

Non-analytic/recurr 10.56% | 238

CANCER STAGE DISTRIBUTION 0

100

Total: 2,502

200

300

400

500

600

700

800

Stage 0 Stage 1 Stage II Stage III StageIV Not Applicable Unknown

MOST FREQUENTLY SEEN MALIGNANCIES

Total: 2,813

(ALL CARILION FACILITES, 2015 CASES) 0 Breast Lung/Bronchus Colorectal Prostate Skin - Melanoma Brain and CNS Uterus NH Lymphoma Urinary Bladder Pancreas All Other

100

200

4.60% 4.30% 3.80% 3.50% 2.60%

6.50%

300

400

9.50% 8.60%

500 14%

600

700

800

16.90%

25.70%

NEW CMC CASES (2015 NEW CANCER DIAGNOSES BY NUMBER OF CASES AND PERCENTAGE) PRIMARY SITE

CMC NUMBER * CMC %* Virginia Number** Virginia %**

US Number** US %**

LUNG AND BRONCHUS

305

15.1

5,580

13.6

224,210

13.5

BREAST

330

16.4

6,170

15.1

232,670

14

COLON AND RECTUM

171

8.5

3,280

8

136,830

8.2

UTERUS

115

5.7

1300

3.2

52,630

3.2

PROSTATE

132

6.5

6330

15.4

233,000

14

MELANOMA

155

7.7

2130

5.2

76,100

4.6

NON HODGKIN LYMPHOMA

87

4.3

1640

4

70,800

4.2

PANCREAS

56

2.8

1060

2.6

46,420

2.8

KIDNEY

42

2.1

1460

3.6

63,920

3.8

LIVER & Intrahepatic Bile Ducts

35

1.7

730

1.8

33,190

2

ALL OTHERS

588

29.2

11,290

27.6

495,770

29.8

TOTALS

2016

100

40,970

100

1,665,540

100

Throughout this report, percentages may not always total 100% due to rounding. This reports excludes basal and squamous cell skin cancers.

State and national numbers are estimates of cancer incidence in the entire state and nation, regardless of where the patient is treated. *The CMC numbers are actual cases that were diagnosed and/or treated at CMC regardless of where the patient lives. These numbers are provided by the Carilion Cancer Registry. ** American Cancer Society, 2015 Facts and Figures, Estimated number of new cases.

Summary by Body System, Sex, Class and AJCC Stage Report All 2015 Carilion Medical Center Cases

Summary by Body System, Sex, Class and AJCC Stage Report

SEX Primary Site

Total (%)

Male

Female

ORAL CAVITY & PHARYNX

64 (2.8%)

46

18

Lip

1 (0.0%)

1

0

Tongue

25 (1.1%)

19

6

Salivary Glands

3 (0.1%)

1

2

Floor of Mouth

2 (0.1%)

2

0

Gum & Other Mouth

5 (0.2%)

3

2

Nasopharynx

2 (0.1%)

0

2

Tonsil

19 (0.8%)

15

4

Oropharynx

2 (0.1%)

2

0

Hypopharynx

4 (0.2%)

2

2

Other Oral Cavity & Pharynx

1 (0.0%)

1

0

402 (17.8%)

226

176

Esophagus

15 (0.7%)

12

3

Stomach

29 (1.3%)

23

6

Small Intestine

17 (0.8%)

10

7

Colon Excluding Rectum

118 (5.2%)

55

63

Rectum & Rectosigmoid

74 (3.3%)

44

30

Anus, Anal Canal & Anorectum

29 (1.3%)

14

15

Liver & Intrahepatic Bile Duct

42 (1.9%)

34

8

Gallbladder

3 (0.1%)

0

3

Other Biliary

7 (0.3%)

3

4

Pancreas

63 (2.8%)

31

32

Retroperitoneum

1 (0.0%)

0

1

Peritoneum, Omentum & Mesentery

4 (0.2%)

0

4

359 (15.9%)

193

166

Nose, Nasal Cavity & Middle Ear

2 (0.1%)

2

0

Larynx

19 (0.8%)

16

3

336 (14.9%)

173

163

2 (0.1%)

2

0

BONES & JOINTS

4 (0.2%)

2

2

SOFT TISSUE

22 (1.0%)

16

6

SKIN EXCLUDING BASAL & SQUAMOUS Melanoma -- Skin Other Non-Epithelial Skin

166 (7.4%)

96

70

160 (7.1%)

94

66

6 (0.3%)

2

4

DIGESTIVE SYSTEM

RESPIRATORY SYSTEM

Lung & Bronchus Trachea, Mediastinum & Other Respiratory Organs

CLASS OF CASE

STAGE DISTRIBUTION - ANALYTIC CASES ONLY

Analy

NA

Stg 0

Stg I

Stg II

Stg III

Stg IV

NA

Unk

60

4

1

6

3

13

34

0

3

1

0

0

1

0

0

0

0

0

25

0

1

2

1

3

17

0

1

3

0

0

1

0

1

1

0

0

1

1

0

0

0

0

1

0

0

5

0

0

1

1

0

3

0

0

2

0

0

0

0

2

0

0

0

18

1

0

1

1

5

10

0

1

2

0

0

0

0

0

1

0

1

3

1

0

0

0

2

1

0

0

0

1

0

0

0

0

0

0

0

341

61

2

67

84

70

103

2

13

15

0

0

0

5

5

5

0

0

28

1

0

4

10

3

7

1

3

15

2

0

7

2

1

5

0

0

107

11

0

14

29

27

35

0

2

64

10

0

22

15

17

6

0

4

8

21

2

2

2

2

0

0

0

35

7

0

12

4

6

12

1

0

3

0

0

0

0

0

2

0

1

5

2

0

0

1

0

4

0

0

56

7

0

6

15

9

24

0

2

1

0

0

0

1

0

0

0

0

4

0

0

0

0

0

3

0

1

327

32

5

82

40

55

140

2

0

0

1

0

0

1

18

1

2

3

6

3

4

305

31

3

78

34

52

135

2 0 0 0

3 0 0 3

2

0

0

0

0

0

0

2

0

4

0

0

2

2

0

0

21

1

0

8

6

4

1

161

5

60

65

19

7

5

155

5

60

62

16

7

5

6

0

0

3

3

0

0

0 1 0 0 0

0 1 5 5 0

Continued...

All 2015 Carilion Medical Center Cases

SEX

Summary by Body System, Sex, Class and AJCC Stage Report

Primary Site

Total (%)

Male

Female

BREAST

361 (16.0%)

361

FEMALE GENITAL SYSTEM

203 (9.0%)

1,236

MYELOMA

23 (1.0%)

LEUKEMIA

36 (1.6%) 11 (0.5%) 24 (1.1%) 1 (0.0%) 4 (0.2%) 43 (1.9%)

0 0 0 0 0 0 0 0 166 159 5 2 88 54 32 2 1 32 19 13 25 10 15 61 4 57 13 19 3 15 1 4 30

2,254

1,018

Cervix Uteri

10 (0.4%)

Corpus & Uterus, NOS

117 (5.2%)

Ovary

37 (1.6%)

Vagina

4 (0.2%)

Vulva

32 (1.4%)

Other Female Genital Organs

3 (0.1%)

MALE GENITAL SYSTEM

166 (7.4%)

Prostate

159 (7.1%)

Testis

5 (0.2%)

Penis

2 (0.1%)

URINARY SYSTEM

120 (5.3%)

Urinary Bladder

62 (2.8%)

Kidney & Renal Pelvis

50 (2.2%)

Ureter

8 (0.4%)

EYE & ORBIT BRAIN & OTHER NERVOUS SYSTEM

1 (0.0%) 101 (4.5%)

Brain

51 (2.3%)

Cranial Nerves Other Nervous System

50 (2.2%)

ENDOCRINE SYSTEM

79 (3.5%)

Thyroid

50 (2.2%)

Other Endocrine including Thymus

29 (1.3%)

LYMPHOMA

100 (4.4%)

Hodgkin Lymphoma

5 (0.2%)

Non-Hodgkin Lymphoma

95 (4.2%)

Lymphocytic Leukemia Myeloid & Monocytic Leukemia Other Leukemia MESOTHELIOMA MISCELLANEOUS Total

203 10 117 37 4 32 3 0 0 0 0 32 8 18 6 0 69 32 37 54 40 14 39 1 38 10

17 8 9 0 0 13

CLASS OF CASE

STAGE DISTRIBUTION - ANALYTIC CASES ONLY

Analy

NA

Stg 0

Stg I

Stg II

Stg III

Stg IV

NA

Unk

330

31

57

150

82

24

15

168

35

1

101

10

31

18

8

2

0

2

2

3

1

115

2

0

87

4

13

7

35

2

0

8

4

13

8

0

4

0

0

0

0

0

7

25

1

3

0

1

2

3

0

0

1

0

1

0

139

27

1

22

88

14

9

132

27

0

19

87

12

9

5

0

0

3

1

1

0

2

0

1

0

0

1

0

106

14

30

37

10

8

17

56

6

24

13

5

3

9

42

8

2

24

5

4

5

8

0

4

0

0

1

3

0

1

0

0

0

0

0

96

5

0

0

0

0

0

48

3

0

0

0

0

0

48

2

0

0

0

0

0

78

1

0

29

5

7

6

50

0

0

29

5

7

6

28

1

0

0

0

0

0

92

8

0

14

17

28

28

5

0

0

0

2

3

0

87

8

0

14

15

25

28

22

1

0

0

0

0

0

31 6 24 1 4 36

5 5 0 0 0 7

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 1 0

0 0 0 0 1 0

0 2 0 1 0 0 0 1 0 0 0 0 2 0 2 0 0 96 48 48 28 0 28 0 0 0 22 31 6 24 1 1 36

2 5 0 3 2 0 0 0 5 5 0 0 2 2 0 0 0 0 0 0 3 3 0 5 0 5 0 0 0 0 0 1 0

2,016

238

157

583

366

262

377

223

48

CARILION CANCER COMMITTEE 2016 Members PHYSICIANS David Buck, M.D., Radiation Oncology, Cancer Committee Chair David Luyimbazi, M.D., General Surgery, Cancer Liaison Physician Emily Doherty, M.D., Genetics Evelyn Garcia, M.D., Radiology Padmaja Mallidi, M.D., Medical Oncology Thomas Morel, M.D., Palliative Care William Jefferson, M.D., Pathology

REQUIRED COORDINATORS Cancer Conference Coordinator: Padmaja Mallidi, M.D. Cancer Registry Quality Coordinator: Leta Vess, B.A., C.T.R., Cancer Registry Manager Clinical Research Coordinator: Natasha Holt, C.C.R.P. Community Outreach Coordinator: Catherine Hagan, R.N., M.S.N., C.B.C.N.ÂŽ Psychosocial Services Coordinator: Jean Westervelt, L.C.S.W., O.S.W.-C., Oncology Counseling Specialist Quality Improvement Coordinator: Lisa Mitchell, M.B.A., Senior Director, Radiology

NON-PHYSICIAN MEMBERS Angela Charlton, R.D.-N., Oncology Dietitian Anne Cattigan, R.N., M.S.N., O.C.N., Oncology Clinical Project Manager Deborah Joyce, B.S., R.T.T., Manager, Rehabilitation Services Jane Johnson, American Cancer Society Julie Wright, R.N., M.S.N., Unit Director, Oncology Leslie Loving, R.N., M.S.N., A.C.N.P.-B.C., Thoracic Oncology Coordinator Mary Ward, R.N., C.T.R., Oncology Nurse Educator Patricia Kingery, R.N., M.S.N., Senior Director, Oncology/Palliative Care Services

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If you believe that Carilion Clinic has failed to meet these standards or provide these services, you can file a written grievance in person or by mail, fax or email with:

Title:

Address: 213 S. Jefferson Street, Suite 1201, Roanoke, Virginia 24011

Carilion Clinic’s Chief Compliance Officer

Phone: (540) 510-4573  |  Fax:

Email:

(540) 224-5787

compliance@carilionclinic.org

If you need help filing a grievance, Carilion Clinic’s Chief Compliance Officer is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

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