2017 Dearborn Cancer Center Annual Report - Southeast Michigan by Corewell Health

OAKWOOD HOSPITAL & MEDICAL CENTER-DEA

Summary by Body System, Sex, Class, Status and Best CS/AJCC Stage Report

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Primary Site Class of Case Total (%)AnalyNAFM SexStage Distribution - Analytic Cases StatusOnly AliveExpStg 0Stg IStg IIStg IIIStg IV88UnkBlank/Oth 39 7 37 946 0 4 0 24 4 5 2 0 Tongue 14 1 14 1 9 615 (0.8%) 0 1 0 12 1 0 0 0 Salivary Glands 3 2 3 2 5 05 (0.3%) 0 0 0 0 0 1 2 0 Floor of Mouth 0 2 2 0 2 02 (0.1%) 0 0 0 0 0 0 0 0 Gum & Other Mouth 5 0 2 3 4 15 (0.3%) 0 1 0 2 0 2 0 0 Nasopharynx 2 0 2 0 1 12 (0.1%) 0 0 0 1 1 0 0 0 Tonsil 9 1 10 0 10 010 (0.5%) 0 1 0 7 1 0 0 0 Oropharynx 1 0 1 0 0 11 (0.1%) 0 0 0 1 0 0 0 0 Hypopharynx 5 1 4 2 6 06 (0.3%) 0 1 0 1 1 2 0 0 285 32 174 143 214 103 317 (16.5%)DIGESTIVE 0 33 28 71 59 64 28 2 Esophagus 22 2 21 3 12 12 24 (1.2%) 0 3 0 8 8 3 0 0 Stomach 23 2 9 16 14 11 25 (1.3%) 0 8 3 8 3 1 0 0 Small Intestine 11 0 5 6 10 111 (0.6%) 0 1 5 1 3 1 0 0 Colon Excluding Rectum 93 9 55 47 84 18 102 (5.3%) 0 8 5 15 23 28 12 2 19 18 1 9 10 15 4 Cecum 0 1 2 7 3 4 0 5 4 1 2 3 5 0 Appendix 0 2 2 0 0 0 0 22 20 2 13 9 16 6 Ascending Colon 0 0 4 6 5 4 0 5 5 0 5 0 4 1 Hepatic Flexure 0 0 0 2 1 1 0 8 8 0 2 6 6 2 Transverse Colon 0 0 1 2 5 0 0 3 2 1 2 1 3 0 Splenic Flexure 0 1 0 0 1 0 0 4 4 0 4 0 4 0 Descending Colon 0 0 1 0 1 1 0 31 27 4 15 16 27 4 Sigmoid Colon 0 0 5 5 10 2 2 5 5 0 3 2 4 1 Large Intestine, NOS 0 1 0 1 2 0 0 Rectum & Rectosigmoid 42 8 29 21 41 950 (2.6%) 0 6 1 9 11 11 4 0 8 7 1 6 2 5 3 Rectosigmoid Junction 0 0 2 2 2 1 0 42 35 7 23 19 36 6 Rectum 0 1 7 9 9 3 0 Anus, Anal Canal & Anorectum 10 0 4 6 9 110 (0.5%) 0 0 0 1 4 5 0 0 Liver & Intrahepatic Bile Duct 17 5 14 8 12 10 22 (1.1%) 0 0 4 5 2 2 4 0 16 14 2 11 5 7 9 Liver 0 3 5 1 2 3 0 6 3 3 3 3 5 1 Intrahepatic Bile Duct 0 1 0 1 0 1 0 Gallbladder 6 0 3 3 5 16 (0.3%) 0 0 0 3 1 2 0 0 Other Biliary 6 1 5 2 3 47 (0.4%) 0 2 1 0 0 1 2 0 Pancreas 48 5 26 27 21 32 53 (2.8%) 0 5 2 21 4 10 6 0 Peritoneum, Omentum & Mesentery1 0 0 1 1 01 (0.1%) 0 0 1 0 0 0 0 0 Other Digestive Organs 6 0 3 3 2 46 (0.3%) 0 0 6 0 0 0 0 0 329 35 169 195 230 134 364 (18.9%)RESPIRATORY 0 5 5 154 59 35 71 0 Nose, Nasal Cavity & Middle Ear 2 0 0 2 2 02 (0.1%) 0 0 1 0 1 0 0 0 Larynx 20 2 17 5 21 122 (1.1%) 0 2 0 4 4 6 4 0 Lung & Bronchus 306 33 152 187 206 133 339 (17.6%) 0 3 4 150 54 29 66 0 Trachea, Mediastinum & Other Respiratory Organs 1 0 0 1 1 01 (0.1%) 0 0 0 0 0 0 1 0 Page 1

OAKWOOD HOSPITAL & MEDICAL CENTER-DEA

Summary by Body System, Sex, Class, Status and Best CS/AJCC Stage Report

Primary Site Class of Case Total (%)AnalyNAFM SexStage Distribution - Analytic Cases StatusOnly AliveExpStg 0Stg IStg IIStg IIIStg IV88UnkBlank/Oth 1 1 2 02 0 0 0 0 0 1 0 0 Bones & Joints 1 1 2 0 2 02 (0.1%) 0 0 0 0 0 1 0 0 8 0 8 08 0 1 2 1 0 2 2 0 Soft Tissue (including Heart) 8 0 3 5 8 08 (0.4%) 0 1 2 1 0 2 2 0 7 3 6 4 7 310 (0.5%) SKIN EXCLUDING BASAL & SQUAMOUS 0 1 0 3 1 0 1 1 Melanoma -- Skin 5 3 5 3 5 38 (0.4%) 0 0 0 3 1 0 0 1 Other Non-Epithelial Skin 2 0 1 1 2 02 (0.1%) 0 1 0 0 0 0 1 0 348 16 5 359 346 18 364 (18.9%)BREAST 0 10 0 14 44 85 131 64 Breast 348 16 5 359 346 18 364 (18.9%) 0 0 14 44 85 131 64 130 68 0 198 177 21 198 (10.3%)FEMALE 0 14 8 16 26 9 57 0 Cervix Uteri 9 45 0 54 51 354 (2.8%) 0 2 0 2 3 1 1 0 Corpus & Uterus, NOS 76 5 0 81 74 781 (4.2%) 0 10 3 4 8 5 46 0 Ovary 33 3 0 36 28 836 (1.9%) 0 2 3 6 12 2 8 0 Vagina 3 0 0 3 3 03 (0.2%) 0 0 0 1 1 0 1 0 Vulva 5 14 0 19 16 319 (1.0%) 0 0 0 2 1 1 1 0 Other Female Genital Organs 4 1 0 5 5 05 (0.3%) 0 0 2 1 1 0 0 0 142 29 162 9171 0 12 0 14 27 69 20 0 Prostate 135 29 164 0 155 9164 (8.5%) 0 8 0 14 26 69 18 0 Testis 7 0 7 0 7 07 (0.4%) 0 4 0 0 1 0 2 0 129 15 102 42 123 21 144 (7.5%)URINARY 0 8 0 20 5 21 44 31 Urinary Bladder 68 10 58 20 64 14 78 (4.1%) 0 2 0 9 4 15 8 30 Kidney & Renal Pelvis 58 4 41 21 56 662 (3.2%) 0 6 0 9 1 6 36 0 Ureter 3 1 3 1 3 14 (0.2%) 0 0 0 2 0 0 0 1 22 5 9 18 23 427 (1.4%)BRAIN & OTHER NERVOUS SYSTEM 0 0 22 0 0 0 0 0 Brain 13 3 6 10 12 416 (0.8%) 0 0 13 0 0 0 0 0 Cranial Nerves Other Nervous System 9 2 3 8 11 011 (0.6%) 0 0 9 0 0 0 0 0 59 3 60 262 0 10 6 5 7 4 27 0 Thyroid 56 0 14 42 54 256 (2.9%) 0 10 3 5 7 4 27 0 Other Endocrine including Thymus 3 3 4 2 6 06 (0.3%) 0 0 3 0 0 0 0 0 70 13 45 38 66 17 83 (4.3%)LYMPHOMA 0 3 0 31 12 14 10 0 Hodgkin Lymphoma 7 0 7 0 7 07 (0.4%) 0 0 0 2 3 1 1 0 Non-Hodgkin Lymphoma 63 13 38 38 59 17 76 (4.0%) 0 3 0 29 9 13 9 0 58 48 10 30 28 43 15 NHL - Nodal 0 3 0 22 8 13 2 0 18 15 3 8 10 16 2 NHL - Extranodal 0 0 7 1 0 7 0 32 6 34 438 0 0 32 0 0 0 0 0 Myeloma 32 6 19 19 34 438 (2.0%) 0 0 32 0 0 0 0 0 34 9 25 18 28 15 43 (2.2%)LEUKEMIA 0 0 34 0 0 0 0 0 Lymphocytic Leukemia 13 9 13 9 19 322 (1.1%) 0 0 13 0 0 0 0 0 3 2 1 3 0 2 1 Acute Lymphocytic Leukemia 0 2 0 0 0 0 0 17 9 8 8 9 15 2 Chronic Lymphocytic Leukemia 0 9 0 0 0 0 0 Page 2

OAKWOOD HOSPITAL & MEDICAL CENTER-DEA

Summary by Body System, Sex, Class, Status and Best CS/AJCC Stage Report

Primary Site Class of Case Total (%)AnalyNAFM SexStage Distribution - Analytic Cases StatusOnly AliveExpStg 0Stg IStg IIStg IIIStg IV88UnkBlank/Oth 2 2 0 2 0 2 0 Other Lymphocytic Leukemia 0 2 0 0 0 0 0 Myeloid & Monocytic Leukemia 21 0 12 9 9 12 21 (1.1%) 0 0 21 0 0 0 0 0 12 12 0 5 7 4 8 Acute Myeloid Leukemia 0 12 0 0 0 0 0 1 1 0 1 0 0 1 Acute Monocytic Leukemia 0 1 0 0 0 0 0 6 6 0 4 2 4 2 Chronic Myeloid Leukemia 0 6 0 0 0 0 0 2 2 0 2 0 1 1 Other Myeloid/Monocytic Leukemia 0 2 0 0 0 0 0 1 0 1 01 0 0 0 1 0 0 0 0 Mesothelioma 1 0 1 0 1 01 (0.1%) 0 0 0 1 0 0 0 0 1 0 1 01 0 0 1 0 0 0 0 0 Kaposi Sarcoma 1 0 1 0 1 01 (0.1%) 0 0 1 0 0 0 0 0 40 3 20 23 18 25 43 (2.2%)MISCELLANEOUS 0 0 40 0 0 0 0 0 Miscellaneous 40 3 20 23 18 25 43 (2.2%) 0 0 40 0 0 0 0 0 Total 1,677 245 808 1,114 1,922 1,537 385 98 393 309 244 354 178 101 0 Exclusions:Not Male and Not Female 0 Page 3

Summary by Body System and Sex Report

MalesFemales

Oral Cavity & Pharynx - 31 (4%)

Lung & Bronchus - 138 (20%)

Pancreas - 24 (3%)

Kidney & Renal Pelvis - 38 (5%)

Urinary Bladder - 51 (7%)

Colon & Rectum - 73 (10%)

Prostate - 135 (19%)

Non-Hodgkin Lymphoma - 33 (5%)

Melanoma of the Skin - 2 (0%)

Leukemia - 20 (3%)

All Other Sites - 158 (22%)

Thyroid - 42 (4%)

Lung & Bronchus - 168 (17%)

Breast - 344 (35%)

Kidney & Renal Pelvis - 20 (2%)

Ovary - 33 (3%)

Uterine Corpus - 76 (8%)

Colon & Rectum - 62 (6%)

Non-Hodgkin Lymphoma - 30 (3%)

Melanoma of the Skin - 3 (0%)

Leukemia - 14 (1%)

All Other Sites - 182 (19%)

Page 3 OAKWOOD HOSPITAL & MEDICAL CENTER-DEA

Febrile neutropenia MUE

BACKGROUND

• Chemotherapy is one of the mainstays of treatment for many oncologic disorders

• Chemotherapy use is often associated with myelosuppression, including neutropenia

• Febrile neutropenia (FN) is an oncologic emergency and is defined as:

o Absolute neutrophil count (ANC) of < 500 cells/mm3 or expected to decrease to < 500 cells/mm3 in the next 48 hours AND

o Temperature of ≥ 38.3°C (101°F) or ≥ 38.0°C (100.4°F) sustained over a 1-hour period

• Management of FN

o Prompt evaluation

o Initiation of an anti-pseudomonal antimicrobial

o Additional antimicrobial therapy is determined by risk factors for gram-positive, fungal, and mold infections

o Delay in antimicrobial administration or improper selection is associated with increased mortality

STUDY AIM

• The purpose of the study was to evaluate the appropriate use of antimicrobial agents for the management of FN at Beaumont Hospital - Dearborn.

STUDY DESIGN

• Single-center, retrospective cohort of patients with documented ICD-10 codes for FN between October 2016 to October 2017

• Descriptive statistics

PRIMARY OUTCOMES

• Evaluate the appropriate selection of antimicrobial agents in patients with documented FN

• Assess the appropriate duration of antimicrobial therapy in FN

SECONDARY OUTCOMES

• Document the use of granulocyte colony-stimulating factor (G-CSF) agents in patients with FN

INCLUSION CRITERIA

• Age ≥ 18 years of age

• Receipt of chemotherapy within 30 days of diagnosis of FN

• Fulfilled criteria for FN (or clear evidence of neutropenia episode with fever, if not explicitly stated)

EXCLUSION CRITERIA

• Received chemotherapy greater than 30 days of FN diagnosis or not on active chemotherapy

• No cancer diagnosis

• No documented evidence of fevers

Data collection Patient demographics Cancer type Chemotherapy regimen Microbiology and lab results Empiric antimicrobial agents used Duration of antimicrobial agents used Appropriate therapy dose Duration of FN event

Indications for empiric gram-negative coverage

Ciprofloxacin 750 mg PO Q12 hours + amoxicillinclavulanate 875/125 mg PO Q12 hours

Penicillin allergy (hives or bronchospasm): Ciprofloxacin

750 mg PO Q12 hours + clindamycin 300 mg PO Q6 hours

Ciprofloxacin or levofloxacin monotherapy

Indications for empiric gram-negative coverage (High risk)

Cefepime 2 g IV Q8 hours

If mucositis present: Consider piperacillin-tazobactam 4.5g IV Q6 hours (or adding metronidazole to cefepime)

Penicillin allergy: aztreonam 2 g IV Q8 hours

Extended-spectrum beta-lactamase (ESBL) risk: meropenem 1 g IV Q8 hours

Indications for empiric gram-positive coverage (Mainly MRSA)

Hemodynamic instability

Pneumonia documented radiographically

Suspected line of catheter-related infection

Colonization or infection with MRSA, VRE, or penicillin-resistant Streptococcus pneumoniae

Persistently febrile on anti-pseudomonal therapy for ≥48 hours

Additional considerations:

Evidence of severe sepsis

Blood culture for gram-positive bacteria

Skin or soft-tissue infection at any site

Severe mucositis (if ceftazidime used and fluoroquinolone prophylaxis had been given)

Linezolid and daptomycin for severe vancomycin allergy, history, or risk of VRE

• Appropriate antipseudomonal coverage was evaluated based on the National Comprehensive Cancer Network “Prevention and Treatment of Cancer-Related Infections” guideline and from an antimicrobial stewardship standpoint. The need for additional coverage such as anaerobes or ESBL resistant pathogens was assessed.

• Duration of therapy is determined by the organism and site of infection but should continue for at least the duration of neutropenia (ANC ≥ 500 cells/mm3 x 48 hours)

o For unexplained fevers the treatment should be continued until there are clear signs of marrow recovery (ANC ≥ 500 cells/mm3 x 48 hours)

o If a treatment course has been completed and all signs and symptoms have resolved a neutropenic patient may resume oral fluoroquinolone prophylaxis until marrow recovery (ANC ≥ 500 cells/mm3 x 48 hours)

PATIENT SCREENING

• 131 patients screened

• 39 patients included for analysis and 92 patients excluded

Empiric therapy

RESULTS

CONCLUSION

• Overall appropriate empiric anti-PSA and anti-MRSA therapy at FN onset

• Largely inappropriate selection of anti-pseudomonal agent, considering specific risk factors

• Duration of empiric antimicrobial therapy is consistent with resolution of neutropenia

• High use of G-CSF agents in FN patients considering that it is not routinely recommended in the treatment of febrile neutropenia

• Action plan:

o Present findings at next oncology section meeting

o Consider automatic consult to oncology and infectious diseases

o Education to oncology, infectious disease, and internal medicine staff

o Involve the antimicrobial stewardship program

o Investigate feasibility of febrile neutropenia order set

o Continue tracking G-CSF agent use and duration of therapy

References

1. Prevention and treatment of cancer-related infections. National Comprehensive Cancer Network. 2017.

2. Siegel RL, Miller KD, and Ahmedin J. Cancer Statistics 2017. CA Cancer J Clin. 2017; 67:7-30.

3. Freifeld AG, Bow EJ, Sepkowitz KA, et al. Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the Infectious Diseases Society of America. Clinical Infectious Diseases. 2011; 52(4): 56-93.

4. Lyman GH and Rolston KV. How we treat febrile neutropenia in patients receiving cancer chemotherapy. J Oncol Pract. 2010; 6(3): 149-152.

5. Lyman GH, Michels SL, Reynolds MW, et al. Risk of mortality in patients with cancer who experience febrile neutropenia. Cancer. 2010; 5555-5563.

6. Michels SL, Barron RL, Reynolds MW, et al. Costs associated with febrile neutropenia in the U.S. Pharmacoeconomics. 2012; 30(9): 809-823.

7. NCCN guidelines – Myeloid Growth Factors

8. Bennett CL, Djulbegovic B, Norris LB, et al. Colony-stimulating factors for febrile neutropenia during cancer therapy. N Engl J Med. 2013; 368(12): 1131-1139.

9. Raja AS. Stop treating all patients with febrile neutropenia similarly. N Engl J Med - Journal Watch. 2016