2017 Cancer Institute Annual Report - Southeast Michigan

BEAUMONT CANCER INSTITUTE RESULTS FROM 2017

A MESSAGE FROM THE COMMISSION ON CANCER, CANCER LIAISON PHYSICIAN

It has been another exciting year at Beaumont, with many accomplishments.

In June 2017, we opened Michigan’s first operational Proton Therapy Center at Beaumont Hospital, Royal Oak. The center is the first of its kind to feature pencil-beam scanning, delivering a single, narrow beam to the tumor site. This intensity modulated proton therapy allows for the physician to precisely target the tumor and deliver powerful radiation doses with optimal accuracy.

Knowing patients would travel from throughout the country to receive proton therapy at Beaumont, one of our cancer program goals in 2017 was to address those travel challenges and assist patients and families in making travel/housing arrangements during their treatment. Overall, We partnered with the American Cancer Society, which has eight hotel partners within the Oakland County area to support Beaumont. With support from the ACS and arrangements with Homewood Suites, we have seen great improvement finding accommodation opportunities for patients.

A 2017 Programmatic Goal was to set up a transportation van for cancer treatment patients. In the last quarter of 2017, the van was up and running with a trained driver. In November, we completed around 60 transports. In 2018, we will have more specific demographic statistical reports on gender, distance traveled, etc., which will allow us to refine and adjust the program to meet the needs of our patients.

This report includes the 2017 Patient and Program Outcomes Reporting and includes descriptions of many of our activities and accomplishments, including:

• Rapid Quality Reporting System

• Continuous Quality Improvement Reports

• Monitoring Compliance with Evidence-Based Guidelines

• Community Outreach Summary

• 2017 Studies of Quality and Quality Improvements

– Reinvigorating Cancer Clinical Trials

– Text Messaging to Decrease Patient Cancellations and No Shows

– Decrease Radiation Oncology Patient Wait Times

– Survivorship Fatigue

The end of 2017 inspired plans for new goals to achieve in 2018, including:

• Improving the process for developing Survivorship Care Plans, making them electronic instead of manual, through implementing Epic’s Beacon Oncology Module and expanding Inpatient Computerized Physician Order Entry.

• Launching a pilot study for Fact-F to address survivorship fatigue, including having it embedded in Epic Beacon.

Sincerely,

Adli Yakan, M.D. Chief of Medical Oncology, Internal Medicine BMG GP Cancer Liaison Physician to The American College of Surgeons Commission on Cancer

2017 CANCER COMMITTEE

Beaumont’s Cancer Committee is a diverse group of health care professionals that represents our multidisciplinary approach toward cancer care.

Adil Akhtar, M.D. Hematology/Oncology Committee Chair

Janette Bell, RN, BSN, OCN, NE-BC Royal Oak Oncology Nursing

Lisa Benedetti, M.S., DABMP Director Clinical Physics, Royal Oak Linda Caurdy-Bess, LMSW Manager Social Work

Ann Marie Blenc, M.D. Medical Director, Hematopathology

Erin Camilleri, RN Hospice

Patricia Cardoze Director, Radiation Oncology

Angela Chmielewski, M.D. Palliative Care

Pamela Colburn, CTR Oncology Data Services

Reyna Colombo, MA, PT Director Rehab Services, Troy

Lisa D’Andrea Assistant Nurse Manager, Wilson Cancer Resource Center

Alicia DeCaria, RN, BSN, NE-BC Administrative Manager, Oncology Services

Nayana Dekhne, M.D. Comprehensive Breast Care Program

Joshua T. Dilworth, M.D., Ph.D. Radiation Oncology

Sean Doyle Pharmacy

Robin Duris, RN Cancer Clinical Trials Office

Monty Fakhouri, MSCHS, CHES, Ph.D. Cand. Business Manager, Minority Outreach Program Adjunct Assistant Professor, Family Medicine

Josephine Garnoc, RN, BSN,CRNI, OCN Director, Infusion Services, Grosse Pointe

Basil Hakmeh Operations Support Specialist, Oncology Services Administration

Deborah Harreld Oncology Data Services

Brian Hart, R.Ph. Pharmacy

Ishmael Jaiyesimi, D.O. Hematology/Oncology

Andrew Kacir, RHIT Oncology Data Services

Mary Kalil, MSW Social Worker

Hassan D. Kanaan, M.D. Pathology

Robert Kilpatrick, BSRS, RT(R) Administrative Director, Grosse Pointe

Nirish Lal, M.D. Diagnostic Radiology

Thomas Lanni, MBA, FACHE Vice President, Oncology, Medicine and Imaging

Rev. Renee Machiniak, M.Div. Oncology Chaplain, Spiritual Care

Jennifer Martens Palliative Care

Deb Martz, RD Oncology Nutrition

Lisa Muma, RN, BSN Supportive Care Nurse II, Pediatrics Pediatrics Survivorship

Jennifer Nagy, B.S. American Cancer Society

Sirisha Nandalur, M.D. Radiation Oncology

Jan Parslow Oncology Nurse Navigator

Jeanne Parzuchowski, RN, M.S., OCN Oncology Nurse Navigator, Adult Survivorship

Gail Elliott-Patricolo Director, Integrative Medicine

Paul Rigo, B.S. Corporate Manager, Oncology Data Services

Kimberly Round, RN Nurse Navigator

Jennifer Roye, RN Cancer Clinical Trials Office

Janet Seidell Physical Therapy

Bernadine Sherwood Nurse Navigator

Michael Stender, M.D. Hematology/Oncology

Lesley Sturgess, CTR Oncology Data Services

DiAne Townsel Cancer Community Educator

Matthew Trunsky, M.D. Palliative Care

Lucy Vail, RN Hospice

Stephen Vartanian, M.D. Diagnostic Radiology

Patrick Williams, MPA Operations Support Specialist

Ryan Wood Manager, Management Engineering

Adli Yakan, M.D. Hematology/Oncology Cancer Liaison Physician

Dana Zakalik, M.D. Cancer Genetics Program

ONCOLOGY DATABASE

Supporting research, planning and patient care

The Cancer Treatment and Outcomes Registry maintains a complete database for all patients diagnosed and/or treated at Beaumont with a malignancy or reportable benign tumor since Jan. 1, 1973.

The American College of Surgeons, or ACoS, reference date for Royal Oak and Troy hospitals, is Jan. 1, 1994 and for Grosse Pointe, Jan. 1, 2008. As of 2013, the Beaumont Health System Integrated Network Cancer Program (INCP) includes Royal Oak, Troy and Grosse Pointe. This means there is current and updated survival information on all patients from those dates forward. For the INCP from Jan. 1, 1994, to Dec. 31, 2015, the database includes more than 120,000 cancer cases, of which more than 105,000 are analytic cases. Annual lifetime follow-up of analytic cases is an ACoS requirement. Beaumont maintains a better than 90 percent followup rate as required by these standards. Currently, more than 48,000 cancer survivors are followed at Beaumont Health Systems. Followup is accomplished by monitoring inpatient and outpatient activities and by contacting physicians, other institutions or patients.

Approximately 4,000 visits per month are reviewed at Beaumont Hospitals for new accessions, readmissions, radiation oncology, chemotherapy and outpatient visits.

In 2017, more than 300 of the cases abstracted were audited for accuracy and consistency. The physician-advisor to the oncology database reviews medical records, comparing them to abstracts for overall integrity with specific review of the topography, morphology, American Joint Committee on Cancer and Collaborative stage, extent of disease, and first course of treatment documentation where there are . This has contributed to abstracting consistency and accuracy. The physician-advisor also monitors and reports results to the Cancer Committee on physician use of AJCC or other appropriate staging, site specific prognostic indicators and evidence-based national treatment guidelines in treatment planning for cancer patients.

As an ACoS-approved network cancer program, Beaumont participates in the National Cancer Database “Call for Data,” ACoSCoC Benchmarking and Quality Assurance Studies and monitoring of compliance with ACoS-CoC standards. As a participant, Beaumont has access to our hospital’s outcomes data compared to the aggregate national data. The oncology database has been used for a variety of purposes, including research studies, publications, grant applications, data to support certificate of need applications and hospital planning.

Oncology Data Services

Oncology Data Services provides support to the entire medical staff, to the quality assessment goals of the Cancer Committee and to administrative planning for allocation of hospital resources.

Oncology Data Services promotes quality assessment reviews and audits for evaluation of patient care, monitors trends in diagnostic and therapeutic techniques, provides lifetime follow-up information on cancer patients, and provides incidence and survival data for comparison to local, regional and national trends. The comprehensive Oncology Data Services database includes information such as:

• primary site

• histologic type and grade of tumor

• general summary stage and American Joint Committee on Cancer stage

• first course of treatment

• first recurrence and first recurrence treatment

• subsequent metastases and subsequent treatment

• quality and duration of survival and geographic distribution of cases

Analytic case report

During 2017, Beaumont added 7,216 new patients to the network oncology database, of which 4,093 were female and 3,122 were male. The analytic cases (Figure 1), those who received all or part of their first course of therapy at Beaumont, comprised 5,889 of the total volume. The graphs on the following pages will display a five-year survival by stage for some of the most commonly seen cancers at Beaumont.

2017 statistical summary

The most frequently diagnosed malignancy was breast cancer with 1,478 total new cases, of which 1,387 were analytic or 17 percent of the total newly diagnosed cases in the state of Michigan (Figure 2).

Cancer facts and figures 2017, American Cancer Society

The comparison of the five most frequently diagnosed sites at Beaumont (Figure 3), compared to the American Cancer Society estimates for Michigan and the United States, show that Beaumont continues to treat a higher percentage of breast cancer cases compared statewide or nationally.

Age distribution – 2017 analytic cases

The age distribution (Figure 4) indicates that the majority of cases at Beaumont Hospitals were diagnosed in the 60-69 age group.

Figure 2

Most Frequently Diagnosed Sites at Beaumont - Analytic Cases Only

Beaumont Major Site Comparison with State and National

Figure 4

Age Distribution - 2016 Analytic Cases

SURVIVOR ANALYSIS

SURVIVOR ANALYSIS

PRIMARY SITE TABLE 2017

PATIENT AND PROGRAM OUTCOMES REPORTING

Cancer Program Practice Profile Reports (CP3R) Accountability Measures/Quality Improvement Measures

A requirement for Commission on Cancer (CoC) accredited cancer programs is to monitor compliance with evidence-based treatment guidelines. In addition to performing site-specific studies to assess compliance with evidence-based national treatment guidelines, we are required to monitor compliance with evidence-based guidelines by utilization of the CoC quality reporting tools of the Cancer Program Practice Profile Reports (CP3R).

The Cancer Committee reviewed National Cancer Database (NCDB) benchmark reports for Beaumont Health System for breast cancer and colon cancer stage and treatment. We are consistent with first course of treatment benchmarks comparing to both national and Michigan hospitals. Beaumont diagnoses and treats 17 percent of breast cancer cases and 9.85 percent of colorectal cases in Michigan. In order to best track the treatment process of our patients and position ourselves for commendable status with Commission on Cancer Rapid Quality Reporting System standards, we are analyzing breast and colorectal cases on a concurrent basis.

The CP3R has been implemented by the CoC for the purpose of fostering quality improvement at cancer programs awarded CoC Accreditation by utilization of quality of care measures. Facilitated by the National Quality Forum (NQF), CoC, American Society for Clinical Oncology (ASCO) and NCCN agreed to synchronize their developed measures for breast and colorectal cancer to ensure that a unified set of quality of care measures were put forth to the public. Each year the cancer committee is required to review the quality of patient care using the CP3R to evaluate care within and across disciplines, to discuss successful processes and to evaluate how processes can be improved to promote evidence-based practice. An accountability measure is the standard of care based on clinical trial evidence. A quality improvement (QI) measure is one that demonstrates good practice but is not based on clinical trial

evidence. In 2017, we evaluated issues with obtaining all first course of therapy information to comply with documentation for standards of care. We have made good progress in gaining access to ongoing treatment that takes place in our private practice physician’s offices or that are referred elsewhere to complete their first course of therapy. For the CoC evaluation of accountability measures and quality improvement measures compared to other hospitals, Beaumont rated higher:

• Quality measure reports for breast cancer demonstrate a higher rate of compliance with standards of care for all accountability, quality improvement and surveillance measures compared to state, census region, ACS division, CoC program type and all CoC programs.

• Review of the performance measures for colon cancer also demonstrated a higher rate of compliance with standards of care.

Beaumont Health Systems exceeds the performance rates/benchmarks specified by the CoC for quality improvement measures. As outlined above, the cancer committee reviewed the comparison of all breast cancer and colorectal cancer CP3R measures and Beaumont rates significantly higher than other hospitals measured in the National Cancer Database and exceeds national benchmarks.

Late in 2016, we did identify, through the 2014 CP3R reports, an opportunity to improve compliance with a specific NCCN guideline related to gastric cancer. The cancer committee provided data to various departments implementing an action plan and at the end of 2017 we were able to demonstrate measurable improvement to exceed guidelines. We have also worked with our physician’s offices to obtain treatment documentation to demonstrate our patients have a higher compliance with national standards of care.

Rapid Quality Reporting System (RQRS)

In January 2014, Beaumont began participation in the Rapid Quality Reporting System (RQRS) which was developed to assist CoC-accredited cancer program in promoting evidence-based cancer care at the local level. Eligible cases are submitted monthly for all performance measures. It is a Web-based, systematic data collection and reporting system that advances evidence-based treatment through a prospective alert system for anticipated care that supports care coordination required for breast and colorectal cancer patients at participating cancer programs. The 2016 CoC Standards require that cancer cases for breast and colorectal be RQRS submitted within three months of date of first contact for the cancer program to be recognized for commendable performance. We have performed concurrent of breast and colorectal cases for submission to RQRS within three months as required for commendable recognition. This provides further opportunity to identify cases and monitor and update their first course of treatment more in real-time.

Continuous Quality Improvement (CQIP) Reports

The cancer committee also reviewed the Continuous Quality Improvement (CQIP) reports. CQIP reports are a CoC summary of our activity compared to national benchmarks. The cancer committee review of the many major points outlined were consistent with our understanding of our program and our expectations. We did not identify any discrepancies where we could implement an intervention for the improvement of quality of cancer care. With the use of RQRS, concurrent analysis/abstracting of breast and colorectal cases, and CP3R review, any potential issues are already identified and addressed. CQIP report findings are shared at all of the facility and corporate Oncology Center of Excellence (COE) meetings.

Monitoring Compliance with Evidence-Based Guidelines

Adli Yakan, M.D. reported on the review of compliance with evidenced-based guidelines, National Comprehensive Cancer Network (NCCN), for lymph node positive bladder cancers in Beaumont’s Integrated Network Cancer Program (INCP). Review of cases for 2015 and the first six months of 2016 demonstrated that our INCP was 100% compliant with NCCN guidelines for node positive bladder cancers.

2017 Studies of Quality and Quality Improvements

INCREASE BREAST CANCER CLINICAL TRIAL ACCRUALS

The Clinical Trials subcommittee was created in January 2017 with the purpose of reinvigorating cancer clinical trials at Beaumont and evaluating:

• Strategies for continued NCORP support

• Current marketing materials

• Physician engagement

• Current clinical trial recruitment practices

NCI’s National Clinical Trials Network published key strategies that health centers can adopt through patient advocacy to increase participation in clinical trials including public education on the availability of clinical trials, development of patient-centered materials to help physicians discuss trials with their patients and the marketing of clinical trial results in plain language. They also noted a lack of physician participation and engagement correlated with declining accrual rates.

• Design a corrective action plan based on evaluation of the data

1. Establish and implement clearly defined expectations for site PI’s

2. Identify and promote protocols with potential for high enrollment

3. Expand trials recruitment to the Grosse Pointe and Dearborn sites

4. Initiate an external evaluation of CCTO staffing and operations

5. Increase staffing for data entry in CCTO, thus allowing nurse and coordinator staff to focus on screening, consenting, visits, etc. Need to develop rationale for number and credentials of new hires.

6. Address IT infrastructure to improve efficiency of work flow by CCTO staff

7. Develop marketing strategy and begin implementation

continued on next page

• Establish follow-up steps to monitor the actions implemented

Possible Next Steps

1. Follow-up evaluation for clinical trial offices to monitor staffing and operations

2. Increase physician education of current clinical trials

• Describe the cancer-related Quality Improvement:

3. Development and approval of marketing items

4. Increase patient outreach

5. Monitor monthly accrual numbers

– External evaluation of CCTO received and results utilized in improvement plan (internally and as presented in the NCORP report)

– Increased recruitment in NCORP trials - >10 new enrollments each month

TEXT MESSAGING TO DECREASE PATIENT CANCELLATIONS AND NO SHOWS

Documenting missed appointments and identifying barriers that led to patient no-shows allows oncology leadership to determine more effective appointment reminder methods. Reviewing the data shows many patients forgot about their appointment. They either missed their phone call reminder and never listened to the voicemail or ignored it. Based off of this finding, oncology administration was able to evaluate patient preferences for appointment reminders and identify more effective measures.

• Design a corrective action plan based on evaluation of the data

Implement a Text Message Appointment Reminder

1. Continue to monitor no-show rates in the breast care center.

2. Once text reminders are implemented, track missed appointments for comparison.

3. Follow-up with patients who opt in for text reminders and track their perception of effectiveness.

• Establish follow-up steps to monitor the actions implemented

Possible Next Steps

1. Approval to move on with the project

2. Finalization from IT, legal and compliance

3. Approval text wording

• Prepare a summary of the study findings The study is currently ongoing.

DECREASE RADIATION ONCOLOGY PATIENT WAIT TIMES

4. Give patients to option to opt in for the service

5. 1Pilot within the breast care center

Develop a method of shortening the time patients spend waiting to be transported from the Radiation Oncology Department to the Oncology inpatient unit.

• Review of records documenting:

– Patient time of arrival to Radiation Oncology

– Completion of radiation

– Time of phone call to alert Patient Transportation team that patient is ready to return to the Oncology inpatient unit

– Patient transporter time of arrival

• Design a corrective action plan based on evaluation of the data

1. Continue monitoring the wait times following radiation treatment.

2. Request a patient transporter to arrive prior to the patient completing treatment.

• Establish follow-up steps to monitor the actions implemented

Possible Next Steps

1. Collaborate with Patient Transportation to see if a patient transporter can be assigned to Oncology instead of covering the entire hospital.

2. Assess how long it takes for a transporter to arrive to Radiation Oncology.

3. Assess if requests for patient transportation needs to occur at an earlier time.

• Prepare a summary of the study findings

The study is currently ongoing.

SURVIVORSHIP FATIGUE

4. Assess how long each radiation treatment is. Depending on the type of treatment, Radiation Oncology can submit a transport request at the specific amount of time before the completion of treatment as it takes for the transporter to arrive.

5. Continue data collection.

In 2014-2016, Beaumont rehabilitation and the Beaumont Troy Breast Survivorship Clinic implemented utilization of the FACT-G Quality of Life (QOL) tool (www.facit.org). This was determined to be an opportunity as current QOL monitoring and modifications to interventions based on QOL were not consistently implemented. Beaumont Rehab collaborated with Oakland University to analyze the results of the first sample of FACT-G Quality of Life surveys.

Methods: A retrospective analysis utilizing medical records of participants in a breast cancer survivorship clinic. Measurement data included demographics and FACT-G results. Descriptive analysis of demographics and trends in referral recommendations and FACT-G scores was completed.

Approved via IRB and study completed. Presented findings at national physical therapy conference (American Physical Therapy Association’s Combined Sections Meeting 2017 – San Antonio, TX). The article is currently under peer-review in the Cureus Medical Journal.

• Prepare a summary of the study findings

Results: All 30 participants were females diagnosed with breast cancer of various stages, ages 28 to 81 years. Approximately 1.5 years lapsed between cancer diagnosis and completion of the FACT-G. Participants received surgery (100%), radiation (76%), and chemotherapy and/or hormonal therapy (43%). Results demonstrated that participants reported having a lack of energy (24%) and were bothered by side effects of their treatment (20%). The greatest impact on functional well-being difficulty sleeping (50%).

Limitations: Decreased ability to generalize the data to breast cancer survivors secondary to small sample size from one institution and potential referral bias.

Conclusions: Cancer survivors experience QOL issues throughout the continuum of their care, which can result in long-term effects on their physical, functional, social and emotional well-being. QOL is a major focus for cancer survivors and many times determines a survivor’s health care decisions. QOL measurements can be utilized at multiple points during survivorship to identify the need for referrals and guide interventions.

•

Design a corrective action plan based on evaluation of the data

Implemented FACT-G use for cancer survivors in cancer rehabilitation in the outpatient clinics. Currently monitoring compliance rates of cancer survivors. A root issue was identified that there was an opportunity to track and identify cancer patients in outpatient rehabilitation in order to track compliance. Currently working with IT to designate cancer rehabilitation patients.

• Establish follow-up steps to monitor the actions implemented

Completed a root cause analysis of current impairments by cancer survivors and determined that fatigue was also an issue. Based on this information, the decision to adopt and implement the FACIT-F Quality of Life tool system-wide integrated into the electronic medical record was necessary. This is currently being rolled out with a go-live date of December 15, 2017 with education and phased implementation to continue throughout 2018.

• Describe the cancer-related Quality Improvement

Implementation of FACIT-F. The FACIT Fatigue Scale is a short, 13-item, easy to administer tool that measures an individual’s level of fatigue during their usual daily activities over the past week. The goal of the implementation was to:

To assess the QOL and FATIGUE of cancer patients at before, during and after treatment for cancer

– To more accurately determine areas of challenge and deficits(domains) that prevent them from functioning at their highest level

2017 Community Outreach

To determine if and to whom they may need a referral (rehab, social work, nutrition, medicine, integrative health, etc.

The Community Outreach Coordinator shared the 2017 summary of outreach activities with the cancer committee. The total number of participants in Health Fairs with prevention and screening programs was 1,661. We had a collaborative effort with the MIU and HFH for colorectal screening which was in October of 2017. We saw 181 men, they had the opportunity to interact with the nine volunteer professionals, including the Director of the Proton Center. We had six positive findings. Of the six positive findings reported was a gentlemen who had adenomas. All of those who were positive were followed up by their PCPs or we found PCPs for them closer to home and they all had colonoscopies. Of the six positives we had no cancers. We identified one person with a very strong history of colon cancer in his family and he was referred for genetic counseling. We had no patients referred in from breast of prostate screenings.