Cancer Services 2013 Annual Report

ed Health Hope Healing

2013 ANNUAL REPORT

CANCER SERVICES

Introduction VINCENT BJORLING, MD 05 Outstanding Achievement JOANNE KRIEG 06 Nebraska Colon Cancer Screening Program PAULETTE SCHNELL, RN 08 Cancer Conference 10 Cancer Registry 11 Cancer Committee 12 Colon Cancer Facts and Figures 13 Comparison of Cancer Data 14 Primary Site Table 15 Colon Cancer Graphs 17 Lynch Syndrome 18 Glossary 20

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Introduction I’m pleased to introduce Regional West Medical Center’s 2013 Cancer Services annual report. This year our focus is on colon cancer.

Vince Bjorling, MD Chairman Cancer Committee

Colorectal cancer is the second leading cause of cancer-related deaths in the United States and the third most common cancer in men and in women.

In 2011, Regional West Medical Center diagnosed 26 cases of colon cancer, behind breast (80 cases), lung (42 cases), and prostate (38 cases). The 26 cases comprised seven percent of that year’s cancer diagnoses for Regional West, compared with six percent of Nebraska’s total colon cancer diagnoses for 2011.

Although statistics are important, I want to focus on the professionals who comprise the Cancer Treatment Center in Scottsbluff and the Dorwart Cancer Care Center in Sidney.

Regional West Cancer Services is just one of just 10 cancer programs nationwide to earn its fourth consecutive Outstanding Achievement Award from the American College of Surgeons Commission on Cancer. The

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Outstanding Achievement Award demonstrates that Regional West meets the highest national standards for state-of-the-art cancer prevention, early diagnosis, pretreatment evaluation, staging, optimal treatment, rehabilitation, surveillance for recurrent disease, support services, and end-of-life care.

It’s a commitment that encompasses the compassionate care our caregivers, clinicians, and providers extend to our patients and their loved ones every day.

For more information about cancer services, support programs, and activities for cancer survivors and their loved ones, call Regional West Physicians Clinic-Oncology at 308.630.2101, the Cancer Treatment Center-Scottsbluff at 308.630.1348, or the Dorwart Cancer Care Center-Sidney at 308.254.9192.

Sincerely, Vince Bjorling, MD Chairman, Cancer Committee

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Outstanding Achievement Regional West Cancer Services Receives Fourth Consecutive Outstanding Achievement Award From American College of Surgeons

By Joanne Krieg Regional West Medical Center Marketing and Public Relations Department

Regional West Cancer Services recently learned that it is one of 10 cancer programs nationwide to earn its fourth consecutive Outstanding Achievement Award from the American College of Surgeons Commission on Cancer.

The award recognizes cancer programs that achieve excellence in providing quality care to cancer patients.

Regional West received the Outstanding Achievement Award in 2004, 2007, and 2010 and was among 74 cancer programs nationwide to receive the award in 2013. This represents about 14 percent of programs surveyed by the Commission on Cancer last year.

“This is a testament to the commitment and cooperation among our caregivers, clinicians, and providers to offer the highest quality and most compassionate care for our cancer patients,” said internal medicine physician Vince Bjorling, MD, chairman of the Regional West Cancer Committee.

prevention, early diagnosis, pretreatment evaluation, staging, optimal treatment, rehabilitation, surveillance for recurrent disease, support services, and end-of-life care.

“We offer the very latest in screening, diagnosis, treatment, and support services all on one campus, which is a tremendous benefit for our patients,” said radiation oncologist Mark Hartman, MD. “All of the experts connected with a patient’s care are right here, so we can easily collaborate to develop the best treatment plan for each individual.”

In addition to exceeding standards for program activity, Regional West Cancer Services received compliance ratings on an additional 27 program standards.

“I couldn’t be more proud of our staff and physicians for the care they provide to every cancer patient,” said Todd S. Sorensen, MD, MS, President and CEO of Regional West Health Services.

The Outstanding Achievement Award demonstrates that Regional West meets the highest national standards for state-of-the-art cancer

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Nebraska Colon Cancer Screening Program

Paulette Schnell, RN Nurse Manager Community Health

The Nebraska Colon Cancer Screening Program helps men and women 50 years of age and older make decisions about colon cancer screening.

Services include fecal occult blood test (FOBT) kit for at home testing, follow-up colonoscopy, and information about healthy living.

The Scotts Bluff County Health Department and Regional West Medical Center work together with the Nebraska Colon Cancer Screening Program to provide a collaborative, community-based screening program. The overall goal is to increase awareness of the problem of low colorectal screening rates and create an environment where more people choose to be screened.

Some examples of public awareness efforts that were conducted in 2013 included:

• Speaker’s bureau, providing presentations to area organizations and groups • TV ad placements • Radio interviews • Worksite communications and publicity Structured FOBT kit distribution was done at pharmacies, awareness presentations, worksites, special events, health fairs, faith-based initiatives, and collaborative partner opportunities. The structured distribution process that was developed by the state of Nebraska was used everywhere a kit was offered. It included these components: •

Distributors trained to provide screening education

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Demographic information collected in exchange for the FOBT kit

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Opportunity for participants to contact a provider with questions before screening

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Written reminder about screening for those who obtained FOBT kits

• Human interest stories • Newspaper section highlighting survivor stories • Special event opportunities, such as Farm and Ranch days and the Home and Garden Show

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Translated materials available where necessary

A FOBT kit processing and clinical results follow up was conducted. This component included a follow-up system for testing, patient notification, and treatment that includes qualified location for kit return and test processing, a plan for communicating test results to patients including locating difficult to reach participants, clinical case management to ensure appropriate followup testing and treatment, provisions for those who lack insurance or sources for health care services, and reporting results to collaborative partners.

A total of 274 kits were handed out during the 2013 campaign, an increase of over 50 percent from the 129 distributed in 2012. In 2013, eight tests came back with one leading to a diagnosis of colon cancer. As you can see, 2013 was a very successful year for the colon cancer FOBT kit distribution program.

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Cancer Conference Regional West Medical Center held 22 bimonthly multidisciplinary Cancer Conferences in 2013 to review and discuss current trends in the treatment of cancer.

Pathologist Peter Schilke, MD served as the 2013 coordinator.

Physician representatives from all appropriate disciplines, as well as other cancer health care providers, attend and participate in these conferences. On an average, nine physicians who actively participate in cancer care attended Cancer Conference. The multidisciplinary average attendance was nine.

In n2 2013, 013, 230 cases were cases were presented. Sites discussed included: breast, colon, rectum, lung, esophagus, prostate, testis, liver, appendix, kidney, brain, endometrium, bladder, thyroid, melanoma, lymphoma, head/neck carcinoma, stomach, and pancreas.

To arrange for case presentation at Cancer Conference or for further information regarding the Cancer Registry, please call 308.630.2421.

Cancer Registry

By Cindy Keller Keller, CTR Cancer Registry Coordinator

The Cancer Registry is a component of the cancer program that is responsible for the accurate and timely collection of cancer patient data used for the evaluation of patient outcomes.

The Cancer Registry is responsible for monitoring and coordinating many of the activities of the Regional West Medical Center Cancer Program and our participation in the American College of Surgeons (ACoS) Commission on Cancer (CoC) as an accredited program. Regional West’s Cancer Registry has been accredited since 1985.

at Regional West West. Th These cases are part of the computerized database utilizing Rocky Mountain Cancer Data Systems in Salt Lake City, Utah. The updated registry computer system allows instant retrieval capabilities.

The database includes information on demographics, anatomic site, extent of disease at the time of diagnosis, history, staging of the cancer, and treatment summary. There were a total of 433 analytic cases added to the registry in 2013. See the primary site table on page 17.

In October, the Data Specialist and Cancer Registrar attended the 36th Annual Tumor Registrars Association of Nebraska TRAN workshop in Omaha, Neb.

The Cancer Registry is responsible for the data collection and follow-up of all cancer patients diagnosed and/or treated

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Cancer Committee Membership Medical Oncology • Vincent Bjorling, MD Chairman, Cancer Committee • Regine Leconte, MD • Clinton Merrill, MD

Palliative Care Services • Diana Rohrich, RN Director, Palliative Care/Home Care/ Prairie Haven Hospice • Linda Rock, BA

Radiation Oncology • Mark Hartman, MD

Adhoc Membership • Todd Sorensen, MD, MS President/CEO Regional West Health Services • Shirley Knodel, RN, MS Chief Nursing Officer/ Vice President Patient Services • Jan Taylor, MT (ASCP) Vice President Ancillary Services • John Kabalin, MD Urology • Becci Bowman, DNP, APRN-C, AOCNP, ACHPN Internal Medicine • Nancy Sloan, PharmD Clinical Pharmacist • Kim Croft, RN, BSN Cancer Patient Navigator • Martha Stricker, RN, BSN Nurse Manager • Sharon McKinney Director, Imaging Services Department • Karen Johnson, RN, CSO, LMNT Dietician • Nichole Nelson, PT Physical Therapist • Amy Potts Medical Staff Office • Jill Koch American Cancer Society Representative

Pathology • Carol Willis, MD, MBA, FCAP • Peter Schilke, MD, FCAP • Randall Williams, MD, FASCP Diagnostic Radiology • Stephen Johnson, MD, PhD • Gitesh Chedda, MD Surgery • Jason Walsh, MD, FACS • Melissa Stade, MD, FACS Cancer Liaison Physician • Melissa Stade, MD, FACS Cancer Program Administrator • Jeff Kriewald, B.S. RT(R)(T) Certified Tumor Registrar • Cindy Keller, CTR Social Worker • Carol Diffendaffer, PMHP, PMSW, OCW-C Quality Management • Margo Ferguson, MT (ASCP)

Colon cancer facts and figures •

Colorectal cancer is the second leading cause of cancer-related deaths in the United States and the third most common cancer in men and in women.

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In 2010, 131,607 people in the United States were diagnosed with colorectal cancer, including 67,700 men and 63,907 women.

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In 2010, 52,045 people in the United States died from colorectal cancer, including 27,073 men and 24,972 women.

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As of January 1, 2012, there were almost 1.2 million Americans living with a history of colon cancer. Some were cancer-free; others still had evidence of cancer and may have been undergoing treatment.

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Incidence and death rates for colon cancer increase with age. Overall, 90 percent of new cases and 93 percent of deaths occur in people 50 years of age and older.

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The median age at colon cancer diagnosis is 69 in men and 73 in women.

Overall, colorectal cancer incidence and mortality rates are about 30 to 40 percent higher in men than in women.

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Based on 2008-2010 data, approximately 4.8 percent of men and women will be diagnosed with colon and rectum cancer at some point during their lifetime.

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In 2011, there were an estimated 1,162,426 people living with colon and rectum cancer in the United States.

Sources: American Cancer Society, cancer.org

Oncology Nursing • Sue Schoeneman, APRN-C, OCN

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Cancer Incidence by Primary Site 2013 Cancer Treatment Center and Dorwart Cancer Care Center

2013 COMPARISON OF CANCER DATA In 2013, there were 433 cases of cancer and reportable tumors in the Regional West Medical Center Cancer Registry. Of these, 33 cases were non-analytic, and a total of 466 cases qualified for analysis (See primary site table on page 15). Breast cancer is the most frequently diagnosed and treated primary site at Regional West. The “All” graphs shown include analytic cases only

CASE COUNTS COUNTS BY

BY COUN COUNTY TY OF RESIDENCE RESIDENC

COMPARISON CHARTS

Dawes 16

Regional West

Box Butte 39

21%

Breast

45%

Lung/Bronchus

380 Cases

11%

Scotts Bluff 199

Colon 10%

Garden 11

Cheyenne 41

Kimball 10

Bladder All other sites

7%

6%

Morrill 19

Banner

Prostate

Cherry

Sheridan 13

Sioux 1

Grant 3

Hooker

Arthur

McPherson

Keith 4

Deuel 5

Thomas

Logan

Lincoln

Perkins

Total equals 433 cases for 2013

Chase 1

Out of state: 71

Dundy

Hayes

Frontier

Hitchcock Red Willow

Nebraska

TOP FIVE INCIDENCE SITES-MEN

16% 47%

Breast Lung/Bronchus

8,381 Cases

13%

13%

6%

Prostate 52

Prostate

25%

Colon

Lung 26

Bladder

Bladder 16

All other sites

5%

Melanoma of Skin 15

12% 42%

212 Cases

Colon 13 8%

6%

7%

Other 90

18%

Breast

47%

TOP FIVE INCIDENCE SITES-WOMEN

Lung/Bronchus

1,169,431 Cases

14%

11%

6% 4%

Breast 81

Prostate Colon

Corpus Uteri 18

34%

Bladder

37%

All other sites 221 Cases 6%

SOURCE: American College of Surgeons, National Cancer Data Base (NCDB), Hospital Comparison Benchmark report, 2011.

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(includes nonanalytic)

Analytic Cases Only

11 1 4 4 1 1 70 3 5 31

Rectum and Rectosigmoid Liver Gallbladder Other Biliary Pancreas Other digestive organs

Primary Site

7%

8% 8%

Colon 18

Sex

Best AJCC Stage

M

F

Stage 0

Stage I

Stage II

Stage III

Stage IV

Not Staged

11 1 4 4 1 1 68 3 4 31

8 0 3 4 0 1 39 2 3 13

3 1 1 0 1 0 29 1 1 18

1 1 0 0 0 0 2 0 0 2

3 0 2 1 0 0 14 0 3 6

0 0 0 0 0 0 20 1 0 11

0 0 0 0 0 0 12 1 1 7

6 0 2 2 1 1 19 1 0 5

1 0 0 1 0 0 1 0 0 0

17

16

13

3

0

4

6

2

4

0

4 1 1 7 1

4 1 1 7 1

3 0 1 4 0

1 1 0 3 1

0 0 0 0 0

0 0 1 0 0

1 0 0 1 0

1 0 0 0 0

2 1 0 6 0

0 0 0 0 1

Respiratory System Nasal Cavity Sinuses and Larynx Lung, Bronchus

52 7 45

48 6 42

30 4 26

18 2 16

0 0 0

9 0 9

4 1 3

10 1 9

22 3 19

3 1 2

Bones and Joints Soft Tissue

1 3

1 2

0 0

1 2

0 0

0 1

0 0

0 0

1 1

0 0

Skin (Exc. Basal & Sq. Ca) Melanoma of the Skin

28 26 2 83 30 8 18 2 1 1

25 23 2

17 15 2

8 8 0

6 6 0

12 11 1

5 4 1

2 2 0

0 0 0

0 0 0

82

1 0

81 29

16 0

32 18

17 2

12 1

5 6

0 2

0 0 0 0 0

8 18 1 1 1

0 0 0 0 0

4 14 0 0 0

1 1 0 0 0

1 0 0 0 0

1 2 1 1 1

1 1 0 0 0

65 62 1 2 33 22 10

55 52 1 2 31 20 10

Ureter Brain and Other Nervous System Endocrine System Thyroid Gland Other Endocrine

1 13 20 15 5

Lymphatic System Hodgkin’s Disease Non-Hodgkin’s Disease

28 3 25

Buccal Cavity/Pharynx Lip Tongue Major Salivary Gland Gum/Other Mouth Tonsil Digestive System Esophagus Stomach Colon, Excluding Rectum

Other Skin Cancer Breast Female Genital Cervix Uteri Corpus Uteri Ovary Vaginea Vulva Male Genital Prostate Testis Penis Urinary System Urinary Bladder Kidney and Renal Pelvis

National

All Cases

29 8 18 1 1 1

55

0

0

16

29

3

7

0

52 1 2 25

0 0 0 6

0 0 0 12

15 0 1 11

28 0 1 4

2 1 0 0

7 0 0 4

0 0 0 0

16 8

4 2

11 0

6 5

3 1

0 0

0 4

0 0

1 12 18 15 3

1 6 4 2 2

0 6 14 13 1

1 N/A 0 0 N/A

0 N/A 11 11 N/A

0 N/A 2 2 N/A

0 N/A 1 1 N/A

0 N/A 1 1 N/A

0 12 3 0 3

25 3 22

14 1 13

11 2 9

0 0 0

7 2 5

6 1 5

6 0 6

6 0 6

0 0 0

Lung 16

Multiple Myeloma

5

5

5

0

N/A

N/A

N/A

N/A

N/A

5

Thyroid Gland 13

Blood/Leukemia Other, Ill-defined and Unknown

9 15

8 13

4 4

4 9

N/A N/A

N/A N/A

N/A N/A

N/A N/A

N/A N/A

8 13

All Sites Combined

466

433

212

221

37

134

89

47

78

48

Other 75

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M=male, F=female, AJCC stage grouping T, N, and M categories describe the anatomic extent of disease.

Stage groupings gather cases into homogeneous categories to facilitate analysis. See glossary.

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Colon Cancer Diagnosed

2011

National Cancer Data Base: Benchmark Reports Communi Community nity ty H Hospitals ospitals in All States – 414 hospitals (10,075 cases), Hospitals in Nebraska – 3 hospitals (107 cases) and Regional West Medical Center (26 cases)

Age at Diagnosis 100 90 80 70 60

Reg. West

50

Nebraska

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2014 Goals Development of Stereotactic Body Radiation Therapy (SBRT) program. This therapy can be used for many types of patients and can reduce the treatment time and course duration.

Implementation will involve the evaluation of the necessary equipment and the associated cost. Development of this service will take time and resources, but will prove beneficial to patients and the facility.

All States

30 20 10 0

Cancer Program

Under 20

20-29

30-39

40-49

50-59

60-69

70-79

80-89

90+

AJCC Stage 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

All States Nebraska Reg. West

Treatment Modalities

Work with the Regional West Medical Center Marketing Department on an in-house and external marketing campaign with a focus on public and internal educational forums as well as external presentations sponsored by the Regional West Foundation, all of which will draw attention to the quality cancer treatment services available at Regional West. Small inservices may be utilized at various department staff meetings in order to help highlight the Cancer Services program. The Regional West Medical Center campus Intranet will be utilized for advertising and informational items. Offering external quarterly presentations where different disciplines share information about their specialty may also be planned.

2013 Accomplishments Improvement of colorectal screening: There were 278 FOBT kits distributed in 2013.

Awareness and educational materials were presented at a minimum of six community events, plus the use of multiple avenues of promotions such as radio, television, and social media. Panhandle Work Site Wellness Council members.

Coordination of initial cancer care access: Looked at barriers to treatment (i.e. cost, insurance coverage, education) to care and time to treatment. The referral process is being streamlined for all uninsured patients at Regional West Medical Center and these patients are being referred to the FAST office. This same process will be implemented for the Regional West Physicians Clinic.

Surgery Only

Surgery & Chemotherapy

Reg. West Nebraska All States

No Treatment

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Lynch Syndrome

Peter Schilke, MD

Western Pathology Consultants

Lynch Syndrome, also known as hereditary nonpolyposis colorectal cancer syndrome (HNPCC), is an inherited condition that increases a patient’s risk for colon cancer, endometrial (uterine) cancer, and other types of cancer. Most colon cancers are not hereditary, but approximately two to four percent of people who have colon cancer have Lynch Syndrome. Since Lynch Syndrome is an inherited condition, there is often a family history of multiple members having colon or endometrial cancer.

People with Lynch Syndrome are more likely to be diagnosed with colon cancer at a younger age, often before the age of 50. They also have an approximate 60 to 80 percent risk of developing colon cancer during their lifetime. The incidence of Lynch Syndrome is 1/100,000 to 1/300,000 people in the US and is the most common syndrome associated with hereditary colon cancer.

Lynch Syndrome results from germline mutations in DNA mismatch repair (MMR) genes.

These MMR genes are involved in many cell functions, including repair of DNA errors which can lead to development of a tumor.

Mutations of the MMR genes lead to the increased risk for colon cancer in people with Lynch Syndrome.

Lynch Syndrome is diagnosed by a review of medical and family history along with tumor testing by immunohistochemistry (IHC) testing or microsatellite instability (MSI) testing. IHC testing is performed on a patient’s surgically resected tumor and involves four screening antibodies to detect whether certain proteins from MMR genes are present in the tissue.

MSI testing involves DNA analysis to detect errors or instabilities in short DNA sequences prone to errors. While microsatellite instability is a hallmark feature of Lynch Syndrome, it also occurs in approximately 15 percent of noninherited associated colon cancers.

in their cancer cells, but don’t actually have Lynch Syndrome, which is a germline mutation involving all cells. If the screening test is positive, a genetic counselor will be consulted with and will discuss the results with the patient.

Additional blood tests might be performed to rule out Lynch Syndrome.

The National Comprehensive Cancer Network (NCCN) guidelines recommend Lynch Syndrome screening by IHC or MSI should be considered in patients diagnosed with colon cancer less than or equal to 70 years old and also those over 70 years old who meet the revised Bethesda guidelines.

Both IHC and MSI testing are screening tests for Lynch Syndrome, but a positive result does not mean that a person has Lynch Syndrome. Some people can develop gene mutations only

The revised Bethesda guidelines for screening for Lynch Syndrome include: • Colorectal cancer diagnosed in an individual who is younger than 50 years of age.

• Presence of multiple synchronous or metachronous Lynch Syndrome associated tumors, regardless of age.

• Colorectal cancer with MSI-H histology diagnosed in a patient younger than 60 years of age.

• Colorectal cancer diagnosed in one or more first-degree relatives with a Lynch

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Lynch Syndrome is inherited from a person’s parents. Every cell has two copies of each gene and one copy is inherited from the mother and one from the father. Lynch Syndrome is an autosomal dominant inherited disease where only one abnormal or mutated gene is required to cause Lynch Syndrome. A parent with Lynch Syndrome will pass either the mutated gene or the normal gene onto a child, which means that a child will have a 50 percent chance of inheriting Lynch

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Syndrome. Other siblings will also have a 50 percent chance of inheriting the mutated gene, and males and females are affected equally.

• Syndrome related tumor, with one of the cancers being diagnosed in a patient younger than 50 years of age.

• Colorectal cancer diagnosed in two or more first- or second-degree relatives with Lynch Syndrome-related tumors, regardless of age.

Lynch Syndrome accounts for a small number of overall colon cancers, but the ramifications of a diagnosis of Lynch Syndrome can impact many people’s lives.

Recognition of this is leading to more universal screening in patients who have developed colon cancer.

If a person is diagnosed with Lynch Syndrome, genetic testing of other family members might be performed to see if they have the abnormal gene. People with Lynch Syndrome usually undergo colonoscopy every one to two years beginning in their 20s. Women with Lynch Syndrome may undergo annual endometrial biopsies to screen for endometrial cancer and other screening tests for ovarian cancer.

People who have been diagnosed with Lynch Syndrome should contact their physician if they have the following symptoms, which could be associated with colon cancer: • Rectal bleeding or blood in stool following a bowel movement • Prolonged constipation or diarrhea • A change in the size or shape of stool • Abdominal pain

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Glossary Of Terms AJCC STAGE American Joint Committee on Cancer Staging Scheme using tumor size, node involvement and metastases to distant sites, T=primary tumor size; N=regional lymph node involvement; M=metastasis or distant spread.

AJCC STAGE GROUPINGS (FOR MOST SITES) Stage 0: Carcinoma in-situ Stage I: Localized carcinoma Stage II: Limited local extension and/or limited regional lymph node involvement Stage III: More extensive local extension or regional lymph node involvement Stage IV: Involvement of distant sites ANALYTIC Cancer cases initially diagnosed and/or having received all or part of the first course of treatment at Regional West Medical Center.

NCDB National Cancer Data Base.

For additional copies Call

308.630.2421

Write

Regional West Medical Center Cancer Treatment Center Attention: Cindy Keller, CTR Cancer Registry Coordinator 3911 Avenue B, Suite G100 Scottsbluff, NE 69361

Email

kellerc@rwmc.net

Web

Access the report at RegionalWestCTC.org

OBSERVED SURVIVAL RATE The literal survival rate from counting each case in the Registry STAGE GROUPING PURPOSE T, N, and M categories describe the anatomic extent of the disease. Stage grouping gathers cases into homogenous categories to facilitate analysis.

UNKNOWN Tumor is said to be unknown when the stage cannot be determined from the medical record or a medical authority.

2013 annual report published October 2014 Teresa Clark, Editor

FIRST COURSE OF TREATMENT Planned definitive therapy initiated within four months following initial diagnosis.

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