NOVEMBER 2013
2013
Cancer Program ANNUAL REPORT
C h a i r p e r s o n’s R e p o r t 2013 has been a memorable year for Howard County General Hospital (HCGH). We have been celebrating 40 years of excellence in health care; we transitioned to Epic, a single, integrated electronic medical record (EMR) that will improve patient care throughout the Johns Hopkins Medicine (JHM) system; and we are saying farewell to Vic Broccolino, our president and CEO of 24 years.
Sally Cheston, M.D. Radiation Oncology, Cancer Committee Chair
The HCGH Cancer Program has seen many changes and advances during the past year. The most challenging but rewarding change was the transition to Epic, an advance that will literally change the way we care for our cancer patients as well as all other patients. All care providers now have access to vital patient information whenever and wherever they receive treatment throughout the Johns Hopkins Medicine system. In addition, Epic users can access and share records of patients at any hospital where Epic is installed, nationwide. The switch to Epic EMR has improved three major processes in the day-to-day operations of the Cancer Registry: • For abstracting new cancer cases into the registry database, a significant amount of the diagnostic and therapeutic data, as well as data scanned in office notes, H&P’s, diagnostic imaging and pathology reports from other Johns Hopkins facilities, is readily available to registry staff. This has greatly reduced the number of letters and calls required to complete the abstracts. • Epic has also streamlined the process of preparing for cancer conferences. Needed reports can most often be found without having to call or fax requests to physician offices. Being able to rapidly identify the location of a patient’s outside diagnostic studies provides staff with additional time to obtain the slides and images requested for review. • Follow-up information from physician offices and other facilities is available online. This allows registry staff to obtain more accurate and detailed information on the patient’s current status and any recurrences or additional treatments they may have received. It has reduced the number of follow-up letters being sent to physician offices and other facilities. Biomedical discovery and research is one of six priorities in the Johns Hopkins Medicine five-year strategic plan, “Leading the Change.” This year, HCGH established a research office that is part of the JHM research network – Capital Area Research (CAPRES) – to develop and nurture research in the three JHM community hospitals (Suburban Hospital, Sibley Memorial Hospital and HCGH) and to expand and coordinate research that was historically based at The Johns Hopkins Hospital. Cancer related studies will be coming in the future. The Breast Center at HCGH is working to expand its existing range of multidisciplinary breast care services by more closely integrating plastic/reconstructive services and increasing its patient capacity with the addition of a breast health nurse practitioner. (See Focus on Breast Cancer, Page 9, for information about our breast cancer programs.) In April, the Claudia Mayer Cancer Resource Center (CMCRC) celebrated 15 years of providing support for men and women living with and surviving cancer. To meet the needs of busy care givers and cancer patients, CMCRC has added monthly care giver and patient-focused support group meetings on Saturdays. CMCRC also collaborated with the Sidney Kimmel Comprehensive Cancer Center and other JHM system entities to provide a conference that focused on survivorship. Additionally, HCGH offered a Continuing Medical Education program in June with a focus on palliative care. As we move forward into the next decade of excellent patient care, the HCGH Cancer Program looks forward to leading the change in how we treat, cure and comfort our cancer patients.
Sally Cheston, M.D. Radiation Oncology, Cancer Committee Chair
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Cancer Conference Report Cancer conferences improve the care of patients with cancer by providing multidisciplinary treatment planning and contribute to physician and allied medical staff education. The HCGH Cancer Program currently offers four cancer conferences (see chart, below). Cases are presented at a point when patient care management can be directly influenced by the discussion. Each discussion includes the patient's medical history; physical findings; diagnostic, pathologic and operative findings; staging; and treatment options. Discussions also include national evidence-based guidelines, protocol updates, literature reviews and presentation of cancer registry data.
Day Day Time Time Location: Medical Pavilion Location: MedicalofPavilion Number Meetings
General Breast Thoracic Genito-Urinary All Conferences Conference Conference Conference General Breast Thoracic Conference Genito-Urinary Combined All Conferences Conference Conference Conference Combined 2ndConference and 4th Every
Friday 2nd and 4th Tuesday Every Friday Tuesday 12:15 p.m. 7:30 a.m. 12:15 p.m. 7:30 a.m. Suite G010 Suite G010 Suite G010 Suite G010 20 47 Number of Meetings 20 47 Attendance 6 (30%) 47 (100%) by Attendance Surgeon 6 (30%) 47 (100%) Attendance by by Surgeon 11 (55%) 47 (100%) Diagnostic Radiology Attendance by 11 (55%) 47 (100%) Attendance Diagnostic Radiology 20 (100%) 47 (100%) by Attendance Pathology 20 (100%) 47 (100%) Attendance by by Pathology 20 (100%) 47 (100%) Medical Oncology Attendance by 20 (100%) 47 (100%) Attendance by Medical Oncology 18 (90%) 47 (100%) Radiation Oncology Attendance by 18 (90%) 47 (100%) Radiation Oncology 236 Total Attendance 793 Total Attendance Average Attendance 12 236 17 793
3rd Friday 3rda.m. Friday 7:30
1st Tuesday 1st Tuesday Noon
7:30 a.m. Suite G010 Suite G010 10 10 9 (90%) 9 (90%) 7 (70%) 7 (70%) 10 (100%) 10 (100%) 10 (100%) 10 (100%) 10 (100%) 10 (100%) 109 11 109
Noon Suite G030 Suite G030 10 10 10 (100%) 10 (100%) N/A* N/A* N/A* N/A* 8 (80%) 8 (80%) 10 (100%) 10 (100%) 122 12 122
87 87 72 (83%) 72 (83%) 65 (84%)* 65 (84%)* 77 (100%)* 77 (100%)* 85 (98%) 85 (98%) 83 (95%) 83 (95%) , 1260 14 1260
Average Attendance 12 17 11 12 14 Total Number of 80 302 44 34 460 Patients Total Discussed Number of 80 302 44 34 460 Average Number of Patients Discussed 4 6 4 3 5 Cases Per Meeting Average Number of 4 6 4 3 5 Cases Per Meeting *Representatives from Diagnostic Imaging and Pathology are not required to attend the GU conferences. Therefore, their average attendance is calculated on a total of 77 meetings.
Site Lung Site Hodgkin/NHL Lung Colorectal Hodgkin/NHL Breast Colorectal Other GI Breast GYN Other GI GYN
Case Distribution for 2012 General Conferences # of Cases 19 Cases # of 17 19 8 17 8 8 8 8 3 8 3
Site Male Genital Site Unknown / Non-malignant Male Genital H&N Unknown / Non-malignant CNS H&N Connective Tissue CNS Hematopoietic Connective Tissue TOTAL Hematopoietic TOTAL
# of Cases 3 Cases # of 5 3 2 5 1 2 1 1 5 1 80 5 80
All conferences are coordinated through the Oncology Data Office. For additional information, contact Sheryl Daugherty at
[email protected] or 410-740-7956; or Sharon Tunney at
[email protected] or 410-720-8515.
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Cancer Registry Report For more information about the HCGH Cancer Registry, please call 410-740-7956.
The Oncology Data Office at HCGH, a part of the Health Information Management Department, collects data on all cancer patients diagnosed and/or treated at the hospital. Hospital-based cancer registries serve as the nation’s primary source of oncology statistics. This comprehensive collection of patient data facilitates comparisons between individual facilities and the state, or the nation as a whole. As with all cancer registries, the role of the Oncology Data Office at HCGH continues to grow and evolve. With advances in cancer-related research, technology and treatments, the registry collects more detailed information than ever before. Information collected and analyzed includes demographic, personal and family histories, risk factors, diagnostic procedures, site and histology, tumor markers, prognostic indicators, staging, treatment, follow-up and survival data for each case. In 2012, 609 analytic cases were accessioned to HCGH's registry database (table 1, page 5). Over the past year, the number of new breast cancer cases increased by 11.5 percent from 157 cases to 175, and remained the most frequently seen primary site at HCGH, making up 28.7 percent of the entire analytic case load, and 46 percent of the female analytic caseload (table 2, page 6). The second most frequently seen primary site in 2012 was lung with 73 cases (12 percent of the total caseload). This represents a decrease of 17 percent from the 88 lung cancer cases accessioned in 2011. The other top primary sites seen at the hospital were colorectal, melanoma and non-Hodgkin lymphoma (NHL). The number of colorectal cancer cases increased by 2.9 percent, from 69 cases in 2011 to 71 in 2012. Melanoma cases decreased from 39 to 34 over the past year. This is a decrease of 12.8 percent. NHL cases decreased from 37 cases in 2011 to 29 cases in 2012. This is a decrease of 21.6 percent. For 2012, colorectal cancer cases made up 11.7 percent of the total analytic caseload. Melanoma was 5.6 percent and NHL was 4.8 percent of the analytic caseload. When compared to state and national statistics (table 3, page 7), HCGH continued to see female breast cancer as a significantly higher percentage of its total caseload. The incidence of colorectal and lymphoma cases were also higher at HCGH than for the state of Maryland or the nation. The incidence of melanoma was higher than that of the U.S., but slightly lower than for the state of Maryland. The incidence of lung cancer seen at HCGH was at a lower rate than both the state and nation. Individual registries help hospital physicians and administrators track quality of care and treatment by monitoring compliance with national evidence-based guidelines. Registry data is also used by the hospital for cancer conference presentations, administrative reports, to evaluate staffing and equipment needs, and guide the development of educational and screening programs for both patients and the community. The Oncology Data Office staff also compiles the required documentation to insure the HCGH oncology program’s compliance with all standards established by the American College of Surgeons (ACoS) Commission on Cancer (CoC) to maintain its accreditation as a Comprehensive Community Cancer Program (CCCP).
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Sex Primary Site
TABLE 1
HCGH 2012 Site Distribution Table Analytic Cases
M
F
0
I
II
III
IV
9 4 1 1 2 1
8 4 1 1 1 1
1 0 0 0 1 0
2 2 0 0 0 0
4 1 1 0 2 0
0 0 0 0 0 0
1 0 0 0 0 1
2 1 0 1 0 0
0 0 0 0 0 0
0 0 0 0 0 0
140 6 17 7 46 8 17 5 5 1 4 23 1
68 3 11 3 19 5 12 1 3 0 3 9 0
72 3 6 4 27 3 5 4 2 1 1 14 1
1 0 0 0 0 0 1 0 0 0 0 0 0
24 2 3 0 12 1 1 1 2 0 0 4 0
24 2 0 0 10 1 3 1 0 0 1 6 0
34 0 3 4 14 4 5 2 1 0 0 0 0
44 2 6 2 10 2 5 1 2 1 0 11 1
3 0 2 0 0 0 0 0 0 0 1 0 0
10 0 3 1 0 0 2 0 0 0 2 2 0
Respiratory System Larynx Lung & Bronchus
75 2 73
33 1 32
42 1 41
0 0 0
11 0 11
10 0 10
12 0 12
39 1 38
0 0 0
3 1 2
Skin (Excludes Squamous & Basal Cell) Melanoma Other Non-Epithelial Skin
35 34 1
19 19 0
16 15 1
19 19 0
11 11 0
1 1 0
3 3 0
0 0 0
0 0 0
1 0 1
1
1
0
0
0
0
1
0
0
0
175
3
172
44
67
44
12
6
2
0
Female Genital Organs Cervix Uterus Ovary
18 3 11 4
0 0 0 0
18 3 11 4
0 0 0 0
8 1 6 1
0 0 0 0
4 0 2 2
2 1 0 1
0 0 0 0
4 1 3 0
Male Genital Organs Prostate Testis
27 22 5
27 22 5
0 0 0
0 0 0
11 8 3
12 12 0
2 0 2
2 2 0
0 0 0
0 0 0
Urinary Tract Urinary Bladder Kidney & Renal Pelvis
35 24 11
27 22 5
8 2 6
17 17 0
8 4 4
2 1 1
4 1 3
2 0 2
0 0 0
2 1 1
Brain / Other Nervous System Meninges/Brain/CNS Benign & Borderline Brain, Malignant
19 15 4
6 3 3
13 12 1
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
19 15 4
0 0 0
Endocrine System Thyroid Thymus
17 16 1
7 7 0
10 9 1
0 0 0
8 8 0
3 3 0
3 3 0
1 1 0
1 0 1
1 1 0
Lymphoma Hodgkin Lymphoma Non-Hodgkin Lymphoma
35 6 29
19 1 18
16 5 11
0 0 0
6 1 5
9 3 6
3 0 3
16 2 14
0 0 0
1 0 1
Myeloma
4
3
1
0
0
0
0
0
4
0
Leukemia Lymphocytic Myeloid & Monocytic
6 1 5
5 1 4
1 0 1
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
6 1 5
0 0 0
14
6
8
0
0
0
0
0
14
0
609
232
377
83
159
105
77
114
49
22
Oral Cavity, Pharynx Tongue Salivary Gland Floor of Mouth Gum & Other Parts of Mouth Tonsil Digestive Organs Esophagus Stomach Small Intestine Colon Rectosigmoid Rectum Anus & Anal Canal Liver & Intrahep Bile Ducts Gallbladder Other Biliary Pancreas Peritoneum, Omentum & Mesentery
Soft Tissue Breast
Abbreviations: M=Male, F=Female, UNK=Unknown or Unstageable, N/A=Not Applicable *Carcinoma in situ/CIN-III of the cervix is no longer reported nationally or to the state
AJCC Stage at Dx
Cases
Unknown Primary Site ALL SITES
5
N/A UNK
Abbreviations: M=Male, F=Female, UNK=Unknown or Unstageable, N/A=Not Applicable *Carcinoma in situ/CIN-III of the cervix is no longer reported nationally or to the state
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Prostate 22 (9.48%)
Breast - Male 3 (1.29%)
Report #2-20-03 09/12/2013 Format Copyright (c) 2011, Onco, Inc. ver 4.2 Prepared by: Sheryl Daugherty Data Set: Temp Filter Results by
TABLE 2
Total Males:
Occurrence of Cancer by Site and Sex
232 (100.00%)
HOWA RD
Pancreas
Stomach
Lung
Esophagus
14 (3.71%)
6 (1.59%)
40 (10.61%)
3 (0.80%)
Percentages shown are gender/column specific
Page 1 of 2
Other Digestive Organs 10 (4.30%) 12 (3.19%) Melanoma skin 19 (8.19%) 15 (3.98%) Non-Hodgkin Lymphoma 18 (7.76%) 11 (2.92%) Leukemia 5 (2.15%) 1 (0.27%) All Other Sites 22 (9.49%) 27 (7.20%)
Colon, Rectum 35 (15.08%) 36 (9.55%) Kidney 5 (2.16%) 5 (1.33%) Urinary Bladder 22 (9.48%) 2 (0.53%)
9 (3.88%)
11 (4.74%)
33 (14.22%)
3 (1.29%)
Lip, Oral Cavity, Pharynx, Larynx 9 (3.88%) 2 (0.54%)
Benign Brain and CNS 3 (1.29%) 12 (3.18%)
Brain & Nervous System 3 (1.29%) 1 (0.27%)
COUN TY
2012 ANALYTIC CASES G E N E RA L H OS Howard County General Hospital
Cervix 3 (0.80%)
Corpus Uteri 11 (2.92%)
Ovary 4 (1.06%)
Breast Female 172 (45.62%)
Reported Cases
Total Females: 377 (100.00%)
P I TA L
Occurrence2012 of Cancer and Sex A n a l y t i c Cby a s eSite s
609
HCGH Top 5 Site Comparison 2012 Analytic Cases
TABLE 3
Non-Hodgkin NHL Lymphoma
Melanoma US MD Colorectal
HCGH
Lung
Breast
0
5
10
15
20
25
30
Percentage of Total Caseload
PERCENTAGE OF TOTAL CASELOAD US and MD statistics from ACS Facts and Figures
US and MD statistics from ACS Facts and Figures
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N C D B Pe r f o r m a n c e Me a s u r e s Ongoing quality reviews monitor HCGH's compliance with nationally established evidence-based treatment guidelines for the management of care for cancer patients. This review includes six measures and compares our performance rate with those from the state of Maryland and the entire U.S. This data is compiled by the National Cancer Data Base (NCDB) using information submitted by cancer registries at all CoC accredited hospitals countrywide (table 4, below). This year’s review includes data from 2011 (table 5, below). HCGH scored higher than the overall state and national rates for all six monitors. TABLE 4
Measure
Performance Rate HCGH MD US
Definition
BCS/RT
Radiation therapy is administered within one year (365 days) of diagnosis for women under age 70 receiving breast conserving surgery for breast cancer.
97.50%
83.90%
84.60%
MAC
Combination chemotherapy is considered or administered within four months (120 days) of diagnosis 100% for women under 70 with AJCC T1c N0 M0, or Stage II or III ERA and PRA negative breast cancer.
86.80%
86.40%
HT
Tamoxifen or third generation aromatase inhibitor is considered/administered within one year (365 days) of diagnosis for women with AJCC T1c N0 M0, or Stage II or III ERA and/or PRA positive breast cancer.
ACT
Adjuvant chemotherapy is considered or administered within four months (120 days) of diagnosis for patients under the age of 80 with Stage III (lymph node positive) colon cancer.
100%
12 RLN
At least 12 regional lymph nodes are removed and pathologically examined for resected colon cancer.
Ajd RT
95% 77% 77% 77.50%
80.70%
95%
89.20%
87.50%
Radiation therapy is administered within six months (180 days) of diagnosis for patients under the age of 100% 80 with clinical or pathologic AJCC T4 N0 M0 or Stage III receiving surgical resection for rectal cancer.
90.50%
88.50%
NCDB Performance Measures 2011 Analytic Cancer Cases
2011 Analytic Cases 1.2
Compliance Rate
TABLE 5
C o m p l i a n c e R a t e
1
0.8
HCGH
0.6
Maryland US
0.4
0.2
0 BCS/RT
MAC
HT
ACT
12 RLN
Performance Measure Performance Measure
8
Ajd RT
Focus on Breast Cancer Breast cancer is the most common cancer to occur in women and, after lung cancer, the second most common cause of cancer death in women. Over 200,000 women are diagnosed with breast cancer every year, but the good news is that there are 2.6 million breast cancer survivors in the United States. Breast cancer awareness is highly visible in the United States due to active breast cancer support groups and everything turning pink in the month of October. That visibility has been used to promote breast cancer screening as a way to improve survival. The success of screening is demonstrated by the large percent of women that are diagnosed with early stage breast cancer: stage 0, 1 or 2 (table 6, page 10). That early diagnosis has resulted in fewer complications from breast cancer treatment and more survivors.
Lisa Jacobs, M.D. Medical Director, Breast Center, Howard County General Hospital
Breast cancer arises in the portion of the breast that makes milk. This is termed the breast lobule and ductal system. There are approximately 15 lobular units in each breast which open onto the nipple through eight to 10 sites. The lining of these ductal lobular units is the cell that results in breast cancer. The two most common types of breast cancer are ductal carcinoma (which accounts for 72 percent) and lobular carcinoma (accounting for 14 percent) (table 8, page 11). A number of important features of breast cancer are used to determine an individual’s prognosis. The most important is the cancer’s stage, which is determined by the size of the invasive tumor and the presence of lymph nodes involved with tumor. In Howard County, the majority of women are diagnosed at an early stage. Other important features in determining treatment and survival are the estrogen and progesterone receptor status, the presence of Her-2-neu receptors on the cell surface, and estimates of the rate of growth of the tumor. Each of these features is used to personalize the treatment of the cancer to the specific features that the cancer exhibits. This allows us to select treatments that are more likely to be effective and, therefore, limit the complications and risks of treatment. The most gratifying aspect of taking care of breast cancer patients is that the majority of them will survive. This allows the doctors and nurses involved to approach every patient with a positive perspective and an expectation that they will do well. In developing the Breast Center at HCGH, we have taken the view that high-quality breast cancer screening coupled with compassionate, well-coordinated, state-of-the-art care will result in more breast cancer survivors in our community. Despite heightened awareness and availability of mammography, only 50 percent of women get the recommended yearly mammogram. At the Breast Center at HCGH, we have a goal to increase our screening and diagnostic mammography rates by providing high-quality services in a convenient setting. We have begun to see steady increases in the number of women diagnosed and treated for breast cancer in the county. The key to increased survival in breast cancer is early detection and up-to-date management once a diagnosis is made. We work to improve early detection through community education events emphasizing availability of screening services. We are also fortunate to have health care providers whose primary practice is focused on breast cancer care. This allows us to offer our patients the best treatment options available that are specifically targeted to their tumor. The results of these efforts (table 7, page 10) demonstrate that Howard County has a much higher breast cancer survival rate than the remainder of the United States.
Lisa Jacobs, M.D. Medical Director, Breast Center at Howard County General Hospital
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25
AGE BY STAGE DISTRIBUTION HCGHAge 2012 ANALYTIC BREAST CANCER CASES by Stage Distribution
HCGH 2012 Analytic Breast Cancer Cases 20 N U M B E 15 R
0 I
NUMBERS OF CASES
II III IV
O F
TABLE 6
NA/UNK
C 10 A S E S 5
0
