A Community Cancer Center Program: Getting to the Next Levelcme.baptisthealth.net/hybridsymposium/documents/petrelli.pdfA Community Cancer Center Program: Getting to the Next Level

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COMMISSION ON CANCER ONCOLOGY LECTURE

Community Cancer Center Program:etting to the Next Level

icholas J Petrelli, MD, FACS

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n an editorial entitled, “A Presidential Blue Print for Suc-ess and Change,” Frederick Greene, MD, previous Chairf the Commission on Cancer of the American College ofurgeons stated, “All of us dedicated to cancer care will gainuch insight from the Graham Center’s blue print.”1 I

ope that some of you in the audience today will be able tose in your own institutions some of the successes that weave had in our Cancer Program at the Helen F Grahamancer Center at Christiana Care. To put the Cancer Pro-ram in context, Table 1 illustrates the 2008 key metrics forhe Christiana Care Health Systems. I would point out thathere were 42,362 surgical procedures, 3,239 analytic can-er cases, and there are 229 Christiana Care residents andellows as part of the independent training programs athristiana Care approved by the American College ofraduate Medical Education. This includes a general sur-

ery residency program that graduates 5 chief residentsach year.

The components for a successful community cancerrogram include a core of high-quality well-trained profes-ionals; resources; collaboration with institutions of higherearning; and collaboration with community organiza-ions. Building an academic community cancer center re-uires the collaboration of several institutions. Figure 1emonstrates those institutions that we have been fortu-ate enough to develop programs with during the last sev-ral years. As illustrated in Figure 1, the Helen F Grahamancer Center has 3 types of practices. The overwhelmingajority of physicians are in private practice, and a small

ercentage is employed by Christiana Care. There is thehird type, which I have labeled as “hybrid.” This is a situ-tion where a private practice might be in the position toecruit an additional member. The Cancer Center, at the

isclosure information: Nothing to disclose.upported, in part, by the National Cancer Institute, National Institutes ofealth, under contract no. HHSN261200800001E.he content of this publication does not necessarily reflect the views orolicies of the Department of Health and Human Services, nor does mentionf trade names, commercial products, or organizations imply endorsement ofhe United States Government.

eceived October 19, 2009; Accepted November 20, 2009.rom the Helen F Graham Cancer Center, Newark, DE and Thomas Jeffer-on University, Philadelphia, PA.orrespondence address: Nicholas J Petrelli, MD, FACS, Helen F Grahamancer Center at Christiana Care Health Services, 4701 Ogletown Stanton

td, Newark, DE 19713. email: [email protected]

2612010 by the American College of Surgeons

ublished by Elsevier Inc.

Downloaded from ClinicalKey.com at Baptist Health SyFor personal use only. No other uses without permission. Cop

ame time, might need a Director of the Breast Center or airector of Translational Cancer Research, for example. So

n a combined recruitment, that individual can be given atipend by the Cancer Center as a director of these pro-rams. The other component in Figure 1 is the State Can-er Control Program, from which the Delaware Canceronsortium was formed in 2001 and launched its first

tatewide program in 2002 for colorectal screening. Dela-are does not have the physical presence of a medical

chool. The chartered medical school of the state is Jeffer-on Medical College. Research agreements between theelen F Graham Cancer Center and the Kimmel Cancerenter at Thomas Jefferson University and the Universityf Delaware were completed as part of the building processor an academic community cancer center. Figure 1 alsoemonstrates those community organizations with whichhe Helen F Graham Cancer Center has collaborativefforts.

ATIONAL CANCER INSTITUTE COMMUNITYANCER CENTER PROGRAMefore I discuss the programs at the Helen F Graham Can-er Center, I would like to spend some time on the Na-ional Cancer Institute Community Cancer Centers Pro-ram (NCCCP). As Figure 2 demonstrates, this programas 7 pillars that range from clinical trials to survivorship.hese pillars are integrated with disparities, quality of care,

nformation technology, and electronic health records. Theeasons for the establishment of the NCCCP are that 85%f cancer patients in the United States are diagnosed atospitals in their communities and the remaining 15% areiagnosed at National Cancer Institute (NCI)�designatedancer centers, which are mainly in urban areas. Also, manyatients are not treated at major cancer centers because ofistance from home, personal, or economic reasons.The goals of the NCCCP are as follows: expanding clin-

cal trials with an emphasis on minority recruitment; estab-ishing the multidisciplinary team approach to cancer care;educing cancer health care disparities; developing qualityf life best practice outcomes and survivorship programs;eveloping a national database of electronic medical recordy participating in the NCI Cancer Biomedical Informat-cs Grid; and collecting, storing, and sharing blood and
issue samples needed for translational cancer research.
ISSN 1072-7515/10/$36.00doi:10.1016/j.jamcollsurg.2009.11.015

stems of South Florida February 13, 2017.yright ©2017. Elsevier Inc. All rights reserved.

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262 Petrelli Community Cancer Center Program J Am Coll Surg

I would like to briefly share with you the accomplish-ents of the NCCCP during the last 2 years. First, the

nstitutions have formed a network for clinical trials Web-ased tool to track patient demographics, protocol screen-ng methods, and enrollment details such as reasons foratients not participating in a clinical trial. Second, severalnstitutions have adopted the Cancer Bioinformatics Gridetwork. Third, a dashboard has been created with dispar-

ties metrics for each program’s focused area to trackrogress at the sites and to track pilot-wide disparities ini-iatives. Fourth, several institutions have adopted the NCIest practices for biospecimen resources. Fifth, a geneticounseling and multidisciplinary care assessment matrixool has been developed and a cost study of the project islso currently ongoing. The last accomplishment has beenartnering NCCCP institutions with NCI-designated can-er centers for early-phase clinical trials and researchrojects.It is my opinion that, in the future, there will be 3 types

f NCI-designated cancer centers. We currently have 2 iniew of the comprehensive cancer centers and clinical can-er centers. I believe sometime in the future, NCI-esignated community cancer centers arising out of theCCCP pilot will become a reality. This is a 3-year pilot,hich in June 2009 received a 4th year of funding.

Helen F Graham Cancer Center

Private practiceEmployed

Hybrid

Jefferson MedKimmel CanUniversity o(Research A

Delaware Breast CancerCoalition

American Cancer Society

Figure 1. The components that drive the He

Abbreviations and Acronyms

CCOP � Christiana Community Clinical OncologyProgram

CTCR � Center for Translational Cancer ResearchNCCCP � National Cancer Institute Community Cancer

Centers ProgramNCI � National Cancer Institute

academic community cancer center.


ELAWARE CANCER CONTROL PROGRAMSs illustrated in Table 2, in 2009 it was projected thereould be 4,690 new cancer cases in the state of Delaware.he overall population of Delaware is 870,653. You can see

n Table 2 that lung, breast, prostate, and colorectal cancersere the most common cancers diagnosed in the state.here are also a substantial number of melanomas becausef the beautiful beaches in the southern part of the state andubsequent unprotected sun exposure by individuals. It ismportant to note that Delaware continues to have the

ost rapid decline in cancer mortality in the United States,wice that of the US rate. In the past, Delaware was rankedumber 1 in the country for both cancer incidence andortality. The American Cancer Society’s estimates for

009 placed Delaware number 8 in incidence and number1 in cancer deaths.2

In view of these results, what are the programs that havend will continue to play a role? First, we can review thetate government programs. The Clean Indoor Air Act wasassed in November 2002, and I will share results with youlong with the recent results of the statewide Colorectalcreening Program. It is also important to note that anninsured family of 4 in the state of Delaware making up to

tate Cancertrol Program

aunched 2003)

Collegeenter

awareents)

Federally QualifiedHealth Care Centers

&Wellness Community

Leukemia & Lymphoma Society

Graham Cancer Center toward becoming an

able 1. Christiana Care Health Systems Key Metrics for theear 2008mergency department visits 146,736dmissions 55,049urgical procedures 42,362irths 7,249ancer cases 3,239edical/dental staff 1,432edical students, Jefferson 420hristiana Care Health Systems residents/fellows 229

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263Vol. 210, No. 3, March 2010 Petrelli Community Cancer Center Program

120,000 per year can receive 2 years of cancer treatment.human papilloma virus vaccine education program was

tarted in 2007, but it is too early to discuss the impact ofhat program.

Together with state government programs, the Helen Fraham Cancer Center has developed additional pro-

rams. I will discuss the Ruth Ann Minner High Risk Fam-ly Cancer Registry, the Delaware Christiana Communitylinical Oncology Program (CCOP) for NCI clinical tri-

ls, the multidisciplinary disease site centers, and the Cen-er for Translational Cancer Research (CTCR) with addi-ional development of the Delaware Center for Canceriology. We have an extremely successful Cancer Outreachrogram focused in the city of Wilmington, but there willot be time to discuss this project.As far as the State Cancer Control Programs, Figure 3

emonstrates the Delaware and national adult smokingrends. You can see that, for the first time, the Delaware

Figure 2. The activities of the National Canc(NCCCP) which began in 2007. The NCCCP incross-section of community hospitals and he

able 2. The Most Common New Cancer Cases in the Statef Delaware for 2009ype of cancer n

ung 800reast 600rostate 550olorectal 440elanoma 220

otal 4,690

Sotal population is 870,653.


dult smoking rate is less than the national average, asllustrated in 2007. This is because of the Clean Indoor Airct passed in November 2002 and also the Helen F Gra-am Cancer Center Lung Cancer Prevention and Screen-

ng Institute, which has several smoking-cessation pro-rams. Another funded statewide program is the goal tocreen all Delawareans 50 years of age and older for colo-ectal carcinoma. Figure 4 demonstrates the percent ofdults who have ever had a sigmoidoscopy or colonoscopyy race. As noted in 2008, Delaware’s colorectal screeningate for Caucasians was 17% higher than the United States.or African Americans, Delaware’s rate was 25% higherhan the rest of the country. As you can see in Figure 4, in008, the top 2 graphs demonstrate that the disparity inolorectal screening between Caucasians and African-mericans is now nonexistent.

elen F Graham Cancer Center Programsenetic counseling and gene testingefore 2002, there was not a full-time adult genetic coun-

elor in the state of Delaware. Since 2002, 3 full-time ge-etic counselors have been hired by the Cancer Center andave built a high-risk family cancer registry named after theormer Governor, Ruth Ann Minner. This registry is theirst and only program in the state with 1,539 families and3,919 individuals. On a weekly basis, the genetic coun-elors visit the Tunnel Cancer Center at Beebe Hospital inhe southern part of the state under the direction of James

stitute Community Cancer Centers Programs a network of 14 institutions representing aare systems in the United States.

er Involve

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or Delaware. This avoids the need for patients to travel tohe northern part of the state to see the genetic counselorsor evaluation. The genetic counseling program also startedprimary care pilot in Kent County, in the middle of the

Figure 3. The adult smoking rate for Delaware comparrate in Delaware is falling twice as fast as the nationa

Figure 4. The percentage of adults by race in Delaw
2002�2008. Note that in 2008 there was no disparity betwe

tate, in July of 2007, which continues to be successful.igure 5 illustrates that the total encounters and number ofndividuals referred to the genetic counselors has increasedn each succeeding year since 2002 because of a tremendous

ith the national rate, 1997�2007. The adult smoking.

who have undergone screening for colorectal cancer,

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ducational effort for both professionals and the publicbout the importance of family history in cancer care. Therogram results of individuals with gene alterations haveesulted in 90% to 95% of family members having anmpact on their health care management. This has beenith the recommendation of prophylactic surgery, chemo-revention, or increased surveillance. There is no questionhat the genetic counseling and gene testing program hasontributed to the rapid decline in cancer mortality in thetate of Delaware.

linical trialswould like to now turn our attention to the NCI Dela-are Christiana Community Clinical Oncology Program.ecause of the efforts of our physicians and our clinical

esearch nurses, our NCI accrual to clinical trials increasedrom 14% in 2004 to 26% in 2008. Our accrual goaluring the next 3 years is to reach 30%. There are severaleasons for this high accrual. First, the established diseaseite multidisciplinary centers are staffed by clinical research

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urses as part of the multidisciplinary team. These clinical u


esearch nurses know the details of the clinical trials as wells the principle investigators. Second, we place a clinicalesearch nurse in the physicians’ private offices only if theyeet performance expectations. Third, we have a monthlyCOP newsletter that we share with our satellites and aonthly CCOP meeting with trial review so that those

rials that are not accruing during a certain period of timere brought to the “trial of the month” at Tumor Confer-nces to encourage physicians to talk to their patients aboutossible eligibility status. Lastly, we have an Annual CCOPymposium where we give awards to the high accruinghysicians. This includes surgeons who receive accrualredit if they refer a patient to a medical or radiation on-ologist and that patient participates in a clinical trial.

On a monthly basis, we share with all of our physicianshe accrual for treatment, cancer control, prevention, phar-aceutical and translational research trials so that they can

ee where their individual accrual status stands with theireers. A new program was started in January 2008 to help

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rial investigators earning their status. For a physician toaintain his or her clinical trials investigator status, theyust meet certain criteria, ie, a minimum of 4 patients

ccrued per calendar year to NCI clinical trials; they mustttend 1 NCI Cooperative Group or CCOP research-basedeeting every other year; and their medical records must

ndergo an audit in preparation for NCI Cooperativeroup audits. Failure to meet these criteria means a loss of

nvestigator status. Physicians can be reinstated, but theyust wait 1 year, attend an NCI Cooperative Group meet-

ng, and pay a $500 fee.3 In 2008, this program resulted inphysicians who accrued a total of 31 patients and who

reviously, despite resources, had not accrued any patientsn clinical trials during the previous 4 years .

ultidisciplinary disease site centershere are several key elements to the multidisciplinary carerocess. The first is a nurse navigator to coordinate sched-ling and guide the patient through the complex maze ofancer care. The second is a needed centralized registrationor one point of entry for the patient and to use informa-ion technology to communicate system-wide. There alsoust be coordinated support care services, such as nutri-

ion, social service, palliative care, and pastoral care. Thenstitution must also develop a model that can optimizerofessional and facility fee billing, especially in those in-titutions that depend on private practices. Lastly, all ele-ents of the multidisciplinary care process must support

n efficiently run system.What is the buy-in for physicians to participate in mul-

idisciplinary disease site centers? First, the patient’s treat-ent plan is established in a shorter time frame and face-

o-face discussions with the 3 major disciplines of surgery,adiation, and medical oncology, along with support ser-ices, results in less biased decisions. As stated before, theultidisciplinary disease site centers also help increase ac-

rual to clinical trials because the clinical research nurse isn important member of the multidisciplinary team. Theres also better communication with the family by the 3 ma-or disciplines because the family can meet with all disci-lines in 1 visit. Once the multidisciplinary team membersre organized, they can also build programs, such as theepatoma-screening program built by our Hepatobiliaryancreatic Multidisciplinary Center.There are 4 major elements for starting a multidisci-

linary disease site center or clinic. The first is a lead phy-ician who can direct the center members and, in general,urgeons are best qualified for this role. Second, physicianembers must believe in the vision of the cancer program.hird, a financial expert is needed to design and review ailling plan with hospital and legal counsel. Last, a leader-
hip committee needs to be developed to design and review f

erformance criteria and patient outcomes so that physi-ians maintain their high-quality cancer care. Table 3 dem-nstrates the 11 performance expectations for physicians toarticipate in the multidisciplinary disease site centers.It is important to note that private practice physicians

ho participate in the multidisciplinary centers do theirwn billing. An example would be a patient who presentsith a rectal cancer. If the multidisciplinary team decides

hat surgery would be performed first, followed by chemo-adiation, it is the surgeon who will bill the level 5 charge,nd the medical and radiation oncologist will be the 2onsultants.

Initially, we started with 3 multidisciplinary centers.here was thoracic, head and neck, and a general oncology

enter to see other cancers. Figure 6 demonstrates the mul-idisciplinary disease site centers that we have today at theelen F Graham Cancer Center. Aside from the disease site

enters, such as head and neck, thoracic, genitourinary, etc,here are also centers that deal with survivorship and painnd symptom management, and an ostomy center. Theseenters have led to an increase in patient visits to the Cancerenter. In 2003, there were approximately 60,000 patient

isits, and in 2008, there were �110,000 patient visits.atient self-referrals have also increased from 44 patients in003 to 189 patients in 2008.Program-building also leads to attraction of additional

atients. This is best exemplified by 7,783 mammogramserformed in 2001 and 16,658 mammograms performedn 2008. Performance improvements of the multidisci-linary team have been illustrated by increasing stage IIIolon cancer patient referrals to medical oncology from7% to 95%; reducing the average length of hospital stayy 0.67 days; reducing the waiting time for radiologic pro-edures from 2 to 3 weeks to 1 week, and in the case of CTcan from 1 week to 1 day; and, lastly, meeting the emo-ional, social, and spiritual needs of patients and their

able 3. The 11 Performance Expectations Required forhysicians to Participate in the Cancer Programccrue patients to clinical trials yearlyomplete Institutional Review Board ethics training course.0 Continuing Medical Education oncology credits every 2 yearsinimum 66% attendance at tumor conferences

articipate in professional cancer organizationsomplete specialty training in oncology or focused interest in 1 or2 disease sitesaintain a publication record or presentations at regional/nationaloncology conferencesork with nurse navigators and support care services (ie,psychology, nutrition) as part of the multidisciplinary teamonitor and improve clinical outcomes for patient cancer care

each oncology topics to trainees/paramedical personneleet all criteria as an active staff member of the hospital

amilies.


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The American College of Surgeons Commission onancer realizes that cancer conferences are an integral partf improving the care of cancer patients. We have beenuccessful in establishing a statewide community cancerenter videoconferencing program.4 As part of our tumoronferences, nurse navigators review the rate of complianceith tumor conference treatment recommendations.These

ecommendations are based on the National Comprehen-ive Cancer Center Network or the American Society oflinical Oncology guidelines. In 2007, compliance with

hese recommendations was 92%, and in 2008 it was 85%.ata for 2009 are pending.

ranslational cancer researchhe last area I would like to discuss concerns the question

Can a community cancer center be successful with a pro-ram of translational cancer research?” To establish a bio-edical research initiative, there were 2 critical and grow-

ng building blocks in place in the state of Delaware. Theirst was the Helen F Graham Cancer Center, whichpened in mid-2002, and the second was the Delawareiotechnology Institute at the University of Delaware,

Monday Tuesday Wedne7:00

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Thoracic/ Esophageal GOLD TEAM -Wkly 9am-3pm

1:00

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2:00

Pain & Symptom Management

Thoracic/ Esophageal BLUE TEAM - Weekly (8am-4pm)

Pain & SymptomMgmt. -Weekly (1-3pm)

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Brain/Spine Cyberknife

4:00

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5:00

Rectal/Anus -Wkly (5-6pm)

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Figure 6. The multidisciplinary disease site centers at the Helen Fand radiation oncologist with the necessary support staff and phys

hich opened in 1999. The success of this biomedical re- a


earch initiative has led to prevention, early detection, andreatment of major diseases where the initial focus has beenn cancer. It has also resulted in cutting-edge educationnd training for physicians, scientists, and students alongith undergraduate and graduate internships. This in-

ludes a new undergraduate program of genetic counselingt the University of Delaware.

One of the goals of this biomedical research initiativeas to create a medical school without walls, and the mottof the program was “failure is not an option.” Delaware’sedical and scientific community teamed up in 2003 to

stablish a nationally recognized biomedical research pro-ram in the state. This was the development of the CTCR,hich is now housed in the new pavilion of the Helen Fraham Cancer Center expansion. The objectives of theTCR were to create a center focused on coordinating

linical and basic science effort in translational cancer re-earch within the state of Delaware using managed core andesearch facilities at the Delaware Biotechnology Institutend the University of Delaware. Clinical partners would behose physicians at the Helen F Graham Cancer Center,

Thursday Friday

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am Cancer Center. The centers are staffed by a surgeon, medicalsubspecialties.

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ped with the AI DuPont Hospital for Children/Nemoursesearch Institute in Delaware.This effort has led to matching Helen F Graham Cancer

enter clinicians with scientists to foster better cancer caren the state. Examples of some of these NIH-fundedrojects are illustrated in Figure 7. The CTCR is also suc-essful because of the development at the Helen F Grahamancer Center of a Tissue Procurement Center, which haseen funded from the NIH from 2003 to the present. Theissue Procurement Center has �1,000 specimens inclu-

ive of a database for patient demographics, disease, andreatment status built on the NCI’s Cancer Bioinformaticsrid. The success of the CTCR and the Tissue Procure-ent Center led to funding for the Helen F Graham Can-

er Center to participate in the Cancer Genome Atlasroject in October 2008. The funding is $4.6 million overyears.All of these efforts have led to a 124,000 square foot

xpansion of the Helen F Graham Cancer Center, whichas dedicated in June 2009 and has doubled the space of

he original center. The expansion includes 6,000 squareeet for the Center for Translational Cancer Research,hich includes the first ever wet laboratories on the campusf Christiana Care Health Systems. Figure 8 demonstrateshat the vision has become a reality. In March of 2009, the

Salivary Gland Tissue EnJia, Wi�

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Stem cells in CRC-Boman/Denstman

Bone Marrow Stromal CellInterac�ons Prostate Ca- Sikes ,Schneider

Figure 7. Some of the grant-funded projects of the Center forphysicians at the Helen F Graham Cancer Center and scientists at

elaware Health Sciences Alliance was formed between $


homas Jefferson University, the University of Delaware,I DuPont Children’s Hospital, and Christiana Careealth Systems. This vision will lead to the physical pres-

nce of the Delaware School of Medicine, which will be anxtension of Jefferson Medical College and an expansion ofhe Center for Translational Cancer Research, which wille the Delaware Center for Cancer Biology. Figure 9 illus-rates the concept for the Delaware Center for Cancer Bi-logy inclusive of the biomarker and stem cell researchrograms of the CTCR and subsequently adding proteom-cs and genomics and research for population science andancer control.

ummarybelieve that the Helen F Graham Cancer Center programevelopment along with statewide cancer control has trans-ormed Delaware. Cancer mortality rates and the adultmoking rate in the state are dropping twice as fast as theational average. Cancer incidence is declining amongfrican-Americans 3 times faster than among Caucasians.he Center for Translational Cancer Research and the Tis-

ue Procurement Center have allowed clinicians at theelen F Graham Cancer Center and scientists to work

ogether and receive NIH grants. Importantly, NIH fund-ng to Delaware grew 6-fold from $5 million in 1995 to

3D Biomedical Visualiza�on –Steiner/Bauer

Chick Embryo Model for Brain & Breast Cancer – Galileo/Boulos/

Dickson Witmer

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Liver Surgery –eider, Benne�

lational Cancer Research illustrating the collaboration betweenniversity of Delaware.

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30 million in 2008.The NCCCP has expanded the Helen


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Graham Cancer Center Outreach to underserved areas,ncreased minority recruitment to clinical trials and led tounding for the Cancer Genome Atlas Project.

The Helen F Graham Cancer Center Outreachrogram together with the State Cancer Controlrograms have resulted in Delaware being third in thenited States for women who have received a mammo-

THE CON

DELAWARE CENTER FOR

CTCR:BiomarkersStem Cell Research

Proteomics/Genomics research (UD,K

Tissue Procurem

Cancer Genome

High Risk Family C

Christiana Care OutCORE RESOURCE

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Delaware TechDelaware State University

Tunnell Cancer CenterBayhealth

Center for Translational Cancer Research

(CTCR)Reality→

Delaware Health SciencCollaborations inInitial focus on cFuture efforts in

Figure 8. The establishment of the DelawarCare Health Systems, Thomas Jefferson UnChildrens Hospital. This will establish the DJefferson Medical College.

infrastructure of the Center for Translational Canc


ram in the last 2 years, third for women who haveeceived a Pap smear in the last 3 years, and first forndividuals who have received a colonoscopy or sig-

oidoscopy in the last 5 years. The High Risk Familyancer Registry, the multidisciplinary disease site cen-

ers, our Cancer Outreach Program, the NCI clinicalrials, and Center for Translational Cancer Research are

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Alliance (DHSA)- March 2009ucation, R&D, personneler & cardiovascular researchabilitation & neuroscience

alth Sciences Alliances involving Christianaity, University of Delaware, and AI DuPontare School of Medicine as an extension of

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he strong foundation to build on for the Cancer Pro-ram in the next 5 years.

In conclusion, one can define program success in a com-unity cancer center as follows: gather a core of high-quality

ndividuals who believe in your vision and build programs;eep the vision simple with 5-year strategic plan intervals;ork hard to get resources and use existing community orga-izations and resources; and surround yourself with people
ho are smarter than you, but just do not let them know that.

EFERENCES

. Green F. A presidential blue print for success and change. AnnSurg Oncol 2008;15:2355–2356.

. Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2009. CACancer J Clin 2009;59:225–263.

. Petrelli N, Grubbs S, Price K. Clinical trial investigator status:you need to earn it. J Clin Oncol 2008;26:2440–2441.

. Dickson-Witmer D, Petrelli N, Witmer D, et al. A statewidecommunity cancer center videoconferencing program. Ann Surg
Oncol 2008;15:3058–3064.

Documents

A Community Cancer Center Program: Getting to the Next Levelcme.baptisthealth.net/hybridsymposium/documents/petrelli.pdfA Community Cancer Center Program: Getting to the Next Level