Cancer Services

Annual Report 2019Statistical Data 2018

Message from Cancer Committee Chairman

The Forrest General Hospital Cancer Committee is glad to present our 2019 Cancer Program Annual Report. The report consists of the dedicated efforts made by the Cancer Committee, Cancer Registry, Administration, Physicians and Cancer Team Members.

In 2019, the cancer care team has continued to improve our cancer services at Forrest General Hospital. Our team maintains its focus on serving our patients, families and community with the best care. Through the American College of Surgeons Commission on Cancer, we have a vision of the highest standard of patient care in every area of our patient’s journey.

This past year our team has made progress with improving and addressing patients’ spiritual needs during the navigation of their patient journey. Additionally, we have provided several educational programs to support group members. Topics included coping with cancer, nutrition, clinical trial program information, and fitness options for patients during and after treatment. Strategic planning has been performed to improve the complete scope of care at the Forrest General Hospital Cancer Center. Patient barriers included the needs for transportation, spiritual and mental assistance, and treatment education for patients. These needs were assessed with each patient during radiation and chemotherapy treatment. The easy access of a social worker at the cancer center and a genetic counselor available for our patients weekly is part of our future goals.

Through much dedication and persistence, we will see these goals and dreams for our patient’s come to fruition. In the fall of 2019, the Commission on Cancer plans to release the 2020 Cancer Standards for Cancer Programs, and our cancer team will implement and maintain the standards beginning January 1, 2020, and forward. Our Cancer Committee will attend all educational webinars and will incorporate the new and updated standards into our patient’s and family’s journey.

Sincerely,John S. Hrom, MD

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2019 Cancer Committee

Surgery Medical Oncology PathologyNeal Holm, MD John S. Hrom, MD Timothy Cole, MDCancer Committee Liaison Committee Chair

Gastroenterology Radiation Oncology Palliative Care ServicesKevin Barker, MD Joseph Salloum, MD Theresa Dueitt, NP Sophy Mangana, MD

Radiology Non-Medical Staff Members Amber Chancelor, RNC. Alexander Hudson, MD Gladys Wolff, Medical Director PCS Palliative Care Services

Paula Hand Lesley Wood Ramona Martin, RNMedical Social Services Marketing/Communications Patient Navigator

Anne Kealhofer Juliet Hinton, CTR Jena Hopkins, CTRQuality Management Cancer Registry Cancer Registry

Tammy McBeth, RN Joe Marcello Rebecca Pardue, PCMClinical Research Nurse Service Line Administrator Home Care/Hospice

Ramata Sakhanokh Daphne Nix, CTR Sky Johnson, RNClinical Pharmacist Cancer Registry Patient Care Manager

Dorothy Stone, MS, RD Damita Hines Michelle Williams, RNDietician Cancer Center American Cancer Society Clinical Specialist Oncology

Donna Wheeless Rodger MooreDirector of Rehabilitation Pastoral CareServices & Wellness Services

Cancer Services

The Oncology Service Line provides a continuum of compassionate, high quality, state-of-the-art services for the detection, prevention and treatment of cancer through a well-trained multidisciplinary team that maintains a personalized focus on the needs of the individual. Forrest General’s Cancer Center, which ranks among the largest and most sophisticated regional cancer centers in south Mississippi, offers a place where patients can receive technologically-advanced care in an environment of beauty, caring and compassion.

Forrest General’s Oncology Services strives to improve the quality and length of life for the cancer patient and to further research on the cause, prevention, treatment, and cure of cancer. We value compassion, respect, integrity, creativity, teamwork, commitment, and excellence in all that we do. The FGH Cancer Program is accredited through the American College of Surgeons Commission on Cancer and is the one of the first programs started in the state of Mississippi. For more information about Forrest General’s Oncology Services, call Forrest Health Information at 1-800-844-4445.

ServicesSurgery Home Care Hospice Nutritional CarePastoral Services Mental Health Services Chemotherapy ImagingExercise and Wellness Services Plastic Surgery Radiation Oncology RadiologyInterventional Radiology Hematology/Oncology OPACS Palliative Care Services – IPPain Management Medical Social Services Navigation Clinical TrialsWound Care Services Hostess Care & Assistance Genetic Counseling Survivorship Care – Follow-up Treatment PlanResearch and Standards – CoC Spiritual Care Healing Garden Music TherapyFitness and Exercise Coping Mechanisms/Sessions

Survivorship Support Group Forrest General Healthcare FoundationCamp Bluebird - Look Good, Feel Better; FGH Foundation Adult Survivors Camp Brave, Brilliant & Resilient www.fghfoundation.com Bereavement Support Group TreeofLife, InPatient Hospice Campaign, Healing Garden, Navigator, OPACS, Clinical Trials & Research

Clinical Trials

At the Cancer Center, there are multiple ongoing clinical trials available to patients that include the newest immunotherapies, targeted therapies, as well as newer chemotherapies. Many of these trials are not available elsewhere in the state of Mississippi.

This allows patients to receive the best treatment without the need to travel outside the Pine Belt, and our program has a full-time dedicated research staff person to assist with patient care during the clinical trial.

To find out if you are a candidate or need more information, contact the Clinical Trials Coordinator, Tammy McBeth at 601-288-1700.

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Forrest General’s Hospice Ranks Top 5 Percent in National Survey Earning Best Hospice Caregiver Satisfaction Award

Forrest General’s Home Care and Hospice received the Strategic Healthcare Programs’ (SHP) Best Hospice Caregiver Satisfaction Award. The award recognizes the hospital for achieving an overall score that ranked within the top 5 percent in the SHP national Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospice benchmark and above the SHP national average for each CAHPS hospice quality measure in the 2018 calendar year.

This award is unique because it is measured from the caregiver’s point of view meaning that the survey is delivered to patients’ families, friends, and other caregivers.

“Our team works hard to provide high quality care to our patients and their loved ones. It is a huge honor to be recognized by such a prestigious organization and confirms that we are offering the best possible care and compassion for our patients. It is especially rewarding to know that caregivers trust us and the level of care we’re providing their family members,” said Rebecca Pardue, director, Forrest General Home Care, Hospice, and Asbury Hospice House.

This annual program acknowledges home health and hospice providers who have proven to provide high quality care to their patients. The CAHPS surveys are given to caregivers who score the care their loved one has received; this data is then compared to national quality standards and ranked next to other providers. According to the SHP website, “With the largest HHCAHPS benchmark in the nation, SHP is in a unique position to identify and recognize organizations that have made patient satisfaction a priority and have been rewarded for their efforts with high marks on the HHCAHPS survey.”

SHP Best Hospice Caregiver Satisfaction Award

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Hattiesburg Clinic CT Screening

http://www.quitlinems.com/index.phphttps://www.cdc.gov/cancer/lung/pdf/guidelines.pdf

FGH Cancer Center

Prevention and Screening 2019September 12, 2019

Organizations:MSDH, MOHCA, PRCC, FGH, FGH Wellness, FGH Cancer Registry, MP3C, SEMRHI

Education Session Speakers:Dr. James Weir, Associate Dean, Students Affairs, William Carey University Dana Thomas, RN MSDH Vaccine Manager

Forty-seven (47) participants were seen during the Head and Neck Screening. Seven (7) were initiated for additional follow-up and potential biopsy. They were scheduled for follow-up at the SEMRHI Clinic at the dental clinic for further evaluation and treatment..

Camp Bluebird 2019

2018 Cases Distribution by County

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CAMP BLUEBIRD, the first camp in Mississippi for adult cancer patients and survivors. This two and one-half day camp is held annually at Paul B. Johnson State Park and includes recreational activities, social events, devotional and educational opportunities de-signed to minister to the whole person with fun and

fellowship. The purpose of the camp is to promote a sense of wellbeing among campers, to teach them how to live with cancer and cancer treatments and to provide a time of rest and relaxation. Pictured are staff members, volunteers and campers who partici-pated in Camp Bluebird 2019.

camp BlueBird

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Primary Site 2018 (Analytic – 1,252 Non-analytic - 224) Total: 1,476

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Summary of Cases

There were 1,476 new cases entered into the cancer registry in 2018, 1,252 analytic cases diagnosed and/or treated at FGH, and 224 non-analytic cases seen at FGH. The top sites for 2018 were Lung 267, Prostate 259, Breast 213, Colorectal 146, Lymphatic/Hematopoietic 131 and Head and Neck 66. The distribution by sex was male 797 (54%) and female 679 (46%) for 2018.

Primary Payer

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Cancer Registry

The Cancer Registry is the cornerstone of the cancer program at Forrest General Hospital. The Registry’s focus is to exceed the expectations of the American College of Surgeons Commission on Cancer standards and fulfill the Cancer Committee’s vision. From our reference year of 2002, our goal is to guarantee accurate and timely collection of diagnosed and/or treated cancer patient data, which allows for the efficacy in evaluation of patient outcomes and identification of opportunities for improvement. Since 1968, there have been 45,117 cases entered into the database. Since our reference year of 2002, we have 21,342 cases. Lifetime follow-up of patients included in the database supports clinical follow-up and surveillance of additional primaries. Currently, the cancer

registry maintains follow-up on 7,399 cases with a follow-up rate is 97%.

The Cancer Registry activities included Weekly Data Submission to the Mississippi Cancer Registry, National Cancer Database Submission, studies requested in 2018, completion of 2018 Cancer Program Annual Report, and maintenance of the Facility Information Profile System (FIPS) – public viewing of resources and data of the Commission on Cancer approved programs listed on the American Cancer Society website, Survey Application Record (SAR), Follow-up Care: Survivorship IRB Studies, Rapid Quality Reporting System (RQRS) through Commission on Cancer, and CP3R Reports.

Physician Presenters at Cancer Conference 2018

Orlando Andy, MD, Surgery Kevin Barker, MD, GI John S. Hrom, MD, HEM/ONC

Louis Varner, MD, HEM/ONC Richard Pecunia, MD, PLAS/SURG Duncan Donald MD, Surgery

Laurie Douglas, MD, HEM/ONC Charles McCollum, MD PULM Neal Holm, MD, Surgery

John A. Johnson, MD, Surgery David Morris, HEM/ONC Charles Parkman, MD, PULM

Joseph Salloum, MD, RAD ONC Daniel Smith, MD, Surgery Georgia Wahl, MD, Surgery

William Whitehead, MD, Surgery Michael Raggio, MD, PULM Joseph Phillips, MD, GI

Cancer Conference

The cancer (tumor) conference is held weekly on Tuesday at noon and offers multidisciplinary consultative services for patients, discussion among cancer program team members, and educational conferences for the physicians and allied health professionals. In 2018, 214 cases were discussed at conference. Prospective cases were 99%. The top sites included Breast, Lung, Colon, Prostate, Head

and Neck, Brain, Unknown, and Lymphoma/Leukemia. Forrest General Hospital is accredited by the Ochsner to provide continuing medical education (CME) for physicians in this educational activity for one credit towards the AMA Physician’s Recognition Award. For more information about the Cancer Conference, please contact the Cancer Registry at (601) 288-2914.

John S. Hrom, MD Laurie Douglas, MD David Morris, MDHattiesburg Clinic, P.A. Hattiesburg Clinic, P.A. Hattiesburg Clinic, P.A.Hematology/Oncology Hematology/Oncology Hematology/OncologyMedical School: UMMC UMMC Medical School: UMCInternship: UMMC UMMC Internship: UMMCResidency: UMMC University of Alabama Birmingham Residency: UMMCFellowship: University of Texas Southwestern Wake Forest Baptist Health Fellowship: UMMC

J. Michael Herrington, MD Sophy Mangana, MD N. Joseph Salloum, MDHattiesburg Clinic, P.A. South MS Associates of Radiation Therapy South MS Associates of Radiation TherapyHematology/Oncology FGH Cancer Center: Radiation Oncology FGH Cancer Center: Radiation OncologyMedical School: UMMC The Warren Alpert Medical School of University of CairoInternship: UMMC Brown University Cairo University HospitalResidency: UMMC Roger Williams Medical Center (IM & RO) New York Methodist HospitalFellowship: UMMC Loyola University Medical Center

Bradley Myers, NP Whitney Wilkinson, NP Julie Simmons, NPHattiesburg Clinic, P.A. FGH Cancer Center Hattiesburg Clinic, P.A.HBC Medical Oncology Radiation Oncology HBC Medical Oncology

Oncology Team

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Estimated Number of New Cases for 2019 — USA

More than 1.7 million new cancer cases are expected to be diagnosed in 2019 (Table 1). This estimate does not include carcinoma in situ (noninvasive cancer) of any site except urinary bladder, nor does it include basal cell or squamous cell skin cancers because these are not required to be reported to cancer registries. Table 2 provides estimated new cancer cases in 2019 by state.

About 606,880 Americans are expected to die of cancer in 2019 (Table 1), which translates to about 1,660 deaths per day. Cancer is the second most common cause of death in the US, exceeded only by heart disease. Table 3 provides estimated cancer deaths by state in 2019.

A substantial proportion of cancers could be prevented, including all cancers caused by tobacco use and other

unhealthy behaviors. According to a recent study by American Cancer Society researchers, at least 42% of newly diagnosed cancers in the US – about 740,000 cases in 2019 – are potentially avoidable, including the 19% of all cancers that are caused by smoking and the 18% that are caused by a combination of excess body weight, physical inactivity, excess alcohol consumption, and poor nutrition. Certain cancers caused by infectious agents, such as human papillomavirus (HPV), hepatitis B virus (HBV), hepatitis C virus (HCV), and Helicobacter pylori (H. pylori), could be prevented through behavioral changes or vaccination to avoid the infection, or treatment of the infection. Many of the more than 5 million skin cancer cases that are diagnosed annually could be prevented by protecting skin from excessive sun exposure and not using indoor tanning devices.

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Screening can help prevent colorectal and cervical cancers by detecting precancerous lesions that can be removed. It can also detect some cancers early, when treatment is more often successful. Screening is known to help reduce mortality for cancers of the breast, colon, rectum, cervix, prostate, and lung (among current or former heavy smokers). In addition, a heightened awareness of changes in certain parts of the body, such as the breast, skin, mouth, eyes, or genitalia, may also result in the early detection of cancer. For complete cancer screening guidelines, see page 71.

How Many People Alive Today Have Ever Had Cancer?

More than 15.5 million Americans with a history of cancer were alive on January 1, 2016, most of whom were diagnosed many years ago and have no current evidence of cancer.

Cancer death rates are the best measure of progress against the disease because they are less affected by detection practices than incidence and survival. The overall age-adjusted cancer death rate rose during most of the 20th century, peaking in 1991 at 215 cancer deaths per 100,000 people, mainly because of the tobacco epidemic. As of 2016, the rate had dropped to 156 per 100,000 (a decline of 27%) because of reductions in smoking, as well as improvements in early detection and treatment. This decline translates into more than 2.6 million fewer cancer deaths from 1991 to 2016, progress that has been driven by steady declines in death rates for the four most common cancer types – lung, colorectal, breast, and prostate (Figure 1 and Figure 2).

Cancer usually develops in older people; 80% of all cancers in the United States are diagnosed in people 55 years of age or older. Certain behaviors also increase risk, such as smoking, having excess body weight, and drinking alcohol. In the US, approximately 39 out of 100 men and 38 out of 100 women will develop cancer during their lifetime (Table 6). These probabilities are estimated based on cancer occurrence in the general population and may overestimate or underestimate individual risk because of differences in exposures (e.g., smoking), family history, and/or genetic susceptibility. For most types of cancer, risk is higher with a family history of the disease. This is thought to result primarily from the inheritance of genetic variations that confer low or moderate risk and/or similar exposures to lifestyle/environmental risk factors among family members, as opposed to inheritance of genetic alterations that confer a very high risk, which occurs much more rarely.

Relative risk is the strength of the relationship between exposure to a given risk factor and cancer. It is measured by comparing cancer occurrence in people with a certain exposure or trait to cancer occurrence in people without this characteristic. For example, men and women who smoke are about 25 times more likely to develop lung cancer than nonsmokers, so the relative risk of lung cancer among smokers is 25. Most relative risks are not this large. For example, women who have a mother, sister, or daughter with a history of breast cancer are about twice as likely to develop breast cancer as women who do not have this family history; in other words, their relative risk is about 2.

Estimated Number of New Cases for 2019 — USA (continued)

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What Percentage of People Survive Cancer?

The 5-year relative survival rate for all cancers combined has increased substantially since the early 1960s, from 39% to 70% among whites and from 27% to 63% among blacks. Improvements in survival (Table 7) reflect advances in treatment, as well as earlier diagnosis for some cancers. Survival varies greatly by cancer type, as well as stage and age at diagnosis (Table 8).Relative survival is the proportion of people who are alive for a designated time (usually 5 years) after a cancer diagnosis divided by the proportion of people of similar age, race, etc. expected to be alive in the absence of cancer based on normal life expectancy. Relative survival does not distinguish between patients who have no evidence of cancer and those who have relapsed or are still in treatment; nor does it represent the proportion of people who are cured, because cancer death can occur beyond 5 years after diagnosis. For information about

how survival rates were calculated for this report, see Sources of Statistics on page 69.

Although relative survival rates provide some indication about the average experience of cancer patients, they should be interpreted with caution for several reasons. First, 5-year survival rates do not reflect the most recent advances in detection and treatment because they are based on patients who were diagnosed at least several years in the past. Second, they do not account for many factors that influence individual survival, such as access to treatment, other illnesses, and biological or behavioral differences. Third, improvements in survival rates over time do not always indicate progress against cancer. For example, increases in average survival rates occur when screening results in the detection of cancers that would never have caused harm if left undetected (over-diagnosis). (Cancer Facts and Figures 2019, Page 3).

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Estimated Number of New Cases for 2019 — USA (continued)

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Estimated Number of New Cases for 2019 — USA (continued)

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Estimated Number of New Cases for 2019 — USA (continued)

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The Agency for Healthcare Research and Quality estimates that the direct medical costs (total of all health care expenditures) for cancer in the US in 2015 were $80.2 billion. Fifty-two percent of those costs were for hospital outpatient or office-based provider visits, and 38% were for inpatient hospital stays. These estimates are based on a set of large-scale surveys of individuals and their medical providers called the Medical Expenditure Panel Survey, the most complete, nationally representative data on health care and expenditures. Visit meps.ahrq.gov/mepsweb/ for more information.

Lack of health insurance and other barriers prevents many Americans from receiving optimal cancer prevention, early detection, and treatment. According to the US Census Bureau, 28.5 million Americans

(9%) were uninsured during the entire 2017 calendar year, down more than 13 million from 2013 because of the implementation in January 2014 of several new provisions of the Affordable Care Act (ACA). The largest increase in health insurance coverage was among those with the lowest education and income. Hispanics and blacks continue to be the most likely to be uninsured, 16% and 11%, respectively, compared to 6% of non-Hispanic whites. The percentage of uninsured ranged from 3% in Massachusetts to 17% in Texas. Uninsured patients and those from many ethnic minority groups are substantially more likely to be diagnosed with cancer at a later stage, when treatment is often more extensive, costlier, and less successful. To learn more about how the ACA helps save lives from cancer. (Cancer Facts and Figures 2019, Page 9).

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FGH Colorectal Cancer Years: 2008-2014 Analytical Cases N: 692

Colorectal cancer is the third commonly diagnosed cancer in the United States. The American Cancer Society’s estimates for the number of colorectal cancer cases in the United States for 2019 are:

• 101,420 new cases of colon cancer• 44,180 new cases of rectal cancer

The American Cancer Society’s estimates for the number of colorectal cancer cases in the United States for 2019 are:

• 101,420 new cases of colon cancer• 44,180 new cases of rectal cancer

Overall, the lifetime risk of developing colorectal cancer is: about 1 in 22 (4.49%) for men and 1 in 24 (4.15%) for women. This risk is slightly lower in women than in men. In the United States, colorectal cancer is the third leading cause of cancer-related deaths in men and in women, and the second most common cause of cancer deaths when men and women are combined. It’s expected to cause about 51,020 deaths during 2019.

The death rate (the number of deaths per 100,000 people per year) from colorectal cancer has been dropping in both men and women for several decades. There are a number of likely reasons for this. One is that colorectal

polyps are now being found more often by screening and removed before they can develop into cancers or are being found earlier when the disease is easier to treat. In addition, treatment for colorectal cancer has improved over the last few decades. As a result, there are now more than 1 million survivors of colorectal cancer in the United States. Although the overall death rate has continued to drop, deaths from colorectal cancer among people younger than age 55 have increased 1% per year from 2007 and 2016.

Risk factors: Based on a study by American Cancer Society researchers, more than half (55%) of colorectal cancers in the US are attributable to potentially modifiable risk factors. Modifiable factors that increase risk include obesity, physical inactivity, long-term smoking, high consumption of red or processed meat, low calcium intake, moderate to heavy alcohol consumption, and very low intake of fruits and vegetables and whole-grain fiber. Hereditary and medical factors that increase risk include a personal or family history of colorectal cancer and/or polyps (adenomatous), certain inherited genetic conditions (e.g., Lynch syndrome), a personal history of chronic inflammatory bowel disease (ulcerative colitis or Crohn’s disease), and type 2 diabetes.

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The Agency for Healthcare Research and Quality estimates that the direct medical costs (total of all health care expenditures) for cancer in the US in 2015 were $80.2 billion. Fifty-two percent of those costs were for hospital outpatient or office-based provider visits, and 38% were for inpatient hospital stays. These estimates are based on a set of large-scale surveys of individuals and their medical providers called the Medical Expenditure Panel Survey, the most complete, nationally representative data on health care and expenditures. Visit meps.ahrq.gov/mepsweb/ for more information.Lack of health insurance and other barriers prevents many Americans from receiving optimal cancer prevention, early detection, and treatment. According to the US Census Bureau, 28.5 million Americans (9%) were uninsured during the entire 2017 calendar

year, down more than 13 million from 2013 because of the implementation in January 2014 of several new provisions of the Affordable Care Act (ACA). The largest increase in health insurance coverage was among those with the lowest education and income. Hispanics and blacks continue to be the most likely to be uninsured, 16% and 11%, respectively, compared to 6% of non-Hispanic whites. The percentage of uninsured ranged from 3% in Massachusetts to 17% in Texas. Uninsured patients and those from many ethnic minority groups are substantially more likely to be diagnosed with cancer at a later stage, when treatment is often more extensive, costlier, and less successful. To learn more about how the ACA helps save lives from cancer. (Cancer Facts and Figures 2019, Page 9).

Regular long-term use of nonsteroidal anti-inflammatory drugs, such as aspirin, reduces risk, but these drugs can have serious adverse health effects, such as stomach

bleeding. Decision making about aspirin use should include a conversation with your health care provider.

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FGH Colorectal Cancer Years: 2008-2014 Analytical Cases (continued)

Early detection: Screening can prevent colorectal cancer through the detection and removal of precancerous growths, as well as detect cancer at an early stage, when treatment is usually less extensive and more successful. Regular adherence to either of the two types of testing (stool or structural exams) over a lifetime of screening results in a similar reduction in premature colorectal

cancer death. New guidelines from the American Cancer Society recommend that men and women at average risk for colorectal cancer begin screening at 45 years of age and continue up to age 85 depending on health status/life expectancy, with more individualized decision making from ages 76 to 85 based on patient preferences and prior screening history.

Signs and symptoms: Symptoms include rectal bleeding, blood in the stool, a change in bowel habits or stool shape (e.g., narrower than usual), the feeling that the bowel is not completely empty, abdominal cramping or pain, decreased appetite, and weight loss. In some cases, the cancer causes blood loss that leads to anemia (low number of red blood cells), resulting in symptoms

such as weakness and fatigue. Increasing incidence of colorectal cancer in young individuals, who are often diagnosed with advanced disease, reinforces the need for timely evaluation of persistent symptoms in all patients. Early-stage colorectal cancer typically does not have symptoms, which is why screening is usually necessary to detect this cancer early.

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Noteswww.cancer.org Cancer Facts and Figures 2019. American Cancer Society. Pages 13-15.https://www.nccn.org/patients/guidelines/colon/12/ NCCN Guidelines for Patients Colon Cancer 2018.https://www.ccalliance.org/about/never-too-young/survey/2018-young-onset-colorectal-cancer-survey-report

Treatment: Surgery is the most common treatment for colorectal cancer that has not spread. A permanent colostomy (creation of an abdominal opening for elimination of body waste) is rarely necessary for colon cancer and not usually required for rectal cancer. For most patients whose cancer has penetrated the bowel wall deeply or spread to lymph nodes, chemotherapy

is given after surgery for colon cancer, and before and/or after surgery, alone or in combination with radiation, for rectal cancer. For colorectal cancer that has spread to other parts of the body (metastatic colorectal cancer), treatments typically include chemotherapy and/or targeted therapy. Immunotherapy is a newer option for some advanced cancers.

Survival: FGH Relative 5-Year survival is 76% (2008-2014). The 5-year relative survival rate for colorectal cancer is 65%. Only 39% of patients are

diagnosed with localized disease, for which 5-year survival is 90%.

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FGH Breast Cancer Years: 2008-2014 Analytical Cases N: 1,385

Breast cancer is the most common invasive cancer in women, and the second main cause of cancer death in women, after lung cancer.

Advances in screening and treatment have improved survival rates dramatically since 1989. There are around 3.1 million breast cancer survivors in the United States (U.S.). The chance of any woman dying from breast cancer is around 1 in 37, or 2.7 percent.

New cases: In the US in 2019, there will be an estimated 268,600 new cases of invasive breast cancer diagnosed in

women; 2,670 cases diagnosed in men; and an additional 62,930 cases of in situ breast lesions (ductal carcinoma in situ [DCIS] or lobular carcinoma in situ [LCIS]) diagnosed in women.

Incidence trends: From 2006 to 2015, invasive female breast cancer incidence rates increased slightly, by 0.4% per year.

Deaths: An estimated 42,260 breast cancer deaths (41,760 women, 500 men) will occur in 2019.

Mortality trends: The female breast cancer death rate peaked at 33.2 (per 100,000) in 1989, then the rate declined by 40% to 20.0 in 2016. This progress reflects improvements in early detection (through screening, as well as increased awareness of symptoms) and treatment, and translates to an estimated 348,800 fewer breast cancer deaths than would have been expected if the death rate had remained at its peak. From 2007 to 2016, the breast cancer death rate declined by 1.8% per year.

Risk factors: Older age and being a woman are the strongest risk factors for breast cancer. Potentially modifiable factors that increase risk include weight gain after the age of 18 and/or being overweight or obese (for postmenopausal breast cancer); menopausal hormone therapy (combined estrogen and progestin); alcohol consumption; and physical inactivity. Breastfeeding for at least one year decreases risk. Non-modifiable factors that increase risk include a personal or family

history of breast or ovarian cancer; inherited mutations (genetic alterations) in breast cancer susceptibility genes (e.g., BRCA1 or BRCA2); certain benign breast conditions, such as atypical hyperplasia; a history of ductal carcinoma in situ (DCIS) or lobular carcinoma in situ (LCIS); high breast tissue density (the amount of glandular tissue relative to fatty tissue measured on a mammogram); and high-dose radiation to the chest at a young age (e.g., for treatment of lymphoma).

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Early detection: Mammography is a low-dose x-ray procedure used to detect breast cancer at an early stage. Early diagnosis reduces the risk of dying from breast cancer and provides more treatment options. However, like any screening tool, mammography is not perfect. It can miss cancer (false negative) or appear

abnormal in the absence of cancer (false positive); about 1 in 10 women who are screened have an abnormal mammogram, but only about 5% of these women have cancer. Other potential harms include detection of cancers and in situ lesions (e.g., DCIS) that would never have progressed or caused harm (i.e., over-diagnoses), and cumulative radiation exposure, which increases breast cancer risk. For women at average risk of breast cancer, the American Cancer Society recommends that those 40 to 44 years of age have the option to begin annual mammography; those 45 to 54 undergo annual mammography; and those 55 years of age and older may transition to biennial mammography or continue annual mammography. Women should continue mammography as long as overall health is good and life expectancy is 10 or more years. For some women at high risk of breast cancer, annual magnetic resonance imaging (MRI) is recommended to accompany mammography, typically starting at age 30.

Signs and symptoms: Early breast cancer usually has no symptoms and is most often diagnosed through mammography screening. When symptoms occur, the most common is a lump or mass in the breast. Other

symptoms may include persistent changes to the breast, such as thickening, swelling, distortion, tenderness, skin irritation, redness, scaliness, and nipple abnormalities or spontaneous nipple discharge.

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Notes:https://www.medicalnewstoday.com/articles/37136.php Nordqvist, Christian. “What you need to know about breast cancer”. 13 November 2018.www.cancer.org Cancer Facts and Figures 2019. American Cancer Society. Pages 10-11.https://www.nccn.org/patients/guidelines/breast-invasive/10/ NCCN Guidelines for Patients Breast Cancer Invasive.

FGH Breast Cancer Years: 2008-2014 Analytical Cases N: 1,385 (continued)

Treatment: Treatment usually involves either BCS (breast conserving surgery) (surgical removal of the tumor and surrounding tissue, sometimes called a lumpectomy) or mastectomy (surgical removal of the breast), depending on tumor characteristics (e.g., size and extent of spread) and patient preference. Radiation to the breast is recommended for most patients having breast-conserving surgery. For women with early-stage breast cancer studies indicate that breast conserving surgery plus radiation therapy results in long-term outcomes equivalent to, and possibly even better than, mastectomy. Although most patients undergoing mastectomy do not need radiation, it is sometimes recommended when the tumor is large or lymph nodes are involved. One or more underarm lymph nodes are usually evaluated during surgery to determine whether the tumor has spread beyond the breast. Women

undergoing mastectomy who elect breast reconstruction have several options, including the type of tissue or implant used to restore breast shape. Reconstruction may be performed at the time of mastectomy (also called immediate reconstruction) or as a second procedure (delayed reconstruction), but often requires more than one surgery.

Treatment may also involve chemotherapy (before or after surgery), hormone (anti-estrogen) therapy, and/or targeted therapy, depending on cancer stage, subtype, and the anticipated benefits of each treatment component. Women with early-stage breast cancer who test positive for hormone receptors benefit from treatment with hormone therapy for 5 or more years.

Survival: FGH Relative Survival 5-year is at 97% (years 2008-2014). The 5- and 10-year relative survival rates for women with invasive breast cancer are 90% and 83%,

respectively. Sixty-two percent of cases are diagnosed at a localized stage (no spread to lymph nodes, nearby structures, or other locations outside the breast), for which the 5-year survival is 99%. Survival rates have improved over time for both white and black women, but remain about 10% lower (in absolute terms) for black women. Continuing disparities in outcomes for black women are an area of national focus. Awareness of the symptoms and the need for screening are important ways of reducing the risk.

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Quality Improvements 2019

I. Define Problem StatementGap in Care Services and Health Care Technology for Patients – Each of the Radiation Therapy Accelerators are over on the daily usage of patient volume and time. Due to increase in volume, patients have to be re-scheduled when machine is down, new patients are schedule a month out or more, increased Radiation Therapists and caused high turnover rate. Low employee morale and decreased patient satisfaction to have treatment on time and not have to wait so long.

II. Data collection to determine root cause of the problem? Not able to provide quality of care, high patient volume, and long waiting time, equipment breakdown and long staff hours. Access to care is an issue when the equipment is down and patients have to reschedule for the next day or week. The physicians workload as well as all others involved is increased when the machines are down and patients are rescheduled.

III. National Benchmarks or Published ArticleRadiotherapy Program Thrives Amid Major Patient Volume Increases. Pantarotto,MD Jason. https://www.itnonline.com/content/radiotherapy-program-thrives-amid-major-patient-volume-increases.Discuss “Grey Tsunami”. “Our volume has grown 30 percent in the last decade, and that’s mainly due to an increase in the cancer incidence among individuals in their mid-50s to mid-70s — the baby boomer generation,” said Jason Pantarotto, M.D., head, Radiation Medicine Program at TOH, which has radiation therapy services at its General Campus and Queensway Carleton Hospital. “But it’s also a result of our efforts to ensure that every patient in our region has access to radiotherapy services.”

Missed Radiation Therapy Sessions Increase Risk of Cancer Recurrence. National Cancer Institute Staff. https://www.cancer.gov/news-events/cancer-currents-blog/2016/missed-radiation-therapy.Patients who miss radiation therapy sessions

during cancer treatment have an increased risk of their disease returning, even if they eventually complete their course of radiation treatment, according to a new study.The magnitude of the effect was higher than the researchers anticipated, which they believe suggests that noncompliance with radiation therapy may be an indicator for other risk factors that could negatively affect outcomes. Compensability index for compensation radiotherapy after treatment interruptions, Putora, Paul Martin; Schmuecking, Michael; Aebersold, Daniel; & Plasswilm. Radiation Oncology. 7 Article Number: 208 (2012). Treatment breaks due to technical problems, organisational or patient-related issues, holidays or even side effects of treatment may arise. These treatment interruptions are usually not accounted for sufficiently when treatment is simply continued with the originally planned fractionation. If a sub-optimal compensatory regime is chosen the tumour control rate may be jeopardized or unacceptable side effects risked. Radiation oncologists are often confronted with the decision to adapt a radiotherapy regime when unscheduled interruptions take place. The decision may be to compensate by additional treatment fractions, adapting the dose per fraction of the remaining fractions or changing both, or even the timing (e.g. twice daily treatments). Depending on the clinical scenario, not adapting a radiotherapy regime and accepting deviations may also be an option. Increasing the total dose (by increasing the number of fractions or increasing the dose per fraction) to adapt to the same expected tumour control rate may not always be the best solution. Many treatment regimens are determined and limited by the possible acute or late side effects. By increasing the dose to compensate for treatment brakes one might increase the risk for side effects on normal tissues.American College of Radiology (ACR) ASTRO (the American Society for Radiation Oncology) State of Mississippi Hospital Regulations for Radiation Oncology

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Quality Improvements 2019 (continued)

IV. Summary of FindingsForrest General Cancer Center’s two (2) existing linear accelerators exceeded 16,000 treatments per year for the two most recent consecutive years as reported on Forrest General’s Renewal of Hospital License and Annual Hospital Report.

In the Fiscal Year 2016, Forrest General Cancer Center’s two linear accelerators performed 17,281 treatments or on an average of 8,640.5 treatments per unit.

In the Fiscal Year 2017, Forrest General Cancer Center’s two linear accelerators performed 17, 184 treatments or on an average of 8,592 treatments per unit.

Accordingly, Forrest General Cancer Center’s radiation therapy equipment has performed in excess of 8,000 treatments per unit per year for the most recent 24 month period, in compliance the Need Criterion.

V. Recommendation of Improvement (as appropriate)The final analysis assisted the administration to budget for a new accelerator and vault. The building process was started in February 2019. Currently the building process is fifty percent completed. The entire building project is planned to be completed within eight months. Once the accelerator and vault are utilized by the Radiation oncology patients, the Cancer Committee, Quality Improvement subgroup will monitor the volume, the ease of care and the staffing schedules and satisfaction.

VI. Reviewed and Approved at Quarterly Cancer Committee Meeting – Tuesday, September 17, 2019 at 12:30 p.m. Cancer committee minutes in which the results of the studies were reported – see September 17th.The results of this study were reported to the Cancer Committee on September 17, 2019. The Committee reviewed and approved the quality improvement. The QI will be uploaded into the SAR.

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I. Define Problem StatementNeed to minimize the manual lifting of all patients who are unable to bear weight or get out of vehicle. Need for patients to be removed from vehicle and into the clinic safely and securely by staff. Need for ability to take out patient without harming the patient and injuring the staff with back problems or other physical demands.

II. Data collection to determine root cause of the problem? Removing non-ambulatory or heavy patients from their mode of transportation when arriving at entrance of clinic.Replacing non-ambulatory or heavy patients into their mode of transportation when leaving from entrance of clinic.Protecting the staff from injury when trying to the extracting or replacing non-ambulatory or heavy patients from/to their mode of transportation at the clinic entrance.

III. National Benchmarks or Published ArticleFDA Guide for Lifting Patients Safely. https://www.fda.gov/files/medical%20devices/

published/Patient-Lifts-Safety-Guide.pdf OSHA Lift Safety. American Red Cross. Assisting with positioning and transferring. In: American Red Cross. American Red Cross Nurse Assistant Training Textbook. 3rd ed. American National Red Cross; 2013:chap 12.Smith SF, Duell DJ, Martin BC, Gonzalez L, Aebersold M. Body mechanics and positioning. In: Smith SF, Duell DJ, Martin BC, Gonzalez L, Aebersold M, eds. Clinical Nursing Skills: Basic to Advanced Skills. 9th ed. New York, NY: Pearson; 2017:chap 12.Timby BK. Assisting with basic needs. In: Timby BK, ed. Fundamentals of nursing skills and concepts. 10th ed. Philadelphia, PA: Wolters Kluwer Health: Lippincott Williams & Wilkens; 2013:unit 6.

IV. Summary of FindingsFrom the NCDB graph below of FGH shows that 66% of our patients are older and with age several of our patients need assistance. Most of our radiation therapy patients coming to the clinic are over age of 60. 60-69 is 31%, 70-79 is 25% and 80-89 is 10%.

A log 9/2018 – 12/2018 was kept to determine how many patients required the full support of one or more FGHCC employees to extract to replace them from/into their vehicles.A cursory review of previous treated patients’

charts (2018) were performed to determine how many were non-ambulatory or required assistance going from/to their mode of transportation at the entrance of the clinic.

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Quality Improvements 2019 (continued)

V. Recommendation of Improvement (as appropriate)The lift has successfully been used on six patients since its acquisition. No patient or staff injuries have been reported.

A log is now being kept to determine how often the lift is used. The overall use is expected to be relatively small based on overall patient population. However, the lift was purchased primarily to protect both patient and staff from bodily injury when extracting/inserting them from their mode of transportation.

The findings of the studies and subsequent improvement (Standard 4.8) are documented in the minutes and shared with the medical staff and administration.

The use of the lift is going to be monitored. Hopefully, the utilization will prevent any staff or patient injuries.

VI. Reviewed and Approved at Quarterly Cancer Committee Meeting – Tuesday, September 17, 2019 at 12:30 p.m. Cancer committee minutes in which the results of the studies were reported – see September 17th.The results of this study were reported to the Cancer Committee on September 17, 2019. The Committee reviewed and approved the quality improvement. The QI will be uploaded into the SAR.

I. Define Problem StatementGap in the items listed in the Radiation Therapy End of Treatment Note that is used to code several data fields in METRIQ (Cancer Registry DB).

II. Data collection to determine root cause of the problem? Need improvement of End of Treatment Reports for certain items for patients summaries and for accurate coding of the Radiation Therapy data fields. Radiation Therapy End of treatment Notes should meet criteria of certain data items. Non- compliant case count that does not include radiation treatment items that are needed in the summary report. Radiation Oncologists are not listing all the treatment items needed (ex. Date of brachytherapy, daily dose).

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National Benchmarks or Published ArticleTreatment Summaries in Radiation Oncology and Their Role in Improving Patients Quality of Care: Past, Present and Future. Hayman, MD, James A. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2790684/. Journal of Oncology Practice, 2009 May; 5(3): 108-109. 1. American College of Radiology: ACR Practice Guideline for Communication: Radiation Oncology, 2004. http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines/ro/comm_radiation_oncology.aspx2. Malin JL, Schneider EC, Epstein AM, et al: Results of the National Initiative for Cancer Care Quality: How can we improve the quality of cancer care in the United States? J Clin Oncol 24:626-634, 2006 [PubMed] [Google Scholar]3. American Medical Association: Oncology Physician Performance Measurement Set.

http://www.ama-assn.org/ama1/pub/upload/mm/370/oncology-ms.pdf4. National Quality Forum: National Quality Forum endorses National Consensus Standards promoting accountability and public reporting. http://www.qualityforum.org/news/releases/080508-endorsed-measures.asp5. Physician Quality Reporting Initiative: 2009 PQRI Measures List. http://www.cms.hhs.gov/PQRI/Downloads/2009_PQRI_MeasuresList_030409.pdfCTR Guide to Coding Radiation Therapy Treatment in the Store Manual. Version 1.0 March 15, 2019.

III. Summary of FindingsJanuary 1, 2018 – March 31, 2018 and January 1, 2019 – March 31, 2019 case were compared to find out if all the data items needed for EOT were correctly listed.

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Quality Improvements 2019 (continued)

IV. Recommendation of Improvement (as appropriate)Radiation Oncologists will implement all the required data fields in the EOT treatment note. The EPIC analyst Lisa Lee has built a report with smart text so those patients being treated with the same standard radiation can automatically be put into the report. In the future we will conduct another Quality Improvement to check to see if this issue has resolved with the new the implementation of Smart text in EPIC. Physician education is needed to improve the few treatment items that need to be listed in the summary of treatment report.

V. Reviewed and Approved at Quarterly Cancer Committee Meeting – Tuesday, September 17, 2019 at 12:30 p.m. Cancer committee minutes in which the results of the studies were reported – see

September 17th.

The results of this study were reported to the Cancer Committee on September 17, 2019. The Committee reviewed and approved the quality improvement. The QI will be uploaded into the SAR.

HPV Testing performed on Head and Neck cases

I. Define Problem StatementIn 2017 a Quality improvement was evaluated for the testing of HPV on Oropharyngeal cancer cases. During that evaluation it was found that only 50 percent of the time the HPV testing was being performed on the Head and Neck patients.

II. Data collection to determine root cause of the problem? The Cancer Registry reviewed the data for

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patients who were diagnosed from 9/1/2018 through 8/31/19 to see if the HPV testing was being performed on the Oropharyngeal cases.

III. National Benchmarks or Published ArticleHPV-Associated Oropharyngeal Cancer Rates by Race and Ethnicit: By Viens LJ, Henley SJ, Watson M, Markowitz LE, Thomas CC, Thompson TD, Razzaghi H, Saraiya M, Centers for Disease Control and Prevention (CDC). Human papillomavirus-associated cancers-United States 2002-2012. MMWR 2016;65(26): 661-666

The role of sexual behavior in Head and Neck cancer: implications for prevention and therapy: 1. Eleni Rettig 2. Ana Ponce 3. Carole

Fakhry1. Department of Otolaryngology-Head and

Neck Surgery, Johns Hopkins Medicine, 601 N. Caroline St. Baltimore, MD 21287, USA

2. Department of Radiation Oncology, Johns Hopkins Medicine, 401 N Broadway, Baltimore, MD 21231, SA

3. Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD 21205, USA

IV. Summary of Findings:As identified in the chart below the patients that were diagnosed in the timeframe of 9/1/18 – 8/31/19 all patients were tested for HPV.

V. Recommendation of Improvement (as appropriate)No recommendations needed as goal was met – Measure Closed

VI. Reviewed and Approved at Quarterly Cancer Committee Meeting

CEA done within 4 months of curative resection of colorectal cancer

VII. Define Problem Statement

In 2012 a Quality Improvement study was done on CEA checked within 4 months of curative resection of colorectal cancer. In that study 96 cases were checked and found that only 72% of patients had their CEA checked within that 4 month period.

In 2019 a comparative study was done to see if we have improved in checking the CEA within 4 months of curative resection.

VIII. Data collection to determine root cause of the problem?

The Cancer Registrar reviews data for patients who had curative resection of colon cancer during the time frame of September 1, 2018 to August 31, 2019 to identify patients who did or did not receive a CEA test within 4 months of resection. Cases included Stage I – III (analytic).

IX. National Benchmarks or Published ArticleAdvances in Biomarkers: Going Beyond the Carcinoembryonic Antigen.1. Nicole E. Lopez, MD 2. Carrie Y.

Peterson, MD1. Division of Surgical Oncology,

University of North Carolina, Chapel Hill, North Carolina.

2. Division of Colorectal Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin. Address for correspondence Carrie Y. Patterson, MD Medical College of Wisconsin, 9200 West Wisconsin Avenue, Division of Colorectal Surgery, Milwaukee, WI 53226, cy.peterson@mcw.edu

The role of tissue and serum carcinoembryonic

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Quality Improvements 2019 (continued)

antigen in stages I to III of colorectal cancer-A retrospective cohort study.

1. Guojun Tong, Jian Liu, Zhaozheng Zheng, and Yan Chen 2. Wei Xu, Pingping Nie, and Xuting Xu 3. Guiyang Zhang 1. Department of Colorectal Surgery,

Huzhou Central Hospital, Zhejiang, China,

2. Central Laboratory, Huzhou Central Hospital, Zhejiang, China,

3. Pathological Department, Huzhou Central Hospital, Zhejiang, China,Guojun Tong, Email: tgj97114@sina.com.

X. Summary of Findings:As identified in the chart below the patients meeting criteria to receive CEA test was 99. Of these patients 50 did not receive a test.

V. Recommendation of Improvement (as appropriate)Recommend speaking with Physicians regarding the importance of having test for CEA within 4 months of curative resection. Revisit this measure again in the future.

VI. Reviewed and Approved at Quarterly Cancer Committee Meeting

By: Dr. Joseph Salloum and Jena Hopkins.

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FGH IRB Study 2018

Breast Cancer Timeliness to Treatmentand Financial ImpactN: 27

Breast CancerTimeliness Diagnosis to Treatment

and Financial ImpactPatient Satisfaction Survey

N: 27

Timeliness of Care

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FGH IRB Study 2018 (continued)

Financial Impact

Financial Impact: After Treatment

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Follow-up Visits

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FGH IRB Study 2017 ACS Commission on Cancer CP3R Measures

FGH Cancer RegistryCP3R Study Reviews

GastricAt least 15 regional lymph nodes are removed and pathologically examined for resected gastric cancer (Quality Improvement) 1-1-14 to 11-30-16. Coc Std/% = 4.5/80%

ColonAt least 12 regional lymph nodes are removed and pathologically examined for resected colon cancer (Quality Improvement) 1-1-14 to 11-30-16. CoC Std/% = 4.5/85%

RectumPreoperative chemo and radiation are administered for clinical AJCC T3N0, T4N0, or Stage III; or Postoperative chemo and radiation are administered within 180 days of diagnosis for clinical AJCC T1-T2N0 with pathologic AJCC T3, T4N0, or Stage III; or treatment is recommended; for patients under the age of 80 receiving resection for rectal cancer (Quality Improvement) 1-1-12 to 11-30-16. CoC Std/% = 4.5/85%

LungAt least 10 regional lymph nodes are removed and pathologically examined for AJCC stage IA, IB, IIA, and IIB resected NSCLC (Surveillance) 1-1-16 to 11-30-16. CoC Std/% = 4.5/85%

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LungSurgery is not the first course of treatment for cN2, M0 lung cases (Quality Improvement) 1-1-14 to 11-30-16. CoC Std/% = 4.5/85%

BladderAt least 2 lymph nodes are removed in patients under 80 undergoing partial or radical cystectomy (Surveillance) 1-1-2010 to 11-30-16. CoC Std/% not applicable

CervixRadiatiaon Therapy completed within 60 days of initiation of radiation among women diagnosed with any stage of cervical cancer (Surveillance) 1-1-14 to 11-30-16. CoC Std/% not applicable

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FGH IRB Study 2017 (continued)

Action Plan and Summary

Forrest General Hospital is increasing with the non-compliant cases instead of increasing with the compliant cases with the gastric cases.

Forrest General Hospital is increasing with the compliant cases for colon lymph nodes but still short of the 85% for compliance with the Standard 4.5.

Forrest General Hospital is not compliant with the rectal measure for neoadjuvant treatment. The clinical AJCC T3, T4 N0, or Stage III should get neoadjuvant treatment as ours were administered with postoperative treatment. We did not meet Standard 4.5 for this measure.

Forrest General Hospital lung resected cases are not compliant with the number of regional lymph nodes

removed (10 lymph nodes).

Forrest General Hospital met the lung cases that should not have surgery for first course treatment for cN2, M0. Standard 4.5.

Forrest General Hospital cervix cases that receive radiation therapy within 60 days of initiation of radiation are compliant with the quality standard.

The CP3R 2011 -2014 had this measure at zero but bladder cases are have increased the percentage of cases whom have at least 2 lymph nodes removed in patients under 80 undergoing partial or radical cystectomy to 50%.

By: Daphne Nix

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Forrest General Hospital Cancer ProgramPerformance Improvement Year 2017 Data ReviewStudy Topic: Adherence to National Comprehensive Cancer Network (NCCN) Guidelines for Colon Cancer

Objective: To ensure patient treatment plans meet NCCN Guidelines.

Measurement: Random sample of 30% analytic colon cancer cases (June 1, 2016 – March 31, 2017).

Method: Retrospective chart review. A total of 20 cases were reviewed.

Results:

Conclusions: CBC/Platelets, Chest X-ray, DRE, Clinical Stage, Right vs Left Colon Cancer are 100%. CEA is 50%. CT Abdomen and Colonoscopy is 80%.

Recommendations/Actions: The majority of checklist items meet the guidelines for colon.

Performance Improvement Year 2016 Data Review

Study Topic: Adherence to National Comprehensive Cancer Network (NCCN) Guidelines for Prostate Cancer

Objective: To ensure patient treatment plans meet NCCN Guidelines.

Measurement: Random sample of 30% of the analytic Prostate cancer cases (April 1, 2015 – March 31, 2016).

Method: Retrospective chart review. A total of 85 cases were reviewed.

Results:

**Mandatory only for Gleason score greater than or equal to 8 or PSA greater than 20 or Tumor Greater than or equal to T3, or N1, or M1. Conclusions: The DRE, PSA, Gleason Score – Primary Pattern & Secondary Pattern are 100%. US is 56%. The Bone scan is actually 100% since mandatory see note above. CT Pelvis is 74% and MRI is actually 100% since mandatory see above.

Recommendations/Actions: The US is low at 56%. Most patients have a CT ABD/PEL.

Performance Improvement Year 2015 Data Review

Study Topic: Adherence to National Comprehensive Cancer Network (NCCN) Guidelines for Lung Cancer

Objective: To ensure patient treatment plans meet NCCN Guidelines.

Measurement: Random sample of 30% of analytic Lung cancer cases (Oct-Dec 2014).

Method: Retrospective chart review. A total of 11 cases were reviewed.

Results:

Conclusions: Retrospective chart review revealed the following:Pathology, H&P (Performance Status, Weight Loss), CBC, Platelets, Calcium, LFT, Smoking Cessation, MRI Head are 100%. The Chest X-ray, CT Chest & upper Abdomen including adrenals are 91%. PET Scan imaging is at 82%.

Recommendations/Actions: The majority of checklist items meet the guidelines needed for lung. The PET scan may increase with the next retrospective group reviewed.

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American Cancer Society