DeCesaris - Anne Arundel Medical CenterThe DeCesaris Cancer Institute Cancer Registry systematically tracks the diagnosis, treatment and lifetime follow-up of our cancer patients

DeCesaris Cancer Institute

2017ANNUAL REPORT

THE SCIENCE TO HEAL. THE SPIRIT TO CARE.Using 2016 Cancer Registry Data.

GREETINGS

ANNE ARUNDEL MEDICAL CENTER RETURN TO TABLE OF CONTENTS2

A Message from the Chairs 1

Patient Support Services 2

Cancer Registry 4

Cancer Registrars 5

Cancer Conference Activity 6

Measuring Performance 7

u Cancer Registry Data 7

u Commission on Cancer’s Rapid Quality Reporting System (RQRS) 8

u Summary by Body System, Sex, Class, Status and Best AJCC Stage Report 9

u Cancer by Diagnosis 10

u Cancer by Race 11

Clinical Research Internship 14

AAMC Research Institute 15

Abstracts 17

Survivor Stories 23

Lung Screening 25

Benign Breast Disease 27

HPV Task Force 29

Tobacco Control 30

Community Spotlight 31

Nicotine replacement 32

Committee members 33

TABLE OF CONTENTS


GREETINGS

Geaton and JoAnn DeCesaris Cancer Institute

Focusing on a Patient’s Unique Health Care Needs

The Geaton and JoAnn DeCesaris Cancer Institute at Anne Arundel Medical

Center (DCI) is a comprehensive community cancer program delivering high

quality, low cost cancer care. In 2016, there were 1,851 analytic cases evaluated

at our center, representing a high level of trust within the community.

Our physicians, nurses, and staff remain at the forefront of the latest advancements in cancer prevention, screening, diagnosis, treatment and supportive care. Functioning in multidisciplinary teams these providers ensure that each patient is receiving scientifically- based and compassionate care to achieve the best possible outcomes.

The delivery of cancer care has experienced significant changes and challenges, particularly in community-based hospital settings. Among the trends affecting cancer care delivery are:

• The aging population

• Increased obesity rates and other lifestyle choices

• The ascendance of patient preference

• The increasing age and accompanying illnesses of thetypical cancer patient

• The introduction of therapies with novel mechanisms atvery high costs

• Value-based payment reform

We have established several programs and processes to achieve high quality low cost outcomes and remain committed to studying their effectiveness. We are not just focused on the treatment period but also cancer prevention, early detection through screening and reducing the impact of cancer on patients and families. As a result we had several 2017 cancer quality initiatives directed toward those goals including: increasing colon cancer screening in diverse populations, educating providers and the public on appropriate vaccinations for human papilloma virus (HPV), increasing palliative care use amongst oncology patients, decreasing emergency room and unplanned admissions and reducing financial burden for cancer patients.

Our supportive care services include social work: nutrition, oncology rehabilitation, financial and genetics counseling, nurse navigation, patient and family advocates, and survivorship programs are aligned to reduce the burden of cancer on patients and families. Further investments in resources to advance our programs and services have been made such as an oncology nurse symptom management and triage phone line, assessment of high risk and early intervention nurse navigation process and increased access to financial navigation and social work to address social determinants and improved access to our palliative care program.

Together our continued investment in the delivery of high quality of cancer care is translating to improved outcomes.

It is an honor to receive ongoing support from our community. The providers and staff of the DeCesaris Cancer Institute extend their appreciation.

CATHERINE COPERTINO,

BSN, MS, OCN

Vice President,

Cancer Services & Palliative Care


BARRY MEISENBERG, MD

Medical Director,



PATIENT SUPPORT SERVICES


At the DeCesaris Cancer Institute (DCI), we believe that every aspect of treatment is connected. For this reason, we make sure that our patients and their loved ones receive comprehensive, multi-specialty care that addresses their needs during each step in the healing journey. From the most advanced care and clinical trials to financial counseling, our patients have access to a robust array of physical, psychosocial, emotional and spiritual resources at DCI.

Nutrition Counseling

Nutritional support is a key component of cancer treatment at DCI. Our dietitians and nutritionists help make sure patients stay strong and nourished before, during and after cancer treatment. By educating patients about dietary requirements, meal plan design, alternative food choices and supplements, they also help patients cope with the emotional and physical stresses of cancer.

Support Groups

Support groups provide a time and space for patients and family members to discuss feelings, concerns and attitudes in a caring atmosphere. At DCI we have a variety of professionally facilitated, educational support programs for oncology patients, survivors and their loved ones. There are support groups focused on head and neck cancer, lung cancer, prostate cancer and breast cancer.

Survivorship Services

When patients at DCI are at the end of their treatment or in maintenance therapy, our oncology care team provides a formal survivorship visit. A designated health professional meets with the survivor at his/her routine follow-up visit to provide the survivor with an individualized Treatment Summary/Survivorship Care Plan (TS/SCP). In this integrative model, survivors continue to see their primary oncology provider and primary care provider for long-term follow-up, as well as survivorship care.

Left to right – Cancer Survivor, Molly Rusch, RD, LDN, Monique Willingham, NP.



Nurse Navigator Services

Our nurse navigators exist to provide guidance, support and direction. They serve patients and their families by streamlining care and providing a comforting, consistent presence during a stressful time. We think of them as advocates, helping patients access multidisciplinary treatment, communicate with their primary care doctors and specialists, and translate or interpret complex care plans. Patients can choose a navigator in various specialty areas including breast, prostate, genitourinary, thoracic and gastrointestinal cancers, among others.

Palliative Care

Palliative care focuses on relieving suffering and improving quality of life for patients and their families while they are getting treatment for an illness. At DCI, we aim to provide comfort while accounting for a patient and family wishes, ideals, beliefs and culture. Our palliative care team of physicians, nurse practitioners, social workers and chaplains help control difficult symptoms, negotiate realistic goals for care, estimate and communicate prognosis, facilitate challenging family meetings, coordinate treatment teams, and manage end-of-life situations.

Social Services

How patients cope with their cancer diagnosis and treatment affects their progress and overall physical health. Our oncology social workers provide supportive counseling and other services to help meet patients’ psychosocial needs in both inpatient and outpatient settings. They provide practical problem- solving, financial assistance information, referrals to community resources and professional guidance to support patients with the challenges that come with a cancer diagnosis. These services are an integral part of medical treatment here at DeCesaris Cancer Institute and are offered at no additional cost to the patient.

Spiritual Care

Responding to the spiritual needs of patients and families is a priority for us. When patients are apprehensive about surgery, overwhelmed by illness or grieving, our team fosters a compassionate presence, providing spiritual and emotional support and encouraging hope. They serve as resources during times surrounding the death of a loved one, and at the point of decision-making regarding end-of-life care.

Genetic Counseling

Awareness of risk factors can empower patients and inspire preventive behaviors. For people with a personal or family history of cancer, our genetic counselors are here to discuss factors in their history that could indicate a genetic predisposition to cancer. Our genetic counselors also provide education and support. Counselors are available to facilitate genetic testing, interpret the results, and discuss the impact of genetic testing on a patient’s screening or medical management for cancer.

Oncology Rehabilitation Services

Starting with pre-habilitation, our oncology rehabilitation program includes a comprehensive team of physical therapists, occupational therapists, speech language pathologists, nurses, nutritionists and social workers, all who focus on improving the quality of life for cancer survivors.

Financial Counseling

Finances are often a major concern during an illness. Our team of financial counselors work to ease that burden by helping patients navigate payment options and understand medical bills and eligibility for financial assistance. Oncology social workers also direct patients to additional financial services that meet their individual needs.

Margo Faust Gallegos, MS, CGC and genetic counseling patient.


CANCER REGISTRY

CANCER REGISTRY

The DeCesaris Cancer Institute Cancer Registry systematically tracks the diagnosis, treatment and lifetime follow-up of our cancer patients. Researchers, physicians and health care providers use our data to improve the outcome of cancer treatment.

The Commission on Cancer (CoC) requires that cancer programs maintain an 80 percent tracking rate of all eligible cancer patients starting from the reference year (2000). The CoC also requires a 90 percent followup rate on all patients diagnosed with cancer within the last five years. The DeCesaris Cancer Institute continues to exceed these benchmarks.

FOLLOW-UP OF PATIENTS SINCE 2000 (19,408) FOLLOW-UP OF PATIENTS DIAGNOSED IN THE LAST 5 YEARS (7,631)

84.33%CURRENT RATE

[REQUIRED RATE 80%]

91.42%CURRENT RATE

[REQUIRED RATE 90%]


CANCER REGISTRARS

CANCER REGISTRARS

The DeCesaris Cancer Institute Cancer Registry monitors cancer trends over time and shows cancer patterns in different populations thus detecting high-risk groups. The registry systematically tracks the diagnosis, staging, treatment and lifetime follow-up of our cancer patients. Researchers, physicians and health care providers use our data to calculate cancer incidence, evaluate efficacy of treatment modalities, determine survival rates, conduct research on treatments, and develop targeted educational and screening programs. All our cancer registrars are certified and are part of the National Cancer Registrars Association.

The Commission on Cancer (CoC) requires that cancer programs maintain an 80 percent tracking rate of all eligible cancer patients starting from the reference year (2000). The CoC also requires a 90 percent follow-up rate on all patients

diagnosed with cancer within the last five years. The DeCesaris Cancer Institute continues to exceed those benchmarks with performance of 84 percent and 91 percent, respectively for reference and follow-up. In 2016, our registrars analyzed 1,851 cases of cancer.

To accomplish this high accuracy rate, our abstractors prepare abstracts for each cancer patient with demographic information and cancer type, accurately record staging, along with treatment, follow-up, and survivorship details. In the process they review facility records, diagnostic radiology, pathology, immunotherapy, hormone, and medical and radiation records. Through many resources they follow patients from diagnosis to survivorship and death. Once a year, the hospital registry sends this information to the Maryland Cancer Registry, the central cancer registry for the state.

Left to right – Glen Gibson, MD Surgical Oncologist and Naeem Newman, MD Surgical Oncologist.


MONITORING CANCER CONFERENCE ACTIVITY

ANNE ARUNDEL MEDICAL CENTER6

ALL TUMOR BOARDS FOR JAN-DEC 2017

CONFERENCE

TOTAL TUMOR BOARD CONF.

MED ONC.

RAD ONC.

SURGEON PATHOLOGIST RADIOLOGISTCASES

PRESENTEDPROSPECTIVE

CASES

BRAIN/CNS 51 44 51 47Not

Required39 390 347

GU-ONCOLOGY 11 10 11 11Not

RequiredNot

Required69 61

GYNONCOLOGY 10 10 10 10 10 10 89 78

THORACIC 51 51 51 50 51 47 420 270

BREAST 48 47 48 48 48 48 151 150

GENERAL 38 38 38 38 37 33 282 253

HEMATOLOGY 12 12 Not Required

Not Required

Not Required

Not Required 52 17

AVERAGE % ATTENDANCE

96% 100% 98% 99% 89%

TOTAL 221 1,453 cases 1,176 cases

FOR ALL CASES REVIEWED: 1. Photographs, 2. NCCN Compliance, 3. Detection & Treatment, 4. Clinical Trials Case discussion includes AJCC staging, consideration for need of genetic testing and counseling, palliative, psychosocial, nutrition and rehab services and plastic surgery. Individual tumor board activity reports are available upon request. *Radiologist is now a required specialty for GYN Conference — implemented May 2015 per Cancer Committee

Comprehensive Cancer team participating in tumor board.


MEASURING PERFORMANCE

PRESENTING 2016 CANCER REGISTRY DATA

The DeCesaris Cancer Institute participates in the CoC’s Rapid Quality Reporting System (RQRS).

This reporting and quality improvement tool provides real, clinical-time assessment

of hospital-level adherence to National Quality Forum-endorsed quality of cancer care measures for breast and colon cancers.

The five rating dials display the year-to-date facility performance rate achieved in 2016. There is one rating dial for each of the measures we monitor and report through RQRS.

READING THE DIALS

The year-to-date (YTD) performance rate is based on the total number of cases for which chemotherapy was given, or was expected to be given, within the past year (365 days). For this measure, this includes all cases of patients diagnosed within the past 24 months.

Gray needle points to the current YTD performance rate.

Shaded areas represent the range of performance rates for other participating programs:

GREEN: Top quartile, 75th–100th percentile

YELLOW: 50th–75th percentile

RED: 25th–50th percentile

1

2

3

1020

3040 50 60

70

8090

85.0% n = 561

23

BREAST MEASURES COLON MEASURES*

BCSRT — Radiation therapy is administered within one year (365 days) of diagnosis for women under age 70 receiving breast-conserving surgery for breast cancer.

12RLN — At least 12 regional lymph nodes are removed and pathologically examined for resected colon cancer.

MASTRT — Radiation therapy is recommended or administered following any mastectomy within one year (365 days) of diagnosis of breast cancer for women with >=4 positive regional lymph nodes

HT — Tamoxifen or third-generation aromatase inhibitor is considered or administered within one year (365 days) of diagnosis for women with AJCC T1cN0M0 or stage II or III hormone receptor-positive breast cancer.

ACT — Adjuvant chemotherapy is considered or administered within four months (120 days) of diagnosis for patients under age 80 with AJCC stage III (lymph node positive) colon cancer.

*The colon cancer measure for the number of nodes removed and pathologically examined reflects the proportion of patients who were diagnosed within the last 365 days and for whom 12 or more regional lymph nodes were examined. The rates shown in these dials indicate the proportion of patients for whom adjuvant chemotherapy was expected to be started within the last 365 days.

92.8% n = 236 92.8% n = 236

92.8% n = 236 92.8% n = 236 92.8% n = 236

1020

3040 50 60

70

8090

94.3% n = 173

MAC — Combination chemotherapy is considered or administered within four months (120 days) of diagnosis for women under age 70 with AJCC T1cN0M0 or stage II or III hormone receptor-negative breast cancer.

1020

3040 50 60

70

8090

96.7% n = 21094.3% n = 173

1020

3040 50 60

70

8090

100.0% n = 8

70

1020

3040 50 60

70

8090

100.0% n = 14

1020

3040 50 60

70

8090

100.0% n = 1

1020

3040 50 60

70

8090

80.0% n = 5



MEASURING PERFORMANCE: COMMISSION ON CANCER’S RAPID QUALITY REPORTING SYSTEM (RQRS)

At the DeCesaris Cancer Institute, our goal is to meet and exceed national averages. These graphs reflect our ongoing commitment to continually improve the delivery of quality cancer care.

COLON 12RLN

12RLN-The colon cancer measure for the number of nodes removed and pathologically exam-ined reflects the proportion of patients who were diagnosed within the last 365 days and for whom 12 or more regional lymph nodes were examined. Performance rate> = 80%

BREAST MAC

MAC-combination chemotherapy is considered or administered within four months (120 days) of diagnosis for women under age 70 with AJCC T1cN0M0, or stage II or III hormone recep-tor-negative breast cancer. Performance Rate> = 90%

BREAST BCS

BCS-radiation therapy is administered within one year (365 days) of diagnosis for women under age 70 receiving breast-conserving surgery for breast cancer. Performance Rate> = 90%

BCSRT AAMC BCSRT Maryland State

100%

80%

60%

40%

20%

0%2014 2015 2016

BREAST HT

HT-tamoxifen or third-generation aromatase inhibitor is considered or administered within one year (365 days) of diagnosis for women with AJCC T1c N0 M0, or stage II or III hormone receptor-positive breast cancer

HT AAMC HT Maryland State

100%

80%

60%

40%

20%

0%2014 2015 2016

MAC AAMC MAC Maryland State

100%

80%

60%

40%

20%

0%2014 2015 2016

MASTRT AAMC MASTRT Maryland State

100%

80%

60%

40%

20%

0%2014 2015 2016

12RLN AAMC 12RLN Maryland State

100%

80%

60%

40%

20%

0%2014 2015 2016

COLON ACT

ACT-adjuvant chemotherapy is considered or administered within four months (120 days) of diagnosis for patients under age 80 with AJCC stage III (lymph node positive) colon cancer. Performance Rate > = 90%

ACT AAMC ACT Maryland State

100%

80%

60%

40%

20%

0%2014 2015 2016

MASTRT

Radiation therapy is recommended or administered following any mastectomy within 1 year (365) days of diagnosis of breast cancer for women with >=4 positive regional lymph nodes



SUMMARY BY BODY SYSTEM, SEX, CLASS, STATUS AND BEST AJCC STAGE REPORT

SEX CLASS OF CASE STATUS STAGE DISTRIBUTION — ANALYTIC CASES ONLY

Primary Site Total (%) M F Analy NA Alive Exp Stg 0 Stg I Stg II Stg IIIStg IV

88 Unk

Oral Cavity & Pharynx 37 (2.0%) 22 15 37 0 32 5 1 3 5 7 17 0 4

Digestive System 273 (14.7%) 154 119 273 0 176 97 0 48 58 58 78 8 23

Respiratory System 257 (13.9%) 125 132 257 0 145 112 2 78 28 36 110 0 3

Skin Excluding Basal & Squamous

60 (3.2%) 34 26 60 0 59 1 12 25 7 8 4 1 3

Breast 534 (28.8%) 1 533 534 0 511 23 81 253 136 41 19 1 3

Female Genital System 102 (5.5%) 0 102 102 0 82 20 0 45 12 11 19 0 15

Male Genital System 170 (9.2%) 170 0 170 0 164 6 0 21 108 17 16 0 8

Urinary System 93 (5.0%) 66 27 93 0 72 21 11 35 11 17 9 0 10

Brain & Other Nervous System

54 (2.9%) 20 34 54 0 39 15 0 0 0 0 0 54 0

Endocrine System 42 (2.3%) 16 26 42 0 41 1 0 12 5 6 5 11 3

Lymphoma 73 (3.9%) 46 27 73 0 66 7 0 29 13 8 22 0 1

Myeloma 42 (2.3%) 24 18 42 0 33 9 0 0 0 0 0 42 0

Leukemia 37 (2.0%) 25 12 37 0 28 9 0 0 0 0 0 37 0

Mesothelioma 5 (0.3%) 4 1 5 0 4 1 0 0 1 0 3 1 0

Miscellaneous 72 (3.9%) 42 30 72 0 36 36 0 2 0 0 1 69 0

TOTAL 1,851 749 1,102 1,851 0 1,488 363 107 551 384 209 303 224 73



CANCERS BY DIAGNOSIS

0 100 200 300 400 500 600

UNKNOWN

STAGE IV

STAGE III

STAGE II

STAGE I

STAGE 0

0 100 200 300 400 500 600

90+

80 - 89

70 - 79

60 - 69

50 - 59

40 - 49

30 - 39

0 - 29

N/A

BREAST28.2%

FEMALE GENITAL SYSTEM

5.5%MALE GENITAL SYSTEM

9.2%URINARY SYSTEM5.0%

BRAIN & OTHER NERVOUS SYSTEM2.9%ENDOCRINE SYSTEM2.3%

LYMPHOMA3.9% MYELOMA2.3%

RESPIRATORY SYSTEM13.9%

LEUKEMIA2.0%

MESOTHELIOMA 0.3%

ORAL CAVITY & PHARYNX

2.0%MISCELLANEOUS3.6%

SKIN3.2%

DIGESTIVE SYSTEM14.7%

AGE AT DIAGNOSIS (IN YEARS) – 2016 AJCC STAGE GROUP AT DIAGNOSIS – 2016

1,851 cases in 2016



CANCERS BY RACE

HEMATOPOIETIC & RETICULOENDO

SYSTEM

BREAST

PROSTATE GLAND

AFRICANAMERICAN

13.6% 8.4%

44%

12.8%

13.2%

8%

BRONCHUS & LUNG

COLON

OTHER

CAUCASIAN


SYSTEM

BREAST

COLON

19.1% 7%

36.2%

PROSTATE GLAND10.5%

7.2%

BRONCHUS & LUNG

20.1%OTHER

COLON

OTHER


SYSTEM

BREAST

9.4%

9.4%

56.3%

PROSTATE GLAND

9.4%

3.1%BRONCHUS & LUNG

COLON

12.5%OTHER



“ Some assume that working in the Infusion Center and caring for cancer patients would be sad. This could not be further from the truth. Our unit environment is positive and upbeat. The staff feel privileged to be working with these individuals and this pride is evident in the care we provide day to day and the outcomes achieved.” —CAROL BRUMSTED



Dr. Brian Hasson, Chief Medical Physicist and Senior Dosimetrist Ahssan Balawi work to develop the optimal Stereotactic Radiosurgery plan for a patients upcoming treatment. The multi-departmental program has been recognized internationally for their collaborative work in radiosurgery treatments.


CLINICAL RESEARCH INTERNSHIP

MEASURING QUALITY THROUGH SCIENTIFIC INQUIRY

Positive ultrasound-guided lymph node needle biopsy in breast cancer may not mandate axillary lymph node dissection.

Harris CK, Tran HT, Lee K, Mylander C, Pack D, Rosman M, Tafra L, Umbricht CB, Andrade R, Liang W, Jackson RS.

Prospective study comparing surgeons’ pain and fatigue associated with nipple-sparing vs. skin-sparing mastectomy.

Rubie Sue Jackson, Sanders T, Park A, Buras R, Liang W, Harris C, Mylander C, Rosman M, Holton L, Singh D, Martino L, Tafra L.

Routine axillary ultrasound for patients with T1-2 breast cancer does not increase the rate of axillary lymph node dissection based on predictive modeling.

Wellington J, Sanders T, Mylander C, Alden A, Harris C, Buras R, Tafra L, Liang W, Stelle L, Rosman M, Jackson RS. Combined pathologic-genomic algorithm for early stage breast cancer improves cost-effective use of the 21-gene recurrence score assay.

Gage MM, Mylander WC, Rosman M, Fujii T, Le Du F, Raghavendra A, Sinha AK, Fernandez JRE, James A, Ueno NT, Tafra L, Jackson RS

Can a management model incorporating axillary ultrasound be used to decrease the number of axillary lymph node dissections in patients with T1-2 breast cancer?

Ashley Alden, Tom Sanders, Christine Harris, Martin Rosman, Lorraine Tafra, Wen Liang, Robert Buras, Rubie Sue Jackson

Case Series: Retrospective Review of Safety, Tolerance, and Efficacy of Multiple Courses of Lung Stereotactic Body Radiation Therapy (SBRT) in the Same Patient

John Kessler II,1 Zachary Smith,2 Ryan Bathras,3 Cody Tidwell,4 Dr. Charles Mylander, Ph.D.5 Dr. Luqman Dad, M.D.6

Four Year Report on Clinical Outcomes of Stereotactic Body Radiation Therapy (SBRT) for Definitive Treatment of Medically Inoperable Early-Stage Non-Small Cell Lung Cancer (NSCLC) at Anne Arundel Medical Center

John Kessler II,1 Zachary Smith,2 Ryan Bathras,3 Cody Tidwell,4 Charles Mylander, Ph.D.5, Luqman Dad, M.D.6

Assessment of Opioid Utilization and Prescribing Practices Following Lobectomy

Sarah Jahnige; Avedis Meneshian MD; Stephen Cattaneo MD; Laura Korpon PA; Barry Meisenberg MD

Outpatient Palliative Care (OPC) Usage among Oncology Patients

Akhil Uppalapati, Barry Meisenberg, Patrice Richardson, Jane Rhule, Theresa McKay, Geri Raber

Left to right – John Moxley, MS, MHA, CCRP,

Clinical Research Student Interns, Barry

Meisenberg, MD, Medical Director DeCesaris

Cancer Institute.


AAMC RESEARCH INSTITUTE

7.0%

76.13%

8.64%

4.12%

11.11%

23.05%

Treatment Biomarker Screening Registry

Surgical Quality of Life

ONCOLOGY ENROLLMENT BY STUDY TYPE – 2016

0

100

200

300

400

500

2014 2015 2016

Treatment Biomarker Screening Registry

Surgical Quality of Life TOTAL

2012 2013

ONCOLOGY ENROLLMENT BY STUDY TYPE – 2016


AAMC’s Research Institute brings together a team of professional research nurses, research coordinators, data managers and physicians.

All research efforts carefully safeguard the rights and safety of clinical trial patients, ensuring regulatory compliance and promoting excellence in clinical practices. Our dedication to research excellence ensures we are contributing to generalizable knowledge.

Our goals for the research program are:

f To maintain a comprehensive menu of clinical trials so that many patients have the opportunity to participate in research studies.

f To maintain a sensitive and compassionate approach that meets all regulatory standards for discussing clinical trial options with patients.

f To search out and develop basic science liaisons and relationships to improve translational research in cancer.

f To provide opportunities to our faculty and staff for research project development, funding and support of clinical trials.

Clinical Trials

AAMC evaluates cancer patients for clinical trial eligibility at the time of diagnosis and following surgery. Patients are also evaluated at each of their initial appointments in the specialty practices (medical and radiation oncology). Potential clinical trials for patients are also discussed at monthly tumor board meetings. At each step of the patient’s journey, we want to make the most appropriate and thoughtful treatment options available to him or her, including participation in suitable clinical trials. When a patient expresses interest in participating in a clinical trial, our research staff guides him or her through each step of the process.

A list of active clinical trials supported by AAMC Research Institute can be found at: https://www.aahs.org/Research-Institute

Over the years, the number and type of trials that a patient can participate in has grown. We have access to research studies in which patients can donate their blood or biopsy tissue for tumor biology research studies to learn more about

1,851 CASES IN 2016

243 ENROLLED IN STUDIES

& TRIALS = 13%

https://www.aahs.org/Research-Institute

https://www.aahs.org/Research-Institute



how cancer develops and grows. We also participate in clinical trials that evaluate how well a new medical device or a new drug treatment works.

AAMC has exceeded the CoC standard of four percent accrual to cancer related clinical research studies. Of approximately 1,851 cancer cases in 2016, 243 (13 percent) were enrolled in cancer related research studies and clinical trials. The breakdown of patient enrollments by study type is shown in the figure above.

Clinical Breast Care Project

Since 2006, more than 2,500 breast cancer patients at AAMC have donated more than 20,000 blood and tissue samples for research. This work is part of the Clinical Breast Care Project in which AAMC partners with the Walter Reed National Military Medical Center and Windber Research Institute.

Network of Collaboration

AAMC has helped connect patients with cutting-edge treatment options through our collaborations with the National Cancer Institute (NCI), pharmaceutical companies, and the Johns Hopkins Clinical Research Network (JHCRN). JHCRN gives AAMC patients expanded access to clinical trials by facilitating a partnership between physicians at AAMC and Johns Hopkins to open clinical trials. Patients can receive the same treatment and trial options they would receive in a university setting right here in their community.

Clinical Research Internship

The Research Institute offers a Clinical Research Internship that pairs bright, motivated college students with a physician mentor to complete a clinical research or quality improvement project. These projects have led to a number of publications in scientific journals and have provided valuable data used to improve the quality of care for AAMC patients.

Tessa White, Pharmacy Technician.


ABSTRACT

ABSTRACT

CAN A MANAGEMENT MODEL INCORPORATING AXILLARY ULTRASOUND BE USED TO DECREASE THE NUMBER OF AXILLARY LYMPH NODE DISSECTIONS IN PATIENTS WITH T1-2 BREAST CANCER?

Ashley Alden, Tom Sanders, Christine Harris, Martin Rosman, Lorraine Tafra, Wen Liang, Robert Buras, Rubie Sue Jackson

BACKGROUND Minimizing axillary lymph node dissections (ALND) for breast cancer (BC) is of interest due to the rate of surgical comorbidities. We previously found in patients with 1 abnormal LN on axillary ultrasound (axUS), and axUS-biopsy proven metastasis, 50% have only N1 disease and probably do not need an ALND. We adopted an institutional consensus that luminal A/B BC meeting these criteria will undergo sentinel lymph node biopsy (SNBx); patients with US-detected nodal metastasis outside of these criteria will undergo neoadjuvant chemotherapy.

OBJECTIVE To test if routine use of axUS for newly diagnosed, cT1-2N0 BC, along with our institutional policy for management of axUS-detected metastasis, can decrease ALNDs compared to a policy of no axUS.

METHODS Two models were constructed: one for expected outcomes using axUS and one without. The endpoint was the proportion of patients undergoing ALND. Proportions were assigned to branch points based on retrospective review of an institutional database containing newly diagnosed BCs who underwent axUS and a PubMed literature review. The probability of receiving an ALND was calculated and compared between the axUS and no axUS models.

RESULTS Using our model, we predicted 11% of T1-2cN0 BC would receive an ALND using routine axUS and the AAMC consensus statement (Figure 1), compared to 6% without axUS. At our institution, for every 100 T1-2 BC, 9 unnecessary negative LN biopsies would be performed, and 8 positive LN biopsies would be performed without resulting in decreased ALND rates.

DISCUSSION We were unable to demonstrate that a model incorporating routine axUS could decrease ALND rates. This calls into question the practice of routine biopsy of suspicious lymph node(s) on axUS. We suggest continued routine axUS, but limiting LN needle biopsy to cases with suspected benefit based on surgeon discretion. Continued research may identify a subset of patients that could benefit from LN needle biopsy.

The DeCesaris Cancer Institute’s Clinical Research Internship pairs bright, motivated students with a physician/provider/administrative mentor to complete a clinical research or quality improvement project. These projects have led to a number of publications in scientific journals and have provided valuable data used to improve the quality of care for AAMC patients.

Left to right - Kimberly Stewart, RN, BSN, CBCN, Nurse Navigator at the Rebecca Fortney Breast Center and breast cancer survivor.


ABSTRACT

ABSTRACT

FOUR YEAR REPORT ON CLINICAL OUTCOMES OF STEREOTACTIC BODY RADIATION THERAPY (SBRT) FOR DEFINITIVE TREATMENT OF MEDICALLY INOPERABLE EARLY-STAGE NON-SMALL CELL LUNG CANCER (NSCLC) AT ANNE ARUNDEL MEDICAL CENTER

John Kessler II,1 Zachary Smith,2 Ryan Bathras,3 Cody Tidwell,4 Charles Mylander, Ph.D.5, Luqman Dad, M.D.6

BACKGROUND SBRT has achieved tumor control and overall survival that is comparable to surgery and higher than 3D-CRT in non-random studies in medically inoperable patients. SBRT is a novel method of delivering highly conformal and precise radiation therapy to patients with early-stage NSCLC, who are not candidates for surgical treatment. SBRT and sub-lobar surgery achieve comparable survival and tumor control, and is the subject of the current randomized intergroup study of the Joint Lung Cancer Trialist’s Coalition (JoLT-Ca Stable-Mates Trial). In 2012, AAMC launched the SBRT Program.

PURPOSE This retrospective report offers evidence on the relative safety and efficacy of SBRT in patients with medically inoperable early-stage NSCLC, our pilot disease site.

METHODS Data from the tumor registry and billing, since 2012, yielded 45 patients with 52 tumors consistent with primary early-stage medically inoperable NSCLC. A Retrospective chart review was conducted to evaluate toxicity and clinical outcomes using the NCI criteria among consecutive patients treated at AAMC from May 2012 through June 2017.

RESULTS Median Follow up was 41.2 months (range 6.1-61.4). At time of follow up, 51 of 52 tumors were evaluable. Of the evaluable patients, median age at diagnosis was 79 years (range 58-91), 36 of 44 patients (81.8%) were alive at time of follow-up. The estimated survival at 36 months is 74.9% (Figure 1) and the estimated progression free survival at 36

months is 66.3% (Figure 2). Of the 51 evaluable tumors, 28 were central tumors, while 23 were peripheral tumors. The peripheral tumors had a statistically better overall survival (Figure 3). At time of follow-up, local control was 43 of 51 (84.3%, 95% CI 70.9-92.5), 40 tumors (78.4%, 95% CI 64.3-88.3) had regional-nodal control (78.4%, 95% CI 64.3-88.3), and 41 tumors (80.4%, 95%CI 66.5-89.7) were distally controlled. Of the 11 tumors which experienced regional-nodal failure, 7 (63.6%) were central and 4 (36.4%) were peripheral. Grade 3 radiation pneumonitis was experienced by 5 patients (9.8%, 95% CI 3.7-22.2). Grade 3 chest wall toxicity was experienced by 1 patient (2.0%, 95% CI 0.1-11.8). There were no grade 4-5 toxicities.

CONCLUSION The observed clinical outcomes are comparable to published data. The observed rates of toxicity were also similar to published rates. Our study represents one of the first reports from a community setting with 4 year follow up. SBRT has proven to be an excellent option for medically inoperable patients with early stage NSCLC.

1Creighton University, School of Medicine, Omaha, Nebraska 2University of Maryland College Park, College Park, Maryland 3Columbia University in the City of New York, New York, New York 4St. Mary’s College of Maryland, St. Mary’s City, Maryland 5Rebecca Fortney Breast Center, Anne Arundel Medical Center, Annapolis, Maryland 6DeCesaris Cancer Institute, Anne Arundel Medical Center, Annapolis, Maryland

Left to right - Luqman Dad, MD Radiation Oncologist, Leah Vinson, RT (R) (T) Lieanna LePore, Charles Geraghty, MS.


ABSTRACT

ABSTRACT

2017 ASSESSMENT OF OPIOID UTILIZATION AND PRESCRIBING PRACTICES FOLLOWING LOBECTOMY

Sarah Jahnige; Avedis Meneshian MD; Stephen Cattaneo MD; Laura Korpon PA; Barry Meisenberg MD

BACKGROUND Maryland reports opioid deaths have increased by 62% in 2016 compared to just one year earlier. The over-prescribing of opioids following surgery has been cited as a causative factor for addiction and death by overdose. Risk factors for high perioperative opioid use and post-operative narcotic prescribing practices are not well understood. The goal of this project is to identify the risk factors for high opioid utilization and elucidate the patterns of opioid prescription following surgery.

METHODS We retrospectively reviewed consecutive patients undergoing lobectomy between March 2016 and May 2017. Data regarding pre-op opioid use, perioperative non-narcotic analgesic (gabapentin) use, post-operative opioid utilization, perioperative pain score, length of surgery, patient and prescriber demographics, and total opioid prescribed at discharge were collected. All opioid data were converted to morphine milligram equivalents (MME) for standardization.

RESULTS Fifty-four patients (37% Male, 63% Female) with mean age and BMI of 66 years and 29 kg/m2 were included in the study. Mean pain score (0-10), length of surgery, and post-op opioid utilization were 4.26, 147 minutes, and 114 MED/day, respectively. 37% of patients were prescribed gabapentin as a non-narcotic adjunct analgesic perioperatively and 28% used opioids prior to surgery. 31 different providers (4 CRNP, 17 MD, 10 PA-C) wrote prescriptions for opioids with a mean of 198 MME per prescription.

CONCLUSIONS Pre-operative opioid use and lack of the non-narcotic adjunct perioperatively predicted higher post-op narcotic utilization. Future initiatives should focus on limiting pre-op opioid use, while encouraging the use of gabapentin

and other non-narcotic analgesics (NSAIDS, acetaminophen, and local nerve block) perioperatively in an attempt to limit total post-op opioid utilization. Amount of opioid prescribed at discharged varied greatly depending upon prescriber and had no correlation with amount of post-op opioid used. Discharge prescribing practices should better reflect perioperative narcotic utilization to better tailor post-operative narcotic needs. A patient diary could be implemented in order to accurately record the amount of opioid used following discharge to develop an understanding of how much opioids patients actually use and for how long.

RISK FACTORS FOR POST-OP OPIOID UTILIZATION High patient-reported pain scores and longer surgical times predicted higher post-op opioid utilization. Pre-op opioid use predicted higher post-op opioid utilization. The use of gabapentin perioperatively predicted lower post-op opioid utilization.

PREDICTORS OF OPIOID PRESCRIPTION AT

DISCHARGE There was no correlation between documented post-op opioid utilization and total opioid prescribed at discharge. Age, gender, and race of patient played no role in amount of opioid prescribed at discharge. Amount of opioid prescribed varied significantly depending upon individual prescriber. No significant difference between amount of opioid prescribed and prescriber title.


ABSTRACT

ABSTRACT

2017 UNPLANNED ADMISSIONS AND PATIENT PERCEPTIONS

BACKGROUND Unplanned admissions can be costly for the hospital, patient, and payers. Previous research identifies many admissions as preventable, but few have addressed the patient perspective. The goal of this study was to obtain a better understanding of the patient perceptions of the causes of unplanned admissions.

METHODS An IRB approved survey was issued to a convenience sample of admitted patients on the AAMC Oncology floor. In addition to the survey responses, medical record reviews were used to gather more information about the patient’s disease state.

RESULTS 61 patients were approached with the survey: 9 patients declined, 5 surveys were never returned, and 47 completed surveys were received. 38% of patients had advanced stage cancer while 62% had early stage cancer. 23% of unplanned admissions were referrals from physicians or hospital staff. 55% of pts did not attempt to reach their doctors. The top 3 reasons were: 1-because it was

an emergency, 2-they didn’t think they could help, and 3- weakness. Patients did not report trouble with access, transportation, costs appointment scheduling or medication adherence. 2% of patients had prior Palliative Care consults while none were enrolled into Hospice.

CONCLUSION Most cancer patients like to avoid unplanned admissions to the hospital however few believe that their admission was avoidable. A slight majority of cancer patients failed to contact hospital staff/physicians prior to hospital arrive despite the lack of difficulties concerning the logistics, costs or appointment availability. Pt’s cite a belief that their symptoms constituted an emergency and held the perception that contact prior to hospital arrival would not help. Pts expressed a strong belief that the hospital is the safest place for them. A minority expressed an interest in learning more about both palliative care and hospice. Even among pts with advanced disease, only a minority had discussed end of life care planning with their oncologist.

CANCER STAGE

PATIENT CHARACTERISTICS EARLY STAGE (N=29) ADVANCED STAGE (N=18) TOTAL (N=47)

On active chemotherapy 66% 67% 66%

View hospital admissions as something they would like to avoid 69% 78% 75%

Believe that their hospital admission was avoidable 11% 11% 11%

Tried to contact doctor or hospital staff prior hospital arrival 41% 50% 45%

Wanted more information on Palliative Care 38% 50% 43%

Wanted more information on Hospice 23% 41% 30%

Received information about advanced directives and living wills 63% 63% 63%

Has discussed end of life plan with doctor 33% 40% 36%


ABSTRACT

ABSTRACT

PALLIATIVE CARE (OPC) USAGE AMONG ONCOLOGY PATIENTS

Akhil Uppalapati, Barry Meisenberg, Patrice Richardson, Jane Rhule, Theresa McKay, Geri Raber

BACKGROUND Palliative care (PC) is recommended as adjunctive care for all advanced cancer patients even though data on its efficacy is not robust. Many oncology patients are referred to palliative care (PC) only at end of life. The usage and efficacy of this service varies between different demographic groups.

OBJECTIVE To determine the usage of a new outpatient PC (OPC) program among cancer patients.

METHODS Retrospective chart review of oncology patients referred to OPC during a six-month period in 2016 and 2017.

Demographic and diagnostic groups were compared in order to determine which patients were most likely to use PC and how effective the service was. Effectiveness was compared by looking at subsequent Emergency Department (ED) usage and whether or not a patient had any form of advanced directive. Differences between groups of patients were compared using a 2-tailed Fisher’s exact test.

RESULTS 48 referred patients were identified; 21 patients did not keep their initial appointment. Primary reason for not keeping the initial appointment included: pt. referred to hospice (5), pt. unable to leave home (5), pt. declined services, NOS (11). Patients who were married or undergoing adjuvant treatment (initial stages of cancer) were more likely to keep the

ACCEPTED OPC (N=27) DID NOT USE OPC (N=21) P = 0.68

Black 3 4 7/48 (14.5%)

White 23 17 40/48 (83%)

USED PCDID NOT USE PC

P = 0.25

Married 14 8 22/48 (46%)

Not Married 11 13 24/48 (50%)

USED PCDID NOT USE PC

P = 0.12

Married 14 8 22/48 (46%)

Not Married 11 13 24/48 (50%)

USED PC DID NOT USE PC P = 0.25

Adjuvant 6 1 7/48 (15%)

Refractory to last course of Rx 12 9 21/48 (44%)

Advanced, but not refractory 9 11 21/48 (44%)

# PTS. WHO VISITED ED WITHIN 3 MONTHS OF REFERRAL # PTS. WHO VISITED ED 3 MONTHS AFTER REFERRAL

Accepted OPC Referral pts. 9/18 (50%) 3/18 (17%)

Declined OPC Referral pts. 12/19 (63%) 8/19 (42%)


ABSTRACT

OPC appointment, but due to small sample size, differences were not statistically significant. All patients who utilized OPC for whom an advanced directive was appropriate completed one (of the 9 pts. to complete OPC, 3 had directive before referral, 4 filled out documentation after, and 2 were not appropriate for end of life discussion). Patients who utilized OPC were less likely to use the ED both prior to and after OPC referral than those that did not use the service. 37 patients were evaluable for ED usage 90 days pre and post OPC referral.

DISCUSSION While existing literature supports the outcomes of this study with regards to demographic factors and acceptance of palliative care, more data is needed to make statistically significant conclusions. This study was not controlled, so pts. who accepted an OPC may have already

been predisposed toward a limited treatment approach. 10 of the 21 pts. who declined OPC were unable to accept it due to hospice referral or limitations in their ability to travel, indicating that they were referred later in the course than is appropriate. Those who were undergoing adjunctive care were more likely to use OPC despite OPC being generally used for terminal patients. It may be that adjunctive pts regard PC as less threatening since plans for end-of-life need not be paramount. Further study of this phenomenon is indicated. The finding that all appropriate patients who finished their OPC treatment completed a form of advanced directive indicates that this service is effective in end of life discussions.

Patient, Jaqueline Shanahan, RN Nurse Navigator, Madelaine Binner, MBA, CRNP


SURVIVOR STORIES

SURVIVOR STORIES

LUNG CANCER SURVIVOR JAQUELINE UPSHUR

Three years ago, Jaqueline

Upshur left AAMC with a Stage

1A lung cancer diagnosis.

One of the deadliest

cancers, lung cancer

claims more lives in

Maryland than breast,

prostate and colon

cancers combined. The

best chance of surviving

is detecting the cancer early,

when it is more likely to be cured

through a surgical procedure.

However, only 15 percent of lung cancers are diagnosed in

the early stages.

“When we’re lucky, we catch them at Stage 1 or 2,” says

Stephen Cattaneo, MD, thoracic surgeon and medical director

of Thoracic Oncology at AAMC. “But more often than not we

catch them at Stage 3 or 4.”

Jaqueline found out she had lung cancer through her primary

care doctor. After one of her scans showed a troubling

nodule, she underwent a minimally invasive surgery called a

segmentectomy. A biopsy of the removed tissue revealed that

she had early-stage lung cancer.

From there, the dedicated cancer team at the DeCesaris

Cancer Institute, headed by Dr. Cattaneo, created a

comprehensive treatment plan. Jaqueline later walked

away a lung cancer survivor.

“My experience with Dr. Cattaneo has been marvelous. He’s

one of the best doctors I’ve ever had,” says Jaqueline.

We aim to make Jacqueline’s a more common story. Thanks to

a grant from the Bristol-Myers Squibb Foundation, AAMC will

expand lung cancer prevention and screening services within

high-risk populations in Maryland counties. The three-year,

$1.25 million grant has been beneficial in expanding AAMC’s

award-winning Rapid Access Chest and Lung Assessment

Program (RACLAP). RACLAP is designed to quickly identify,

evaluate and manage early-stage lung cancer.

“It was early detection —

I’m grateful for that. Really grateful

for that.”

“ My experience with Dr. Cattaneo has been marvelous. He’s one of the best doctors I’ve ever had,” says Jaqueline.


SURVIVOR STORIES

SURVIVOR STORIES

BREAST CANCER SURVIVOR KIMBERLY COLLINS

Kimberly Collins lives in southern Maryland, about two hours away from Anne Arundel Medical Center. But she still traveled to AAMC to get a second opinion on her breast cancer diagnosis—and then, ultimately, treatment and breast reconstruction.

“When it comes to getting good care, two hours is a drop in the bucket,” Kimberly says.

She opted to undergo a double mastectomy with Wen Liang, MD, a breast surgeon at AAMC’s Rebecca Fortney Breast Center, followed by reconstructive surgery with Devinder Singh, MD, chief of Plastic Surgery at AAMC and medical director of Anne Arundel Medical Group (AAMG) Plastic Surgery.

AAMG Plastic Surgery’s plastic surgeons work closely with the breast surgeons, oncologists and radiologists at the Rebecca Fortney Breast Center—a level of collaboration that is unusual in highly specialized care.

A breast cancer diagnosis can be terrifying. Kimberly was drawn to Dr. Liang’s compassion as well as her expertise and knowledge. “When I walked into the Fortney breast center, I knew I was in the right place,” Kimberly says. “Dr. Liang treated me not just as a cancer patient, but as an individual.”

Dr. Liang ordered scans but didn’t give them to the radiologist until she reviewed them herself. According to Kimberly, “She wanted to see for herself what she was dealing with.”

“And she actually had some questions,” Kimberly adds. “She went to the Radiology department that same afternoon during my consult and had them read my films and address her questions. When you have a doctor with that much buy-in and partnership in your diagnosis and treatment, you don’t question it.”

Kimberly says she’d spent a lot of time researching Dr. Liang, but no time researching a plastic surgeon. That’s when the partnership between the Fortney Center and AAMG Plastic Surgery was especially important.

“If I had had to research a plastic surgeon, it would have changed my whole emotional journey,” she says. “Dr. Singh was the jewel in my crown of my treatment.”

Dr. Singh says it’s a team effort. Ken Collins, Kimberly’s husband, adds that the team approach was evident as Drs. Liang and Singh worked to include all members of their family, including their two children, in discussions about Kimberly’s care.

“Everybody was a part of it,” he says. “It was an incredible experience that I wish I had never had.”

“ When I walked into the Fortney breast center, I knew I was in the right place,” Kimberly says. “Dr. Liang treated me not just as a cancer patient, but as an individual.”

“Everybody was a part of it,” he says.

“It was an incredible experience that I wish

I had never had.”


LUNG SCREENING

LUNG SCREENING

Lung Cancer Screening in the Community Setting

Stephen M. Cattaneo, II, MD, Barry R. Meisenberg, MD, Maria C. M. Geronimo, MSN, MBA, Bishal Bhandari, MBA, John W. Maxted, and Catherine J. Brady-Copertino, MS, OCN

Division of Thoracic Oncology, DeCesaris Cancer Institute, Anne Arundel Medical Center, Annapolis; and DeCesaris Cancer Institute, Anne Arundel Medical Center, Annapolis, Maryland

BACKGROUND Lung cancer has high incidence and high mortality burden, particularly because it is typically diagnosed in later stages. The National Lung Screening Trial demonstrated a lung cancer–specific mortality benefit in high-risk current and former smokers with yearly low-dose chest computed tomography (CT). Lung cancer screening is thus recommended, but it is unclear whether the results of the National Lung Screening Trial can be replicated in community settings.

METHODS A retrospective review was performed of the lung screening program over its first 5 years, 2012 to 2016. Patients’ demographics, initial screening results, followup, and management results were analyzed in relation to the National Lung Screening Trial results. Annual adherence was defined as returning for imaging within 1 year D 90 days.

DEMOGRAPHICS AND LUNG-RADS CATEGORY

CHARACTERISTIC VALUE

Baseline scans 1,241

Sex

Male 47.5%

Female 52.5%

Race

White 87.3%

African American 10.2%

Other 1.5%

Race not reported 1.0%

Smoking status

Current smoker 49.1%

Previous smoker 48.2%

Not reported 2.7%

Median pack-year for smokers 40

Insurance status

Medicare 45.5%

Private 49.7%

Medicaid 1.4%

Not reported 3.4%

Self-pay

Median age (y) 66

Age group (y)

<55 (15/1,241) 1.2%

55–77 (1194/1,241) 96.2%

78–80 (25/1,241) 2.0%

>80 (7/1,241) 0.6%

Results by Lung-RADS category

Category 1 (504/1,241) 40.6%

Category 2 (472/1,241) 38.0%

Category 3 (184/1,241) 14.8%

Category 4 (81/1,241) 6.5%

Lung-RADS 1⁄4 Lung imaging reporting and data system.

A total of

1,241 PERSONS

underwent initial screening over the 5-year period.


LUNG SCREENING

RATES OF ADHERENCE

CHARACTERISTIC ANNUAL ADHERENCE RATE ANY FOLLOW-UP RATE

All Patients (191/511) 37.4% (261/511) 51.1%

Sex

Male (82/231) 35.5% (112/231) 48.5%

Female (109/280) 38.9% (149/280) 53.2%

Race

White (178/455) 39.1% (238/455) 52.3%

African American (9/44) 20.5% (16/44) 36.4%

Other (4/12) 33.3% (7/12) 58.3%

Smoking status

Current smoker (87/229) 38.0% (114/232) 49.1%

Previous smoker (102/247) 41.3% (141/247) 57.1%

Not reported (2/35) 5.7% (6/32) 18.8%

Insurance status

Medicare (92/225) 40.9% (120/225) 53.3%

Private (96/253) 37.9% (131/252) 52.0%

Medicaid (0/10) 0% (2/10) 20.0%

Not reported (3/23) 13% (8/22) 36.4%

Self-pay 0 (2/2) 100%

Annual adherence 1⁄4 patient returned within 1 year þ 90 days for annual low-dose chest computed tomography; any follow-up 1⁄4 patient returned for screening low-dose chest computed tomography at any time after the initial screening scan.

RESULTS A total of 1,241 persons underwent initial screening over the 5-year period; 78.6% of findings were benign, and only annual repeat low-dose chest CT was recommended. A total of 29 cancers were identified in 26 participants (2%), of which 72% were stage I. The annual adherence rate to repeat imaging after a low-risk baseline scan was 37%, and the any follow-up rate was 51% despite programmatic efforts to follow screening recommendations. When positive findings required more intensive evaluation, most commonly by repeat chest CT scan, adherence was 88%. A total of 1.1% of all participants had invasive biopsies for benign results. Complications of biopsy were minimal.

Conclusions This review demonstrates that a community-based program can approximate the results of the National Lung Screening Trial in detecting early lung cancers. Further study of the adherence phenomenon is essential.

Left to right - Laura Korpon, PA, Stephen Cattaneo, MD, Medical Director of Thoracic Oncology and Division Director of Surgical Oncology and

Avedis Meneshian, MD, Thoracic Surgeon


BENIGN BREAST DISEASE

SELECT CHOICES IN BENIGN BREAST DISEASE

An Initiative of the American Society of Breast Surgeons for the American Board of Internal Medicine Choosing Wisely campaign

Roshni Rao MD1, Kandace Ludwig MD2, Lisa Bailey MD3, Tiffany S. Berry MD4, Robert Buras MD5, Amy Degnim MD6, Oluwadamilola M. Fayanju MD7, Joshua Froman MD8, Negar Golesorkhi MD9, Caprice Greenburg MD10, Ayemoe Thu Ma MD12, Starr Koslow Mautner MD13, Helen Krontiras MD14, Michelle Sowden MD15, Barbara Wexelman MD16, Jeffrey Landercasper MD17

BACKGROUND Up to 50% of all women encounter benign breast problems during their lifetime. In contrast to the treatment of breast cancer, high level evidence from randomized clinical trials is not available to guide treatment decisions for benign breast disease. Subsequently, management is largely based on individual physician experience or training. In 2012, The American Board of Internal Medicine (ABIM) initiated it’s Choosing Wisely® campaign to promote conversations between patients and physicians about challenging the use of commonly performed tests or procedures which may not be necessary. The American Society of Breast Surgeons (ASBrS) Patient Safety and Quality Committee (PSQ) chose to participate in this campaign by creating a list of practices that physicians and patients should question in regards to the management of benign breast disease.

METHODS The PSQ solicited candidate measures for the Choosing Wisely® campaign that addressed benign breast disease. PSQ surgeons represent a wide variety of practice patterns which include academic and private practices across the country. The resulting list of “appropriateness” measures of care was ranked by a modified Delphi appropriateness methodology. Two rounds of ranking were performed to achieve the final list, which was subsequently approved by the ASBrS Board of Directors and endorsed by the ABIM.

RESULTS The final five measures are as follows.

f 1 Don’t routinely excise areas of psueodoangiomatous stromal hyperplasia (PASH) of the breast in patients who are not having symptoms from it.

f 2 Don’t routinely surgically excise biopsy proven fibroadenomas that are smaller than 2 centimeters in size.

f 3 Don’t routinely operate for a breast abscess without an initial attempt to percutaneously aspirate or drain it.

f 4 Don’t perform screening mammography in asymptomatic patients with normal exams who have less than 5-year life expectancy.

f 5 Don’t routinely drain non-painful; fluid-filled cysts.

CONCLUSIONS The ASBrS Choosing Wisely® measures that address benign breast disease management are easily accessible to patients via the internet. Consensus was reached by the group regarding these recommendations, likely reflecting broad applicability of these measures. These measures provide guidance for shared decision making for patients and physicians.

1Department of Surgery, Division of Breast Surgery, Columbia University Medical Center, New York, New York 2University of Indiana, Indianapolis, Indiana 3Bay Area Breast Surgeons, Oakland, California 4Norton Surgical Specialists, Louisville, Kentucky 5Anne Arundel Medical Center, Annapolis, Maryland 6Mayo Clinic, Rochester, Minnesota 7Duke University, Durham, North Carolina 8Mayo Clinic Health System, Owatonna, Minnesota 9Sentara Comprehensive Breast Center, Lorton, Virginia 10University of Wisconsin, Madison, Wisconsin 11Mount Sinai Health System, New York, New York 13Miami Cancer Institute, Miami, Florida 14University of Alabama, Birmingham, Alabama 15The University of Vermont Medical Center, Burlington, Vermon 16Trihealth Cancer Institute, Cincinnati, Ohio 17Gunderson Medical Foundation, La Crosse, Wisconsin


BENIGN BREAST DISEASE

CHOOSE WISELY CAMPAIGN

1. Don’t culture nipple discharge unless there is clinical evidence of infection

2. Don’t send breast cyst fluid for cytology unless clinically suspicious

3. Do talk to your primary care provider about lifestyle changes that can reduce your risk of developing breast cancer and improve your overall health

4.Don’t do mammography in pregnant or nursing patients unless highly suspicious

5.Don’t perform screening mammography in asymptomatic patients with normal exams who have less than 5 year life expectancy

6. Do not assume that if you have no family history or other risk factors that you are not at risk for development of breast cancer. Most patients who develop breast cancer have no identifiable risk factors

7. Don’t routinely aspirate asymptomatic breast cysts with non-suspicious clinical and imaging features

8. Don’t always perform breast operations under general anesthesia

9. Don’t perform diagnostic breast evaluation in women with “physiologic” nipple discharge and normal examination

10. Don’t operate on a breast abscess without an initial attempt to percutaneously aspirate or drain it

11. Don’t perform surgical excision of painful areas of fibrocystic breast disease

12. Don’t routinely surgically excise biopsy proven fibroadenomas that are <2cm in size

13. Don’t routinely excise ectopic axillary breast tissue

14. Don’t routinely excise biopsy proven papillomas that do not demonstrate atypia

15. If you notice any persistent change in either breast, do not assume that it is be benign, even if you have had recent breast imaging. Call and make an appointment with your primary care provider or with a breast specialist.

16. Don’t order prolactin and thyroid tests routinely in women with nipple discharge

17. Don’t perform mammogram, biopsy or hormone testing in boys and young men with psuedogynecomastia

18. Don’t routinely excise asymptomatic PASH of the breast

19. Don’t do thermography of the breast as a diagnostic examination

20. Don’t routinely give narcotics for excision of benign lesions

21. Don’t routinely do 6 month follow-up for benign lesions or unlimited follow-up

22. Even if you have had lumps in your breasts in the past that were cysts or fibroadenomas, do not assume that a new lump is benign

23. Do not assume that if you had a normal mammogram that a persistent change in one of your breasts is not serious

24. Don’t routinely excise high risk lesions of the breast

25. Don’t attempt to obtain secretions from the nipples as part of a routine breast examination. (i.e. do not squeeze the nipples as part of a routine breast examination)

26. Do not order genetic testing when it is unlikely to yield actionable results

27. Do talk to your primary care provider about lifestyle changes that can reduce your risk of developing breast cancer and improve your overall health

28. Do not have a breast MRI if it is unlikely to resolve your or your physician’s concern or an abnormal imaging finding.


HPV TASK FORCE

MARYLAND CANCER CONTROL PLAN

AAMC HPV Task Force Established

Every year in the United States, 31,000 women and men are diagnosed with a cancer caused by an HPV infection. Generally, these cancers aren’t detected until later stages when they’re difficult to treat. Most could be prevented by the HPV vaccination. The DeCesaris Cancer Institute at Anne Arundel Medical Center (AAMC) established the AAMC HPV task force to align strategies with the Maryland Comprehensive Cancer Control Plan and increase the rates of HPV vaccinations.

The CDC recommends 11- to 12-year-olds get two doses of the HPV vaccine to protect against cancers caused by HPV. However, only 48.1 percent of children in Maryland are completing the process. The AAMV HPV task force aims to increase this number by boosting awareness of HPV cancer and educating providers and parents on the importance and effectiveness of the HPV vaccine.

OBJECTIVE Increase HPV vaccination and completion by 10 percent in 2018

AUDIENCE Preteens (children 11 to 12 years old) and their parents; providers

MESSAGES HPV vaccine is cancer prevention

IMPLEMENTATION

f Increase awareness

f Educate providers

f Engage cancer experts and leaders

f Educate communities

f Implement system changes

CALL TO ACTION Talk to your doctor about vaccinating your 11- to 12-year-old sons and daughters against HPV.

PG

Girls 11-12 years old Boys 11-12 years old

25%

20%

15%

10%

5%

0%

5.31.17

30%

PG AP

11.1.17

AP

2.1.18

PG AP

5.1.18

PG AP

8.1.18

PG AP

Linear (Girls 11-12 years old) Linear (Girls 11-12 years old)

PG

Girls 11-12 years old Boys 11-12 years old

50

40%

30%

20%

10%

0%

5.31.17

60%

PG AP

11.1.17

AP

2.1.18

PG AP

5.1.18

PG AP

8.1.18

PG AP

Linear (Girls 11-12 years old) Linear (Girls 11-12 years old)

HPV VACCINATION INITIATION DATA

Pediatric Group (PG) & Annapolic Pediatrics (AP)

Data Collection Initiated in FY17

HPV VACCINATION COMPLETION DATA

Pediatric Group (PG) & Annapolic Pediatrics (AP)

Data Collection Initiated in FY17

Only 41 percent of children in Maryland are

completing the HPV vaccinations.

GREETINGS


TOBACCO CONTROL

TOBACCO CONTROL EFFORTS

Training Health Care Professionals in Evidence-Based Tobacco Treatment

Health Care professionals play a key role in reducing preventable tobacco-related death and disability. With more than a billion patient interactions annually, there is tremendous potential for Health Care professionals to have an even greater impact on this insidious health issue.

At AAMC, we capitalize on this potential by training our professionals in evidence-based tobacco treatment. They use this training to advance programs that help our community control tobacco use. These programs center around developing an understanding of addiction, exploring barriers to change, talking about tobacco use and the health consequences of smoking, and creating an environment supportive of tobacco treatment services.

In 2017, we trained eight new providers in evidence-based tobacco treatment. Our tobacco control efforts included:

f Become Tobacco-Free Classes

f Individual Counseling

f Teen Tobacco Road Show

Our multi-disciplinary team approach drives our ability to deliver the highest quality care tailored to each patient’s needs. A variety of programs have been implemented through our Spine Pathway.

BECOME TOBACCO FREE CLASSES

Six classes per year with an average cessation rate of

39%INDIVIDUAL COUNSELING

122 clients in 2017 with an average

tobacco cessation rate of

29%

TEEN TOBACCO ROAD SHOW

2,559school-aged youth

reached with tobacco avoidance education

QUIT RATE

The quit rates for classes is one year of follow up and for individual counseling it is 6 months of follow up.


COMMUNITY SPOTLIGHT

COMMUNITY SPOTLIGHT

LUNG SCREENING

Lung cancer is the deadliest form of cancer in the United States, and the lung cancer mortality rates at AAMC exceed both state and national rates. For this reason, AAMC continues to educate providers and the community about lung cancer screening.

The DeCesaris Cancer Institute has used Rapid Access Chest and Lung Access Program (RACLAP) since 2010. RACLAP is designed to quickly identify, evaluate and manage early-stage lung cancer. Thanks to a grant from the Bristol-Myers Squibb Foundation, AAMC will continue to expand lung cancer prevention and screening services within high-risk populations in Maryland counties, including Prince George’s County.

AAMC is a designated lung cancer screening center of excellence by the Lung Cancer Alliance. The Thoracic Program coordinator collects lung screening data and follow-up on all positive findings.

LDCT LUNG SCREENINGS 2017

TOTAL SCANS

707

BASELINE SCANS

456ANNUAL SCANS

251CASES

MALIGNANT FINDINGS

11


NICOTINE REPLACEMENT

IMPLEMENTING NICOTINE REPLACEMENT

People who are dependent on tobacco suffer from a chronic, relapsing disease and typically require repeated intervention and multiple attempts to quit. Despite facing myriad challenges, only 20.7 percent of identified tobacco users reported receiving tobacco cessation counseling (CDC, 2014 Ambulatory Health Care Data). In response, AAMC’s Nicotine Dependence Program counselors are conducting bedside tobacco cessation counseling for all inpatients identified as tobacco users.

We train our counselors in tobacco treatment because research shows that even brief bedside counseling can be effective in

promoting prolonged smoking cessation. Our goal is to offer nicotine replacement therapy to patients at discharge along with post-discharge follow-up in the hope of increasing quit rates.

With the help of a Nursing Bedside Quality Improvement grant, we hope to increase successful quit rates for inpatients with existing cardiovascular disease and neurovascular disease by giving them the tools and support they need to remain tobacco-free at discharge—and for six months following discharge.

Left to right – Tuesday Tynan, RN, BSN, TTS Cancer Prevention/Nicotine Dependence and Joanne Ebner, BSN, OCN, C-TTS, Manager Cancer Prevention Department.


COMMITTEE MEMBERS

2017 COMMITTEE MEMBERS

Required Physicians

LUQMAN DAD, MDCancer Liaison Physician

JASON TAKSEY, MD Hematology Oncology

SANFORD ROBBINS, MDChief Pathologist

STEPHEN CATTANEO, MD Thoracic Surgeon

ANGEL TORANO, MDRadiation Oncologist

AMY SARINA, MDDiagnostic Radiology

LORRAINE TAFRA, MDMedical Director of the Breast Center and

Breast Surgeon

Required Members

CATHERINE COPERTINO, BSN, MS, OCN Vice President, Cancer Services

& Palliative Care

JOANNE EBNER, RN, BSN, TTSCommunity Outreach Coordinator

ASHLEY ALLENBY, M.G.C, C.G.CGenetics Professional/Coordinator

VALERIE LEHMAN, MGAPalliative Care Services & Government Affairs

JAMIE CALDWELL, PHDDirector Pharmacy

KYLEEN TICE, MSPTManager Oncology Rehabilitation

MAUREEN SHACKELFORD, RD, LDRegistered Dietician

SHIRLEY KNELLY, MS, SPCAQ, LDADCChief Patient Safety & Compliance Officer

BONNIE BRESNAHAN, RT (R)(T)Director, DeCesaris Cancer Institute

Members

ARUN BHANDARI, MDHematology Oncology

PETER GRAZE, MDHematology Oncology

STANLEY WATKINS, MDHematology Oncology

STEVEN PROSHAN, MDColorectal Surgeon

BRIAN HASSON, PHDChief Medical Physicist

DAWN GOODBURNStrategist PR/Marketing

JACKIE SHANAHAN, RN, OCNNurse Navigator

MADELANIE BINNER, MBA, CRNP, DNPSurvivorship Care Plan

MARIA GERONIMO, RN, MSN, MBA Thoracic Program Coordinator

PAUL HAYESPractice Director, Breast Center

SUSAN HULLAAMC Oncology Surgery

SUSANNE TAMERISPractice Manager Annapolis Oncology

THERESA PUTSCHER, RN, BSN, OCNNurse Navigator

RACHEL SERIOAmerican Cancer Society Representative

AUDREY BUCHANANSenior Data Analyst

KATHLEEN WHITTAKERPatient Advocacy

BARRY MEISENBERG, MDChair, Quality Improvement Coordinator

JOANNE EBNER, RN, BSNTTS Community Outreach Coordinator

JOHN MOXLEY, MS, MHA, CCRPClinical Research Coordinator

LAURIE SELBY, LCSW-CPsychosocial Services ONC Manager

LENORA BURWELL BS, LPN, CTRCancer Conference & Quality Coordinator

RETURN TO TABLE OF CONTENTS

2001 MEDICAL PARKWAY ANNAPOLIS, MD 21401

GIVING TO AAMC–GIVING TO THE COMMUNITY

As a nonprofit organization, AAMC honors its tax-exempt status and fulfills its responsibilities to the community through programs and activities providing treatment, promoting health and responding to the community’s needs. Call our Foundation at 443-481-4747 or visit ask AAMC.org/foundation to learn how your gift can make a difference in the health of your community.

https://www.aamc.org

Documents

DeCesaris - Anne Arundel Medical CenterThe DeCesaris Cancer Institute Cancer Registry systematically tracks the diagnosis, treatment and lifetime follow-up of our cancer patients