2012 Annual Cancer ReportIncorporating 2011 Statistics

A Message from the Chairman of the Cancer Committee: It is a pleasure to present the 2012 Annual Report for the Cancer Institute at Holy Cross Hospital. This year has been very productive. We have:

Initiated an Acute Leukemia Induction program in collaboration with Kaiser Permanente.

Developed a multi-modality Neuro-oncology clinic.

Created a new Cancer Institute website highlighting awards, specialties and innovations related to our Program.

Introduced Endoscopic Bronchial Ultrasound (EBUS) as a modality for the diagnosis of lung tumors, a first in Montgomery County.

Continued to grow our NAPBC Accredited Breast Cancer Program, under the leadership of Eric Oristian, M.D., Medical Director of the Breast Service.

Purchased Onco-Nav, a new software program designed to help oncology patient navigators to schedule, track, organize, and report their interactions with patients, leading to improve patient care coordination, program management, and data collection.

Expanded our selection of treatment options through clinical trials for a variety of cancers. Increased patient enrollment in key studies, focusing on patients with metastatic and advanced diseases.

Implemented DoseEdge, a software system that enhances patient safety for chemotherapy medications provided to our patients.

All of the above highlight the level of commitment by the Hospital and its Health Care Providers towards providing the highest quality of care to our patients undergoing cancer treatments. We are unwavering in our determination to defeat this disease. Sincerely, P. D. Gutman, M.D., M.B.A. Chairman, Cancer Committee Holy Cross Hospital Cancer Institute

Breast Center Report Multidisciplinary breast cancer care is the standard of care both nationally and internationally for the treatment of patients with breast cancer. The physicians of The Breast Center at Holy Cross Hospital have made the commitment to treat their patients diagnosed with breast cancer in a multidisciplinary fashion following nationally accepted guidelines and conforming to the rigorous standards of the American College of Surgeons and the National Accreditation Program of Breast Centers. The Breast Center at Holy Cross Hospital is the first breast cancer treatment center in Montgomery County to make this commitment to patient care and has been granted full three-year accreditation fulfilling all 27 NAPBC standards. History of Breast Cancer Treatment at Holy Cross Hospital

• First mammogram performed in Montgomery County in the 1960’s

• CoC / American College of Surgeons certified cancer center

• In April 2003, Holy Cross Hospital was the first hospital in suburban Maryland to offer Partial Breast Irradiation using Mammosite Radiation Therapy.

• Nurse navigator program was initiated in 2003 to serve women with breast and

gynecologic cancer

• In 2004,Holy Cross in cooperation with Clinical Radiology began using a dedicated MRI breast coil for diagnosis and biopsy

• Breast Imaging Center opened in 2005 • Mammography room • Stereotactic biopsy room, • Minor procedure room with ultrasound equipment, • Bone density screening capabilities.

• Holy Cross Hospital and Susan G. Komen for the Cure have worked together for

nine years to decrease breast cancer disparities among racial and ethnic minorities.

• Grant funding received from Susan G. Komen for the Cure since 2002 is more than $1.3 million

• In 2008, the Holy Cross appointed a Medical Director of Breast Services • It was recognized that multidisciplinary care was standard of care for the

treatment of patients with breast cancer • The goal was set for NAPBC certification

• In 2009 annual presentation of breast cancer data and quality indicators began

• In August 2010, digital mammography came to Holy Cross Hospital.

• In April 2011, the Breast Service at Holy Cross was formed using NAPBC

standards as a template The Breast Center at Holy Cross Hospital On November 11, 2011 the Breast Center at Holy Cross Hospital underwent a day-long survey of its goals, procedures, processes, patient charts, and physical facilities. On November 28, 2011 The Breast Center at Holy Cross Hospital was granted full three-year NAPBC accreditation.

All 27 standards passed The Breast Center at Holy Cross Hospital is one of only 12 certified centers in Maryland and the first certified breast cancer treatment center in Montgomery County Program Elements

• Dedicated group of physicians including oncologists, plastic surgeons, and general surgeons (including a fellowship trained breast surgeon) who are willing to embrace multidisciplinary care as the standard for breast cancer treatment.

• Adopted NCCN guidelines as treatment guidelines

• State of the art medical imaging technology to diagnose breast cancer: digital mammography, dedicated breast ultrasound and stereotactic biopsy technology, breast MRI

• In process for ACR certification

• Holy Cross Hospital Radiation Treatment Center, offers the latest in breast cancer therapy

• HDR (High Dose Rate) Therapy • IMRT (intensity-modulated radiation therapy) • Partial Breast Irradiation • External Beam Therapy • Advanced CT Stimulation • 3-D Treatment • PET scanning

• Semimonthly dedicated breast tumor board meetings with virtual component,

CMEs awarded for either virtual or in person attendance

• Outstanding Pathology department providing rapid, accurate pathologic evaluations that are CAP compliant including synoptic reporting

• Certified Cancer Nurse Navigator

• Tumor Registry

• Patient Education Resource Center

• Community Outreach

• Clinical Trials

• Genetic Evaluation and Consultation (referred)

• Edward Taubman, M.D. 301-774-5771

• Lymphedema Therapy

• A full range of ancillary support services to meet patients psychosocial needs

• Outpatient Oncology Social Work • Psychiatric social worker • Support Groups

• Mentoring • Transition to Wellness Workshop • Partner Support Workshop

The Breast Center at Holy Cross has proven its leadership role in our county for the treatment of breast cancer in by adopting and following the management guidelines set forth by the American College of Surgeons through the NAPBC. Future Goals

• BETTER CARE OF OUR PATIENTS

• Increase quality of care by recruiting additional physicians who support the NAPBC’s guiding principles, adapted by the Breast Center.

• Lectures in association with the Tumor Board

• Year long Webinar discussing controversies in Breast Cancer treatment

• Increased use of virtual technology

• Clinical Consultations • Education and Training • Virtual Visiting • Second Opinions

• Virtual tumor board on demand

The Breast Center at Holy Cross Hospital Certified by the American College of Surgeons Eric Oristian, M.D 301-942-4080 Lawrence Starin,M.D. 301-933-4283 Francisco Espinel, M.D. 301-754-7571 Medical Oncology Cheryl Aylesworth, M.D. Linda Burrell, M.D 301-942-9220 Kashif Firozvi, M.D. Alida Espinoza, M.D F. David Min, M.D 301-933-3216. Ram Trehan, M.D 301-424-1559

Radiation Oncology Sheela Modin, M.D. Daniel Clarke, M.D. 301-681-4422

Plastic Surgery Ali Al-Attar, M.D. 703-207-3065 Douglas Forman, M.D. Kathy Huang, M.D 301-881-7770 Stephane Corriveau, M.D 301-966-0010 Sung Yoon, M.D 301-913-0304 Radiology Mammogaphy HCH 301-754-7350 Clinical Radiologists 301-681-8242

Breast Outcome Report What is breast cancer?

Cancer is a group of disease that causes cells in the body to change and grow

out of control. Most types of cancer cells eventually form a lump or mass called a

tumor, and are named after the part of the body where the tumor originates. Breast

cancer begins in breast tissue, which is made up of glands for milk production, called

lobules, and the ducts that connect the lobules to the nipple. The remainder of the

breast is made up of fatty, connective, and lymphatic tissue.

Most masses are benign; that is, they are not cancerous, do not grow

uncontrollably or spread, and are not life-threatening. Some breast cancers are called

in situ because they are confined within the ducts (ductal carcinoma in situ or DCIS) or

lobules (lobular carcinoma in situ or LCIS) where they originated. Many oncologists

believe that LCIS (also known as lobular neoplasia) is not a true cancer, but an

indicator of increased risk for developing invasive cancer in either breast. The majority

of in situ breast cancers are DCIS, which accounted for about 83% of in situ cases

diagnosed during 2004-2008. LCIS is much less common than DCIS, accounting for

about 11% of female in situ breast cancers diagnosed during 2004-2008. · Other in situ

breast cancers have characteristics of both ductal and lobular carcinomas or have

unspecified origins. Most breast cancers are invasive, or infiltrating. These cancers

started in the lobules or ducts of the breast but have broken through the duct or

glandular walls to invade the surrounding tissue of the breast.

While clinical assessment clues (such as findings on breast exam or breast

imaging results) may be strongly suggestive of a cancer diagnosis, microscopic analysis

of breast tissue is necessary for a definitive diagnosis of breast cancer and to determine

whether the cancer is in situ or invasive and lobular or ductal. The micro-scopic analysis

can be obtained via a needle biopsy or a surgical biopsy. Selection of the type of biopsy

is based on individual factors and availability.

The seriousness of invasive breast cancer is strongly influenced by the stage of

the disease; that is, the extent or spread of the cancer when it is first diagnosed. The

TNM classification of tumors uses information on tumor size and how far it has spread

within the breast and nearby organs (T), lymph node involvement (N), and the presence

or absence of distant metastases (spread to distant organs) (M).1 Once the T, N, and M

are determined, a stage of 0, I, II, III, or IV is assigned, with stage 0 being in situ, stage I

being early stage invasive cancer, and stage IV being the most advanced. The TNM

staging system is commonly used in clinical settings.

First Course Treatment

What are the signs and symptoms of breast cancer?

Breast cancer typically produces no symptoms when the tumor is small and most

treatable. Therefore, it is very important for women to follow recommended screening

guidelines for detecting breast cancer at an early stage, before symptoms develop.

When breast cancer has grown to a size that can be felt, the most common physical sign

is a painless lump. Sometimes breast cancer can spread to underarm lymph nodes and

cause a lump or swelling, even before the original breast tumor is large enough to be

felt. Less common signs and symptoms include breast pain or heaviness; persistent

changes to the breast, such as swelling, thickening, or redness of the breast’s skin; and

nipple abnormalities such as spontaneous discharge (especially if bloody), erosion,

inversion, or tenderness.

In 2011, an estimated 230,480 new cases of invasive breast cancer will be

diagnosed among women, as well as an estimated 57,650 additional cases of in situ

breast cancer. In 2011, approximately 39,520 women are expected to die from breast

cancer. In 2011, about 2,140 cases of breast cancer are expected to occur among men,

accounting for about 1% of all breast cancers. In addition, approximately 450 men will

die from breast cancer.

One of the first steps in assessing patients with breast complaints includes a

proper understanding of their genetic risk. A 5 percent to 10 percent of breast cancer

cases are thought to be hereditary; resulting directly from gene defects (called

mutations) inherited from a parent The risk may be as high as 80 percent for members of

some families with BRCA mutations. These cancers tend to occur in younger women,

unlike women who are not born with one of these gene mutations. Furthermore, women

with these inherited mutations also have an increased risk for developing other cancers,

particularly ovarian cancer.

Most early breast cancer is demonstrated on routine screening mammograms,

the most common physical sign of breast cancer is a new lump or mass. For this

reason, it is important that any new mass, lump or breast change is checked by a

healthcare professional with experience in diagnosing breast diseases.

Although the treatment of invasive breast cancer is determined by the stage of

disease, breast-conserving surgery is often appropriate for earlier stage invasive breast

cancers. If the cancer is too large, a mastectomy would be needed, unless pre-

operative (neoadjuvant) chemotherapy could shrink the tumor. Lymph node sampling

and possible total axillary (lymph node) resection would be done in either case. Finally,

radiation would be needed for almost all patients. Also adjuvant systemic therapy

(chemo or hormonal therapy) would be given based on the size and characteristics of

the cancer.

At Holy Cross Hospital, relative to our hospital size, our five-year survival rates

for breast cancer by stage are relatively comparable to those of the nation. For

example, HCH stage 3 breast cases have a five-year survival rate of 69.4 percent

compared to the National rate of 66.1 percent. Although our results demonstrate an

improved survival rate, we continue to raise our expectations through our patient-

centered approach.

Observed Survival for Breast for (Holy Cross Hospital) Cases Diagnosed in 2003-2005

Compare to National, AJCC TNM 6 ED Source: National Cancer Database/ Commission on Cancer

Stage of Disease

ENTER 0.0 yr 1.0 yr2.0 yr

3.0 yr

4.0 yr

5.0 yr

95% Confidence Interval

Stage 0 92 100.0 100.0 98.9 95.4 95.4 93.5 87.8 - 99.2

Stage I 262 100.0 98.9 96.5 94.6 92.9 90.9 87.1 - 94.6

Stage II 198 100.0 97.5 93.9 90.2 87.3 80.7 74.7 - 86.7

Stage III 79 100.0 96.2 85.9 76.7 72.5 69.4 58.9 - 79.9

Stage IV 12 Insufficient cases to display survival information

Observed Survival for Breast (National) Cases Diagnosed in 2003-2005

Data from 1486 Programs

Stage of Disease

ENTER 0.0 yr 1.0 yr

2.0 yr

3.0 yr

4.0 yr

5.0 yr

95% Confidence Interval

Stage 0 77643 100.0 99.4 98.6 97.7 96.8 95.6 95.4 - 95.7

Stage I 156118 100.0 99.1 97.7 96.0 94.2 92.1 92 - 92.3

Stage II 113508 100.0 98.0 94.9 91.5 88.3 85.3 85 - 85.5

Stage III 43066 100.0 94.2 85.4 77.7 71.3 66.1 65.6 - 66.5

Stage IV 15362 100.0 64.5 47.3 35.3 26.8 20.9 20.3 - 21.6

Cancer Registry Report The cancer registry reports cancer information to the Maryland Cancer Registry

quarterly and to the ACOS (American College of Surgeons) and National Cancer Data

Base on an annual basis. Most important, this data is used to analyze current trends to

improve patient care by comparing diagnostic studies, treatment, stage and survival data

for national research. The Cancer Registry is also required to conduct a lifetime follow-

up of the patients. Current health status information is obtained monthly via letters to

physicians, hospitals and patients. The HCH cancer registry database consists of 8,953

patients since our reference date of 2006.

Holy Cross Hospital Malignancies by Gender

Summary by Body System

Cancer Institute Navigator Report Oncology Nurse Navigation Services Currently, in 2013, oncology nurse navigators of the Cancer Institute are navigating breast cancer patients exclusively. Navigation services to a variety of cancers will begin soon. Patient Services Oncology nurse navigators (ONN) begin working with patients when a biopsy performed at the Holy Cross Breast Center has a positive result or when referred to them by a partnering physician or hospital department (e.g. Holy Cross Radiation Treatment Center). Our ONNs accompany patients from biopsy to post treatment survivorship. They are available for patient support, education, advocacy, resource access and support services management. Oncology nurse navigators answer patient questions and concerns about the treatment team, all treatment types and more in order to provide patients with the information they need to make the best informed healthcare decisions for their particular situation. Our ONN’s explain pathology reports, treatment side effects and diagnostic tests, and they educate patients regarding lymph edema prevention, post treatment survivorship planning and healthy living practices. They link patients to support services available from the hospital and the local community including financial services, support groups, genetic counseling, wig and prosthesis programs or other specialists (e.g. massage, complementary medicine, lymphedema specialists, exercise programs, etc). Our ONNs accompany patients to appointments with surgeons, medical oncologists and radiation oncologists, providing notes and explanations of complex discussions as needed. They coordinate a peer mentoring program called Survivors Offering Support, providing newly diagnosed breast cancer patients with trained mentors who are breast cancer survivors themselves and also facilitate a program called Transition to Wellness; helping patients who have completed treatment make the transition to healthy living. Recently, navigation services served as a beta testing site and has implemented new software called ‘OncoNav’ developed by Onco and Next Path to facilitate documentation of patient navigation information and services. Hospital Support Navigators participate in weekly hospital Cancer Conference; a multidisciplinary team discussion of patient cases across several cancer sites. ONNs are members of the Breast Center Leadership team; assisting with data collection regarding NAPBC standard measures required to maintain our accreditation and helping with planning activities, evaluation and strategy development for the Breast Center. They volunteer at the annual Hospital Cancer Education and Screening Days; helping participants receive the information and screening they need to prevent and detect cancers.

Navigators also participate in the planning and implementation of Holy Cross Hospital’s annual Cancer Survivor’s Day – a celebration of individuals who have been diagnosed and/or been treated for cancer with survivor stories, physician reflections, fun activities, music and food. Community Involvement Holy Cross Hospital ONNs participate in the Patient Navigation Partnership, comprised of navigators and coordinators from health care organizations from the local area including hospitals, clinics, and support organizations. This group meets regularly to discuss areas of concern regarding barriers to obtaining care, sharing of resources and information and networking to build relationships in the community. Our ONNs also participate in the Breast Health Quality Consortium, which meets quarterly to discuss on-going research regarding local area barriers to care and methods for overcoming these barriers. Holy Cross Hospital ONNs are also members of the local Nurse Navigator Coalition which meets quarterly for educational in-services and networking. National Participation Holy Cross Hospital ONNs are members of the Oncology Nursing Society (ONS) and

participate in ONS special interest groups, online forums and the ONS annual

conference. They also keep up-to-date with ONS’ Connect e-mails and publications,

which provide articles and discussions around the latest in oncology nursing research,

including treatment modalities and all aspects of cancer care. A Holy Cross Hospital

ONN will present a research poster at this year’s ONS national conference. Holy Cross

Hospital ONNs are also members of the National Consortium of Breast Centers and

have participated in their annual conference.

The Cancer Institute Research Program

The primary mission of the Cancer Research Program at Holy Cross Hospital is to

provide participants with access to cutting edge cancer care in prevention, treatment and

support services through participation in clinical trials.

Individuals at risk for cancer and/or those already diagnosed with cancer are offered a

unique opportunity to participate in cancer research studies or clinical trials that may

represent the latest developments in treatment.

The Cancer Research Program provides access to state-of-the-art clinical trials offered

by the National Cancer Institute (NCI), private research organizations, academic

institutions, and the pharmaceutical industry. The Cancer Research Program has been

in operation at the hospital for over 14 years, with the first clinical trial being conducted in

1999. Currently, there are more than 25 open clinical trials active to enroll research

participants, with 127 participants registered during the 2012 calendar year.

Participants joining our clinical trials may be motivated by the knowledge that

experimental cancer treatments could prove more effective than existing options.

Moreover, they are an essential component to help scientists and clinicians develop new

ways to treat and cure cancer.

The Cancer Research Program at Holy Cross Hospital has been vital in providing useful

services in an effort to improve the health and well-being of its patients and the broader

community overall.

Cancer Institute Social Work Services Cancer is not just a physical illness. The illness and the treatment may have a profound effect on a person's financial, social and emotional life. Practical issues arise regarding the grueling treatments that are often necessary. The Cancer Institute social worker accepts referrals from Holy Cross Hospital staff, the Outpatient Infusion Center, the Holy Cross Radiation Center and Holy Cross affiliated physicians. Patients (and sometimes families) are seen individually and counseled/advised/assisted on issues ranging from coping emotionally, dealing with employers, paying for treatments, finding transportation and communicating with loved ones. The social worker refers patients to appropriate community resources when indicated. In addition, the social worker facilitates a GYN cancer support group and co-facilitates a breast cancer support group, a support group for Latinas and the ACS sponsored Look Good Feel Better class. Currently, the social worker is a LCSW-C (licensed certified social worker-clinical) and a CCM (certified case manager) and a member of AOSW (Association of Oncology Social Workers).