Athens Regional Medical Center
2001 Oncology Annual Report
OverviewOverview
Mission Statement & Values
Oncology Committee Year 2001
CHAIRMAN'S REPORT CANCER PROGRAM 2001
Units and Services
Oncology Inpatient Unit
Medical Oncology
Radiation Oncology
Wound, Ostomy, and Continence Therapy
Loran Smith Center for Cancer Support
Social Work Services
Nutritional Counseling
Chaplain Services
Tumor Registry
Data
Top Ten Sites by Gender, 2001
Comparison of ARMC Top Five Sites
American Cancer Society Estimated New Cancer Cases
Distribution by County
Breast Cancer – Site Specific Study
Distribution of Breast Cancer by Sub-Site
Distribution by AJCC Stage
Initial Therapy
Lung Cancer Site Specific Study
Lung Cancer Stage at Diagnosis
Lung Cancer County of Residence
Lung Cancer - Site Specific Study
Lung Cancer Age at Diagnosis
Athens Regional Medical Center is a 315 bed non-profit hospital, and is the cornerstone of its parent company, Athens Regional Health Services, Inc., with a medical staff of approximately 284 physicians and over 2800 employees. Athens Regional Medical Center offers a full range of medical specialties including Oncology, Obstetrics, Gynecology, Neonatal Care, Cardiology, Pediatrics, Orthopedics, Neurosciences, Anesthesiology, Surgery, Radiology, Internal Medicine, Behavioral Health, Nephrology, Urology, and Pulmonary.
Services are provided through:
Outpatient Surgery Center
Physician's Imaging Center
Outreach Laboratory
24 hour Emergency Department
Endoscopy Center
Specialty Intensive Care Units
Ambulatory Treatment Center
Diabetes Education Center
Regional First Care Occupational Health Services
Regional Rehab Services
Radiation Oncology
Home Health Care
Off-Site Urgent Care
Mission Statement
While striving to be an outstanding health care system, the mission of Athens Regional Medical Center is to provide to its patients, their sponsors, its medical staff and the community quality patient care and a scope of services that are of a superior value, delivered in a caring and safe atmosphere with dignity and compassion by competent professionals.
The credibility and reputation of Athens Regional Medical Center are of the utmost importance to those served by the institution and its supporters.
Based on the continuous assessment of community needs by management, the medical staff, and the governing body, Athens Regional Medical Center shall diversify and provide selected health care programs within the defined region.
Athens Regional Medical Center strives for excellence, patient satisfaction and a sound financial position.
Values
Excellence
Honesty and Integrity
Continuous Improvement
Team Work
Efficiency and Effectiveness
Oncology Committee Year 2001
| Sven Swanson, MD, Chairman | Pathology |
| Mark Ellison, MD | Urology |
| Shiv Khandelwal, MD | Radiation Oncology |
| Kenneth Lipshy, MD | General Surgery |
| Neal Marrano, MD | Medical Oncology |
| Thomas Oliver, MD | Urology |
| Steven Scott, MD | Thoracic Surgery |
| Narendra Shah, MD | Radiation Oncology |
| Michael Smith, MD | OBGYN |
| Ronald Terry, MD | Radiation Oncology |
| Jeffrey Thomas, MD | Medical Oncology |
| Mark Vrana, MD | Medical Oncology |
| R. Glen Wiggans, MD | Medical Oncology |
| Nancy Duval, RN | Oncology Unit Director |
| Mona Mercardante, LCSW | Program Manager, Loran Smith Center for Cancer Support |
| Susan Nemetz, RN, BSN | Oncology Nurse, Loran Smith Center for Cancer Support |
| Karen Szwast | Tumor Registrar |
| Martin Sparks, RN, VP | Patient Care Services |
CHAIRMAN'S REPORT CANCER PROGRAM 2001
Sven Swanson, M.D., Chairman, Oncology Committee
The first year of the new millennium saw further growth and development of the cancer program at Athens Regional Medical Center. There were exciting new opportunities pursued and determined patience maintained to achieve our goal of becoming an American College of Surgeons (ACOS) approved Cancer Program.
As one of the steps to ACOS approval, in January 2001, a consultant from the ACOS Commission on Cancer visited ARMC and evaluated our cancer program. The consultant made several recommendations for improvement to help assure ACOS approval. Recommendations ranged from the suggestion that we document stage of disease at tumor conference; to making sure the Oncology Committee oversees all cancer related activities provided to our cancer patients. Most of the recommendations were simply implemented by better documentation of procedures and processes that were already being performed. Immediately, steps were put in place to follow the consultant's recommendations, and we had anticipated ACOS review for certification no later than Fall 2001. However, due to staffing issues at the ACOS, we were put on a waiting list for review. We now hope for certification in early 2003.
The tumor registry showed a growth in cancer cases. Part of this was likely due to better data collection in our maturing program. Beginning in January 2001, new editions of the International Classification of Diseases for Oncology and the Surveillance Epidemiology and End Results Reporting were used, which help to more uniformly classify cancers and the associated epidemiological information. New registry software was installed later in the year to improve data management and reporting. Staging and registry abstract audit procedures were refined and patient follow-up was still excellent at a 98% rate for patient follow-up.
Oncology Case Conference, as always, is a vital component of our program. The meetings were well attended and the multidisciplinary interactions surely provided quality care for our patients. The growth in cases entered into the registry was reflected in the difficulty triaging which of the difficult and interesting patients were most important to present at the conferences.
The oncology inpatient unit continues to provide excellent nursing care to inpatients and outpatients. One oncology nurse became a chemotherapy instructor, one of only about 300 in the United States. A Performance Improvement Initiative in nursing for decreased medication errors was successful. The Cancer Support program noted an increase in inpatient visits and physician referrals. The Center for Cancer Support hired a second social worker in November. She works with both radiation oncology and ARMC oncology inpatients and has developed support groups for children grieving the loss of a loved one. As usual, ARMC and its employees were important contributors to the American Cancer Society annual Relay for Life. The hospital auxiliary purchased a van to transport cancer patients with no other means of transportation to get to their therapy. The Center for Cancer Support is recruiting volunteer drivers to staff the van services. New programs, through the Rehabilitation Department include massage treatment for lymphedema and a cancer reconditioning exercise program. Athens Regional Medical Center's cancer treatment and diagnostic capabilities continued to expand. In November, prostate cancer treatment by brachytherapy began. In the laboratory, new antibodies were employed to help better define and determine tumor types and sites of origin. A hematopathologist - a pathologist who specializes in the diagnosis of blood related diseases and cancers - began work at ARMC in July. Strides were made to have tissue slides originally diagnosed elsewhere received at ARMC prior to patients being treated here. This practice is employed at a majority of cancer centers.
Important new opportunities presented themselves to ARMC this year, and all were explored. After much effort by our Institutional Review Board and local oncologists, a joint press conference between Athens Regional Medical Center, Medical College of Georgia (MCG), and Hematology and Oncology of Northeast Georgia was held to announce local clinical cancer treatment trials with MCG. The Governor of the State of Georgia announced the creation of the Georgia Cancer Coalition, a well-funded project to stimulate cancer research, screening, diagnosis, treatment, and education in our state. Athens Regional Medical Center, with Medical College of Georgia, and University of Georgia (UGA), submitted a proposal to be a part of this coalition. However, by the end of 2001, no formal response had been received. In 2001, ARMC also made an administrative decision to develop a breast health center. The goal of the center will be to improve access, screening, diagnosis, and treatment of breast disease, including cancer. Commitment of funds from the ARMC Foundation was a major factor making this possible.
Although we were not given the chance to become ACOS approved in 2001, our cancer program cared for our patients as if we were. We continued to grow, learn, mature, and add new components of care for our patients and community. We will patiently and doggedly pursue ACOS certification, and new opportunities. Our goal as always, is to the best of our ability through a process of continuous improvement, care for our community and those patients who entrust their care to us.
Sven Swanson, M.D.
Chairman, Oncology Committee
Oncology Inpatient Unit
The inpatient oncology unit is a designated 12 bed unit. Forty-percent of the nursing staff are oncology certified nurses. In 2001, an oncology staff nurse became certified as a chemotherapy instructor and began offering chemotherapy/oncology review courses at Athens Regional Medical Center for ARMC and other area nurses. Every oncology staff nurse completes one quarterly chemotherapy review course each year.
The inpatient unit also administers outpatient chemotherapy in coordination with Hematology and Oncology of Northeast Georgia. A private family room on the unit is utilized for outpatient treatment and is otherwise available to families for relaxation and consultation without having to leave the unit area.
The performance improvement initiative was related to patient safety. The unit reviewed medication administration procedures and developed new procedures where appropriate. The oncology unit members maintain a community connection through participation in the American Cancer Society Relay for Life and the Avon Breast Cancer Walk. The staff and patients utilize the Loran Smith Center for Cancer Support services. Staff members address the emotional & spiritual issues of patients and coordinate a grief follow-up program for families of patients.
Medical Oncology
Hematology and Oncology of Northeast Georgia is located a few blocks from Athens Regional Medical Center. There are four medical oncologists in the practice and all are on staff at Athens Regional Medical Center. They are active on the cancer committee and contribute to cancer case conferences. State-of-the art cancer treatment is provided in a caring and supportive environment. The physicians travel to eight different offices in outlying counties to increase access to care for cancer patients, as well as, maintain an active office in Athens. Oncology certified nurses provide expert clinical services.
The social, emotional, and spiritual needs of patients are addressed by an on-site oncology social worker and appropriate referrals are made to support services in the community.
Hematology and Oncology of Northeast Georgia has formed a partnership with the Medical College of Georgia. This partnership has provided an affiliate for clinical trials that were previously not available in the Athens area. They are participating in additional clinical trials with ECOG, NSABP, and Pharmaceutical Trials. They are also a member of the Clinical Trials Support Unit, a project sponsored by the National Cancer Institute.
Please visit their website at negacancer.com to learn more about the practice.
Radiation Oncology
The Radiation Oncology department takes a comprehensive approach in the treatment of patients and families with a diagnosis of cancer. The services of a physicist, dosimetrist, oncology nurse, and dietician, join the physician, radiation therapists and clerical staff to provide interdisciplinary quality care. Patients and families are also seen by a social worker from the Loran Smith Center for Cancer Support to provide supportive counseling and inform them of support groups and services available in the area. Another social worker from the hospital social works services department assesses patients for financial aid and transportation needs.
The Prostate Seed Implant Program was launched in 2001. Both the urologists and the radiation oncologists are involved from the pre-planning of each implant through the operative procedure, assuring patients of quality, multidisciplinary treatment and care. Services, which used to be offered only in metropolitan areas, are now more accessible to patients in Athens.
Plans are in process to move the radiation department to the new Medical Services Building on the ARMC campus next year. A new linear accelerator and CT simulator have been purchased. The new facility will provide improved patient access and more efficient operational space.
A physician in private practice in a freestanding radiation oncology clinic in Athens is also on staff at ARMC and provides a full range of services.
Wound, Ostomy, and Continence Therapy
Two enterstomal therapy nurses provide care to both inpatients and outpatients. They see many cancer patients who have an ostomy as a result of oncology surgery. Patient counseling and pre-operative consults are an essential part of this service. This department also treats skin breakdown, radiation reactions, pressure ulcers, and chronic wounds. The services of this specialty make an important contribution to the quality of life of many oncology patients. The ET nurses facilitate a very successful ostomy support group.
Loran Smith Center for Cancer Support
The Loran Smith Center for Cancer Support offers educational, emotional, and spiritual support to cancer patients and families in the community. The Center serves as a resource for patients during and after cancer treatment by providing support groups, individual and family counseling, and an educational resource library. The Center is endowed by Athens Regional Foundation and all services are offered at no charge.
The Support Center is staffed by a licensed clinical social worker, oncology nurse, a licensed social worker, and an office manager. Over 30 volunteers assist staff members in program implementation. Educational workshops, seminars, and individual classes are offered that address physical side effects, psychosocial issues, spiritual concerns, complementary therapies, and grief issues related to the death of a loved one. The social worker and nurse also visit ARMC cancer inpatients and coordinate the Pink Ribbon Team, a group of breast cancer survivors, who visit breast cancer inpatients following their surgery.
The center offers a Breast Cancer Awareness program in October and participates in prostate cancer screenings with the local urologists in September, and skin cancer screenings with dermatologists in May. The staff collaborate closely with the American Cancer Society and the hospital health promotion department in other community prevention, early detection, and support programs.
Social Work Services
An oncology social worker provides psychosocial support and resource planning for cancer inpatients and outpatients. In coordination with the nursing unit care coordinator, effective discharge planning assures continuity of care for patients. The social worker coordinates application for financial resources when needed and serves as an advocate for the patient from diagnosis through treatment. The hospital social worker coordinates with the physician office social workers to provide support and information through the continuum of treatment.
Nutritional Counseling
The dietary department offers a specially trained dietician to provide consultative services to both cancer inpatients and outpatients. Lack of appetite, nausea, and vomiting are problems the cancer patients can experience. A nutritional consult provides information designed to minimize these symptoms and increase one's nutritional status during treatment.
Chaplain Services
Pastoral support is often an important part of the healing experience. Chaplains at ARMC are available twenty-four hours a day should patients desire assistance with faith or spiritual issues, grief support, or ethical dilemmas in patient care and/or family support. You may request a hospital chaplain or arrange to have your own minister, priest or rabbi contacted. An interfaith chapel is open 24 hours a day.
Tumor Registry
Background
The Tumor Registry completed its third year as the database of all cancer patients diagnosed and/or treated at ARMC. Since January, 1999, the Registry has collected statistics on 1920 patients with a cancer diagnosis. 724 of these patients were diagnosed and/or treated in 2001 with 705 of this number being analytical or those patients first diagnosed and/or receiving their first course of treatment at ARMC.
Follow up
Follow up, which continues over the lifetime of each patient in the Registry, in becoming a greater part of daily operations as we are now following patients from 1999 through 2001. We also participate with hospitals both state and nationwide in locating patients for follow up. The Registry continues to maintain 98% follow up rate due to good response from physicians, patients and their families.
Case Conference
Oncology Case Conference provides an opportunity for physicians to discuss cancer diagnoses and treatment options for individual patients. Also, speakers with topics of interest to the group are invited during the year. In 2001 there were 23 conferences with 82 cases presented, representing the diagnosis mix in the Registry. Oncology Case Conference is well supported by both physicians and allied health professionals.
Quality Assurance
The medical staff continues to assure the accuracy of information in the Registry with ongoing audits of patient abstracts. Physicians audit cancer site, diagnosis, staging and timeliness of abstract. Goals
During year 2000 the Registry was able to provide information to the hospital staff as ARMC's Breast Center was being developed. In 2002, ARMC plans to incorporate an Oncology Case Conference dedicated to breast cancer alternating with general oncology cases. With new software which was put into use in 2001, the Registry hopes to provide ARMC with even more oncology information as the hospital continues to look for ways to provide ever higher standards of health care to the communities we serve.
Table 1: Top Ten Sites by Gender, 2001
The Top Ten Sites account for 603 (84%) of the total 724 analytical cases in the tumor registry in year 2001.
|
Site of Cancer |
% |
Male |
Female |
|
|
Lung & Bronchus |
146 |
20 |
93 |
53 |
|
Breast |
131 |
18 |
0 |
131 |
|
Prostate |
97 |
13 |
97 |
0 |
|
Colorectal |
69 |
10 |
34 |
35 |
|
Urinary Bladder |
38 |
5 |
29 |
9 |
|
Kidney & Renal Pelvis |
26 |
4 |
13 |
13 |
|
Hematopoietic |
45 |
6 |
23 |
22 |
|
Pancreas |
20 |
3 |
12 |
8 |
|
Stomach |
16 |
2 |
10 |
6 |
|
Thyroid |
15 |
2 |
5 |
10 |
|
All other Sites |
121 |
17 |
70 |
51 |
| TOTAL | 724 | 100% | 386 | 338 |
| Table 2. Comparison of ARMC Top Five Sites: 1999, 2000, 2001 | ||||||
| Cancer | ARMC 1999 | ARMC 2000 | ARMC 2001 | |||
| # Cases | % Total | # Cases | % Total | # Cases | % Total | |
| Breast | 106 | 20% | 129 | 18% | 131 | 18% |
| Lung | 92 | 17% | 138 | 19% | 146 | 20% |
| Prostate | 73 | 13% | 102 | 14% | 97 | 13% |
| Colorectal | 64 | 12% | 85 | 12% | 69 | 10% |
| Urinary/Bladder | 53 | 10% | -- | -- | -- | -- |
| Hematopoietic | -- | -- | 49 | 7% | 45 | 6% |
| All Other Sites | 154 | 28% | 222 | 31% | 236 | 33% |
| TOTAL | 542 | 100% | 725 | 100% | 724 | 100% |
| Table 3. American Cancer Society Estimated new cancer cases 2001 by gender, for the ARMC Top Ten Sites | ||||
|
Total |
% Total |
Male |
Female |
|
|
Lung & Bronchus |
169,500 |
13% |
90,700 |
78,800 |
|
Breast |
193,700 |
15% |
1,500 |
192,000 |
|
Prostate |
198,700 |
16% |
98,100 |
0 |
|
Colorectal |
135,400 |
11% |
67,300 |
68,100 |
|
Urinary Bladder |
54,300 |
4% |
39,200 |
15,100 |
|
Kidney & Renal Pelvis |
30,800 |
2% |
18,700 |
12,100 |
|
Hematopoietic |
99,500 |
6% |
60,200 |
49,300 |
|
Pancreas |
29,200 |
2% |
14,200 |
15,000 |
|
Stomach |
21,700 |
1% |
13,400 |
8,300 |
|
Thyroid |
19,500 |
5% |
4,600 |
14,900 |
|
All Other Sites |
316,300 |
25% |
||
|
Table 4: Distribution by County ARMC serves a wide geographic area of northeast Georgia as evidenced by the distribution of cases by county. |
|||
| County | 2001 | 2000 | 1999 |
| Baldwin | 1 | 0 | 0 |
| Banks | 10 | 7 | 10 |
| Barrow | 74 | 50 | 31 |
| Butts | 0 | 0 | 1 |
| Camden | 1 | 0 | 0 |
| Cherokee | 0 | 2 | 0 |
| Clarke | 197 | 204 | 159 |
| Clayton | 1 | 1 | 0 |
| Cobb | 0 | 1 | 0 |
| Coweta | 0 | 1 | 0 |
| Dekalb | 0 | 0 | 1 |
| Dougherty | 1 | 0 | 0 |
| Effingham | 0 | 0 | 1 |
| Elbert | 42 | 40 | 33 |
| Franklin | 34 | 36 | 24 |
| Fulton | 0 | 1 | 0 |
| Greene | 20 | 23 | 14 |
| Gwinnett | 1 | 2 | 0 |
| Habersham | 4 | 3 | 2 |
| Hall | 1 | 0 | 0 |
| Hart | 25 | 24 | 20 |
| Jackson | 68 | 58 | 43 |
| Jasper | 0 | 0 | 1 |
| Madison | 78 | 63 | 55 |
| Morgan | 24 | 20 | 18 |
| Newton | 0 | 0 | 2 |
| Oconee | 46 | 53 | 28 |
| Oglethorpe | 36 | 37 | 28 |
| Putnam | 7 | 7 | 4 |
| Rabun | 0 | 0 | 4 |
| Spalding | 0 | 1 | 0 |
| Stephens | 13 | 20 | 5 |
| Stewart | 0 | 2 | 0 |
| Taliaferro | 3 | 0 | 3 |
| Telfair | 1 | 0 | 0 |
| Walton | 21 | 25 | 10 |
| White | 2 | 2 | 0 |
| Wilkes | 7 | 0 | 0 |
| Out of State | 4 | 0 | 0 |
Breast Cancer – Site Specific Study
The highest incidence of breast cancer diagnosed at Athens Regional Medical Center occurred between the ages of 50 to 59, with ages 70 to 79 following closely.While breast cancer predominately occurs in old, it does occur at the extremes of age as well.(See Figure 1)
Figure 1:Distribution of Breast Cancer by Age at Diagnosis
Distribution of Breast Cancer by Sub-Site
Figure 2:Distribution of Breast Cancer by Sub-Site
It can be seen by the above graph, the upper outer quadrant represented the most common site of origin within the breast for breast cancer.This is to be expected as this quadrant typically contains more breast tissue than the other quadrants. This was followed closely by the overlapping lesion category.The other quadrants show an expected distribution of sub-sites (see Figure 2).
Distribution by AJCC Stage
As was the case in 2000, this graph confirms the trend of earlier diagnosis for breast cancer through excellent screening programs. Overall, stages 0-II represent 90% of the cases (see Figure 3).
Figure 3. Distribution by AJCC Stage
Through the efforts of the Oncology Committee, there is more emphasis on the involvement of the surgeon, medical and radiation oncologists, radiologists, and pathologists, so we can provide multidisciplinary care of breast cancer patients. While there are several treatment options available to breast cancer patients, these options depend on many factors including but not limited to tumor type, stage, location, patient age, concomitant medical illnesses, and hereditary/familial factors. The choice of adjuvant treatments with radiation and or chemotherapy also depend on those factors. With this in mind, we have recognized that the treatment of breast cancer is no longer a simple quick decision and that, in most patients, many different considerations need to be taken into consideration prior to treatment. Surgery continues to beoverwhelmingly the initial therapy.
Initial Therapy
Figure 4: Initial Therapy
Our annual analysis of all cancer cases diagnosed and/or treated at ARMC during 2001, has revealed that, of the 724 cancer cases, 131 (18%) were breast cancers (second only to lung cancer). Because breast cancer is the most common malignancy in women and because it is the second leading cause of cancer death in women, we have chosen to focus more attention at Athens Regional Medical Center (ARMC) in the diagnosis and treatment of this disease.
The prevention, early diagnosis and treatment of breast cancer has always been a high priority at Athens Regional Medical Center. A greater effort is being focused toward the identification of the disease at its earliest possible stage when chances of cure and breast preservation are greatest.
Kenneth Lipshey, M.D.
General Surgery
Lung Cancer Site Specific Study
Primary Site Study
Total Patients = 146
Analytic = 145
In the 2001 Athens Regional Medical Center (ARMC) cancer registry, cancer of the lung accounted for the greatest number of analytic cases of any tumor site. In the United States, lung cancer continues to be the second most common cancer in both men and women but the leading cause of cancer death in both sexes. Non-small cell lung cancer (NSCLC) and small cell lung cancer (SMLC) made up the majority of malignant tumors of the lung analyzed pathologically at ARMC, with 113 cases and 32 cases, respectively. The male:female ratio was 1:8:1, higher than the national ratio for 2001 or 1:2:1.
Lung Cancer Stage at Diagnosis
TNM staging is very helpful in assessing prognosis and directing therapy in cases of NSCLC, but is not as useful in SCLC. The unfortunate fact that lung cancer has an overall 5-year survival rate of 14% can be understood in the context of the stage at presentation. Most patients with NSCLC present with state III or IV disease, and 57% of patients at ARMC were in this category. Surgical treatment rarely provides a survival benefit for these advanced stages. Compared to national trends, however, where only 15% of patients present with localized disease, the percentage of patients presenting with stage I or II disease at ARMC (34%) is quite high. (See Figure 5).
Figure 5: Lung Cancer Distribution by AJCC Stage
Lung Cancer County of Residence Distribution
As expected, more of the lung cancer patients diagnosed at ARMC resided in Clarke County than any other single county, making up to 24% of cases. When compared with other cancer patients, however, the percentage of Clarke County residents is relatively low. This is most likely due to the role of ARMC as a regional referral center in the subspecialties of pulmonology, oncology, and thoracic surgery. (See Figure 6).
Figure 6: Lung Cancer Distribution by State/County
Lung Cancer - Site Specific Study
Lung Cancer Anatomic Site of Origin
Carcinoma of the lung occurs more frequently in the right lung that in the left lung, with a ratio of approximately 6 to 4. The upper lobe is the most common site of the origin, and the middle lobe, because of its size, is the least common site. Over 40% of lung cancer diagnosed at ARMC were found in the upper lobes. (See Figure 7).
Figure 7: Lung Cancer Distribution by Subsite
Lung Cancer Age at Diagnosis
The age at diagnosis reflects national trends in lung cancer, with 93% of cases diagnosed in patients age 50 and older. There were three patients with pulmonary malignancies diagnosed under the age of 30, consisting of 2 carcinoid tumors and 1 pulmonary blastoma. All cases of SCLC and NSCLC were encountered in patient age 40 or older. (See Figure 8).
Figure 8: Distribution of Lung Cancer by Age at Diagnosis