2019 Cancer Center Annual Report

Callahan Cancer Center

2019 Annual Report

C O M P A S S I O N A T E C A N C E R C A R E

WELCOME TO THE 2019 GREAT PLAINS HEALTH CANCER REPORT This year, we will focus our attention on melanoma. Although, skin cancer is the most commonly diagnosed cancer in the U.S., many people don't realize this, because it does not cause the most number of deathers. The most common type of skin cancers are basal cell and squamous cell. Melanoma accounts for only 1 percent of all skin cancer cases, but it is associated with the vast majority of skin cancer deaths. The American Cancer Society estimates the following for melanoma in the US in 2019: about 96,480 new cases of melanoma (57,220 in men and 39,260 in women), and approximately 7,230 deaths from melanoma (4,740 in men and 2,490 in women). Melanoma is most commonly diagnosed in non-Hispanic whites. The lifetime risk of developing melanoma is about 2.6 percent for Caucasians, 0.1 percent for African Americans, and 0.58 percent for Hispanics. Incidence rates are higher in women than men before age 50, but by age 65, rates in men are double those in women and by age 80, they are triple.

T H E C A L L A H A N C A N C E R C E N T E R C OM PA S S I O N AT E C A N C E R C A R E

It is important to know the risk factors for melanoma, because there may be things you can do to lower your risk of developing it. A major risk factor for melanoma is high exposure to ultraviolet (UV) radiation, from sunlight or use of indoor tanning. People at highest risk include those with sun sensitivity, for example, individuals who sunburn easily, or people with natural blond or red hair color. Another risk factor is a family history of melanoma or having numerous moles. Most moles will never cause any problems, but someone who has many moles is more likely to develop melanoma. Lastly a person that has a weakened immune system from a certain disease or medical treatment is more likely to develop skin cancer, including melanoma. The most important way to lower your risk of developing melanoma is to protect yourself from exposure to UV rays. You can do this by practicing sun safety when you are outdoors. The American Cancer Society offers this catchphrase to help remember some of the key steps in protection: “Slip! Slop! Slap! And wrap” Slip on a shirt, slop on sunscreen, slap on a hat and wrap on sunglasses. Children need special attention, as the majority of skin damage happens before the age of 24 months. Parents and caregivers should protect children from excess sun exposure by using these same tips. Sunscreen with an SPF of 30 is 97 percent effective in the prevention of skin cancer. Another way to lower risk of melanoma is to avoid the use of tanning beds. Many people believe the UV rays of a tanning bed are harmless. However, this is not true. Melanoma is highly curable if detected in its early stages. To help detect melanoma early, it is important to perform monthly skin self-exams. As you become familiar with your skin, you will

be more alert for an area that appears to be changing. If you see something different, it is important to notify your physician. The ABCDE rule is a helpful guide for features to be on the lookout for during your skin exam. These are: A is for Asymmetry; one half of a mole or birthmark does not match the other half. B is for Border; the edges are irregular, ragged or blurred. C is for Color; the color is not the same all over and may include shades of brown or black or sometimes patches of pink, red, white or blue. D is for Diameter; the spot is larger than 6 mm across, although some melanomas can be smaller than this. E is for Evolving; the mole is changing in size, shape or color. Not all melanomas will have these signs, so it is important to be alert for any new or changing skin growths or spots. Great Plains Health provides a full range of services for prevention, early detection and treatment of melanoma. I would encourage everyone to perform regular skin exams and to promptly notify your primary care physician of any skin changes you notice. Referrals can then be made to our team of specialists here in the North Platte area, including dermatologists, surgeons and oncologists.

Tammy Niemoth, RN BSN OCN Callahan Cancer Center director CoC Cancer Program Administrator

2 0 1 9 A N N U A L R E P O R T

Clinical research Great Plains Health Callahan Cancer

Center’s medical oncology department is dedicated to providing the most up-to- date clinical research for our patients. Our clinical research coordinator, along with our nurse navigator, is responsible for keeping the physicians updated on potential trials, opening new trials, assessing patients for possible enrollment and working with the physicians to determine patient eligibility. Along with registering patients for clinical trials, following these patients’ progress and treatment on a scheduled basis and doing all required data entry and paperwork for each trial and registry.

T H E C A L L A H A N C A N C E R C E N T E R C OM PA S S I O N AT E C A N C E R C A R E

The research program at Great Plains Health is an affiliate of the University of Nebraska Medical Center. Great Plains Health works with them to open new studies and continues to follow-up on individuals who were affiliated with the Alliance for Clinical Trials in the past. In addition, Great Plains Health keeps all regulatory files current for all studies. Studies available vary as to diagnosis, with breast, lung, colon, and prostate being the most commonly available studies. We also enroll patients in the Lymphoma Tumor Registry and the Breast Cancer Collaborative Registry, which allows continued research in these specific areas of cancer. We continue to have available trials open with Cancer Alliance of Nebraska, which provides a number of trials for all cancers available to our patients to be enrolled in providing they meet the inclusion criteria. The Lymphoma Study Group Registry and Tissue Bank through the University of Nebraska Medical Center is another group with which the research coordinator works to follow patients diagnosed with lymphoma. In 2018, thirteen new patients were added to the Lymphoma Study Group, and we continue to screen individuals and follow approximately 250 patients every six months to one year for the group. Twenty-two patients were enrolled in studies/registries in 2018 at the Callahan Cancer Center at Great Plains Health, and we had two patients who we referred to the University of Colorado-Cancer Center Anschutz and enrolled in clinical trials there. These studies consisted of breast cancer patients, lymphoma patients, and head and neck cancer patients. We continue to follow patients who have been enrolled in past clinical trials until their time of death. We are proud of the contributions we are making to research at the Callahan Cancer Center and the accessibility for participation in the leading-edge treatments for our patients. Overall, our Cancer Center enrolled 24 patients in registries and trials in 2018, and that brings us to a six percent accrual, surpassing the four percent required for CoC commendation. Each year, we continue to focus on breast cancer patients, and we are very excited to provide cutting- edge treatments and registries for those patients.

Currently, we enroll breast cancer patients in the Breast Cancer Collaborative Registry, and the Breast Cancer Focus Group Study, which are both affiliated with the University of Nebraska Medical Center. We continue to follow nine breast cancer patients yearly who were enrolled in the 2009 Wyeth 3004 Study, which was turned over to PUMA in 2014.

2018 brought a new electronic medical record system, a new EMR, Epic, at Great Plains Health and the Callahan Cancer Center. Implementation of EPIC brought some challenges with learning a new system, but overall, it's an excellent medical record that makes available to all providers the most current information on our patients. Clinical Research patients are identified for all providers and staff when working with the patient, a great feature in the EPIC system. The Callahan Cancer Center continued in 2019 the work our clinical research and registries do for our patients and the advancement of cancer care in our region. The diagnosis of cancer shakes the world of each and every patient who hears those words. Our goal is to inspire health and healing, and provide support and guidance during their cancer journey. If that journey leads them in the direction of a clinical trial, then our team is here to help with the advancement of cancer care.

Lisa Kosmacek, RN BSN Clinical research coordinator

Sheila Markley, RN BSN CBCN Nurse navigator

2 0 1 9 A N N U A L R E P O R T

Melanoma cases on the rise

Melanoma is a type of skin cancer that begins in the skin’s pigment-producing cells, called melanocytes. These cells make melanin, which is responsible for the color in skin and eyes. Exposure to ultraviolet rays from sunlight is the leading cause behind melanoma. Researchers think that when the sunlight hits the skin, enough UV radiation exposure can damage the DNA in melanocytes, causing them to grow out of control into a tumor. Yet melanoma can occur anywhere on the body where there is melanin, including the eyes and small intestines. The National Cancer Institute says that only two percent of all skin cancers are melanoma, so it is very rare, but it's starting to grow in prominence among all skin cancers. Of all types of skin cancer, melanoma is the deadliest. In 2017, the National Institute of Health estimated a total of 87,000 new cases of melanoma leading to 9,700 deaths.

At our own local screening at Great Plains Health, we screened a total of 80 patients, with two confirmed cases of melanoma. I hope in reading this report, you will learn to guard yourself from the dangers of melanoma, including how to take good care of your skin.

Todd Hlavaty, MD Radiation Oncology Director Cancer Committee Chairman

T H E C A L L A H A N C A N C E R C E N T E R C OM PA S S I O N AT E C A N C E R C A R E

2018 GREAT PLAINS HEALTH Cutaneous melanoma site and histology distribution 29 reportable cases

C44.2

Site

C44.4

C44.1

C44.0 Lip, NOS

0.00

C44.0

C44.1 Eyelid

0.00

C44.2 External ear

0.00

C44.5

C44.3 Face, other

10.34

C44.4 Scalp and neck

3.45

C44.6

C44.5 Trunk

24.14

C44.6 Upper limb and shoulder

34.48

C44.7 Lower limb and hip

24.14

C44.8 Overlapping lesion

0.00

C44.9 Skin, NOS

3.45

C51.x Vulva

0.00

C60.x Penis

0.00

C63.2 Scrotum

0.00

C44.7

14 48.28%

15 51.72%

Histology % 8720/3................Malignant melanoma, NOS (except juvenile melanoma M-8770/0).......................... 14..............48.28 8743/3................Superficial spreading melanoma (C44._)..................................................................... 6..............20.69 8720/2................Melanoma in situ........................................................................................................ 4..............13.79 8721/3................Nodular melanoma (C44._)......................................................................................... 3..............10.34 8744/3................Acral lentiginous melanoma, malignant (C44._)......................................................... 2................6.90 N

2 0 1 9 A N N U A L R E P O R T

Great Plains Health held 20 multidisciplinary Cancer Conferences in 2018 with the goal of providing consultative services to formulate an effective treatment plan and offer education to physicians and allied health professionals. With many specialties in attendance, there were 134 physician representatives, from specialties such as hematology, palliative care, pathology, podiatry, radiology, general surgery, oral surgery, and radiation and medical oncology, along with a total of 348 other allied healthcare providers. 2018 CANCER CONFERENCES Cases were presented by medical oncologists Demytra Mitsis, MD; Avinash Pasam, MD; and Irfan Vaziri, MD; by radiation oncologist Todd Hlavaty, MD; and by surgeon Jacob Wiesen, MD. Pathologists assisting in case presentations were Yomi Asojo, MD; and Byron

Barksdale, MD. Radiologists who presented imaging for cases were Clark Diffendaffer, MD; David Hatch, MD, Rick Kukulka, MD; Ladd Lake, MD; and Imanual Somers-Dehaney, MD. The primary sites covered were anus (1), bladder (2), bone (1), bone marrow (2), breast (18), cecum (1), cervix (2), colon (6), endometrium (1), epiglottis (1), esophagus (2), kidney (4), liver (1), lung (17), lymph nodes (4), ovary (4), pancreas (1), parotid (2), piriform sinus (2), prostate (2), rectum (5), skin (3), supraglottis (2), thyroid (1), tonsil (3), unknown primary (3), and uveal (1). There were a total of 83 patient cases presented for discussion and recommendations on cancer staging, treatments, national guidelines, clinical trials, trends and recurrences.

T H E C A L L A H A N C A N C E R C E N T E R C OM PA S S I O N AT E C A N C E R C A R E

2018 CANCER REGISTRY SUMMARY

In 2018, patients came to Great Plains Health from west-central Nebraska, Kansas and Colorado. The cancer registry collected information on 522 cases, with 422 of those being analytic or cases that were initially diagnosed and/or treated at Great Plains Health. A Certified Tumor Registrar (CTR) documents patient information such as demographics, site and type of cancer, surgery and other types of treatment. The registry submits this data to the Nebraska State Cancer Registry monthly and annually to the National Cancer Data Base. The registry performs annual follow-up on cancer cases for medical surveillance and complete data information and currently maintains a rate of 92 percent (goal 80 percent), with 96 percent (goal 90 percent) for all cases diagnosed in the past five years.

Cancer registry data is utilized to inform program quality improvements in patient care. In 2018, the Great Plains Health cancer registry participated in a national American College of Surgeons-Commission on Cancer study on ductal carcinoma in situ breast cancer, researching records and submitting many more data elements on selected patients’ diagnosing, treatment, follow-up actions by their different physicians, and if and when they had recurrences. The registry also coordinates the multidisciplinary Cancer Committee that is responsible for improving all cancer-related activities in the program and meeting or exceeding all CoC accreditation requirements. The registry facilitates the publication of the Annual Report on Cancer and assists with the multidisciplinary Cancer Conferences.

written by:

Jill Reeves, MS, CTR Cancer Registrar Cancer Conference Coordinator

2 0 1 9 A N N U A L R E P O R T

2019 PHYSICIAN STUDY

Regardless of patient’s risk for positive SLNB, if he or she is medically unfit to act on the information SLNB would provide (lymph node dissection, consideration of adjuvant therapy, pursue surveillance nodal basin ultrasound, or change follow-up schedules), it is reasonable to forego SLNB. Wide excision of primary tumor and a complete therapeutic lymph node dissection is recommended in patients with positive SLNB (Category 1 recommendation). Systemic therapy with Nivolumab or Pembrolizumab or Dabrafenib + Tametinib (in BRAF V600E mutation positive patients) is a Category 1 recommendation. Observation is a Category 2A recommendation. Locoregional RT is a Category 2B recommendation. Study: Seven cases of newly diagnosed cutaneous melanoma from 2018 were reviewed to determine whether sentinel lymph node biopsy was discussed and offered to suspected Stage 3 melanoma patients, and if BRAF testing was performed on Stage 3 and Stage 4 melanomas and if appropriate systemic therapy was offered. The data is listed below:

Every year, in order to maintain the American College of Surgeons’ Commission on Cancer accreditation, Great Plains Health oncologists perform a study to monitor the Callahan Cancer Center’s compliance with evidence-based guidelines. Below is this year’s in-depth analysis to assess and verify that our cancer program patients were evaluated and treated according to National Comprehensive Cancer Network (NCCN) guidelines. Topic: Sentinel lymph node biopsy in suspected Stage 3 cutaneous melanoma, BRAF mutation testing and offering adjuvant systemic therapy in Stage 3 and Stage 4 melanomas Introduction: NCCN guidelines advise discussing and offering sentinel biopsy in suspected Stage 3 cutaneous melanoma. Pathologic features that would qualify for the discussion include:  Breslow thickness > 1 mm with or without ulceration  Breslow thickness < 0.8 mm with ulceration  Breslow thickness < 0.8 mm with or without ulceration with high risk features like high mitotic score (> 2/mm2) or lymphovascular invasion  Breslow thickness 0.8 mm – 1 mm with or without ulceration

Patient ICD-O Site

ICD-O Histology

AJCC Stage

BRAF Stage 3- SLNB

Surgical Treatment

Systemic Treatment

Skin, unspecified malignant neoplasm of skin of ear and external auricular canal

Radical ariculectomy & parotidectomy

Ipilimumab + Nivolumab, followed by Nivolumab alone

Malignant melanoma, NOS

3A Pos

Dissection

Malignant melanoma, desmoplatic type

Skin of scalp and neck

3B Neg SLNB

Wide excision

Nivolumab

Skin of trunk

Superficial spreading melanoma

3B Pos

Dissection Wide excision

Nivolumab

Ipilimumab + Nivolumab, followed by Nivolumab alone

Skin of trunk

Malignant melanoma, NOS

3B Neg SLNB

Wide excision

Skin of trunk

Nodular melanoma

3C Pos

SLNB

Wide excision

Nivolumab

Skin of trunk

Superficial spreading melanoma

3C Neg Excision

Wide excision

Nivolumab

Skin of other and unspeci- fied parts of face

Nodular melanoma

4 Neg N/A

Wide excision

Pembrolizumab

Conclusions: Sentinel lymph node biopsy should be discussed and offered in clinically suspected Stage 3 cutaneous melanoma. BRAF mutation testing should be performed in all Stage 3 and Stage 4 cutaneous melanomas. Systemic therapy with Nivolumab or Pembrolizumab or Dabrafenib plus Trametinib (in BRAF positive patients) should be offered for all patients with Stage 3 or Stage 4 melanomas. In a review of seven cases of Stage 3 and Stage 4 newly diagnosed melanomas, SLNB and/or dissection was performed in 100% of Stage 3 melanomas. BRAF testing was performed in all the cases. Three out of seven had BRAF mutation positivity. Two patients opted for Nivolumab therapy after discussing the side effect profiles of Dabrafenib plus Trametinib versus nivolumab. Another patient started Ipilimumab plus Nivolumab at UNMC, Omaha, and continued the same treatments at our facility. The management of Stage 3 and Stage 4 melanomas at the Callahan Cancer Center adheres to evidence-based guidelines.

Avinash Pasam, MD Callahan Cancer Center Medical Oncology/Hematology

T H E C A L L A H A N C A N C E R C E N T E R C OM PA S S I O N AT E C A N C E R C A R E

TYPES OF MELANOMA There are fourmain types of skinmelanoma:

1 2 3 4

Superficial spreading melanoma (SSM) is the most common type. Superficial spreading melanomas are more commonly found on the arms, legs, chest and back. The melanoma cells usually grow slowly at first and spread out (radially) across the surface of the skin. If not treated, superficial spreading melanomas invade into the underlying skin and require more aggressive treatment.

Nodular melanoma (NM) is the second type of melanoma. Nodular melanomas grow more quickly, frequently invade locally or metastasize sooner than other melanomas. Nodular melanomas are also more likely to lose their color when growing, becoming red (due to increased vascularity) rather than black. Nodular melanomas are more commonly found on the chest, back, head or neck.

Lentigo maligna melanoma (LMM) is the third type of melanoma. It is usually found in people over age 55 years and especially in areas of skin that have had excessive sun exposure over many years; specifically, lentigo maligna melanomas are often found on the face and neck. Lentigo maligna melanomas arise from a slow-growing precancerous condition called a lentigo maligna or Hutchinson’s freckle. Lentigo maligna looks like a yellow macule (flat) stain on the skin of the neck or face, especially on the cheeks. Lentigo maligna melanomas are usually slow-growing and less dangerous than the other types of melanoma.

Acral lentiginous melanoma (ALM) is the rarest type of melanoma. It is usually found on the palms of the hands, soles of the feet, or under fingernails or toenails. Acral lentiginous melanoma is more common in people with black or brown skin (Fitzpatrick skin type 4 and 5). Acral lentiginous melanomas are not thought to be related to sun exposure.

Rarely, melanomas arise in parts of the body other than the skin. Melanomas can start in the eye (ocular melanoma) or in the mucosa that line areas inside the body, such as the anus or rectum (anorectal melanoma), nose, mouth, and lungs.

Byron Barksdale, MD Pathologist

2 0 1 9 A N N U A L R E P O R T

COMMUNITY OUTREACH IN 2019

GP Health continues its extensive community outreach efforts to educate the community about cancer, working in conjunction with community partners such as the American Cancer Society, Wellness Works, North Platte Recreation Complex, Community Connections Tobacco Free Lincoln County Coalition, and The Visiting Nurse Association-funded by Susan G. Comen of NE. Our team develops cancer awareness programs that teach preventive measures and lifestyle changes—such as smoking cessation, dietary modifications and exercise—that aid in reducing incidents of cancer. Outreach is conducted in a variety of ways, including lectures, broadcast media, web-based media, health fairs, brochures and other written media. The Cancer Committee chose to emphasize and promote skin cancer screening for 2019. Skin cancer is the most prevalent type of cancer in the United States, with more than two million people diagnosed annually. The majority of cases are caused by exposure to ultraviolet (UV) light that is generated by the sun or indoor tanning devices. In addition to skin cancer, UV light can cause wrinkles, dark spots and other signs of premature aging. This damage is completely preventable, though, and skin cancer can often be cured if it is found and treated early. “Melanoma Monday” was held on May 6, 2019, with free skin cancer screenings offered by Dr. Mosel at Greater NE Dermatology and Dr. Bunker from Platte Valley Skin Clinic. There were 80 people screened, with nine basal cell carcinomas, one squamous cell carcinoma, and two melanomas diagnosed. Each case was followed by appropriate referrals and treatment. For our 2019 Prevention Program, the Cancer Committee is seeking to raise awareness of the importance of HPV immunization. The human papilloma virus is associated with female cancers and head and neck cancers in men. This virus is now highly preventable with the HPV vaccine. A special educational opportunity was hosted by Great Plains Pediatrics over the lunch hour by Dennis L Vicker, MD, MPH-BIO, on HPV immunizations. In addition to holding or facilitating many other cancer awareness and prevention programs, Great Plains Health also sponsors or facilitates access to support groups for cancer patients and their families. We continually assess the needs of our community and design programs and strategies to address those needs.

Other prevention, education and support programs: • Lymphedema Education and Prevention • Couch to 5K • Palliative Care Services • 2018 Cancer Symposium • NEBRASKAland Days, Tough Enough To Wear Pink • A Gift of Hope • National Cancer Survivors’ Day • Grief Counseling • Footsteps Grief Camp (children and parent/guardian) • I Can Cope • Women’s Cancer Survivor support group • A Time to Heal support group • Look Good, Feel Better The Callahan Cancer Center reaches beyond our immediate community to provide cancer care as close to your home as possible. The medical oncology programs include the following communities: • Benkelman • Broken Bow • Calloway • Gothenburg • Grant • Imperial • Lexington • McCook • Ogallala • Ord • Valentine • Pastoral Care • Relay for Life • Community wellness events

written by:

Pam Garrick, BS Community Outreach Coordinator

T H E C A L L A H A N C A N C E R C E N T E R C OM PA S S I O N AT E C A N C E R C A R E

CANCER COMMITTEE MEMBERS FOR 2019

Physician members

Jan Daniel, APRN Palliative Care

Megan McGown Marketing Manager

Kartik Anand, MD Medical Oncology

Laura McWha, RN, BSN Physician Liaison Amanda Miller, RN, BSN, OCN Medical Oncology CC Quality Improvement Coordinator Ivan Mitchell Chief Operating Officer Tammy Niemoth, RN, BSN, OCN Director of Cancer Center CC Cancer Program Administrator

Tonya Folk Lead Medical Staff Coordinator Danelle Franzen Sr. Director, Ancillary Services Pam Garrick, BS Education CC Community Outreach Coordinator

Byron Barksdale, MD Pathology Raymond Carlson, DO Palliative Care Todd Hlavaty, MD Radiation Oncology Director Cancer Committee (CC) Chairman Ladd Lake, MD Interventional Radiology Director Demytra Mitsis, MD Medical Oncology Avinash Pasam, MD Medical Oncology Michael Simonson, MD General Surgery Katarzyna Wolanin, MD General Surgery CC ACoS CoC Cancer Liaison Physician

Kathy Gunderson, BS Social Worker

Nan Hynes, CM, MSW Case Management Manager CC Psychosocial Services Coordinator

Jason North Director, Pharmacy

Kim Joneson Cancer Registry

Darrick Parker Director, Rehabilitation

Lisa Kosmecek, RN BSN Nurse Manager CC Clinical Research Coordinator Brenda Lee, BA, MDiv, BCC Senior Staff Chaplain Director of Pastoral Services

Cassie Penn Laboratory Director

Barb Peterson Chief Quality Officer

Jill Reeves, MS, CTR Cancer Registrar CC Cancer Conference Coordinator

Fiona Libsack Chief Development Officer

Andy Link American Cancer Society

Nonphysician members

Kari Suhr, CTR Certicode

M Angie Burrows Director, Home Health & Hospice

Shelia Markley, RN, BSN, CBCN Nurse Navigator

Celie Vaughn, CNS Clinical Dietitian

Jennifer Cook, RN, OCN Medical Oncology

Terry Martin, RN, OCN Medical Oncology

2 0 1 9 A N N U A L R E P O R T

SKIN CANCER SCREENING

that people with either a history of skin cancer or an increased risk of skin cancer discuss routine screening increments with a doctor.” Conducting RCTs to evaluate skin cancer screening is fraught with challenges. Comparing mortality due to melanoma in screened versus nonscreened individuals would be difficult and costly, requiring a large population and long follow-up interval to demonstrate a correlation. In addition, identifying a control population might be considered unethical, as a subset of individuals with elevated melanoma risk may be randomized into a nonscreening arm. Also, the potential exists for bias or erroneous comparisons between screened and controlled groups if uneven opportunistic screening occurs. There is literature to suggest that risk-based skin cancer screening is warranted and justifiable. Screening could potentially impact early detection of melanoma, resulting in a reduction of morbidity, mortality and cost of treatment. Self-assessment tools could identify high-risk individuals for screening. A skin cancer screening registry could collect data to standardize screening recommendations, implement these recommendations nationwide and monitor outcomes over time. Dermatologists and other healthcare providers already routinely perform skin cancer screening examinations, as part of routine clinical care and through nationwide public health initiatives such as the SPOTMe® program sponsored by the American Academy of Dermatology (AAD).

Melanoma-related deaths, estimated to be around 10,130 in 2016, account for the majority of skin cancer-related deaths. Over the past four decades, melanoma incidence has increased by nearly 200 percent. It is now the fifth most common invasive cancer in men and the seventh in women, with an estimated 76,380 new cases in the U.S. in 2016. About one in 33 men and one in 52 women in the U.S. will develop melanoma during their lifetime. About 7,230 people die from melanoma each year. New treatments for metastatic melanoma, including immunotherapy and targeted therapy, have shown great promise; however, a diagnosis of metastatic melanoma remains grave. These new treatment regimens are resulting in significant contributions to healthcare costs. It is estimated that more than three million people in the United States are diagnosed with nonmelanoma skin cancer each year. Basal cell carcinoma is far more common than squamous cell carcinoma. About 80 percent of nonmelanoma skin cancer is basal cell carcinoma. About 2,000 people die from basal cell and squamous cell skin cancer each year. For other, less common types of skin cancer, about 4,420 people die every year. Skin cancer screening through total body skin examination is arguably the safest and most uncomplicated screening test in medicine, but there is no consensus regarding its benefit or implementation. There are no randomized controlled trials (RCT) proving that screening reduces melanoma mortality. The US Preventive Services Task Force (USPSTF) concludes that the current evidence is insufficient to assess the balance of benefits and harms of visual skin examination by a clinician to screen for skin cancer in adults. Aside from the USPSTF, only a few professional organizations offer specific statements or recommendations about skin cancer screening; these include the American Academy of Dermatology (AAD), the American Cancer Society, the American Academy of Family Physicians and the Skin Cancer Foundation. The AAD statement “encourages all members of the public to serve as their own health advocates by regularly conducting skin self-examinations. If an unusual lesion is detected, or if any lesions are changing, itching or bleeding, it is recommended that individuals seek evaluation by a board-certified dermatologist. It is also recommended

Daniel Mosel, MD Greater NE Dermatology Clinic

Johnson MM, Leachman SA, Aspinwall LG, et al. Skin cancer screening: recommendations for data-driven screening guidelines and a review of the US Preventive Services Task Force controversy. Melanoma Manag. 2017;4(1):13–37. doi:10.2217/mmt-2016-0022

T H E C A L L A H A N C A N C E R C E N T E R C OM PA S S I O N AT E C A N C E R C A R E

Katarzyna Wolanin MD, CLP ACoS Cancer Liaison Physician General Surgery

EARLY DETECTION IS CRUCIAL

patient outcomes and save lives. Once a diagnosis is obtained and thickness established, the management is a wide local excision. For tumors less than 1 mm in thickness, it is important to obtain a 1cm margin of healthy tissue all around. If the thickness is greater than 1 mm, a 2 cm margin is recommended. Clinical trials have not demonstrated a benefit of a wider margin than 2 cm. Lymph node examination is important in patients who have an intermediate or high risk. Lymphatic mapping with sentinel lymph node biopsy is recommended. This can be done with either blue dye, a radioactive tracer or both. These are injected prior to surgery to help the surgeon determine the affected lymph nodes. If a patient has a large node that can be palpated, it should be biopsied as well. Evidence of tumor spread to lymph nodes is a poor prognostic sign and associated with decreased survival. Additional treatment for melanoma, especially in advanced stages, can include immunotherapy and chemotherapy. There are also numerous clinical trials with new evolving treatment regiments. As with any cancer treatment, melanoma is treated with a multidisciplinary care team approach. The team includes physicians, nurses and a wide array of support staff to treat all aspects of the disease. The great staff at the Callahan Cancer Center work for every patient and family to coordinate and personalize treatment beyond just referrals and treatments. We are able to offer all of the treatment modalities for melanoma, including, but not limited to, surgery and chemotherapy.

According to the CDC, skin cancer is the most common cancer in the United States. Melanoma is the most serious form of skin cancer and represents a portion of these cases. Melanoma is a cancer that develops from the pigment- containing cells known as melanocytes. These cells are mostly found in the skin, but melanomas can rarely occur in the mouth, intestines or eye. There are four major subtypes of melanoma; superficial spreading, nodular, lentigo maligna and acral lentiginous. Superficial spreading is the most common subtype, accounting for about 70 percent of cases, and is highly curable. There are five stages of melanomas, ranging from stage 0 to stage IV. The five-year survival rates for people with melanoma depend on the stage of the disease at the time of diagnosis. or primary care physician. Moles and skin lesions are examined for asymmetry, border irregularities, color variation, large diameter and evolution over time. If any suspicious areas are found, the most important step is to obtain a biopsy. A complete full-thickness excisional biopsy of suspicious lesions with a 1 to 3 mm margin of normal skin and part of the subcutaneous fat should be performed whenever possible. Tumor thickness is the most important determinant of prognosis, as survival rates decrease with increasing tumor thickness. This is why early detection is crucial to improve Diagnosis of skin cancers begins with a thorough history and physical. A skin check will be performed by a dermatologist

2 0 1 9 A N N U A L R E P O R T

Cancer program practice profile reports (CP3R) Using Great Plains Health data submitted annually to the National Cancer Data Base, the American College of Surgeons’ Commission on Cancer compiles our CP3R. These reports show performance rates for 23 quality measures from 10 primary sites including breast, colon, rectum, lung, cervix, gastric, ovary, endometrium, bladder and kidney. Below is an explanation of the types of measures monitored. Not included in the chart are measures for which Great Plains Health had no measurable data.

Measure type Measure definition and use

High level of evidence supports the measure, including multiple randomized control trials. These measures can be used for such purposes as public reporting, payment incentive programs and the selection of providers by consumers, health plans, or purchasers. Evidence from experimental studies, not randomized control trials, supports the measure. These are intended for internal monitoring of performance within an organization. Limited evidence exists that supports the measure or the measure is used for informative purposes to accredited programs. These measures can be used to identify the status quo as well as monitor patterns and trends of care in order to guide decision-making and resource allocation.

Accountability

Quality Improvement

Surveillance

Evaluation criteria of measures To be compliant with Standards 4.4 and 4.5, cancer programs must: • Meet the above performance rates either with their Expected Performance Rate (EPR) in CP3R or the upper bound of the 95 pecent confidence interval; or • If the performance rates are below the EPR, cancer programs must establish and implement an action plan that reviews and addresses improving performance. • Great Plains Health is compliant with all Expected Performance Rates.

T H E C A L L A H A N C A N C E R C E N T E R C OM PA S S I O N AT E C A N C E R C A R E

Commission on Cancer Cancer Program Practice Profile Reports (CP3R) 2016 CP3R Data Released on November 27, 2018

Site

Measure CoC Std / % EPR (%)

Cervix Radiation therapy completed within 60 days of initiation of radiation among women diagnosed with any stage of cervical cancer (Surveillance) Chemotherapy administered to cervical cancer patients who received radiation for stages IB2-IV cancer (Group 1) or with positive pelvic nodes, positive surgical margin, and/or positive parametrium (Group 2) (Surveillance) Use of brachytherapy in patients treated with primary radiation with curative intent in any stage of cervical cancer (Surveillance) Breast Breast conservation surgery rate for women with AJCC clinical stage 0, I, or II breast cancer (Surveillance) Image or palpation-guided needle biopsy (core or FNA) is performed to establish diagnosis or breast cancer (Quality Improvement) Tamoxifen of third-generation aromotase inhibitor is considered or administered within 1 year (365 days) of diagnosis for women with AJCC T1c or stage IB-III hormone receptor positive breast cancer (Accountability) Radiation therapy is considered or administered following any mastectomy within 1 year (365 days) of diagnosis of breast cancer for women with > = 4 positive regional lymph nodes (Accountability) Radiation is administered within 1 year (365 days) of diagnosis for women under the age of 70 receiving breast conservation surgery for breast cancer (accountability) Combination chemotherapy is considered or administered within 4 months (120 days) of diagnosis for women under 70 with AJCCT1c- NO, or stage IB / III hormone receptor negative breast cancer (accountability) Colon Adjuvant chemotherapy is considered or administered within 4 months (120 days) of diagnosis for patients under the age of 80 with AJCC stage III (lymph node positive) colon cancer (Accountability) At least 12 regional lymph nodes are removed and pathologically examined for resected colon cancer (Quality improvement) Lung Surgery is not the first course of treatment for cN2, M0 lung cases (Surveillance) Rectum Preoperative chemo and radiation are administered for clinical AJCC T3N0, T4N0, or Stage III; or postoperative chemo and radiation are administered within 180 days of diagnosis for clinical AJCC T1- 2N0 with pathologic AJCC T3N0, T4N0, or Stage III; or treatment is considered; for patients under the age of 80 receiving resection for rectal cancer (Quality Improvement) Bladder Radical or partial cystectomy, or tri-modality therapy (local tumor dest)

CERRT

Not applicable

100.00% N-3

CERCT

Not applicable

100.00% N-4

CBRRT

Not applicable

100.00% N-2

BCS

Not applicable

100.00% N-17

nBx

4.5/80% 97.10% N-34

4.4/90% 100.00% N-18

MASTRT

4.4/90% 100.00% N-1

BCSRT

4.4/90% 92.90% N-14

MAC

Not applicable

100.00% N-2

ACT

Not applicable

100.00% N-2

12RLN

4.5/85% 100.00% N-7

LNoSurg

4.5/85% 100.00%

RECRTCT

4.5/85% 100.00% N-3

BLCSTRI

Not applicable

100.00% N-1

2 0 1 9 A N N U A L R E P O R T

2018 IMPROVEMENTS • Dignicap scalp cooling system (helps prevent hair loss from chemotherapy) • Telehealth with medical oncologists • On-site thoracic and surgical oncology clinics with Nebraska Medicine physicians

• On-site genetic counseling through Nebraska Medicine • Added a permanent medical oncologist, Kartik Anand, MD

Noteworthy happenings

Genetic counseling for cancer available at GPHealth

On July 29, Dr. Pasam went live with our first telehealth chemotherapy visit in Grant, Nebraska. In the future, we will have telehealth all of our off-site chemotherapy appointments. Having our oncology providers see a patient prior to chemotherapy treatment is the best course for great patient care. Telehealth clinics show GPHealth's dedication to putting our patients first always, whether they are on our campus or at one of our outreach campuses.

Prevention is key when it comes to cancer. However, what do you do when you are predisposed to cancer by way of genetics? Not only do our genes provide us with insights to our eye color, our height and what color hair we have, but they also give us a blueprint of our future health and well-being. Knowing the secrets of your blueprint can, in some cases, even prevent diseases like cancer or, in the very least, improve your prognosis. Offering genetic counseling to patients who may have a genetic predisposition to certain cancers based on their personal and/or family history is one more service that we are proud to be able to offer. GPHealth works with Nebraska Medicine to offer cancer genetic counseling services to our patients via telehealth. Nebraska Medicine leads the state in cancer genetics research. Licensed Genetic Counselor Michael Gurtler provides counseling services through Nebraska Medicine on the third Wednesday of each month at the Callahan Cancer Center via telehealth. Appointments are available by physician referral.

Avinash Pasam, MD Medical oncology and hematology

T H E C A L L A H A N C A N C E R C E N T E R C OM PA S S I O N AT E C A N C E R C A R E

Surgical and thoracic oncology clinic In collaboration with Nebraska Medicine, our clinic specializes in the clinical evaluation and surgical management of diseases of the chest, liver, pancreas and biliary disorders. After an evaluation, we offer an individualized treatment plan for you. consultations and recommendations for surgical oncology conditions closer to North Platte and the surrounding areas. • Patients can receive expert and specialized surgical care at the Nebraska Medicine surgical oncology clinic within the Callahan Cancer Center, with consult and follow-up appointments welcome. • The clinic provides surgical expertise from the Fred & Pamela Buffett Cancer Center, the only National Cancer Institute (NCI) and National Comprehensive Cancer Network (NCCN) designated cancer center in the state of Nebraska. About the clinic • The clinic provides specialized care, surgical

Conditions we treat • Carcinoid and neuroendocrine tumors • Chest wall tumors • Diaphragm paralysis and rupture • Gallbladder cancer • Gastric and esophageal cancers • Liver cancer • Lung and esophageal cancers • Mediastinal adenopathy • Mesothelioma • Neuroendocrine tumors • Pancreas cancer and cysts • Pectus carinatum/excavatum • Pulmonary nodules • Rib fractures • Sarcoma • Tracheal stenosis/tracheal resections • Tracheomalacia/bronchomalacia

Our surgical oncology providers

Rudy Lackner, MD Thoracic Surgical Oncologist

Bradley Reames, MD James Padussis, MD

Quan P. Ly, MD Hepato Pancreato Biliary Surgeon

Chandrakanth (Chandra) Are, MBBS

Hepato Pancreato Biliary Surgeon

2 0 1 9 A N N U A L R E P O R T

Statistical and comparison data 2018 top incidence sites at Great Plains Health by gender

Top five sites and total incidence, 2018 Great Plains Health

Cases

Women

Great Plains Health

Breast

19%

Breast

35%

Lung

13%

Lung

13%

Colorectal

10%

Prostate

10%

Melanoma

Colorectal

Lymphoma

Melanoma

Other

32%

Other

43%

Total all cancer cases

522

Women

United States *

Nebraska *

Cases

Breast

30%

Breast

15%

Lung

13%

Lung

13%

Colorectal

Prostate

Uterine

Colorectal

Thyroid

Melanoma

Other

38%

Other

49%

Total all cancer cases

10,320

Men

Great Plains Health

United States *

Cases

Prostate

22%

Breast

15%

Lung

13%

Lung

14%

Colorectal

Prostate

10%

Melanoma

Colorectal

Lymphoma

Melanoma

Other

43%

Other

48%

Total all cancer cases

1,735,3500

Men

United States *

Prostate

19%

Lung

14%

Colorectal

Bladder

Melanoma

*Estimated, 2018 Cancer Facts & Figures American Cancer Society

Other

44%

T H E C A L L A H A N C A N C E R C E N T E R C OM PA S S I O N AT E C A N C E R C A R E

Accreditations and certification

The Callahan Cancer Center is accredited as a Community Cancer Program from the American College of Surgeons Commission on Cancer (ACoS, CoC) under the Cancer Program Standards: Ensuring Patient-Centered Care. More than 70 % of all newly diagnosed cancer patients are treated in the more than 1,500 CoC-accredited cancer programs nationwide. This accreditation must be renewed with a comprehensive survey every three years. The Great Plains Health Callahan Cancer Center is proud of the work and effort put forth by all the team members of our cancer program to maintain this accreditation since 1995, showing our dedication to quality care for every patient. Our program was awarded its most recent reaccreditation from our Spring 2018 survey. The Callahan Cancer Center is also proud to have achieved QOPI (Quality Oncology Practice Initiative) Certification in 2015. The QOPI Certification Program, an affiliate of the American Society of Clinical Oncology (ASCO), incorporates measures and standards based on clinical guidelines for quality oncology care, and have met chemotherapy safety standards established by ASCO and the Oncology Nursing Society. Only practices that meet or exceed a defined level of performance may achieve QOPI Certified status. To achieve certification, a practice undergoes a thorough assessment of policies and processes, as well as an on-site survey. Our program’s most recent on-site assessment for recertification was in the fall of 2017. The Joint Commission has also granted Great Plains Health a three-year accreditation after a successful survey for all services covered under the Comprehensive Accreditation Manual for Hospitals. An independent, not-for-profit organization, The Joint Commission accredits and certifies more than 20,500 healthcare organizations and programs in the United States. The Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards.

Specialties • Anesthesiology • Bariatric surgery • Cardiology (interventional) • Cardiology (invasive) • Dermatology • Emergency medicine • Endocrinology • Infectious disease • Internal medicine • Medical oncology – hematology • Nephrology • Neurology • Obstetrics and gynecology • Ophthalmology • Oral surgery • Orthopaedic surgery • Family medicine • General surgery • Hospitalist

Our mission: To inspire health and healing by putting patients first – always.

• Otolaryngology • Pain medicine

• Pathology • Pediatrics • Podiatry • Psychiatry • Pulmonology • Radiation oncology • Radiation

• Rheumatology • Sleep medicine • Spine surgery • Urology

2 0 1 9 A N N U A L R E P O R T

Great Plains Health 2018 diagnosis BY CLASS OF CASE * , GENDER AND STAGE **

DIAGNOSTIC SITE

*CLASS CASE

GENDER **STAGE (ANALYTIC CASES)

TOTAL

TOTAL %

Analytic

Nonanalytic M F 0 I

III

IV NA UNK

ORAL CAVITY, PHARYNX

9 6 0 3 1 4 4 0 0

2.87

---Lip

0 0 0 0 0 0 0 0 0

0.00

---Tongue

1 5 0 0 1 2 2 0 0

1.15

---Salivary Gland

2 0 0 0 0 2 0 0 0

0.38

---Floor of Mouth

1 0 0 0 0 0 0 0 0

0.19

---Gum, Other Mouth

0 0 0 0 0 0 0 0 0

0.00

---Tonsil

3 0 0 2 0 0 1 0 0

0.57

---Nasopharynx

0 0 0 0 0 0 0 0 0

0.00

0.38

---Oropharynx

1 1 0 1 0 0 1 0 0

---Hypopharynx

1 0 0 0 0 0 0 0 0

0.19

---Other Oral Cavity and Pharynx

0 0 0 0 0 0 0 0 0

0.00

DIGESTIVE SYSTEM

46 41 2 8 12 11 22 4 9

16.67

---Esophagus

4 2 0 0 2 0 1 1 1

1.15

---Stomach

8 1 0 1 1 2 2 0 1

1.72

---Small Intestine

0 1 0 0 0 0 0 0 0

0.19

---Colon, Rectum, Anus

21 28 2 5 7 8 11 1 6

9.39

---Liver, Gallbladder, Intrahep Bile Duct

3 2 0 1 1 0 1 0 1

0.96

2.87

---Pancreas

9 6 0 1 1 1 7 0 0

---Retroperitoneum

0 0 0 0 0 0 0 0 0

0.00

---Peritoneum, Omentum, Mesentery

0 0 0 0 0 0 0 0 0

0.00

---Other Digestive Organs

1 1 0 0 0 0 0 2 0

0.38

RESPIRATORY SYSTEM

37 36 0 11 4 9 29 4 3

13.98

---Nose, Nasal Cavity, Middle Ear

1 0 0 0 0 0 1 0 0

0.19

---Larynx

5 0 0 1 0 1 2 0 0

0.96

---Pleura

0 0 0 0 0 0 0 0 0

0.00

---Lung and Bronchus

31 36 0 10 4 8 26 4 3

12.84

---Trachea

0 0 0 0 0 0 0 0 0

0.00

---Mediastinum, Other Resp.

0 0 0 0 0 0 0 0 0

BONES, JOINTS

0 0 0 0 0 0 0 0 0

0.00

SOFT TISSUE INCLUDING HEART

1 1 0 0 0 0 0 1 0

0.38

SKIN

19 17 0 5 1 2 1 1 1

6.90

---Skin: Melanoma

17 15 0 5 0 2 1 0 1

6.13

---Skin: Other Non-Epithelial

2 2 0 0 1 0 0 1 0

0.77

---Epithelial Skin

0 0 0 0 0 0 0 0 0

0.00

BREAST

2 98 7 55 14 5 5 0 8

100

19.16

---Female Breast

0 98 7 53 14 5 5 0 8

18.77

---Male Breast

2 0 0 2 0 0 0 0 0

0.38

0 16 0 5 1 2 4 0 2

3.07

FEMALE GENITAL SYSTEM

---Cervix Uteri

0 4 0 2 1 0 1 0 0

0.77

---Corpus, Uterus: NOS

0 8 0 3 0 1 2 0 1

1.53

---Ovary

0 3 0 0 0 1 1 0 0

0.57

---Vagina

0 0 0 0 0 0 0 0 0

0.00

---Vulva

0 1 0 0 0 0 0 0 1

0.19

T H E C A L L A H A N C A N C E R C E N T E R C OM PA S S I O N AT E C A N C E R C A R E

Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Page 11 Page 12 Page 13 Page 14 Page 15 Page 16 Page 17 Page 18 Page 19 Page 20 Page 21 Page 22 Page 23 Page 24

Made with FlippingBook - professional solution for displaying marketing and sales documents online