2 0 1 4 A n n u A l R e p o R t

2 0 1 4 A n n u A l R e p o R t

“these achievements speak volumes about

our programs and people as these honors

do not come easily.”

1

The Cancer Center at Methodist Jennie Edmundson is the only nationally accredited cancer program in southwest Iowa. This accreditation, from theCommission on Cancer of the American College of Surgeons, is testimony to the quality of cancer care available right here at home.

Only one-fifth of the nation’s cancer centers have achieved this substantial accomplishment.

Additional accreditations include accreditation of the Breast Health Center by the National Accreditation Program for Breast Centers (NAPBC), and Mammogram, Breast Ultrasound and Breast Stereotactic Biopsy accreditation by the American College of Radiology.

As recipients of a grant from the Susan G. Komen foundation,

we are proud to have joined with our community partners to use the funding to assure that women who are uninsured or underinsured are given access to care for breast cancer. These grant dollars support our efforts to educate the community about appropriate screening and provide the needed diagnostic studies and treatments for women with need.

These achievements speak volumes about our programs and people as these honors do not come easily. These come only when every member of the team, working together, delivers quality care that puts patients and their families first.

Our work to fight cancer and enhance cancer care continues. Thank you for your support of our mission.

M E T H O D I S T J E N N I E E D M U N D S O N C A N C E R C E N T E R

AnnuAl RepoRt

Donna Hubbell, BSN MHAVP Patient Safety and QualityCancer Program Administrator

2 0 1 4 A n n u A l R e p o R tm j e c A n c e R c e n t e R 32

Breast 79 76 3Lung/Bronchus - Non Small Cell 42 37 5Colon 18 17 1Lung/Bronchus - Small Cell 16 16 0Bladder 16 16 0Kidney & Renal Pelvis 13 12 1Rectum & Rectosigmoid 8 8 0Leukemia 7 7 0Corpus Uteri 7 5 2Anus, Anal Canal, Anorectum 6 6 0Pancreas 6 6 0Non-Hodgkin’s Lymphoma 6 6 0Prostate 5 5 0Thyroid 5 5 0Esophagus 4 4 0Liver 4 4 0Other Nervous System 4 4 0Myeloma 3 3 0Tonsil 2 2 0Stomach 2 2 0Bile Ducts 2 2 0Larynx 2 2 0Other Hematopoietic 2 2 0Melanoma of Skin 2 2 0Vulva 2 2 0Brain 2 2 0Other Endocrine 2 2 0

Site Group Total Cases Analytic Non-Analytic

2013 cAses Accessioned

CLASS

Hodgkin’s Disease 2 2 0Unknown or Ill-Defined 2 2 0Lip 1 1 0Nasopharynx 1 1 0Small Intestine 1 1 0Gallbladder 1 1 0Retroperitoneum 1 1 0Peritoneum, Omentum, Mesentery

1 1 0

Other Digestive 1 1 0Pleura 1 1 0Uterus 1 1 0Ovary 1 1 0Vagina 1 1 0Testis 1 1 0Ureter 1 1 0 ALL SITES 284 272 12

Site Group Total Cases Analytic Non-Analytic

2013 cAses Accessioned (continued)

CLASS

2 0 1 4 A n n u A l R e p o R tm j e c A n c e R c e n t e R 54

0 (In Situ) 19 7%I 75 28%II 35 13%III 41 15%IV 41 15%NA/Unknown 56 21%

ToTAL 267 100%

AJcc stAge At diAgnosistop ten cAnceRs (All sites) 2013

0

10

20

30

40

50

60

70

80

Thyro

id

Prosta

te

Non-

Hodg

kin's

Lym

phom

a

Panc

reas

Leuk

emia

Kidne

y & Re

nal

Bladd

er

Color

ectal

Lung

& B

ronc

hus

Brea

st

Stage Cases % of Cases

Breast 76 36.0%Lung & Bronchus 53 25.1%Colorectal 25 11.8%Bladder 16 7.6%Kidney & Renal Pelvis 12 5.7%Leukemia 7 3.3%

Pancreas 6 2.8%Non-Hodgkin’s Lymphoma 6 2.8%Prostate 5 2.4%Thyroid 5 2.4%

ToTAL 211 100%

Cases % of CasesCancer SiteStage Cases % of Cases

28%

13%

15%

15%

21%

7%

76

25

16

12

53

7 6 56 5

2 0 1 4 A n n u A l R e p o R tm j e c A n c e R c e n t e R 76

pAtient Age At diAgnosis

20-29 2 2% 2 1%30-39 1 1% 3 2%40-49 5 5% 12 7%50-59 15 14% 33 20%60-69 32 29% 46 28%70-79 30 28% 38 23%80-89 22 20% 26 16%90+ 2 2% 3 2% ToTALS 109 100% 163 100%

Age at Diagnosis Male % of Male Female % of Females

90+

80-89

70-79

60-69

50-59

40-49

30-39

20-29

0

10

20

30

40

50

Male

Female

OUT OF STATE

Nebraska 2.6% (7)Colorado 0.4% (1)Kansas 0.7% (2)Missouri 1.1% (3)Oregon 0.4% (1)

OTHER COUNTIES

Polk 0.4% (1)Webster 0.4% (1)

2013 southwest iowA cAnceR RefeRRAls to mJe

H A R R I S O N

MONOA C R AW F O R D C A R R O L L

MON TGOM E R Y A DAM S

P OT TAWAT TAM I E C A S S

M I L L S

AU DO B ONS H E L B Y

PAG E TAY LO RF R EMON T

0 0.7% (2) 0.7% (2)

6.6% (8)

54.8% (149)

13.2% (36)

2.6% (7)

4.0% (11)

1.5% (4)

1.5% (4)

0.4 (1)

6.6% (4)

4.0% (11)

1.1%(3)

2 0 1 4 A n n u A l R e p o R tm j e c A n c e R c e n t e R 98

2013 mJe distRibution of mAJoR pRimARy sites

Breast (female)

Lung/ Bronchus Colon Bladder

Kidney & Renal pelvis

MJE 26.80% 18.70% 6.00% 5.60% 4.20%

ACS - Iowa 13.20% 13.40% 9.40% 4.60% info not available

ACS - US 14% 13.70% 6.20% 4.40% 3.90%

Kidney &Renal Pelvis

BladderColonLung/Bronchus

Breast(Female)

0%

5%

10%

15%

20%

25%

30%

MJE

ACS - IA

ACS - US

Acos ncdb cp3R 2013 meAsuRes

oncology Metric MJEExpected

Performance Rate

The ACoS Commission on Cancer has defined nine Cancer Program Practice Profile Reports (CP3R) that must be evaluated in 2014 for accreditation.

BCS/RT – Radiation therapy is administered within 1 year (365 days) of diagnoses for women under age 70 receiving breast conserving surgery for breast cancer.

100% >=90% or upper bound of 95%

MAC – Combination chemotherapy is considered or administered within 4 months (120 days) of diagnosis for women under 70 with AJCC T1c N0M0 or Stage II or III ERA and PRA negative breast cancer.

100% >=90% or upper bound of 95%

HT – Tamoxifen or third generation aromatase inhibitor is considered or administered within 1 year (365 days) of diagnosis for women with AJCC T1c N0M0 or Stage II or III ERA and PRA positive breast cancer.

90.5% >=90% or upper bound of 95%

ACT – 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.

100% >=90% or upper bound of 95%

nBx – Image or palpation-guided needle biopsy (core or FNA) is performed to establish diagnosis of breast cancer. 96.9% Not yet established

12RLN – At least 12 regional lymph nodes are removed and pathologically examined for resected colon cancer. 91.7%

>=80% or upper bound of 95%

BCS – Breast conservation surgery rate for women with AJCC clinical stage 0, I, or II breast cancer. 62% Not yet established

MASTRT – 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.

0% (no cases qualified)

Not yet established

RECRT – Radiation therapy is considered or administered within 6 months (180 days) of diagnosis for patients under the age of 80 with clinical or pathologic AJCC T4N0M0 or Stage III receiving surgical resection for rectal cancer.

100% Not yet established

*All measures meet or exceed the defined Confidence Interval, given the number of cases classified for the measures by the NCDB.

2 0 1 4 A n n u A l R e p o R tm j e c A n c e R c e n t e R 1110

Skin Cancer Screening - June214 Participants / 70 Abnormal results

(5 Basal Cell Carcinomas, 2 Melanomas)

2013 cAnceR scReening summARies

Normal

Normal

Abnormal

Normal

Abnormal

Basal Cell Carcinoma

Melanoma

Other Abnormal

Colorectal Screening - March 15 Participants1 Abnormal Result

Head & Neck Cancer Screening - April 41 Participants / 14 Abnormal results

Prostate Cancer Screening - September81 Participants / 10 Abnormal Results (1 Prostate Cancer Diagnosed)

Normal

Abnormal

Prostate Cancer

71

9

2013 cAnceR scReening summARies

Breast Cancer Screening Mills County - October9 Participants / 2 Abnormal Results6 – Screening Mammograms2 – Diagnostic Mammograms1 – Ultrasound

Breast/Cervical Cancer Screening - October103 Participants / 18 Abnormal Results34 – Screening Mammograms9 – Diagnostic Mammograms 9 – Ultrasounds

Normal

Abnormal

Normal

Abnormal

Screening Mammogram

Diagnostic Mammogram

Ultrasound

Screening Mammogram

Diagnostic Mammogram

Ultrasound

7

2

6

21

99

3485

18

14

27

144

14

1

63

52

1

2 0 1 4 A n n u A l R e p o R tm j e c A n c e R c e n t e R 1312

• Updated hospital website with current information regarding health screenings, support groups, and available classes.

• Sponsored and participated in the Winter Fundraiser; Healing Touch Program, Golf Tournament, and Healthy Moves in conjunction with Wings of Hope Cancer Support Center.

• Sponsored Look Good and Feel Better Classes in conjunction with the American Cancer Society and Heartland Oncology & Hematology.

• List of Cancer Resources Provided to Patients & Families Available in the MJE Family Resource Center updated.

• Sponsored and participated in the Women’s Health Conference in Glenwood, IA.

• Continue to promote the American Cancer Society fax referral form & personal health manager packets, developed Collaborative Action Plan & Partnership Update, and participated in Daffodil Days. Introduced to the Clinicians Portal.

• Sponsored & participated in both the Mills & Pottawattamie county Relay’s for Life.

• Sponsored and participated in “A Time to Heal” – 12 week program to help patients regain physical, emotional, intellectual, psychological, and spiritual health after undergoing treatment for cancer.

• Participated in the Spirit of Courage weekend benefit to raise money for our cancer patients. Increased employee knowledge & participation in event.

• Sponsored “Women Helping Women”with Wings of Hope.

2013 cAnceR pRogRAm Activities

• Partnered with the VNA Komen Grant to provide resources to breast cancer patients.

• Participated in the Susan G. Komen Race for the Cure in Des Moines.

• Standardized Cancer Screening demographic forms for better tracking.

• Organized and participated in community cancer screening events with particular attention to the underserved populations (Colorectal, Skin, Prostate, Breast & Cervical).

• Developed a Psychosocial Distress Screening Tool. • Participated in various educational and outreach events to promote

Breast Cancer Awareness month activities.

• Participated in an area Ladies Night Out providing educational materials to women.

• Organized and participated in the Bald and the Brave Challenge which raises funds and awareness for the MJE cancer program.

• In process of developing Survivorship Care Plans for cancer patients. • Handed out breast cancer educational materials at the River City

Expo and the Boat, Sport, and Travel Show.

• Participated in the Great American Smoke-out.

2013 cAnceR pRogRAm Activities

John Okerbloom, MDChairman*Medical Oncologist*

Rick BlodgettVolunteer Chaplain

Becky BusseyPhysical Therapist

Connie CassonOncology Nurse

Annabel Galva, MDDiagnostic Radiologist*

Donna HubbellCancer Program AdministratorQuality Improvement Coordinator*

Tammy JohnsonBreast Health Nurse Navigator

Becky Goldberg-Kahn, MDPathologist*

Michelle KaufmanCancer Conference Coordinator*

Barbara KricsfeldOncology Nurse / Radiation Oncology

Carol KroftCancer Registry Quality Coordinator*

Carol ReederDietitian

Michael Romano, MDFamily Practice

Melanie RyanPharmacist

Lyla SchroderClinical Research Representative*

Brent Wakefield, MDUrologist

Dee WicksPsychosocial Services Coordinator*

Michael Zlomke, MDCancer Liaison Physician*Community Outreach Coordinator*

*designates individuals or positions that are required by the American College of Surgeons Cancer accreditation program.

m j e c a n c e r c e n t e r14

2013 cAnceR committee membeRs

©2014 Methodist Jennie Edmundson, an affiliate of Methodist Health System.