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2008 2008 Document Transcript

  • 2008 1 Cancer Program Annual Report 1 1
  • Our Cancer Program would not be the success it is without the support and enthusiasm of its members. Robert Wollman, M.D. 2 2
  • 2008 Cancer Committee Members Table of Contents Saint John’s Health Center Robert Wollman, MD, Radiation Oncology, Chairman Letter From The Chairman 1 Trista Aarnes-Leong, RHIT, CTR, Cancer Registry Warren Allen, MD, Pathology; Cancer Conference Coordinator Breast Cancer Report – Alice P. Chung, MD 3 Richard Andersen, PharmD, Pharmacy Robert Andrews, MD, Otolaryngology 2008 Primary Site Table 6 Julie Ascher, Regulatory Compliance Manager Cancer Registry Stats 7 Mary Bomba, MDiv, Chaplain Services Stanley Brosman, MD, Urology Cancer Liaison Physician Report 9 Mary Jo Byrne, MSW, Social Work Rebecca Crane-Okada, PhD, RN, AOCN, CNS, Clinical Nurse Researcher Pain Management Pharmacist 2008 Report 10 Maggie DiNome, MD, General Surgery; Community Outreach Coordinator Margaret Eade, Service Line Director Spiritual Care Report 13 Teresa Fan, PharmD, Pharmacy Janice Frost, RN, Interim Oncology Director Social Services Report 13 Mark Faries, MD, Surgical Oncology; QA Coordinator Positive Appearance Center Report 14 Tiffany Grunwald, MD, Plastic Surgery Omid Hamid, MD, Hematology/Oncology Community Education – Cancer Center Outreach 14 Kathryn A. Henick, MD, Hematology/Onc; Cancer Registry Data Coordinator Chia Chi Kao, MD, Plastic Surgery Pathology Department 15 Daniel F. Kelly, MD, Neurosurgery Ian Levin, MD, Diagnostic Radiology Cancer Conferences 1 16 Mary Luthy, Community Benefits Doug Maier, Regulatory Affairs Diagnostic Radiology 17 Michael Nicholl, MD, Surgical Oncology Cancer Registry 17 Margaret Pfeiffer, RN, MSN, Vice President Patient Care Lisa Schwartz, MD, Radiation Oncology Inpatient & Outpatient Services 18 Gagandeep Singh, MD, Cancer Liaison Physician Deb Weintraub, MPH, American Cancer Society JWCI Breast Center 19 Saint John’s Health Center • 1328 Twenty Second Street • Santa Monica, CA 90404 • www.cancercenters.stjohns.org
  • Letter from the Chairman As chairman of the Saint John’s Health Center Cancer Committee, I am pleased to present our 2008 Oncology Annual Report. The Cancer Program at Saint John’s Health Center continues to grow and expand. The Oncology Annual Report details the activities of the Cancer Program at Saint John’s Health Center but some of the highlights include: • In-depth Analysis of Breast Cancer by Dr. Alice Chung • Cancer Liaison Physician Report • Cancer Registry Statistics • Pain Management Report • Clinical Trials Report • Community Outreach Report The Cancer Committee sets goals each year. The following goals were set and achieved in 2008: • Community Outreach Activities that included programs presented on Colorectal Health, Melanoma Awareness, and updates on Breast Cancer Research & Treatment. • Quality Improvement Activities included Patient Satisfaction Scores, Improvement in Turn Around Time for Physician Orders, and Decreasing Patient Length of Stay. • Clinical Improvement Activities for staff included a pain management symposium for nursing personnel, pain management education for new nursing graduates, and pain assessment education for staff. • Programmatic endeavors include on-going review and updates on the cancer program standards to ensure compliance at the time of three year accreditation survey. Breast cancer is the focus of this Oncology Annual Report. Dr. Alice P. Chung, Assistant Director of the Breast Center at Saint John’s Health Center evaluated the survival and treatment options for patients with breast cancer. Our Cancer Program would not be the success it is without the support and enthusiasm of its members. I would like to thank all of the physicians, nurses, and administrative staff who have graciously offered their time and talent to making our Cancer Program a success throughout the 2008 year. Sincerely, Robert Wollman, MD Department of Radiation Oncology Chairman, Cancer Committee 1
  • 5 Robert Wollman, MD
  • Alice P. Chung, MD 2008 Oncology Report: Breast Cancer At Saint John’s Health Center Alice P. Chung, MD opening of the new Howard Keck Center, patients will have Assistant Director, Breast Center access to the most updated technology in breast imaging, Saint John’s Health Center; Lead Investigator housed in the Margie and Robert E. Petersen Breast Center, as well as radiation oncology, located in the Vasek Polak Partha S. Ray, MD Radiation Therapy Center. The Positive Appearance Center, Surgical Oncology Fellow, John Wayne located in the Breast Center, carries an array of garments Cancer Institute; Co-Investigator that address the cosmetic side effects of breast cancer. Treatment for our patients is tailored to each individual B reast cancer affects about 1 out of and may include surgical excision with or without breast every 7 women and is the second reconstruction, chemotherapy or hormonal therapy with the most common malignancy in women, opportunity to participate in national clinical trials, genetic counseling, and prevention and treatment of lymphedema. following skin cancer. It is the second leading cause of cancer-related death in With the latest recommendations set forth by the U.S. women after lung cancer. Approximately Preventive Services Task Force, screening guidelines 200,000 new breast cancer cases are for breast cancer have come into question. Along diagnosed each year, and over 40,000 with the American Cancer Society, Saint John’s Health breast cancer deaths are reported per year. Center recognizes the importance of early detection in the prevention and treatment of breast cancer. The following breast cancer screening guidelines have The John Wayne Cancer Institute at Saint John’s Health been maintained by the American Cancer Society: Center, where the sentinel node biopsy was pioneered by Drs. Donald Morton and Armando Giuliano, is recognized 1. Annual screening mammography starting at age 40 as one of the largest tertiary referral centers in the greater 2. Clinical breast examination every 3 years Los Angeles area for patients with breast cancer. With the between age 20-39, and yearly at age 40 3
  • 3. Self breast examination monthly starting at age 20 Figure 1: Breast Cancer Patients by TNM Stage: One modification that has been made in the guidelines as a result of the U.S. Task Force recommendations is that women should be counseled that self breast examination has both benefits and limitations. Because research has shown that self breast examination plays a very small role in cancer detection, it is now acceptable for women to choose not to do this exam or to do it less frequently. Women who are considered to have an increased risk of breast cancer should speak to their physicians about the most appropriate screening program, which may include the addition of breast MRI. Significant risk factors include strong family history, genetic mutation carriers, and prior radiation exposure to the chest wall. Figure 2: Breast Cancer Patients by Age at Diagnosis: Saint John’s Experience 2008: In the year of 2008, 438 patients were diagnosed with breast cancer, and 485 were treated for breast cancer at Saint John’s Health Center. Nineteen percent presented with Stage 0 disease; 43% were Stage I; 25% were Stage II; 9% were Stage III, and 2% presented with Stage IV disease (Figure 1). Over 50% of patients were diagnosed between the ages of 50 and 69. However, 23% presented between the age of 30 and 49, and 24% of patients were over 70 (Figure 2). The primary diagnosis was infiltrating ductal carcinoma, followed by infiltrating lobular carcinoma and ductal Figure 3: Breast Cancer Patients by Histologic Type: carcinoma in situ, with a small percentage of patients presenting with other subtypes (including micropapillary invasive carcinoma and mucinous adenocarcinoma) (Figure 3). Over 60% of patients were treated with surgery alone as the first course of treatment, while 15% were treated with surgery and radiation alone. Those that had chemotherapy and/or hormonal therapy in addition to surgery as their first course of treatment represented less than 10% of all breast cancer cases (Figure 4). In 2008, there were 4 breast cancer deaths and 38 breast cancer recurrences that presented at Saint John’s Health Center. Of the recurrences, 22 were local recurrences, 14 were distant recurrences, and 2 were recurrences of unknown type. 4
  • Figure 4: First Course Treatment Summary: Many surgeons argue that performing the SNB prior to initiating chemotherapy provides more accurate staging than doing the procedure after treatment, since the true effects of preoperative chemotherapy on the accuracy of SNB are unknown. Opponents of this argument believe that SNB performed after chemotherapy can spare patients an additional operation by doing the axillary staging at the same time as the removal of the breast cancer without significantly compromising the accuracy of the SNB. The Z-1071 trial is enrolling patients with needle biopsy proven node- positive breast cancers, which are undergoing preoperative Advances in Breast Cancer Therapy chemotherapy, to have SNB and axillary lymph node dissection after chemotherapy. The estimated enrollment Saint John’s physicians are involved in a number of research for this multicenter trial is 550, and this trial is now open activities in an effort to improve treatment, survival, and to patients at Saint John’s Health Center. On completion, quality of life for breast cancer patients. Under the direction this trial will determine the accuracy of SNB in node- of Armando Giuliano, M.D., Chief of Medicine and Science positive breast cancer patients after completing preoperative and the John Wayne Cancer Institute and Director of the new chemotherapy. Margie and Robert E. Petersen Breast Center, Saint John’s Health Center has been active in participating in breast cancer The John Wayne Cancer Center has recently been accepted clinical trials, including multicenter randomized trials, such as an active site for the National Surgical Adjuvant Breast as those led by the American College of Surgeons Oncology and Bowel Project (NSABP) cooperative group. Through Group (ACOSOG). Patients enrolled in the ACOSOG this affiliation, additional multicenter clinical breast cancer Z-10 and Z-11 trials have been followed for the acquisition trials will soon become available to patients at Saint John’s of long-term outcome data to address the clinical question Health Center. In addition to multicenter trials, the John of the prognostic significance of micrometastases in breast Wayne Cancer Institute/Saint John’s Health Center has also cancer. In addition, two additional ACOSOG trials have been active in enrolling patients to clinical trials within its recently been opened for enrollment at the John Wayne own institution. These trials include the study of outcome Cancer Institute/Saint John’s Health Center: Z-1031 and in patients undergoing mastectomy with nipple-preservation Z-1071. and breast reconstruction. This trial has recently been modified to evaluate the safety of this procedure particularly Women with large breast tumors frequently present as an in women who are carriers of the gene mutations, BRCA1 operative challenge, meaning the tumor may be difficult to and BRCA2. Saint John’s Health Center physicians have also remove with breast conservation therapy or even mastectomy. collaborated with basic science laboratories at JWCI for the In such cases when the tumor responds to estrogen, study of breast cancer biomarkers. In addition, collaboration treatment with a hormonal therapy agent or anti-estrogen, with a biomedical imaging company, known as IntraMedical such as an aromatase-inhibitor, may result in shrinkage of the Imaging, has led to a study to evaluate the efficacy of a tumor that will improve the operability of the tumor. The novel hand-held camera to detect microscopic disease at the Z-1031 is investigating three different aromatase-inhibitors margins of the lumpectomy cavity in patients undergoing in post-menopausal women presenting with T2-T4 breast breast conservation therapy. cancer to determine the most effective therapy in this setting. The goal is to enroll a total of 567 patients, and Saint John’s In conclusion, there have been tremendous strides in the Health Center is now a participating site for this trial. On diagnosis and treatment of breast cancer. The survival of completion, this trial will determine the best hormonal breast cancer is increasing with an estimated 2.5 million therapy to use in postmenopausal women in the preoperative breast cancer survivors in the United States today. Saint John’s setting. Health Center is at the forefront of breast cancer research and treatment and our physicians continue to practice their Another area of controversy in breast cancer is the optimal commitment to the education, treatment, and prevention of timing of lymph node evaluation by the sentinel node biopsy breast cancer. (SNB) in patients undergoing preoperative chemotherapy. 5
  • 2008 Primary Site Table Site Total Class Sex Stage Group Cases Analytic NonAn M F Stage 0 Stage I Stage II Stage III Stage IV N/A Unk. ALL SITES TOTALS 2052 1746 306 825 1227 252 595 318 177 155 196 53 LIP 1 1 0 0 1 0 1 0 0 0 0 0 TONGUE 13 12 1 5 8 0 5 1 1 4 0 1 SALIVARY GLANDS, MAJOR 9 8 1 5 4 0 3 0 1 4 0 0 FLOOR OF MOUTH 1 1 0 1 0 0 0 0 0 1 0 0 MOUTH, OTHER & NOT 2 1 1 0 2 0 1 0 0 0 0 0 OTHERWISE SPECIFIED TONSIL 4 3 1 4 0 0 0 0 0 3 0 0 NASOPHARYNX 1 1 0 0 1 0 0 0 1 0 0 0 HYPOPHARYNX 1 1 0 1 0 0 0 1 0 0 0 0 ESOPHAGUS 5 4 1 5 0 0 0 1 0 2 0 1 STOMACH 20 14 6 12 8 0 5 2 1 6 0 0 SMALL INTESTINE 5 5 0 2 3 0 1 0 0 1 3 0 COLON 100 87 13 40 60 3 24 20 18 21 1 0 RECTUM & RECTOSIGMOID 34 25 9 22 12 2 5 3 8 2 4 1 ANUS,ANAL CANAL,ANORECTUM 12 8 4 5 7 4 1 2 0 0 1 0 LIVER 18 16 2 10 8 0 3 2 4 5 0 2 GALLBLADDER 1 1 0 1 0 0 0 0 0 1 0 0 BILE DUCTS 12 10 2 9 3 0 6 1 0 0 0 3 PANCREAS 38 21 17 18 20 0 3 8 1 9 0 0 RETROPERITONEUM 1 1 0 1 0 0 0 0 0 1 0 0 PERITONEUM,OMENTUM,MESENT 4 3 1 0 4 0 0 0 0 0 3 0 OTHER DIGESTIVE 1 1 0 0 1 0 0 0 0 0 1 0 NASAL CAVITY,SINUS,EAR 2 2 0 1 1 0 0 0 0 0 2 0 LARYNX 5 5 0 5 0 0 2 0 0 2 0 1 LUNG/BRONCHUS-SMALL CELL 8 6 2 4 4 0 1 0 1 4 0 0 LUNG/BRONCHUS-NON SM CELL 78 64 14 30 48 2 13 2 17 26 1 3 PLEURA 1 1 0 0 1 0 0 1 0 0 0 0 LEUKEMIA 52 33 19 29 23 0 0 0 0 0 33 0 MYELOMA 13 10 3 5 8 0 0 0 0 0 10 0 OTHER HEMATOPOIETIC 18 15 3 13 5 0 0 0 0 0 15 0 BONE 6 2 4 5 1 0 1 0 0 0 0 1 SOFT TISSUE 31 14 17 17 14 0 4 2 5 3 0 0 MELANOMA OF SKIN 510 453 57 303 207 117 228 51 32 12 0 13 KAPOSI’S SARCOMA 1 0 1 0 1 0 0 0 0 0 0 0 OTHER SKIN CANCER 6 6 0 2 4 0 1 0 3 0 2 0 BREAST 533 498 35 6 527 97 213 124 45 7 0 12 CERVIX UTERI 6 3 3 0 6 0 2 1 0 0 0 0 CORPUS UTERI 32 29 3 0 32 0 15 0 5 1 5 3 UTERUS NOS 1 0 1 0 1 0 0 0 0 0 0 0 OVARY 24 17 7 0 24 0 1 4 6 2 1 3 VAGINA 3 3 0 0 3 1 1 0 0 0 1 0 VULVA 6 5 1 0 6 2 0 1 1 0 0 1 OTHER FEMALE GENITAL 2 2 0 0 2 0 0 0 0 0 2 0 PROSTATE 114 92 22 114 0 0 1 76 8 5 0 2 TESTIS 6 5 1 6 0 0 4 0 0 0 1 0 PENIS 1 0 1 1 0 0 0 0 0 0 0 0 BLADDER 48 41 7 32 16 24 11 4 0 1 0 1 KIDNEY AND RENAL PELVIS 20 13 7 13 7 0 8 2 3 0 0 0 URETER 2 2 0 1 1 0 1 0 0 1 0 0 EYE 3 0 3 3 0 0 0 0 0 0 0 0 BRAIN 14 12 2 8 6 0 0 0 0 0 12 0 OTHER NERVOUS SYSTEM 38 35 3 10 28 0 0 0 0 0 35 0 THYROID 44 39 5 13 31 0 20 1 8 9 0 1 OTHER ENDOCRINE 56 43 13 25 31 0 0 0 0 0 43 0 HODGKIN'S DISEASE 10 9 1 4 6 0 2 2 2 2 0 1 NON-HODGKIN'S LYMPHOMA 51 43 8 24 27 0 8 6 6 20 0 3 UNKNOWN OR ILL-DEFINED 24 20 4 10 14 0 0 0 0 0 20 0 6
  • Saint John's Health Center Caseload Trend 1999-2008 2500 2000 256 307 288 278 245 225 313 187 282 243 1500 1000 1773 1745 1678 1669 1666 1661 1580 1578 1459 1375 500 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Year at Diagnosis Analytic Non-Analytic 2008 Cases - Stage at Diagnosis Num ber of Cases 0 100 200 300 400 500 600 700 Stage 0 - 14.4% Stage I - 34.1% Stage II - 18.2% Stage III - 10.1% Stage IV - 8.9% Not Applicable 11.2% Unknown - 3% 7
  • Sex Female Male 0 200 400 600 800 1000 1200 2008 Total Cases 2008 Age at Diagnosis 0 -19 (0.3%) 20 - 29 (2%) 30 - 39 (5.4% 40 - 49 (12.3% 50 - 59 (22.1% 60 - 69 (22.6%) 70 - 79 (19.1% 80 - 89 (14.5% 90 - 99 (2.1%) 0 50 100 150 200 250 300 350 400 Number of Cases 90 - 99 80 - 89 70 - 79 60 - 69 50 - 59 40 - 49 30 - 39 20 - 29 0 -19 (2.1%) (14.5% (19.1% (22.6%) (22.1% (12.3% (5.4% (2%) (0.3%) Series1 36 253 334 395 385 214 94 29 6 8
  • Cancer Liaison Physician Report 2008 In 2008 the Cancer Program at Saint John’s Health Center At Saint John’s total patient care extended beyond medical continued its primary goal of providing innovative, therapy for cancer to include a multi-specialty group of comprehensive cancer care to fully satisfy its patient’s non-physicians at the service of our patients. Social service, needs. With over 142,000 new cases expected in California spiritual care and specialized nursing services ensured that for 2008, this task was a daunting, but welcome one. emotional and spiritual support needs of our patients were met and exceeded. As palliative care became a national issue, Throughout the year, Saint John’s physicians continued Saint John’s was at the forefront with our palliative care team. their dedication to high quality research into epidemiology, translational therapeutics, and clinical medicine in order In 2008 Saint Johns continued to exhibit the qualities to promote advances in treatment, survival, and quality that have made it a recognized national leader in of life for cancer patients. As in previous years, data cancer care. With the continued promise to this level obtained from this research was presented and well of care that the New Saint John’s Hospital and the received at various national and international meetings. upcoming Chan Soon-Shiong Center for Translational In this year’s Cancer Program Annual Report, Dr. Sciences hold, the future can only be brighter. Alice Chung highlights Saint John’s similar leadership activities in regard to Breast Cancer throughout 2008. Education remained a top priority in 2008. The physicians at Saint John’s continued their mission to inform health professionals and educate citizens regarding specific health risks, early detection, and treatment for cancers Omid Hamid, MD known to be elevated in their communities. Multiple Medical Oncology educational symposia and community outreach projects ensured that this goal was met and exceeded by our Cancer Liaison Physician physicians; a responsibility to improve clinical practice at the local level and collaborate with local agencies to reduce the burden of cancer in the community. 9
  • Cancer Committee 2008 Pain Management Pharmacist Report 2008 In 2008, the pain management pharmacist (PMP) made pain assessments and provided management to 1,497 patients who were on PCA and/or epidural infusion, daily, Monday through Friday (Fig. 1). In addition, the PMP also followed patients who were on the comfort care and palliative care for pain and symptoms management. Figure 1 illustrates the trend in the number of PCA patients seen by the pain pharmacist in the last 9 years. Figure 1. • In 2006, the total number of PCA patients was lower than previous years. There # PCA PATIENTS IN 2008 was a change in pain management practice with one of the orthopedic group. 1963 Instead of having PCA as a scheduled UCL 1886.4 1863 medication, it now changed to be used only when other medications fail. 1763 • In 2007, there was a noticeable 1663 (10%) increased in PCA patients, as # PCA patients 1563 CL 1546.8 compared to 2006. The increased 1463 in PCA patients in 2007 may be due to more surgeons are joining their 1363 practices at St John Health Center. 1263 LCL 1207.2 • In 2008, the total number of PCA 1163 patients captured on this report was 1063 12.4% lower than previous year due to 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 the pain pharmacist’s personal leave. YEAR The PMP presented a semi-annual quality assurance report on pain management to the Pharmacy and Therapeutic Committee (P&T). The report included data such as the number of PCA, comfort care and palliative care patients seen by the PMP, numbers and types of interventions, drug utilization reviews, adverse events, and medication errors. The P&T Committee reviews all protocol exceptions, therapeutic updates, formulary issues and other problem encountered. Pain Management Pharmacist Daily Activities in 2008 A. Clinical Activities • Manage PCA and epidural patients. • Provide consultation on patients through pain pharmacist referral program. (see Fig. 2) • Evaluate and provide pain and symptoms management on comfort care and palliative care patients. • Provide “mandatory “pain consultation by admission diagnosis of pain. • Review Omnicell dispensing and overrides reports. • Attend multidisciplinary discharge rounds and patient care case conference. 10
  • Cancer Committee 2008 Pain Management Pharmacist Report 2008 B. Omnicell Review Figure 2. The PMP continues to review Omnicell (automated system) PAIN PHARMACIST REFERRALS YEARLY CHART dispensing and overrides reports as 337 part of the medication monitoring and utilizing reviews. At Saint John 287 UCL 292.4 Health Center, medication profiling interfaces with the Omnicell. The 237 nursing staff requests to have certain #Pain Rx referrals medications that can be overridden 187 CL 176.3 for emergency or urgent uses. Occasionally medication errors and 137 drug diversion are found during the reviews. 87 LCL 60.1 C. Special Projects 37 A one-month retrospective data collection was done to evaluate safety -13 of using combination analgesic 2002 2003 2004 2005 2006 2007 2008 products in post-cesarean section YEAR patients in October 2008. I. Background information: 1. Combination analgesic products are described as products that contain an opioid plus acetaminophen in this data collection. 2. Safety of acetaminophen use is described as acetaminophen use ≤ 4 grams per day in patients with normal liver function. 3. Under medication section of the physician order set, “order set post partum” offered the choice of using Percocet, Darvocet N-100 and Tylenol for breakthrough pain. II. Data collection methods: 1. Using billing and DRG codes to generate a list of patients who were post-cesarean patients in October 2008. 2. Reviewed opioids used from Omnicell reports in post-cesarean patients in October 2008. 3. Opioids being reviewed included combination analgesic products that contain acetaminophen. 4. Patients who received acetaminophen >4 grams per day were considered as having excessive doses of acetaminophen that may increase potential risk of hepato-toxicity. III. Findings: 1. A total of 160 postpartum patients were identified in October, which included 49 post-cesarean patients and 111 patients with vaginal delivery. 2. 7 out of 49 (14.3%) post-cesarean patients received greater than 4 grams of acetaminophen per day during this review. 3. 88% of the postpartum patients have orders for NSAIDs. 4. Current postpartum order set have Tylenol, Darvocet N-100 and Percocet available in check off boxes for mild, moderate and severe pain. 4a. According to regulatory guidelines, no more than one medication should be checked off for mild pain, no more than one medication should be checked off for moderate pain, and no more than one medication should be checked off for severe pain. 4b. 55/160 (34.4%) patients had orders checked for Darvocet N-100 and Percocet (either 3 out of 4 orders, or all 4 orders). 4c. 6/160 (3.75%) patients had Darvocet N-100 ordered for pain management. 4d. Overall only 12/160 (7.5%) patients received Darvocet N-100. 11
  • IV.Items discussed with nursing educator and director at the OB/GYN units: 1. Regulatory level: Multiple opioids prescribed for moderate and severe pain. 2. Use of NSAIDs on schedule basis if no contraindication (provides synergistic effect with opioids) 3. Pain management issue: Darvocet N-100 (propoxyphene) is a poor analgesic. (American Pain Society and JCAHO discouraged use of propoxyphene for chronic pain management) 4. Opioids are being ordered as Q3H on the order set (exceeds 4 grams of acetaminophen a day) 5. St John’s is the only Sister Charity Hospitals using Percocet-5 in the postpartum order set. 6. Revise postpartum order set. V. Recommendation: 1. Report findings to OB Committee. 2. Revise medication section of the order set for post partum. 3. Continue the use of NSAIDs in postpartum patients on schedule basis if no contraindication. 4. Delete Darvocet N-100 from the postpartum order set. 5. Changing oxycodone/acetaminophen 5/325 (Percocet-5) to q4h if needed for pain (not to exceed 12 tablets/day). 6. Adding hydrocodone/acetaminophen 5/500mg (Vicodin) q4h if needed for pain (not to exceed 8 tablets/day). D. Education by The PMP in 2008 • Pain lectures to ICU training series. • Pain lectures to new grad/hires during orientation. • Pain management work rounds with UCLA Masters clinical nursing programs. • Pain management work rounds with new hires. • Pain management work rounds with USC 4th year pharmacy school student. • A lecture on “Update on pain management” was given at Saint John’s Nursing Oncology Symposium. E. Publication The PMP, together with the clinical coordinator of the pharmacy department, published an article in the American Journal of Health-System Pharmacists (AJHP) highlighting the role of the PMP at St John’s Health Center. Pain Management Pharmacy Service In a Community Hospital. Teresa Fan, Tanya Elgourt. Am J Health-Syst Pharm- Vol 65 Aug 15, 2008 1-6 12
  • Spiritual Care 2008 C ancer challenges the whole person: physical, emotional and spiritual. At Saint John’s Health Center, the Spiritual Care Department attends to the spiritual and emotional needs of patients and their families. An interfaith chaplain, trained in Clinical Pastoral Education (CPE) and board certified, visits oncology patients on the inpatient unit and on referral to the John Wayne Cancer Institute Breast Center and Cancer Center. Respectful of the many belief systems, faith traditions, and cultural practices of our patient population, the interfaith chaplain helps patients and families draw upon their own spiritual resources. Patients may also choose to receive visits from our faith-specific chaplains, including a full-time Catholic priest, a visiting rabbi and visiting Protestant clergy, or they may request our assistance in contacting a representative from their own faith community. Chaplains can help patients address the existential questions that often arise with a diagnosis of cancer. They can help patients manage stress, gain perspective, and renew hope. Chaplains participate in rounds and are an integral part of the interdisciplinary care team. T otal patient care extends beyond that provided by physicians and nurses. A diagnosis of cancer brings with it profound psychological trauma. Patients and their families are under a tremendous amount of pressure to cope effectively with the treatments, side effects and anxieties that accompany the diagnosis. Clinical social workers assist patients and family members in navigating their way through the disease process beginning with initial diagnosis and throughout corresponding treatment. They provide crisis intervention, brief insight oriented psychotherapy, guided meditation for stress reduction, conflict resolution, assistance with health care directives, improved communication with the treatment team, discussion of end of life issues, maintenance of a resource library and support for staff members. They refer to national and local agencies such as American Cancer Society, Wellness Community, Our House and We Spark and in an effort to support both the patients and their families. In addition, social workers facilitate programs such as Aim at Melanoma to increase cancer awareness and promote preventive interventions both medical and non medical within the community. 13
  • Positive Appearance Center 2008 The Positive Appearance Center, a non- profit facility, was the first of its kind on the Westside to address the cosmetic side effects and comfort needs related to cancer treatment. The Center has a warm boutique-like setting which provides a nurturing environment where cancer patients may receive individualized and specialized care. The Center offers an array of products and services to meet the needs of men and women undergoing cancer treatment. The Positive Appearance Center carries breast prostheses, mastectomy bras, camisoles, and bathing Community Education– suits as well as wigs and other alternatives including Cancer Outreach Activities Calendar Year 2008: hats, caps, turbans and scarves. The Positive The Community Education Program offered a Appearance Center also carries support garments for variety of programs, classes, health fairs and lymphedema and has a certified fitter on staff for both screenings for our community. In 2008, the compression garments and mastectomy prosthesis and following Community Education Forums were held: bras. There is no charge for fittings or consultations. Colorectal Cancer Awareness In addition, the Positive Appearance Center carries Wednesday, March 19, 2008-2:00 to 4:00 p.m. skin care products, sun blocks and sun protective Santa Monica Public Library, MLK Jr. Auditorium hats, especially important for melanoma patients. The Positive Appearance Center also hosts the Look Good, Speakers: Saint John’s oncologist, Sean Fischer, MD; Feel Better program sponsored by the American Saint John’s gastroenterologist Martha Hierro, MD; Saint Cancer Society. John’s surgeon Gagandeep Singh, MD; and Director, Saint John’s Medical Radiology Dept. Ira Smalberg, MD The Positive Appearance Center is open for walk-in Spot A Spot-Melanoma Prevention visits Monday through Friday from 10 am to 4pm. Tuesday, May 13, 2008-- 6:30-8:30 pm Appointments are encouraged, though not required, Wednesday, May 15, 2008—2:00 to 4:00 pm for fittings of prostheses and wigs. Home visits are Santa Monica Public Library-MLK Jr. Auditorium available when needed. Speakers: Saint John’s oncologist, Omid Hamid MD, The Positive Appearance Center is located in the John Michael B Nicholl, MD (JWCI Fellow), Leonard W. Wayne Cancer Institute Breast Cancer at Saint John’s Sender, MD, Medical Director of Cancer Institute at Health Center. Children’s Hospital of Orange County, and Ali Ansary, Director National Melanoma Awareness Project 14
  • Pathology Department 2008 T he Saint John’s Department of prognosis. The full resources of the Saint John’s Laboratory Pathology and Laboratory Medicine are often involved, including Hematology Flow Cytometry provides key laboratory support during testing for the characterization of leukemias and lymphomas. all phases of diagnosis and management of Each pathologist has areas of expertise, such as cancers of cancer patients. The Anatomic Pathology Department the skin, of the breast, or of bone marrow, all of which is composed of eight board-certified pathologists are frequently shared so that most cancer diagnoses are plus key supporting staff such as pathology assistants, the product of a wealth of knowledge and experience. cytotechnologists, histotechnologists and secretarial staff. This team is responsible for the accurate diagnosis, grading When patients are undergoing therapy at Saint John’s, and staging of all cancers that present and are treated at Saint the Laboratory provides an extensive menu of key tests John’s Health Center and the John Wayne Cancer Center. to assess the patient’s status and to ensure their safety. Monitoring for toxicity of certain chemotherapies, assessing The pathologists work closely with clinicians, surgeons bone marrow response to therapy, and following tumor and interventional radiologists during the biopsy and markers are some of the tests that oncologists rely upon. surgical phase of cancer care to assure that diagnostic This support is one of the reasons that modern cancer material is adequate and of sufficient quality. This care has become so remarkably effective and safe. frequently requires making immediate cytologic or frozen section diagnoses during biopsy procedures. Other integral services provided by the department include intra-operative consultation with frozen section During the diagnosis phase of cancer care, pathologists diagnosis, performance of bone marrow biopsies and and lab personnel engage in an ongoing dialogue with fine needle aspiration biopsies of both palpable and the treating medical oncologists, radiation therapists and deep-seated tumors. Since the John Wayne Cancer oncologic surgeons to provide the information necessary Center and many Saint Johns associated physicians are for cancer patients to receive the correct therapy for their actively involved in research protocols, the pathology particular cancer. The department relies on molecular department has collaborated in the publication of many diagnostic techniques such as immunochemistry to assist ground-breaking clinical studies affecting cancer care. in determining the type of cancer cells involved and their 15
  • Cancer Conferences 2008 C ancer Conferences at Saint John’s Health Center are multidisciplinary, and include Breast Conference, Neuro-Endocrine Conference, Pre- Op Surgical Conference, Gastroenterology Conference, Research Conference and General Tumor Board. The conferences are attended by physicians from all specialties. Physicians representing the fields of General Surgery, Surgical Oncology, Neurosurgery, Hematology/Oncology, Radiation Oncology, Diagnostic Radiology, Pathology, Internal Medicine, Family Practice, Pulmonary, Gastroenterology, and Plastic Surgery all attended Cancer Conferences in 2008. Cancer Conferences focus on pretreatment evaluation, staging, Mark Faries, MD treatment strategies, referrals to research protocols and rehabilitation. Cancer Conference Calendar In 2008, there were a total of 140 meetings, with 296 cases Breast Cancer Tumor Board presented. Of the total cases presented, 100% were prospective • Every Monday at 8 a.m. 3 West cases. The primary sites presented reflect our caseload, with the General Tumor Board most number of cases presented being breast and melanoma. • 2nd Wednesday at 8 a.m. The other primary sites presented include but were not limited to: 3 West Bladder, Colon, Esophagus, Gallbladder, Head and Neck, Leukemia, Gastroenterology Conference Liver, Lung, Lymphoma, Meningioma, Pancreas, Pituitary Gland, • Last Tuesday at 7:30 a.m. 3 West Prostate, Rectum, Small Bowel, Stomach, Testis, and Thyroid. Pre-Op Surgical Conference • Every Friday at 7:30 a.m. Jack Green Conference Room Research Conference • Wednesdays at 5:30 p.m. Jack Green Conference Room Neuro-Endocrine Conference • 4th Wednesday at 8 a.m. 3 West 16
  • Diagnostic Radiology 2008 T he Department of Imaging performs a full range of routine diagnostic procedures including CT, MRI and ultrasound. Interventional specialists perform therapeutic procedures such as chemoembolization and radiofrequency ablation of the liver under CT guidance. Specialized staff in the Breast Cancer perform stereo-tactic core biopsies and pre-operative localization of breast lesions. Cancer Registry T he Cancer Registry Department at Saint John’s Health Center is one of the five major components of being an approved cancer program through the American College of Surgeons (ACoS) Commission on Cancer (CoC). Accurate data collection is a priority of the cancer registry. This is achieved by coordinating the collection, management, analysis, lifetime follow-up and dissemination of the cancer registry data. Registry staff compiles a detailed computerized cancer-focused abstract on every patient who is diagnosed and/or treated at our facility. Cancer abstracting must be performed or supervised by a CTR using data standards defined by the CoC and the California Cancer Registry (CCR). Confidentiality is maintained on each patient entered into our database according to HIPAA regulations. In 2008, there were 2,052 new cancer cases added to the cancer data base. Of these, 1,746 were analytic cases (diagnosed and/or treated at Saint John’s during their first course of treatment) and 306 cases were non-analytic cases (patients receiving care at Saint John’s for recurrence of their disease). The entire data base exceeds 39,000 cases and includes both living and expired patients. Each month the cancer registry conducts ongoing follow-up estimated at 700-900 cases. These cases are updated on patient vital and disease status, recurrence and additional treatment information as indicated, as well as the patient’s current physician and family member contacts. The ACoS CoC requires that 90% of analytic cancer patients be updated annually with less than 10% of these cases being lost to follow-up. Follow-up is achieved by contacting patients, physicians and facilities on the current follow-up status. The data maintained by the Cancer Registry is available for use by the medical staff, hospital administration, and other health care professionals for special studies, end-results reporting, medical education, patient care evaluations, and research. In 2008, the Cancer Registry responded to approximately 50 requests for data from physicians, administrators, hospital staff, and outside sources. The data is used for treatment planning and evaluation, outcome measures, clinical research, and cancer program strategic planning. For information regarding the Cancer Registry or for data requests, please contact the Cancer Registry at (310) 829-8860. 17
  • Inpatient & Outpatient Services 2008 P atients requiring inpatient care are treated at Saint John’s Health Center’s 16-bed oncology unit, on the fourth floor of the Chan Soon-Shiong Life Sciences building. Having received intensive training and certification in oncology nursing, the staff is well qualified in caring for the specialized needs of oncology patients The oncology unit utilizes the interdisciplinary team approach to patient care management with daily patient care rounds, patient care conferences and bioethics consultations. The interdisciplinary team includes the oncology unit director, clinical social worker, pastoral care, rehabilitation services, certified oncology nurses, pharmacist and physicians. Case Managers provide discharge planning, emotional support and utilization review. Saint John’s Health Center offers a full range of referral based services from its’ world renown physicians at the John Wayne Cancer Institute and the Margie Peterson Breast Center. The Margie Peterson Breast Center operates a full service surgical clinic that provides consultations, pre-operative and post-operative treatment and follow- up. The highly skilled and dedicated nursing staff provides comprehensive teaching services to the newly diagnosed patient. The Department of Breast Imaging located within the Breast Center provides state of the art screening and diagnostic mammography exams, stereotactic breast biopsy procedures, ultrasound exams of the breast and ultrasound guided breast biopsy procedures. Bone Density exams are provided as well. The Breast Center works off the model of “one stop shopping” to provide same day clinical and imaging services to the patient’s they serve. Support groups for patients and families focus on cancer information, nutrition, stress management and coping strategies. A library and audio-visual resource center are open to all patients and family members as well as the public. Genetic screening is also available for patients and their families. The Positive Appearance Center is a unique, one-stop service, adjacent to the Breast Center that helps patients deal with the cosmetic side effects and comfort needs related to their disease and cancer treatment. Paul Song, MD 18
  • Armando E. Giuliano, MD JWCI Breast Center 2008 Report T he John Wayne Cancer Institute (JWCI) and its treatment. Both popular and professional books, Breast Center was founded in 1993 literature, and videotapes are available for patients and their by its current director, Armando E. families to use at the Center or to check out and take with Giuliano, M.D. The Breast Center, located within Saint them for further review. Internet access is also available for John’s Health Center (SJHC), provides multidisciplinary care patient and family use. The Breast Center offers treatment to patients with breast problems. Cutting-edge research is for benign breast disease as well as a comprehensive performed under the umbrella of JWCI which supports and approach to the detection and management of cancer in its maintains the laboratories and administrative structure of the earliest forms. The program provides patients with breast breast program. Thus, the Breast Center functions in a unique cancer screening, breast health education, supportive care, environment that blends a rigorous academic program with and prevention strategies. Additionally the Center provides the beauty and efficiency of an extraordinary community interdisciplinary care for patients with complex problems hospital, Saint John’s Health Center, listed as one of the top in breast cancer. Patients are evaluated for multimodality 50 hospitals in the United States by AARP Modern Maturity treatment (surgery, radiation therapy, chemotherapy, and/ in May/June 2002. The state-of-the-art Breast Center was or hormonal therapy) by a team of physicians and nurses. recognized by Self magazine in 1999 as one of the 10 best The program approaches the patient as a whole person and breast centers in the United States. This recognition is based includes dedicated breast imaging, breast pathology, breast on outstanding patient care and new and innovative clinical, radiation oncology, surgical oncology, medical oncology, translational, and basic science research that is carried out in a nutritional counseling, psychosocial support, plastic and warm, inviting, and non-threatening setting. reconstructive surgery, community service and outreach, and research. We collaborate closely with the American Cancer The Breast Center has two surgical oncologists, three Society and the Wellness Community. dedicated breast imaging specialists, two endocrinologists (dedicated to the management of hormone deficiency The Breast Center offers its patients a level of medical syndrome in breast cancer), two full-time oncology nurses, expertise and an increasing repertoire of innovative one physician assistant, the Banchik Family Breast Cancer diagnostic and therapeutic procedures not available at most Library, and a Positive Appearance Center (to address body community hospitals and often not offered at other tertiary image issues). The Library offers a comfortable setting in cancer centers. For instance, the Breast Center is one of the which to review the latest information about breast cancer very few centers that also treat patients with breast disease- 19
  • related endocrine disorders such as osteoporosis and hormone deficiency syndrome. With the addition of our satellite digital imaging unit, more than 22,000 breast imaging studies were performed in 2008. There were nearly 850 new breast cancers, thyroid cancer, and parathyroid tumor cases evaluated in 2008. Annually there were over 12,000 patient visits. In 1999, the John Wayne Cancer Institute expanded its spectrum of academic training programs to include a Breast Fellowship for surgeons interested in advanced training in the field of breast disease. Commencing in 2002, the Society of Surgical Oncology (SSO) recognized the need for a discrete Breast Fellowship, and the JWCI Breast Center at SJHC Interdisciplinary Breast Fellowship program was subsequently approved by the SSO. In 2008, the number of fellows training in JWCI’s year- long program increased from one to two. The unique clinical resources of the Breast Center and the basic science resources of the JWCI have a proven track record in obtaining grant and philanthropic support and have made major contributions to the treatment and understanding of breast cancer. The sentinel node biopsy, which has altered breast cancer management throughout the world, was developed at this institution from a philanthropic grant. Commencing in 1991, this grant enabled us to perform the research that has resulted in a new way to treat breast cancer. This minimally invasive operation has had a major impact on the treatment of node-negative women, especially those who are postmenopausal. 20
  • Saint John’s Health Center • 1328 Twenty Second Street • Santa Monica, CA 90404 • www.cancercenters.stjohns.org