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Cancer Program Annual Report

2008

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Our Cancer Program would not be the success it is without the support and enthusiasm of its members. Robert Wollman, M.D.

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2008 Cancer Committee MembersSaint John’s Health Center

Robert Wollman, MD, Radiation Oncology, Chairman

Trista Aarnes-Leong, RHIT, CTR, Cancer Registry

Warren Allen, MD, Pathology; Cancer Conference Coordinator

Richard Andersen, PharmD, Pharmacy

Robert Andrews, MD, Otolaryngology

Julie Ascher, Regulatory Compliance Manager

Mary Bomba, MDiv, Chaplain Services

Stanley Brosman, MD, Urology

Mary Jo Byrne, MSW, Social Work

Rebecca Crane-Okada, PhD, RN, AOCN, CNS, Clinical Nurse Researcher

Maggie DiNome, MD, General Surgery; Community Outreach Coordinator

Margaret Eade, Service Line Director

Teresa Fan, PharmD, Pharmacy

Janice Frost, RN, Interim Oncology Director

Mark Faries, MD, Surgical Oncology; QA Coordinator

Tiffany Grunwald, MD, Plastic Surgery

Omid Hamid, MD, Hematology/Oncology

Kathryn A. Henick, MD, Hematology/Onc; Cancer Registry Data Coordinator

Chia Chi Kao, MD, Plastic Surgery

Daniel F. Kelly, MD, Neurosurgery

Ian Levin, MD, Diagnostic Radiology

Mary Luthy, Community Benefits

Doug Maier, Regulatory Affairs

Michael Nicholl, MD, Surgical Oncology

Margaret Pfeiffer, RN, MSN, Vice President Patient Care

Lisa Schwartz, MD, Radiation Oncology

Gagandeep Singh, MD, Cancer Liaison Physician

Deb Weintraub, MPH, American Cancer Society

Table of Contents

Saint John’s Health Center • 1328 Twenty Second Street • Santa Monica, CA 90404 • www.cancercenters.stjohns.org

Letter From The Chairman 1

Breast Cancer Report – Alice P. Chung, MD 3

2008 Primary Site Table 6

Cancer Registry Stats 7

Cancer Liaison Physician Report 9

Pain Management Pharmacist 2008 Report 10

Spiritual Care Report 13

Social Services Report 13

Positive Appearance Center Report 14

Community Education – Cancer Center Outreach 14

Pathology Department 15

Cancer Conferences 16

Diagnostic Radiology 17

Cancer Registry 17

Inpatient & Outpatient Services 18

JWCI Breast Center 19

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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,

Letter from the Chairman

Robert Wollman, MDDepartment of Radiation OncologyChairman, Cancer Committee

5Robert Wollman, MD

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Alice P. Chung, MD Assistant Director, Breast CenterSaint John’s Health Center; Lead Investigator

Partha S. Ray, MD Surgical Oncology Fellow, John Wayne Cancer Institute; Co-Investigator

Breast cancer affects about 1 out of every 7 women and is the second most common malignancy in women,

following skin cancer. It is the second leading cause of cancer-related death in women after lung cancer. Approximately 200,000 new breast cancer cases are diagnosed each year, and over 40,000 breast cancer deaths are reported per year.

The John Wayne Cancer Institute at Saint John’s Health Center, where the sentinel node biopsy was pioneered by Drs. Donald Morton and Armando Giuliano, is recognized as one of the largest tertiary referral centers in the greater Los Angeles area for patients with breast cancer. With the

opening of the new Howard Keck Center, patients will have access to the most updated technology in breast imaging, housed in the Margie and Robert E. Petersen Breast Center, as well as radiation oncology, located in the Vasek Polak Radiation Therapy Center. The Positive Appearance Center, located in the Breast Center, carries an array of garments that address the cosmetic side effects of breast cancer. Treatment for our patients is tailored to each individual and may include surgical excision with or without breast reconstruction, chemotherapy or hormonal therapy with the opportunity to participate in national clinical trials, genetic counseling, and prevention and treatment of lymphedema.

With the latest recommendations set forth by the U.S. Preventive Services Task Force, screening guidelines for breast cancer have come into question. Along with the American Cancer Society, Saint John’s Health Center recognizes the importance of early detection in the prevention and treatment of breast cancer. The following breast cancer screening guidelines have been maintained by the American Cancer Society:

1. Annual screening mammography starting at age 402. Clinical breast examination every 3 years

between age 20-39, and yearly at age 40

2008 Oncology Report: Breast Cancer At Saint John’s Health Center

Alice P. Chung, MD

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3. Self breast examination monthly starting at age 20

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.

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 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.

Figure 1: Breast Cancer Patients by TNM Stage:

Figure 2: Breast Cancer Patients by Age at Diagnosis:

Figure 3: Breast Cancer Patients by Histologic Type:

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Figure 4: First Course Treatment Summary:

Advances in Breast Cancer Therapy Saint John’s physicians are involved in a number of research activities in an effort to improve treatment, survival, and quality of life for breast cancer patients. Under the direction of Armando Giuliano, M.D., Chief of Medicine and Science and the John Wayne Cancer Institute and Director of the new Margie and Robert E. Petersen Breast Center, Saint John’s Health Center has been active in participating in breast cancer clinical trials, including multicenter randomized trials, such as those led by the American College of Surgeons Oncology Group (ACOSOG). Patients enrolled in the ACOSOG Z-10 and Z-11 trials have been followed for the acquisition of long-term outcome data to address the clinical question of the prognostic significance of micrometastases in breast cancer. In addition, two additional ACOSOG trials have recently been opened for enrollment at the John Wayne Cancer Institute/Saint John’s Health Center: Z-1031 and Z-1071.

Women with large breast tumors frequently present as an operative challenge, meaning the tumor may be difficult to remove with breast conservation therapy or even mastectomy. In such cases when the tumor responds to estrogen, treatment with a hormonal therapy agent or anti-estrogen, such as an aromatase-inhibitor, may result in shrinkage of the tumor that will improve the operability of the tumor. The Z-1031 is investigating three different aromatase-inhibitors in post-menopausal women presenting with T2-T4 breast cancer to determine the most effective therapy in this setting. The goal is to enroll a total of 567 patients, and Saint John’s Health Center is now a participating site for this trial. On completion, this trial will determine the best hormonal therapy to use in postmenopausal women in the preoperative setting.

Another area of controversy in breast cancer is the optimal timing of lymph node evaluation by the sentinel node biopsy (SNB) in patients undergoing preoperative chemotherapy.

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

chemotherapy, to have SNB and axillary lymph node dissection after chemotherapy. The estimated enrollment for this multicenter trial is 550, and this trial is now open to patients at Saint John’s Health Center. On completion, this trial will determine the accuracy of SNB in node-positive breast cancer patients after completing preoperative chemotherapy.

The John Wayne Cancer Center has recently been accepted as an active site for the National Surgical Adjuvant Breast and Bowel Project (NSABP) cooperative group. Through this affiliation, additional multicenter clinical breast cancer trials will soon become available to patients at Saint John’s Health Center. In addition to multicenter trials, the John Wayne Cancer Institute/Saint John’s Health Center has also been active in enrolling patients to clinical trials within its own institution. These trials include the study of outcome in patients undergoing mastectomy with nipple-preservation and breast reconstruction. This trial has recently been modified to evaluate the safety of this procedure particularly in women who are carriers of the gene mutations, BRCA1 and BRCA2. Saint John’s Health Center physicians have also collaborated with basic science laboratories at JWCI for the study of breast cancer biomarkers. In addition, collaboration with a biomedical imaging company, known as IntraMedical Imaging, has led to a study to evaluate the efficacy of a novel hand-held camera to detect microscopic disease at the margins of the lumpectomy cavity in patients undergoing breast conservation therapy.

In conclusion, there have been tremendous strides in the diagnosis and treatment of breast cancer. The survival of breast cancer is increasing with an estimated 2.5 million breast cancer survivors in the United States today. Saint John’s Health Center is at the forefront of breast cancer research and treatment and our physicians continue to practice their commitment to the education, treatment, and prevention of breast cancer.

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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 53LIP 1 1 0 0 1 0 1 0 0 0 0 0TONGUE 13 12 1 5 8 0 5 1 1 4 0 1SALIVARY GLANDS, MAJOR 9 8 1 5 4 0 3 0 1 4 0 0FLOOR OF MOUTH 1 1 0 1 0 0 0 0 0 1 0 0MOUTH, OTHER & NOT OTHERWISE SPECIFIED 2 1 1 0 2 0 1 0 0 0 0 0

TONSIL 4 3 1 4 0 0 0 0 0 3 0 0NASOPHARYNX 1 1 0 0 1 0 0 0 1 0 0 0HYPOPHARYNX 1 1 0 1 0 0 0 1 0 0 0 0ESOPHAGUS 5 4 1 5 0 0 0 1 0 2 0 1STOMACH 20 14 6 12 8 0 5 2 1 6 0 0SMALL INTESTINE 5 5 0 2 3 0 1 0 0 1 3 0COLON 100 87 13 40 60 3 24 20 18 21 1 0RECTUM & RECTOSIGMOID 34 25 9 22 12 2 5 3 8 2 4 1ANUS,ANAL CANAL,ANORECTUM 12 8 4 5 7 4 1 2 0 0 1 0LIVER 18 16 2 10 8 0 3 2 4 5 0 2GALLBLADDER 1 1 0 1 0 0 0 0 0 1 0 0BILE DUCTS 12 10 2 9 3 0 6 1 0 0 0 3PANCREAS 38 21 17 18 20 0 3 8 1 9 0 0RETROPERITONEUM 1 1 0 1 0 0 0 0 0 1 0 0PERITONEUM,OMENTUM,MESENT 4 3 1 0 4 0 0 0 0 0 3 0OTHER DIGESTIVE 1 1 0 0 1 0 0 0 0 0 1 0NASAL CAVITY,SINUS,EAR 2 2 0 1 1 0 0 0 0 0 2 0LARYNX 5 5 0 5 0 0 2 0 0 2 0 1LUNG/BRONCHUS-SMALL CELL 8 6 2 4 4 0 1 0 1 4 0 0LUNG/BRONCHUS-NON SM CELL 78 64 14 30 48 2 13 2 17 26 1 3PLEURA 1 1 0 0 1 0 0 1 0 0 0 0LEUKEMIA 52 33 19 29 23 0 0 0 0 0 33 0MYELOMA 13 10 3 5 8 0 0 0 0 0 10 0OTHER HEMATOPOIETIC 18 15 3 13 5 0 0 0 0 0 15 0BONE 6 2 4 5 1 0 1 0 0 0 0 1SOFT TISSUE 31 14 17 17 14 0 4 2 5 3 0 0MELANOMA OF SKIN 510 453 57 303 207 117 228 51 32 12 0 13KAPOSI’S SARCOMA 1 0 1 0 1 0 0 0 0 0 0 0OTHER SKIN CANCER 6 6 0 2 4 0 1 0 3 0 2 0BREAST 533 498 35 6 527 97 213 124 45 7 0 12CERVIX UTERI 6 3 3 0 6 0 2 1 0 0 0 0CORPUS UTERI 32 29 3 0 32 0 15 0 5 1 5 3UTERUS NOS 1 0 1 0 1 0 0 0 0 0 0 0OVARY 24 17 7 0 24 0 1 4 6 2 1 3VAGINA 3 3 0 0 3 1 1 0 0 0 1 0VULVA 6 5 1 0 6 2 0 1 1 0 0 1OTHER FEMALE GENITAL 2 2 0 0 2 0 0 0 0 0 2 0PROSTATE 114 92 22 114 0 0 1 76 8 5 0 2TESTIS 6 5 1 6 0 0 4 0 0 0 1 0PENIS 1 0 1 1 0 0 0 0 0 0 0 0BLADDER 48 41 7 32 16 24 11 4 0 1 0 1KIDNEY AND RENAL PELVIS 20 13 7 13 7 0 8 2 3 0 0 0URETER 2 2 0 1 1 0 1 0 0 1 0 0EYE 3 0 3 3 0 0 0 0 0 0 0 0BRAIN 14 12 2 8 6 0 0 0 0 0 12 0OTHER NERVOUS SYSTEM 38 35 3 10 28 0 0 0 0 0 35 0THYROID 44 39 5 13 31 0 20 1 8 9 0 1OTHER ENDOCRINE 56 43 13 25 31 0 0 0 0 0 43 0HODGKIN'S DISEASE 10 9 1 4 6 0 2 2 2 2 0 1NON-HODGKIN'S LYMPHOMA 51 43 8 24 27 0 8 6 6 20 0 3UNKNOWN OR ILL-DEFINED 24 20 4 10 14 0 0 0 0 0 20 0

Site Total Class Sex Stage

2008 Primary Site Table

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Saint John's Health Center Caseload Trend1999-2008

1459

1375

1669

1580 16

66

1678

1661

1578 17

73

1745

282

243

288

313 27

8

245

225

187

256

307

0

500

1000

1500

2000

2500

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Year at DiagnosisAnalytic Non-Analytic

2008 Cases - Stage at Diagnosis

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%

Number of Cases

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Sex

0 200 400 600 800 1000 1200

Male

Female

2008 Total Cases

0 50 100 150 200 250 300 350 400

Number of Cases

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%)

2008 Age at Diagnosis

Series1 6299421438539533425336

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%)

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In 2008 the Cancer Program at Saint John’s Health Center continued its primary goal of providing innovative, comprehensive cancer care to fully satisfy its patient’s needs. With over 142,000 new cases expected in California for 2008, this task was a daunting, but welcome one.

Throughout the year, Saint John’s physicians continued their dedication to high quality research into epidemiology, translational therapeutics, and clinical medicine in order to promote advances in treatment, survival, and quality of life for cancer patients. As in previous years, data obtained from this research was presented and well received at various national and international meetings. In this year’s Cancer Program Annual Report, Dr. 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 known to be elevated in their communities. Multiple educational symposia and community outreach projects ensured that this goal was met and exceeded by our 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.

At Saint John’s total patient care extended beyond medical therapy for cancer to include a multi-specialty group of non-physicians at the service of our patients. Social service, spiritual care and specialized nursing services ensured that emotional and spiritual support needs of our patients were met and exceeded. As palliative care became a national issue, Saint John’s was at the forefront with our palliative care team.

In 2008 Saint Johns continued to exhibit the qualities that have made it a recognized national leader in cancer care. With the continued promise to this level of care that the New Saint John’s Hospital and the upcoming Chan Soon-Shiong Center for Translational Sciences hold, the future can only be brighter.

Omid Hamid, MDMedical OncologyCancer Liaison Physician

Cancer Liaison Physician Report 2008

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Omid Hamid, MDMedical OncologyCancer Liaison Physician

Cancer Committee 2008

Pain Management Pharmacist Report 2008In 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.

• In 2006, the total number of PCA patients was lower than previous years. There was a change in pain management practice with one of the orthopedic group. Instead of having PCA as a scheduled medication, it now changed to be used only when other medications fail.

• In 2007, there was a noticeable (10%) increased in PCA patients, as compared to 2006. The increased in PCA patients in 2007 may be due to more surgeons are joining their practices at St John Health Center.

• In 2008, the total number of PCA patients captured on this report was 12.4% lower than previous year due to the pain pharmacist’s personal leave.

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.

# PCA PATIENTS IN 2008

1886.4UCL

1546.8CL

1207.2LCL

1063

1163

1263

1363

1463

1563

1663

1763

1863

1963

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008YEAR

# PC

A p

atie

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Figure 1.

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.

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B. Omnicell ReviewThe PMP continues to review Omnicell (automated system) dispensing and overrides reports as part of the medication monitoring and utilizing reviews. At Saint John Health Center, medication profiling interfaces with the Omnicell. The nursing staff requests to have certain medications that can be overridden for emergency or urgent uses. Occasionally medication errors and drug diversion are found during the reviews.

C. Special ProjectsA one-month retrospective data collection was done to evaluate safety of using combination analgesic products in post-cesarean section 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.

PAIN PHARMACIST REFERRALS YEARLY CHART

292.4UCL

176.3CL

60.1LCL

-13

37

87

137

187

237

287

337

2002 2003 2004 2005 2006 2007 2008YEAR

#Pai

n R

x re

ferr

als

Figure 2.

Cancer Committee 2008

Pain Management Pharmacist Report 2008

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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. PublicationThe 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

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Total 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.

Spiritual Care 2008

Cancer 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.

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The Community Education Program offered a variety of programs, classes, health fairs and screenings for our community. In 2008, the following Community Education Forums were held:

Colorectal Cancer AwarenessWednesday, March 19, 2008-2:00 to 4:00 p.m.Santa Monica Public Library, MLK Jr. Auditorium

Speakers: Saint John’s oncologist, Sean Fischer, MD; Saint John’s gastroenterologist Martha Hierro, MD; Saint John’s surgeon Gagandeep Singh, MD; and Director, Saint John’s Medical Radiology Dept. Ira Smalberg, MD

Spot A Spot-Melanoma PreventionTuesday, May 13, 2008-- 6:30-8:30 pmWednesday, May 15, 2008—2:00 to 4:00 pmSanta Monica Public Library-MLK Jr. Auditorium

Speakers: Saint John’s oncologist, Omid Hamid MD, Michael B Nicholl, MD (JWCI Fellow), Leonard W. Sender, MD, Medical Director of Cancer Institute at Children’s Hospital of Orange County, and Ali Ansary, Director National Melanoma Awareness Project

Community Education–Cancer Outreach Activities Calendar Year 2008:

Positive Appearance Center 2008The 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 suits as well as wigs and other alternatives including hats, caps, turbans and scarves. The Positive Appearance Center also carries support garments for lymphedema and has a certified fitter on staff for both compression garments and mastectomy prosthesis and bras. There is no charge for fittings or consultations.

In addition, the Positive Appearance Center carries skin care products, sun blocks and sun protective hats, especially important for melanoma patients. The Positive Appearance Center also hosts the Look Good, Feel Better program sponsored by the American Cancer Society.

The Positive Appearance Center is open for walk-in visits Monday through Friday from 10 am to 4pm. Appointments are encouraged, though not required, for fittings of prostheses and wigs. Home visits are available when needed.

The Positive Appearance Center is located in the John Wayne Cancer Institute Breast Cancer at Saint John’s Health Center.

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The Saint John’s Department of Pathology and Laboratory Medicine provides key laboratory support during

all phases of diagnosis and management of cancer patients. The Anatomic Pathology Department is composed of eight board-certified pathologists plus key supporting staff such as pathology assistants, cytotechnologists, histotechnologists and secretarial staff. This team is responsible for the accurate diagnosis, grading and staging of all cancers that present and are treated at Saint John’s Health Center and the John Wayne Cancer Center.

The pathologists work closely with clinicians, surgeons and interventional radiologists during the biopsy and surgical phase of cancer care to assure that diagnostic material is adequate and of sufficient quality. This frequently requires making immediate cytologic or frozen section diagnoses during biopsy procedures.

During the diagnosis phase of cancer care, pathologists and lab personnel engage in an ongoing dialogue with the treating medical oncologists, radiation therapists and oncologic surgeons to provide the information necessary for cancer patients to receive the correct therapy for their particular cancer. The department relies on molecular diagnostic techniques such as immunochemistry to assist in determining the type of cancer cells involved and their

prognosis. The full resources of the Saint John’s Laboratory are often involved, including Hematology Flow Cytometry testing for the characterization of leukemias and lymphomas. Each pathologist has areas of expertise, such as cancers of the skin, of the breast, or of bone marrow, all of which are frequently shared so that most cancer diagnoses are the product of a wealth of knowledge and experience.

When patients are undergoing therapy at Saint John’s, the Laboratory provides an extensive menu of key tests to assess the patient’s status and to ensure their safety. Monitoring for toxicity of certain chemotherapies, assessing bone marrow response to therapy, and following tumor markers are some of the tests that oncologists rely upon. This support is one of the reasons that modern cancer care has become so remarkably effective and safe.

Other integral services provided by the department include intra-operative consultation with frozen section diagnosis, performance of bone marrow biopsies and fine needle aspiration biopsies of both palpable and deep-seated tumors. Since the John Wayne Cancer Center and many Saint Johns associated physicians are actively involved in research protocols, the pathology department has collaborated in the publication of many ground-breaking clinical studies affecting cancer care.

Pathology Department 2008

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Cancer Conference Calendar

Breast Cancer Tumor Board• EveryMondayat8a.m.3West

General Tumor Board • 2ndWednesdayat8a.m.

3West

Gastroenterology Conference• LastTuesdayat7:30a.m.3West

Pre-Op Surgical Conference• EveryFridayat7:30a.m.Jack

GreenConferenceRoom

Research Conference• Wednesdaysat5:30p.m.Jack

GreenConferenceRoom

Neuro-Endocrine Conference • 4thWednesdayat8a.m.

3West

Cancer 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, treatment strategies, referrals to research protocols and rehabilitation.

In 2008, there were a total of 140 meetings, with 296 cases presented. Of the total cases presented, 100% were prospective cases. The primary sites presented reflect our caseload, with the most number of cases presented being breast and melanoma. The other primary sites presented include but were not limited to: Bladder, Colon, Esophagus, Gallbladder, Head and Neck, Leukemia, Liver, Lung, Lymphoma, Meningioma, Pancreas, Pituitary Gland, Prostate, Rectum, Small Bowel, Stomach, Testis, and Thyroid.

Cancer Conferences 2008

Mark Faries, MD

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The 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.

Cancer Registry

For information regarding the Cancer Registry or for data requests, please contact the Cancer Registry at (310) 829-8860.

Diagnostic Radiology 2008

The 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.

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Inpatient & Outpatient Services 2008

Patients 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

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The John Wayne Cancer Institute (JWCI) Breast Center was founded in 1993 by its current director, Armando E.

Giuliano, M.D. The Breast Center, located within Saint John’s Health Center (SJHC), provides multidisciplinary care to patients with breast problems. Cutting-edge research is performed under the umbrella of JWCI which supports and maintains the laboratories and administrative structure of the breast program. Thus, the Breast Center functions in a unique environment that blends a rigorous academic program with the beauty and efficiency of an extraordinary community hospital, Saint John’s Health Center, listed as one of the top 50 hospitals in the United States by AARP Modern Maturity in May/June 2002. The state-of-the-art Breast Center was recognized by Self magazine in 1999 as one of the 10 best breast centers in the United States. This recognition is based on outstanding patient care and new and innovative clinical, translational, and basic science research that is carried out in a warm, inviting, and non-threatening setting.

The Breast Center has two surgical oncologists, three dedicated breast imaging specialists, two endocrinologists (dedicated to the management of hormone deficiency syndrome in breast cancer), two full-time oncology nurses, one physician assistant, the Banchik Family Breast Cancer Library, and a Positive Appearance Center (to address body image issues). The Library offers a comfortable setting in which to review the latest information about breast cancer

and its treatment. Both popular and professional books, literature, and videotapes are available for patients and their families to use at the Center or to check out and take with them for further review. Internet access is also available for patient and family use. The Breast Center offers treatment for benign breast disease as well as a comprehensive approach to the detection and management of cancer in its earliest forms. The program provides patients with breast cancer screening, breast health education, supportive care, and prevention strategies. Additionally the Center provides interdisciplinary care for patients with complex problems in breast cancer. Patients are evaluated for multimodality treatment (surgery, radiation therapy, chemotherapy, and/or hormonal therapy) by a team of physicians and nurses. The program approaches the patient as a whole person and includes dedicated breast imaging, breast pathology, breast radiation oncology, surgical oncology, medical oncology, nutritional counseling, psychosocial support, plastic and reconstructive surgery, community service and outreach, and research. We collaborate closely with the American Cancer Society and the Wellness Community.

The Breast Center offers its patients a level of medical expertise and an increasing repertoire of innovative diagnostic and therapeutic procedures not available at most community hospitals and often not offered at other tertiary cancer centers. For instance, the Breast Center is one of the very few centers that also treat patients with breast disease-

JWCI Breast Center 2008 Report

Armando E. Giuliano, MD

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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.

Saint John’s Health Center • 1328 Twenty Second Street • Santa Monica, CA 90404 • www.cancercenters.stjohns.org