St. Dominic’s Cancer Services

2014 Statistical DataCancer Program 2015 Annual Report

The Commission on Cancer (CoC) of the American College of Surgeons (ACoS) has granted THREE YEAR ACCREDITATION WITH GOLD-LEVEL COMMENDATION to the cancer program at St. Dominic Hospital. To earn voluntary CoC accreditation, a cancer program must meet or exceed CoC quality care standards, be evaluated every three years through an on-site survey process and maintain levels of excellence in the delivery of comprehensive patient-centered care. All standards have a compliant or non-compliant rating possibility, but seven of the standards have an opportunity for higher level commendation. The Gold-Level Commendation means St. Dominic’s not only complied with all standards, but also received commendation on all seven standards where commendation was a possibility for years 2012, 2013 and 2014.

Because it is a CoC-accredited cancer center, St. Dominic Hospital takes a multidisciplinary approach to treating cancer as a complex group of diseases that requires consultation among surgeons, medical and radiation oncologists, diagnostic radiologists, pathologists and other cancer specialists. This multidisciplinary partnership results in improved patient care.

Table of Contents4 Letters

6 Chairman’s Report

8 Oncology Services

10 Quality Improvements

12 Community Involvement

18 Cancer Program Practice Profile Reports

21 Comprehensive Cancer Services

22 2015 Clinical Trials

23 2014 Statistical Information

26 Oncology Physicians

Letters

For almost 70 years, St. Dominic’s has played a vital role in the overall health and well-being of residents across the state of Mississippi. As a part of our organization’s mission of healing, St. Dominic’s Cancer Services has remained committed to the fight against cancer through refining and improving treatment options and the work performed by our excellent treatment team. We are dedicated to extending our Christian mission of healing to cancer patients and their families.

Since first opening the doors of the St. Dominic’s Cancer Center in December of 1997, St. Dominic’s Cancer Services has continued to evolve with the oncology field, constantly developing and enhancing the ways in which cancer is diagnosed and treated.

St. Dominic’s Cancer Services is led by exceptional physicians, experts and staff whose primary focus remain on prevention, early detection, individualized treatment options and continuing to improve these options for the numerous forms of this disease.

The starting point is the diagnostics phase, which is of upmost importance, directly affecting the treatment options offered to each patient. For this reason, our

physicians have worked together to meet or exceed the complex American College of Radiology standards to ensure a distinguished practice.

The hard work paid off as St. Dominic’s Center for Women’s Health was awarded two accreditations by the American College of Radiology for Stereotactic Breast Biopsy and Breast Ultrasound Biopsy. With these designations, St. Dominic’s Center for Women’s Health is now recognized as a Breast Imaging Center of Excellence (BICOE).

In an effort to provide a more convenient and centralized location for our chemotherapy patients, St. Dominic’s opened the OP Center in April. The OP Infusion Center presents an easy to access, bright, new and comfortable center with 24 chairs to provide infusion treatments to chemotherapy patients as well as many other patients with different diagnoses.

Since 2009, St. Dominic’s Cancer Services has been approved as a Community Hospital Comprehensive Cancer Program by the Commission on Cancer of the American College of Surgeons, a designation granted only to those facilities that have voluntarily committed to provide the best in cancer diagnosis and treatment

and are able to comply with established Commission standards. This year we are honored to announce that the Commission on Cancer of the American College of Surgeons has granted St. Dominic’s the Gold Standard of Three-Year Accreditation with Commendation. The accreditation affirms our multidisciplinary approach to treating cancer as it requires surgeons, medical and radiation oncologists, diagnostic radiologists, pathologists and all other staff involved to work together by communicating on a case by case basis. The result is outstanding, individualized patient care and improved outcomes.

We offer a heartfelt thank you for being a valued partner of St. Dominic Hospital and for helping us to provide our mission of healing. We look forward to working with you in the upcoming year. For more information about our cancer services, visit stdom.com or call St. Dominic’s Cancer Services at 601-200-8000.

Claude W. Harbarger, FACHEPresident, St. Dominic Health Services

Lester K. Diamond, FACHEPresident, St. Dominic Hospital

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Cancer center pic

Chairman’s Report

From new designations, awards, achievements and acquisitions this year St. Dominic’s Cancer Services united to support the common goal of providing the highest quality patient-centered cancer care while carrying on the mission of Christian Healing. During the 2014-2015 calendar year, St. Dominic’s Cancer Services achieved its goal of providing quality patient-centered care and has been recognized for doing so. None of this would have been possible without the physicians, nurses, other clinicians and support staff who provide the most advanced and compassionate care available.

This year, the Commission on Cancer (CoC) of the American College of Surgeons (ACoS) has granted St. Dominic’s Cancer Services a Three-Year Accreditation with Commendation. To earn this voluntary CoC accreditation, St. Dominic’s Cancer Services was required to meet or exceed the 34 CoC quality care standards, be evaluated every three years through a survey process, and maintain levels of excellence in the delivery of comprehensive

patient-centered care. Three-year accreditation with commendation is only awarded to facilities that exceed standard requirements at the time of their triennial survey. This is considered the Gold Standard of designations from the Commission on Cancer, and we are honored to be an accredited recipient.

St. Dominic’s Center for Women’s Health was also awarded two designations by the American College of Radiology for Stereotactic Breast Biopsy and Breast Ultrasound Biopsy. With these designations, St. Dominic’s Center for Women’s Health is now recognized as a Breast Imaging Center of Excellence (BICOE).

St. Dominic’s continues to support the American Cancer Society and the Cancer League by participating in many events and screenings such as Cancer League’s Cancer Gala, Making Strides Against Breast Cancer and the first annual American Cancer Society Tennis Classic.

During the month of October this year, St. Dominic’s was involved in several events topromote breast cancer awareness. St. Dominic’s partnered with Comcast for the “#Selfies2Survive” event, which was a huge success in bringing awareness about breast cancer and early detection. St. Dominic’s also partnered with The Outlets of Mississippi in Pearl for the second annual “Shop Pink” event which raised money for the many women’s programs and services at St. Dominic’s.

We are excited to share our many accomplishments from this year with you. It is our hope that you will review and share the information in this 2015 Annual Cancer Report. This report will provide you with an overview of the services offered during 2015 and the statistical data from 2014. For more information about St. Dominic’s Cancer Services, visit stdom.com or call 601-200-8000.

MANUBHAI S. PATEL, MDChairman, St. Dominic Cancer Committee

St. Dominic’s Cancer Programcontinues to grow each year, yet ourcommitment to compassion and thetreatment of cancer remains the same.As Chairman of St. Dominic’s CancerCommittee, I am proud to present the2015 Annual Cancer Report.

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4 SOUTH CELEBRATED BREAST CANCER AWARENESS MONTH

The oncology nursing team works collaboratively with the dieticians, pharmacists, social services, pastoral care services, navigators and palliative care to meet the unique needs of each patient and family.

ONCOLOGY NAVIGATOR

St. Dominic’s oncology navigator, Polly Cowden, RN, BSN, CCM, is a nurse who is available to help cancer patients and their loved ones on the journey from diagnosis through treatment and beyond. The role of the oncology navigator is to provide individ-ualized support and information tailored to each patient.

The Oncology Navigation Program Benefits Patients through:• Improved and more timely access to healthcare services and information• Fewer delayed and missed patient appointments• Increased satisfaction with the healthcare experience

BREAST HEALTH NAVIGATOR

Jenny Miller, RN, MHA, OCN, CN-BN, is the breast health navigator at St. Dominic’s. She guides patients and their loved ones through their breast cancer journey from diagnosis through treatment and beyond, providing individualized support and information personalized for each patient. This includes providing assistance in filling out necessary forms, locating local resources and support services and answering any questions the family may have.

Recently, Jenny earned her Breast Patient Navigator Certification through the National Consortium of Breast Centers (NCBC).

The NCBC identifies the purpose of certification as a means to set standards of achievement and the professionals role; enhance patient safety, quality of care and delivery of services; and to recognize professionals who advance beyond basic knowledge in a field of specialty

SURVIVORSHIP NAVIGATOR

Jimmie Wells, RN, MSN, OCN, St. Dominic’s is the survivorship navigator at St. Dominic’s. Her role is to help patients with the ongoing process of cancer survivorship. It begins with diagnosis and continues throughout a patient’s life. She helps to develop Survivorship Care Plans for identified patients completing active treatment and/or upon request. St. Dominic’s currently utilizes the “Journey Forward” program as the basis for formal survivorship care plan development. Survivorship care plans are documents that include a summary of treatment received, expected follow-up and information to address the unique concerns of patients completing active treatment.

Oncology Services

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POLLY COWDEN, RN, BSN, CCM, ST. DOMINIC’S ONCOLOGY NAVIGATOR

JIMMIE WELLS, RN, MSN, OCN, ST. DOMINIC’S SURVIVORSHIP NAVIGATOR

JENNY MILLER, RN, MHA, OCN, CN-BN, ST. DOMINIC’S BREAST HEALTH NAVIGATOR

PALLIATIVE CARE

Established in April 2007 and expanded to include palliative medicine specialists in July 2014, the Palliative Care Inpatient Consultation team at St. Dominic’s works hand-in-hand with the oncologists and other specialty physicians to meet the needs of seriously ill patients and their families. Although our team does not just see oncology patients, the oncologists have been physician champions from the start of the program and remain one of the top referring physician groups.

Palliative care is a specialized medical care for people with a serious illness. It focuses on providing patients with relief from the symptoms, pain and stress of a serious illness—such as cancer, cardiac diseases, chronic obstructive pulmonary disease, stroke, kidney failure, Alzheimer’s and

others. The goal is to improve quality of life and decrease suffering for both the patient and the family. It does not replace the primary treatment. Our team partners with the patient’s physician as an additional layer of support, especially in complex cases.

The number of referrals continues to increase with a significant increase noted in ICU referrals. In May of 2015, St. Dominic’s Palliative Care Services submitted our 2014 operational data into the National Palliative Care Registry in order to benchmark our program against other programs. Compared to other palliative care programs, our overall Length of Stay (LOS) is 1.2 days less than other palliative care programs with the same penetration level. Our program has also noticed a decrease by 0.5 days LOS of our referrals when comparing January-June 2014 prior to the new

model adding the Nurse Practitioner to our team and January –June 2015 after adding the Nurse Practitioner to our team. Not only does this reflect the support the team gives to patient and their family as they make decisions, it also represents significant cost savings for the hospital.

The Center to Advance Palliative Care and the National Palliative Care Research Center’s 2015 State by State Report on Access to Palliative Care in our Nation’s Hospitals demonstrates that despite continuing growth in the number of U.S. hospitals reporting Palliative Care programs, access to Palliative Care remains inadequate for millions of Americans, especially in the south. We are proud to be able to offer this option of additional support at St. Dominic’s Hospital when it is needed.

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NICOLE DRAHUSCHAK, CFNP, NURSE PRACTITIONER

ANN TANDY, RN, MSN, PMHCNS-BC RN COORDINATOR

NANCY AYCOCK, RN, BSN, OCN®, CHPN®, PALLIATIVE CARE MANAGER

TERESA WILLIAMS, MSSW, LCSWCCM, SOCIAL WORK

PATRICIA WALDEN, RN, BSNPASTORAL CARE

BOBBY GRAHAM, MD, FACP, MEDICAL PALLIATIVE CARE DIRECTOR

JEAN ROSE, RN, BSN, RN COORDINATOR

ACR AWARDS FOR WOMEN’S HEALTH

The American College of Radiology recently awarded St. Dominic’s Center for Women’s Health two accreditations for Stereotactic Breast Biopsy and Breast Ultrasound Biopsy. With these designations, St. Dominic’s Center for Women’s Health is now recognized as a Breast Imaging Center of Excellence (BICOE). The BICOE designation is awarded to breast imaging centers that achieve excellence by seeking and earning accreditation in all of the ACR’s voluntary breast-imaging accreditation programs and modules, in addition to the mandatory Mammography Accreditation Program.

Breast imaging services at St. Dominic’s Center for Women’s Health are fully accredited in the areas of Mammography, Stereotactic Breast Biopsy, Breast Ultrasound and Ultrasound-Guided Breast Biopsy.

Peer-review evaluations conducted in each breast imaging modality by board-certified physicians and medical physicists who are experts in the field have determined that this facility has achieved high practice standards in image quality, personnel qualifications, facility equipment, quality control procedures, and quality assurance programs.

The ACR, headquartered in Reston, Virginia, is a national organization serving more than 32,000 diagnostic/interventional radiologists, radiation oncologists, nuclear medicine physicians, and medical physicists with programs for focusing on the practice of medical imaging and radiation oncology, as well as the delivery of comprehensive health care services.

COMMISSION ON CANCER ACCREDITATION

The Commission on Cancer (CoC) of the American College of Surgeons (ACoS) has granted Three-Year Accreditation with Commendation to the cancer program at St. Dominic Hospital to award Gold Level Accreditation. All standards have a compliant or non-compliant rating possibility, but seven of the standards have an opportunity for higher level commendation. This Gold Three-Year Accreditation means St. Dominic’s not only complied with all standards, but also received commendation on all seven standards where commendation was a possibility for years 2012, 2013 and 2014.

Quality Improvements in 2015

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OUTPATIENT INFUSION CENTER

Based on our 2014 Outpatient Chemotherapy Clinic Time Analysis Study, our Infusion Clinic was relocated to a more convenient location near the front of the hospital and now includes 24 chairs.

St. Dominic’s Outpatient Infusion Center formally opened and began seeing patients on April 20, 2015. The Outpatient Infusion Center is located on the first floor of the West Towers in the main hospital next to Farlow’s Pharmacy. It is used to treat patients who are receiving chemotherapy through infusions, as well as many other infusions for other diagnoses.

Starting off with 10 infusion chairs in 2011, St. Dominic’s is proud to say that the amount of chairs has more than doubled with 24 chairs subsequent to the opening of this center.

A grand opening event that included a ribbon cutting ceremony, refreshments and a tour was held on April 29, 2015.

Y90 SELECTIVE INTERNAL RADIATION THERAPY

Selective Internal Radiation Therapy (SIRT) is a new radiation therapy treatment, that uses SIR-Spheres microspheres, SIRT is the only fully FDA PMA approved microsphere therapy for patients with inoperable metastatic colorectal cancer to the liver. An interventional radiologist places a transfemoral microcatheter into the hepatic artery and precisely administers millions of micospheres into the bloodstream. The microspheres, containing the isotope yttrium-90, travel through the arterioles and lodge in the tumor plexus.

We now offer this treatment in Diagnostic Imaging at St. Dominic’s.

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GREAT LENGTHS

Great Lengths is an event in which participants cut at least eight inches of their hair on or before a given date. The hair is then donated to Pantene who uses the hair to make wigs that are pledged to the American Cancer Society to provide cancer patients one wig free of charge.

For five years now, St. Dominic’s has partnered with WLBT to promote the “Great Lengths” campaign. St Dominic’s co-hosts “Great Lengths” events with WLBT every other year. This year was a “Great Lengths” donation event year.

In preparation, WLBT started informing the people of Mississippi in July of 2014 so that they could begin to grow out their hair for the official cut date of March 2, 2015. The event took place at the Mississippi Institute of Aesthetics, Nails and Cosmetology in Clinton. At this year’s event more than 275 people donated their hair.

The hair that was donated has been used to craft beautiful quality wigs for Mississippi women who lost their hair while battling cancer.

St. Dominic’s extends our sincere thanks to all who participated and plan on participating in this wonderful event in the future. Giving your hair is such a selfless act of kindness that helps to restore the confidence and self-esteem lost by patients who are undergoing chemotherapy.

HANDS OF HOPE TOUCH OF PINK LUNCHEON

St. Dominic’s Hands of Hope Boutique offers products and services to help minimize the effects of cancer therapy. The boutique carries a large assortment of surgical garments, mastectomy bras, mastectomy forms and swimwear, lymphedema sleeves, head scarves and wraps, DermaQol Skincare, wicking garments and speciality gift items. Hands of Hope also offers one-on-one care for mastectomy patients, including a private fitting room and mastectomy fitter. It is located on the first floor main hallway of the hospital, across from the laboratory.

Hands of Hope Boutique hosted its second annual “A Touch of Pink” luncheon on October 1, 2015 to celebrate breast cancer survivors. Attendees were treated to a catered lunch, gifts and door prizes as well as a performance by singer and breast cancer survivor Vaniessa Cousin. Speakers for the luncheon included Nicole D. Cleveland, M.D., Oncologist from Jackson Oncology Associates, and Jimmie Wells, St. Dominic’s Survivorship Navigator.

Community Involvement 2015

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SHOP PINK & SAVE

St. Dominic’s partnered with the Outlets of Mississippi for their “Shop Pink” fundraiser held during the month of October of 2015. All proceeds from the sales of Shop Pink discount cards were given to St. Dominic’s in support of its many women’s health programs. St. Dominic’s held a “Shop Pink Health Fair” at the Outlets on October 17, 2015 featuring wellness, women’s health and health outreach program representatives who offered educational information to attendees. This year’s campaign raised more than $11,190 through the sale of Shop Pink and Save Discount Cards that entitled the purchaser to a discount at participating outlet stores.

ACS TENNIS CLASSIC

St. Dominic’s sponsored the first American Cancer Society Tennis Classic in honor of Becky Taylor held Friday and Saturday, July 10-11, 2015 at The Club at the Township. The fun-filled weekend featured a Friday night event that took place outside The Club at The Township under a huge tent with delicious food catered by Sombra, a DJ and many door prize and raffle opportunities for the 200 plus guests to enjoy. Over 100 people participated in Saturday’s tournament, and fun was had by all who were involved. Overall, the weekend raised $34,797 for the American Cancer Society.

Honoree Becky Taylor bravely fought cancer over the last five years. Initially, she was diagnosed with brain cancer in 2010 and she later battled and beat breast cancer. A recurrence of the original brain cancer took Becky’s life on August 22, 2015.

St. Dominic’s is proud to sponsor the second annual ACS Tennis Classic in the spring of 2016 in memory of Becky Taylor.

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Ovarian Crosswalk pic

NEWK’S CARES

Each year over 200,000 women worldwide are diagnosed with ovarian cancer, a statistic that hits close to home for Newk’s Eatery CEO Chris Newcomb and his wife Lori, whose personal battle with the disease began in 2013 and inspired the Newk’s Cares movement. With a 90 percent survival rate at early detection, the Newcomb’s have made educating women about ovarian cancer a top priority.

LUNCH AND LEARN

In 2015, St. Dominic’s and Newk’s Cares partnered to host the first annual Ovarian Cancer Lunch

and Learn at St. Dominic’s Centre building and the second annual Ovarian Cycle Jackson spin event at The Club at The Township.

St. Dominic’s and Newk’s Cares hosted the free Ovarian Cancer Lunch and Learn August 27, 2015 to raise awareness about the signs and symptoms of ovarian cancer. Speakers included Lori Newcomb, co-founder of Newk’s Cares, Dr. Paul Seago, St. Dominic’s gynecologic oncologist, and Mechale Mayfield, St. Dominic’s Oncology Service Line and Palliative Care Administrator.

OVARIAN CYCLE

St. Dominic’s and Newks Cares teamed up again on September 17, 2015 for the second annual

Ovarian Cycle Jackson spin celebration held at The Club at The Township. Community members were invited to pedal their way to a cure in support of the Ovarian Cancer Research Fund. The event aimed to spark awareness and support for research in the battle against ovarian cancer, a relatively silent killer that affects one in seventy women.

Cycle participants were spinning for 45-minute time slots from 8:30 a.m. to 2 p.m. with DJ Young Venom and instructors helping participants to keep their spirits high. A total of $143,374 was raised during the event. All funds were donated to the Ovarian Cancer Research Fund, a charity that gives grants to researchers in order to help find a cure for ovarian cancer.

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#SELFIES2SURVIVE

For the first time in 2015, St. Dominic’s partnered with Comcast, Highland Village and Heart of the South in the breast cancer awareness campaign of #Selfies2Survive. The campaign focused on the power of social media to spread and raise awareness for breast cancer by using the #Selfies2Survive.

Each sponsor was given a traveling 8’x8’ banner, lots of fun pink props, selfie sticks and sharpies for individuals to sign the banner. People were encouraged to walk the pink carpet, sign and take photos in front of the banner and post the photos to their social media accounts using the #Selfies2Survive.

Each participant was given a goody bag filled with promotional and educational items related to breast cancer awareness month.

#Selfies2Survive was able to visit over 20 locations in 2015.

PAMPERING OUR PINK PRINCESSES AND BREAST CANCER AWARENESS AFFAIR

On October 17, 2015, Dr. Phillip Ley, St. Dominic’s Breast Health Committee Chair, and Odessa Hawkins of St. Dominic’s Women’s Health and Healing Center, participated in the St. Dominic’s sponsored Pampering Our Pink Princesses and Breast Cancer Awareness Affair at the Jackson Medical Mall. This event featured pampering services for breast cancer survivors including: mini massages, facials, makeovers and more, as well as educational breast health presentations performed by Dr. Ley, breast cancer screenings and many more educational health demonstrations and screenings.

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BREAST RECONSTRUCTION AWARENESS DAY

On October 21, 2015, Hands of Hope Boutique hosted an event to celebrate Breast Reconstruction Awareness Day with Mississippi Premier Plastic Surgery. The event featured cupcakes and refreshments and an opportunity for patients to learn more about reconstructive options and speak one-on-one with the expert surgeons of Mississippi Premier Plastic Surgery.

ACS MAKING STRIDES LUNCHEON

American Cancer Society’s Making Strides Against Breast Cancer is a celebration of breast cancer survivors and an occasion to come together to raise funds in hopes of finding a cure. This year, St. Dominic’s hosted the 10th annual Making Strides Against Breast Cancer Kick-Off Luncheon at The South Warehouse on August 20. Hundreds of people from the Jackson Metro community gathered to kick-off the Making Strides Against Breast Cancer Events. Speakers,

Vaniessa Cousin, three-time cancer survivor and songwriter, and Jennifer Sinclair, Executive Vice President of Operations at St. Dominic Hospital, were introduced by emcees: Maggie Wade, anchor from news channel WLBT, and Kim Allen from iHeart Radio. At this event breast cancer survivors were honored and attendees were encouraged to participate in the Making Strides Against Breast Cancer annual 5K walk that took place on October 31 this year in downtown Jackson.

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GUANGZHI QU, MD, PHD PRESENTED THE “UPDATE ON

MEDICAL THERAPY OF BREAST CANCER” AT THE 2015 ANNUAL

MULTISPECIALTY CME. THE CONFERENCE WAS HELD MARCH 7-10

AT THE LODGES AT DEER VALLEY – PARK CITY, UTAH.

Cancer Program Practice Profile Reports (cp3r)

St. Dominic’s Cancer Committee monitors and ensures that patients treated at St. Dominic Hospital receive high quality care that is congruent with nationally accepted measures. To promote comparison and allow for monitoring, the Commission on Cancer (CoC) measures compliance with specific CoC reporting tools - Cancer Program Practice Profile Reports (CP3R). Below is the summary of (CP3R) performance grid for 2013 breast cancer cases at St. Dominic Hospital. We are proud that our program is meeting or exceeding all of the required performance expectations of the CoC for breast quality measures.

Quality Metric Required Per-formance Rate

Estimated Per-formance Rate for 2013

Cases Eligible for Measure

Concordant, Treatment Administered or Considered

Nonconcordant

Image or palpation-guided needle biopsy (core or FNA) of the primary site is performed to establish diagnosis of breast cancer.

80% 89.40% 66 59 7

Tamoxifen or third generation aromatase inhibitor is recommended or administered within 1 year (365 days) of diagnosis for women with AJCC T1c or stage IB-III hormone receptor positive breast cancer.

90% 100% 49 45 4

Radiation therapy is recommended or administered following any mastectomy within 1 year (365 days) of diagnosis of breast cancer for women with >= 4 positive regional lymph nodes.

90% 100% 49 45 4

Radiation is administered within 1 year (365 days) of diagnosis for women under the age of 70 receiving breast conservation surgery for breast cancer.

90% 95.10% 41 39 2

Combination chemotherapy is recommended or administered within 4 months (120 days) of diagnosis for women under 70 with AJCC T1cN0, or stage IB - III hormone receptor negative breast cancer.

90% 100% 17 16 1

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A Project to Assure Quality Cancer CareSt. Dominic Cancer Center

Project BackgroundSince 1999, the Institute of Medicine has identified critical short-comings and disparities in cancer care in the United States, as well as opportunities for improving quality of care. In response, professional organizations (e.g., American Society of Clinical Oncology, American Psychosocial Oncology Society), accrediting bodies (e.g., American College of Surgeons Commission on Cancer), and associations of cancer treating programs (e.g., National Comprehensive Cancer Network) have developed standards and initiatives for improving the quality of cancer care. As the US experiences a shift from volume-based care to value-based care, achieving the highest levels of quality will depend upon how well psychosocial and behavioral health providers, and specifically oncology social workers, are integrated into health care systems and enabled to enhance patient outcomes as well as operational efficiencies and cost-offsets.

A Project to Assure Quality Cancer Care (APAQCC), funded by the Association of Oncology Social Work (AOSW) through a gift from Takeda Oncology, is a project to assure that cancer patients and families get the psychosocial care they need, when they need it.

As of 2015, approximately 1,500 cancer treating institutions (that treat approximately 75 percent of cancer patients in the United States) will be obligated to demonstrate compliance with the American College of Surgeon’s Commission on Cancer Standard 3.2 for distress screening. They will need to demonstrate that distress screening is being implemented as intended and that patients are being served appropriately.

The purpose was to examine the implementation of the psychosocial or distress screening protocols prescribed by each cancer program. Oncology social workers at 57 cancer programs across North America conducted a retrospective review from February – April 2015 of the medical records for patients seen in their cancer program.

The two main elements of the review included: (1) Adherence: The extent to which each cancer program’s screening procedure has been conducted as prescribed. (2) Responsiveness: The extent to which each cancer program responds according to their individual protocols when patient screenings indicate a need for attention.

This report provides an overview of the retrospective review completed at St. Dominic’s Cancer Center, and compares our results, anonymously, to other cancer programs of similar type.

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Institutional SummaryLocation(s) for Data Collection: Radiation-Oncology Timeframe: July-August 2014Pivotal Time Point(s): Screen within 10 days of beginning radiation treatment Distress Screening Tool Used: Distress Thermometer (with problem checklist) Number of Patient Visits Reviewed: 67

Adherence: The extent to which St. Dominic’s program’s distress screening procedure has been conducted as prescribed. From the data collected, 97 percent of patients were screened at St. Dominic’s Cancer Center when they were supposed to be screened, as indicated by St. Dominic’s distress screening protocol.Overall, there was a 68 percent adherence rate to institution’s distress screening protocols. At individual institutions, adherence rates ranged from 12 percent to 100 percent.

Of the 9,780 patient visits review, screening was completed at 6,611 of those visits (68 percent). A small portion of patients (4 percent) declined to be screened and 28 percent of patients were not screened when they were supposed to be screened per the institution’s protocol.

Of the 4,974 patient visits reviewed with a Distress Thermometer (DT) score, the DT score ranged from 0 to 10, with a median of 3.

Responsiveness: The extent to which St. Dominic’s Cancer Center responds according to the protocol when patient screenings indicate a need for attention. At St. Dominic, 95 percent of patients required response to their screen according to protocol. Appropriate response occurred 100 percent of the time with these patients.

Overall, there was an 87 percent responsiveness rate among patients who were screened and required action. At individual institutions, responsiveness rates ranged from 22 percent to 100 percent.Of the 6,611 patients screened, 3,675 patients (56 percent) required appropriate action be taken based on the individuals institution’s protocols. In 13 percent of cases, appropriate action was not taken when screening indicated the need for action or follow-up as per the institution’s protocol.

APAQCC Participants A total of 61 institutions participated in APAQCC from across the United States and Canada.

Conclusions from Quality StudyWhen compared to other participating institutions, we were well above the average of comparative institutions. We feel our rates of screening adherence and responsiveness for distress screening is equitable at St. Dominic’s Cancer Center.

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Comprehensive Cancer Services

DIAGNOSTIC

MRIBreast MRIDigital MammographyTOMOPET/CTLaboratory Services

TREATMENTY90 Selective Internal Radiation TherapyGeneral SurgerydaVinci Robotic SurgeryGynecologic Oncology SurgeryReconstructive SurgeryExternal Radiation TherapyIntensity ModulatedRadiation Therapy (IMRT)Image Guided RadiationTherapy (IGRT)High Dose Rate BrachytherapyBrainLab StereotacticRadiosurgeryPartial Breast IrradiationProstate Seed ImplantationOutpatient Chemotherapy ClinicRadiopharmaceutical Therapy

SUPPORT SERVICESCamp Bluebird, Adult Cancer CampCancer Support GroupsCancer Orientation ClassClinical ResearchCoordinatorConsumer HealthResource CenterCounseling CenterHospice Program“Look Good…Feel Better”Lymphedema and OncologyRehab ClinicMemorial ServiceOncology Nurse NavigatorsRehabilitation ServicesRegistered DietitiansPain ManagementPalliative Care ProgramPastoral CareSocial WorkersWig ProgramWound and Ostomy Care NurseCancer PreventionScreening Events

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2015 Clinical TrialsSt. Dominic’s offers various types of clinical trialswhich include quality of life and treatment andtranslational research trials (studying of tumortissue and blood to learn causes and treatmentsof gynecologic cancer). Paul Seago, MD, serves asprincipal investigator for Gynecologic OncologyGroup clinical trials at St. Dominic’s.

BENEFITS OF CLINICAL TRIALS INCLUDE THE FOLLOWING:

• Participants have access to promising new approaches often not available outside a clinical trial setting• The approach being studied may be more effective than the standard approach• Participants receive regular and careful medical attention from a research team that includes doctors and other health professionals• Participants may be the first to benefit from the new method under study• Results from the study may help others in the future

GOG 286BA randomized phase II/III study of Paclitaxel/carboplatin/metformin (NSC#91485) versuspaclitaxel/carboplatin/placebo as initial therapyfor measurable stage III or IVA, stage IVB, orrecurrent endometrial cancer.

GOG-0277 (IRCI 001)A Phase III Randomized Trial of Gemcitabine(NSC # 613327) plus Docetaxel (NSC # 628503)followed by Doxorubicin (NSC # 123127) versusObservation for Uterus-Limited, High-GradeUterine Leiomyosarcoma.

GOG 225Can diet and exercise modulate ovarian,fallopian tube or primary peritoneal cancerprogression-free survival?

GOG 3007 A Randomized Phase II Trial of Everolimus and Letrozole or Hormonal Therapy (Tamoxifen/Medroxyprogesterone Acetate) in women with advanced, persistent, or recurrent endometrial carcinoma

GOG 3005 A Phase 3 Placebo-Controlled Study of Carboplatin/Paclitaxel With or Without Concurrent and Continuation Maintenance Veliparib (PARP inhibitor) in Subjects with Previously Untreated Stages III or IV High-Grade Serous Epithelial Ovarian, Fallopian Tube, or Primary Peritoneal Cancer

ONCOLOGY MASSAGE TRIALStudy to assess oncological massage for painalleviation in patients with breast cancer atany stage.

CANCER EXPERIENCE REGISTRYThe Cancer Support Community’s (CSC) Research and Training Institute has created the Cancer Experience Registry to identify and advance the understanding of the emotional and social needs of people who have been diagnosed with cancer. The Cancer Experience Registry is a research project based on a grassroots effort to recruit cancer survivors and those living with a diagnosis to answer questions about their social and emotional experiences and needs throughout their cancer journey.

TRIAL ASSESSING BARRIERS TO GENETIC TESTINGTo determine percentage of eligible patient’sfor hereditary breast, ovarian and endometrialcancer genetic testing and patient barriers tonot undergoing testing.

PAUL SEAGO, MD, ANDREGINA OUTLAW, RHIT, CCRP

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2014 Statistical Report of Registry Data-Analytic CasesTOP PRIMARY SITESSite 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Colon 89 86 82 127 135 107 140 143 122 140 132

Female Breast 131 108 141 166 163 197 187 184 147 152 225

Lung 181 171 181 194 168 169 181 160 200 177 181

Prostate 148 133 166 208 208 160 190 175 150 160 147

AGE DISTRIBUTION14-29 23

30-39 38

40-49 124

50-59 267

60-69 407

70-79 307

80-89 132

90-100 24

RACE DISTRIBUTIONWhite 766

Black 540

Other (see below) 16 Filipino 1 Asian Indian 7 Chinese 1 Latin American 7

SEX DISTRIBUTIONMale 543

Female 779

CLASS OF CASEAnalytic 1322

Non-Analytic 112

COMPARISON OF HOSPITAL, STATE AND NATIONAL DATA (ANALYTIC CASES)Primary Site St. Dominic’s Mississippi NationalFemale Breast 225 (17%) 2,050 (13%) 231,840 (14%)Uterine Cervix 20 (2%) 140 (1%) 12,900 (1%)Colon & Rectum 132 (10%) 1,460 (9%) 132,700 (8%)Uterine Corpus 62 (5%) 390 (3%) 54,870 (3%)Leukemia 21 (2%) 450 (3%) 54,270 (3%)Lung & Bronchus 181 (14%) 2,340 (14%) 221,200 (13%)Melanoma 15 (1%) 540 (3%) 73,870 (5%)Non-Hodgkin’s Lymphoma 35 (3%) 550 (3%) 71,850 (4%)Prostate 147 (11%) 2,150 (13%) 220,800 (13%)Urinary Bladder 31 (2%) 500 (3%) 74,000 (5%)Other Sites 453 (33%) 5,690 (35%) 510,070 (31%)

Totals 1,322 16,260 1,658,370

Figures do not include carcinoma in situ of the cervix or localized basal and squamous cell skin cancers. Mississippi and National figures are estimated new cases for 2015 by the American Cancer Society. St. Dominic’s figures are based on analytic cases for 2014.

23

Geographic Distribution (analytic cases) Desoto

Lafayette

Itaw

amba

Lee

Union

Prentiss

Tish

amin

go

Alcorn

Tippah

Benton

Marshall

Yalobusha

CalhounMonroeChickasaw

PontotocCoahomaQuitman

Tunica

Panola

Tate

WebsterMont-gomery

Carroll

Grenada

Le�ore

Bolivar

Sun�

ower

Tallahatchie

Was

hing

ton

Shar

key

HumphreysHolmes

Attala

Leake KemperNeshoba

Winston

Noxubee

Oktibbeha Lowndes

Clay

Choctaw

Wayne

Clarke

Newton Lauderdale

Yazoo

Madison

RankinHinds

Warren

Issaquena

Scott

Walthall

MarionLamar

Forr

est

StoneGeorge

GreenePerry

Jones

JasperSmith

Covington

Claiborne

Je�erson

Franklin Lincoln

CopiahSimpson

Law

renc

e

Je�e

rson

Dav

is

Amite Pike

JacksonHarrison

Hancock

Pearl River

Adams

Wilkinson

GEOGRAPHIC DISTRIBUTIONAdams 18 Lee 2

Amite 5 Leflore 16

Attala 32 Lincoln 23

Bolivar 15 Lowndes 6

Carroll 12 Madison 172

Chickasaw 3 Monroe 4

Choctaw 4 Montgomery 7

Claiborne 5 Neshoba 9

Clarke 2 Newton 2

Clay 6 Noxubee 2

Copiah 36 Okitbbeha 6

Covington 1 Pearl River 2

Forrest 5 Pike 12

Franklin 10 Rankin 224

Grenada 3 Scott 44

Hinds 332 Sharkey 1

Holmes 35 Simpson 47

Humphreys 4 Smith 9

Itawamba 1 Sunflower 15

Jackson 1 Tallahatchie 3

Jasper 4 Tishomingo 1

Jefferson 7 Warren 31

Jefferson Davis 2 Washington 17

Jones 8 Wayne 1

Kemper 1 Webster 4

Lamar 1 Wilkinson 1

Lauderdale 5 Winston 9

Lawrence 13 Yazoo 26

Leake 45

OUT OF STATEAlabama 2

Arkansas 1

Illinois 1

Louisiana 4

Missouri 1

Texas 1

LEGEND Less than 5 5-10 11-30 More than 30

24

Geographic Distribution (ANALYTIC CASES)

PRIMARY SITE TOTAL CASES PERCENTAGE

Head and Neck Site 58 4%

Pharynx 6

Larynx 5

Major Salivary Glands 2

Thyroid 41

Tongue 4

Digestive System 228 17%

Esophagus 8

Stomach 15

Small Intestine 11

Colon and Rectum 132

Anal Canal 3

Liver and Intrahepatic Bile Ducts 17

Gallbladder 3

Exocrine Pancreas 37

Ampulla of Vater 2

Thorax 185 14%

Lung 181

Thymus 4

Musculoskeletal Sites 10 1%

Soft Tissue Sarcoma 10

Skin 18 1%

Melanoma 15

Other skin 3

PRIMARY SITE TOTAL CASES PERCENTAGE

Breast 1225 17%

Gynecologic Sites 1135 10%

Vulva 16

Cervix Uteri 20

Corpus Uteri 62

Ovary 31

Vagina 5

Fallopian Tube 1

Genitourinary Sites 260 20%

Prostate 147

Testis 3

Kidney 72

Penis 4

Renal Pelvis and Ureter 3

Urinary Bladder 31

Central Nervous System 61 5%

Lymphoid Neoplasms 77 6%

Unknown Primary 35 3%

Other 30 2%

TOTALS 1,322

25

Oncology ServicesMEDICAL ONCOLOGY

Justin Baker, MD Nicole Cleveland, MD** Bobby L. Graham, MD, FACP**

Guangzhi Qu, MD, PhD**Manu S. Patel, MD** Martin M. Newcomb, MD

Grace G. Shumaker, MD Bobby Wilkerson, MD Tammy H. Young, MD

RADIATION ONCOLOGY DIRECTORY

Eric Balfour, MD Al Johnson, MD

Margaret Wadsworth, MD Steven Zachow, MD

GYNECOLOGIC ONCOLOGY

Paul Seago, MD*

*Dr. Seago’s medical office is

located in St. Dominic’s West

Medical Tower

**Drs. Cleveland, Graham,

Patel, and Qu’s medical office

is located in the

St. Dominic’s Cancer Center.

St. Dominic Hospital

601-200-2000

Cancer Services

601-200-3300

Cancer Center

601-200-3070

Cancer Registry

601-200-6597

Center for Women’s

Health

601-200-4935

Madison Medical Imaging

601-853-9149

Radiology

601-200-6150

American Cancer Society

1-800-227-2345

The Leukemia &

Lymphoma Society

1-877-583-5364

Women’s Health

and Healing Center

601-200-7465

26

27

Accredited Cancer Program Performance Report 11/11/2015

Accredited Cancer Program Performance Report forSt. Dominic-Jackson Memorial Hospital

Jackson, MSFacility Identification Number 6540390

Accreditation Award:3 YR with Commendation

Survey Performed: 9/23/2015Surveyed by: William Chesnut Dooley, MD, FACS

Next Survey Due: September 2018

Accreditation Details

Total number of standards rated - Compliant 23

Total number of standards rated - Non-compliant 0

Total number of standards rated - Not applicable 4

Total number of standards rated - Commendation 7

Accreditation Award 3 YR with Commendation

1 - 6 11/11/2015 2:09:07 PM