c a r e a n d t r e a t m e n t - Chesapeake Regional Treatment...Dr. Mathew Sinesi and Dr....

c a n c e r c a r e

a n d t r e a t m e n t A s I n d i v i d u a l A s Y o u .

c h e s a p e a k e r e g i o n a l h e a l t h c a r e

S i d n e y m . O m a n c a n c e r t r e a t m e n t c e n t e r

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PPage Page

Mission and Vision 3

Introduction 4

Our Medical Team 5

Cancer Committee 6

Cancer Conferences 7

• Cases by Site Presented at Conferences 7

Patient Care Team 8

• Patient Resource Navigator 8

• Breast Health Navigator 9

• Radiology Nurse Navigator 10

• Breast Surgeon 10

• Digestive & Colorectal Navigator 11

• Pelvic Health Navigator 11

• Thoracic & Lung Health Navigator 12

• Oncology Nutrition Navigator 13

• Oncology Social Worker Services Navigator 13

Wound Care & Hyperbaric Center: Cancer Care 14

Standard 4.6 Physician Led Study 15

Standard 4.7 Study of Quality 19

2016 Cancer Registry Report 20

2016 Gender Stats 21

2016 Top 10 Histologies 22

2016 Top 10 Sites 22

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Mission – Chesapeake Regional Healthcare and its affiliated

partners will improve the health and well-being of the communities served.

Vision – Chesapeake Regional will be the preferred integrated health care

delivery system, coordinating the provision of a full range of safe, high quality,

affordable and personalized health care services.



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Since 1995, the Sidney M. Oman Cancer Treatment Center has provided innovative cancer services to the region’s residents. To deliver on our commitment to provide patients with world class and compassionate care, we continuously review and update our processes and utilize a team approach to offer our patients a comprehensive program. Exceptional, compassionate and coordinated care is what you can expect from the Sidney M. Oman Cancer Treatment Center. Our Radiation Oncology Department is staffed by: • Board-certified radiation oncologists, Dr. Mathew Sinesi and Dr. Christopher Sinesi • One certified dosimetrist • Nurses who specialize and are certified in the care of oncology patients • Two board-certified physicists • ARRT registered radiation therapists • One oncology-certified social worker • One registered dietitian • One American Cancer Society patient navigator • Support staff to greet and escort patients to all areas of the center In 2016, this exceptional team delivered over 8,030 external beam treatments, 21 prostate seed implants, eight partial breast HDR treatments, 11 HDR cylinder treatments and one HDR bronchoscopy treatment. The radiation oncologists performed 628 consultations, which resulted in 363 new courses of treatments being prescribed. The radiation oncology leadership implemented two new procedures in 2016. Space OAR Hydrogel was added to the prostate cancer treatment regime, and 14 procedures were completed this year. Our brachytherapy program was also expanded when HDR Tandem and Ring procedures were implemented.

Our outpatient infusion staffing consists of: • Two full-time staff and two flexi registered nurses • Support staff to greet and escort patients to all areas of the cancer center

The Outpatient Infusion Unit performs procedures ranging from injections, infusions and blood transfusions to chemotherapy. Our registered nurses performed approximately 5,624 procedures in 2016. Working out of eight infusion chairs, the unit serves an average of 13 patients per day. Our Cancer Registry database is managed by: • One cancer coordinator • One abstractor (resigned 5/2016) • One follow-up clerk The highlight of 2016 was the added ability to provide personalized radiation therapy suites through the collaboration with Sentient Suites. All radiation patients have the ability to select a tailored treatment environment, enabling them to set the mood with lighting, sound and video imagery. These personalized suites have allowed the patients to relax, meditate and journey through a natural setting while receiving their treatment.

Together, this extraordinary team is highly committed to delivering superior outcomes for our patients.

Barbara BellidoOperational ManagerCancer Treatment Center



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Dr. William P. Clark, Jr., Cancer Conference CoordinatorDr. William Clark has been in private practice since 1984. He received his medical degree from Georgetown University in Washington, D.C. and completed an internship at Roger Williams General Hospital in Providence, R.I. Dr. Clark completed an internal medicine residency at Hartford Hospital in Hartford, Conn. and also completed a hematology and oncology fellowship at the University of Massachusetts in Worcester, Mass. He is a member of the Medical Society of Virginia, the Virginia Beach Medical Society, the American Medical Association and American Society of Clinical Oncology. Dr. Clark is a diplomat of the American Board of Internal Medicine and is board certified in medical oncology.

Dr. Valiant Tan, Chairman, Cancer CommitteeDr. Valiant Tan is board certified in medical oncology and hematology. He received his medical degree from the University of Santo Tomas in Manila, Philippines and completed internships at Chinese General Hospital in Manila and Interfaith Medical Center in Brooklyn, N.Y. Dr. Tan completed an internal medicine residency at the New York Medical College in New York, N.Y., where he served as chief resident. He also completed an additional residency at the Interfaith Medical Center in Brooklyn, N.Y. His hematology and oncology fellowship was completed at Montefiore Medical Center in Bronx, N.Y. Dr. Bruce Waldholtz, Cancer Liaison PhysicianDr. Bruce Waldholtz received his medical degree from the University of Pittsburgh in Pittsburgh, Pa. He completed an internship and internal medicine residency at The Johns Hopkins University/Johns Hopkins Bayview Medical Center in Baltimore, Md. He also completed a gastroenterology fellowship at The Johns Hopkins University. Dr. Waldholtz serves on the board of directors of the South Atlantic Division of the American Cancer Society. He has been board certified in gastroenterology since 1989 and serves as an assistant professor of clinical internal medicine at Eastern Virginia Medical School in Norfolk, Va., where he mentors first- and second-year medical students.

Dr. Mathew Sinesi, Medical Director of Sidney M. Oman Cancer Treatment Center, Radiation OncologistDr. Mathew P. Sinesi is a board-certified radiation oncologist. Having been on the active medical staff here at Chesapeake Regional Medical Center for over 30 years, he was closely involved with the development, design, construction and daily workings of the Cancer Treatment Center during its initial construction and later expansion. Dr. Sinesi graduated from the University of Massachusetts-Amherst with a Bachelor of Science degree. He received his medical degree from Boston University Medical School and then completed a medical internship in Framingham, Mass. before his Radiation Oncology residency at the University of Texas, M.D. Anderson Hospital and Tumor Institute, Houston, Texas, where he also served as Chief Resident. Dr. Sinesi is a member of the American Society for Radiation Therapy and Oncology (ASTRO), the American Medical Association, The Radium Society and the Chesapeake Medical Society. Dr. Christopher Sinesi, Radiation OncologistDr. Christopher Sinesi graduated from Brown University in Providence, R.I. in 1978 and Boston University School of Medicine in 1982. He completed his residency in Radiation Oncology at M.D. Anderson Hospital in Houston, Texas in 1986 and came to Hampton Roads where he helped establish radiation services at Chesapeake Regional. Dr. Sinesi has served as Radiation Safety officer and Cancer Committee Chairman at CRMC. He is author of a NCI registered prospective study for the treatment of early breast cancer and has particular expertise in the area of prostate cancer, head and neck cancer, and gynecologic malignancy. Dr. Sinesi is past chairman of the High Dose Rate Committee for the GOG (Gynecologic Oncology Group) and is a member in good standing of ASTRO (American Society for Radiation Therapy and Oncology).



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The Cancer Committee consists of primary and specialty care physicians and representatives from hospital departments involved in the care of cancer patients. This multidisciplinary committee meets quarterly to review and

evaluate the quality of care for cancer patients at Chesapeake Regional Healthcare. They oversee the overall direction of the program and make recommendations for improvements.

Chairman Valiant Tan, M.DCancer Liaison Physician Bruce Waldholtz, M.D.Cancer Conference Coordinator William Clark, M.D.Medical Oncology William Clark, M.D.Radiation Oncology Mathew Sinesi, M.D. and Christopher Sinesi, M.D.Diagnostic Radiology Michael Petruschak, M.D. and Natalie Simmons, M.D.Quality Improvement Coordinator Dan Albrecht, D.O. and Jan Young, R.N. Cancer Registry Quality Coordinator Kimberly Bradbury, CTR Cancer Conference Coordinator Diane BatchelderPsychosocial Services Coordinator Rene Hale, MSW, LCSW, OSW-CCommunity Outreach Coordinator Beth Reitz, Director of Comm. Health ServicesClinical Research Coordinator Heather Hyler, R.N., OCNSurgeon Lynne Skaryak, M.D.Pathology Dan Albrecht, D.OCancer Program Administrator Barbara Bellido, B.A RTTOncology Nurse Aurora Cruz, R.N.Palliative Care Gabriella Miller, M.D.Certified Tumor Registrar Athena Bullard, CTRAdministrative Cheryl Paige, MPH, MT(ASCP)SMRehabilitation Services Melinda Shuler, MPT, CMLDTPharmacy Tracy Blalock, Pharm.DPatient Resource Navigator Ellie DuarteBreast Care Center Meg Shrader, R.N.Dietary Services Charlene CurtisPastoral Care Marie Pogorelec, CPSPHospice Donna Marchant-Roof, MSW, LCSW, ACHPSWAmerican Cancer Society Jan Bennett, Health Systems Manager, HospitalsHIM Elizabeth Leff, RHIA



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2016 Breast Colon Lung Prostate Bladder Rectum Liver AllOther Total

January 8 2 1 0 1 1 0 3 16

February 4 2 2 0 1 1 0 2 12

March 4 1 3 0 1 1 0 6 16

April 8 2 1 0 1 0 0 4 16

May 8 3 3 0 0 1 0 1 16

June 12 4 2 1 0 0 0 1 20

July 8 3 2 0 0 1 0 3 17

August 8 4 2 0 0 1 0 1 16

September 8 3 3 0 1 1 1 3 20

October 8 3 2 0 1 0 0 1 15

November 9 3 1 0 0 0 0 1 14

December 12 3 3 0 0 2 0 0 20

Totals 97 33 25 1 6 9 1 26 198

Cancer Conferences at Chesapeake Regional Healthcare are held weekly on Thursday mornings from 7-8 a.m. Dr. William Clark moderates the multidisciplinary discussion at each conference. In order to provide excellent personalized care,

cases are presented at each conference in front of a multidisciplinary team of surgeons, medical and radiation oncologists, pathologists, diagnostic radiologists and medical students. Representatives from social services, the cancer registry, nursing,

and radiation technicians are also in attendance. A review of the cancer case and overview of nationally recognized treatment guidelines are provided and discussed to ensure premier care for each patient.

In 2016, 198 cases were presented at 49 Cancer Conferences, respectively. All cancer sites are discussed. Every other week breast cases are presented as called for by the breast management pathway. Also, for the year 2016, CRH hosted one guest

speaker to present cancer-focused presentations to staff, outlining the most up-to-date cancer treatments and trends. The element of expertise is of educational value to both the medical and ancillary staff.

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Ellie Duarte, Patient Resource Navigator

Personalized care for every patient is our goal. That’s why Chesapeake Regional is proud to offer a Patient Resource Navigator, in partnership with the American Cancer Society (ACS). Since 2005, Ellie Duarte has provided support to thousands of patients throughout their cancer diagnosis and the treatment process. CRH was the first health care organization in Virginia to offer the program and only the second in the nation.

Ellie’s personalized support goes beyond end of treatment. She works with our patients through three stages of survivorship:

Stage I - Living with cancer: Starting from the minute a patient receives a cancer diagnosis and through any treatment that may follow. Stage II – Living through cancer: The period following treatment in which the risk of recurrence is relatively high. During this time, patients are relieved that treatment is over, but anxious about no longer seeing their cancer “family” on a regular basis. Stage III – Living beyond cancer: Post treatment and long-term survivorship. Some patients continue to have physical, psychosocial and financial consequences. While there is never an average day for Ellie, some of her responsibilities include: • Identifying resources for financial assistance, home health care and insurance issues• Encouraging patients to investigate all sources of cancer information and recommends they seek a second opinion if they are not comfortable with their physician’s diagnosis

• Locating community support programs and educational materials • Assisting in navigating the health care system• Arranging for language translation or interpretation services• Arranging transportation to and from doctors’ visits• Providing patients with as-needed support, such as Thanksgiving and Christmas baskets, by getting to know each patient• Helping patients keep their care appointments organized, providing every cancer patient with a tabbed file folder to ensure patients keep all of their medical documents together, in addition to a caregiver binder

Ellie is someone who can truly empathize with cancer patients because she knows firsthand what it is like to cope with the disease. Not only is she a fourth-stage colon cancer survivor, but her husband is a kidney cancer survivor as well. The couple has been cancer-free for more than 16 years.

She is involved with numerous programs through the ACS, including Look Good Feel Better, The Lydia Project, Road to Recovery and Hope Lodge. Ellie is a member of the Virginia Cancer Patient Navigators Network (VACPNN), Cancer Action Coalition of Virginia (CACV) and many other in-house committees. She attends at least two national meetings per year and speaks at 40-50 presentations per year.

Chesapeake Regional’s partnership with the ACS has a positive impact on the care and health management for our cancer patients. Ellie’s presence at the Sidney M. Oman Cancer Treatment Center benefits not only the patient and families, but the hospital and staff as well.



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Meg Shrader, R.N., B.S.N., C.B.C.N.Breast Care Nurse Navigator

Our certified breast care nurse and breast health navigator aims to make the care process less burdensome. She guides patients and their families through the complex health care system by connecting them with the appropriate resources and support. She assists women and men who are going through the diagnostic process as well as those who have been recently diagnosed with breast cancer. Meg Shrader, R.N., B.S.N., C.B.C.N., whose office is located within the state-of-the-art Breast Center, began her tenure at CRH in 2015.

She helps patients coordinate care among the multitude of health care professionals available to Breast Center patients, including primary care physicians, radiologists, general surgeons, medical and radiation oncologists, plastic surgeons, nutritionists and social workers. Meg explains and reinforces information given by the different clinicians, enabling patients to make informed decisions about their care. She continually educates and provides emotional support to the patients and their families as they continue on their journey. She is also an active member of the Breast Friends support group and often visits with patients on the morning of their surgery to provide support. Realizing that there were inconsistencies with data collection, Meg took over the data collection for the NAPBC

standards in 2016. As the program grew, she also began data analysis of time from biopsy to surgery and identified roadblocks in the system like scheduling issues for different modalities and specialties. Her analysis is reported in the Breast Steering Committee minutes. She continues to work with Melinda Schuler, physical therapist, to make sure that appropriate patients are referred for lymphedema therapy. Meg helped create an educational binder for newly diagnosed breast cancer patients. It includes basic information about breast cancer, information about the patient’s subtype and pathology report, treatment options, specialists, lymphedema educational material, support group material and survivorship guidelines. The binder is tailored to the individual patient’s needs, is distributed by Meg and has been well received. Meg participated in many outreach activities throughout the year that included writing educational newspaper articles, providing television interviews, performing free clinical breast exams and assisting with the Bra-ha-ha® outreach event.

We saw exponential growth of the breast program in 2016, and we are looking forward to the same growth in 2017.




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Lou Verdes, R.N., C.B.C.N.Radiology Nurse Navigator, Breast Center

Chesapeake Regional Healthcare is committed to reducing the number of sleepless nights that women and men may experience during the diagnostic process for breast issues. In March of 2015, Chesapeake Regional Healthcare instituted the Comprehensive Breast Evaluation Program. This program allows referring providers to partner with the hospital and permits Lou Verdes, Radiology Nurse Navigator, to meet with patients and schedule additional testing. Prior to implementation of this program, the average number of business days between abnormal imaging to the date of biopsy was eight-to-nine days. That average has decreased to approximately five days since the inception of the program. As part of our comprehensive breast program and commitment to personalized care, this helps to decrease the amount of stress our patients experience during the process.




A.J. Ruiz, M.D., F.A.C.S.Breast Surgeon

In 2015 Chesapeake Regional Medical Group recruited the surgeons of Carolina Surgical Care. This group, which already owned existing offices in Elizabeth City and Kitty Hawk, N.C., allowed Chesapeake Regional to further expand its reach. With this addition, Antonio Ruiz, M.D., F.A.C.S. joined the Breast Center at Chesapeake Regional as the medical director to provide surgical care to our cancer patients. Dr. Ruiz attended the College of William and Mary in Williamsburg, Va. and received his medical degree from Eastern Virginia Medical School in Norfolk, Va. He completed a general surgery residency at Roanoke Memorial Hospital in Roanoke, Va. and the University of Virginia Medical Center in Charlottesville, Va. He is board certified in stereotactic breast procedures and general surgery.

Ruiz participates in registry trials by Targeted Medical Education, an elite group of community-based breast cancer physicians dedicated to identifying genuine advances in the breast cancer field including percutaneous lumpectomies. In his previous position at Sentara Albemarle Medical Center, he was chair of the multidisciplinary breast program and director of the breast biopsy program at Albemarle and Kitty Hawk as well. He is a member of the American Society of Breast Surgeons and the American College of Surgeons.

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Mindy Petit, RN, CGRNDigestive Health Program Coordinator As the coordinator for the Digestive Health program, Mindy reaches out to providers and educates as many individuals as possible to facilitate screening colonoscopies. She also works with individuals diagnosed with colorectal cancers to help make their treatment journey as smooth as possible by providing assistance with everything from scheduling diagnostic testing and appointments to providing support and resources.

Colorectal cancer is one of the most common malignancies in the United States. About 30 percent of eligible adults in the United States have never been screened for colorectal cancer, mostly due to disparities in education, availability, insurance coverage and the ability to afford medical treatment.

The major goal of our Digestive Health Program is to save lives by ensuring that all eligible people have access to the screening they need. We want to continually pursue a strong fight against colorectal cancer. Screening can prevent most colorectal cancers or detect them early enough to be cured.

Meredith Felix, R.N.Pelvic Health Nurse Navigator As the Pelvic Health Nurse Navigator, Meredith Felix, R.N., works with both physicians and patients to provide seamless care management and personalized patient support and education. She provides patient education, schedules specialist appointments and offers tailored care for our patients. She also delivers support for patients who require surgical intervention or physical therapy for their condition. Our comprehensive program is designed for both men and women. The specialists in the Pelvic Health Program include a gynecologist and urologist who specialize in pelvic medicine and reconstructive surgery, a urologist specializing in men’s health and a board-certified colon and rectal surgeon. They use leading-edge therapies to accurately treat the cause of symptoms and are supported by Meredith who helps to provide quality care to pelvic health patients across the continuum. Meredith has most recently started to direct her focus on the male prostate cancer arena by working with primary care physicians and urologists to emphasize the need for prostate cancer screenings. She works with these physicians and patients to deliver education and follow-up support. The hope is to decrease the community’s overall undetected prostate cancer numbers.




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Vicky West, R.N.Thoracic & Lung Health Nurse Navigator

Lung cancer is the leading cause of cancer death among both men and women. Approximately 220,000 new cases are diagnosed each year and nearly 160,000 people die from the disease. Cigarette smoking accounts for 85 percent of all lung cancer, and 84 million current and past smokers are at risk. Smoking cessation is the most important thing one can do to prevent lung cancer, but many of our patients remain high risk for 15 years after quitting cigarette smoking. We stress regular screening for all high-risk patients because early stage lung cancer detection saves lives. That’s why we founded the Thoracic & Lung Health program—to promote early screening and offer effective, comprehensive treatment.

As Lung Health Nurse Navigator at Chesapeake Regional Healthcare, Vicky West works to educate, schedule and follow-up with patients who are at high risk for lung cancer because of their health history. In addition to the screening program for lung cancer, we have a comprehensive, highly experienced team of doctors and surgeons to manage the cancers that are found. Through this multi disciplinary

approach, Vicky can manage these patients through their cancer experience making it easier and less stressful to move through the next appointments, procedures and treatments. The Lung Screening program at CRH began in August 2015. Since that time, 500 high-risk (for lung cancer) patients have been screened. There have been ten patients with positive screens that resulted in further interventional diagnostic procedures and/or surgery. Four of those patients were benign, and the other six had malignant adenocarcinoma. Of these, one stage IV patient passed away, and the five others have received treatment and remain cancer-free at this time.

Another aspect of Vicky’s role focuses on incidental lung findings. Radiological tests performed on our ED patients focus on their acute symptoms at the time of the visit. Occasionally, an unexpected finding will be present on these tests. Often the patient is unaware of these insignificant findings that could potentially lead to a serious cancer in the future. Vicky reviews tagged ED radiology results to search for incidental findings and schedules these patients for follow up at our clinic hopefully reducing the chances of a critical lung cancer in their future.




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Jessica Edmonds, R.D.N.Oncology Nutrition Services

Jessica Edmonds, R.D.N., is available to assist patients with all of their nutritional needs before, during and after treatment. Nutritional management during cancer treatment is vital to the health and well-being of cancer patients. Those patients receiving nutrition intervention have demonstrated less fatigue, fewer infectious complications and a more rapid recovery from treatment. Adequate nutrition is also linked to fewer side effects from treatment overall, fewer hospitalizations and a possible delay or prevention of disease progression. Jessica has served the Sidney M. Oman Cancer Treatment Center since March of 2015. She was educated at the University of Texas at Austin and has more than 20 years experience working with clinical dietary needs. Jessica provides assessments, education and support on an individual basis and in group settings. She is available at the clinic on Thursdays. Rene Hale, L.C.S.W., O.S.W.-C.Oncology Social Worker Services A diagnosis of cancer brings with it a variety of challenges and often overwhelming emotions. Rene Hale, our on-site Licensed Clinical Social Worker and Oncology-Certified Social Worker, works with patients and their families to cope with these emotions and provides supportive therapy

as they move forward on their journey. She facilitates a monthly general cancer support group called “People Helping People” offered at CRH.

Rene brings years of experience in mental health, home health and hospice counseling and support. The role of a social worker is to connect the patient and their family to community resources to provide financial, emotional and physical assistance. She is ready to help with the practical problems of a family facing cancer such as finding transportation to medical appointments or finding ways to cover the cost of medication. Financial concerns are frequently identified as a stressor for patients and their families. Rene has worked with patients to determine which programs might be able to help them in their current circumstances such as Medicaid and SNAP. At other times, the family may need assistance with the Family Medical Leave Act (FMLA) and short-term disability paperwork. When needed, she assists with gathering the necessary documents to apply for Social Security Disability.

In addition to these services, Rene assists patients and families with Advanced Directives and helps them to understand advanced care options such as home health, palliative care and hospice services. As an Oncology Social Worker, Rene Hale wants to make the cancer journey a little easier for her patients by finding the right resource for each person.




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Healing for the patients, value of the physician Chesapeake Regional’s Advanced Wound and Hyperbaric Center provides physicians with a valuable resource for their patients with hard-to treat wounds. Our full-service approach covers every aspect of wound healing from a highly qualified team of physicians and wound-certified nurses that use an evidence-based approach for treating wounds. Our team approach follows a clinical pathway designed to heal patients in 14 weeks using advanced wound therapy. Chesapeake Regional’s Advanced Wound and Hyperbaric Center consistently averages above a 90% patient healing outcome for difficult-to-heal wounds. Patients will return to their primary care providers healthier and happier with their wounds fully healed. Hyperbaric Oxygen (HBO) Therapy for Late Effects of Radiation

HBO is the administration of 100% oxygen at environmental pressures greater than one atmosphere absolute (ATA). Administration involves placing the patient in an airtight vessel, increasing the pressure within that vessel and giving 100% oxygen for respiration. In this way, it is possible to deliver higher doses of oxygen to the lungs, blood and tissues at increased pressure. The American Cancer Society estimates there are over 15.5 million cancer survivors in the United States.

About 50% of those survivors have received radiation therapy to fight cancer. A small amount, 5-15% of those long-term survivors, may deal with the late effects of radiation. Common symptoms include fecal incontinence, fecal urgency, diarrhea and constipation. Patients with severe complications dealt with rectal bleeding, ulceration and fistulae.

HBO therapy stimulates new blood vessels and tissue growth and restores associated soft tissue fibrotic changes. Our physician-led wound care center has been treating patients with HBO for 18 years. Wound Care TeamAnthony W. Viol, M.D., – Wound Center Medical Director

Dr. Viol is the medical director who leads the team of highly-qualified physicians and nurses at Chesapeake Regional’s Wound Care and Hyperbaric Center. He received his medical degree from Eastern Virginia Medical School in Norfolk, Va., where he also completed a residency program in general surgery. He completed a fellowship in plastic surgery at Duke University in Durham, N.C. and has vast experience in caring for slow-to-heal wounds as well as the surgical treatment of skin concerns.

Cynthia L. Bowling, R.N., M.S.N., F.N.P.-C. Cynthia Bowling is an integral part of the wound care team and follows clinical pathway plans designed to heal patients quickly and thoroughly. She earned her Bachelor of Science in Nursing from Virginia Commonwealth University in Richmond, Va., and a Master of Science degree in Nursing from Old Dominion University in Norfolk, Va. Bowling has been a Nurse Practitioner for nearly 20 years.



w o u n d c a r e a n d h y p e r b a r i c c e n t e r : c a n c e r c a r e

The mission of the Advanced Wound and Hyperbaric Center is to improve the quality of life for our patients. That means aggressively managing wounds to ensure they heal quickly and completely. We partner with referring physicians to determine a complete set of wound care protocols for each patient’s needs. And we provide patients

with treatments that will enable them to return to a life free from the pain of chronic wounds.

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Following the Commission on Cancer program standards, the CRH Cancer Committee designates a physician member to complete an in-depth analysis to assess and verify that cancer program patients are evaluated and treated according to evidence-based national treatment guidelines. In 2016, Standard 4.6, Physician-Led Study, was conducted and compiled by physicians Christopher Sinesi, M.D., Mathew Sinesi, M.D. and Tyvin Rich, M.D.

For the purposes of this review, cancer of the liver will be broken into two general categories - primary hepatocellular cancer and metastatic disease. The treatment of these cancers can vary widely. Primary hepatocellular cancers present a diagnostic and therapeutic challenge which can involve surgery, chemotherapy and radiation therapy. In addition to primary tumors of the liver, the liver is often the site of metastatic disease from primary cancers in virtually every organ system. Metastatic disease to the liver has traditionally been considered a death knell and an indication for palliative intervention only, but advances in chemotherapy, both systemic and intra-arterial, as well as advances in external beam radiation and intra-arterial radiation combined with advanced surgical procedures, have opened the door to a more aggressive approach for liver metastases, particularly in the setting of colorectal cancers in which the liver represents the sole site of metastatic disease . This review will track a sampling of patients who presented at our institution with liver tumors, and their treatments will be compared to NCCN guidelines and recommendations for improved care of this common disease entity.



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Christopher Sinesi M.D., Mathew Sinesi M.D., Tyvin Rich M.D., F.A.C.R.

Primary cancer of the liver occurs in approximately 22,000 cases per year and results in some 17,000 deaths in the United States. Hepatocellular carcinoma is the most frequent primary lesion followed by gallbladder cancer, extrahepatic cholangiocarcinoma, and the least-common tumor, intrahepatic cholangiocarcinoma. Primary hepatocellular carcinoma is four times more common in men and is some 250 times more common in patients with chronic hepatitis B. Cirrhosis, hepatitis C and aflatoxin exposure are also risk factors. Prevention is aimed mainly at proper use of the hepatitis B vaccine. The treatment of choice for this disease when possible is partial hepatectomy. Patients who undergo partial surgical resection can expect a 35-40% five-year overall survival period. For patients with small tumors with advanced cirrhosis, total hepatectomy with liver transplant can be an option with five-year survival rates that have approached 70%. Unfortunately local failure is common, and the role of adjuvant and neoadjuvant therapy is unclear. Local treatment of the tumors can include ablative procedures. Alcohol injection and cryoablation, which were once used on tumors up to six centimeters in size, are no longer available in the United States. Chemo-embolization and intrahepatic artery chemotherapy have demonstrated response rates between 40 and 50%, but it is difficult to demonstrate long-term improvement in survival.

Systemic chemotherapy has generally low response rates without survival benefit. External beam radiation is limited by the sensitivity of the surrounding liver tissue and care must be taken to limit the dose to normal tissue to avoid hepatic failure.

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Highly conformal techniques such as SBRT have been utilized with some suggestion of improved survival. Yttrium microsphere and Iodine 131 Lipiodol are intra-arterial radiation techniques that could be used to target multiple tumors in the liver simultaneously. Stereotactic body radiation (SBRT) is the use of multiple intersecting radiation, and aims to increase the dose of radiation delivered to the tumor within the liver while limiting the dose to surrounding tissues. Specialized particle beam and intraluminal radioactive sources can also be used to accomplish the goal of high localized dose to the tumor with doses to the remaining liver below the normal tissue tolerance. The liver location beneath the diaphragm has significant respiratory excursion, making tumors within the liver a moving target and a challenge to external radiation treatment techniques. Metastatic disease to the liver often represents end-stage disease, and palliative therapy directed at relief of symptoms is often the most reasonable course of action. Standard external beam radiation techniques can be used to reduce pain associated from capsule distention and temporarily reverse obstructive symptoms. Recent evidence has suggested that, under certain circumstances, an aggressive approach to liver metastases may in fact improve a patient’s chance for survival. The term oligometastatic disease has recently been popularized and is often defined as less than five separate sites of metastatic disease. Some tumors may have limited metastatic potential and aggressive treatment of the metastatic sites will improve the patient’s survival. ln particular, gastrointestinal primary tumors, which have metastasized to the liver, have demonstrated improved prospect for control when the liver disease is aggressively treated.





Options for treatment of metastatic disease to the liver are similar to those for primary cancer of the liver, but metastases to the liver commonly present as multiple sites of disease precluding resection. Resection can still be considered for localized metastatic deposits, but the options of stereotactic radiation, intra-arterial chemotherapy, Therasphere (SJR S spheres) treatment and particle beam therapy must also be carefully considered. Below is a brief review of the clinical course of nine patients who presented with cancer in the liver during 2016 and their ultimate disposition. • 79 y.o. male. Dx’ s obstructing colon Ca, biopsy+ liver mets. Underwent diverting surgery to relieve obstruction then pt. transferred to Obici Hospital.

o NCCN Guidelines followed: yes, up until pt. transferred out of CRMC group. o Benefit from THERASPHERE: unknown, pt’s care out of system.

• 50 y.o. female. Rectal cancer treated with pre-op XRT/CTX completed 5/19/2015. CT 6/8/15 showed possible liver mets. Pt underwent treatment at another institution (embolization/ resection of liver) but no records available. CT 9/9/2016; shawed metastatic density in left lobe of liver at site of prior lesion.

o NCCN Guidlelines followed: yes, while pt. under CRMC care. o Benefit from THERASPHERE: possibly for new liver lesion. Pt’s care again taken out of CRMC. • 52 y.o. female. Small cell ca lung. Rx with CTX, XRT for brain met 10/10/15. CT 10/15/15 -4.3 cm liver mass, repeat CT 12/30/15-stable liver mass,

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liver biopsy 1/25/16 + small cell ca. Pt admitted 11/29/16 with intractable pain (NOT from liver met). Last contact 11/29/16. No recent abd CT.

o NCCN Guidelines followed: yes. o Benefit from THERASPHERE: Pt’s liver lesions were asymptomatic.

• 49 y.o. female. Obstructing sigmoid colon ca. Underwent sigmoid resection and bilateral pelvic LN dissection 3/14/16. CT abd 7/6/16 showed 3 liver lesions R lob e, largest 2.8 cm. Required kyphoplasty (L-2, L-4). New abd CT scheduled for 12/ 28/ 16.

o NCCN Guidelines followed: yes o Benefit from THERASPHERE: possibly, pending results of CT 12/28/16 • 52 y.o. female. Came to ER with large painful pelvic mass on CT, also multiple pulmonary emboli. CT showed multiple liver mets, pancreas mets, ascites. Paracentesis showed+ malignant cells, CT bx of pelvis mass showed + malignant cells consistent with mucinous ovarian primary. Started anticoagulants + CTX. Pt’ s pain from pelvic mass, no sx’s from liver lesions.

o NCCN Guidelines followed: yes o Benefit from THERASPHERE: not at this time, pt’s symptoms from pelvic mass, not liver.

• 79 y.o. male. Hepatocellular CA stage 4 at diagnosis. Pt DECLINED embolization, enrolled on Hospice and expired.

o NCCN Guidelines followed: pt. declined therapy. o Benefit from THERASPHERE: possibly, if pt. had allowed it.

• 72 y.o. female. Metastatic lung ca admitted with acute pancreatitis, + liver mets. Intractable pain from pancreatitis, not liver. Pt enrolled on palliative care and expired.

o NCCN Guidelines followed: Palliative care only. o Benefit from THERASPHERE: No, pt. wished palliative care only and had no symptoms from liver lesions. • 55 y.o. male. Small cell lung ca presenting with SVC obstruction. Emergency XRT - CTX. Mild response from CTX and pt. expired. Solitary liver met by ct.

o NCCN Guidelines followed: yes o Benefit from THERASPHERE: Pt expired before liver mets became symptomatic.

• 80 y.o. male. Adeno Ca RUL, + liver mets, + bone met s. Rx chemotherapy. Underwent vertebroplasty of painful L-3, followed by L-spine XRT. Pain from L-spine mets only, no pain from liver, pt. expired.

o NCCN Guidelines followed: yes o Benefit from THERASPHERE: No, pt. Expired before liver lesions became symptomatic. The average age was 63 and four patients were male and five female. One had primary hepatocellular cancer and the rest had metastatic disease to the liver. Systemic chemotherapy was the most commonly prescribed treatment and was used in at least four patients. The majority of patients had at least part of their treatment outside of this institution, and thus we have limited records for evaluation. At least one of the patients received Theraspheres; one patient was embolized, and two patients went directly to hospice.

r e v i e w >





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The NCCN guidelines address the treatment of primary liver cancer but do not speak directly to the management of metastatic disease. The management of metastatic disease to the liver is addressed by the NCCN in the section on each primary cancer. In all cases within this review, treatment performed at CRMC conformed to NCCN guidelines, but many patients were unable to receive their full course of therapy at our institution partly due to the lack of available subspecialty technique. Patients in need of surgical resection, intra-arterial chemotherapy and Therasphere treatment were referred appropriately to local institutions that have these capabilities.

The fact that many patients completed treatment outside this institution suggests an area for improvement within our facility. We propose the development of a GI cancer review committee with a dedicated GI cancer tumor board. The goal of this new committee would be to develop new treatment capabilities for CRMC including radioactive microsphere instillation, SBRT and brachytherapy techniques. We would also work to enhance surgical options and integrate state-of-the-art systemic and intra-arterial chemotherapy using a multidisciplinary approach establishing Chesapeake Regional Medical Center as a center of excellence in the treatment of GI cancers.

b i b l i o g r a p h y

1. Abou-Alfa GK, Schwartz L, Ricci S, et al. Phase II Study of Sorafenib in Patients with Advanced Hepatocellular Carcinoma. J. Chin Oncol 2006; 24; 4293-4300.2. Borghero Y, Crane CH, Szklaruk J, et al. Extrahepatic Bile Duct Adenocarcinoma: Patients at High Risk for Local Recurrence Treated with Surgery and Adjuvant Chemoradiation Have an Equivalent Overall Survival to Patients with Standard-R is k Treated with Surgery Alone. Ann Surg Oncol 2008; 15: 3147-3 156.3. Dawson LA, Normolle D Baker JM et al. Escalated Focal Liver Radiation and Concurrent Hepatic Artery Fuorodeoxyuridine for Undetectable Intrapehatic Malignancies. J Chin Oncol 2000; 18:22 10-2218.4. Dawson LA, Normolle D Baker JM et al. Analysis of Radiation-Induced Liver Disease Using the Lyman NTCP Model. Int J Radiat Oncal Biol Phys 2002; 53: 810-821.5. Lau WY, Lai EC, Leung TW et al. Adjuvant Intra-arterial Iodine 131 Labeled Lipiodol for ResectableHepatocellular Carcinomas: A Prospective Randomized Trial - Update on 5-Year and I0-Year Survival. Ann Surg 2008; 247:43-48.6. Llovet JM, Ricci S. Mazzaferro V et al. Sorafenib in Advanced Hepatocellular Carcinoma. N Engl J Med 2008; 359; 378-390.7. Mornex F. Girarda N. Beziat C, et al. Feasibility and efficacy of high-dose three-dimensional radiotherapy in cirrhotic patients with small-size hepatocellular carcinoma non-eligible for curative therapies - mature results of the French phase II RTF-I trial lnt J Radiat Oncol Biol Phys 2006;66: 11 52-8.8. Tf ! RY, Kim JJ, Hawkins M et al. Phase I Study of individualized Stereotactic Body Radiotherapy for Hepatocellular Carcinoma and lntrahepatic Cholangetic Sarcoma. J Clin Oncol 2008; Epub Jan 2.9. Zeng ZC, Tang ZY, Fan Jet al. A comparison of chemoembolization combination with and without radiotherapy for unresectable hepatocellular carcinoma. Cancer J 2004; I 0:307-316.

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2 0 1 6 4 . 7 s t u d y o f q u a l i t y

s t u d y o f i n c i d e n t a l l u n g n o d u l e s

Incidental lung nodules found on CT scans in the Emergency Department were not being adequately reported to patients for potential follow-up. Evidence-based guidelines suggest that pulmonary nodules need to be evaluated for possible malignancy. As a result of the identified gap in reporting, Vicky West, R.N., B.S.N., thoracic & lung health nurse navigator, conducted a study by evaluating three months of abdominal and/or pelvic CTs ordered by the Emergency Department from March to May 2016.

All radiologist reports indicating the presence of a lung nodule were included in the study, and medical records of these patients were subsequently reviewed to determine whether or not the patient was notified of the incidental finding. Of all radiologist reports indicating incidental lung nodules, the Emergency Department notified 11% of patients in March, 14% in April, and 12% in May.

The following corrective and follow-up action has been implemented based on study findings:

1) A report in EPIC has been created to identify all abdominal and chest CT radiology reports that contain key words indicating lung or pulmonary nodules or masses.

2) A Lung Nodule Clinic has been established to provide patients the appropriate follow-up care to include subsequent CT scans or referral for pulmonary or thoracic intervention. Per NCCN guidelines, a nodule size of greater than 6mm, but no larger than 8mm, should be tested again in three months. Patients with smaller nodules should start yearly lung cancer screening with low-dose computed tomography. The Lung Nodule Clinic treats patients without a current PCP or Pulmonologist following them as well as patients referred to the Clinic by their PCP for further lung nodule follow up.

3) The lung nurse navigator reviews the EPIC report bi weekly by analyzing radiology reports for incident finding and reviewing the patient medical records for documentation of the patient being informed of the incidental nodule finding. If it is determined that the patient was not notified, the patient is notified by phone or certified letter after three failed phone attempts. Additionally, patient PCPs receive a notification letter and radiology report via fax.

4) Data is tracked on all incidental lung nodule patients to ensure follow-up steps are taken to monitor the implemented corrective actions. The Incidental Lung Finding Database includes patient MRN, Emergency Department visit date, imaging performed, whether the patient was informed, date of phone follow up, reason patient is not followed, whether a letter was sent to the patient’s PCP, Lung Clinic appointment date and overall outcome.

5) The findings and follow-up actions were shared with the cancer committee and other departments to advance patient care.

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A comprehensive community cancer registry provides the means to monitor all cancers diagnosed and/or treated at an institution. This is a critical component in the evaluation of cancer care.

What is a Cancer Registry?

Since 1976, Chesapeake Regional Medical Center has maintained an active Cancer Registry. The Cancer Registry staff continues to collect, manage and report cancer data to the CRH Cancer Committee, State of Virginia and National Cancer Data Base (NCDB). This data includes demographics, anatomic sites/metastatic sites, histologic type, AJCC stage and treatments. These data components contribute to treatment planning, staging and continuity of care for oncology patients.

How can a Cancer Registry benefit a Hospital? The collection of cancer registry data can identify facility and community needs, thus providing the community with needed screenings and interventions while evaluating access to care. Reliable registry data is fundamental to a variety of research efforts including those aimed at assessing effectiveness of cancer prevention, control or treatment programs.

How does the Registry protect privacy? All information reported to the State of Virginia and the National Cancer Data Base is confidential and strict procedures are enforced to protect patient privacy. For all records sent to the state and national organizations, all patient indicators have been removed.

• Each and every patient in the CRH Cancer Registry is followed annually via the follow up clerk. Our Cancer Registry follow-up rate was an average of 98.84% (exceeds Commission on Cancer requirement of 90%).

• The Cancer Registry is maintained by Cancer Program Coordinator, Kimberly Bradbury (CTR), Athena Bullard (CTR) and Follow-Up Clerk, Diane Batchelder.

• CRH Cancer Registry analytic cases (Jan-Sept ’16) = 557 primaries and 4 non-analytic primaries totaling 561 cases accessioned, thus far.



2 0 1 6 c a n c e r r e g i s t r y r e p o r t

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Disease Site Males Females Total Lip Oral Cavity Pharynx 8 (4.00 %) 4 (1.32 %) 12 (2.39 %) Esophagus 8 (4.00 %) 2 (0.66 %) 10 (1.99 %) Stomach 3 (1.50 %) 2 (0.66 %) 5 (0.99 %) Small Intestine 1 (0.50 %) 1 (0.33 %) 2 (0.40 %) Colon 20 (10.00 %) 28 (9.24 %) 48 (9.54 %) Rectum 9 (4.50 %) 7 (2.31 %) 16 (3.18 %) Anus 1 (0.50 %) 4 (1.32 %) 5 (0.99 %) Liver 8 (4.00 %) 0 (0.00 %) 8 (1.59 %) Pancreas 12 (6.00 %) 13 (4.29 %) 25 (4.97 %) Other Digestive Organ 1 (0.50 %) 1 (0.33 %) 2 (0.40 %) Larynx 2 (1.00 %) 2 (0.66 %) 4 (0.80 %) Lung 41 (20.50 %) 40 (13.20 %) 81 (16.10 %) Other Respiratory 1 (0.50 %) 1 (0.33 %) 2 (0.40 %) Bones and Joints 0 (0.00 %) 0 (0.00 %) 0 (0.00 %) Soft Tissue 0 (0.00 %) 0 (0.00 %) 0 (0.00 %) Melanoma skin 3 (1.50 %) 1 (0.33 %) 4 (0.80 %) Kaposis sarcoma 0 (0.00 %) 0 (0.00 %) 0 (0.00 %) Mycosis Fungoides 0 (0.00 %) 0 (0.00 %) 0 (0.00 %) Other Skin 0 (0.00 %) 0 (0.00 %) 0 (0.00 %) Breast Female 0 (0.00 %) 124 (40.92 %) 124 (24.65 %) Breast Male 2 (1.00 %) 0 (0.00 %) 2 (0.40 %) Cervix 0 (0.00 %) 2 (0.66 %) 2 (0.40 %) Corpus Uteri 0 (0.00 %) 21 (6.93 %) 21 (4.17 %) Ovary 0 (0.00 %) 10 (3.30 %) 10 (1.78 %) Other Female Genital 0 (0.00 %) 4 (1.32 %) 4 (0.89 %) Prostate 29 (14.50 %) 0 (0.00 %) 29 (7.47 %) Other Male Genital 3 (1.50 %) 0 (0.00 %) 3 (0.18 %) Urinary Bladder 17 (8.50 %) 11 (3.63 %) 28 (5.16 %) Kidney 8 (4.00 %) 2 (0.66 %) 10 (1.99 %) Other Urinary 4 (2.00 %) 0 (0.00 %) 4 (0.80 %) Eye and Orbit 0 (0.00 %) 0 (0.00 %) 0 (0.00 %) Brain & Nervous System 4 (2.00 %) 0 (0.00 %) 4 (0.80 %) Thyroid 1 (0.50 %) 10 (3.30 %) 11 (2.19 %) Other Endocrine System 0 (0.00 %) 0 (0.00 %) 0 (0.00 %) Non-Hodgkins Lymphoma 5 (2.50 %) 5 (1.65 %) 10 (1.99 %) Hodgkins Lymphoma 1 (0.50 %) 0 (0.00 %) 1 (0.20 %) Multiple Myeloma 1 (0.50 %) 0 (0.00 %) 1 (0.20 %) Lymphoid Leukemia 1 (0.50 %) 1 (0.33 %) 2 (0.40 %) Myeloid and Monocytic Leukemia 0 (0.00 %) 1 (0.33 %) 1 (0.20 %) Leukemia other 0 (0.00 %) 0 (0.00 %) 0 (0.00 %) Other Hematopoietic 0 (0.00 %) 0 (0.00 %) 0 (0.00 %) Unknown Sites 6 (3.00 %) 4 (1.32 %) 10 (1.99 %) Ill-Defined Sites 0 (0.00 %) 0 (0.00 %) 0 (0.00 %) Other 0 (0.00 %) 0 (0.00 %) 0 (0.00 %) Benign Brain and CNS 0 (0.00 %) 2 (0.66 %) 2 (0.40 %) TOTALS 200 (100.00%) 303 (100.00%) 503 (100.00%)



2 0 1 6 d i a g n o s i s b y g e n d e r - n c i d i s t r i b u t i o n *

*The data elements and graphs, provided via the Cancer Registry, represent January through September 2016 data.

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t o p 1 0 s i t e s 2 0 1 6



2 0 1 6 t o p 1 0 h i s t o l o g i e s a t c h e s a p e a k e r e g i o n a l m e d i c a l c e n t e r

Adenocarcinoma 151 Ductal Carcinoma 87 Squamous Cell Carcinoma 31 Endometrial Adenocarcinoma 17 Mucinous Adenocarcinoma 17 Papillary Transitional Cell Carcinoma/Non-Invasive 13 Squamous Cell Carcinoma, keratinizing 12 Carcinoid Tumor 10 Ductal Carcinoma in Situ with mixed subtypes 10 Small Cell Carcinoma 9

Breast 124 Lung 81 Colon 48 Prostate 29 Urinary Bladder 28 Pancreas 25 Corpus Uteri 21 Rectum 16 Lip/Oral Cavity/Pharynx 12 Thyroid 11

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