Transforming Care

Through Technology

Ella Milbank Foshay Cancer Center’sComprehensive

Oncology Program

2018 Quality and Accreditation Report

K. Adam Lee, MDChair, Cancer Committee Board Certified, General and Cardiothoracic Surgery Medical Director, Thoracic Surgery & Lung Center of Excellence

The Comprehensive Cancer Program is accredited, with commendation, by the Commission on Cancer as a Comprehensive Community Cancer Program. Only 30 percent of cancer programs in the United States hold this accreditation. As a patient you can be assured that we have met the highest quality standards established by the Commission on Cancer. Radiation Oncology is accredited by the American College of Radiology and the Comprehensive Breast Care Program is accredited by the National Accreditation Program

for Breast Centers, the first facility in Palm Beach and Martin counties to achieve this prestigious accreditation.

2018 marked the launch of our newest program in gastrointestinal cancer care. As part of the comprehensive approach at Jupiter Medical Center our team of physicians came together to form a multidisciplinary conference where patient cases are discussed to determine personalized treatment plans. One of the outcomes of this conference was the surveillance of high-risk pancreatic cysts.

Another new program underway is the Women’s Lung Health Program. The Lung Clinic identified that many women are not aware of the risk factors and the importance of screening and early detection. Lung cancer in those who have never smoked is now considered the 6th most common cause of cancer deaths in the United States.

At Jupiter Medical Center we are continuously working to improve cancer care which includes incorporating the best and latest equipment. Technology is rapidly evolving to provide tools that our physicians use to investigate and research treatment options. Technological advances that combine with artificial intelligence are at the early stages of exploration and use.

In 2018 Jupiter Medical Center started its second year using IBM Watson for Oncology Artificial Intelligence (IBM WFO AI). WFO is an advisory tool that combines the speed of Watson with patient information

to provide oncologists with treatment recommendations. Standard practice relies on physician decision-making for treatment planning however IBM WFO has been useful as a comparative tool and has shown very high concordance levels. The summary data we have collected indicates 91 percent of patients were pleased with WFO and 92.5 percent would use it again. We had the opportunity to present Jupiter Medical Center data results at the International Society for Minimally Invasive Cardiothoracic Surgery (ISMICS) in New York City and at the European Lung Cancer Congress (ELCC) in Geneva in 2018.

Our participation has also been an opportunity to support physicians and patients in second and third world countries who lack the resources available to us. WFO is being used in over 15 countries with over 140,000 cancer patients. In China, for example, a medical oncologist sometimes sees 70 patients in a day and IBM WFO provides treatment information to support their care.

The physicians in Oncology and leadership at Jupiter Medical Center will remain vigilant in keeping abreast of new and emerging ways to improve cancer care for the patients we serve.

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One of the most rapidly changing technological advances in breast cancer detection, prevention and treatment has been genetic testing. As this aspect of cancer care evolves so do the array of challenges. These include cost, variability in physician use of testing, quality of testing, patient and patient’s family willingness to test, and genetic professionals who can provide counseling and testing.

In 2018 considerable progress has been made in this field thanks to the advances in broad genetic testing which allows for treatments to be personalized for patients by targeting the different types of tumors.

At Jupiter Medical Center genetic testing is and has been a key component of the Comprehensive Breast Program. Patients are referred to the Cancer Genetics and High-Risk Program by outside providers, self-referral or from the Margaret W. Niedland Breast Center.

Following referral, a member of the genetics clinical team will review the patient’s genetic packet, develop a pedigree, gather medical records, pathology reports, additional family history, and run appropriate risk models. After the pertinent information is obtained, a testing strategy is developed. A pretest appointment would then be scheduled for the patient and next steps, including whether testing is recommended, would be discussed. If testing is performed, a results disclosure appointment is

scheduled and during this visit the results are reviewed and a care plan and other resources as appropriate are provided.

The Comprehensive Breast Program will continue to evolve along with genetic testing to bring the latest benefits to our patients.

Over the last five years, technology has been transformational in cancer care at Jupiter Medical Center. This annual report focuses on this new technology and the resulting changes. In Radiation Oncology alone we have introduced IOERT, CyberKnife® M6TM, Multileaf Collimator, MRI Guided Brachytherapy, as well as Prone Board techniques for breast cancer, providing patients with the most advanced treatments available. These technologies have made treatments shorter, decreased radiation exposure, reduced impact on areas near the treatment site, and allowed patients to resume normal activities faster. These technologies and their benefits are showcased on the following pages.

We are excited to announce that in 2019 Jupiter Medical Center we will be adding a TrueBeam® radiology system to Radiation Oncology. The precision of the TrueBeam system is measured in increments of less than a millimeter. This accuracy is made possible by the system’s sophisticated architecture, which synchronizes imaging, patient positioning, motion management, beam shaping and dose delivery, performing accuracy checks every ten milliseconds throughout the entire treatment.

One aspect of adding new technology to a program is to make sure the clinical benefit is reflected in the outcomes. As the Cancer Liaison Physician (CLP) my responsibility is to review the metrics for our program to make sure we meet the required Commission on Cancer standards and National benchmarks and report the outcomes to the Cancer Committee.

Metrics that are especially important to Jupiter Medical Center are those related to patient satisfaction. We want to know what our patients think of every step of their cancer care and survey each patient to determine what they think is working and what needs to be improved. Over the course of the last five years, we have seen a dramatic improvement in many metrics including patient satisfaction.

Outcomes projects are another way to identify opportunities for improvement including diagnosis, treatment and supportive care. Each year the Cancer Committee selects

at least two outcomes projects. The retrospective project summary below focuses on reviewing if patients diagnosed with rectal cancer were properly staged prior to surgery and pretherapy.

We at Jupiter Medical Center strive to deliver multidisciplinary academic style cancer care in a patient centered environment. By continuing to focus on improving outcomes through our state of the art technology and multi-disciplinary approach, we hope to continue to elevate the patient care within our community.

Rectal Cancer StagingCommission on Cancer Standard 4.6 – Monitoring Compliance with Evidence-Based Guidelines

This project was initiated to verify that Jupiter Medical Center met the NCCN guidelines of performing staging rectal cancer patients in 2017. Appropriate preoperative and pretherapy staging is required per NCCN guidelines with EUS or MRI (preferred) for rectal cancer patients.

All cases for 2017 listed in the Tumor Registry with rectal cancer were sent to Dr. Nathan Tennyson for review to determine if proper staging was performed. The review confirmed all appropriate cases were properly staged. See chart summary below.

Following completion of the project it was recommended to continue monitoring cases for staging and to develop a specific MRI protocol.

Nancy J. Taft, MD, FACSChair, Breast Program Standards and Development Committee Board Certified, General and Breast Surgery Medical Director, Comprehensive Breast Care

Nathan Tennyson, MDCancer Liaison Physician, Cancer Committee Chair, Radiation Oncology Continuous Quality Improvement Board Certified, Radiation Oncology

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Patients listed as rectal cancer patients

Patients were neuroendocrine rectal cancers and were excluded

Patients had defused metastatic disease and didn’t need local staging

Patients received MRI or EUS for staging

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SUPINE POSITION PRONE POSITIONIOERT (intraoperative electron radiotherapy) in breast cancer is used either as a boost followed by whole breast irradiation or as a full-dose partial breast irradiation during breast-conserving surgery.

IOERT has been shown to be advantageous for several reasons: Geographic misses are avoided due to direct visualization of the tumor bed, a high single dose is delivered with utmost precision to small volumes, completely sparing the skin and ensuring good long-term cosmetic outcome.

Cyberknife uses a lightweight linear accelerator mounted to a robotic arm. This provides more flexibility and freedom of motion in how the radiation beams are delivered. The CyberKnife’s integrated x-ray imagers provide continual image guidance and real-time tracking capabilities which ensure the radiotherapy treatment is highly accurate and precise.

A Multileaf Collimator (MLC) is a device made up of individual ‘leaves’ of high atomic numbered material, usually tungsten, that can move independently in and out of the path of a radiation beam in order to shape it and vary its intensity. The MLC allows conformal shaping of the beam to match the borders of the target tumour.

Brachytherapy is an advanced, highly targeted cancer treatment in which radiotherapeutic sources are placed in or near tumor, giving high radiation dose to the tumor while reducing the radiation exposure in the surrounding healthy tissues. High Dose Rate (HDR) Brachytherapy introduces the radiation source for a certain time using special applicators.

Currently at Jupiter Medical Center Brachytherapy is used to treat cervical and endometrial cancers.

Prone Breastboard allows placing the patient in the prone position. This helps increase the separation of the breast from critical organs at risk. This means that exposure to the heart, lung and surrounding healthy tissue may be minimized, while providing the potential for more uniform dose delivery, less skin toxicity, and reduced respiratory motion due to patient position.

Advancing Radiation Treatment through Technology 2014-2018

2014

IOERT

CyberKnife® M6TM

Multi-Leaf Collimator for Cyberknife M6

Brachytherapy

Prone Breastboard

2016

2015 2017

2018

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Smitha Gubbi, MD, CCRCDirector of Clinical Research

Raymond Golish, MDMedical Director, Clinical Research

Oncology Research and Clinical TrialsResearchers across the nation work every day to find new and better ways to treat and cure disease and improve the health of patients. Clinical Trials are research studies in which patients may volunteer to take part. The Clinical Research Program at Jupiter Medical Center is under the medical direction of Raymond Golish, MD. New cancer drugs or drug combinations, new approaches to radiation therapy, surgical techniques, quality of life and genomic tissue are some of the trials available to our cancer patients. Our research department also works to help maintain the comprehensive cancer accreditation for the oncology program. We exceeded the commendation status with the Commission of Cancer, and substantially exceeded the National Accreditation Program for Breast Centers annual clinical trial accrual level for 2018.

Collaborations with major pharmaceutical companies have offered cutting edge diagnostic and treatment trials to better serve our community. Prevention trials test new approaches with medicines, vitamins, minerals or other supplements that may lower the risk of specific cancers. These trials may discover ways to prevent cancer in people who have never had cancer or to prevent the return of cancer in patients who have already had cancer. Screening trials test the best way to find cancer in its early stages and quality of life trials explore ways to improve comfort and daily living for cancer patients.

Highlights of 2018Oncology Research is under the direction of Smitha Gubbi, MD, CCRC, Director of Clinical Research. Her leadership and the support of the administration has intensified the focus of research to bring treatment directed trials to oncology. Accruals have increased by over 50 percent by concentrating on the strong specialty programs that are in place for Breast, Lung, Gynecology and GI.

Collaborations have been created with local research institutions such as Scripps, Max Planck as well as with various pharmaceutical companies. These collaborations will further increase the availability of drugs and novel therapies for patients in our local community. By working and collaborating with local institutions and pharmaceutical companies it has real implications for people facing illness and disease in Palm Beach and Martin counties. Together, investigators along with the research team will work to conduct basic, clinical, epidemiologic, and translational research, striving to rapidly transform scientific advances into improved patient care and outcomes.

Highlights of Oncology ResearchOncology Bio Specimen Trials: Jupiter Medical Center currently has over 25 bio specimen trials open in Breast, Lung, Gynecology and GI. Enrollment/accruals have consistently doubled since previous years.

The table below represents the 2018 Research Accrual Totals exceeding the commendation status percent set by both the COC and NAPBC.

Summary by Body System, Sex, Class, Status and Best CS/AJCC Stage ReportThe Cancer Registry is the department designated to collect, manage, analyze and report information on every cancer patient diagnosed and/or treated at our center. The information collected for each patient includes routine personal and demographic data, diagnosis, stage of disease at diagnosis, medical history, laboratory data, tissue diagnosis and course of treatment.

To protect the privacy of each patient, each case is de-identified and coded by number rather than name, and personal/demographic information is removed before it is reported to the Florida Cancer Registry and the National Cancer Database to help health officials to better monitor and advance cancer treatments, conduct research and improve cancer prevention and screening programs.

The Cancer Committee uses the Cancer Registry data to measure compliance with evidence-based clinical practice guidelines endorsed by the American College of Surgeons Commission on Cancer through dedicated quality control measures while strict confidentiality is maintained to protect patient privacy.

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Accreditation To Achieve Accrual 2018 Body Commendation Status (%) Accrual

COC (Commission on Cancer) 6% 12.3%

NAPBC (National Accreditation 2% 22.9% Program for Breast Centers)

Basal & Squamous Skin 0.1% 1

Brain & Other Nervous System 0.2% 2

Breast 30.2% 289

Digestive System 13.7% 131

Endocrine System 0.3% 3

Female Genital System 15% 143

Oral Cavity & Pharynx 0.3% 3

Respiratory System 14.4% 138

Skin Excluding Basal & Squamous Cell 2.3% 22

Urinary System 9.5% 91

TOTAL 957

Leukemia 1.4% 13

Lymphoma 2.3% 22

Male Genital System 7.8% 75

Mesothelioma 0.1% 1

Miscellaneous 1.9% 18

Myeloma 0.5% 5

2018 Body Systems

13.7%

15%0.3%

1.9%

14.4%

2.3%0.2%

1.4%

0.3%

9.5%

7.8%

0.5%

30.2%

0.1%2.3%

0.1%

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Summary by Body System, Sex, Class, Status and Best CS/AJCC Stage Report

SEX CLASS OF CASE STATUS STAGE DISTRIBUTION - Analytic Cases OnlyPRIMARY SITE TOTAL (%) M F ANALY NA ALIVE EXP STG 0 STG I STG II STG III STG IV 88 UNK BLANK/OTH

BASAL & SQUAMOUS SKIN 1 (0.1%) 0 1 0 1 1 0 0 0 0 0 0 0 0 0

Basal/Squamous cell carcinomas of Skin 1 (0.1%) 0 1 0 1 1 0 0 0 0 0 0 0 0 0

BRAIN & OTHER NERVOUS SYSTEM 2 (0.2%) 1 1 2 0 1 1 0 0 0 0 0 2 0 0

Cranial Nerves Other Nervous System 2 (0.2%) 1 1 2 0 1 1 0 0 0 0 0 2 0 0

BREAST 289 (30.2%) 5 284 275 14 287 2 54 159 25 9 5 9 14 0

DIGESTIVE SYSTEM 131 (13.7%) 75 56 112 19 110 21 1 14 22 19 18 16 20 2

Esophagus 11 (1.1%) 9 2 9 2 11 0 0 1 2 2 1 1 2 0

Stomach 10 (1.0%) 9 1 10 0 8 2 0 0 3 2 0 1 3 1

Small Intestine 5 (0.5%) 4 1 2 3 4 1 0 0 0 0 1 1 0 0

Colon Excluding Rectum 55 (5.7%) 27 28 48 7 50 5 0 7 12 9 7 5 7 1

Cecum 10 6 4 9 1 9 1 0 1 2 0 2 1 3 0

Appendix 8 4 4 7 1 8 0 0 0 1 0 2 4 0 0

Ascending Colon 10 3 7 10 0 8 2 0 2 3 3 0 0 2 0

Hepatic Flexure 2 2 0 2 0 2 0 0 1 0 0 0 0 1 0

Transverse Colon 6 2 4 3 3 6 0 0 0 1 1 1 0 0 0

Splenic Flexure 4 2 2 4 0 4 0 0 0 2 2 0 0 0 0

Descending Colon 2 0 2 2 0 2 0 0 1 1 0 0 0 0 0

Sigmoid Colon 7 3 4 7 0 7 0 0 2 1 3 0 0 0 1

Large Intestine, NOS 6 5 1 4 2 4 2 0 0 1 0 2 0 1 0

Rectum & Rectosigmoid 15 (1.6%) 9 6 13 2 13 2 0 1 4 4 1 0 3 0

Rectosigmoid Junction 8 6 2 8 0 7 1 0 0 2 3 1 0 2 0

Rectum 7 3 4 5 2 6 1 0 1 2 1 0 0 1 0

Anus, Anal Canal & Anorectum 2 (0.2%) 0 2 1 1 1 1 1 0 0 0 0 0 0 0

Liver & Intrahepatic Bile Duct 9 (0.9%) 8 1 8 1 6 3 0 2 1 0 1 3 1 0

Other Biliary 4 (0.4%) 3 1 3 1 3 1 0 0 0 0 1 1 1 0

Pancreas 15 (1.6%) 5 10 13 2 11 4 0 3 0 1 6 0 3 0

Retroperitoneum 1 (0.1%) 0 1 1 0 0 1 0 0 0 1 0 0 0 0

Peritoneum, Omentum & Mesentery 1 (0.1%) 0 1 1 0 1 0 0 0 0 0 0 1 0 0

Other Digestive Organs 3 (0.3%) 1 2 3 0 2 1 0 0 0 0 0 3 0 0

ENDOCRINE SYSTEM 3 (0.3%) 2 1 3 0 3 0 0 1 0 0 0 2 0 0

Thyroid 1 (0.1%) 0 1 1 0 1 0 0 1 0 0 0 0 0 0

Other Endocrine including Thymus 2 (0.2%) 2 0 2 0 2 0 0 0 0 0 0 2 0 0

FEMALE GENITAL SYSTEM 143 (14.9%) 0 143 135 8 135 8 0 61 14 16 10 15 16 3

Cervix Uteri 12 (1.3%) 0 12 10 2 12 0 0 4 5 0 0 0 1 0

Corpus & Uterus, NOS 78 (8.2%) 0 78 77 1 75 3 0 50 4 10 4 3 6 0

Ovary 30 (3.1%) 0 30 28 2 27 3 0 3 3 4 5 4 6 3

Vagina 3 (0.3%) 0 3 2 1 3 0 0 1 0 0 0 1 0 0

Vulva 11 (1.1%) 0 11 9 2 11 0 0 3 1 0 0 5 0 0

Other Female Genital Organs 9 (0.9%) 0 9 9 0 7 2 0 0 1 2 1 2 3 0

SEX CLASS OF CASE STATUS STAGE DISTRIBUTION - Analytic Cases OnlyPRIMARY SITE TOTAL (%) M F ANALY NA ALIVE EXP STG 0 STG I STG II STG III STG IV 88 UNK BLANK/OTH

LEUKEMIA 13 (1.4%) 10 3 12 1 10 3 0 0 0 0 0 12 0 0

Lymphocytic Leukemia 6 (0.6%) 4 2 5 1 6 0 0 0 0 0 0 5 0 0

Acute Lymphocytic Leukemia 1 0 1 1 0 1 0 0 0 0 0 0 1 0 0

Chronic Lymphocytic Leukemia 3 2 1 2 1 3 0 0 0 0 0 0 2 0 0

Other Lymphocytic Leukemia 2 2 0 2 0 2 0 0 0 0 0 0 2 0 0

Myeloid & Monocytic Leukemia 7 (0.7%) 6 1 7 0 4 3 0 0 0 0 0 7 0 0

Acute Myeloid Leukemia 6 6 0 6 0 3 3 0 0 0 0 0 6 0 0

Chronic Myeloid Leukemia 1 0 1 1 0 1 0 0 0 0 0 0 1 0 0

LYMPHOMA 22 (2.3%) 10 12 22 0 19 3 0 2 2 1 5 9 3 0

Hodgkin Lymphoma 2 (0.2%) 2 0 2 0 2 0 0 0 0 0 1 1 0 0

Hodgkin: Nodal 1 1 0 1 0 1 0 0 0 0 0 0 1 0 0

Hodgkin: Extranodal 1 1 0 1 0 1 0 0 0 0 0 1 0 0 0

Non-Hodgkin Lymphoma 20 (2.1%) 8 12 20 0 17 3 0 2 2 1 4 8 3 0

NHL: Nodal 13 5 8 13 0 11 2 0 2 2 1 3 2 3 0

NHL: Extranodal 7 3 4 7 0 6 1 0 0 0 0 1 6 0 0

MALE GENITAL SYSTEM 75 (7.8%) 75 0 58 17 74 1 0 11 21 16 3 1 6 0

Prostate 74 (7.7%) 74 0 57 17 73 1 0 10 21 16 3 1 6 0

Testis 1 (0.1%) 1 0 1 0 1 0 0 1 0 0 0 0 0 0

MESOTHELIOMA 1 (0.1%) 1 0 0 1 1 0 0 0 0 0 0 0 0 0

MISCELLANEOUS 18 (1.9%) 11 7 17 1 13 5 0 0 0 0 0 17 0 0

MYELOMA 5 (0.5%) 3 2 4 1 5 0 0 0 0 0 0 4 0 0

ORAL CAVITY & PHARYNX 3 (0.3%) 3 0 3 0 3 0 0 0 1 0 1 0 1 0

Tongue 3 (0.3%) 3 0 3 0 3 0 0 0 1 0 1 0 1 0

RESPIRATORY SYSTEM 138 (14.4%) 62 76 129 9 113 25 0 37 3 22 38 7 7 15

Larynx 2 (0.2%) 2 0 1 1 2 0 0 0 0 1 0 0 0 0

Lung & Bronchus 136 (14.2%) 60 76 128 8 111 25 0 37 3 21 38 7 7 15

SKIN EXCLUDING BASAL & SQUAMOUS 22 (2.3%) 13 9 18 4 21 1 4 8 1 1 1 0 3 0

Melanoma: Skin 20 (2.1%) 12 8 16 4 19 1 4 7 1 1 1 0 2 0

Other Non-Epithelial Skin 2 (0.2%) 1 1 2 0 2 0 0 1 0 0 0 0 1 0

URINARY SYSTEM 91 (9.5%) 72 19 86 5 86 5 1 27 13 6 4 1 3 31

Urinary Bladder 61 (6.4%) 49 12 57 4 57 4 1 13 10 1 1 1 0 30

Kidney & Renal Pelvis 25 (2.6%) 18 7 24 1 24 1 0 13 1 5 2 0 3 0

Ureter 5 (0.5%) 5 0 5 0 5 0 0 1 2 0 1 0 0 1

Total 957 343 614 876 81 882 75 60 320 102 90 85 95 73 51

Exclusions: Not Male and Not Female 0

Ella Milbank Foshay Cancer Center1240 S. Old Dixie Hwy., Jupiter, FL 33458 | 561-263-4400

Anderson Family Cancer Institute

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