15-OUT-350All Cleveland Clinic Outcomes books are available in print and online. Additional data are...

9500 Euclid Avenue, Cleveland, OH 44195 clevelandclinic.org

15-OUT-350

Taussig Cancer Institute

2014 Outcomes

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Measuring Outcomes Promotes Quality Improvement

This project would not have been possible without the commitment and expertise of a team led by Mikkael Sekeres, MD, Mary T. Cusick, Alicia M. Redden, and Dennis S. Urbanek.

Graphic design and photography were provided by Cleveland Clinic’s Center for Medical Art and Photography.

© The Cleveland Clinic Foundation 2015


Measuring and understanding outcomes of medical treatments promotes quality improvement. Cleveland Clinic has created a series of Outcomes books similar to this one for its clinical institutes. Designed for a physician audience, the Outcomes books contain a summary of many of our surgical and medical treatments, with a focus on outcomes data and a review of new technologies and innovations.

The Outcomes books are not a comprehensive analysis of all treatments provided at Cleveland Clinic, and omission of a particular treatment does not necessarily mean we do not offer that treatment. When there are no recognized clinical outcome measures for a specific treatment, we may report process measures associated with improved outcomes. When process measures are unavailable, we may report volume measures; a relationship has been demonstrated between volume and improved outcomes for many treatments, particularly those involving surgical and procedural techniques.

In addition to these institute-based books of clinical outcomes, Cleveland Clinic supports transparent public reporting of healthcare quality data. The following reports are available to the public: • Joint Commission Performance Measurement Initiative (qualitycheck.org)

• Centers for Medicare and Medicaid Services (CMS) Hospital Compare (HospitalCompare.hhs.gov), and Physician Compare (medicare.gov/PhysicianCompare)

• Cleveland Clinic Quality Performance Report (clevelandclinic.org/QPR)

Our commitment to transparent reporting of accurate, timely information about patient care reflects Cleveland Clinic’s culture of continuous improvement and may help referring physicians make informed decisions.

We hope you find these data valuable, and we invite

your feedback. Please send your comments and

questions via email to:

[email protected] or scan here.

To view all of our Outcomes books, please visit clevelandclinic.org/outcomes.

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Dear Colleague:

Welcome to this 2014 Cleveland Clinic Outcomes book. Every year, we publish Outcomes books for 14 clinical institutes with multiple specialty services. These publications are unique in healthcare. Each one provides an overview of medical or surgical trends, innovations, and clinical data for a particular specialty over the past year. We are pleased to make this information available.

Cleveland Clinic uses data to manage outcomes across the full continuum of care. Our unique organizational structure contributes to our success. Patient services at Cleveland Clinic are delivered through institutes, and each institute is based on a single disease or organ system. Institutes combine medical and surgical services, along with research and education, under unified leadership. Institutes define quality benchmarks for their specialty services and report on longitudinal progress.

All Cleveland Clinic Outcomes books are available in print and online. Additional data are available through our online Quality Performance Report (clevelandclinic.org/QPR). The site offers process measure, outcome measure, and patient experience data in advance of national and state public reporting sites.

Our practice of releasing annual outcomes books has become increasingly relevant as healthcare transforms from a volume-based to a value-based system. We appreciate your interest and hope you find this information useful and informative.

Sincerely, Delos M. Cosgrove, MD CEO and President

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Prefer an e-version?

Visit clevelandclinic.org/OutcomesOnline, and

we’ll remove you from the hard copy mailing list

and email you when next year’s books are online.

what’s inside

Chairman’s Letter 04

Institute Overview 05

Quality and Outcomes Measures

Outcomes Data 09

Hematologic Oncology and Blood Disorders 10

Acute Myeloid Leukemia/ Myelodysplastic Syndromes 10

Blood and Marrow Transplant 14

Lymphoma 18

Multiple Myeloma and Amyloidosis 24

Benign Hematology 28

Solid Tumor Oncology 29

Brain Tumors 29

Breast Cancer 31

Cervical Cancer 42

Colon Cancer 48

Head and Neck 52

Esophageal Cancer 52

Oral Cavity and Pharynx Cancer 56

Lung Cancer 69

Prostate Cancer 81

Renal Cell Cancer 89

Palliative Medicine 92

Institute Quality Improvement 100

Institute Patient Experience 106

Cleveland Clinic — Implementing Value-Based Care 108

Innovations 114

Contact Information 118

About Cleveland Clinic 120

Resources 122

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Chairman LetterChairman’s Letter

Dear Colleagues,

I am proud to share the annual outcomes data from the Taussig Cancer Institute. Our cancer center is home to more than 250 top cancer specialists, researchers, nurses, and technicians who are dedicated to delivering the most effective medical treatments and access to the latest research and clinical trials for our patients.

In 2014, we broke ground on construction of the new Cleveland Clinic Cancer Institute. The new building reflects our vision of unified cancer care at Cleveland Clinic — multidisciplinary cancer specialists, leading-edge science, clinical support, and psychosocial services delivering an exceptional patient experience. That same vision and high standards apply at our 17 locations in northern and central Ohio.

In the pages that follow, you will find examples of the clinical excellence, innovation, and patient-centered care we deliver. It is our patients who inspire us to provide the best care possible and to work hard toward the ultimate goal of beating cancer.

We welcome your feedback, questions, and ideas for collaboration. Please contact me via email at [email protected] and reference the Taussig Cancer Institute book in your message.

Sincerely,

Brian J. Bolwell, MD, FACP Chairman, Taussig Cancer Institute Professor, Cleveland Clinic Lerner College of Medicine

Outcomes 20144

Institute OverviewInstitute Overview

Cleveland Clinic Taussig Cancer Institute is a multidisciplinary cancer center committed to providing patients with superior cancer care in a cooperative, compassionate, and innovative practice. At the hub of cancer services at Cleveland Clinic, Taussig Cancer Institute physicians and specialists collaborate and coordinate care with other cancer specialists throughout Cleveland Clinic. The combined clinical experience and expertise of more than 250 top cancer specialists, researchers, nurses, and technicians ensures that each patient receives the best care, including:

• Accurate diagnosis and customized therapy

• Access to clinical trials of the newest drugs and integration with world-renowned translational research that brings discoveries in the laboratory to patient care

• Disease management developed using evidence-based paradigms, including genomics and molecular pathology to inform effective treatment

• Support programs to promote well-being and address psychological health concerns

• Close monitoring during and after treatment

Multidisciplinary teams at the institute include clinicians who specialize in medical and radiation oncology, bone marrow transplantation, palliative care, oncology nursing, cancer research, and psychosocial support. Care teams provide seamless coordination with cancer specialists at Cleveland Clinic such as surgical oncologists, plastic surgeons, gastroenterologists, interventional radiologists, pathologists, and genetic counselors.

Taussig Cancer Institute offers patients and families a range of programs and survivorship services to enhance quality of life and provide support as they cope with the challenges of cancer and its treatment. Convenient access to physicians, medical and radiation oncology treatment, clinical trials, and support services is available at community locations throughout northern Ohio.

Taussig Cancer Institute was

ranked the top cancer center in

Ohio by U.S. News & World Report

in 2014.

Taussig Cancer Institute 5

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Institute Overview

Therapies and Volumes

Provided below is an overview of the number of patients seen and the range of therapies provided at Taussig Cancer Institute in 2014.

Location

Hematology & Medical Oncology Radiation Oncology Cleveland Clinic Cancer Center

Total Main Campus Regional Main Campus Regional Sandusky Mansfield

Total visits 359,829 86,209 108,845 53,308 51,225 34,236 26,006

Professional visits 196,812 91,342 64,781 8183 3619 17,638 11,249 Main campus (%) 99,525 (51) Regional (%) 97,287 (49)

New outpatient visits/consults 18,080 6953 4682 2834 1617 1233 761

Outpatient visits 143,045 54,307 50,672 7691 3413 16,829 10,133

Inpatient visits 53,767 37,035 14,109 492 206 809 1116

Inpatient admissions 6311 2353 3255 268 100 273 62

Treatment visits 175,984 30,167 56,503 28,877 32,088 16,300 12,049 Main campus (%) 59,044 (34) Regional (%) 116,940 (66)

Chemotherapy treatment visits 97,817 30,167 56,503 – – 6384 4763 Main campus (%) 30,167 (31) Regional (%) 67,650 (69)

Radiation therapy treatment visits 78,167 – – 28,877 32,088 9916 7286 Main campus (%) 28,877 (37) Regional (%) 49,290 (63)

Total visits represent all outpatient visits with a clinical provider or resource; professional visits are for evaluation and management; inpatient admissions represent patients discharged at main campus by institute physician staff. Patients seen by Taussig Cancer Institute staff at main campus, family health/cancer centers, and Cleveland Clinic regional hospitals unless otherwise noted.

Outcomes 20146

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Institute Overview

Outpatient and Inpatient Visits by Disease Group or Site (N = 196,502)

2014

Disease/Site Number of Visits

Benign hematology 19,830 Breast 29,163 Central nervous system 4884 Endocrine 924 Gastrointestinal 26,780 Genitourinary 14,698 Gynecological 3038 Head and neck 6665

Disease/Site Number of Visits

Leukemia/myelodysplastic syndromes 22,815 Lung 18,112 Lymphoma 16,670 Melanoma 2858 Myeloma 12,127 Sarcoma 6467 All others 11,471

Patients seen by Taussig Cancer Institute staff at main campus, family health centers/cancer centers, and professional visits at Cleveland Clinic regional hospitals


Cleveland Clinic is a member of the Case Comprehensive Cancer Center (Case CCC), an NCI-designated partnership

organization supporting all cancer-related research efforts at Case Western Reserve University, University Hospitals Case

Medical Center, and Cleveland Clinic.

American College of Surgeons (ACoS) Commission on Cancer (CoC) — Cleveland Clinic’s cancer program is CoC-accredited

with commendation in all 4 areas possible for an NCI-designated cancer center.

National Cancer Institute (NCI)-Designated Cancer Center

Patient Beds and Chemotherapy Chair Capacity

2014

Inpatient Bedsa for Patients 103

With solid tumors 36 Undergoing blood and marrow transplantation 22 With leukemia 22 Receiving palliative care 23

Outpatient Chemotherapy Chairs 283

Main campus 72 Community locationsb 211aExcluding Cleveland Clinic regional hospitals bIncluding Cleveland Clinic regional hospitals

In 2014, 2240

patients participated

in 357 cancer-related

clinical trials conducted

at Cleveland Clinic,

including 400 patients

who participated in

70 clinical trials at

community locations.

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Institute Overview

Radiation Oncology Treatment Procedures

2014

Procedure Type N (%)

Gamma Knife® 482 (37) Low-dose-rate brachytherapy 302 (23) High-dose-rate brachytherapy 98 (7) Eye plaques 64 (5) Hyperthermia 18 (1) Stereotactic body radiosurgery (total) 356 (27) Lung 183 Spine 110 Liver 21 Other 42

Total 1320

Taussig Cancer Institute Publications (N = 722)

2014

Articles in High Chapters and Impact Journalsa, Books, N Articles, N N (%)

All staff 82 640 282 (44) Primary appointment staff 37 349 148 (42)

Secondary appointment staff 45 291 134 (46)

aJournal impact factor of 4 or greater based on Journal Citation Reports® data

Outcomes 20148

15+ millionP A G E V I E W S

in 2014 of

Chemocare.com,

a web resource for

information about

chemotherapy

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The main data sources for the quality and outcomes measures presented in the following pages are the Taussig Cancer Institute tumor registry, radiation oncology database, and Institutional Review Board-approved research studies.

Tumor Registry

• The tumor registry currently includes data on more than 172,000 patients.

• Data included in the outcomes graphs derived from the tumor registry are from patients receiving initial treatment at Cleveland Clinic.

Radiation Oncology Database

• Database of patients who have received radiation oncology treatments at Cleveland Clinic.

• For prostate cancer, radiation and surgery patients are tracked in a single database.

• Includes treatment and follow-up data on more than 16,000 patients with prostate cancer.

Research Studies

• Data for some outcomes measures are from Institutional Review Board approved research studies conducted by Cleveland Clinic investigators.

Survival

Outcomes measures of survival are presented primarily as overall survival or as indicated in the graph title.

• Overall survival measures include all causes of death (in addition to cancer).

• Relative survival measures estimate cancer survival excluding other causes of death.

Benchmarks

• When possible, outcomes measures include reference to a publicly available source for comparison, such as the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute (seer.cancer.gov) or the American Joint Commission on Cancer (AJCC) Staging Manual.

• Inclusion of benchmark references does not and is not intended to represent controlled, direct comparisons.

• When data similar to or related to the measure presented are available in another known, published source, the source is provided for your reference.

Outcomes Data

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Time From Diagnosis to Treatment for Patients With Acute Myeloid Leukemia and Acute Lymphocytic Leukemia (N = 81)

2014

Acute Myeloid Leukemia

Median = 4Mode = 1Median = 4Mode = 1

Days From Diagnosis to Treatment0 5 10 15 25 30 45 50 55 60 80 9020 35 40 65 70 75 85

Outcomes 201410

Hematologic Oncology and Blood Disorders | Acute Leukemia/Myelodysplastic Syndromes

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Font color of gene in above table denotes condition for which mutation is more common. pAML = primary acute myeloid leukemia, sAML = secondary acute myeloid leukemia

Identifying chromosomal abnormalities has played an important role in understanding disease progression and risk stratification among patients with acute myeloid leukemia (AML). Patients with secondary AML (sAML) face a particularly poor prognosis. Whole genome sequencing and whole exome sequencing analysis of 142 patients with normal karyotype revealed different genomic patterns between patients with primary AML (N = 101) and sAML (N = 42).1 The unique genomic pattern of these AML subtypes warrants treatment recommendations that consider these genomic variations and associated functional pathways.

1. Nazha A, Seastone DJ, Pophali PA, Radivoyevitch T, Carraway HE, Advani AS, Kalaycio ME, Rupp G, Colaluca K, Przychodzen BP, Makishima H, Maciejewski JP, Sekeres MA. Different genomic patterns in patients with primary acute myeloid leukemia (AML) compared to secondary AML in patients with normal karyotype. Poster presented at: 56th ASH Annual Meeting and Exposition; Dec. 6-9, 2014; San Francisco, CA. Poster 1054. Blood. 2014;124(21):1054. © the American Society of Hematology. bloodjournal.org/content/124/21/1054.

Genomic Variations Among Patients With Primary Acute Myeloid Leukemia Compared With Secondary Acute Myeloid Leukemia (N = 143) 2003 – 2013

Functional Pathway Gene (Most Common Mutations, %) Mutations More Common In

RNA splicing SF3B1, U2AF1 (8%)/2, SRSF2, ZRSR2 sAML

DNA methylation TET2 (11%), DNMT3A (27%), IDH1 (12%)/2 (12%) pAML

Chromatin modification ASXL1 (8%), EZH2, MLL, SUZ12, KDM6A sAML

Transcription RUNX1 (14%), CEBPA, NPM1 (35%), sAML BCOR (5%)/BCORL1, SETBP1, ETV6

Activating signaling FLT3 (25%), JAK2 pAML

Cohesion STAG2 (12%), SMC3, RAD21 sAML

RAS superfamily K/NRAS (8%), NF1, PTPN11 (11%), CBL sAML

Tumor suppressor genes TP53, APC, WT1 (6%), PHF6 (5%) pAML and sAML


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Patients with higher-risk myelodysplastic syndromes (MDS) and chronic myelomonocytic leukemia often experience cytopenias, higher risk of progression to acute myeloid leukemia, and reduced survival. In a randomized trial, the standard of care drug, azacitidine, was compared with the addition of lenalidomide or vorinostat. The primary endpoint was improvement in overall response rate (ORR), and relapse-free survival was evaluated from time of response. The ORR was similar in the 3 treatment arms, but some subgroups may have benefited from combination therapy and there was a trend for improved relapse-free survival in patients receiving azacitidine plus vorinostat.1

1. Sekeres MA, Othus M, List AF, Odenlike O, Stone RM, Gore SD, Litzow MR, Buckstein B, Velasco M Jr, Gaur R, Atallah E, Attar E, Appelbaum FR, Erba HP. A randomized phase II study of azacitidine combined with lenalidomide or with vorinostat vs. azacitidine monotherapy in higher-risk myelodysplastic syndromes (MDS) and chronic myelomonocytic leukemia (CMML): North American Intergroup Study SWOG S1117. Presented at: 56th ASH Annual Meeting and Exposition; Dec. 6-9, 2014; San Francisco, CA. Abstract LBA-5. Blood. 2014;124(21):LBA-5. © the American Society of Hematology. bloodjournal.org/content/124/21/LBA-5.

Randomized Study of Azacitidine Alone and in Combination With Lenalidomide or Vorinostat in Patients With Higher-Risk Myelodysplastic Syndromes and Chronic Myelomonocytic Leukemia (N = 276) March 2012 – June 2014

00

100100

4040

6060

8080

2020

Relapse-Free Survival (%)Relapse-Free Survival (%)

0 105Months After Response

15 20

Number at RiskAzacitidine 33 19 7 4 1Azacitidine + lenalidomide 34 23 8 5 1Azacitidine + vorinostat 20 13 9 5 1

Azacitidine (N = 92)Azacitidine + lenalidomide (N = 93)Azacitidine + vorinostat (N = 91)

Outcomes 201412

Hematologic Oncology and Blood Disorders | Acute Leukemia/Myelodysplastic Syndromes

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MDS are a group of complex bone marrow stem cell disorders that have confusing terminology and limited treatment options. In an online survey, communication gaps between patients and physicians during the course of the disease and reasons for treatment discontinuation were assessed. Results indicated a decline in disease and treatment education over the course of the disease. When treatment was discontinued, patients tended to cite treatment ineffectiveness as the reason for stopping treatment, whereas physicians cited patient or disease factors as reasons for stopping treatment.1

1. Gerds AT, Dennison B, Latsko J, Houk A, Chisolm S, Huber JM, Stone RM, Maciejewski JP, Komrokji RS, Garcia-Manero G, Steensma DP, Sekeres MA. Doctor-patient communication and perception of treatment discontinuation in myelodysplastic syndromes (MDS) diverge at the time of progression. Poster presented at: 56th ASH Annual Meeting and Exposition, Dec. 6-9, 2014, San Francisco, CA. Poster 2642. Blood. 2014;124(21):2642. © the American Society of Hematology. bloodjournal.org/content/124/21/2642.

The incidence and age at diagnosis of MDS reported in national registries differ by race and are lower among black patients compared with white patients. In a study of survival and genomic analysis of 341 patients with MDS, black patients had worse overall survival compared with white patients (17.9 vs 27.5 months, respectively, at 36 months median follow-up).1 Genomic analysis of 62 common gene mutations revealed that black patients were more likely to have Tp53 (17% vs 4%, P = 0.04) and ZRSR2 (21% vs 6%, P = 0.02) mutations and less likely to have gene mutations related to the functional pathways of transcription factors and chromatin modifications. Treatments targeting transcription and chromatin modification pathways may be less beneficial for black patients compared with white patients.

1. Nazha A, Radivoyevitch T, Seastone DJ, Dienes B, Przychodzen BP, Carew JS, Mukherjee S, Carraway HE, Advani AS, Kalaycio ME, Hobson S, Rupp G, Colaluca K, Gerds AT, Maciejewski JP, Sekeres MS. Differences in genomic patterns and clinical outcomes between African-American and white patients with myelodysplastic syndromes (MDS). Poster presented at: 56th ASH Annual Meeting and Exposition, Dec. 6-9, 2014, San Francisco, CA. Poster 3274. Blood. 2014;124(21):3274. © the American Society of Hematology. bloodjournal.org/content/124/21/3274

Patients With Myelodysplastic Syndromes and Physicians Report When Disease and Treatment Education Provided (N = 365) February – April 2014

Differences in Overall Survival in Patients With Myelodysplastic Syndromes by Self-Reported Race (N = 341) 2000 – 2012

Myelodysplastic Syndromes

00

100100

4040

6060

8080

2020

Survival (%)Survival (%)

10 32Years After Diagnosis

4 5 6 7 8 9 10 11 12 13 14 15

P = 0.03

Black (N = 44)White (N = 297)

100

80

0

60

40

20

Reporting (%)

DuringWorkup

Diagnosis StartTreatment

ChangeTreatment

DiseaseProgression

P = 0.005

Patients (N = 314)Physicians (N = 51)

P < 0.001

P = 0.632

P = 0.002P < 0.001


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100-Day Survival After Autologous Hematopoietic Cell Transplantation for Patients With Myeloma and Lymphoma 2013 – 2014

100-Day Survival After Allogeneic Hematopoietic Cell Transplantation Using Related Donor for Patients With Acute/Chronic Leukemia and Myelodysplastic Syndromes 2013 – 2014

Cleveland Clinic’s 100-day survival outcomes of 100% for patients with myeloma and 95% for patients with lymphoma are similar to national benchmarks. The Center for International Blood and Marrow Transplant Research (CIBMTR) reports 100-day mortality after autologous transplantation to be about 2% for myeloma, 8% for non-Hodgkin lymphoma, and 10% for patients with Hodgkin lymphoma.

aPasquini MC, Wang Z. Current use and outcome of hematopoietic stem cell transplantation: CIBMTR Summary Slides, 2013. Available at: cibmtr.org.

Cleveland Clinic’s outcomes for related donor allogeneic hematopoietic cell transplantation for acute/chronic leukemia and myelodysplastic syndromes are similar to national benchmarks.

100

80

0

60

40

20

Survival (%)

Myeloablative Reduced Intensity

N = 29 12

100

80

0

60

40

20

Survival (%)

Myeloma Lymphoma

N = 97 118

Referencea

Outcomes 201414

Hematologic Oncology and Blood Disorders | Blood and Marrow Transplant

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Cleveland Clinic’s outcomes for unrelated donor hematopoietic cell transplantation for patients with acute/chronic leukemia and myelodysplastic syndromes1 are similar to national benchmarks.

1. Pasquini MC, Wang Z. Current use and outcome of hematopoietic stem cell transplantation: CIBMTR Summary Slides, 2013. Available at: cibmtr.org.

100-Day Survival After Allogeneic Hematopoietic Cell Transplantation Using Unrelated Donor for Patients With Acute/Chronic Leukemia and Myelodysplastic Syndromes

2013 – 2014

100-Day Survival After Allogeneic Hematopoietic Cell Transplantation Using Haploidentical Donor Blood for Patients With Acute/Chronic Leukemia and Myelodysplastic Syndromes

2013 – 2014

100

80

0

60

40

20

Survival (%)

MyeloablativeUnrelated

Reduced IntensityUnrelated

N = 21 25

100

80

0

60

40

20

Survival (%)

MyeloablativeHaploidentical

Reduced IntensityHaploidentical

N = 9 3

500+Number of patients receiving blood and marrow transplant

(BMT) seen in the new BMT Acute Care Clinic since April 2014.

The clinic facilitates same-day or urgent visits with a BMT

physician for these patients who are prone to complications and

benefit from coordinated care to achieve optimal outcomes.


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Quality of Life in Older Patients After Allogeneic Hematopoietic Cell Transplantation (N = 351)

June 2003 – 2010

As the only curative option for many hematologic malignancies, allogeneic hematopoietic cell transplantation (HCT) has become a standard of care for older patients as a result of advances in HCT and supportive care. Many cancer survivors cite health-related quality of life (QOL) issues such as physical, emotional, and social functioning as important concerns. Although data suggest that HCT is safe and beneficial in older patients, few data exist on the impact of HCT on QOL in older patients.

In a longitudinal study of 351 patients with hematologic malignancies and bone marrow failure syndromes undergoing hematopoietic cell transplantation, researchers compared health-related

≥ ≥reported better social (P = 0.006) and functional (P = 0.05) well-being, as well as better total scores (P = 0.043) on the Functional Assessment of Cancer Therapy-Bone Marrow Transplant Scale at all time points. No significant differences in overall survival, relapse-free survival, or relapse/chronic graft-versus-host disease were observed during the 49 months median follow-up.1

1. Hamilton BK, Rybicki L, Dabney J, McLellan L, Haddad H, Foster L, Abounader D, Kalaycio M, Sobecks R, ≥

allogeneic hematopoietic cell transplantation. Bone Marrow Transplant. 2014;49(11):1426-1431.

FACT-BMT = Functional Assessment of Cancer Therapy-Bone Marrow Transplant Scale

00

200200

8080

120120

160160

4040

FACT-BMT Total ScoreFACT-BMT Total Score

PostDischarge

Visit After Transplant

100Days

180Days

365Days

≥ 65 (N = 47) < 65 (N = 304)

Age at transplant, years

Outcomes 201416

Hematologic Oncology and Blood Disorders | Blood and Marrow Transplant

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Long-Term Survival of Patients With Peripheral T Cell Lymphoma After Autologous Stem Cell Transplantation (N = 78)

1996 – 2013

Autologous stem cell transplantation (ASCT) is a commonly used consolidation treatment for patients with peripheral T cell lymphomas (PTCL) that improves progression-free survival. The optimal timing of ASCT for PTCL is not well defined but has been studied as both an upfront therapy and a relapse therapy. However, long-term outcomes of ASCT, especially when used as upfront consolidation, have not been well described.

In a retrospective study of 78 patients with PTCL treated with ASCT between 1996 and 2013, 31% attained a complete response (CR) post-ASCT. The 5-year relapse rates (RR) for CR1, CR2, and PR1 were 22%, 53%, and 66%, respectively, implying that both the disease status and response prior to transplant are key determinant factors for long-term outcome. The median follow-up was 55 months. The RR plateaued after 8 years, indicating that a proportion of patients had attained a durable remission. The 10-year RR, relapse-free survival, and overall survival were 64%, 25%, and 31%, respectively.

In conclusion, upfront consolidative ASCT in chemosensitive PTCL patients resulted in lower RR and improved long-term relapse-free and overall survival.1

1. Jagadeesh J, Rybicki L, Abounader DM, Hill BT, Dean RM, Duong HK, Sobecks RM, Hamilton BK, Gerds A, Ferraro C, Green G, Cherni K, Pohlman B, Kalaycio ME, Bolwell BJ, Majhail NS. Long term outcomes after autologous stem cell transplantation for peripheral T cell lymphomas. Poster presented at: 56th ASH Annual Meeting and Exposition, Dec. 6-9, 2014, San Francisco, CA. Poster 1200. Blood. 2014;124(21):1200. © the American Society of Hematology. bloodjournal.org/content/124/21/1200.

CR1 = first complete response, CR2+ = second or higher complete response, PR1 = first partial response, PR2+ = second or higher partial response

00

100100

4040

6060

8080

2020


0 21Years After Transplant

3 4 5 6 7 8 9 10 11 12

CR1 (N = 16)PR1 (N = 11)CR2+ (N = 15)PR2+ (N = 29)Refractory (N = 7)


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Differences in Human Leukocyte Antigen Alleles Associated With Risk of Chronic Lymphocytic Leukemia in Black and White Populations

The largest study to date of human leukocyte antigen (HLA) associations in chronic lymphocytic leukemia (CLL) found that HLA alleles predisposing development of CLL in blacks are different than in whites.1 CLL exhibits a high familial predisposition and occurs much more frequently in white populations than in black populations. The genetic basis for these differences is unclear; however, in many cancers, several forms of HLA genes are involved in the ability of the immune system to find and destroy cancer cells. HLA typing of 3491 white and 397 black patients with CLL compared with the National Marrow Donor Program/Be The Match collection control group (N = 50,000 per population) identified several HLA alleles (corresponding pairs of genes at a specific location on chromosomes) associated with the development of CLL in whites and blacks. DRB4*01:01 is one allele that predisposes to CLL that is less common in black populations. In addition, another HLA allele, C*04:01, was found to be uniquely protective in blacks and occurs at relatively high frequency (21%) in this population.

1. Gragert L, Fingerson S, Albrecht M, Maiers M, Kalaycio M, Hill BT. Fine-mapping of HLA associations with chronic lymphocytic leukemia in US populations. Blood. 2014;124(17):2657-2665. © the American Society of Hematology. bloodjournal.org/content/124/17/2657.

Chronic Lymphocytic Leukemia

30

20

0

15

10

5

Allele Frequency (%)

25

DRB4*01:01Black White

Predisposing

Outcomes 201418

Hematologic Oncology and Blood Disorders | Lymphoma

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The addition of the monoclonal antibody rituximab (R) in the 1990s substantially changed the approach to treating patients with indolent (low-grade) B-cell lymphoma. As these diseases are highly treatable but generally not considered curable, there are many possible approaches to treatment. Many patients are treated with a regimen designed for more aggressive lymphomas that incorporates R, termed R-CHOP (cyclophosphamide, hydroxydaunorubicin, Oncovin® [vincristine], prednisone), which is effective but does have some toxicity. Several studies have indicated that R combined with a somewhat less toxic single agent called bendamustine (BR) is at least as effective as R-CHOP. Some patients can even be treated with R without other chemotherapy. Further, once in remission, some patients undergo active observation while others continue on R as maintenance therapy. Below are the outcomes for patients whose initial treatment was with BR, R-CHOP, or R alone, as well as with R maintenance or observation. While these results cannot be directly compared because patients’ individual characteristics influence the choice of treatment used, some general conclusions can be drawn. The overall survival, which not long ago was an average of 8 to 10 years, has markedly improved, regardless of treatment approach, to the point where approximately 90% of patients are alive at 5 years after the start of treatment.

Five-Year Overall Survival of Patients With Indolent Lymphoma by Treatment Type (N = 246)

December 2001 – April 2014

Lymphoma

Patients with lymphoma receive state-of-the-art therapy at Taussig Cancer Institute. As part of the institute’s mission to improve patient outcomes, staff constantly update and review standard-of-care treatments, participate in clinical trials of new treatment strategies, and work closely with the bone marrow transplant program. The results of this carefully coordinated approach are reflected in the outcomes shown in the survival curves below. These results are outstanding and are among the best reported in major cancer centers in the country.

CHOP = cyclophosphamide, hydroxydaunorubicin, Oncovin, prednisone; R = rituximab

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0 1 2 3 4 5Years After Start of Treatment

Bendamustine-R (N = 45)R alone (N = 105)R-CHOP (N = 96)


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Five-Year Overall Survival of Patients With Indolent Lymphoma by Treatment Type for Patients Not Receiving Maintenance Rituximab (N = 169)


Five-Year Overall Survival of Patients With Indolent Lymphoma by Treatment Type for Patients Receiving Maintenance Rituximab (N = 77)




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Progression-free survival is the time interval before the disease returns and is not necessarily the time another treatment needs to be started because some patients can be monitored for a time before needing additional therapy. Focusing on progression-free survival for patients with lymphoma, it is clear that patients treated with R alone can have several years of remission. The addition of chemotherapy can prolong this disease-free interval by several more years. These results in the institute’s patient population support the clinical trial data that BR and R-CHOP provide similar benefit. Most of the institute’s patients now receive BR because it has fewer side effects, and outcomes data also are in concert with clinical trial data showing that R maintenance does prolong the time to disease recurrence. Although good options for second treatment are available, they do not necessarily improve long-term survival, so the decision of whether or not to use maintenance R is based on individual characteristics. Several new targeted drugs for B-cell lymphoma, some already approved and others available in clinical trials, expand treatment options for subsequent therapy, so that patients’ outcomes for these diseases should continue to improve.

Five-Year Progression-Free Survival of Patients With Indolent Lymphoma by Treatment Type (N = 246)



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Progression-Free Survival (%)Progression-Free Survival (%)




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Five-Year Progression-Free Survival of Patients With Indolent Lymphoma by Treatment Type for Patients Not Receiving Maintenance Rituximab (N = 169)


Five-Year Progression-Free Survival of Patients With Indolent Lymphoma by Treatment Type for Patients Receiving Maintenance Rituximab (N = 77)




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Outcomes 201422


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Radiation Exposure and Cancer Risk From CT and PET/CT in Patients With Lymphoma (N = 76)

2008 – January 2012

Scans Performed During Treatment and Surveillance

Treatment, N Surveillance, N

Scans Patients Scans Patients

CT 161 45 378 60

CT/PET 73 39 39 25

Patients with lymphoma typically experience normal life span but undergo serial CT or PET/CT imaging during treatment and surveillance for their disease. In a retrospective study of 76 patients with lymphoma (54 with non-Hodgkin and 22 with classical Hodgkin), radiation exposure and cancer risk related to CT and PET/CT were evaluated. The surveillance duration was 8 months for patients with non-Hodgkin lymphoma and 23 months for patients with classical Hodgkin lymphoma. In all, 17 of 76 (22.4%) patients had a total radiation cumulative dose > 100 mSv, and the mean increase in estimated cancer risk was 0.04%. The total mean dose and mean estimated cancer risk for patients with lymphoma undergoing serial CT and PET/CT imaging does not appear to be a major factor in follow-up imaging.1

1. Guttikonda R, Herts BR, Dong F, Baker ME, Fenner KB, Pohlman B. Estimated radiation exposure and cancer risk from CT and PET/CT scans in patients with lymphoma. Eur J Radiol. 2014;83(6):1011-1015. © 2014 Elsevier Ireland Ltd. All rights reserved.


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Five-Year Overall Survival of Patients With Multiple Myeloma After First Treatment (N = 741)

2005 – 2012

Outcomes for patients with multiple myeloma and amyloid light-chain (AL) amyloidosis treated at Taussig Cancer Institute compare favorably with other reported outcomes. Life expectancy continues to improve for patients with multiple myeloma who are < 75 years of age at the start of treatment, though such a trend cannot be seen yet for myeloma patients ≥ 75 years of age at therapy initiation and for patients with systemic AL amyloidosis. The relative lack of progress in older patients with myeloma over the past decades has been observed in multiple studies and may have to do with age-related frailty and comorbidities rather than myeloma behavior. In AL amyloidosis, the major therapeutic progress has been the introduction of bortezomib in treatment regimens, which was done at the institute in 2008, affecting outcomes of earlier and more recent cohorts. Overall favorable data may reflect care by a specialized healthcare team, common use of maintenance therapy in myeloma, and access to novel therapies, including within the context of clinical trials.

Multiple Myeloma

Percent Survival and (Number at Risk) by Years After First Treatment

Years After First Treatment

Years 1 2 3 4 5

2005 – 2008 91 (309) 81 (273) 71 (240) 61 (208) 53 (181)

2009 – 2012 92 (368) 82 (327) 74 (224) 67 (128) 59 (55)

SEER = Relative survival after diagnosis from Fast Stats: An interactive tool for access to Surveillance, Epidemiology, and End Results (SEER) cancer statistics. Surveillance Research Program, National Cancer Institute. seer.cancer.gov/statfacts/html/mulmy.html Accessed on Mar. 31, 2015.00

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3 4 5

2005 – 2008 (N = 339)2009 – 2012 (N = 402)Ref

First myeloma treatment

Based on SEER 18 data, patients with multiple myeloma diagnosed between 2004 and 2010 have 5-year relative survival rates of 44.9% from time of diagnosis, meaning death from other causes is not counted in this number. Under a more stringent analysis, where all deaths are counted and survival is measured from the start of therapy rather than from diagnosis, 5-year survival estimates increased from 53% for patients who started treatment between 2005 and 2008 to 59% for patients who began myeloma therapy between 2009 and 2012 (P = 0.22 by log-rank test).

Outcomes 201424

Hematologic Oncology and Blood Disorders | Multiple Myeloma and Amyloidosis

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Five-Year Overall Survival of Patients With Multiple Myeloma by Age at First Treatment (N = 741)

2005 – 2012



Years 1 2 3 4 5

2005 – 2008, < 75 93 (285) 83 (254) 73 (223) 63 (194) 56 (172)

2005 – 2008, ≥ 75 75 (24) 59 (19) 53 (17) 44 (14) 28 (9)

2009 – 2012, < 75 94 (334) 84 (298) 76 (205) 71 (121) 64 (54)

2009 – 2012, ≥ 75 76 (34) 64 (29) 55 (20) 38 (7) 15 (1)

The improvement of outcomes for myeloma patients in recent years is still limited to patients < 75 years of age at the start of therapy who had 5-year survival estimates of 64% compared with 56% in the earlier time period (P = 0.12). Although these data are not adjusted for age-related life expectancy, lack of improvement in relative survival has been reported for this age group by other researchers.1

1. Sant M, Minicozzi P, Mounier M, Anderson LA, Brenner H, Holleczek B, Marcos-Gragera R, Maynadié M, Monnereau A, Osca-Gelis G, Visser O, De Angelis R; EUROCARE-5 Working Group. Survival for haematological malignancies in Europe between 1997 and 2008 by region and age: results of EUROCARE-5, a population-based study. Lancet Oncol. 2014;15(9):931-942.

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2005 – 2008, < 75 (N = 307)2005 – 2008, 75+ (N = 32)2009 – 2012, < 75 (N = 357)2009 – 2012, 75+ (N = 45)

First myeloma treatment, years of age


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Pilot Study of Response-Adaptive Care Path for Patients With Myeloma (N = 24)

October 2012 – March 2014

1. Narkhede M, Valent J, Cummings C, Glass K, Hastings D, Faiman B, Hamilton K, Reed J, Karam MA, Kalaycio ME, Bolwell BJ, Smith MR, Duong HK, Samaras C, Reu FJ. Results of an upfront myeloma carepath pilot with response-adapted therapy. Poster presented at: 56th ASH Annual Meeting and Exposition; Dec. 6-9, 2014; San Francisco, CA. Poster 2620. Blood. 2014;124:2620. © the American Society of Hematology. bloodjournal.org/content/124/21/2620.

Two standard regimens for initial treatment of patients with multiple myeloma are the 2-drug combination of lenalidomide and dexamethasone (Rd) and the 3-drug combination of bortezomib, lenalidomide, and dexamethasone (RVD). While RVD is preferred at many cancer centers because of the favorable response rate, a higher risk of side effects such as neuropathy, higher drug costs, and as yet undemonstrated improved survival warrant further study. Cleveland Clinic conducted a pilot care path for patients newly diagnosed with multiple myeloma that utilized a 2-drug regimen adapted by the addition of other drugs to achieve disease control.1 Of 24 patients on the care path, the 2-drug regimen achieved disease control in 63% (N = 15) of patients, the 3-drug regimen achieved disease control in 30% (N = 7) of patients, and a 4-drug regimen achieved disease control in 10% (N = 2) of patients. The reduced risk of neuropathy, drug cost savings, and response assessment supports the care path and further evaluation of overall survival using this approach.

Rd = lenalidomide, dexamethasone RVD = lenalidomide, bortezomib, dexamethasone RVDC = lenalidomide, bortezomib, dexamethasone, cyclophosphamide VCD = bortezomib, cyclophosphamide, dexamethasone VD = bortezomib, dexamethasone

Partial response (PR)or better

after 2 cycles?

Addition of 3rd drug RVD (N = 6): VGPR = 1; PR = 4; stable disease (SD) = 1 VCD (N = 1): minor response = 1 VD to Rd (N = 2): VGPR =1; PR = 1

Addition of 4th drug RVDC (N = 3): VGPR = 1; PR = 1; SD = 1

Rd (N = 12): very good (VG) PR = 8; PR = 4VD (N = 3): VGPR = 3

No

Yes

Rd(N = 17)

VD(N = 7)

Patients newly diagnosed withsymptomatic multiple myeloma (N = 24)

No Yes

Cast nephropathy suspectedor high lenalidomide copay?

Outcomes 201426

Hematologic Oncology and Blood Disorders | Multiple Myeloma and Amyloidosis

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Five-Year Overall Survival of Patients With Amyloidosis Ineligible for Autologous Stem Cell Transplant After Start of Treatment (N = 138)

2005 – 2012



Years 1 2 3 4 5

2005 – 2010 72 (60) 63 (52) 52 (43) 45 (36) 42 (28)

2011 – 2012 76 (42) 64 (34) 54 (16) 46 (1) 0 (0)

The AL amyloidosis program at the institute has grown, with 55 new patients starting treatment in the 2 years between 2011 and 2012 compared with 83 total patients over the preceding 6 years. Median overall survival of 3.3 years and 3.4 years for earlier and later time cohorts in this patient population with predominantly cardiac amyloidosis suggests comparably favorable outcomes considering a reported median survival of 7 months for patients with cardiac stage III AL amyloidosis,1 which represents 50% to 70% of the institute’s patient population.2

1. Wechalekar AD, Schonland SO, Kastritis E, Gillmore JD, Dimopoulos MA, Lane T, Foli A, Foard D, Milani P, Rannigan L, Hegenbart U, Hawkins PN, Merlini G, Palladini G. A European collaborative study of treatment outcomes in 346 patients with cardiac stage III AL amyloidosis. Blood. 2013;121(17):3420-3427.

2. Bumma N, Reu FJ, Samaras C, Duong HK, Smith MR, Valent J. Safety and efficacy of once weekly subcutaneous bortezomib in advanced stage AL amyloidosis. Poster presented at: 56th ASH Annual Meeting and Exposition; Dec. 6-9, 2014; San Francisco, CA. Poster 4753. Blood. 2014;124:4753. © the American Society of Hematology. bloodjournal.org/content/124/21/4753.

Amyloidosis

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2005 – 2010, (N = 83)2011 – 2012, (N = 55)

First amyloid treatment


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Long-Term Follow-Up of Survivors of Thrombotic Thrombocytopenic Purpura Reveals Increased Morbidity (N = 91) January 2000 – March 2012

aBased on National Health and Nutrition Examination Survey data

Thrombotic Thrombocytopenic Purpura

A long-term follow-up study1 of 91 patients with thrombotic thrombocytopenic purpura (TTP) revealed higher prevalence of depression, chronic kidney disease, hypertension, and stroke and lower prevalence of diabetes compared with the reference population adjusted for age and sex. During the course of follow-up (median, 59 months), 18 patients had disease relapse. The higher risk of morbid conditions may be due to organ damage during acute episodes of TTP or to other comorbid conditions that are independent risk factors of poor outcomes, such as autoimmune disease. Long-term follow-up is needed to address morbid conditions that impair quality of life in TTP survivors.

1. Chaturvedi S, Abbas H, McCrae KR. Increased morbidity during long term follow up of survivors of thrombotic thrombocytopenic purpura. Presented at: 56th ASH Annual Meeting and Exposition; Dec. 6-9, 2014; San Francisco, CA. Abstract 230. Blood. 2014;124:230. © the American Society of Hematology. bloodjournal.org/content/124/21/230

80

0

60

40

20

Percent

Depression Diabetes Chronic KidneyDisease

Hypertension Stroke

TTP survivorsUS populationa

Outcomes 201428

Hematologic Oncology and Blood Disorders | Benign Hematology

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100

80

60

40

20

0

Percent

20141819

SchwannomaPituitary tumorMeningiomaMetastasesGlioma

20131859N =

The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center (BBTC) of the Neurological Institute is one of the largest and most comprehensive programs in the country and is dedicated to providing exceptional patient care, including surgery, radiation, chemotherapy, and clinical research trials for brain tumor patients. Patient care is provided by a multidisciplinary team consisting of neurosurgeons, radiation oncologists, neuro-oncologists, medical oncologists, psychiatrists, and neuropsychologists, along with nurses, physician assistants, case managers, and social workers who all specialize in treating patients with brain tumors. The BBTC is dedicated to bringing forward novel treatment options emerging from the institute’s extensive basic and translational research programs. The primary mission is to offer excellent care through surgical intervention and to conduct clinical research to enhance patient outcomes. The BBTC enrolled 273 patients in therapeutic research trials in the past 5 years (2010–2014).

As in prior years, gliomas remain the most common brain tumor seen in the BBTC.

Brain Tumor Diagnosis Distribution


Solid Tumor Oncology | Brain Tumors

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Gamma Knife® radiosurgery is the most common procedure performed, followed by supratentorial craniotomy and Novalis® stereotactic radiosurgery.

100

80

60

40

20

0

Percent

2014979

Infratentorial craniotomyPituitary surgeryBrain biopsyNovalis radiosurgerySupratentorial craniotomyGamma Knife radiosurgery

2013866N =

Brain Tumor Procedures

Outcomes 201430

Solid Tumor Oncology | Brain Tumors

Reference = Software: Surveillance Research Program, National Cancer Institute SEER*Stat software (seer.cancer.gov/seerstat) version 8.1.5. Data: Surveillance, Epidemiology and End Results (SEER) Program (seer.cancer.gov). SEER*Stat Database: Incidence — SEER 18 Regs Research Data + Hurricane Katrina Impacted Louisiana Cases, November 2013 Sub (1973–2011 varying) — Linked to County Attributes — Total U.S., 1969–2012 Counties, National Cancer Institute, DCCPS, Surveillance Research Program, Surveillance Systems Branch, released April 2014 (updated 5/7/2014), based on the November 2013 submission.

100

80

60

40

20

00

Years After Diagnosis

3 761 42 5

Survival (%)

Cleveland Clinic

Reference

Glioblastoma Multiforme

In 2014, 109 patients with newly diagnosed glioblastoma, the most common type of malignant primary brain tumor, underwent initial surgical resection and treatment at Cleveland Clinic. Approximately 12,000 cases of glioblastoma are diagnosed each year in the United States.

Glioblastoma Treatment: Survival (N = 738)

2001 – 2010

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Screening Mammograms Resulting in Callback Needle Core or Fine Needle Aspirate Biopsy Prior to Surgical Treatment of Breast Cancer (N = 796) 2012 – 2013

Data from Cleveland Clinic main campus and family health centers (Beachwood, Solon, Willoughby Hills, Twinsburg, Independence, Strongsville, Lorain, Elyria, Richard E. Jacobs, and Brunswick) Data from Cleveland Clinic tumor registry for main campus and family

health center locations

Cleveland Clinic’s performance was 89.3% (711 of 796 patients) from 2012–2013 for this Commission on Cancer (CoC) standard of care quality measure (95% confidence interval [CI], 87.2–91.5). Cleveland Clinic performs within the acceptable range for biopsy prior to surgical treatment of breast cancer.

The Comprehensive Breast Cancer Program at Cleveland Clinic is committed to providing patients with the best possible prevention, detection, and treatment options for breast disease. A multidisciplinary team comprising surgeons, medical oncologists, radiation oncologists, nurses, and social workers collaborates with each patient to develop a care plan.

The main campus, Beachwood Family Health Center, and Fairview Hospital Breast Centers are accredited by the National Accreditation Program for Breast Centers (NAPBC), a program administered by the American College of Surgeons.

Prevention and Screening Quality Measures

15

12

0

9

5

3

Percent

2012 2013 2014

7914N = 8985 8909

100%100%

10.7% Not performed (N = 85)

89.3% Performed (N = 711)


Solid Tumor Oncology | Breast Cancer

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3232

Cleveland Clinic’s performance was 41.1% (295 of 717 patients) in 2013 for this CoC standard of care quality surveillance measure (95% CI, 37.5–44.7). No estimated performance rate is defined by the CoC. The NAPBC standard is 50%. The rate at Cleveland Clinic reflects patient choice and referral bias of patients seeking surgery and reconstruction at Cleveland Clinic.

Breast Conservation Surgery Rate for Women With Clinical Stagea 0, I, or II Breast Cancer (N = 717)

2013

aAmerican Joint Committee on Cancer

Data from Cleveland Clinic tumor registry for main campus and family health center locations

Community Outreach and Cancer Navigation — Cleveland Clinic provides

programs to reduce late-

stage cancer diagnosis and

secure health services for

individuals in minority and

underserved communities.

In 2014, a state-of-the-

art mammography suite

opened at the Langston

Hughes Community Health

and Wellness Center in

Cleveland. The Jonnie Ruth

Brown Mammography Suite

improves access to care

and timely breast cancer

screening and detection

within the community.

100%100%

41.1% Performed (N = 295)

58.9% Not performed (N = 422)

Outcomes 201432


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Time From Diagnosis to Treatment for Female Patients With Breast Cancer (N = 716)

2014

Five-Year Overall Survival of Female Patients With All Stages of Breast Cancer (N = 5694)

2006 – 2013

Treatment

American Joint Committee on Cancer (AJCC) stage I–IV breast cancer

Median = 39Mode = 36Median = 39Mode = 36

Days From Diagnosis to Treatment0 20 60 100 120 160 18040 80 140

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3 4 5

Percent Survival(Number at Risk) =

98.6(5227)

96.5(4201)

94.6(3328)

93.1(2620)

91.3(1984)

33Taussig Cancer Institute 33

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Five-Year Overall Survival of Female Patients With All Stages of Breast Cancer by Racea (N = 5528)

2006 – 2013

Percent Survival and (Number at Risk) by Racea


Race 1 2 3 4 5

Black 97.3 (735) 93.8 (582) 90.4 (438) 88.7 (330) 86.9 (249)

White 98.9 (4354) 97.0 (3517) 95.3 (2809) 93.9 (2221) 92.1 (1679)

aSelf-reported

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3 4 5

Black (N = 870)White (N = 4658)

Outcomes 201434


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Five-Year Overall Survival of Female Patients With All Stages of Breast Cancer by Hormone Receptor Status (N = 5428)

2006 – 2013

Five-Year Overall Survival of Female Patients With All Stages of Breast Cancer by HER2 Status (N = 3980)

2006 – 2013

Percent Survival and (Number at Risk) by HER2 Status


Status 1 2 3 4 5

HER2 negative 98.5 (3008) 95.8 (2386) 93.8 (1853) 92.1 (1491) 89.9 (1233)

HER2 positive 98.6 (670) 97.3 (535) 94.4 (415) 92.2 (326) 90.0 (268)

HER2 = human epidermal growth factor receptor 2

ER = estrogen receptor, PR = progesterone receptor

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ER and PR negative (N = 1059)ER or PR positive (N = 4371)

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3 4 5

HER2 negative (N = 3265)HER2 positive (N = 715)


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Overall Survival by ER, PR, and HER2 Status for Breast Cancer Patients (N = 4022)

2006 – 2013

Percent Survival and (Number at Risk) by Receptor HER2 Status


Status 1 2 3 4 5

ER or PR positive 99.1 (2557) 97.5 (2038) 96.0 (1584) 94.5 (1278) 92.0 (1041)

HER2 positive 98.6 (669) 97.3 (534) 94.4 (414) 92.2 (326) 90.0 (268)

Triple negative 95.5 (489) 87.6 (373) 83.4 (279) 80.8 (220) 79.2 (193)

ER = estrogen receptor, HER2 = human epidermal growth factor receptor 2, PR = progesterone receptor

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ER or PR positive (N = 2765)HER2 positive (N = 715)Triple negative (N = 542)

Outcomes 201436


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Five-Year Overall Survival of Female Patients With Stage 0 and I Breast Cancer (N = 3234)

2006 – 2013

CC = Cleveland Clinic

AJCC = Reference group data from the National Cancer Data Base (Commission on Cancer of the American College of Surgeons and the American Cancer Society) 2000-2002, as reported in: Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A. AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer Science & Business Media; 2010.

Percent Survival and (Number at Risk) by Stage


Stage 1 2 3 4 5

0 99.5 (864) 98.9 (694) 98.2 (563) 97.8 (458) 97.3 (338)

I 99.7 (2121) 99.1 (1725) 98.2 (1394) 97.6 (1116) 96.2 (869)

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Stage 0 CC (N = 953)Stage 0 AJCCStage I CC (N = 2281)Stage I AJCC


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Five-Year Overall Survival of Female Patients With Stage II Breast Cancer (N = 1556)

2006 – 2013





Stage 1 2 3 4 5

IIA 99.3 (990) 98.1 (797) 97.4 (647) 96.4 (509) 93.7 (395)

IIB 99.0 (469) 95.7 (365) 93.6 (274) 90.5 (197) 89.4 (143)

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Stage IIA CC (N = 1055)Stage IIA AJCCStage IIB CC (N = 501)Stage IIB AJCC

Outcomes 201438


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Five-Year Overall Survival of Female Patients With Stage IIIA and IIIB Breast Cancer (N = 442)

2006 – 2013





Stage 1 2 3 4 5

IIIA 97.6 (307) 93.5 (257) 89.1 (199) 86.1 (158) 82.3 (108)

IIIB 99.0 (95) 86.4 (67) 72.0 (43) 66.5 (33) 64.2 (23)

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Stage IIIA CC (N = 341)Stage IIIA AJCCStage IIIB CC (N = 101)Stage IIIB AJCC


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Five-Year Overall Survival of Female Patients With Late Stage Breast Cancer (N = 330)

2006 – 2013





Stage 1 2 3 4 5

IIIC 95.2 (114) 84.7 (92) 76.2 (60) 73.4 (46) 68.2 (35)

IV 82.4 (150) 72.8 (109) 60.6 (66) 49.7 (45) 44.7 (31)

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Stage IIIC CC (N = 128)Stage IIIC AJCCStage IV CC (N = 202)Stage IV AJCC

Outcomes 201440


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Hyperthermia Therapy for Patients With Breast Cancer

2014

Patients Receiving Comprehensive Survivorship Treatment and Care Plans

2010 – 2014

Survivorship

Before (left) and after (right) images of the response to hyperthermia therapy in a patient with estrogen receptor-positive breast cancer.

Cleveland Clinic is the only cancer program in Ohio that offers hyperthermia therapy. Hyperthermia therapy is a noninvasive method of increasing tumor temperature to stimulate blood flow, increase oxygenation, and render tumor cells more sensitive to radiation. For patients with breast cancer or superficial cancers (e.g., melanoma, squamous cell carcinoma, dermal metastases) who failed other systemic or radiation therapy, hyperthermia therapy effectively treats superficial recurrence such as the chest wall or tumors within a few centimeters of the surface of the body.

250

200

0

150

100

50

Completed Survivorship Visits

2010 2011 2012 2013 2014


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Five-Year Overall Survival of Patients With All Stages of Cervical Cancer (N = 270)

2006 – 2013

Radiation oncologists and medical oncologists work in close collaboration with gynecologic oncologists to treat patients with gynecologic cancers. Gynecologic tumor sites include the vulva, vagina, cervix, uterine body, and uterine adnexa. Standard radiation treatment employs high-dose-rate brachytherapy and external beam radiotherapy.

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3 4 5


90.0(204)

80.7(144)

75.1(109)

72.8(82)

70.8(59)

Outcomes 201442

Solid Tumor Oncology | Cervical Cancer

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Five-Year Overall Survival of Patients With Stage I Cervical Cancer (N = 107)

2006 – 2013



Stage 1 2 3 4 5

IA 100 (21) 100 (15) 100 (11) 100 (9) 100 (8)

IB 95.9 (65) 92.7 (52) 86.9 (41) 86.9 (31) 86.9 (23)



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Stage IA CC (N = 27)Stage IA AJCCStage IB CC (N = 80)Stage IB AJCC


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Five-Year Overall Survival of Patients With Stage II Cervical Cancer (N = 47)

2006 – 2013



Stage 1 2 3 4 5

IIA 92.6 (12) 84.2 (9) 84.2 (7) 60.1 (5) 60.1 (3)

IIB 100 (28) 92.0 (20) 92.0 (18) 92.0 (12) 92.0 (10)



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3 4 5


Outcomes 201444


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Five-Year Overall Survival of Patients With Late Stage Cervical Cancer (N = 88)

2006 – 2013

Percent Survival and (Number at Risk) by Stagea


Stage 1 2 3 4 5

IIIB 89.3 (45) 73.7 (28) 67.8 (20) 67.8 (16) 62.7 (10)

IVB 55.1 (11) 49.9 (9) 31.2 (4) 23.4 (3) 23.4 (2)

aData for Stage IIIA and IVA not shown due to N < 10.



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Stage IIIB CC (N = 61)Stage IIIB AJCCStage IVB CC (N = 27)Stage IVB AJCC


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Five-Year Overall Survival of Patients With Early Stage Cervical Cancer Treated With Radiation by Stage at Diagnosis (N = 73)

2006 – 2013

Percent Survival and (Number at Risk) by Stagea


Stage 1 2 3 4 5

IB 97.2 (32) 97.2 (28) 93.6 (24) 93.6 (19) 93.6 (13)

IIA 100 (14) 92.6 (12) 92.6 (10) 92.6 (8) 79.4 (5)

IIB 100 (17) 87.1 (12) 87.1 (10) 87.1 (6) 87.1 (6)

aData for Stage 0 and IA not shown due to N < 10.



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Stage IB CC (N = 39)Stage IB AJCCStage IIA CC (N = 14)Stage IIA AJCCStage IIB CC (N = 20)Stage IIB AJCC

Outcomes 201446


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Five-Year Overall Survival of Patients With Stage IIIB Cervical Cancer Treated With Radiation (N = 40)

2006 – 2013



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Stage IIIB CC (N = 40)Stage IIIB AJCC


89.6(33)

67.2(23)

60.7(16)

56.6(13)

51.7(9)


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Time From Diagnosis to Treatment for Patients With Colon and Rectum Cancer (N = 330)

2014

Multidisciplinary teams comprising surgeons and physicians from the departments of Colorectal and General Surgery, Gastroenterology, Interventional Radiology, Medical Oncology, and Radiation Oncology tailor treatment regimens for patients with gastrointestinal cancer. Treatment regimens include adjuvant therapy following surgical resection for patients with tumors at risk for recurrence as well as systemic therapies for patients with inoperative, incurable advanced disease. Clinical trials provide important treatment options to patients.

The data shown below for colorectal cancer demonstrate superior healthcare outcomes in advanced-stage cancer. Disparities in healthcare are a concern at Cleveland Clinic, and eliminating healthcare outcomes disparities in underserved populations is a priority.

Colon Cancer

Five-Year Overall Survival of Patients With All Stages of Colon and Rectum Cancer (N = 2764)

2006 – 2013

American Joint Committee on Cancer (AJCC) stage I–IV colon and rectum cancer

AJCC = Reference group data from the National Cancer Data Base (Commission on Cancer of the American College of Surgeons and the American Cancer Society) 2000-2002, as reported in: Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A, eds. AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer Science & Business Media; 2010.

Median = 24.5Mode = 0Median = 24.5Mode = 0

Days From Diagnosis to Treatment0 20 40 60 80 100 120 140 160 180 200

100

80

0

60

40

20

Survival (%)

Years After Diagnosis0 1 2 3 4 5

Percent Survival 89 79 72 64 59(Number at Risk) = (2367) (1759) (1200) (816) (557)

Outcomes 201448

Solid Tumor Oncology | Colon Cancer

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Five-Year Overall Survival of Patients With Colon and Rectum Cancer by Stage (N = 2764)

2006 – 2013

American Joint Committee on Cancer (AJCC) stage I–IV colon cancer


AJCC = Reference group data from the National Cancer Data Base (Commission on Cancer of the American College of Surgeons and the American Cancer Society) 2000-2002, as reported in: Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A, eds. AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer Science & Business Media; 2010.



Stage 1 2 3 4 5

I 93.6 (621) 89.2 (497) 84.3 (356) 79.6 (263) 74.6 (184)

II 93.2 (589) 88.7 (466) 83.7 (334) 79.5 (245) 75.0 (164)

III 91.8 (735) 84.2 (550) 76.6 (375) 66.9 (236) 61.5 (166)

IV 74.3 (422) 51.2 (246) 36.8 (135) 26.5 (72) 19.0 (43)

100

80

0

60

40

20

Survival (%)


Stage I CC (N = 689)Stage I AJCCStage II CC (N = 662)Stage II AJCCStage III CC (N= 822)Stage III AJCCStage IV CC (N = 591)Stage IV AJCC


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Five-Year Overall Survival of Patients With All Stages of Colon and Rectum Cancer by Racea (N = 2705)

2006 – 2013

Cleveland Clinic is actively participating in efforts to address outcome disparities due to race and other factors. One method employed by the Taussig Cancer Institute is the dissemination of information at minority health fairs and other community education events, which includes encouraging individuals to complete the recommended cancer screenings that can lead to early detection and treatment of disease and improve treatment outcomes.

aSelf-reported

American Joint Committee on Cancer (AJCC) stage I–IV colon and rectum cancer

Percent Survival and (Number at Risk) by Racea


Race 1 2 3 4 5

Black 86.3 (234) 74.3 (173) 65.4 (117) 55.1 (76) 48.4 (51)

White 89.1 (2086) 80.1 (1551) 72.4 (1056) 65.4 (719) 60.0 (492)

100

80

0

60

40

20

Survival (%)


Black (N = 282)White (N = 2423)

Outcomes 201450

Solid Tumor Oncology | Colon Cancer

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At Least 12 Regional Lymph Nodes Are Removed and Pathologically Examined for Patients Undergoing Resection for Colon Cancer

2012 – 2013

The National Cancer Data Base (NCDB) is a nationwide oncology outcomes database and is a joint program of the Commission on Cancer (CoC) and the American Cancer Society (ACS).

Quality Measure

Cleveland Clinic’s performance was 97% (211 of 218; 95% CI, 94.4%–99.1%) from 2012–2013 for this National Cancer Data Base (NCDB) standard of care quality measure, exceeding the 80% performance rate.

100%100%

97% Concordant (N = 211)97% Concordant (N = 211)

3% Nonconcordant (N = 7)3% Nonconcordant (N = 7)


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Five-Year Overall Survival of Patients With All Stages of Esophageal Adenocarcinoma (N = 663)

2006 – 2013

American Joint Committee on Cancer (AJCC) stage I–IV esophageal adenocarcinoma

Esophageal Adenocarcinoma

At Cleveland Clinic, patients with head and neck cancers benefit from multidisciplinary care involving a complete assessment by surgical, medical, and radiation oncologists. Individualized treatment plans for patients with these malignancies are developed through the collaborative efforts of all specialists. For patients with localized disease, surgery or radiation therapy is the mainstay of their care plans. The head and neck cancer care team is actively involved in cooperative group research studies and also conducts in-house clinical trials.

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3 4 5


74.0(441)

56.1(255)

49.5(163)

44.1(96)

40.7(57)

Outcomes 201452

Solid Tumor Oncology | Head and Neck Cancer

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Five-Year Overall Survival of Patients With Stage 0 and I Esophageal Adenocarcinoma (N = 100)

2006 – 2013

American Joint Committee on Cancer (AJCC) stage 0 and I esophageal adenocarcinoma





Stage 1 2 3 4 5

0 100 (19) 94.4 (16) 94.4 (11) 94.4 (2) 94.4 (2)

IA 96.2 (50) 89.7 (36) 86.4 (16) 86.4 (6) NA (0)

IB 92.3 (24) 87.9 (17) 76.2 (11) 54.4 (1) NA (0)

NA = not applicable

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Stage 0 CC (N = 20)Stage 0 AJCCStage IA CC (N = 54)Stage IA AJCCStage IB CC (N = 26)Stage IB AJCC


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5454

Five-Year Overall Survival of Patients With Stage II Esophageal Adenocarcinoma (N = 100)

2006 – 2013

American Joint Committee on Cancer (AJCC) stage II esophageal adenocarcinoma





Stage 1 2 3 4 5

IIA 89.6 (34) 83.8 (26) 80.3 (20) 71.6 (15) 61.7 (12)

IIB 88.2 (51) 65.0 (28) 62.3 (19) 54.5 (11) 54.5 (1)

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Outcomes 201454


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Five-Year Overall Survival of Patients With Stage III Esophageal Adenocarcinoma (N = 150)

2006 – 2013

American Joint Committee on Cancer (AJCC) stage III esophageal adenocarcinoma





Stage 1 2 3 4 5

IIIA 75.4 (52) 55.9 (29) 45.0 (17) 34.6 (6) 34.6 (1)

IIIB 79.5 (31) 41.2 (10) 21.8 (3) NA (0) NA (0)

IIIC 51.2 (20) 22.8 (6) 17.1 (1) 17.1 (1) NA (0)

NA = not applicable

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Stage IIIA CC (N = 69)Stage IIIA AJCCStage IIIB CC (N = 39)Stage IIIB AJCCStage IIIC CC (N = 42)Stage IIIC AJCC


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Five-Year Overall Survival of Patients With All Stages of Oral Cavity Cancer (N = 344)

2006 – 2013

Five-Year Overall Survival of Patients With Early Stage Oral Cavity Cancer (N = 146)

2006 – 2013

American Joint Committee on Cancer (AJCC) stage I–IV oral cavity cancer. Data include patients with squamous cell histology only.

American Joint Committee on Cancer (AJCC) stage I and II oral cavity cancer. Data include patients with squamous cell histology only.



Oral Cavity Cancer



Stage 1 2 3 4 5

I 97.0 (94) 94.7 (74) 93.2 (50) 89.2 (41) 84.3 (31)

II 95.3 (39) 87.3 (29) 87.3 (22) 77.9 (13) 77.9 (12)

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89.4(284)

79.6(197)

75.4(137)

69.5(106)

65.8(79)

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Stage I CC (N = 101)Stage I AJCCStage II CC (N = 45)Stage II AJCC

Outcomes 201456


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Five-Year Overall Survival of Patients With Late Stage Oral Cavity Cancer (N = 139)

2006 – 2013

American Joint Committee on Cancer (AJCC) stage III and IV oral cavity cancer. Data include patients with squamous cell histology only.





Stage 1 2 3 4 5

III 87.5 (27) 63.9 (18) 63.9 (16) 55.4 (12) 55.4 (8)

IV 84.1 (79) 65.4 (41) 55.8 (22) 50.3 (17) 46.6 (9)

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Stage III CC (N = 33)Stage III AJCCStage IV CC (N = 106)Stage IV AJCC


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Five-Year Overall Survival of Patients With Stage II–IV Oral Cavity Cancer Treated With Radiation (N = 67)

2006 – 2013

American Joint Committee on Cancer (AJCC) stage II–IV oral cavity cancer. Data include patients with squamous cell histology only.





Stage 1 2 3 4 5

II 89.5 (8) 75.7 (4) 75.7 (4) 75.7 (2) 75.7 (1)

III 83.3 (15) 54.6 (9) 54.6 (8) 47.3 (6) 47.3 (5)

IV 81.3 (29) 71.8 (19) 67.4 (13) 67.4 (12) 67.4 (9)

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Stage II CC (N = 10)Stage II AJCCStage III CC (N = 18)Stage III AJCCStage IV CC (N = 39)Stage IV AJCC

Outcomes 201458


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Five-Year Overall Survival of Patients With All Stages of Oropharyngeal Cancer (N = 501)

2006 – 2013

Five-Year Overall Survival of Patients With Early Stage Oropharyngeal Cancer (N = 62)

2006 – 2013

American Joint Committee on Cancer (AJCC) stage I–IV oropharyngeal cancer. Data include patients with squamous cell histology only

American Joint Committee on Cancer (AJCC) stage I and II oropharyngeal cancer. Data include patients with squamous cell histology only.



Oropharyngeal Cancer

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3 4 5


93.2(441)

86.3(334)

82.8(250)

81.0(199)

76.7(133)



Stage 1 2 3 4 5

I 100 (28) 91.8 (19) 91.8 (15) 91.8 (10) 91.8 (8)

II 100 (30) 86.4 (25) 86.4 (16) 86.4 (12) 86.4 (10)

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Five-Year Overall Survival of Patients With Late Stage Oropharyngeal Cancer (N = 395)

2006 – 2013

American Joint Committee on Cancer (AJCC) stage III and IV oropharyngeal cancer. Data include patients with squamous cell histology only.



The better outcomes for stage IV compared with stage III might reflect a higher number of patients who are positive for human papilloma virus in the stage IV group, a factor associated with better outcomes.



Stage 1 2 3 4 5

III 90.2 (72) 83.4 (55) 78.5 (45) 73.0 (38) 63.4 (19)

IV 92.4 (272) 86.0 (204) 82.7 (152) 82.1 (121) 79.0 (83)

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Outcomes 201460


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Five-Year Overall Survival of Patients With Stage II–IV Oropharyngeal Cancer Treated With Radiation (N = 298)

2006 – 2013

American Joint Committee on Cancer (AJCC) stage II–IV oropharyngeal cancer. Data include patients with squamous cell histology only.





Stage 1 2 3 4 5

II 100 (15) 92.9 (13) 84.8 (9) 84.8 (6) 84.8 (6)

III 91.5 (53) 85.9 (42) 79.5 (36) 70.3 (29) 58.3 (19)

IV 95.9 (209) 90.5 (166) 86.7 (119) 85.9 (100) 82.9 (64)

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Stage II CC (N = 15)Stage II AJCCStage III CC (N = 59)Stage III AJCCStage IV CC (N = 224)Stage IV AJCC


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Five-Year Overall Survival of Patients With All Stages of Hypopharyngeal Cancer (N = 75)

2006 – 2013

Five-Year Overall Survival of Patients With Late Stage Hypopharyngeal Cancer (N = 60)

2006 – 2013

American Joint Committee on Cancer (AJCC) stage I–IV hypopharyngeal cancer. Data include patients with squamous cell histology only.

American Joint Committee on Cancer (AJCC) stage III and IV hypopharyngeal cancer. Data include patients with squamous cell histology only.



Hypopharyngeal Cancer

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83.2(56)

62.8(37)

47.3(20)

42.4(16)

39.3(11)



Stage 1 2 3 4 5

III 89.5 (8) 89.5 (8) 73.2 (3) 73.2 (3) 73.2 (2)

IV 79.8 (35) 55.0 (21) 40.2 (11) 32.5 (8) 28.2 (6)

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Outcomes 201462


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Five-Year Overall Survival of Patients With Stage IV Hypopharyngeal Cancer Treated With Radiation (N = 29)

2006 – 2013

American Joint Committee on Cancer (AJCC) stage IV hypopharyngeal cancer. Data include patients with squamous cell histology only.



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Stage IV CC (N = 29)Stage IV AJCC


86.0(24)

59.2(14)

41.0(8)

30.7(6)

30.7(6)


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Five-Year Overall Survival of Patients With All Stages of Laryngeal Cancer (N = 424)

2006 – 2013

Five-Year Overall Survival of Patients With Early Stage Laryngeal Cancer (N = 171)

2006 – 2013

American Joint Committee on Cancer (AJCC) stage I–IV laryngeal cancer. Data include patients with squamous cell histology only.

American Joint Committee on Cancer (AJCC) stage I and II laryngeal cancer. Data include patients with squamous cell histology only.



Laryngeal Cancer

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93.3(380)

85.6(277)

81.8(207)

76.7(160)

72.2(108)



Stage 1 2 3 4 5

I 99.0 (102) 96.9 (79) 95.5 (61) 92.1 (49) 87.8 (35)

II 95.3 (60) 86.6 (44) 84.5 (39) 71.0 (30) 68.3 (21)

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Outcomes 201464


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Five-Year Overall Survival of Patients With Late Stage Laryngeal Cancer (N = 184)

2006 – 2013

American Joint Committee on Cancer (AJCC) stage III and IV laryngeal cancer. Data include patients with squamous cell histology only.





Stage 1 2 3 4 5

III 91.5 (53) 76.3 (35) 64.2 (23) 61.0 (17) 61.0 (14)

IV 86.0 (102) 76.7 (72) 75.4 (53) 72.3 (42) 64.4 (27)

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Five-Year Overall Survival of Patients With Early Stage Laryngeal Cancer Treated With Radiation (N = 43)

2006 – 2013

American Joint Committee on Cancer (AJCC) stage I and II laryngeal cancer. Data include patients with squamous cell histology only.





Stage 1 2 3 4 5

I 100 (19) 94.7 (18) 94.7 (15) 94.7 (14) 86.8 (9)

II 91.7 (22) 87.3 (19) 82.3 (15) 71.0 (12) 63.9 (7)

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Outcomes 201466


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Five-Year Overall Survival of Patients With Late Stage Laryngeal Cancer Treated With Radiation (N = 78)

2006 – 2013

American Joint Committee on Cancer (AJCC) stage III and IV laryngeal cancer. Data include patients with squamous cell histology only.





Stage 1 2 3 4 5

III 96.0 (24) 91.4 (17) 85.3 (12) 85.3 (11) 85.3 (9)

IV 92.4 (48) 79.6 (33) 79.6 (23) 75.8 (17) 65.7 (11)

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Relapse-Free Survival of Patients by Treatment Arm (N = 69)

February 2008 – October 2011

Relapse-Free Survival of Patients by Cancer Type and HPV/p16 Expression (N = 68)

February 2008 – October 2011

Randomized Trial of 2 Chemoradiation Regimens for Patients With Locally Advanced Head and Neck Squamous Cell Carcinoma

Arm A = radiation (70-74.4 Gy) and cisplatin (100 mg/m2) on radiation days 1, 22, 43; Arm B = radiation (70-74.4 Gy) and cisplatin (20 mg/m2/day) and 5-fluorouracil (1000 mg/m2/day) continuous 96-hour infusion for radiation weeks 1 and 4

HPV = human papilloma virus

A randomized trial of 2 chemoradiation regimens for patients with locally advanced head and neck squamous cell cancer compared a multiagent combination of chemotherapy and radiation with a single-agent chemotherapy and radiation.1 The more intensive multiagent chemotherapy regimen showed no outcomes benefit, required more hospitalization, and resulted in more blood and dermatologic toxicity. The study included a high number of patients with HPV-positive oropharyngeal cancer (49 patients, or 71%), whose more favorable prognosis may account for the better results achieved in both treatment arms compared with historical controls. Use of the more costly and toxic multiagent chemoradiation regimen for patients with HPV-positive cancer may not be warranted.

1. Rodriguez CP, Adelstein DJ, Rybicki LA, Savvides P, Saxton JP, Koyfman SA, Greskovich JF, Yao M, Scharpf J, Lavertu P, Wood BG, Burkey BB, Lorenz RR, Rezaee RP, Zender CA, Ives DI. Randomized phase III study of 2 cisplatin-based chemoradiation regimens in locally advanced head and neck squamous cell carcinoma: Impact of changing disease epidemiology on contemporary trial design. Head Neck. 2014 Jun 7. doi: 10.1002/hed.23794. [Epub ahead of print]

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0 246Months After Treatment

30 3612 18 42 48 54 60 66

P = 0.24

Arm A (N = 35)Arm B (N = 34)

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0 246Months After Treatment

30 3612 18 42 48 54 60 66

P = 0.31

HPV+ oropharynx (N = 49)Non-oropharynx and HPV– (N = 19)

Outcomes 201468


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Five-Year Overall Survival of Patients With All Stages of Non-Small Cell Lung Cancer (N = 3266)

2006 – 2013

American Joint Committee on Cancer (AJCC) stage I–IV non-small cell lung cancer

The Thoracic Oncology Program at the Taussig Cancer Institute offers patients with thoracic malignancies leading-edge, multidisciplinary care. In consultation with patients, collaborative teams of surgical, medical, and radiation oncologists tailor treatment plans to the needs of each patient. An active clinical research program provides patients with additional treatment options to consider.

The Department of Radiation Oncology actively participates in Cleveland Clinic in-house protocols and is a full member of NRG Oncology. The department is one of the leading institutions nationally for accrual of patients to NRG Oncology lung cancer clinical trials.

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70.0(1976)

53.6(1143)

44.4(705)

38.5(450)

33.5(293)

Non-Small Cell Lung Cancer


Solid Tumor Oncology | Lung Cancer

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Five-Year Overall Survival of Patients With Stage I Non-Small Cell Lung Cancer (N = 875)

2006 – 2013

American Joint Committee on Cancer (AJCC) stage I non-small cell lung cancer





Stage 1 2 3 4 5

IA 94.0 (496) 84.7 (348) 74.7 (226) 67.6 (159) 60.2 (115)

IB 89.1 (261) 78.9 (187) 70.9 (131) 60.7 (75) 55.1 (49)

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Stage IA CC (N = 566)Stage IA AJCCStage IB CC (N = 309)Stage IB AJCC

Outcomes 201470


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Five-Year Overall Survival of Patients With Stage II Non-Small Cell Lung Cancer (N = 323)

2006 – 2013

American Joint Committee on Cancer (AJCC) stage II non-small cell lung cancer





Stage 1 2 3 4 5

IIA 84.0 (95) 73.7 (59) 66.7 (41) 58.6 (21) 55.1 (11)

IIB 86.4 (157) 63.5 (91) 54.2 (61) 47.3 (42) 46.0 (29)

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Five-Year Overall Survival of Patients With Stage III Non-Small Cell Lung Cancer (N = 654)

2006 – 2013

American Joint Committee on Cancer (AJCC) stage III non-small cell lung cancer





Stage 1 2 3 4 5

IIA 75.9 (263) 60.2 (144) 47.1 (78) 39.9 (42) 35.4 (26)

IIIB 65.4 (148) 40.4 (72) 33.3 (52) 29.8 (40) 26.0 (32)

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Outcomes 201472


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Five-Year Overall Survival of Patients With Stage IV Non-Small Cell Lung Cancer (N = 1267)

2006 – 2013

Overall Survival of Patients With Medically Inoperable Stage I Non-Small Cell Lung Cancer Treated With Stereotactic Body Radiation Therapy (N = 585)

2006 – 2013

American Joint Committee on Cancer (AJCC) stage IV non-small cell lung cancer



American Joint Committee on Cancer (AJCC) stage I non-small cell lung cancer


Reference = Zheng X, Schipper M, Kidwell K, Lin J, Reddy R, Ren Y, Chang A, Lv F, Orringer M, Spring Kong FM. Survival outcome after stereotactic body radiation therapy and surgery for stage I non-small cell lung cancer: a meta-analysis. Int J Radiation Oncol Biol Phys. 2014 Nov 1;90(3):603-611.

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48.6(463)

27.6(183)

18.2(86)

14.3(55)

9.5(24)


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80.3(435)

61.0(264)

42.9(138)

33.5(75)

23.0(35)

Stage I CC (N = 585)Stage I Reference


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Local Control for Patients With Medically Inoperable Stage I Non-Small Cell Lung Cancer Treated With Stereotactic Body Radiation Therapy (N = 585)

2006 – 2013

Five-Year Overall Survival of Patients With Stage III Non-Small Cell Lung Cancer Treated With Radiation (N = 283)

2006 – 2013

American Joint Committee on Cancer (AJCC) stage II non-small cell lung cancer


Reference = Zheng X, Schipper M, Kidwell K, Lin J, Reddy R, Ren Y, Chang A, Lv F, Orringer M, Spring Kong FM. Survival outcome after stereotactic body radiation therapy and surgery for stage I non-small cell lung cancer: a meta-analysis. Int J Radiation Oncol Biol Phys. 2014 Nov 1;90(3):603-611.

American Joint Committee on Cancer (AJCC) stage III non-small cell lung cancer





Stage 1 2 3 4 5

IIIA 74.7 (128) 61.4 (77) 50.1 (51) 46.8 (38) 41.1 (23)

IIIB 63.0 (54) 36.3 (24) 25.2 (152) 19.6 (9) 17.3 (7)

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3 4 5

Stage I CC (N = 585)Stage I Reference


96.1(383)

84.8(212)

83.4(109)

81.0(57)

78.5(25)

Outcomes 201474


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Five-Year Overall Survival of Patients With Stage IV Non-Small Cell Lung Cancer Treated With Radiation (N = 236)

2006 – 2013

Five-Year Overall Survival of Patients With All Stages of Small Cell Lung Cancer (N = 362)

2006 – 2013

American Joint Committee on Cancer (AJCC) stage IV non-small cell lung cancer



American Joint Committee on Cancer (AJCC) stage I–IV small cell lung cancer00

100100

4040

6060

8080

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3 4 5


60.8(179)

37.9(71)

27.3(34)

22.1(23)

19.7(11)

00

100100

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8080

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3 4 5



53.1(100)

29.4(43)

22.0(26)

17.5(18)

14.2(11)

Small Cell Lung Cancer


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Five-Year Overall Survival of Patients With Early Stage Small Cell Lung Cancer (N = 50)

2006 – 2013

American Joint Committee on Cancer (AJCC) stage I and II small cell lung cancer





Stage 1 2 3 4 5

I 79.7 (23) 62.9 (11) 48.9 (5) 36.7 (2) 36.7 (2)

II 84.2 (15) 66.8 (11) 52.7 (6) 43.9 (5) 43.9 (2)

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Outcomes 201476


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Five-Year Overall Survival of Patients With Late Stage Small Cell Lung Cancer (N = 296)

2006 – 2013

American Joint Committee on Cancer (AJCC) stage III and IV small cell lung cancer





Stage 1 2 3 4 5

III 71.4 (62) 55.1 (31) 46.8 (18) 38.5 (13) 34.7 (6)

IV 48.8 (68) 18.8 (13) 8.5 (3) 5.1 (1) NA (0)

NA = not applicable

00

100100

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8080

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3 4 5



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Five-Year Overall Survival of Patients With Late Stage Small Cell Lung Cancer Treated With Radiation (N = 59)

2006 – 2013

American Joint Committee on Cancer (AJCC) stage III and IV small cell lung cancer





Stage 1 2 3 4 5

III 80.6 (27) 60.8 (16) 56.3 (10) 56.3 (9) 48.3 (4)

IV 50.0 (6) 27.8 (1) NA (0) NA (0) NA (0)

NA = not applicable

00

100100

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8080

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3 4 5


Outcomes 201478


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Systemic Chemotherapy Administered 4 Months to 1 Day Preoperatively or Day of Surgery to 6 Months Postoperatively, or Considered for Surgically Resected Cases With Pathologic Lymph Node-Positive (pN1 or pN2) for Patients With Non-Small Cell Lung Cancer (N = 67)

2012 – 2013

aIncludes 2 patients whose chemotherapy fell outside the recommended treatment window

Quality Measures

Cleveland Clinic’s performance was 96% (64 of 67 patients) from 2012–2013 for this Commission on Cancer quality improvement measure (95% confidence interval, 91.3%–100.7%). Of 17 patients receiving preoperative chemotherapy, 16 (94%) received treatment 4 months before surgery; of 43 patients receiving postoperative chemotherapy, 42 (98%) received treatment within 6 months after surgery; of 7 patients not receiving chemotherapy, 6 (87%) were considered but chemotherapy was not administered for medical reasons or patient refusal.

100%100%

4% Not considered or administereda (N = 3)

96% Considered or administered (N = 64)


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Patients With Non-Small Cell Lung Cancer on Chemotherapy Regimens at Low Risk for Febrile Neutropenia Receiving Prophylactic Granulocyte-Colony Stimulating Factor

2006 – 2013

Some chemotherapy regimens for patients with non-small cell lung cancer represent a low risk (< 10%) for febrile neutropenia (FN). Established guidelines recommend against use of prophylactic granulocyte-colony stimulating factor (pGCSF) for such patients. Cleveland Clinic initiated a quality improvement project to ensure appropriate use of pGCSF in these patients. Education of lung cancer specialists including mid-level providers and nurses, modification of the medical record order set removing pGCSF from low-risk regimens, and development of consensus guidelines resulted in a 75% improved compliance with pGCSF guidelines. The resulting decrease in use of pGCSF represents a 25% reduction in the number of patients receiving pGCSF.1

1. Goodman LM, Moeller M, Dalby CK, Guthrie AE, Earl MA, Pennell NA, Shapiro MA, Velcheti V, Ma PC, Stevenson J. Improving prophylactic growth factor (pGCSF) use in non-small cell lung cancer (NSCLC) patients (pts) receiving chemotherapy (CT) at the Cleveland Clinic Taussig Cancer Institute (TCI). Presented at: ASCO Quality Care Symposium; Oct. 17-18, 2014; Boston, MA. Abstract 83. J Clin Oncol. 2014;32(suppl 30):Abstract 83. © American Society of Clinical Oncology. meetinglibrary.asco.org/content/137183-152.

pGCSF = prophylactic granulocyte-colony stimulating factor

100%100%

20% Received pGCSF (N = 23)

80% Did not receive pGCSF (N = 93)

5% Received pGCSF (N = 7)

95% Did not receive pGCSF (N = 125)

Baseline (N = 116)April – November 2013

After Quality Improvement Project (N = 132)Jauary – September 2014

Outcomes 201480


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Biochemical Relapse-Free Survival of Patients With Low-Risk Prostate Cancer by Treatment Type (N = 2024)

1996 – 2014

Low-, intermediate-, and high-risk stratification done per National Comprehensive Cancer Network (NCCN) criteria. NCCN Clinical Practice Guidelines in Oncology – Prostate Cancer. Version 2.2007, Apr. 9, 2007. National Comprehensive Cancer Network, Inc.

Genitourinary Oncology Program

Taussig Cancer Institute’s Genitourinary Oncology Program has made advancements in the treatment of adrenal, bladder, renal, testicular, and prostate cancer through research and innovation. The program’s multidisciplinary approach offers exceptional clinical care using surgery, chemotherapy, radiation therapy, and innovative clinical treatments for patients in all stages of disease.

Prostate Cancer

Percent Biochemical Relapse-Free Survival and (Number at Risk) by Treatment Type

Treatment Type 5-Year 10-Year 15-Year

External beam radiotherapy 96 (325) 86 (127) 68 (9)

Low-dose-rate brachytherapy 95 (723) 86 (123) 78 (6)

00

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2020


20 64Years After Treatment

12 188 10 14 16

External beam radiotherapy (N = 495)Low-dose-rate brachytherapy (N = 1529)


Solid Tumor Oncology | Prostate Cancer

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Biochemical Relapse-Free Survival of Patients With Intermediate-Risk Prostate Cancer by Treatment Type (N = 1721)

1996 – 2014


Low-, intermediate-, and high-risk stratification done per National Comprehensive Cancer Network (NCCN) criteria. NCCN Clinical Practice Guidelines in Oncology – Prostate Cancer. Version 2.2007, Apr. 9, 2007. National Comprehensive Cancer Network, Inc. High-intermediate risk is defined as having ≥ 2 intermediate risk factors.

Biochemical Relapse-Free Survival of Patients With High-Intermediate-Risk Prostate Cancer by Treatment Type (N = 419)

1996 – 2014



External beam 85 (266) 73 (104) 65 (5) radiotherapy

Low-dose-rate 91 (350) 79 (33) 74 (2) brachytherapy




Low-dose-rate 78 (53) 45 (1) NA (0) brachytherapy

NA = not applicable

00

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8080

2020



12 188 10 14 16


00

100100

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12 188 10 14 16


Outcomes 201482


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Biochemical Relapse-Free Survival of Patients With High-Risk Prostate Cancer by Treatment Type (N = 796)

1996 – 2014



Cumulative Incidence of Death Due to Prostate Cancer of Patients With Low-Risk Prostate Cancer by Treatment Type (N = 2024)

1996 – 2014




Low-dose-rate 69 (37) 58 (5) NA (0) brachytherapy

NA = not applicable

Percent Cumulative Incidence of Death Due to Prostate Cancer and (Number at Risk) by Treatment Type


External beam 0.9 (378) 2.0 (204) 3.3 (28) radiotherapy

Low-dose-rate 0.3 (876) 2.4 (192) 2.4 (16) brachytherapy

00

100100

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2020

Cumulative Incidence of Death (%)Cumulative Incidence of Death (%)


12 188 10 14 16


00

100100

4040

6060

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12 188 10 14 16



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Cumulative Incidence of Death Due to Prostate Cancer of Patients With Intermediate-Risk Prostate Cancer by Treatment Type (N = 1721)

1996 – 2014


84



External beam radiotherapy 2.0 (352) 5.0 (173) 7.8 (16)

Low-dose-rate brachytherapy 0.5 (439) 2.9 (70) 9.7 (4)

00

100100

4040

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8080

2020



12 188 10 14 16


Outcomes 201484


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Low-, intermediate-, and high-risk stratification done per National Comprehensive Cancer Network (NCCN) criteria. NCCN Clinical Practice Guidelines in Oncology – Prostate Cancer. Version 2.2007, Apr. 9, 2007. National Comprehensive Cancer Network, Inc. High-intermediate risk is defined as having ≥ 2 intermediate risk factors.

Cumulative Incidence of Death Due to Prostate Cancer of Patients With High-Intermediate-Risk Prostate Cancer by Treatment Type (N = 419)

1996 – 2014




Low-dose-rate brachytherapy 2.0 (78) 2.0 (8) NA (0)

NA = not applicable

00

100100

4040

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8080

2020



12 188 10 14 16



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Cumulative Incidence of Death Due to Prostate Cancer of Patients With High-Risk Prostate Cancer by Treatment Type (N = 796)

1996 – 2014





Low-dose-rate brachytherapy 4.8 (63) 6.3 (10) NA (0)

NA = not applicable

00

100100

4040

6060

8080

2020



12 188 10 14 16


Outcomes 201486


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Prostate Specific Antigen Value 6 Months After Radiation and Androgen Deprivation Therapy for Patients With Prostate Cancer Is Predictive of Long-Term Outcomes (N = 532)

1996 – 2012

Prostate specific antigen (PSA) measured 6 months after completion of external beam radiation therapy (EBRT) and androgen deprivation therapy (ADT) in patients with intermediate- and high-risk prostate cancer was predictive of disease progression. Analysis confirmed PSA > 0.1 ng/mL posttreatment was an independent predictor of worse biochemical relapse-free survival, distant metastasis-free survival, and prostate cancer specific mortality.1 Identifying patients at higher risk of disease progression may inform physicians and patients regarding the use of early salvage therapies to improve clinical outcomes.

1. Naik M, Reddy CA, Stephans KL, Tendulkar RD. Post-treatment PSA 6 months after radiation and androgen deprivation therapy predicts for distant metastases and prostate cancer specific mortality. Presented at: American Society for Radiation Oncology 56th Annual Meeting; Sept. 14–17, 2014: San Francisco. Int J Radiat Oncol Biol. 2014:90(1)Supp1:S155-S156.

100

80

0

60

40

20

Percent

5-Year

BiochemicalRelapse-Free Survival

P < 0.0001

Distant Metastasis-Free Survival

Prostate CancerSpecific Mortality

PSA ≤ 0.1 ng/mL at 6 monthsPSA > 0.1 ng/mL at 6 months

P < 0.0001

P < 0.0001


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Outcomes for Brachytherapy Compared With Intensity Modulated Radiotherapy in Patients With High-Risk Prostate Cancer (N = 453)

1997 – 2010

ADT = androgen deprivation therapy; CI = confidence interval (95%)

In this study of 453 patients with high-risk prostate cancer, biochemical relapse-free and distant metastasis-free survival were comparable among patients treated with brachytherapy compared with patients treated with high dose intensity modulated radiotherapy and androgen deprivation therapy.1

1. Weller MA, Reddy CA, Kittel J, Smith K, Tendulkar RD, Stephans KL, Klein EA, Angermeier KW, Ulchaker J, Campbell S, Stephenson A, Ciezki JP. Comparison of outcomes between brachytherapy and intensity modulated radiotherapy in high-risk prostate cancer. Poster presented at: American Society for Radiation Oncology 56th Annual Meeting; Sept. 14–17, 2014: San Francisco. Int J Radiat Oncol Biol. 2014:90(1)Supp1:S210.

100

80

0

60

40

20

Percent

5-Year

BiochemicalRelapse-Free Survival

P = 0.90

CI: 65.5%-80.8%

CI: 64.8%-81.3%

CI: 88.1%-95.6%CI: 82.5%-94.3%

Distant Metastasis-Free Survival

Brachytherapy with orwithout ADT (N = 295)Intensity modulated radiotherapywith ADT (N = 158)

P = 0.90

Outcomes 201488


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Five-Year Overall Survival of Patients With All Stages of Renal Cell Cancer (N = 3039)

2006 – 2013

American Joint Committee on Cancer (AJCC) stage I–IV renal cell carcinoma

89

00

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2020



3 4 5


92(2604)

86(2037)

82(1406)

77(948)

73(641)


Solid Tumor Oncology | Renal Cell Cancer

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Five-Year Overall Survival of Patients With Renal Cell Cancer by Stage at Diagnosis (N = 3039)

2006 – 2013

American Joint Committee on Cancer (AJCC) stage I–IV renal cell carcinoma





Stage 1 2 3 4 5

I 98 (1696) 96 (1398) 94 (993) 91 (685) 90 (470)

II 96 (120) 92 (100) 88 (73) 82 (46) 77 (27)

III 91 (576) 84 (420) 78 (272) 70 (175) 63 (115)

IV 59 (214) 39 (119) 28 (68) 20 (42) 15 (29)

00

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3 4 5

Stage I CC (N = 1853)Stage I AJCCStage II CC (N = 133)Stage II AJCCStage III CC (N = 683)Stage III AJCCStage IV CC (N = 370)Stage IV AJCC

90 Outcomes 201490

Solid Tumor Oncology | Renal Cell Cancer

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Representative cases prior to and after pazopanib treatment as illustrated by CT. A 60-year-old man with a solitary kidney, hilar tumor extending almost into the main renal vein, and chronic kidney disease (CKD) (A) demonstrated substantial regression of the tumor (B) after pazopanib. Partial nephrectomy (PN) yielded negative margins and 81% of the renal function was preserved. A 64-year-old woman with a solitary kidney, hilar tumor, and CKD (C) experienced minimal reduction in tumor size after pazopanib (D), although tumor vascularity was decreased and substantial necrosis was observed. PN was performed with negative margins and 78% of the renal function was preserved. A 58-year-old man with a large, perihilar tumor and severe contralateral atrophy (E) appeared to demonstrate substantial regression after pazopanib (F). However, on exploration, unrecognized satellite lesions (G) were encountered and radical nephrectomy (RN) was performed. The first and third cases were thought likely to require RN prior to therapy by the involved surgeon, primarily related to large tumor size and unfavorable location precluding adequate parenchymal preservation.

For patients with localized renal masses, PN is the preferred surgical course to preserve renal function. In some patients, the size and location of the tumor may preclude PN and require RN. Vascular endothelial growth factor (VEGF)-targeted agents such as pazopanib have demonstrated reduction in tumor size in patients with renal cell carcinoma (RCC). Twenty-eight patients with localized clear cell RCC ineligible for PN received pazopanib daily. Imaging was performed at 8 and 16 weeks to evaluate patients’ suitability for PN based on whether their tumor had been sufficiently reduced, as determined by the surgeon. Tumor reduction enabled 21 patients (90%) to receive PN while 7 patients received RN.1,2

1. Alvarez AL, Plimack ER, Dreicer R, Gilligan TD, Garcia JA, Elson P, Campbell SC, Krishnamurthi V, Kaouk J, Fergany AF, Uzzo RG, Stephenson AJ, Wood LS, Chen DYT, Rini BI. A phase II study of pazopanib (P) in patients (Pts) with localized renal cell carcinoma (RCC) to enable partial nephrectomy (PN). Abstract presented at: 2014 American Society of Clinical Oncology (ASCO) 50th Annual Meeting; May 29–June 3, 2014; Chicago, IL. Abstract 4522. J Clin Oncol. 2014;32:5s (suppl, abstr 4522). meetinglibrary.asco.org/content/128766-144.

2. Rini BI, Plimack ER, Takagi T, Elson P, Wood LS, Dreicer R, Gilligan T, Garcia J, Zhang Z, Kaouk J, Krishnamurthi V, Stephenson AJ, Fergany A, Klein EA, Uzzo RG, Chen DYT, Campbell SC. A Phase II study of pazopanib in patients with localized renal cell carcinoma to optimize preservation of renal parenchyma. J Urol. 2015 Mar 23 [Epub ahead of print].

VEGF-Targeted Agents to Enable Partial Nephrectomy in Patients With Localized Clear Cell Renal Cell Carcinoma (N = 28)

10

0

-50

-20

-30

-40

Change in Maximum Tumor Diameter (%)

Patients

-10


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92

The Harry R. Horvitz Center for Palliative Medicine, part of Taussig Cancer Institute, is the only medical program in the United States recognized as a European Society of Medical Oncology Designated Care Center of Integrated Oncology and Palliative Care and is one of only a few comprehensive and integrated palliative medicine programs in the country. The program is also a World Health Organization Demonstration Project in Palliative Medicine.

Of 572 patients admitted to the palliative medicine unit, 66% were patients with a cancer diagnosis and 41% were new patients.

Source of Admission of Patients to the Palliative Medicine Inpatient Unit (N = 572) 2014

Source of Intensive Care Unit Referrals to Palliative Medicine (N = 620) 2014

100%100%

37% Outpatient37% Outpatient

31% Emergency department31% Emergency department

21% Home21% Home

6% Outside hospital transfer6% Outside hospital transfer

5% Hospice5% Hospice

100%100%

61% Medical61% Medical

17% Neurological17% Neurological

15% Cardiac15% Cardiac

5% Surgical5% Surgical2% Cardiovascular surgery2% Cardiovascular surgery

Outcomes 201492

Palliative Medicine

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Source of Inpatient Referrals to Palliative Medicine (N = 1016) 2014

Source of Outpatient Referrals to Palliative Medicine (N = 456) 2014

Of 456 patients referred to Palliative Medicine for outpatient consults, 420 (92%) patients were given recommendations to receive palliative medicine follow-up.

100%100%

33% Internal medicine33% Internal medicine

31% Hematology and oncology31% Hematology and oncology

17% Cardiology17% Cardiology

10% Surgery10% Surgery4% Gynecologic oncology4% Gynecologic oncology3% Other3% Other2% Neurology2% Neurology

100%100%

75% Hematology and oncology75% Hematology and oncology

9% Radiation oncology9% Radiation oncology6% Cardiology6% Cardiology3% Gynecologic oncology3% Gynecologic oncology3% Neurology3% Neurology2% Internal medicine2% Internal medicine2% Other2% Other


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A total of 1004 inpatients were discharged from care or expired in 2014.

Symptoms assessed and reported for 1004 inpatients in 2014, including symptoms data for expired patients up to the time of death.

Advance Directives Discussed With Patient 2013 – 2014

Symptoms Present at Admission and Discharge 2014

100

0

40

60

80

20

Patients Reporting “Yes” (%)

Discussed atAdmission/Transfer

Discussed byDischarge

2013 (N = 1108)2014 (N = 1004)

886N = 769 946 834

100

0

40

60

80

20

Patients Reporting “Yes” (%)

Loss ofAppetite

Anxiety Constipation Depression Drowsiness Dyspnea Fatigue Nausea Pain

Present at admission/transferPresent at discharge

614N = 582 645 550 654 678 636 675 703

Outcomes 201494

Palliative Medicine

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In 2014, of 614 inpatients assessed, 419 (68%) reported loss of appetite on admission/transfer or at discharge (including symptoms data for expired patients up to the time of death).

In 2014, of 582 inpatients assessed, 289 (50%) reported anxiety on admission/transfer or at discharge (including symptoms data for expired patients up to the time of death).

Loss of Appetite Status at Discharge 2013 – 2014

Anxiety Status at Discharge 2013 – 2014

100%100%

2013

515N =

Patients Reported (%)

BetterSameWorse

18%

43%

39%

2014

419

18%

41%

41%

100%100%

2013

327N =


BetterSameWorse

33%

39%

28%

2014

289

29%

36%

35%


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96

In 2014, of 645 inpatients assessed, 282 (44%) reported constipation on admission/transfer or at discharge (including symptoms data for expired patients up to the time of death).

In 2014, of 550 inpatients assessed, 234 (43%) reported depression on admission/transfer or at discharge (including symptoms data for expired patients up to the time of death).

Constipation Status at Discharge 2013 – 2014

Depression Status at Discharge 2013 – 2014

100%100%

2013

245N =


BetterSameWorse

2014

234

34%

45%

21%

34%

34%

32%

100%100%

2013

364N =


BetterSameWorse

2014

282

47%

26%

28%

54%

24%

22%

Outcomes 201496

Palliative Medicine

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In 2014, of 654 inpatients assessed, 318 (49%) reported drowsiness on admission/transfer or at discharge (including symptoms data for expired patients up to the time of death).

Drowsiness Status at Discharge 2013 – 2014

In 2014, of 678 inpatients assessed, 207 (31%) reported dyspnea/shortness of breath on admission/transfer or at discharge (including symptoms data for expired patients up to the time of death).

Dyspnea Status at Discharge 2013 – 2014

100%100%

2013

388N =


BetterSameWorse

2014

318

29%35%

26%

39% 43%

28%

100%100%

2013

287N =


BetterSameWorse

2014

207

40%

33%

26%

41%

37%

22%


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In 2014, of 636 inpatients assessed, 507 (80%) reported fatigue on admission/transfer or at discharge (including symptoms data for expired patients up to the time of death).

Fatigue Status at Discharge 2013 – 2014

100%100%

2013

584N =


BetterSameWorse

20%

45%

35%

2014

507

17%

43%

40%

In 2014, of 675 inpatients assessed, 248 (37%) reported nausea on admission/transfer or at discharge (including symptoms data for expired patients up to the time of death).

Nausea Status at Discharge 2013 – 2014

100%100%

2013

318N =


BetterSameWorse

14%

26%

60%

2014

248

15%

26%

59%

Outcomes 201498

Palliative Medicine

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Comfort as reported by caregivers for patients receiving comfort measures prior to death in the hospital or while awaiting discharge planning/placement.

In 2014, of 703 inpatients assessed, 570 (81%) reported pain on admission/transfer or at discharge (including symptoms data for expired patients up to the time of death).

Comfortable End-of-Life Care 2013 – 2014

Pain Status at Discharge 2013 – 2014

100%100%

2013

670N =


BetterSameWorse

2014

570

11%

61%

28%

11%

56%

33%

100%100%

2013

263N =


NoYes

90%

10%

2014

262

91%

9%


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Cleveland Clinic strives to deliver the best possible care to patients with cancer and empower employees to actively evaluate and improve patient experience. Efforts to improve the quality of care and patient experience include responding to direct feedback from patients, regularly monitoring patient ratings of their care and patient outcomes, continuously improving processes, reorganizing the delivery of care, and managing resources effectively. Below are some examples of initiatives to improve access, quality of care, and services for patients and their loved ones.

54Cancer-related care path guides completed or underway. Care paths define the standard of care and reduce treatment variations, thereby driving more effective evaluation, innovation, and improvement in treatment outcomes and patient quality of life.

Time Study of Genetic Counselor Care With and Without Medical Geneticist

Cleveland Clinic researchers conducted a first of its kind time study in a traditional clinic of patient visits conducted by genetic counselors with a medical geneticist (GC/MD) present compared with genetic counselor only (GCO) appointments. Six GCs prospectively tracked time for 351 unique patients in GC/MD (109 patients) and GCO (242 patients) visits. Overall, time spent by GCs per patient was lower in the GCO setting (105.5 minutes) compared with the GC/MD setting (157.5 minutes; P < 0.001). Despite the additional time spent by GCs in the GC/MD setting, there were no differences in the number of case preparation activities or topics covered during sessions. The results suggest GCO visits are a better use of GCs’ time, with no reduction in the completion of patient-related activities.

Genetic Counselors’ Time Spent by Activity for All Patients July 2009 – March 2010

Heald B, Gustafson S, Mester J, Arscott P, Lynch K, Moline J, Eng C. A time study of cancer genetic counselors using a genetic counselor-only patient care model versus a traditional combined genetic counselor plus medical geneticist care model. J Natl Compr Canc Netw. 2013;11(9):1076-1081. Reprinted with permission from JNCCN—Journal of the National Comprehensive Cancer Network.

80

0

40

60

20

Average Minutes

Preparation Face to Face Follow-Up Telephone ResultsDisclosure

Genetic counselor only (N = 242)Genetic counselor & medical geneticist (N = 109)

P < 0.001

P < 0.001

P < 0.001

Not significant

Institute Quality Improvement

100 Outcomes 2014

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Patient Liaison Promotes Positive Patient Experience

The Taussig Cancer Institute Patient Liaison Program improves the patient experience by greeting patients who come for consultations, providing information about patient service programs, and immediately addressing patient complaints. In mid-2012, the program added a second liaison to greet more patients and resolve more issues. Of 635 issues managed in 2013, most related to scheduling, wait times, and delays in test results.

Shenal J, Somershield T, Kilbane M. Patient liaison program: an effective method to promote a positive patient experience. Poster presented at: 2014 Patient Experience + Innovation Summit; May 18–21, 2014; Cleveland, OH.

Patients Greeted and Complaints Managed by Patient Liaisons

3000

0

2000

1000

Number

2012 2013

Patients greetedComplaints managed

In 2014, the American Cancer Society’s partnership withCleveland Clinic resulted in:

• 1125 service referrals for 748 unique patients

• 233 wigs provided to patients

• 168 patients seen by the Patient Navigator Program

• 767 patient stays at Hope Lodge

101Taussig Cancer Institute

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Volunteer Mentors for Patients and Caregivers Nationwide

The 4th Angel Mentoring Program (4thangel.org) is a free, national support program for any patient or caregiver affected by a cancer diagnosis. The program provides one-on-one support to patients and caregivers by trained volunteers (mentors) who are also cancer survivors or have cared for loved ones with cancer. Patients and caregivers are matched with mentors based on similar diagnoses, treatments, age, gender, and other factors. Participants connect by phone or email regardless of where they live or are treated. The 4th Angel program partners with more than 900 organizations including the American Cancer Society, the National Institutes of Health, and the American Psychosocial Oncology Society.

The 4th Angel Mentoring Program

An active member of the Volunteer Management in Cancer Care Coalition (vmcancercare.org), a network of national, peer-mentoring programs and volunteer directors in cancer care.

In May 2015, Cleveland Clinic hosted the 2nd Volunteer Management in Cancer Care Symposium focusing on best practices and improving support services for patients and families.

Mentoring Program Matches and Active Mentors

1000

400

800

600

Number

2011 2012 2013 2014

MatchesActive mentors


102 Outcomes 2014

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Tinzaparin vs Warfarin for Recurrent Venous Thromboembolism in Patients with Cancer

Patients with cancer and a history of venous thromboembolism (VTE) are at increased risk of recurrent VTE. In a collaborative, international randomized study, researchers compared the efficacy of tinzaparin with warfarin in preventing recurrent VTE. Patients with active cancer and acute, symptomatic proximal deep vein thrombosis (DVT) and/or pulmonary embolism were randomized to receive tinzaparin (N = 449) or warfarin (N = 451). During the 6-month trial, 31 patients (6.9%) receiving tinzaparin had recurrent VTE compared with 45 patients (10%) receiving warfarin. While there was no difference in the incidence of major bleeding, clinically relevant non-major bleeding was significantly less (P = 0.03) in patients receiving tinzaparin (N = 50, 11%) compared with patients receiving warfarin (N = 73, 16%).

HR = hazard ratio, CI = confidence interval

Lee AYY, Kamphuisen PW, Meyer G, Bauersachs R, Janas MS, Jarner MF, Khorana AA; CATCH Investigators. A randomized trial of long-term tinzaparin, a low molecular weight heparin (LMWH), versus warfarin for treatment of acute venous thromboembolism (VTE) in cancer patients - the CATCH Study. Presented at: 56th ASH Annual Meeting and Exposition; Dec. 6–9, 2014; San Francisco, CA. Abstract LBA-2. Blood. 2014;124(21):LBA-2. © the American Society of Hematology. http://www.bloodjournal.org/content/124/21/LBA-2

Recurrence of Venous Thromboembolism (N = 900)August 2010 – April 2014

12

0

810

2

46

Cumulative Incidence (%)

300 60 90 150 180

Warfarin (N = 451)Tinzaparin (N = 449)HR = 0.65 (95% CI, 0.41–1.03, P = 0.07)

120

Days in Study


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Over Half of Patients Enter Clinical Trials

Advances in cancer prevention, screening, and treatment depend on evidence-based clinical research. Participation in clinical trials provides patients with important treatment options and opportunities to contribute to advancing high-quality care. Initiatives employed to increase participation in trials include an intranet-based catalog of trials for point-of-care evaluation of candidates by providers at any location and increased availability of updated patient information materials. Letters of appreciation and certificates are provided to patients participating in therapeutic trials. Cleveland Clinic is a National Cancer Institute-designated cancer center, and its clinical trials accrued 51% of patients, exceeding the commendation rate of 30% established by the American College of Surgeons Commission on Cancer.

Percentage of Patients Entering Clinical Trials (N = 7430) 2013

aCommission on Cancer (CoC) clinical trial accrual commendation rate (30%) for National Cancer Institute-designated cancer centers

100%100%

51% (N = 3788)Patients entering trials51% (N = 3788)Patients entering trials

49% (N = 3642)Patients not entering trials49% (N = 3642)Patients not entering trials

CoC commendationaCoC commendationa


104 Outcomes 2014

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Five-Day Outpatient Follow-Up Appointment Scheduling

The days immediately following discharge are a vulnerable period for oncology patients due to the burden of disease and treatment, along with changes to existing medical therapy that may worsen or produce new symptoms. Most symptoms treated in a timely manner do not require hospitalization. In June 2014, a new process was implemented requiring inpatient physicians to schedule an outpatient follow-up appointment for all patients discharged home and remaining in the care of a Taussig Cancer Institute physician. The goal is to achieve 100% compliance in scheduling 5-day follow-up appointments at discharge.

Compliance Scheduling Appointments for Patients Discharged to Home and in Care of Taussig Cancer Institute Physician 2014

100

0

40

60

80

20

Percent

Jun Jul Aug Sep Oct Nov Dec

General oncologyPalliative medicineCleveland Clinic target

121 32 99 28 112 22 127 29 108 23 117 25 114 21N =


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106 Outcomes 2014106

Patient Experience — Taussig Cancer Institute

Cleveland Clinic is dedicated to delivering excellent clinical outcomes surrounded by the best possible experience for patients and their families. Reported patient experiences are shared with caregivers and used to identify opportunities to improve care. Cleveland Clinic’s Office of Patient Experience supports caregivers through education and guidance to help them deliver consistent, patient-centered care.

Outpatient Office Visit Survey — Taussig Cancer Institute

CG-CAHPS Assessmenta 2013 – 2014

aIn 2013, Cleveland Clinic began administering the Clinician and Group Practice Consumer Assessment of Healthcare Providers and Systems surveys (CG-CAHPS), standardized instruments developed by the Agency for Healthcare Research and Quality and supported by the Centers for Medicare & Medicaid Services for use in the physician office setting to measure patients’ perspectives of outpatient care.bBased on results submitted to the CG-CAHPS database from 2172 medical practices in 2013.cResponse options: Always, Usually, Sometimes, Never dResponse options: Yes, definitely; Yes, somewhat; NoeResponse options: Yes, No

Source: Press Ganey, a national hospital survey vendor

100

80

0

60

40

20

Percent Best Response

CG-CAHPS 2013 database average(all practices)b

AppointmentAccess

(% Always)c

DoctorCommunication

(% Yes, Definitely)d

Doctor Rating

(% 9 or 10)0 – 10 Scale

Clerical Staff


Test ResultsCommunication

(% Yes)e

2013 (N = 2352)2014 (N = 4832)

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HCAHPS Overall Assessment 2013 – 2014

Inpatient Survey — Taussig Cancer Institute

The Centers for Medicare & Medicaid Services requires United States hospitals that treat Medicare patients to participate in the national Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, a standardized tool that measures patients’ perspectives of hospital care. Results collected for public reporting are available at medicare.gov/hospitalcompare.

HCAHPS Domains of Carea 2013 – 2014

100

80

0

60

40

20

Best Response (%)

aBased on national survey results of discharged patients, January 2013 – December 2013,from 4067 US hospitals. medicare.gov/hospitalcomparebResponse options: Definitely yes, Probably yes, Probably no, Definitely no


2014 (N = 529)

National averageall patientsa

2013 (N = 601)

Hospital Rating(% 9 or 10)0 – 10 Scale

Recommend Hospital(% Definitely Yes)b

100

80

0

60

40

20

Best Response (%)

DischargeInformation

% Yes

Doctor Communication

Nurse Communication

PainManagement

RoomClean

New MedicationsCommunication

Responsivenessto Needs

Quiet atNight

% Always(Options: Always, Usually, Sometimes, Never)

2014 (N = 529)National average all patientsb

2013 (N = 601)

aExcept for “Room Clean” and “Quiet at Night,” each bar represents a composite score based on responses to multiple survey questions. Source: Press Ganey, a national hospital survey vendorbBased on national survey results of discharged patients, January 2013 – December 2013, from 4067 US hospitals. medicare.gov/hospitalcompare

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108

Cleveland Clinic Overall Mortality Observed/Expected Ratio

2013 – 2014

Source: Data from the UHC Clinical Data Base/Resource ManagerTM used by permission of UHC. All rights reserved.

Cleveland Clinic’s observed/expected (O/E) mortality ratio outperformed its internal target derived from the University HealthSystem Consortium (UHC) 2014 risk model. Ratios less than 1.0 indicate mortality performance “better than expected” in UHC’s risk adjustment model.

Overview

Cleveland Clinic health system uses a systematic approach to performance improvement while simultaneously pursuing 3 goals: improving the patient experience of care (including quality and satisfaction), improving population health, and reducing the cost of healthcare. The following measures are examples of 2014 focus areas in pursuit of this 3-part aim. Throughout this section, “Cleveland Clinic” refers to the academic medical center or “main campus,” and those results are shown. Real-time dashboard data are leveraged in each Cleveland Clinic location to drive performance improvement. Although not an exact match to publicly reported data, more timely internal data create transparency at all organizational levels and support improved care in all clinical locations.

Cleveland Clinic has implemented several strategies to reduce central line-associated bloodstream infections (CLABSI), including a central-line bundle of insertion, maintenance, and removal best practices. Focused reviews of every CLABSI occurrence support reductions in CLABSI rates in the high-risk critical care population.

Cleveland Clinic Central Line-Associated Bloodstream Infection — ICU Rate per 1000 Line Days

2013 – 2014

Improve the Patient Experience of Care

1.0

0.0Q1 Q2

2013 2014

Q3 Q4 Q1 Q2 Q3 Q4

0.8

0.6

0.4

0.2

O/E Ratio

Cleveland ClinicCleveland Clinic target

2.5

0.0

2.0

1.5

1.0

0.5

Rate per 1000 Line Days


Q1 Q2

2013 2014

Q3 Q4 Q1 Q2 Q3 Q4

Outcomes 2014108

Cleveland Clinic — Implementing Value-Based Care

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109

Cleveland Clinic Postoperative Pulmonary Embolism or Deep Vein Thrombosis Risk Adjusted Rate per 1000 Eligible Patients

2013 – 2014

Improved screening, risk adjustment, and prevention strategies have supported Cleveland Clinic’s continued improvement with respect to perioperative pulmonary embolism and deep vein thrombosis (AHRQ Patient Safety Indicator 12). Embolism/thrombosis prevention remains a safety priority for Cleveland Clinic in 2015.

Source: Data reported from the National Database for Nursing Quality Indicators® (NDNQI®) with permission from Press Ganey.

Source: Data from the UHC Clinical Data Base/Resource ManagerTM used by permission of UHC. All rights reserved.

A pressure ulcer is an injury to the skin that can be caused by pressure, moisture, or friction. These sometimes occur when patients have difficulty changing position on their own. Cleveland Clinic caregivers have been trained to provide appropriate skin care and regular repositioning help while taking advantage of special devices and mattresses to reduce pressure for high-risk patients. In addition, they actively look for hospital-acquired pressure ulcers and treat them quickly if they occur.

Cleveland Clinic Hospital-Acquired Pressure Ulcer Prevalence (Adult)

2013 – 2014

Rate per 1000 Patients


10

0

8

6

4

2

Q1 Q2

2013 2014

Q3 Q4 Q1 Q2 Q3 Q4

5

0

4

3

2

1

Percent

Cleveland ClinicNDNQI 50th percentile(academic medical centers)

Q1 Q2

2013 2014

Q3 Q4 Q1 Q2 Q3 Q4


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110 Outcomes 2014110


Cleveland Clinic is dedicated to delivering excellent clinical outcomes surrounded by the best possible experience for patients and their families. Reported patient experiences are shared with caregivers and used to identify opportunities to improve care. Cleveland Clinic’s Office of Patient Experience supports caregivers through education and guidance to help them deliver consistent, patient-centered care.

Outpatient Office Visit Survey — Cleveland Clinic

CG-CAHPS Assessmenta 2013 – 2014

aIn 2013, Cleveland Clinic began administering the Clinician and Group Practice Consumer Assessment of Healthcare Providers and Systems surveys (CG-CAHPS), standardized instruments developed by the Agency for Healthcare Research and Quality (AHRQ) and supported by the Centers for Medicare & Medicaid Services for use in the physician office setting to measure patients’ perspectives of outpatient care.bBased on results submitted to the AHRQ CG-CAHPS database from 2172 practices in 2013cResponse options: Always, Usually, Sometimes, Never dResponse options: Yes, definitely; Yes, somewhat; NoeResponse options: Yes, No


100

80

0

60

40

20

Best Response (%)

AppointmentAccess

(% Always)c

Primary Care

(% Always)c

Specialty Care


Doctor Rating

(% 9 or 10)0 – 10 Scale

Clerical Staff


Test ResultsCommunication

(% Yes)e

2013 (N = 64,792)2014 (N = 124,521)

CG-CAHPS 2013 database average(all practices)b


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HCAHPS Overall Assessment 2013 – 2014

Inpatient Survey — Cleveland Clinic

The Centers for Medicare & Medicaid Services requires United States hospitals that treat Medicare patients to participate in the national Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, a standardized tool that measures patients’ perspectives of hospital care. Results collected for public reporting are available at medicare.gov/hospitalcompare.

HCAHPS Domains of Carea 2013 – 2014

100

80

0

60

40

20

Best Response (%)

aBased on national survey results of discharged patients, January 2013 – December 2013, from 4067 US hospitals. medicare.gov/hospitalcomparebResponse options: Definitely yes, Probably yes, Probably no, Definitely no


2014 (N = 10,369)

National averageall patientsa

2013 (N = 10,730)

Hospital Rating(% 9 or 10)0 – 10 Scale

Recommend Hospital(% Definitely Yes)b

100

80

0

60

40

20

Best Response (%)

DischargeInformation

% Yes


Nurse Communication

PainManagement

RoomClean

New MedicationsCommunication

Responsivenessto Needs

Quiet atNight

% Always(Options: Always, Usually, Sometimes, Never)

2014 (N = 10,369)National average all patientsb

2013 (N = 10,730)

aExcept for “Room Clean” and “Quiet at Night,” each bar represents a composite score based on responses to multiple survey questions. Source: Press Ganey, a national hospital survey vendorbBased on national survey results of discharged patients, January 2013 – December 2013, from 4067 US hospitals. medicare.gov/hospitalcompare

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112 Outcomes 2014

Cleveland Clinic is developing and implementing new models of care that focus on “Patients First” and aim to deliver on the Institute of Medicine goal of Safe, Timely, Effective, Efficient, Equitable, Patient-centered care. Creating new models of Value-Based Care is a strategic priority for Cleveland Clinic. As care delivery shifts from fee-for-service to a population health and bundled payment delivery system, Cleveland Clinic is focused on concurrently improving patient safety, outcomes, and experience.

What does this new model of care look like?

• The Cleveland Clinic Integrated Care Model (CCICM) is a value-based model of care, designed to improve outcomes while reducing cost. It is designed to deliver value in both population health and specialty care.

• The patient remains at the heart of the CCICM.

• The blue band represents the care system, which is a seamless pathway that patients move along as they receive care in different settings. The care system represents integration of care across the continuum.

• Critical competencies are required to build this new care system. Cleveland Clinic is creating disease- and condition-specific care paths for a variety of procedures and chronic diseases. Another facet is implementing comprehensive care coordination for high-risk patients to prevent unnecessary hospitalizations and emergency department visits. Efforts include managing transitions in care, optimizing access and flow for patients through the CCICM, and developing novel tactics to engage patients and caregivers in this work.

• Measuring performance around quality, safety, utilization, cost, appropriateness of care, and patient and caregiver experience is an essential component of this work.

Focus on Value

HomeRetail Venues

Integrated Care Model

Outpatient Clinics

IndependentPhysicianOffices

Skilled NursingFacilities Rehabilitation

Facilities

Community-BasedOrganizations

Post-Acute(other)

AmbulatoryDiagnosis & Treatment

Hospitals

Emergency

Care System

MyChart

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113

CMI = case mix index aTotal discharges Source: Data from the UHC Clinical Data Base/Resource ManagerTM

used by permission of UHC. All rights reserved.

a2015 ACO 90th percentile bLower is better

Cleveland Clinic All-Cause 30-Day Readmission Rate to Any Cleveland Clinic Hospital 2013 – 2014

Select Accountable Care Organization Performance Measures

Cleveland Clinic monitors 30-day readmission rates for any reason to any of its system hospitals. Unplanned readmissions are actively reviewed for improvement opportunities. Strategies associated with communication, education, and follow-up have been implemented for several high-risk conditions, including heart failure and pneumonia. These practices are being expanded and enhanced to reduce overall avoidable readmissions. Sicker, more complex patients are more susceptible to readmission. Case mix index (CMI) reflects patient severity of illness and resource utilization. Cleveland Clinic’s CMI remains one of the highest among American academic medical centers.

As part of Cleveland Clinic’s commitment to population health and in support of its newly certified Accountable Care Organization (ACO), these primary care ACO measures have been prioritized for monitoring and improvement. Cleveland Clinic is improving performance in these measures through enhanced care coordination, optimizing technology and information systems, and engaging primary care physicians and specialists directly in the improvement work. These pursuits are part of Cleveland Clinic’s overall strategy to transform care in order to improve health and make care more affordable.

Reduce the Cost of CareImprove Population Health

Percent of DischargesPercent of Discharges Case Mix Index

0.0

3.0

1.5

00

1818

99

1212

1515

66

33

Q1 Q2

201352,104Na =

201450,755

Q3 Q4 Q1 Q2 Q3 Q4

Cleveland Clinic rateCleveland Clinic CMIUHC academic medical centers CMI

Measure Cleveland Clinic 2014 Cleveland Clinic Performance (%) Goala (%)

Pneumococcal 84.9 100 vaccination

Colorectal 72.3 100 cancer screening

Mammography 77.5 ≥ 99.6 screening

Hemoglobin 20.5 ≤ 10b A1c > 9%

Hypertension 69.3 ≥ 79.7 control


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Genomic Profiles Inform Treatment

Scientific and medical research has identified gene mutations associated with some solid tumors. Since late 2013, Cleveland Clinic has performed genomic analysis on tumors from 250 patients with incurable solid organ cancer. Genomic analysis is performed using FoundationOne® (Foundation Medicine, Inc., Cambridge, MA) for 315 cancer-related genes and selected noncoding segments of DNA from 28 genes. Results are reviewed by Cleveland Clinic physicians and scientists at a weekly Genomic Tumor Board to inform treatment decisions. In a subset of 45 patients with metastatic colorectal cancer, 22 patients (49%) had genomic alterations with potential for use of targeted therapy. Clinical trials were recommended for most of the 22 patients (88%). Targeted therapies and clinical trials of treatments for patients with certain genomic alterations may expand treatment options.

The research was first presented by Davendra Sohal, MD, MPH, principal investigator, at the 2015 Gastrointestinal Cancers Symposium, “Bridging Cancer Biology to Clinical GI Oncology,” Jan. 15–17, 2015; San Francisco, CA.

First in Ohio Radiosurgery System Reduces Treatment Visits for Patients

In 2014, Cleveland Clinic became the first hospital in Ohio and the second in the US to implement the Edge™ Radiosurgery Suite (Varian Medical Systems, Inc., Palo Alto, CA). The Edge is a noninvasive radiosurgery system integrating real-time imaging, tumor tracking, tumor motion management, and robotic patient positioning for precise radiation delivery. The system is equipped with advanced features to deliver extra-high dose rate radiation to quickly and accurately treat the targeted treatment area. The powerful and precise delivery of radiation results in shorter treatment times and fewer treatment visits for patients. Using this system, patients with early-stage lung cancer, prostate cancer, and multiple brain and spine metastases are treated in a week or less using 1 to 5 treatment sessions.

Image courtesy of Varian Medical Systems, Inc. All rights reserved.

The top 10 medical

innovations for 2014

were announced at the

12th Annual Medical

Innovations Summit

held October 27–29,

2014. More than 1500

attendees participated

in the event, titled “Now

It’s Personal: Cancer and

Personalized Medicine.”

Visit:

Summit.ClevelandClinic.org/Top-10-Innovations/Top-10-for-2014.aspx

Outcomes 2014

Innovations

114

97925_CCFBCH_Rev3_114-114.pdf 1 7/28/15 9:01 AM

Blood Metabolites Differ in Patients With Lung Cancer

Research led by Peter J. Mazzone, MD, MPH, has found differences in blood metabolites in patients with lung cancer compared with matched controls. In the study, blood from 284 individuals was analyzed, including 94 patients with stage I–III lung cancer matched to 2 control individuals. A total of 534 metabolites were identified with the concentration of 149 metabolites differing significantly (q value < 0.05) between patients with cancer and the controls. Among patients with lung cancer, 70 metabolite concentrations were lower and 79 metabolite concentrations were higher. Detecting differences in the metabolic processes in people with cancer could lead to defining a diagnostic marker for lung cancer.

Mazzone P, Wang X, Beukeman M, Zhang Q, Seeley M, Mahoney R, Holt T, Pappan K. The analysis of small molecule metabolite profiles in the blood as a biomarker of lung cancer. In: Chest. Austin, TX: American College of Chest Physicians; 2014; 146(4_MeetingAbstracts):587A. doi:10.1378/chest.1989452.

Subclassification of Myelodysplastic Syndromes Based on Ancestral Mutations

Mutations in DNA that occur after birth (ie, somatic) are noted features in myelodysplastic syndromes (MDS). Somatic mutations in MDS are acquired in a specific order but less is known about the role of ancestral mutations (ie, germinal mutations passed to offspring). In acute myeloid leukemia, ancestral mutations are an important and better basis for classification of the disease. Researchers at Cleveland Clinic used whole exome sequencing (WES) and deep next generation sequencing (NGS) to investigate ancestral mutations in MDS. While both somatic and ancestral mutations may affect clinical expression of the disease, ancestral events are less diverse and more subtype specific. Findings suggest ancestral mutations may determine subsequent mutations and are associated with certain disease features and outcomes.

Most Frequent Ancestral Gene Mutations and Survival of Patients With TP53 Mutations Compared With TET2 and SRSF2 Mutations

Overall Survival (%)

Months After Diagnosis

TP53 vs TET2: HR = 3.11 (95% CI, 1.14–9.25, P = 0.02)

TP53 vs SRSF2: HR = 2.86 (95% CI, 1.05–8.53, P = 0.04)

00 20 40 60 80 100

20

40

60

80

100

Mutated Gene TP53 TET2 SRSF2

Makishima H, Yoshida K, LaFramboise T, Przychodzen BP, Ruffalo M, Gómez-Seguí I, Shiraishi Y, Sanada M, Nagata Y, Sato Y, Sato-Otsubo A, Chiba K, Tanaka H, Nakamaki T, Hofmann W-K, Miyawaki S, Chiba S, Miyano S, Husseinzadeh H, Hosono N, Polprasert C, Patel BJ, Thota S, Dienes B, Guinta KM, Shih L-Y, Saunthararajah Y, Okuno Y, Sekeres MA, Ogawa S, Maciejewski JP. In analogy to AML, MDS can be sub-classified by ancestral mutations. Presented at: 56th ASH Annual Meeting and Exposition; Dec. 6–9, 2014; San Francisco, CA. Abstract 823. Blood. 2014;124(21):Abstract 823. © the American Society of Hematology. www.bloodjournal.org/content/124/21/823

Makishima H, Yoshida K, Ruffalo M, Przychodzen BP, LaFramboise T, Hosonol N, Gómez-Seguí I, Holleh D, Husseinzadeh H, Thota S, Clementel MJ, Guinta KM, Dienes B, Shiraishi Y, Sanada M, Nagata Y, Okuno Y, Sato Y, Sato-Otsubo A, Chiba K, Tanaka H, Nakamaki T, Miyano S, Miyawaki S, Saunthararajah Y, Chiba S, Sekeres MS,

Shih L-Y, Ogawa S, Maciejewski JP. Landscape of somatic mutations in whole exomes of myelodysplastic syndromes and related myeloid neoplasms. Nature Genetics. Submitted.

Mutated Gene %

TET2 11

SF3B1 10

DNMT3A 8

SRSF2 6

TP53 5

Others 60

CI = confidence interval, HR = hazard ratio


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GSC = glioma stem cell, NSTC = nonstem tumor cell

Man J, Shoemake J, Zhou W, Fang X, Wu Q, Rizzo A, Prayson R, Bao S, Rich JN, Yu JS. Sema3C promotes the survival and tumorigenicity of glioma stem cells through Rac1 activation. Cell Rep. 2014;9(5):1812–1826.

Sema3C Contributes to Survival and Adaptation of Glioma Stem Cells

Glioblastomas are highly malignant brain tumors that arise from normal brain tissue and reproduce quickly to invade and survive within normal brain tissue. Glioma stem cells (GSCs) are a type of tumor cell that communicates in ways to adapt, invade, and survive despite treatment with standard therapy. Research led by Jennifer Yu, MD, PhD, found the protein Sema3C contributes to the survival and adaptation of GSCs. Sema3C is used by GSCs to promote growth but is not used by normal brain stem cells (neural progenitor cells) or nonstem tumor cells. Disrupting Sema3C destroys GSCs by stopping Rac1 activation, which is needed for survival of GSCs. Sema3C is not needed by neural progenitor cells; thus, it may kill GSCs with limited normal brain side effects. The research suggests therapeutics targeting Sema3C may lead to more effective treatments for glioblastoma.

Innovative Software Estimates Risk Over Time of Acute Myeloid Leukemia and Myelodysplastic Syndromes After Treatment for Cancer

Acute myeloid leukemia (AML) and myelodysplastic syndromes (MDS) are rare complications of cancer treatment. Researchers at Cleveland Clinic developed innovative software combining 3 Surveillance, Epidemiology, and End Results (SEER) Program databases to estimate relative risk over time of AML and MDS in patients previously treated for cancer. Relative risk of AML and MDS increased 9 to 12 months after diagnosis, peaked 1.5 to 2.5 years after diagnosis, and returned to steady state 10 to 15 years after diagnosis. Patients with non-Hodgkin lymphoma (NHL) or lung or breast cancer had the highest relative risk of AML and MDS. These findings suggest that research of gene mutation interactions with cancer therapies should focus on patients with NHL or lung or breast cancer who develop AML or MDS 1 to 12 years after diagnosis.

AML = acute myeloid leukemia, MDS = myelodysplastic syndromes

Radivoyevitch T, Sachs RK, Gale RP, Sekeres MA, Maciejewski JP, Kalaycio M, Mukherjee S. Estimating therapy-related myeloid neoplasm risks in the US. Poster presented at: 56th ASH Annual Meeting and Exposition; Dec. 6–9, 2014; San Francisco, CA. Poster 2617. Blood. 2014;124:2617. © the American Society of Hematology. https://ash.confex.com/ash/2014/webprogram/Paper75153.html

Risk of Acute Myeloid Leukemia and Myelodysplastic Syndromes After Diagnosis of First Cancer

EarlyRelative Risk

Years After Diagnosis of First Cancer

8

6

4

2

0

2

1

00 1 2 3 4 5 10 15 20

3

Late

Female

Male

Second cancerAML 1973 – 2011, N = 1953MDS 2001 – 2011, N = 1695

PlexinA2/D1 NRP1 Sema3C

Outcomes 2014

Innovations

116

97925_CCFBCH_Rev0_1-124.pdf 116 7/16/15 11:53 AM

New Stereotactic Body Radiosurgery Treatment Algorithms for Pancreatic Cancer

Recent innovations in radiation therapy include hypofractionated regimens — the delivery of several large radiation doses at specific intervals. Hypofractionated dosages improve local control for patients with lung, brain/spine, and liver cancers. Some studies of stereotactic body radiotherapy (SBRT) using hypofractionated regimens for patients with pancreatic cancer have reported a higher incidence of gastrointestinal toxicity due to the radiosensitivity of normal organs such as the stomach and duodenum. Cleveland Clinic initiated a program using hypofractionated SBRT for patients with pancreatic cancer featuring new treatment algorithms to optimize tumor control while protecting normal organs. The technique delivers radiation at a high dose per fraction with increased accuracy and rapid fall-off of radiation beyond the treatment area.


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Taussig Cancer Institute Appointments/Referrals

216.444.7923 or 866.223.8100

Blood and Marrow Transplant Program Appointments/Referrals

This internationally recognized program offers autologous, allogeneic, reduced-intensity, related and unrelated transplants. Cell sources include bone marrow, peripheral stem cell and umbilical cord blood transplants for treating patients with leukemias, lymphomas, and other hematological malignancies and bone marrow failure states.

216.445.5600 or 800.223.2273, ext. 55600

Bone Marrow Failure Clinic Appointments/Referrals

This subspecialty clinic offers expertise in aplastic anemia, myelodysplasia, single-lineage cytopenias, paroxysmal nocturnal hemoglobinuria, large granular lymphocytic leukemia and other immune-mediated hematologic diseases.

216.445.5962 or 800.223.2273, ext. 55962

Radiation Oncology Appointments/Referrals

216.444.5571 or 800.223.2273, ext. 45571

Cancer Answer Line

For questions or concerns about cancer, or to schedule a second opinion (Monday through Friday, 8 a.m. to 5 p.m.)

216.444.7923 or 866.223.8100

Staff Listing

For a complete listing of Cleveland Clinic’s Taussig Cancer Institute staff, please visit clevelandclinic.org/staff.

Publications

Taussig Cancer Institute staff authored 665 publications in 2014.

For a complete list, go to clevelandclinic.org/outcomes.

Helen Meyers McLoraine Patient Resource Center

Staffed by two clinical nurse specialists and an administrative coordinator, the center is open Monday through Friday, 8 a.m. to 5 p.m. Resources include:

• Free pamphlets and informational brochures

• Computer for Internet access and searches

• A room for nurse/patient discussions, teaching and educational video viewing

• Listings and registration for support groups and other patient-related events

• Listings of resources, such as wigs, transportation and lodging

On the Web at clevelandclinic.org/cancer

Outcomes 2014118

Contact Information

97925_CCFBCH_Rev0_1-124.pdf 118 7/16/15 11:53 AM

http://my.clevelandclinic.org/services/cancer?utm_campaign=cancer-redirect&utm_medium=offline&utm_source=redirect

http://my.clevelandclinic.org/staff_directory?utm_campaign=staff-url&utm_medium=offline&utm_source=redirect

http://my.clevelandclinic.org/about-cleveland-clinic/quality-patient-safety/treatment-outcomes.aspx?utm_campaign=outcomes-url&utm_medium=offline&utm_source=redirect

Locations

For a complete listing of Cleveland Clinic’s Cancer Care locations, please visit clevelandclinic.org/cancer.

Additional Contact Information General Patient Referral

24/7 hospital transfers or physician consults

800.553.5056 General Information

216.444.2200 Hospital Patient Information

216.444.2000 General Patient Appointments

216.444.2273 or 800.223.2273 Referring Physician Center and Hotline

855.REFER.123 (855.733.3712)

Or email [email protected] or visit clevelandclinic.org/refer123 Request for Medical Records

216.444.2640 or 800.223.2273, ext. 42640

Same-Day Appointments

216.444.CARE (2273) Global Patient Services/ International Center

Complimentary assistance for international patients and families

001.216.444.8184 or visit clevelandclinic.org/gps Medical Concierge

Complimentary assistance for out-of-state patients and families

800.223.2273, ext. 55580, or email [email protected] Cleveland Clinic Abu Dhabi

clevelandclinicabudhabi.ae Cleveland Clinic Canada

888.507.6885 Cleveland Clinic Florida

866.293.7866 Cleveland Clinic Nevada

702.483.6000 For address corrections or changes, please call

800.890.2467


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http://my.clevelandclinic.org/professionals/referring.aspx?utm_campaign=refer123-url&utm_medium=offline&utm_source=redirect

http://my.clevelandclinic.org/patients-visitors/international?utm_campaign=gps-url&utm_medium=offline&utm_source=redirect

https://www.clevelandclinicabudhabi.ae/en/pages/default.aspx

http://my.clevelandclinic.org/services/cancer?utm_campaign=cancer-redirect&utm_medium=offline&utm_source=redirect

mailto:[email protected]


Overview

Cleveland Clinic is an academic medical center offering patient care services supported by research and education in a nonprofit group practice setting. More than 3200 Cleveland Clinic staff physicians and scientists in 130 medical specialties and subspecialties care for more than 5.9 million patients across the system, performing more than 192,000 surgeries and conducting more than 497,000 emergency department visits. Patients come to Cleveland Clinic from all 50 states and more than 147 nations. Cleveland Clinic is an integrated healthcare delivery system with local, national, and international reach. The main campus in midtown Cleveland, Ohio, has a 1400-bed hospital, outpatient clinic, specialty institutes, labs, classrooms, and research facilities in 42 buildings on 165 acres. Cleveland Clinic’s CMS case-mix index is the second highest in the nation. Cleveland Clinic encompasses more than 90 northern Ohio outpatient locations, including 18 full-service family health centers, 8 regional hospitals, an affiliate hospital, and a rehabilitation hospital for children. Cleveland Clinic also includes Cleveland Clinic Florida; Cleveland Clinic Nevada, which includes the Lou Ruvo Center for Brain Health in Las Vegas, and urology and nephrology services; Cleveland Clinic Canada; and Sheikh Khalifa Medical City (management contract). Cleveland Clinic Abu Dhabi is a full-service hospital and outpatient center in the United Arab Emirates (UAE), which began offering services in spring 2015. Cleveland Clinic is the second-largest employer in Ohio, with more than 42,500 employees. It generates $12.6 billion of economic activity a year. Cleveland Clinic Global Solutions supports physician education, training and consulting, and patient services around the world through offices in Canada, China, the Dominican Republic, El Salvador, Guatemala, Honduras, Panama, Peru, Saudi Arabia, Turkey, UAE, and the United Kingdom.

The Cleveland Clinic Model

Cleveland Clinic was founded in 1921 by 4 physicians who had served in World War I and hoped to replicate the organizational efficiency of military medicine. The organization has grown through the years by adhering to the model set forth by the founders. All Cleveland Clinic staff physicians receive a straight salary with no bonuses or other financial incentives. The hospital and physicians share a financial interest in controlling costs, and profits are reinvested in research and education. The Cleveland Clinic health system began to grow in 1987 with the founding of Cleveland Clinic Florida and expanded in the 1990s with the development of 18 family health centers across Northeast Ohio. Fairview Hospital, Hillcrest Hospital, and 6 other regional hospitals have joined Cleveland Clinic over the past 2 decades, offering Cleveland Clinic institute services in heart and neurological care, physical rehabilitation, and more. Clinical and support services were reorganized into 27 patient-centered institutes beginning in 2007. Institutes combine medical and surgical specialists for specific diseases or organ systems under unified leadership and in a shared location to provide optimal team care for every patient. Institutes work with the Office of Patient Experience to give every patient the best outcome and experience. A Clinically Integrated Network

Cleveland Clinic is committed to providing value-based care, and it has grown the Cleveland Clinic Quality Alliance into the nation’s second-largest and Northeast Ohio’s largest clinically integrated network. The network comprises more than 5400 physician members, both employed and independent physicians from the community. Led by its physician members, the Quality Alliance strives to improve quality and consistency of care; reduce costs and increase efficiency; and provide access to expertise, data, and experience.

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About Cleveland Clinic

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Cleveland Clinic Lerner College of Medicine

Lerner College of Medicine is known for its small class sizes, unique curriculum, and full-tuition scholarships for all students. Each new class accepts 32 students who are preparing to be physician investigators. Cleveland Clinic is building a multidisciplinary Health Education Campus as the new home of the Case Western Reserve University (CWRU) School of Medicine and Cleveland Clinic’s Lerner College of Medicine, as well as the CWRU School of Dental Medicine, the Frances Payne Bolton School of Nursing, and physician assistant and allied health training programs.

Graduate Medical Education

In 2014, nearly 1800 residents and fellows trained at Cleveland Clinic and Cleveland Clinic Florida, which is part of a continuing upward trend.

U.S. News & World Report Ranking

Cleveland Clinic is consistently ranked among the top hospitals in America by U.S. News & World Report. It is ranked No. 1 in urology and has ranked No. 1 in heart care and heart surgery since 1995. In 2014, 4 of its programs were ranked No. 2 in the nation: diabetes and endocrinology, gastroenterology and GI surgery, nephrology, and rheumatology.

For more information about Cleveland Clinic, please visit clevelandclinic.org.

Cleveland Clinic Physician Ratings

At Cleveland Clinic, we believe in transparency. We also believe in the positive influence of the physician-patient relationship on healthcare outcomes. To continue to meet the highest standards of patient satisfaction, we now publish Cleveland Clinic physician ratings, based on nationally recognized Press Ganey patient satisfaction surveys, online at clevelandclinic.org/staff.


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http://my.clevelandclinic.org/

http://my.clevelandclinic.org/staff_directory?utm_campaign=staff-url&utm_medium=offline&utm_source=redirect

Referring Physician Center and Hotline

Call 24/7 for access to medical services or to schedule patient appointments: 855.REFER.123 (855.733.3712), email [email protected], or go to clevelandclinic.org/Refer123. The free Cleveland Clinic Physician Referral App, available for mobile devices, gives you 1-click access. Available at the App Store or Google Play. Remote Consults

Anybody anywhere can get an online second opinion from a Cleveland Clinic specialist through our MyConsult service. For more information, go to clevelandclinic.org/myconsult, email eclevelandclinic.org, or call 800.223.2273, ext. 43223. Request Medical Records

216.444.2640 or 800.223.2273, ext. 42640 Track Your Patients’ Care Online

Cleveland Clinic offers an array of secure online services that allow referring physicians to monitor their patients’ treatment while under Cleveland Clinic care, as well as access test results, medications, and treatment plans. my.clevelandclinic.org/online-services

DrConnect (online access to patients’ treatment progress while under referred care): 877.224.7367; [email protected]

MyPractice Community (affordable electronic medical records system for physicians in private practice): 866.320.4573

eRadiology (teleradiology consultation provided nationwide by board-certified radiologists with specialty training, within 24 hours or stat): 216.986.2915; [email protected]

Medical Records Online

Patients can view portions of their medical record, receive diagnostic images and test results, make appointments, and renew prescriptions through MyChart, a secure online portal. All new Cleveland Clinic patients are automatically registered for MyChart. clevelandclinic.org/mychart Critical Care Transport Worldwide

Cleveland Clinic’s fleet of ground and air transport vehicles is ready to transfer patients at any level of acuity anywhere on earth. Specially trained crews provide Cleveland Clinic care protocols from first contact. To arrange a transfer for STEMI (ST-elevation myocardial infarction), acute stroke, ICH (intracerebral hemorrhage), SAH (subarachnoid hemorrhage), or aortic syndrome, call 877.379.CODE (2633). For all other critical care transfers, call 216.444.8302 or 800.553.5056. CME Opportunities: Live and Online

Cleveland Clinic’s Center for Continuing Education operates the largest CME program in the country. Live courses are offered in Cleveland and cities around the nation and the world. The center’s website (ccfcme.org) is an educational resource for healthcare providers and the public. It has a calendar of upcoming courses, online programs on topics in 30 areas, and the award-winning virtual textbook of medicine, The Disease Management Project. Clinical Trials

Cleveland Clinic is running more than 2100 clinical trials at any given time for conditions including breast and liver cancer, coronary artery disease, heart failure, epilepsy, Parkinson disease, chronic obstructive pulmonary disease, asthma, high blood pressure, diabetes, depression, and eating disorders. Cancer Clinical Trials is a mobile app that provides information on the more than 100 active clinical trials available to cancer patients at Cleveland Clinic. clevelandclinic.org/cancertrialapp.

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Resources

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http://my.clevelandclinic.org/professionals/referring.aspx?utm_campaign=refer123-url&utm_medium=offline&utm_source=redirect

http://my.clevelandclinic.org/online-services/myconsult.aspx?utm_campaign=myconsult-redirect&utm_medium=offline&utm_source=redirect

http://my.clevelandclinic.org/online-services/myconsult.aspx?utm_campaign=myconsult-redirect&utm_medium=offline&utm_source=redirect

http://my.clevelandclinic.org/online-services

http://my.clevelandclinic.org/online-services/mychart.aspx?utm_campaign=mychart-url&utm_medium=offline&utm_source=redirect

http://www.clevelandclinicmeded.com/

http://my.clevelandclinic.org/services/cancer/clinical-trials-research?utm_campaign=cancertrialapp-url&utm_medium=offline&utm_source=redirect

mailto:eclevelandclinic.org





Healthcare Executive Education

Cleveland Clinic has programs to teach people from outside the organization how it operates a major medical center. The Executive Visitors’ Program is an intensive 3-day behind-the-scenes view of the Cleveland Clinic organization for the busy executive. The Samson Global Leadership Academy is a 2-week immersion in challenges of leadership, management, and innovation taught by Cleveland Clinic leaders, administrators, and clinicians. Curriculum includes coaching and a personalized 3-year leadership development plan. Learn more at clevelandclinic.org/executiveeducation. Consult QD Physician Blog

A singular blog for physicians and healthcare professionals from Cleveland Clinic. Discover the latest research insights, innovations, treatment trends, and more for all specialties. Join the conversation: consultqd.clevelandclinic.org. Social Media

Cleveland Clinic uses social media to help caregivers everywhere provide better patient care. Millions of people currently like, friend, or link to Cleveland Clinic social media — including leaders in medicine.

Facebook for Medical Professionals facebook.com/CMEclevelandclinic

Follow us on Twitter @cleclinicMD

Connect with us on LinkedIn Clevelandclinic.org/Mdlinkedin


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Notes

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Measuring Outcomes Promotes Quality Improvement

This project would not have been possible without the commitment and expertise of a team led by Mikkael Sekeres, MD, Mary T. Cusick, Alicia M. Redden, and Dennis S. Urbanek.

Graphic design and photography were provided by Cleveland Clinic’s Center for Medical Art and Photography.

© The Cleveland Clinic Foundation 2015


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15-OUT-350


2014 Outcomes


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