2015 ancer Program Report · 2018-12-11 · 2015 Annual ancer Program Report Page 3 HAIRMAN’S...

2015 Cancer

Program Report

2015 Cancer

Program Report

Incorporating a statistical summary of

the 2014 cancer registry data.

Schneck Medical Center

INDEX

Chairman’s Message 3

Cancer Committee 4

Screenings, Support & Education 5

Cancer Registry Report 6

Schneck Data 7

Perspective 9

Lung Cancer Analysis 10

Nurse Navigation Update 14

Directory of Terms 14

Palliative Care Program 15

Schneck Medical Center (812) 522-2349

Toll Free (800) 234-9222

Cancer Services Center (812) 522-0480

Cancer Registry (812) 522-0475

Screening Information Line (812) 522-0477

Community Wellness (812) 523-5861

Diagnostic Imaging (X-Ray) (812) 522-0144

Diagnostic Laboratory (Lab) (812) 522-0152

Home Services & Hospice (812) 522-0460

Nutrition Services (812) 522-0148

Pain Center (812) 524-4253

Patient Services (812) 522-0440

(Social Work, Case Management, Discharge Planning)

Psychological Services (812) 522-5739

Rehab Services (812) 522-0177

Schneck Foundation (812) 524-4244

Smoking Cessation Classes (812) 522-0401

Wound Care (812) 522-0177

The vision of the Cancer Program at Schneck Medical Center is to be the provider of choice for cancer care in our community. Our mission is to provide excellence in prevention, diagnosis, and treatment throughout the continuum of cancer care. Schneck Medical Center’s Community Cancer Program is based on the standards prescribed by the American College of Surgeons, Commission on Cancer (ACoS, CoC). Schneck is accredited with Commendation by the ACoS, CoC. The CoC recommends that this program publish an annual report. A time lag is caused by the length of time which may occur between diagnosis and first course of treatment and the time required for generation of data.

SERVICE DIRECTORY

2015 Annual Cancer Program Report

CHAIRMAN’S MESSAGE The Cancer Center at


again succeeded in providing

excellent care to the

patients of Jackson and its

surrounding counties in

2015. This was facilitated by

the strong leadership of Dr.

Dolores Olivarez, our full-

time medical oncologist. Dr. Higinia Cardenes

joined us this year as the cancer center’s full-time

radiation oncologist, adding her expertise and

drive to our talented staff. Dr. Amanda Dick

continued to serve as our cancer liaison physician.

Dr. LeAnn Stidham also continued as our

radiologist and Dr. Whitler as our pathologist.

Anita Collins, a nurse practitioner, joined the

cancer center this year with dedication to the

Palliative Care program.

As cancer treatment requires the most up-to-date

innovations and technology, the Schneck Cancer

Center met this challenge by transitioning to

electronic medical records. This allowed the vital

chemotherapies and other orders to be entered

electronically, improving patient safety. We also

purchased a new nasopharyngeal scope to

visualize and aid in the treatment of head and

neck cancers. In addition to these updated

technologies, we began a research project

involving an enhanced treatment process called

photodynamic therapy. These cases are being

discussed in the context of our “All Things Chest”

cancer conference which served to augment our

continuing breast conferences with the addition

of lung cancer cases.

Lynda Richey, an experienced nurse at the

cancer center, has continued in the role as our

Patient Navigator. This role serves to guide the

patient through the emotional and

overwhelming terrain on their path to diagnosis

and treatment, and we continued to solidify this

process with improved treatment plans and

communication goals. In conjunction with this

process, the cancer center has a more cohesive

survivorship care plan that communicates to the

patient expectations once treatment is

completed.

The Schneck Cancer Center continues to flourish

in 2015 as the incredible staff and innovative

technologies aid us in marrying art and science

to provide excellent cancer care.

Grant J. Olsen, M.D.

2014 Distribution by County Schneck Medical Center Total Analytic Cases 220

Schneck serves Jackson County as well as

many surrounding counties in Indiana.

Jackson 147 Jennings 38 Scott 17 Bartholomew 6 Rush 3

Lawrence 2 Washington 2 Clark, Dubois, Greene, Harrison, and Jefferson 1 each


CANCER COMMITTEE The Cancer Committee is comprised of physicians and other healthcare professionals dedicated to providing the community with state-of-the-art cancer control efforts in prevention, early diagnosis, pre-treatment evaluation, staging, treatment, rehabilitation, and surveillance. The Committee provides leadership to plan, initiate, stimulate, and assess all cancer-related activities at Schneck. Members include:

Sally Acton, RN, BSN, OCN, MSM, Director, Cancer & Palliative Care Services (Cancer Program Administrator) Aaron Banister, PhD, HSPP, Mental Health & Wellness (Psychosocial Services Coordinator)

Donna Butler, MSN, ANP-BC, OCN, ACHPN, FAAPM, Palliative Care

Higinia Cárdenes, M.D., Ph.D., Radiation Oncologist

Debbie Clontz, RN, BSN, OCN, Oncology Nurse, Cancer Services

Leighana Crenshaw, MSW, LSW, Case Manager, Patient Services

Tammi Covert, OTR, Rehab Coordinator, Rehab Services

Amanda Dick, M.D., General Surgeon (ACoS Cancer Liaison Physician)

Sherry Dowling, CTR, Cancer Registrar, Cancer Services (Cancer Conference Coordinator)

Vicki Johnson-Poynter, MSN, RN, NE-BC, CSSBB, VP of Nursing Services and Chief Nursing Officer

Suzie McDonald, RN, BSN, MHA, Nurse Manager, Hospice Services

Dolores Olivarez, M.D., Medical Oncologist (Clinical Research Representative)

Grant Olsen, M.D., Hospitalist (Chairman)

Lynda Richey, RN, BSN, OCN, Oncology Nurse and Nurse Navigator, Cancer Services (Community Outreach Coordinator)

LeAnn Stidham, M.D., Diagnostic Radiologist

Ann Wenderoth, Coordinator, Health Initiatives, Great Lakes Division, American Cancer Society

J. Wesley Whitler, M.D., Pathologist (Quality of Cancer Registry Data Coordinator) Suki Wright, MSM, CSSBB, Director, Organizational Excellence and Innovation (Quality Improvement Coordinator)


COMMUNITY OUTREACH

Lynda Richey, Community Outreach Coordinator, monitors outreach activity, assuring that materials and staff are available for screening and educating the community. She reports these events to the Cancer Committee.

Screenings Early detection is the key to finding cancer in an early stage, thus providing a better chance for cure. Screenings can detect cancers in early stages, before symptoms would prompt a physician office visit. Schneck Medical Center provided the following screenings:

ColoCare, a test for detecting blood in the stool, was distributed for colon cancer screening at numerous health events.

Skin cancer screenings were held by a local dermatologist at the Cancer Center. Prostate cancer screenings were held in September by Dr. McAleese at the Cancer Center. Breast health screenings were held in May and September; a cervical screening was included. Oral screening was performed by Dr. Hiester-Stout at the community health fair. CT lung cancer screening is available through Schneck Diagnostic Imaging.

Public Education Public education is provided through many venues. Professional staff of the Schneck Cancer Center provides information about prevention, detection, and good health habits to various community organizations. In addition, instruction and literature about various cancer topics are provided at community events.

Support Psychological services and social workers are available to provide emotional support and assistance with community resources throughout the disease process. Other venues for support include the following:

Research Computers with internet access are located in our Resource Center with easy access to the National Cancer Institute and clinical trials. Patient tracking of those participating in clinical trials is being done by the cancer center staff.

Lynda Richey, RN, BSN, OCN

Community Outreach Coordinator

Cancer support group Leukemia & Lymphoma support group Fresh Start Smoking Cessation program Nutritional counseling Genetic testing and counseling through referral Cancer navigation program

Grief counseling Free wig bank (ACS) Look Good Feel Better program (ACS) Road to Recovery (ACS) Reach to Recovery (ACS) Palliative Care Team


SCHNECK CANCER REGISTRY SUMMARY

A follow-up rate of 80% for all analytic patients is required by the ACoS, CoC.

SCHNECK CANCER PATIENTS ENTERED IN THE LAST FIVE YEARS SUMMARY

A follow-up rate of 90% for analytic patients entered in the last five years is required by the ACoS, CoC. Calculations based on September 2015 follow-up. Cancer Registry reference date: January 1, 1986

Total number of cases in registry since 5894

Total number of cases requiring follow-up 4412

Less number of deceased cases 2846

Total number of cases followed 1566

Cases with current follow-up 1289

Total follow up rate 93.7%

Total number of cases in registry last five years 869

Total number of cases requiring follow-up 869

Less number of deceased cases 358

Total number of cases followed 511

Cases with current follow-up 478

Total follow up rate 95.6%

Quality of the Cancer Registry is monitored and reported quarterly to the Cancer Committee. This includes monitoring of case finding, accuracy of data collection and staging, abstracting timeliness (RQRS), follow-up, and data reporting.

As a pathologist, Dr. Whitler also oversees the quality of the pathology reporting system.

J. Wesley Whitler, M.D. Quality of Registry Data

Coordinator

Cancer Registrars monitor, report, and analyze all types of cancer diagnosed or treated in an institution. Maintaining a cancer registry ensures that health officials have accurate and timely data for treatment, research,

and educational purposes. Fundamental research on the epidemiology of cancer is initiated using the accumulated data reported to central (state/national) registries.

Our Cancer Program is accredited by the American College of Surgeons, Commission of Cancer, CoC, with commendation level of compliance on all required standards, therefore receiving the CoC Outstanding Achievement Award.

Our registry has implemented the CoC Rapid Quality Reporting System (RQRS) to actively monitor and assess compliance with several National Quality Forum endorsed measures to support efforts in maintaining a high-level of evidence-based cancer care.

Currently, I am honored to serve as treasurer of the Indiana Cancer Registry Association. As a member of the National and State Cancer Registrars’ Associations, I have the opportunity to interact with registrars across the nation and to stay current with required changes in coding documentation.

Please take a few moments to look over the graphs on the following pages. While the cancer registry compiles the data, this is truly a reflection of everyone working together to care for our patients.

Sherry L. Dowling, CTR, Cancer Registrar

CANCER REGISTRY REPORT


SCHNECK CANCER CASES BY PRIMARY

0 5 10 15 20 25 30 35 40 45

Other/Ill Defined/Unknown

Tongue

Ovary

Leukemia

Melanomas

Soft Tissue (incl. head)

Liver

Cervix Uteri

Multiple Myeloma

Larynx

Hodgkin's disease

Kidney and Renal Pelvis

Stomach

Rectum and Rectosigmoid

Thyroid Gland

Corpus Uteri

Pharynx other bucca

Non-Hodgkin's Lymphoma

Pancreas

Urinary Bladder

Prostate

Colon

Breast

Lung & Bronchus

Analytic

Non-Analytic

*Other includes sites with frequency of two or less.

Breast cancer is our top analytic site, followed by lung, colon, prostate, and urinary bladder cancers. Lung cancer is highlighted later in this report by Dr. David Wilson. Our top sites coincide with the top sites nationally.

2014 Frequency by Primary Site 261 Total: Analytic 220, Non-Analytic 41

35/8

36/3

18/7

22/0

11/10

12/1

10/3

7/1

8/0

2/1

5/0

5/0

3/0

2/1

4/0

1/2

3/0

8/1

4/3

6/0

6/0

4/0

4/0

4/0


SCHNECK CANCER CASES BY PATIENT DISTRIBUTION

6

14 15

18

37

128

41

19

14

25

11

0

5

10

15

20

25

30

35

40

45

In Situ I II III IV N/A or Unknown

Male Female

1

8

23

31

23

14

24

10

22

3230

17

3

0

5

10

15

20

25

30

35

30-39 40-49 50-59 60-69 70-79 80-89 90-99

Male Female

2014 Age by Gender at Diagnosis 220 Analytic Cases: 102 male, 118 female

2014 AJCC Stage by Gender at Diagnosis 220 Analytic Cases: 102 male, 118 female

Cancer incidence rises with age, with most cases affecting adults in mid-life or older. Females

predominated at 118 of the total 220 cases.

The stage of cancer at diagnosis refers to the extent of cancer growth or spread. Detecting cancer in an earlier stage can often lead to a higher survival rate. The majority of females were diagnosed at Stage II or earlier.


PERSPECTIVE Lung cancer is the leading cause of cancer death in the U.S. and as such presents tremendous challenges. But, the opportunity for improved diagnosis and care is great. With this backdrop of challenges and opportunities, Schneck implemented new technology for lung cancer detection and therapy in late 2014. But first, let’s detail the

lung cancer experience at Schneck for 2014.

There were 36 cases of Lung cancer in 2014. Demographically 25% occurred at less than 60 years of age. The sixth decade of life was the most common for incident lung cancer at 41.7%. 22.2% occurred in the age range of 70-79 and only 11.1% greater or equal to the age of 80.

This roughly mimics the U.S. experience as a whole. Detection strategies with lung cancer screening should improve earlier disease recognition. Presumably, this would lower the age incidence. The National Lung Cancer Screening Trial defined a screening benefit with low dose Chest CT scans that promises to aid in early detection of lung cancer. Many insurers and CMS now cover low dose Chest CT for lung cancer screening.

Stage remains the most important predictive factor in lung cancer outcomes, and 26 patients presented at Stage III and IV disease. This is actually better than national data. Stage III and IV disease at Schneck is at 67%, while nationally this number is closer to 85%. 10 cases presented at Stage I and II which carry a much better prognosis. Lung cancer survival remains at only 15% nationally. This is defined as cancer free status at five years from diagnosis.

The location of lung cancer has slowly moved further to the periphery and away from the central airways. The 2014 Schneck experience shows this to be accurate. Only two cases, or 5.6%, were in main airways (trachea/Main stem bronchi). Upper lobe predominance was present at 55.5%. This is also nationally and historically the case. Lower lobe disease occurrence was less at 19.4%.

Treatment regimens at Schneck were multi-modality with combinations of surgical, chemotherapeutic, and radiation therapy. No one approach predominated. This is very common and expected given the complex nature of lung cancer. Eleven patients in the cohort chose no therapy or were beyond the point of tolerating therapy. Again, this is a tragic malignancy and detection at a late stage often limits therapy options.

Challenging diseases also create enormous opportunities. Schneck embraced opportunities to improve lung cancer detection by investing in the Veran Navigational Bronchoscopy/Percutaneous Biopsy System in late 2014. Combined with Transthoracic Needle Biopsy with CT guidance, it gives Schneck the ability to have three non-surgical methods to detect earlier stage lung cancer. This has also lead to re-thinking the Cancer Nurse Navigator role to include identification of abnormal chest x-rays and chest CTs. The hope of early detection is promising. Surgery is the most curative therapy. But, surgery is best with early stage disease. Lung cancer surgical case volumes at Schneck began to rise in late 2014 largely due to identifying early stage disease.

Newer therapy modalities were embraced in 2014 as well. Schneck has implemented the only Photodynamic Therapy (PDT) program for lung cancer treatment in the state. Patients with lung cancer have better therapeutic outcomes if tumors occluding airways are destroyed. Many methods exist to eradicate airway tumors, but PDT with Laser excitation of a cytotoxic photophryn drug is reemerging as a preferred method because it is less traumatic to the patient. This PDT program has treated many patients to improve their ability to undergo chemotherapy and radiation therapy. The future of lung cancer detection and treatment remains optimistic.

David S. Wilson MD, FCCP


3

6

15

8

31

0

5

10

15

20

40-49 50-59 60-69 70-79 80-89 90-99

SCHNECK NON-SMALL CELL CARCINOMA CANCER DATA

2, 5%

20, 56%

1, 3%

7, 19%

6, 17%Main Bronchus

Upper lobe,lung

Middle lobe,lung

Lower lobe,lung

Unknown

46 6

20

0

5

10

15

20

25

I II III IV

The sixth decade of life was the most common for incidence, 41.7%, of lung cancer.

Twenty six patients, or 67%, presented at Stage III and IV. This is better than the national data in which closer to 85% of patients present at Stage III or IV.

2014 Age at Diagnosis 36 Analytic Lung Cases

2014 AJCC Stage at Diagnosis 36 Analytic Lung Cases

2014 Topography at Diagnosis 36 Analytic Lung Cases

More than half, 55.5%, of our patients presented with cancer in the upper lobe.

11, 31%

3, 8%

3, 8%

5, 14%

9, 25%

2, 5%

1, 3% 2, 6%No Treatment

Surgery alone

Chemotherapy alone

Radiation alone

Radiation / Chemo

Surgery / Chemo

Surgery / Radiation

Surgery / Radiation / Chemo

2014 Treatment at Diagnosis 36 Analytic Lung Cases

Treatment at Schneck follows national standards. Unfortunately, due to late stage diagnosis, patients may not be able to tolerate therapy and may opt to forgo treatment due to the progression of cancer.


NON-SMALL CELL CARCINOMA CANCER NCDB COMPARATIVE ANALYSIS

1

7

20

29 29

13

11

5

16

3032

15

1

0

5

10

15

20

25

30

35

30-39 40-49 50-59 60-69 70-79 80-89 90+

SM C

NCDB

107

30

51

2

25

8

22

37

8

0

10

20

30

40

50

60

I II III IV Unknown

SMC

NCDB

Percentage of Cases, Age at Diagnosis* Schneck Medical Center & NCDB 2003-2013 Total Analytic Cases: 247 Schneck, 1,320,025 NCDB

Percentage of Cases, AJCC Stage at Diagnosis* Schneck Medical Center & NCDB 2003-2013 Total Analytic Cases: 247 Schneck, 1,320,025 NCDB

Incidence of cancer increases with age, with most cases affecting adults in mid-life or older. Schneck’s age groups at initial diagnosis track national trends closely.

The stage of cancer at diagnosis refers to the extent of cancer growth or spread. Data shows the majority of lung cancers are diagnosed in the later stages of disease .


NON-SMALL CELL CARCINOMA CANCER ANALYSIS (CONT.)

5.7

26.3

0.8 2.4

29.2

13.4

2.4 1.6

18.220.2

14.2

1.1

4.9

21

13

2.92.4

20.3

0

5

10

15

20

25

30

35

Surge ry Only RadiationOnly

Surgery &Radiation

Surgery &Chemo

Radiation &Chemo

Chemo Only Surgery,Radiation &

Chemo

OtherSpecified

Therapy

No FirstCourse of

Treatment

SMC NCDB

Percentage of First Course of Treatment* Schneck Medical Center & NCDB 2003-2013 Total Analytic Cases: 247 Schneck, 1,320,025 NCDB

Schneck’s first course of treatment very closely matches national statistics. Many patients only require surgery. Depending upon the stage of disease, national guidelines recommend additional treatment.

* Comparison data provided by 2015 National Cancer Data Base (NCDB) / Commission on Cancer (CoC) as of Tuesday, October 20, 2015.

RESEARCH Schneck joined Indiana University in a lung cancer screening research study, “Measuring Stigma and Health Beliefs about Lung Cancer Screening in Long-Term Smokers.” This study should help us better understand factors that may influence screening behavior and help us identify effective recruitment methods.


NCBD, CP3R Performance Rate Comparisons*

NON-SMALL CELL CARCINOMA CANCER ANALYSIS (CONT.)

2011 2012 2013

SMC IN NCDB SMC IN NCDB SMC IN NCDB

L no Surgery—Surgery is not the first

course of treatment for cN2, cM0 lung

cases.

100% 91.6% 89.9% 100% 91.3% 90.8% 100% 93.8% 91.6%

LCT—Systemic chemotherapy is

administered within 4 months to day

preoperatively or day of surgery to 6

months postoperatively or it is

considered for surgically resected

(pN1) and (pN2) NSCLC.

100% 89.1% 85.6% N/A 90.9% 90.3% N/A 91.5% 88%

National performance measures are used to measure treatment practices. Schneck monitors and compares data in an effort to maintain a high-level of cancer care. Schneck’s performance rate exceeds others across the nation.

Schneck Medical Center is leading the way for improved cancer care for patients in our community. As Dr. Wilson outlined earlier in this report, unique therapies, including photodynamic therapy and navigational bronchoscopy, are now being offered as

part of our approach to treating lung cancer.

Current treatment guidelines for lung cancer recommend consideration of chemotherapy for lymph node positive (pN1 and pN2) non-small cell lung cancer within 4 months pre-operatively or 6 months post-operatively. In 2011, every patient treated at Schneck Cancer Center met that guideline. Additional goals include appropriate selection of patients for surgical treatment. Recommendations are for non-surgical treatment as the first course for node positive non-small cell

lung carcinoma. We met that guideline 100% of the time. Surgical treatment of lung cancer here at Schneck is a relatively new occurrence. Optimal outcomes and appropriate surgical therapy will remain a focus as we continue to treat more lung cancer patients here at Schneck.

Cancer prevention through education of both patients and providers as well as preventative care measures will help reduce the incidence of cancer. Community outreach and education regarding causes of lung cancer and who is appropriate to seek screening tests will be a big focus for the coming year. Timely diagnoses and nationally recognized care are paramount to potential cure and faster return to their lives and loved ones.

Amanda Dick, M.D. Cancer Liaison Physician


NURSE NAVIGATION

DIRECTORY OF TERMS

AJCC Stage of Diagnosis: Depending on the TNM classifications or anatomic extent of disease, cases are placed into “Stage Groupings” or levels of disease. Early disease is classified as Stage 0 with the stage increasing with the amount of disease present.

Analytic: Cases diagnosed and/or treated initially at Schneck Medical Center since the Cancer Registry reference date of January 1, 1986.

Non-Analytic: Cases diagnosed and/or treated elsewhere; cases diagnosed and treated at Schneck Medical Center prior to the Cancer Registry reference date of January 1, 1986, and which have returned with recurrent disease during the current year; cases diagnosed at autopsy; or known cases diagnosed and initially treated in a staff physician’s office.

Survival: Observed rate is the calculation made without correcting for other types of mortality.

OUR NURSE NAVIGATOR HELPS PATIENTS THROUGH

A COMPLEX CANCER DIAGNOSIS.

DEDICATED TO GIVING PATIENTS MORE CONTROL OF THEIR CANCER

As our Cancer Center Nurse Navigator, Lynda Richey, RN, BSN, OCN, focuses

on helping each patient after their diagnosis no matter what type of cancer it

is. This includes providing education to patients, giving emotional support, and

connecting them to crucial resources in the surrounding area. With more than

25 years of experience in cancer care, Lynda helps our cancer patients and

their families move through the healthcare process from diagnosis through

treatment and into survivorship. Lynda continues to stay in contact with

physician offices, providing treatment plans and updates as needed. She

focuses on addressing the barriers of cancer patients on an individual level

using interdisciplinary resources as appropriate.

For referrals, please call 812-523-5210.


PALLIATIVE CARE PROGRAM

Rev. Stephen Barrett has been a Hospice/Palliative Care Chaplain at Schneck since 2011. A pastor for twelve years, he is a member of the Association of Professional Chaplains.

Aaron Banister, Ph.D., is a licensed counseling psychologist specializing in health psychology, cognitive behavioral therapy, and anxiety-based disorders. He has been with Schneck since 2013.

Donna Butler, MSN, ANP- BC, OCN, ACHPN, FAAPM, has been focusing on palliative care since 2003. She is certified in oncology, advanced hospice, and palliative care nursing and a fellow of the American Academy of Pain Management.

Anita Collins, MSN, FNP-BC, has been a nurse practitioner since 2008, focusing on pain management. She recently joined palliative care. She has worked at Schneck Medical Center since 1991.

Leighana Crenshaw, MSW, LSW, has been a social worker since 1994, joining Schneck in 2000. She has been active in the Palliative Care program since 2011. David Hartung, DO, is the medical director of the Palliative Care Program. Dr. Hartung joined Schneck’s medical staff in 2005. He is board certified in family medicine.

Schneck’s palliative care team will work with primary care physicians to combine pain and symptom

control in all aspects of our patient’s care plan.

Colette Mills, RN, BSN, CHPN, has been an RN since 1989. With Schneck Hospice since 2008, she has served on the Palliative Care team since 2011. She is a certified Hospice and Palliative Care nurse.

Dana Prieto, RN, BSN, is an experienced nurse with training in pediatrics, medical/surgical, ICU and oncology. She become an RN in 2007, joining Schneck in 2010. Dana has served on the Palliative Care team since 2012.

PALLIATIVE CARE PROGRAM UPDATES

Since beginning the program in 2011, Donna Butler

has expanded Schneck’s program to encompass a

wide range of patients. The goal of the program is

to improve quality of life both for the patient and

their family by addressing goals of care, life goals,

and advance care planning. Donna has mentored

regional programs, helping other organizations

initiate or improve their palliative care programs.

Performance improvement is continually

monitored and demonstrates improved symptom

management.

Sally Acton, Cancer Center Director, spoke about

the program in November at the Center to

Advance Palliative Care. In her poster

presentation, Sally highlighted Schneck’s

commitment to advancing the services provided at

Schneck by training more nurse practitioners. This

strategic initiative allowed for Anita Collins to join

the palliative care program in 2015.

2015 ancer Program Report · 2018-12-11 · 2015 Annual ancer Program Report Page 3 HAIRMAN’S...

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