2019 Cancer Program Annual ReportWith Statistical Registry Data from 2018

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Letter from the ChairMartha Hosford, MDChairperson, Cancer Committee

The mission of the Union Hospital Cancer Program is to provide the highest quality of Oncology healthcare to the Cecil County community. The Oncology Services offered by Union Hospital support this mission through a multi-disciplinary team of physicians, researchers, genetic counselors, nurses, administrators and other healthcare professionals. Together they provide excellent care addressing everything from cancer prevention to diagnostic work-up, from cutting edge therapies to palliative care. While striving to achieve this mission, we are pleased to present to you the 2019 Cancer Program Annual Report recognizing the hard work and many achievements of the Union Hospital Cancer Program.

I would like to provide you with a brief overview of our comprehensive services and present statistics regarding cancer patients diagnosed and treated at our facility. At Union Hospital, we provide cancer care for adults in the fields of Hematology/Oncology, Radiation Oncology, Surgery and Palliative Care. With the inclusion of non-analytical data, the top 4 sites were breast, lung, prostate and colorectal.

At Union Hospital Cancer Program, we provide dynamic educational conferences, including tumor boards with patient-centered prospective discussion of diagnosis and treatment options by a team of multidisciplinary physicians. In accordance with the AJCC (American Joint Committee on Cancer) standards, all cases presented include clinical and pathological staging, followed by discussion of treatment plan.

Patients have been prospectively discussed in our 2019 tumor board meetings.

Our cancer program is committed to a patient-centered approach — as evidenced by the multitude of outreach and cancer prevention activities coordinated by the Union Hospital cancer program staff.

Our program is nationally certified by the Commission on Cancer and the National Program for Breast Centers.

Quite an impressive year for 2019. It is an honor and privilege to serve as Chairperson of the Cancer Committee. We pledge to provide the highest level of cancer care which our Cecil County community deserves. We try never to forget that each person treated at our facility deserves personalized, patient-centered attention. I cordially invite you to review our Annual Report.

Martha HosfordMartha Hosford, MDMedical OncologistChairperson, Cancer Committee

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Table of ContentsBreast Health Center at Union Hospital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-6Cancer Registry Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7-9Multidisciplinary Cancer Conferences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10-12Oncology Nursing 2019 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-14Oncology Support Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Palliative Care Team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Social Worker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Resource Center . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Union Hospital Cancer Committee Members for 2019Cancer Committee Chair:M. Hosford, MDF. Rahman, MD (Alt)

Diagnostic Radiologist:D. Nussbaum, MDH. Yeung, MD (Alt)

Pathologist:B. Kumar, MDA. Darko, MD (Alt)

Surgeon:E. Lowe, MDJ. Sausville, MD (Alt)

Medical Oncologist:F. Rahman, MDM. Hosford, MD (Alt)

Radiation Oncologist:M. Dzeda, MDS. Shah, MD (Alt)

Cancer Liaison:J. Nunez, MDN. Hasan, MD (Alt)

Cancer Program Administrator:E. Money, BSN, RN, OCNK. Hanna, MBA, BSN, RN, OCN (Interim)

Oncology Nurse:D. Payne, BSN, RNF. Crum, RN, OCN (Alt)

Social Work:D. Brooks, LMSWS. Moorefield, MSW, LCSW-C (Alt)

Certified Tumor Registrar:C. Dogbe-Ullery, CTRE. Weber, CTR (Alt)

Palliative Care Professionals:B. McKenzie, NPA. Manning, NP

Genetics Professional:K. Bisordi, MS, MGC, CGC

Cancer Conference Coordinator:J. Kidd, BA

Quality Improvement Coordinator:S. Schooley, BSN, RNP. Ives, BSN, RN

Cancer Registry Quality Coordinator:C. Dogbe-Ullery, CTRE. Weber, CTR

Community Outreach Coordinator: J. Kelly, BA, MPH-HPD. Payne, BSN, RN (Alt)Clinical Research Representative:D. Kamara, Research Quality Coordinator

Psychosocial Service Coordinator:D. Brooks, LMSWS. Moorefield, LCW-C (Alt)

Nutrition Services:C. Bruce, RDJ. Noll, RD (Alt)

Pharmacist:T. McQuaide, RPHJ. Khov, RPH (Alt)

Rehabilitation Services:C. OverstreetJ. Worton (Alt)

Pastoral Care:G. ManuelM. Truman (Alt)

ACS Representative:S. Kelly

Breast Health Center:S. Stewart, MPH, RN, AE-C

Corporate Compliance:R. Emrick, OHCC, RHIA, BS, CCSM. Prince (Alt)

Imaging:G. Brunson

Public Health:J. Conley-Mahan, RN

Marketing:K. McKinneyT. Collins (Alt)

Patient Representative:L. StahlD. Owens (Alt)

Administration:R. Geracimos, MD, CMOS. Kelley, CNO (Interim)

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Breast Health Center at Union Hospital

Under the talented and insightful leadership of Medical Director Elizabeth P. Lowe, MD, the Breast Center at Union Hospital is fully accredited by the National Accreditation Program for Breast Centers (NAPBC). The Breast Health Center at Union Hospital was the first breast center in Maryland to be accredited by the NAPBC in 2009 and received another full three-year accreditation in 2018. All 29 standards were met.

Accreditation by the NAPBC recognizes those centers that have voluntarily committed to providing the highest level of quality for breast care. The Breast Health center performs 2D and 3D tomosynthesis screening, mammography, diagnostic mammography, breast ultrasound, breast biopsy and bone density testing.

The Breast Health Center medical and professional team includes:

• Radiologist with extensive experience in breast imaging

• Medical and radiation oncologists specializing in breast disease

• Radiology technologists certified in mammography

• Certified breast health RN navigators

• Surgeons, including reconstructive surgeons

• Family practitioners, physical therapists, dietitians and counselors

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BREAST PROGRAM LEADERSHIP QUALITY REVIEWMRI BIOPSY CASES RECOMMENDED

NEW SERVICE OFFERED AT UNION HOSPITAL INITIATED I/9/19 TO 11/30/19

14 CASES RECOMMENDED (all from Union Hospital Breast Health Center)

2 canceled at time of biopsy due to area not able to clearly identify lesion1 change in recommendation after further review second radiologist (Clinical Lead)1 DCIS

3 atypical 1 Non-concordant 6 benign

ACR PRACTICE PARAMETER FOR THE PERFORMANCE OF MAGNETIC RESONANCE IMAGING-GUIDED BREAST INTERVENTIONAL PROCEDURES

https://www.acr.org/-/media/ACR/Files/Practice-Parameters/MR-Guided-Breast.pdf

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A BREAST CENTER THAT ACHIEVES NAPBC ACCREDITATION HAS DEMONSTRATED A FIRM COMMITMENT TO OFFER ITS PATIENTS EVERY SIGNIFICANT ADVANTAGE IN THEIR BATTLE AGAINST BREAST DISEASE.

FOR MORE INFORMATION ABOUT THE NATIONAL ACCREDITATION PROGRAM FOR BREAST CENTERS, VISIT THEIR WEBSITE AT WWW.ACCREDITEDBREASTCENTERS.ORG

Keeping up to date on breast health issues and techniques is important to promoting prevention and good breast health practices. To educate the public about breast disease, we support and teach at local programs, churches and organizations. The Breast Health Center works in collaboration with the Cecil County Health Department to meet the needs of the uninsured, underinsured and minority populations.

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Cancer Registry Report The Union Hospital Cancer Registry has maintained a CoC (Commission on Cancer) approved cancer program since 2002 that benefits physicians, patients and hospital staff as well as the community it serves. Our registry works with the Cancer Committee to assure that all requirements for an accredited cancer program are maintained.

The registry also plays a vital role in improving early detection, prevention and the treatment of cancer. Our primary role is to collect data, both demographic and clinical, beginning at diagnosis and continuing throughout the cancer patient’s lifetime. This collection is an invaluable tool in our fight against cancer.

Many Uses of Registry Data include:

• Diagnostic and treatment research• Calculation of survival rates• Submission of data to state and national databases for comparison• Development of knowledge of staff, patients and the public through education• Evaluation of the effectiveness of current treatment modalities• Treatment planning at Multidisciplinary Cancer Conferences

Analytic Cases include:

• Patients whose cancers were diagnosed and initially treated at Union Hospital• Patients whose cancers were diagnosed at Union Hospital and initially treated elsewhere• Patients whose cancers were diagnosed elsewhere, but who received all or part of their

treatment at Union Hospital

Non-Analytic Cases include:

• Patients whose cancers were diagnosed and initially treated elsewhere and who present to Union Hospital for disease recurrence or persistence

• Patients whose cancers were diagnosed and initially treated elsewhere and have active cancer recurrent, metastatic or persistence and present for other medical conditions

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We follow approximately 4,453 analytic cancer patients in the registry.

Follow-up is conducted annually and throughout the lifetime of each cancer patient. Our overall follow-up rate is a strong 81.34%, well within the Commission on Cancer standard requirement. In 2018, our top four sites of newly diagnosed cases (analytic only) were breast (43), prostate (36), lung (32) and colorectal (17).

Resource: American Cancer Society. Cancer Facts & Figures 2018. Atlanta: American Cancer society; 2018, pg 4-5

Additional information collected by the registry includes demographic statistics for research. For instance, as demonstrated below, the gender totals are higher in the male population when compared to the American Cancer Society’s Cancer Facts & Figures Report.

Source: Oncolog 2019

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Additional information provided by the cancer registry shows the age of the cancer patients:

Source: Data pulled from the Union Hospital Registry, 11.25.2019

In many ways, the cancer registry is an essential partner to ensuring quality cancer care, while providing quality data to cancer committee and healthcare professionals. To learn more about the cancer registry, visit ncra-usa.org.

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Multidisciplinary Cancer Conferences

Cancer Conferences (Tumor Board) are a multidisciplinary educational activity that is planned and monitored by the Cancer Committee. Annually, the Cancer Committee establishes the frequency and format that facilitates prospective review of cancer cases and multidisciplinary involvement in the discussion. The cancer conference provides physicians with periodic updates on new developments in the diagnosis and treatment of various cancers. Physicians from Medical Oncology, Radiation Oncology, General Surgery, Pathology, Radiology and other specialties regularly attend and discuss treatment option and patient management of the cases presented.

In 2019 our cancer program presented two educational conferences: • Thyroid Cancer • Prostate Cancer

This year from January through November, our Cancer Conference presented 164 cases with 140 of them being analytical. This conference exceeded the CoC requirement for 2019.

Radiation TherapyRadiation Therapy is provided in the dedicated facility on the Union Hospital campus. Our center was built in 2015 and it has the latest technology, which ensures our patients get the very best treatment here in Elkton. Below is a list of services offered at Union Radiation Oncology:

• External beam radiation therapy (EBRT)• 3D Conformal radiation therapy (3D-CRT)• Intensity modulated radiation therapy (IMRT)• Volumetric modulated radiation therapy (VMAT)• Radiation therapy - Photons• Radiation therapy - Electrons

• CT Simulation• Conebaum CT-CBCT• Surface guided radiation therapy (SGRT)• Inage guided radiation therapy (IGRT)• Brachytherapy (Coming in spring 2020)

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Lung Nodule ClinicIn 2017, Union Hospital started a multidisciplinary Lung nodule clinic with a goal to provide a way to detect lung cancer earlier. In the 2019 Cecil County Needs assessment, an estimated 24.8% of adults reported smoking cigarettes in Cecil County in 2017. Again, this showed an increase from the last community needs assessment, which reported an estimated 24% of adult smokers in this age group. Nearly 27% of this group were between the ages of 25 and 64 which is the primary targeted age for low dose lung screening.

Year Patients receiving low dose CT screenings2016 1602017 1912018 2052019 180

*Totals for 2019 through November pending end of year accrual totals

Goal set by the Community Health Improvement Plan — By 2019, increase number of individuals receiving low dose lung CT screenings by 5% to increase awareness for lung cancer prevention.

From registry data reveals that the program established 2017 is showing to have improvement in diagnosis of stage I and II with a reduction in stage IV.

Year of Diagnosis

Alive Dead Male Female 0 I II III IV UNK Stage Totals

2014 8 36 23 21 0 5 4 11 23 1 44

2015 24 39 39 24 0 11 9 15 28 0 63

2016 26 38 33 31 1 15 3 14 31 0 64

2017 22 30 30 22 0 13 2 8 28 1 52

2018 19 13 18 14 0 7 1 6 18 0 32

2019 10 4 8 6 1 2 1 3 7 0 14 Source: 2019 Union Hospital Registry Data

Smoking Cessation Referrals

The Cancer Program works closely with the Tobacco Task Force, in an effort to help members of the community stop smoking.

2016 02017 1162018 582019 129

Source: Union Hospital Meditech Report 2019

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Clinical Trial Participation for 2018/2019The Cancer Program is dedicated to improving the lives of patients and families that we serve. This dedicated team of professionals understands that cancer research has been the driving force in producing higher survival rates and improved quality of care for adults with cancer.

At diagnosis, patients and caregivers are provided with up-to-date clinical research information and clinical trial treatment options for their specific type of cancer. In addition, they are afforded the opportunity to participate in any open clinical trials for their disease. The active clinical research group at Union Hospital helps to ensure our patients receive state-of-the-art treatment. In doing this, we make a difference in the future of cancer care.

In 2018: 11 patients enrolled in clinical trials out of 188 analytic cases, which was a total of 5.8% enrollment.

Genetics Trial Prostate Breast Lung Endometrial2 4 2 2 1

In 2019: 7 patients were enrolled into clinical trials from January through mid-December, with total analytic cases pending.

Lymphedema Community Outreach4 3

*January through mid-December

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Oncology Nursing 2019At Union Hospital, our adult oncology patients are cared for by a dedicated team of oncology nurses who have completed the Oncology Nursing Society Chemotherapy and Biotherapy course and receive extensive training in Oncology. There is an inpatient unit that focuses on oncology and one dedicated 10-chair outpatient infusion center in our facility. Union hospital boasts that out of 13 eligible Oncology RNs, 7 are nationally certified as OCN. This 54% certification rate exceeds the required rate for centers to have 25% of their Oncology RN staff certified. In 2019, all Oncology RNs completed annual competencies for medication and skills testing with a passing score of 100%.

Elizabeth Money, BSN, RN, OCN The Oncology Program Administrative Director is Elizabeth Money, BSN, RN, OCN. Beth has been in Oncology Nursing for 30 years and is dedicated to clinical excellence. As Program Administrative Director, she oversees outpatient infusion, clinical program development, community outreach, clinical trial enrollment and bioethics collaboratively with the Oncology Physician leadership. Their combined vision for Oncology is providing a comprehensive approach to cancer care focusing on the patient as an individual. In 2019, the State of Maryland awarded this leader the Governors Volunteer Service Certificate for

her community work with oncology patients.

Kerry D’Alassandro, BSN, RN The inpatient unit is overseen by Kerry D’Alassandro, BSN, RN. Kerry is dedicated to leading her nursing teams to provide not only excellent care, but also an excellent experience. The unit has 10 registered nurses who hold an active ONS chemotherapy/biotherapy provider card and have undergone extensive training.

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SYSTEM: PERFORMANCE:

QUALITY INDICATORS: THRESHOLD: PERIOD-Q4

Indicator:

Increase percentage of patients following through with recommendation for breast screening MRI

Data Source: Union Hospital Breast Center Data

Increase percentage by 5%

Result:

2019: 8.91% Improvement over baseline

Corrective Action:

Continue to educate patients and referring physicians. Monitor for improvement.

SYSTEM: PERFORMANCE:

QUALITY INDICATORS: THRESHOLD: PERIOD-Q4

Indicator:

Improve patient and RN staff perception of quality and effectiveness for outpatient infusion area education by altering the treatment schedule to allow for individual patient education prior to first day of treatment.

Data Source:Union Hospital Oncology Program Data

Improve Satisfaction rating by 5%

Result:

Patients report an improvement with a 19% improvement in satis-faction rating.

RN staff report a 75% improve-ment in satisfaction with the education process.

Corrective Action:

Due to small number of patients surveyed: Continue to evaluate education process and effectiveness to meet the needs of the population.

QI ProjectsThe function of a Quality Improvement measure is to monitor the need for quality improvement of a process or remediation of treatment provided. Evidence from experimental studies, not randomized control trials, supports the quality improvement measures. Quality Improvement Project measures are intended for internal monitoring of performance within the cancer program.

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Oncology Support ServicesOncology Navigation

Deborah Payne, BSN, RN

Breast Health Nurse Navigator

Susan Dewitt, MSN, RN, CN-BN

Breast Health Nurse Navigator

Leonella Moore, BSN, RN, CN-BN

Breast Health Nurse Navigator

In an effort to better serve the needs of Cecil County, the oncology navigator strives to eliminate barriers to quality care and ensure speedy, optimal delivery of appropriate services.

Over the past few years, Oncology Navigation has evolved into a service that supports patients in all phases of the treatment spectrum including: prevention, screening and early detection, diagnosis, treatment and palliative care. By tracking progress, providing check lists, facilitating communication and producing reminders, the navigation nurse is able to keep patients on track. The navigation program at Union Hospital has grown steadily and reported currently a total of 1,771 cancer patients/family encounters in 2018 and 1,554 encounters to date in 2019.

The Oncology Nurse Navigator assists with:• Meeting the patient wherever they are along the cancer care continuum to identify healthcare

disparities and barriers to care

• Increasing patient and family education and awareness about cancer and support services

• Encouraging self-efficacy with patients in communication, resources, advocacy and education

• Planning and implementation of cancer-related community outreach events

• The Breast Health Center has two nurse navigators who are specially trained in breast health

Clinical Cancer GeneticsIn 2017, a Telegenetics program was started under a collaborative agreement with University of Maryland. Patients meet with a Certified Genetics counselor in a private office on campus. A Registered Nurse from the Cancer Program facilitates the consult and results are sent to the referring physician.

Patient by year who have received Telegenetics at Union Hospital

2017 42018 202019* 47

Source: University of Maryland Genetics Department *Numbers are from January to December 2019

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Many complimentary services are provided by Union Hospital’s Palliative Care team, which includes two Nurse Practitioners, Social Worker and a Chaplain. Some of the services that may be provided by your Palliative Care team may include counseling with a Clinical Social Worker, Spiritual support provided by the Palliative Care Chaplin, as well as Healing Touch Massage provided by a certified practitioner.

Source: Billed Visit data from Union Hospital Billing Department

*2019 numbers as of November

Chapain Visits 2019

Individual Patients 885Total Patient Encounters 2660

Bedside Memorial Services 23Source: Cancer Program Data 2019

Gene Manuel, Palliative Care Chaplin

Brenda McKenzie, MSN, CRNP, NP-C

Amber Manning, DNP, CRNP, FNP-C

PALLIATIVE CARE TEAM

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Social WorkerAt Union Hospital, our Licensed Social Worker is an important part of our team addressing needs of patients in all areas of their lives. In the first 11 months of 2019, our Oncology Social Worker completed 742 patient encounters.

Psychosocial distress can arise in response to cancer-related factors such as diagnosis and cancer progression, pain and adverse effects of treatment. Psychosocial distress in patients with cancer may lead to non-adherence to treatment, poorer quality of life and may negatively impact survival, as well as increase treatment burden to the oncology team and health system. At Union Hospital, our goal is to treat the patient as a whole. Our Licensed Social Worker supports the process of Psychosocial Distress Screening for cancer patients at Union Hospital.

Psychosocial Distress Screenings Provided by Year

Year Completed Distress Screens2017 4532018 2862019* 401

Source: Union Hospital Meditech Report *2019 Numbers January through mid-December

Survivorship Care Plans

A survivorship care plan is a record of your cancer and treatment history, as well as any checkups or follow-up tests you need in the future. It may also list possible long-term effects of your treatments and ideas for staying healthy. At Union Hospital, we work to support our oncology patients with a care plan upon completion of their active treatment. In 2019, the Cancer Program is required to provide survivorship care plans to 50% of the eligible patients. The group is on target to meet the requirement.

Cancer Type 2017 2018 2019Bladder 7 2 5Breast 38 40 27Colon 7 4 1Lung 5 2Prostate 13 15 13Rectal 1Kidney 1 6Thyroid 7 8 2Total Complete 78 78 48*# Patients Eligible 127 101 138Percentage 61% 77%

Source: Union Hospital SCP Data * 2019 January through October. Total will be reported first quarter 2020

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Resource CenterThe Cancer Resource Center opened in 2012. It is staffed by volunteers and is open 10 a.m. to 2 p.m., Monday through Friday.

2019 Support Groups offered at Union Hospital: I Can Cope, Survivor Circle

Year Total Contacts New Patients Wigs Education Road to Recovery Trips2018 3764 150 12 1030 1662019* 2896 106 15 833 179

Source: Cancer Program Data * 2019 Data through November

In Cecil County, the most common reported problems are related to adjustment and follow-through with therapy. At Union Hospital, cancer patients have self-reported a gap in completion of cancer therapy and have related this to assistance with practical needs such as (transportation, rent, heat, electric, physician and medication co-pay and nutrition).

Over the years, Union Hospital Cancer Program patients have been supported by many fundraising and donation opportunities. In 2011, Baskets of Hope was started because of a patient who was not showing up for daily radiation treatment. When asked why, he explained that he couldn’t afford the gas for his car nor the physician co-pay. After research, it was found that there is very little support for oncology patient personal needs especially if it was a non-breast cancer patient. In 2019, the basket raffle raised $32,487. Other local fundraisers this year created by the community: Cruzin for the Cause, a local car show; Rally of Hope, a motorcycle rally; and a Wine dinner.

To date in 2019, we have assisted our cancer patients with a total of $39,096 in mini grant support for transportation, gas cards and co-pay assistance.

Food Insecurity — In support of the community cancer patients, a non-perishable food pantry was started. The program donates on average five boxes a week to patients in need of food.