׉?ׁB!בCט((u׉׉ 7cassandra://NC4lyqXi4c7sg4Ncn586-f6APQN8JqizpfZ42qJERbEc`׉ 7cassandra://imBAo61n6EMyJBrtdZ5N-P1pmVNvhup5MjTC1wpQnws͓`m׉ 7cassandra://Fq65giL9wMAK6Mrdt6NlUolwEEPfKhPG2Fk34R8tYL88`K׉ 7cassandra://61lEZKrGPDw9aG1GyHmFvdQsXW6GhjgQ65lLNddtETsi @͠\\X'ͯ-ט(u׈׈E\\X'ͯ-׉EmPowerful Allies Center for Cancer & Blood Disorders 2018 CANCER PROGRAM ANNUAL REPORT Based on 2017 Outcomes ׉ 7cassandra://Fq65giL9wMAK6Mrdt6NlUolwEEPfKhPG2Fk34R8tYL88`K\\X'ͯ-\\X'ͯ- PבCט(u׉׉ 7cassandra://MPqf-OzF3H31Ze-NRwePH2hobDVukNHySEyPD2ecwAg`׉ 7cassandra://3Kw5aizu6J0uknR9mQdNtyNAIcygCLTUPlUCva1dYYU͜Y`m׉ 7cassandra://1FL4JTo2p-hiXT6hkwRav45pwgElKsnUhK3k6xOcIIE5`K׉ 7cassandra://2SO_SFzBBXz6Jl9yeqLHC0a4kXAGt10dxCDVkjqnBac͠\\X'ͯ-ט((u׉׉ 7cassandra://3-aFgqwdfeB_r-9igJ4x__hwg14lGxtw1g6-ehYdPtI`׉ 7cassandra://iQzT9A9PllKzeL2PVtoex39-rOE1PCIYnJJx3u-q8dgͨH`m׉ 7cassandra://MyfaEwUn58iKtBuBi2usBSUITFWTUZ_JKS_79xjFKJ8>=`K׉ 7cassandra://aTRhr_EAvcK7BFejw5DWt2D1DPRTflORY00rhXVVRcY ͠\\X'ͯ-׉EbCancer. A powerful enemy requires powerful allies. Nearly one-third of people in the U.S. will develop cancer in their lifetime. But every year, more people survive by early screening and detection. As the only cancer center in the region to collaborate with Duke Health, we’re bringing the latest in cancer care research and treatment home to Augusta County. That means even when facing a diagnosis of cancer, you’re surrounded by the leading minds. To learn if you should have a cancer screening, call (833) AHC-HLTH to get connected with an Augusta Health physician. Center for Cancer & Blood Disorders ׉ 7cassandra://1FL4JTo2p-hiXT6hkwRav45pwgElKsnUhK3k6xOcIIE5`K\\X'ͯ-׉E6TABLE OF CONTENTS A Message from Leadership 2 Tumor Board and Cancer Committee 3 Finding Focus: SBRT and SRS Analytic Cancer Case Distribution 4 6 Clinical Case Study—Primary Site: Stage IV Non-Small Cell Lung Cancer Down to Earth: Lung Cancer Screening Annual Cancer Symposium Community Outreach 7 10 12 13 ׉ 7cassandra://MyfaEwUn58iKtBuBi2usBSUITFWTUZ_JKS_79xjFKJ8>=`K\\X'ͯ-\\X'ͯ- PבCט(u׉׉ 7cassandra://qYl6mnGrmcNBbVeTUDpK3QPjP8m4tG3wPXP0JQFKlqE`׉ 7cassandra://BuRjNdIhGb5EbsNUsagJ1_vusdLDFC0YFPXmXPMkKo0`m׉ 7cassandra://hR3zf9zLsPrzo4hWdZy3grQoMtU54IgaNLe-UQFYr4YE`K׉ 7cassandra://nHGmBFyPrVEqmoN47wRSy7qCc9jpBGf9hYuD39dXMEwͤz͠\\X'ͯ-ט((u׉׉ 7cassandra://u1_W7Vkl0aClnVVcaspzijbLbHmX4bC1iKm3QoQxFko©`׉ 7cassandra://IsAZaQhtUawfqF9QNkccfDuRXJqs63NnMazDrcCcJq0#`m׉ 7cassandra://nQlNYcSd9krzYefauiIfXy-FtE6o7m4kfD3r2N26sRM8`K׉ 7cassandra://xFN27ghhJuuYvwy17tBoaqLo4QS8MyQR9P5lhOJ2OKkʭ͠\\X'ͯ-׉EA MESSAGE The Cancer Center at Augusta Health experienced some key changes this year, including a name change. Now known as the Augusta Health Center for Cancer & Blood Disorders, the new name more appropriately reflects the broad scope of services the Center has provided the community for more than a quarter century. Of the new patients who register at the Center any given month, nearly half of them have been referred to the Center for suspected blood abnormalities ranging from anemia to leukemia. Ron Turnicky, DO Chairman, Cancer Committee Progress in the treatment of cancer can only occur where clinical research is important part of the delivery of care and the development of tomorrow’s cures. The Augusta Health Center for Cancer & Blood Disorders, with its affiliation with Duke Health, is committed to excellence by participating in clinical trials that evaluate all aspects of care, including screening and prevention, new drugs, new treatment strategies, side-effect management and survivorship. 2 This month we completed a successful survey by the American College of Surgeons’ Commission on Cancer. The program anticipates receiving several commendations when we receive the final report early next year. A successful survey is a testimony to the sustained excellence in cancer care that we have delivered to the cancer patients of Augusta County over the past 10+ years. Our clinical research program is growing. Progress in the treatment of cancer can only occur where clinical research is an important part of the delivery of care and the development of tomorrow’s cures. The Augusta Health Center for Cancer & Blood Disorders, with its affiliation with Duke Health, is committed to excellence by participating in clinical trials that evaluate all aspects of care, including screening and prevention, new drugs, new treatment strategies, side-effect management and survivorship. We continue to work closely with our colleagues at Duke to build a robust clinical trials program that meets our community’s needs and reflects the most common types of cancers treated in this area of Virginia. Our modern clinical trials program provides advanced and up-to-date clinical trials here in Augusta County in a safe and closely monitored environment. Our research staff coordinates regularly with the research support team at Duke as well as participates in national and regional conferences to stay knowledgeable. This year the clinical research team opened more than 10 new trials, doubling the number from prior years. Our low dose lung screening program is making a difference. Typically, 24 lung cancers are detected with every 1000 screening exams. Here at Augusta Health, 37.5 cancers have been diagnosed with every 1000 screen exams – that is 150% more than expected. Of the patients FROM LEADERSHIP diagnosed through our lung screening program, many are found with Stage 1 disease that may be cured with surgery alone. Our cancer screening and prevention efforts are expanding! Our understanding of how inherited genetic make-up predisposes people to certain cancers is expanding. This deepened understanding informs us on how to screen, advise and manage patients and families that may be at increased risk for cancer through the course of their lifetime. Cancer prevention starts with confirming that family members share a genetic mutation, followed by counseling patients and families about the need for continued screening, possible interventions and follow-up visits. The development of community-wide screening programs for at-risk individuals with a family history of cancer is underway at Augusta Health. You can look forward to these services in the community in 2019. Our community is making a difference in the lives of the less fortunate. An important feature of our cancer program is the financial support available to our patients through a philanthropic fund known as the “Bridge Fund.” In total, generous individuals donated $52,000 in 2017 to Augusta Health cancer patients in need. Even more important is the difference these gifts were able to make in the lives of our patients including help with expensive medications, wigs, turbans and head wraps and new and enhanced services through the Bridge Fund. On behalf of our patients, we extend our thanks to those who made a donation, small or large, to the Bridge Fund. Finally, it has been my honor to serve as the Cancer Committee Chair for 2018. My predecessor, Dr. Robert Kyler, and I have agreed to serve in this capacity as Chair because we so firmly believe in the critical mission at Augusta Health to sustain and grow the Cancer Program. As of January 1, 2019, we confidently hand this role to the Cancer Program’s Medical Director, Dr. Kelvin Raybon, who agreed to lead the Cancer Program in the coming years, assuring us of his commitment to clinical research and to providing cutting-edge treatments here in the community. We all thank you for entrusting us with the opportunity to be your caregivers at Augusta Health. AUGUSTA HEALTH • CANCER PROGRAM ANNUAL REPORT ׉ 7cassandra://hR3zf9zLsPrzo4hWdZy3grQoMtU54IgaNLe-UQFYr4YE`K\\X'ͯ-׉E 52018 CANCER COMMITTEE MEMBERS 2017 TUMOR BOARD Patient-focused weekly Tumor Board meetings provide a forum for discussion of complex cases. Multidisciplinary physician attendance and presentation of National Comprehensive Cancer Network guidelines contribute towards the most appropriate management of the disease. Clinical trial options are also discussed as presented by physicians and the Research Coordinator. The Augusta Health Tumor Board is also supported by Duke Health physicians who attend via video conference. Cases presented in 2017 Annual Analytic Caseload 2017 Cases presented prospectively (in diagnosis, staging and/or treatment phase at presentation) Average of physician attendance Average of non-physician attendance 238 32.75% (238/727) 97.5% 12 11 Ronald Turnicky, DO, Pathology, Cancer Committee Chair Naheed Velji, MD, Medical Oncology, Cancer Liaison Physician Robert Kyler, MD, Radiation Oncology, Cancer Conference Coordinator William Thompson, MD, Surgery Matthew Shapiro, MD, Radiology Kelvin Raybon, MD, Medical Director, Medical Oncology Cynthia Allen, MD, Pathology, Cancer Registry Quality Coordinator Patrick Baroco, MD, Palliative Care John Girard, Director of Cancer Services, Cancer Program Administrator Sheryl Search, MSN, RN, OCN, Nurse Manager Oncology and Infusion, Oncology Nursing Leigh Anderson, LCSW, Social Worker, Psychosocial Services Coordinator Angela Bartley, CTR, Cancer Program Coordinator, Certified Tumor Registrar Patricia Benson, RN, Clinical Coordinator, Quality Resource Management, Quality Improvement Coordinator Catherine Raines, CHES, Health Educator, Community Outreach Coordinator Lisa Lenker, BS, Clinical Research Coordinator Donna Markey, RN, MSN, ACNP-cs, Medical Oncology, Genetics Professional Additional/Other Members: William Jones, MD, Urology Carmen Gonzalez, MD, Pulmonology Jared Davis, MD, Pain Management Joe Surratt, NP, Gastroenterology Karen Clark, MT, MBA, Vice President Operations Rader Dod, BA, RT (R), Director of Radiology Services Donna Berdeaux, RN, BSN, Breast Health Navigator Megan Howell, RN, BSN, Aerodigestive Navigator Mary Beth Landes, MS, RD, CSO, Oncology Registered Dietitian/Nutrition Navigator Stephanie Mims, PT, DPT, MBA, Director of Therapy Services Clay Wilson, PharmD, BCOP, Pharmacy Oncology Services Mark Westebbe, Pastoral Care Representative Colleen White, RT(R)(T) Chief Radiation Therapist Annika Dean, American Cancer Society Linda Sutton, MD, Medical Director, Duke Cancer Network Renee Muellenbach, Assistant Vice President, Duke Cancer Network 3 AUGUSTA HEALTH • CANCER PROGRAM ANNUAL REPORT ׉ 7cassandra://nQlNYcSd9krzYefauiIfXy-FtE6o7m4kfD3r2N26sRM8`K\\X'ͯ-\\X'ͯ- PבCט(u׉׉ 7cassandra://AREXCh0vtAUCjga3KYvSKa8sxLH-yfX9L5k3q1cKtlg8`׉ 7cassandra://oybsAyX8Nl7cckI2vnEvWI4WSHd4nZvF95ybf4Ub4o0Ͳr`m׉ 7cassandra://hzdKHZloi7xwGvID-KXzsJxMqv_de-PgUmGDbUpnm787g`K׉ 7cassandra://3YT7HMyZIPz9qDFZ3gd49wMpUgpux4vbNlnmZPm5a7gz͠\\X'ͯ.ט((u׉׉ 7cassandra://se25Z3aulvh4cxnwYLPI82Uqxc5Zspc8l-Yw3Yiauk4\`׉ 7cassandra://52O-osXo1GYf5satb9wtB15yii5-VAyPuYJ8yGt5Mk89`m׉ 7cassandra://PBQw9dwOE3GM-cqqbwMwNwOj0AoXnH7Vxe2t7PZUqWY7P`K׉ 7cassandra://Ox-oXS-L3rVECvmQjk2rMHsHrreyGUOKEqIVA4H44f4̎͠\\X'ͯ.׉EFinding Focus New radiation technique makes treatment less invasive and highly targeted Stereotactic body radiotherapy (SBRT) and stereotactic radiosurgery (SRS) may sound complicated, but their benefits couldn’t be more straightforward: more effective and less invasive treatment for many cancer patients. These highly sophisticated and innovative technologies are now at Augusta Health and will give oncologists the ability to deliver treatment in a number of clinical scenarios, says Robert Kyler, MD, medical director of Radiation Oncology at the Augusta Health Cancer Center, a Duke Health affiliate. SRS is used for lesions in the brain and spine, while SBRT is used to treat lesions in other sites such as the lungs, liver and bones. They both work by aiming multiple narrow radiation beams at the target from multiple angles as the treatment unit rotates around the patient. Because the targets are quite small, minimizing movement during treatment is critical. Patients are therefore rigidly immobilized while being treated, and the 4 AUGUSTA HEALTH • CANCER PROGRAM ANNUAL REPORT equipment features devices that monitor and adjust for patient movement during treatment to ensure a high degree of safety. Range of advantages That kind of focus brings a range of advantages, says Dr. Kyler. The less-invasive approach may be appropriate for some patients who would not be ideal surgical candidates — for example, older patients with early lung cancer who may have COPD — and it also eliminates the need for surgical recovery time. “Surgery is often the first consideration, but not all patients are able or willing to have it. SRS or SBRT is ideal in those settings due to its noninvasive nature and the high likelihood of control,” says Dr. Kyler. “Studies of patients with early lung cancer treated with SBRT have shown rates of tumor control equivalent to those achieved by surgery,” he adds. continued on page 5 ׉ 7cassandra://hzdKHZloi7xwGvID-KXzsJxMqv_de-PgUmGDbUpnm787g`K\\X'ͯ-׉E BTHE GOAL SEAL THAT IS THE GOLD STANDARD Another benefit is time — both in terms of the treatment itself and the number of treatments needed. Conventional radiation for patients entails three to six weeks of daily treatments, which often require ample transportation time and schedule disruption. And with surgery, recovery can take weeks to months. But with SRS and SBRT, treatment can usually be done in just one to five sessions that last from 30 to 60 minutes. Dr. Kyler notes that the procedure is quick and painless, offering a high dose of radiation in just a few treatments. Sparing healthy tissues Also, there is minimal damage to the normal, healthy tissues surrounding a tumor, which improves outcomes and minimizes recovery time. Side effects and complications from the treatments are uncommon, Dr. Kyler adds. This treatment option became available at Augusta Health in October 2017, and Dr. Kyler notes that it is already being used for more patients than anticipated and will continue to be a valuable addition to Augusta Health’s oncology options. “This is a cutting-edge approach, and it’s exciting to have it available to our patients,” he says. “With such a powerful technique, we can target tumors with more precision, in a way that’s safe, noninvasive and highly effective.” Augusta Health Center for Cancer & Blood Disorders’ Radiation Oncology Practice Accredited by the American College of Radiology The Gold Seal is a symbol of quality, but this specific Gold Seal is more than a symbol. The American College of Radiology’s seal is also an assurance and a promise—a promise of the highest level of imaging quality and radiation safety at a facility providing radiation oncology therapy to treat cancer. Radiation oncology therapy is the careful use of high-energy radiation to cure cancer or relieve a cancer patient’s pain. Augusta Health Center for Cancer & Blood Disorders is one of only four sites in the Charlottesville metropolitan area that has earned Radiation Oncology Practice Accreditation from the American College of Radiology (ACR). What does this accreditation mean? It means that: • Augusta Health’s Center for Cancer & Blood Disorders has voluntarily gone through a very rigorous review by the ACR to ensure that it meets the nationally-accepted standards of care; • The staff at the Center are well-qualified, through their education and certifications, to perform medical imaging, interpret the images and administer radiation oncology therapy treatments; and • The equipment is appropriate for any test or treatment its patients will receive and that the facility meets or exceeds all quality assurance and safety guidelines. So the Gold Seal, while small, represents a big effort by the physicians and staff to provide the highest level of care possible. 5 AUGUSTA HEALTH • CANCER PROGRAM ANNUAL REPORT ׉ 7cassandra://PBQw9dwOE3GM-cqqbwMwNwOj0AoXnH7Vxe2t7PZUqWY7P`K\\X'ͯ-\\X'ͯ- PבCט(u׉׉ 7cassandra://M3U07VxcgP6IfKT-3rEiwUtgjmk9MKVRuMMJqpxFuLIO#`׉ 7cassandra://N_DN1C8lNU21KCPfyQvyHRzMlwVw8jZldYJajW56Mz0=`m׉ 7cassandra://DIjccCVN23vao1Z8e0OpAlcllWLbMY9M8pAqr4ofrWg`K׉ 7cassandra://zPXyK77g--2Ge87tdYzi3AdjNP7xwYhkaYJAaYO1QdM/͠\\X'ͯ.ט((u׉׉ 7cassandra://fl0fgF6GVknuezX5kC9YvMPdLa_29-VRFs8v2FBFMO04`׉ 7cassandra://gH1zH-gLTBBF_Ve8ANfnDLQlhB3EvyfQjin9fZhkqJw`m׉ 7cassandra://XiGidnuSdTAxkHdFPZ1hF-cBS3nO5zU-jIy3JQh1NKA>`K׉ 7cassandra://U4PxRj7qqv53ICJi1EjObG6Py5jiM9U_Aia0BicPex0f͠\\X'ͯ.׉Ea2017 Analytic Cancer Case Distribution (N=727) 6 AUGUSTA HEALTH • CANCER PROGRAM ANNUAL REPORT ׉ 7cassandra://DIjccCVN23vao1Z8e0OpAlcllWLbMY9M8pAqr4ofrWg`K\\X'ͯ-׉Ez2018 Standard 4.6 Monitoring Compliance with Evidence-Based Guidelines PRIMARY SITE: STAGE IV NON-SMALL CELL LUNG CANCER Prepared by: Kelvin Raybon, MD, FACP, Medical Director, Center for Cancer and Blood Diseases including lung cancer. The Programmed Death Ligand – 1 (PD-L1) receptor is a down-regulating signal on cytotoxic T lymphocytes; prominent expression of PD-L1 by cancers allows avoidance of recognition and attack by T lymphocytes due to this self-recognition checkpoint. Monoclonal antibodies directed toward either the PD-L1 ligand or its receptor block this checkpoint, allowing greater immune recognition and destruction of tumor. Checkpoint inhibiting monoclonal antibodies have revolutionized the care of non-small cell lung cancer, initially as second-line therapy beyond chemotherapy, and subsequently as first line treatment in cancers that highly express the PDL1 ligand, with or without the addition of chemotherapy. Assays to detect high expression of PD-L1 are therefore useful in treatment selection, and are currently recommended in all lung cancer patients with advanced disease that are candidates for therapy. In this study, we report the initial evaluation and pretreatment studies, testing for molecular mutations and PD-L1 expression, and initial treatment in all newly diagnosed Stage IV lung cancer patients, squamous and nonsquamous, for the year 2017. Goals were to assess the alignment of care with national guidelines, and the impact of cancer testing on therapy, as well as to identify any barriers in care management . Introduction Lung cancer remains the number one cause of cancer death in both men and women in 2018. Although a new approach to early diagnosis with low-dose CT scan lung cancer screening is now available, the majority of lung cancer patients currently present or recur with widely metastatic disease that is incurable. Therefore, most lung cancer therapy remains focused on palliation of symptoms and prolongation of survival with systemic drug therapy. Encouragingly, advances have been made. Since the discovery of the EGFR mutation in 2004, research has increasingly identified subgroups of nonsquamous lung cancers that are “driven” by specific mutations that give the cancer its growth advantage. These molecularly driven forms of lung cancer, often seen in nonsmokers, have allowed the development of drugs specifically targeting these mutations, resulting in treatments that are not curative, but more efficacious and less toxic than traditional chemotherapy. EGFR, ALK, ROS-1 and BRAF represent the currently recognized and targeted molecular mutations in lung cancer. Likewise, research in just the last few years has shown the importance of immune surveillance in the persistence and spread of many cancers, Monitoring Compliance with Evidence-Based Guidelines Current standard of care (NCCN Non-Small Cell Lung Cancer v4.2018) suggests that Stage IV lung cancer patients that are candidates for systemic treatment should be tested for the presence of any mutations that are the targets for currently available therapeutic agents and expression of PD-L1 ligand to help select their optimum treatment. However, specific recommendations have changed rapidly in the last two years; challenging all care providers to remain abreast evidence-based recommendations. Summary of NCCN Lung Cancer Targeted Testing Guideline Recommendations with date of revision: V7.2015 – EGFR and ALK – July 2015 V5.2017 – EGFR, ALK, and PD-L1 – May 2017 V8.2017 – EGFR, ALK, ROS-1, and PD-L1 – August 2017 V2.2018 – EGFR, ALK, ROS-1, BRAF, and PD-L1 – February 2018 continued on page 8 AUGUSTA HEALTH • CANCER PROGRAM ANNUAL REPORT 7 ׉ 7cassandra://XiGidnuSdTAxkHdFPZ1hF-cBS3nO5zU-jIy3JQh1NKA>`K\\X'ͯ-\\X'ͯ- PבCט(u׉׉ 7cassandra://sGl8iQjILQ2kMtof4W257YaMDw9QT1O3mO9_tOwtTDQ]`׉ 7cassandra://Wtmw3HPm2_cunf68L486keZEwr__E6ms5kOt-lDi2xQ `m׉ 7cassandra://1bHN-fB-kSIEZmadahPY9QvpE3Pba8Ff86w-mA3NyxM4`K׉ 7cassandra://RSZ5QVTZZFqq8P6yrckA5JbidbqW-MlR507xIJcD8RAx|T͠\\X'ͯ.ט((u׉׉ 7cassandra://LV2pXevSwmXYRWBYQIdKsM_BaQeXdAQ3E_m2wcbTLOA~`׉ 7cassandra://HDZTRI055iS67VlMZALZlFp0pLWE26oWpEwbiP6syRMB`m׉ 7cassandra://w4VmTJ4CM6895Lxe1dIW3IqDNBMwQeiVektk2eBLohs:`K׉ 7cassandra://9wQed8A9ddU5hr4Mg_llYYKGK-QLAu9n_ant04aTU6oA ͠\\X'ͯ. ׉EwEvidence-based recommendations for the year 2017 specifically included the recommendation to test all non-squamous Stage IV lung cancer tumors for EGFR, ALK, and (starting in August 2017) ROS-1 mutations, as well as for expression of PD-L1 (starting in May 2017). For patients with Stage IV squamous cell lung cancer, testing for tumor expression of PDL1 (starting May 2017) and ROS-1 (August 2017) was recommended; if patients with squamous cell lung cancers had no smoking history, or mixed adeno-squamous histology, then EGFR and ALK testing were additionally recommended. NCCN guidelines otherwise recommend a CT of chest and upper abdomen, CBC, and chemistry profile for all patients with Non-Small cell lung cancer at the time of diagnosis. Additional PET/CT of whole body and MRI of brain is recommended specifically for Stage IV patients. Methods All Non-Small Cell Lung cancers diagnosed in 2017 at Augusta Health with Stage IV disease were identified by chart review. Cases were divided and charts reviewed separately as either Non-squamous or Squamous cell lung cancers. The elements of the pretreatment initial evaluation, including the molecular markers and PD-L1 expression assessed , and initial treatment were individually reviewed, and summarized. Results NON-SQUAMOUS CELL LUNG CANCER (#25) Table 1. Initial Pretreatment Evaluation Non-Squamous Discussion Based upon this study, it appears that there is a high level of compliance at Augusta Health with appropriate testing and treatment of Stage IV non-small cell lung cancer patients who are eligible for treatment, especially in regard to targetable mutations and PD-L1 expression. Most patients underwent elements of the initial evaluation and pretreatment evaluation (Tables 1 and 3). Those that did not undergo advanced testing with PET/CT and/or MRI of Brain were either treated elsewhere, or were not candidates for active treatments. 8 AUGUSTA HEALTH • CANCER PROGRAM ANNUAL REPORT continued on page 9 Table 2. Molecular / Immunologic Testing Non-Squamous SQUAMOUS CELL LUNG CANCER (#10) Table 3. Initial Pretreatment Evaluation Squamous Table 4. Molecular / Immunologic Testing Squamous ׉ 7cassandra://1bHN-fB-kSIEZmadahPY9QvpE3Pba8Ff86w-mA3NyxM4`K\\X'ͯ-׉EIn review of molecular evaluation in non-squamous cases (Table 2), the majority of patients received appropriate testing. Most untested patients were either not candidates for treatment or elected not to receive treatment. Only 1 patient eligible for treatment did not undergo a request for EGFR, ALK, and PD-L1, and 2 patients did not have requests for ROS-1, after its addition to NCCN guideline recommendations. One patient who tested positive for EGFR mutation did not receive targeted treatment with erlotinib due to other clinical circumstances. Two patients had testing elsewhere, with incomplete information available for this study concerning EGFR testing. Two patients received PD-L1 directed treatment as initial therapy. Insufficient tissue for testing was not uncommon in the non-squamous cell cases. Discussion of the challenges to obtaining sufficient tissue is beyond the scope of the current study. The role of “liquid biopsies,” that is, testing for cell-free tumor DNA or RNA mutations circulating in the blood, is an ongoing area of research to supplement tissue biopsies for testing for molecular targets, and there is expected increased utilization of such testing in the near future. All initial treatments of Non-Squamous cell patients were consistent with NCCN guidelines. In review of the cases diagnosed at AH with squamous cell lung cancer (Table 4), PD-L1 expression testing was performed in 8 of 9 patients eligible for therapy, and 2 patients received PD-L1 directed checkpoint inhibition therapy as part of their initial regimen. Six of 9 eligible patients underwent ROS-1 molecular testing; 2 of the 3 patients who did not undergo testing were diagnosed prior to the addition of ROS-1 to recommendations by NCCN guidelines. The current study revealed that there may be opportunities to reduce cost of testing by avoiding molecular tests with low likelihood of benefit. Insufficient tissue was not seen as a problem in the cases of squamous cell histology. All initial treatments of Squamous cell patients were consistent with NCCN guidelines except one (pembrolizumab + gemcitabine). Recommendations The evaluation and management of patients with Stage IV Non-Small Cell cancer will likely continue to increase in complexity as new science expands treatment options in this most lethal of cancers. There will likely be further identification of important target mutations, and drugs to combat them; likewise, the optimal use of immune checkpoint inhibitors is in its infancy, and increasing use is expected. Assessment of patient function to select patients most able to benefit from therapy will remain paramount, as will the early utilization of palliative care services. In reviewing the results generated in this study of data from 2017, several recommendations for the future can be made in the evaluation and management of Stage IV Non-Small Cell Lung Cancer: 1. Expand discussion of the evaluation, pathology, molecular and immunologic markers and management of patients diagnosed with NSCLC at multispecialty tumor conferencess 2. Ensure clinicians have the tools needed to support direct communication between physicians in identifying the molecular and immunologic testing to be performed for individual patients with Stage IV lung cancer 3. Ensure that patient testing and evaluation is commensurate with the extent of the lung cancer and patient’s functional status 4. Evaluate challenges in the collection of tissue samples that cause samples to be inadequate for molecular/immunologic testing in appropriate cases 5. Avoid molecular tests in cases unlikely to be helpful and not in accordance with guidelines (ie, EGFR and ALK in pure squamous histology, unless minimal smoking history) 6. Consider additional means of testing for molecular markers or mutations, such as next generation sequencing of tumors Summary In summary, patients diagnosed with Stage IV Non-Small Cell Lung Cancer at Augusta Health in 2017 underwent initial evaluation, pre-treatment evaluation, and treatment in accordance with NCCN guidelines as deemed appropriate. Additionally, adherence to evolving recommendations concerning molecular and immunologic testing of lung cancer to better select therapy was appropriate. Date Presented to Cancer Committee: 11/01/2018 9 AUGUSTA HEALTH • CANCER PROGRAM ANNUAL REPORT ׉ 7cassandra://w4VmTJ4CM6895Lxe1dIW3IqDNBMwQeiVektk2eBLohs:`K\\X'ͯ-\\X'ͯ- PבCט(u׉׉ 7cassandra://MWvDlCks3mSPne57x2crmWDy64i_p17w7MIgUAo_dOs5m`׉ 7cassandra://x9UurnXlXNnc8WlvVkFFqN_S02oiPc1y1WP1474szNc`m׉ 7cassandra://elCL1B-T72goC6VC_rY4lQqmgymQ9BHPWcOuZZjt5C4>J`K׉ 7cassandra://r9d-wP2HA67781PyWMdiLu6GSMloMKRv7GRPP9CpB_Q_ ͠\\X'ͯ. ט((u׉׉ 7cassandra://CgcKJeuh1IcPZHjAzKv_4KeFeGanaDSi-AhADjr-nAg`׉ 7cassandra://IHh37lEgD0P0Wza6gDDwCjwH6JHRAj8xgbLJWb9OMQQī`m׉ 7cassandra://yJ_GMX3fBothLIb8qRQKFDlKW-7LqCD9GIr_aOOhtZI8>`K׉ 7cassandra://5cDFFj2Ji3rNIsuJjw-MgwahhN9KfgalfCGKfkizH2IfT͠\\X'ͯ. ׉EDown to Earth Routine lung cancer screening detects woman’s lung cancer early Emily Rankin of Stuarts Draft, Virginia, thought she was out of the woods. While she began smoking in her late 20s, she quit in her early 60s. Still, at the advice of her family doctor, Rankin, 71, decided to be screened for lung cancer in May 2017. “There was really nothing to it,” the retiree and avid gardener recalls of the Low-Dose CT Scan. “It took maybe two or three minutes, five at the most. It’s quick and simple. But it did the job.” That simple screening turned out to be a life-changing experience. To Rankin’s surprise, the routine screening found an 8-millimeter mass in her left lung. After a few more CT scans, Rankin’s doctor, Jason Lawrence, MD, a pulmonologist at Augusta Health, sent her to Miguel Aguinaga, MD, FACS, a thoracic surgeon at Augusta Health. In order to have her cancer removed, Dr. Aguinaga performed a lobectomy with robotic assistance, which is a minimally invasive procedure, and therefore has a quicker, easier recovery time than other surgical interventions for lung cancer. The traditional procedure, a thoracotomy, consists of a large incision, and patients typically stay in the hospital for 10 days. Many people also have immense pain following this procedure, Dr. Aguinaga says. The new, minimally invasive surgery is quicker, and patients can be discharged within one to three days, Dr. Aguinaga says. Rankin’s surgery consisted of just six small holes on her side and back. Dr. Aguinaga notes that one benefit of the robotic surgery is that it allows for more precision. “You have a camera inside of the patient, so you’re viewing what’s happening,” he says. “And with your hands, you reproduce the movements you want the robot to do. The reason we use a robot is that you can really get into tight spaces. The vision is incredible.” Rare cancer revealed Rankin had surgery on January 16, 2018. Dr. Aguinaga removed the upper lobe of her left lung. The 8-millimeter mass turned out to be a carcinoid tumor, which is a very rare, slowgrowing cancer. continued on page 11 10 AUGUSTA HEALTH • CANCER PROGRAM ANNUAL REPORT ׉ 7cassandra://elCL1B-T72goC6VC_rY4lQqmgymQ9BHPWcOuZZjt5C4>J`K\\X'ͯ-׉E Rankin’s lymph nodes all tested negative for cancer, and she went home the following day. “I was cancer-free with no chemotherapy, and no radiation treatments had to be done,” Rankin says. “It was all because of this CT scan catching [the cancer] early.” Augusta Health is one of the only hospitals in the area to perform a lobectomy with robotic assistance. “Emily was the first case we’ve done here at Augusta Health using robotics,” Dr. Aguinaga notes. “I believe we are the only program in the entire region that is doing thoracic surgery using robotics.” Fast recovery Rankin’s surgery was in the morning, and that evening she says she was sitting up in a chair eating French fries. “Dr. Aguinaga came in, and he had the biggest smile on his face [because] I had recovered that quickly,” she says. She went home the next day. Within a few weeks, Rankin — who retired from a factory making pharmaceutical tubes in 2011 — says she was in her flowerbeds cleaning out leaves. “I’m doing everything I thought I would never get to do again because I had cancer,” she says. Rankin remains grateful for her husband’s support, along with the outstanding care she received from the medical team at Augusta Health. “I was scared to death,” she says. “Everybody seemed to put me at ease. The healthcare was really great. It was a bad experience that was made good.” Rankin also can’t emphasize how glad she is to have undergone the lung cancer screening. She encourages other high-risk individuals to do the same. “I hadn’t smoked for eight years, so I thought, oh, I’m fine, there’s nothing wrong with me,” she says. “If people would have these [screenings] done — especially if they were smokers and they stopped — they would have a good success story like mine.” IMPACT OF LUNG CANCER SCREENING AT AUGUSTA HEALTH Augusta Health began its Lung Cancer Screening program in April, 2014. According to radiologist Matthew Shapiro, MD, 37 Low Dose CT (LDCT) exams were performed in the first year, and one lung cancer was detected. To date, more than 1,600 LDCT exams have been performed and 43 lung cancers have been detected. That’s a detection rate twice than what was expected when the program began. “When we look only at patients diagnosed with lung cancer through screening, we see an even greater benefit with 53% in Stage 1A and only 7% in Stage 4. This suggests to me that there are probably more patients in our area who are at high risk for lung cancer but are not being screened,” says Dr. Shapiro. Lung Cancer Diagnoses through the Lung Cancer Screening Program, 2014-2018, YTD* Diagnosis 0 Years 2014-2018 *October, 2018 AUGUSTA HEALTH • CANCER PROGRAM ANNUAL REPORT 0% (n=0) 53.5% (n=23) 11.6% (n=5) 30.2% (n=13) 4.7% (n=2) 100% (n=43) 11 I II III IV Total Cases ׉ 7cassandra://yJ_GMX3fBothLIb8qRQKFDlKW-7LqCD9GIr_aOOhtZI8>`K\\X'ͯ-\\X'ͯ- PבCט(u׉׉ 7cassandra://nfbSZ0BTugVdB5um7QdRlh-B5Nohu3Tpy_O4E0SxUOc`׉ 7cassandra://l_4jyzgwfPDdEwEj5tBVBlzrMpRHX82I5a0xQjP7yII`m׉ 7cassandra://Ghal9MIPjGEhdJ6y2bl6irXiUdo9XS19LYQkrAN3LiY@`K׉ 7cassandra://EOb6b5-mOmln52ImgQ8ihsvJKR8N2LvJPW172GxK2u0[8͠\\X'ͯ.ט((u׉׉ 7cassandra://5Oadamt1vd8quuC76sYLRx5BzbxHUBDApwutbgmKK10,a`׉ 7cassandra://J5CgXY4O63J6FWkanypPvUFDgLVTPrwv_6S0BY0TpWYͮ`m׉ 7cassandra://OXM_3hQxPo9XpqOwj63ARLlmJCr3JWKiMinSGXKw3nE6`K׉ 7cassandra://hobVn5OzQilMXkI3yCDIFEzth0jBbOQjfSHvHTEu2mgӸ4͠\\X'ͯ.׉ECreating Allies Through Collaboration Those who care for patients with cancer extend far beyond the walls of the Cancer Center. Primary care providers continue to treat their patients with cancer—as do pharmacists, pulmonologists, therapists, nurse practitioners and physician assistants and other medical professionals. To reach out to all to provide current information and vigorous discussion, Augusta Health Center for Cancer & Blood Disorders annually presents a Cancer Symposium for area providers. This year’s symposium, Advances in the Treatment Modalities of Patients with Cancer, was held October 11. Through the affiliation with Duke Health, the symposium was accredited by the American Nurses Credentialing Center (ANCC), the Accreditation Council for Pharmacy Education (ACPE), and the Accreditation Council for Continuing Medical Education (ACCME) for physicians. The robust agenda focused on a variety of treatments provided at Augusta Health, as well as their application and outcomes. Presenters were all from the Augusta Health Medical Staff. 12 AUGUSTA HEALTH • CANCER PROGRAM ANNUAL REPORT • Rise of the Robots-Surgery’s Past, Present and Future at Augusta Health o Kristin Turza, MD and Brian Stisser, MD • I Was Born this Way—Genetic Counseling o Donna Markey, RN, MSN, ANCP-cs • Manipulating the Hormonal Milieu—Advances in Hormonal Therapies o Reshma Khetpal, MD • Laser Focus—SBRT and the Future of Radiotherapy o David Morgan, MD • Surviving Cancer—Advances in Science, Treatment and Outcomes o Kelvin Raybon, MD • New Frontiers in Cancer Therapy—Exploring the Science of Immunotherapy o Naheed Velji, MD • The Good, The Bad and The Ugly—Management of Immunotherapy Complications o Raymond Cruz, MD • Panel Discussion ׉ 7cassandra://Ghal9MIPjGEhdJ6y2bl6irXiUdo9XS19LYQkrAN3LiY@`K\\X'ͯ-׉ECommunity Outreach Screenings and Preventative Activities throughout 2018: • Mamm & Glam Breast Cancer Screening o September 18 o Partnership with Every Woman’s Life program o 25 screened o 3 call-backs • Prostate Cancer Education and Prevention o July 14 o Augusta Health Expo o 23 attendees • Medical Monday Health Education and Prevention Series o Education and Prevention segments on WHSV’s News at Noon o Segments on screening and prevention for: Cervical Cancer, Colorectal Cancer, Skin Cancer, Prostate Cancer, Breast Cancer and Lung Cancer o 15,000 viewing audience per segment • Lunch and Learn Health Education and Prevention Series o Education and Prevention Lecture Series Facials were provided by Kimberly Glover at the Mamm & Glam Breast Cancer Screening o Lectures on advances in cancer diagnosis and treatment; screening, diagnosis and treatment of colorectal cancer; screening, diagnosis and treatment of lung cancer, preventive nutrition and screening diagnosis and treatment of breast cancer o 375 attendees 13 ׉ 7cassandra://OXM_3hQxPo9XpqOwj63ARLlmJCr3JWKiMinSGXKw3nE6`K\\X'ͯ-\\X'ͯ- PבCט(u׉׉ 7cassandra://ZpuKSiFqo4yJMc8JZe37TLlzfMn-bbl5boFDQyluSeA&;`׉ 7cassandra://wHABrvPGmBQxnjcJuh35xKFbAfED99SaFgxh9WB5AeI6#`m׉ 7cassandra://2x8NabfYDMVzQ2bs25dUSL9y3t2VxSMklDniZml-l4o`K׉ 7cassandra://WoUpII7xeiGbvta7COqUVGgdcfSNdQ0wwPa6lGR3W9k ͠\\X'ͯ.נ\\X'ͯ.ˁ9ׁHhttp://www.augustahealth.comׁ ׁ Ј׉EGCenter for Cancer & Blood Disorders 540-322-5960 www.augustahealth.com ׉ 7cassandra://2x8NabfYDMVzQ2bs25dUSL9y3t2VxSMklDniZml-l4o`K\\X'ͯ-׈E\\X'ͯ-\\X'ͯ- P,!Cancer Program Annual Report 2018\\Ǘ_:t