Sincerely Yours, Dr. Emerado Falcon Cancer Committee Chairman 2011 Brazosport Regional Health System

Transcription

1 Brazosport Regional Cancer Center Annual Report 2011

2 What makes us unique as a Community Hospital is our ability to provide excellent healthcare to our clientele especially in the area of Cancer Care. Through the years, we have strived as a team to maintain our accreditation as Community Cancer Program by the Commission on Cancer of the American College of Surgeons. This reaffirms our status to be at the same level with other known cancer facilities in our State as well as our ability to compete with other well known Cancer Centers around the country. In 2011, the cancer registry added 284 cases to its registry database. This now comes to a total of 6,293 registered cases since the reference year (inception of cancer program in 1993). Though we have seen a decline in our registered cancer cases for various reasons, the goals of the Brazosport Regional Cancer Center Program remained on track. We continue to meet the standards set by the Commission on Cancer as we have continuously provided programs and activities to our clients in terms of cancer support groups, quality improvement studies, screening programs for prostate and breast cancer. At the Cancer Center, we continuously improve to provide onsite comprehensive chemotherapy treatment, state-of-the art radiation therapy including threedimensional (3-D) treatment planning and Intensity Modulated Radiation Therapy (IMRT). This year, the annual report will focus on Bladder Cancer. We will present facts and provide a discussion about this illness. The incidence of Bladder Cancer has not increased these past few years, yet treatment modalities have improved recently. Lastly, Brazosport Regional Cancer Center (BRCC) continues its fight against cancer. We hope to do so in an evidence based format. We hope that the annual report gives you sufficient information about the program and its desire to educate everybody about the battle of specific cancer diseases and its entirety. Sincerely Yours, Dr. Emerado Falcon Cancer Committee Chairman 2011 Brazosport Regional Health System

3 Table of Contents CANCER PROGRAM ACTIVITIES Cancer Committee 2 Hospital Services 2 Radiation Oncology 3 Medical Oncology 3 Tumor Board Conferences 4 STATISTICAL ANALYSIS Cases by Residence 4 Cancer Registry Report 5 Cancer Registry Statistics 5 Brazosport Cancer Center Program 2010 Summary 6 Primary Site and Frequency Table 7 DETAILED ANALYSIS OF TOP PRIMARY SITES Breast 8 Lung 9 Colorectal 10 Prostate 11 REVIEW AND DIALOGUE 2011 Site Specific Study - Bladder Cancer 12 GLOSSARY AND REFERENCES CANCER COMMITTEE MEMBERS 14 - Page 1 -

4 Cancer Committee A key element of a successful cancer program is the leadership of its Cancer Committee. The multidisciplinary cancer team is comprised of physicians who represent the diagnostic and treatment services and nonphysician representatives, such as Administration, Patient Care Services, Social Services, Outcomes Management and Cancer Registry. The committee, which meets quarterly, is responsible for goal setting, planning, initiating, implementing, evaluating and improving all cancer-related activities in the facility to ensure full compliance with all the standards of the American College of Surgeons, Commission on Cancer for accreditation of the cancer program. Accomplishments of the Cancer Committee for 2011 are: Commission on Cancer Standards for Cancer Conference/Tumor Board frequency, multidisciplinary attendance, and cases presentations requirements reviewed and revised. Screening mammography funding provided by the Brazopsort Health Foundation for the Mermaid Project. Prostate screening held during Prostate Cancer Awareness Month September 30, Chemotherapy Certification course offered to BRHS nurses by M D Anderson Cancer Center. Patient care studies for site, stage and cause of death of patients in cancer registry. Hospital Services Brazosport Regional Health System offers the following services to the community and surrounding areas: Acute inpatient medical/surgical and emergency services. Same Day Surgery Medical Oncology Radiation Oncology Diagnostic laboratory and histology Diagnostic Imaging services consist of: Diagnostic Radiology (x-ray) Magnetic resonance imaging (MRI) Computerized topography (CT) scanning Nuclear Medicine Mammography Ultrasound PET (Positron Emission Tomography) scanning Diagnostic cardiology Diagnostic respiratory therapy Wound Healing and Lymphedema Center RehabCare Center Social Services Nutritional Counseling Brazoria County South Visiting Nurses Support Groups - Page 2 -

5 Radiation Oncology Brazosport Regional Health System provides quality radiation oncology to our community. Patients are offered state-of-the-art treatment. The Brazosport Regional Cancer Center plays an essential and pivotal role in the management of many cancer patients: A curative treatment for many patients with malignant tumors; An integrated therapy along with surgery, chemotherapy, and hormones; As a means to palliate those for whom curative treatment is not yet available. Equipment includes a Varian linear accelerator with dual energy photon (6-18 million volt) and electron (6-20 million electron volt) capability; a Varian simulator, CT-guided, computerized, three-dimensional (3-D) treatment planning with state-of-the-art MultiLeaf Collimation and Intensity Modulated Radiation Therapy (MLC/IMRT), as well as, B-mode acquisition technique (BAT) ultrasound localization. Brachytherapy is also available through M. D. Anderson Cancer Center in Houston and is utilized as indicated. The staff includes a board-certified Assistant Professor of Radiation Oncology trained in the premiere practice of Radiation Oncology at M. D. Anderson Cancer Center in Houston, a physicist, three certified radiation therapists, two dosimetrists and a registered nurse. Medical Oncology Outpatient chemotherapy services are provided by board certified medical oncologists and registered nurses trained in the administration of chemotherapeutic agents. The combination of medical and nursing services provided in the free-standing Brazosport Regional Cancer Center affords patients an alternative to treatment in the hospital setting. Currently there are eight chemotherapy chairs and one hospital bed available in the chemotherapy administration suite at the Cancer Center. Therapy includes the use of chemotherapy agents given intravenously, intramuscular or orally; hormonal manipulation; or the use of biological response modifiers, such as Interferon. Newer antimetic agents have greatly reduced the side effects of chemotherapy. - Page 3 -

6 Tumor Conferences Twelve monthly multidisciplinary educational tumor conferences were held in Cases presented represented the top 5 major sites treated at Brazosport Regional Cancer Center. Conferences are integral to improving the care of cancer patients by contributing to the patient management process and outcomes, and providing education to physicians and other staff in attendance. Average monthly attendance is approximately 9 physicians and 19 allied healthcare professionals. Twenty eight prospective cases were discussed for cancer management options, as well as, retrospective presentation and follow-up of several cases previously discussed. Summary of 2011 prospective cases presented: * Breast * Multiple Myeloma * Bladder * Pancreas * Cervix * Prostate * Esophagus * Rectum * Larynx * Salivary Gland * Lung * Blood Dyscrasias * Lymphoma Cases by Residence Primarily, patients diagnosed and/or treated at Brazosport Regional Cancer Center in 2011 are residents of Brazoria County. A little over five percent were not residents of Brazoria County at the time of diagnosis. Patient Origin by County: (Texas Map) COUNTY CASES TOTAL% 1. Brazoria % 2. Matagorda % 3. Out of State 0 0.0% Total % Page 4 -

7 Cancer Registry Report The Cancer Registry is a component of the cancer program designed to accession, abstract, and conduct follow-up for reportable primaries diagnosed and/or treated at Brazosport Regional Health System/ Brazosport Cancer Center. The Cancer Registry of Brazosport Regional Health System, under the supervision of the Cancer Committee, offers services that help the medical staff monitor and evaluate cancer treatment outcomes. The Registry maintains an ongoing record of each cancer patient diagnosed and/or treated by the Brazosport Regional Cancer Center Program. The four basic functions of the Registry are: Identification of all new cases as defined by a reportable list Collection of data from the patient s medical record to summarize diagnosis, staging and treatment Lifetime patient follow-up End-result reporting Beginning with a reference date of January 1993, the registry contains 6,293 cases in its database which include cases that were diagnosed and or received treatment at Brazosport Regional Health System as required by the Commission on Cancer. The registry also maintains state required case submissions and Cancer Committee required casefinding. In 2011 the registry accessioned 202 analytic and 82 non-analytic cases for a total of 284 cases entered into the database. The American College of Surgeons Commission on Cancer requires hospitals with an Approved Cancer Program to maintain an 80% follow-up rate for all analytic patients since reference date and a 90% follow-up for all analytic patients diagnosed within the last five years. Currently, the Registry has a follow-up rate of 94.63%. The registry utilizes the Facility Oncology Registry Data Standards (FORDS), International Classification of Disease for Oncology (ICD-O), SEER Summary Staging Manual, American Joint Commission on Cancer (AJCC), Cancer Staging Manual and Collaborative Staging Manual for data entry. All malignant tumors, benign brain tumors, and those squamous and basal cell carcinomas of the skin treated by radiation therapy are included in the registry. IMPAC Medical System/Medical Registry Services cancer registry software is utilized to maintain our database for all cases abstracted. Brazosport Regional Health System s registry is staffed by one full-time Certified Tumor Registrar (CTR), whose duties include collecting patient data, abstracting new cancer cases using the registry cancer program software; life-long patient follow-up; coordinating quarterly Cancer Committee meetings and monthly Tumor Board conferences, compiling statistical data for Cancer Program Annual Report; and providing data in response to requests by medical staff and other healthcare professions for special studies and reports. The registry is mandated to report all required cancer data to the Texas Cancer Registry and to meet the Commission on Cancer Standard for submitting data for all analytic cases for the calendar year to the National Cancer Data Base (NCDB). In 2011, the registrar s continuing education included attendance at the National Cancer Registrars Association- National Meeting in Walt Disney Orlando Florida, the Texas Department of State Health Services- Texas Cancer Registry s Regional Conference in Rockwall, Texas and Cancer Reporter Training. CANCER REGISTRY STATISTICS Total number of patients in Registry (1/93 through 12/11) % Total number of patients living % Total number of patients expired % Total patients lost to follow-up % Follow-up percentage rate 94.63% 2011 ACCESSION REPORT Analytic Cases by Year: Number of cases accessioned Number of multiple primaries Total cases Page 5 -

8 Brazosport Regional Cancer Center Program 2011 Summary Female 56% Distribution by Sex: Residence at Diagnosis: Male 44% Since 1996, Brazosport Regional Health System has met the approval standards set by the American College of Surgeons Commission on Cancer for a Community Hospital Cancer Program. This report provides a statistical summary of our Cancer Program experience for * In 2011, the male/female ratio of cancer cases at Brazosport Regional Health System was 1 to 1.2. *The top 5 primary sites diagnosed and/or treated were lung, breast, colorectal, prostate and non-hodgkin lymphoma. Other 14% Bay City 5% Comparison of 2011 BRHS Cancer Incidences* Estimated New Cancer Cases for Texas & United States** Sweeny 6% Brazoria 13% Clute 6% Angleton 15% Freeport 13% West Columbia 3% Patient Origin by County at time of Diagnosis: Brazoria % Matagorda % Harris 2 0.7% Polk 1 0.3% Wharton 1 0.3% Jefferson 1 0.3% Denton 1 0.3% Out of State 0 0.0% Total % SITE BRHS* TEXAS ** U.S.** Lung/Bronchus 14.1% 13.9% 14.5% Female Breast 27.0% 12.8% 13.7% Prostate 7.6% 13.6% 14.2% Colorectal 14.8% 9.1% 9.3% Non-Hodgkin Lymphoma 2.7% 4.4% 4.3% Urinary Bladder 2.3% 3.6% 4.6% Cervix 0.8% 1.1% 0.8% Melanoma 1.9% 3.5% 4.5% Leukemia 1.1% 1.4% 2.8% Uterus 1.5% 2.4% 2.8% Other Sites 26.2% 34.3% 43.0% **Excludes basal & squamous cell skin cancers & in situ carcinomas, except bladder. **Reference: Cancer Facts & Figues-2011, American Cancer Society Distribution by Age Distribution by Race 35.0% 30.0% 29.5% Caucasian (Non-Hispanic) 86% 25.0% 20.0% 15.0% 20.2% 23.2% 15.9% Caucasian (Hispanic) African-American 8% 8% 10.0% 5.0% 1.0% 2.3% 4.6% 3.3% Other 0% 0.0% % 50% 100% - Page 6 -

9 2011 Primary Site Table Class of Case Sex Distribution of Stage at Diagnosis* PRIMARY SITE CASES A Non-A M F O I II III IV UNK/ N/A ALL SITES ORAL CAVITY/PHARYNX DIGESTIVE SYSTEM Colon/Rectum Stomach Liver/Intrahepatic Bile Duct Pancreas Esophagus Anus/Anal Canal Small Intestine Other & Ill-Defi ned Digestive Sites RESPIRATORY/INTRATHORACIC Larynx Lung and Bronchus Other Respiratory/Intrahoracic Sites BLOOD & BONE MARROW Leukemia Multiple Myeloma Essential Thrombocythemia SKIN Melanoma of Skin Other Skin BREAST FEMALE GENITAL Cervix Uteri Corpus Uteri Ovary Vulva MALE GENITAL Prostate Testis URINARY Kidney Bladder Other Urinary Organs EYE AND ADNEXA CENTRAL NERVOUS SYSTEM*** Brain Meninges ENDOCRINE - Thyroid LYMPHATIC SYSTEM** Hodgkin Lymphoma Non-Hodgkin Lymphoma UNKNOWN * Tabulations for AJCC Stage Distribution include analytic cases only. ** Includes 1 or more lymphoma cases coded to non-lymphatic site *** Includes benign and borderline cases. ABBREVIATIONS: A=analytic; Non-A=non-analytic; M=male; F=female; UNK=unknown; N/A=not applicable This primary site table provides a breakdown of the total cancer cases entered into the cancer registry for The number of cases is listed for each primary site, with a breakdown by class of case and sex. - Page 7 -

10 2011 Breast Cancer In 2011 breast cancer occurrence at Brazosport Regional Cancer Center tied up with lung as the top primary site. In years it was the top primary site. It accounted for approximately 22% of the analytic cases in The average age at diagnosis was 62. Fifty two percent of the cases were detected at an early stage of the disease (Stage 0 and Stage I). Conservative breast surgery was performed on approximately 74% percent of the patients as compared to 17% who had modified radical mastectomies. Stage III 10% AJCC Stage at Diagnosis Stage IV 8% Stage II 25% Unk 2% Stage I 36% Stage 0 19% Distribution by Race Initial Therapy Surgery/Chemo/Radiation % Surgery/Radiation/Hormone 3 5.1% Surgery/Radiation 3 5.1% Surgery 4 6.8% Surgery/Radiation/Chemo 3 5.1% Surgery/Chemo/Radiation/Hormone 3 5.1% Surgery/Hormone 3 5.1% Surgery/Chemo % Surgery/Chemo/Hormone 2 3.4% Biopsy only/surgery % Biopsy only/radiation 1 1.7% Biopsy only/hormone 0 0.0% Biopsy only/chemo 2 3.4% Biopsy only 2 3.4% 54 Other 8.5% African-American 8.5% 30% Distribution by Age 27.1% 25% 23.7% Caucasian Hispanic) 13.6% 20% 15% 15.3% 16.9% 10% 10.2% Caucasian (Non-Hispanic) 69.5% 5% 3.4% 0% 0.0% 50.0% 100.0% % - Page 8 -

11 2011 Lung Cancer Lung cancer was the top primary cancer diagnosed and/or treated at Brazosport Regional Cancer Center in It accounted for approximately 22% of the total cases for The average age at diagnosis was 67. Chemotherapy and/ or radiation were the primary treatment modalities. With cigarette smoking by far the most important risk factor in development of lung cancer, it is noted that 35% were smoking at the time of diagnosis and 54% had a previous history of smoking. Initial Therapy No treatment 2 5.9% Biopsy Only % Radiation % Chemotherapy 3 8.8% Chemo/Radiation % Surgery 0 0.0% Surgery/Chemo 2 5.9% Surgery/Radiation 0 0.0% AJCC Stage at Diagnosis (Analytic cases only) Stage IV 48% Unknown 2% Stage I 13% Stage II 2% Stage III 35% Distribution by Sex (Analytic cases) Female 59% Male 41% Distribution by Age (Analytic cases only) 45% 40% 38.2% Distribution by Race (Analytic cases only) 35% 30% 25% Caucasian (Hispanic) 14.7% 20% 15% 10% 14.7% 20.6% 17.6% 8.8% African-American 2.9% 5% 0% Caucasian (Non-Hispanic) 79.4% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% - Page 9 -

12 2011 Colorectal Cancer According to the American Cancer Society 2011 Facts and Figures, colorectal cancer is the third most common cancer both in men and in women. At Brazosport Regional Cancer Center colorectal cancer is the third most frequent cancer diagnosed and/or treated. Colorectal cancer accounted for fourteen percent of the analytic cases in More than ninety percent of colorectal cases are diagnosed in individuals over the age of 50. The average age for patients diagnosed and/or treated at BRHS is 65. Surgery with or without neoadjuvant or adjuvant chemotherapy and/or radiation therapy was the primary treatment modality. AJCC Stage at Diagnosis Stage IV 23% Unk/NA Stage 0 0% 6% Stage I 23% Initial Treatment (Analytic Cases) (Analytic Cases) Surgery 9 29% Surgery/Chemo 7 23% Surgery/Chemo/Radiation 3 10% Surgery/ Radiation 2 6% Chemo/Radiation 4 13% No Treatment 6 19% Stage III 29% Stage II 19% Distribution by Race Distribution by Age Caucasian (Hispanic) 13% 35% 30% 25% 20% 22.6% 29.0% 25.8% African American 19% 15% 10% 5% 3.2% 6.5% 9.7% 0% Caucasian (Non- Hispanic) 61% 3.2% 0% 10% 20% 30% 40% 50% 60% 70% - Page 10 -

13 2011 Prostate Cancer Prostate cancer accounted for approximately five percent of new cases accessioned and is the fourth top primary occurrence at Brazosport Cancer Center in Average age at diagnosis is 71 while risk factors according to the American Cancer Society note more than 85% of all prostate cancer cases are diagnosed in men 65 or older. Radiation therapy with or without hormone therapy continues to be the primary treatment regimen for prostate cancer patients diagnosed and/or treated at BRHS as in prior years. Initial Treatment Radiation % Radiation/Hormone % Hormone % Surgery/Radiation/Hormone 1 6.7% No Treatment % 15 AJCC Stage at Diagnosis Stage III 7% Stage IV 13% Stage II 80% Distribution by Age Distribution by Race 80% 70% 60% 50% 40% 30% 20% 10% 0% 73.3% 13.3% 6.7% 6.7% Other African American Caucasain (Hispanic) Caucasian (Non-Hispanic) 6.7% 13.3% 13.3% 66.7% 0% 20% 40% 60% 80% - Page 11 -

14 Site Specific Study - Bladder Cancer Bladder cancer is a disease in which malignant (cancer cells) form in the tissues of the bladder. Most cases are formed from this lining (known as the transitional cell lining) and this cancer is often referred to as transitional cell carcinoma. Recently this has been renamed as urothelial carcinoma. Other variants of bladder cancer, such as adenocarcinoma (2% of bladder cancer) and squamous cell carcinomas (1-2% of cases) are much rarer. An estimated of 69, 250 new cases of bladder cancer are expected to occur in 2011 (Facts and Figures, 2011 American Cancer Society). Since 1990 s, incidence of bladder cancer incidence rates have been stable in both men and women. National data shows that bladder cancer incidence is about four times higher in men than in women and almost twice as high in white men as in African American men. BRHS cancer registry data showed the same trend, from reference year 1993 to 2011, out of 149 bladder cases recorded, 109 (74%) were men and the remaining 39 (26%) were women. In terms of race, 139 (93%) are white and 8 (6%) are African American. The most common symptom is blood in the urine. Other symptoms may include increased frequency or urgency of urination and irritation during urination. Data shows that risk factors for Bladder Cancer is increasingly high in people who works in industries with exposure to dye, rubber or leather or people who lives in communities with high level of arsenic in the drinking water. Smoking is still the most important risk factor. Smokers risk of bladder cancer is approximately three fold that of a non smokers. Ninety six (65%) of bladder cancer cases in BRHS has history of smoking or currently smoking while 36 (24%) are non smokers. Currently, there are no screening methods recommended for individuals at average risk. Diagnosis is being made by microscopic examination of cells from urine or bladder tissue and examination of the bladder wall with a cystocope, a slender tube fitted with a lens and a light that can be inserted through the urethra. Tissue diagnosis plays a major role in the treatment of Bladder Cancer. Seventy three (49%) of bladder cancers recorded in BRHS were made up of papillary transitional cell, transitional cell carcinomas or urothelial carcinomas while 72 (48.9%) were in situ tumors. The American Joint Commission (AJCC) stages these cancers with a TNM system. This system allows the documentation of the extent of disease on presentation. Clinical or pathologic staging can be used for staging. Primary tumors (T) of the bladder can be assessed by bimanual examination under anesthesia before and after endoscopic surgery (biopsy or transurethral resection) which is an indicator of a clinical stage. Pathologic staging involves microscopic examination and confirmation thru total cystectomy (removal of the urinary bladder) and lymph node dissection (N). M is for evaluation of spread to distant organs. A review of cases at BRHS showed that 75 (51%) were stage 0, 23 (15.6%) stage 1, 17 (11.5%) stage 2, 4 (2.7%) stage 3, and 9 (6.1%) stage 4. In comparison with (national) NCDB data, findings showed that majority of bladder cancer cases diagnosed at presentation on a national level (46.77%) were staged at Stage 0 which is similarly close to BRHS data. Surgery, alone or in combination with other treatment is used in more than 90% of cases. Superficial, localized cancers may also be treated immunotherapy or chemotherapy directly into the bladder. BRHS data showed that 132 (89.8%) bladder cancer cases were treated with surgery (surgical excision (TURBT), local tumor excision, radical cystectomy). Sixty five (44.2%) bladder cancer cases were treated with chemo therapy in combination with surgery. NCDB data for cases diagnosed showed a comparatively similar data where approximately eighty to eighty five percent (80-85%) of bladder cases were treated with surgery alone or surgery in combination with chemotherapy. In summary, as with most cancers, there is no definitive cause of bladder cancer. One must be aware of the factors that may increase bladder cancer risk like hereditary, diet, smoking, and exposure to environmental conditions. Therefore, prevention thru smoking cessation, lifestyle change and the like is significantly important in the aspect of bladder cancer care. It is recommended that patients visit their primary care physicians on a regular basis to review any symptoms that might suggest a possibility of bladder cancer. A referral to a specialist is an option for diagnosis and treatment of bladder cancer. The Brazosport Regional Health System provides medical and surgical services for the diagnosis and treatment of Bladder Cancer. - Page 12 -

15 Glossary Accessioned Entered into the Cancer Registry database by the year in which the patient was first seen at Brazosport Regional Health System. AJCC State Classification The American Joint Committee on Cancer Staging Classification based on primary tumor (T), regional lymph node status (N), and distant metastasis (M). Analytic Cases diagnosed and/or receiving all or part of the first course of treatment at Brazosport Regional Health System/Brazosport Regional Cancer Center after reference date of January 1, BRHS Brazosport Regional Health System Carcinoma A malignant tumor of epithelial origin. FORDS Facility Oncology Registry Data Standards. In situ Neoplasm that is non-invasive and confined to a small circumscribed area; may be either benign or malignant. Malignant Mass of cancer cells; many invade surrounding tissues or spread to distant areas of the body. Neoplasm New and abnormal formation of tissue, as a tumor or growth serves no useful function, but grows at the expense of the healthy organ. Non-Analytic Cases receiving all first course of treatment/therapy prior to admission to Brazosport Regional Health System/Brazosport Regional Cancer Center or prior to reference date of January 1, Oncology Science dealing with the physical, chemical, and biological properties and features of cancer, including the causes, the disease process, and treatment. Pathology Science concerned with all aspects of disease, but with specific reference to the essential nature, causes, and development of abnormal conditions, as well as the structural and functional changes that result from the disease processes. Radiology The science of high energy radiation and of the sources and the chemical, physical, and biologic effects of such radiation. Stage of Disease Extent of disease as determined at the time of first course of therapy. AJCC Staging Classification and SEER Summary Staging Manual are used. SEER Surveillance, Epidemiology and End Results. Tumor Abnormal swelling or mass; may be either benign or malignant. REFERENCES Cancer Facts and Figures 2011, American Cancer Society. Standards of the Commission on Cancer, American College of Surgeons. AJCC Cancer Staging Manual, 7th Edition American Joint Commission on Cancer, J.B. Lippincott Co., International Classification of Disease for Oncology (ICD-O), Third Edition, ( Set #2) FORDS, Commission on Cancer, Chicago, Illinois, 2011 (12/21/2010). SEER Summary Staging Manual 2000, National Cancer Institute. ( Errata)

16 2011 Cancer Committee Members Physician Members Emerado Falcon, M.D. Chairman Medical Oncology Mark Bonnen, M.D. Radiation Oncology Thomas Lunsford, M.D. ENT John Maxwell, M.D. Diagnostic Radiology Anupama Pant- Dhodapkar, M.D. Medical Oncology/ Hematology Roland Prezas M.D. Family Practice Robert Thompson, M.D. General Surgery Ann Witson, M.D. Pathology Hospital Staff Connie Ashley, RN Patient Care Services Joan Bell, MBA, CPHQ, RHIA Vice President, Quality Alfred Guevara, FACHE Chief Operating Officer Henry A. Joaquin, BS CTR Cancer Registrar Tiffany Johnson, RND Clinical Nutrition Manager Laurie Kidd, LCSW-CCM Director, Clinical Resources Juliet Lane, RHIT, CCS, CHPC Director, Health Information Management Elvira Ramirez, RN The Mermaid Project Coordinator Sherri Richardson, RN Radiation Oncology Nurse - Page 14 -

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