ballad health cancer care 2019 annual report...velcade received 29 88% received sq 21 72% darzolex...

Ballad Health Cancer Care2019 Annual ReportJanuary-December 2019

2019 Cancer Care Annual Report | Ballad Health I

Table of contentsCancer centers and practices ................................................................................................................................................................................. 1

Multiple myeloma study ........................................................................................................................................................................................... 3

Patient assistance fund ............................................................................................................................................................................................ 5

Low-dose computed tomography outcomes ................................................................................................................................................. 6

Mobile Health Coach: Breast screenings .......................................................................................................................................................... 9

Mouth, throat and skin cancer screeings ......................................................................................................................................................... 11

Breast cancer accountability report ................................................................................................................................................................. 12

Mission, Vision & ValuesOur missionHonor those we serve by delivering the best possible care

Our visionTo build a legacy of superior health by listening to and caring for those we serve

Our valuesCreativityWe seek to discover and promote innovative ideas and the unique talents of each team member to bring value to our community.

CaringWe listen with empathy and appreciation and respond with kindness and compassion.

HonestyWe own our actions and practice the highest ethical standards with transparency and fair behaviors.

RespectWe appreciate the strengths of our community and practice true collaboration and skilled communication in everything we do.

FaithWe nurture the mind, body and spirit of each individual to inspire hope and improve the health and well-being of our community.

QualityWe work as a team to bring best practices, advanced technology, and experiences to provide the highest-quality care. We devote ourselves to continuous improvement, service excellence, and a zero-harm environment.

2019 Cancer Care Annual Report | Ballad Health1

Wise

Russell

Washington

Sullivan

SmythWythe

CarterWashington

UnicoiGreene

Hawkins

Hancock

Lee Scott

Cocke

Hamblen

Tazewell

Buchanan

NORTON, VA

JOHNSON CITY, TN

KINGSPORT, TN

GREENEVILLE, TN

BRISTOL, TN

BRISTOL, VA

ABINGDON, VA

MARION, VA

LEBANON, VA

TN

VA Dickenson

Grayson

Johnson

Ballad Health Cancer Center Territory Map - Updated November 2018

REGIONAL TERRITORIESNorthwestNortheast

SoutheastSouthwestSouthwest

Cancer centers and practices Service map

Wise

Russell

Washington

Sullivan

SmythWythe

CarterWashington

UnicoiGreene

Hawkins

Hancock

Lee Scott

Cocke

Hamblen

Tazewell

Buchanan

NORTON, VA

JOHNSON CITY, TN

KINGSPORT, TN

GREENEVILLE, TN

BRISTOL, TN

BRISTOL, VA

ABINGDON, VA

MARION, VA

LEBANON, VA

TN

VA Dickenson

Grayson

Johnson

Ballad Health Cancer Center Territory Map - Updated November 2018

REGIONAL TERRITORIESNorthwestNortheast

SoutheastSouthwestSouthwest

Cancer centers and practices Service map

Cancer centers and practicesService map

2019 Cancer Care Annual Report | Ballad Health 2

Bristol

OncologyVickie Morgan, MDTamara Musgrave, MDRyan Shao, MDKelley Mayden, FNPKathy Sharp, FNP

Radiation OncologyJohn Fincher, MDMatthew Gestout, MD

Greeneville

OncologyDharmen Patel, MDAnil Tumker, MD

Radiation OncologyJohn Boys, MD

Johnson City

OncologyKanishka Chakraborty, MDDevapiran Jaishankar, MDKoyamangalath Krishnan, MDTeresa Lord, MDElnora Spradling, MDJamie Carnell, NPJulia Davenport, FNPRuth Johnson, FNP

Radiation OncologyKyle Colvett, MDNathan Floyd, MD

Kingsport

OncologyMarcus DaSilva, MDPaul Kramer, MDMalcolm Matthews, MDJamal Maatouk, MDEdwin McElroy, MDIbrahim Nakhoul, MDAsheesh Shipstone, MDKevin Blake, NPMyra Blankenship, NPPaige Goforth, PAMistie Hagaman, NPDonna McDonald, FNPKim Nichols, NPMiranda Thomas, NPWendy Vogel, NP

Radiation OncologyScott Coen, MDBrooks Talton, MDRachael Carter, NP

Tennessee

Virginia

Oncology servicesQuick reference guide

Abingdon

OncologyT. Mark Davis, MDAnthony DeSalvo, MDAhmad Hammad, MDCathy Hopkins, PALydia Novruzov, PA

Radiation OncologyBernie Tisdale, MD

Bristol

OncologyVickie Morgan, MDTamara Musgrave, MDRyan Shao, MDKelley Mayden, FNPKathy Sharp, FNP

Radiation OncologyJohn Fincher, MDMatthew Gestout, MD

Lebanon

OncologyAnthony DeSalvo, MDAshley Jenkins, NP

Marion

OncologyAhmad Hammad, MDJessica Hill, NP

Norton

OncologyNicholas Cook, MDHarish Madala, MDDaryl Pierce, MDApril Wallace, NP

Radiation OncologyScott Coen, MDRachael Carter, NP


Aim: 1. Review of adherence to NCCN guidelines in patients

with multiple myeloma treated at Ballad Health2. Review the administration route of Bortezomib

(Velcade): Subcutaneous vs intravenous3. Review the infusion times of Daratumumab (DARA)

Introduction:Multiple myeloma accounts for <2% of all cancers and 17% of hematologic malignancies in the United States. Median age at diagnosis is 69. Bortezomib has been an integral part of initial treatment of MM. With prolonged therapy, neuropathy has been a major toxicity. Intravenous administration was the standard initially. However subcutaneous administration has been noted to be equally efficacious and less toxic in a phase III non inferiority study1. NCCN has since adopted this as the preferred route of administration. Although responses are typically durable, all patients are expected to relapse. Daratumumab has become an excellent option in this scenario. It is a human IgGk anti-CD38 monoclonal antibody. DARA intravenously induces deep and durable responses in patients with relapsed/refractory multiple myeloma and has been approved both as a monotherapy and in combination with both proteasome inhibitors and immunomodulatory drugs like lenalidomide. However, the infusion time has been a major setback especially during the first infusion. The average infusion times for the first, second and subsequent infusions were noted to be 7.0, 4.3 and 3.4 hours2.

Inclusion criteria:1. Patients age >18 with a diagnosis of multiple myeloma2. Treatment received at Ballad Health

Exclusion criteria:1. Age < 182. Treatment received at non Ballad Health locations

Methods:All patients diagnosed with multiple myeloma over the age of 18 and treated at Ballad Health were identified using the cancer registry.

Charts were reviewed and patients who had received Velcade were identified from the electronic medical record (EMR). The route of administration was noted from the medication administration history. Patients who received DARA were then identified and the infusion times were noted from the medication administration record. The infusion times for the initial infusion and also the maximum and minimum times of infusion for the subsequent infusions were noted. Charts were also reviewed for any history of stem cell transplant. Physician review was done to determine whether the overall treatment approach for these patients was in accordance with NCCN guidelines.

Results:A total of 33 patients were identified and their charts were reviewed. All the patients (100%) were treated in accordance with NCCN guidelines. 29/33 patients received Velcade (88%) at some point. Of the 29, about 21 (72%) received Velcade in the subcutaneous route. The 8 patients who received Velcade in the intravenous route had received it prior to the subcutaneous route being made the preferred route per NCCN.

11/33 patients (33%) had received DARA at some point. All of them had received it in the intravenous form. The average infusion time for DARA was 3 hr 50 min. The average initial infusion time was 4 hr 38 min. One patient had an initial infusion time of 7 hr 1 min. For the subsequent cycles, the average minimum infusion time was 3 hr 27 min and the max was 3 hr 42 min.

10/33 patients had undergone autologous stem cell transplant. At the end of the chart review, 10/33 patients were noted to be deceased; 17 continue to be on active treatment; 1 patient on active surveillance; 1 elderly patient on surveillance due to poor PS and 1 lost to follow-up.

Multiple myeloma site study 2019Harish Madala, MD; Tamara Musgrave, MD; Kelley Mayden, NP

Tamara Musgrave, MDHarish Madala, MD Kelley Mayden, NP


Conclusion:The overall compliance to NCCN guidelines in treatment of MM patients at Ballad Health was noted to be 100%. Velcade was traditionally given in intravenous route. However, a seminal phase 3 study published in 2011 by Moreau, Philippe et al showed that the subcutaneous route was equally efficacious and with significant reduction in toxicity. The ORR was 42% in both groups. Grade 3 or worse adverse events were reported in 57% patients in the subcutaneous group versus 70% in the intravenous group, including hematologic and non-hematologic. There was less incidence of peripheral neuropathy (38% vs 53%) including less grade 3 peripheral neuropathy (6% vs 16%) with subcutaneous than with intravenous administration. The subcutaneous administration in our registry was 72%; however, the ones who received it had received it prior to the current data and the standardization of subcutaneous route.

DARA has fast become an important arsenal in the treatment of multiple myeloma. This has become the preferred second line option in most places in combination with either a proteasome inhibitor or immunomodulatory drug. However, the biggest issue has been “chair time.” The average infusion times for the first, second and subsequent infusions were noted to be 7.0, 4.3 and 3.4 hours2. This is consistent with our findings as well. There are several ongoing studies looking at subcutaneous administration of DARA which could potentially mitigate the infusion time and subsequently the financial burden2,3.

Multiple myeloma study

Cases reviewed 33

Total cases 33

Cases concordant with NCCN 33 100%

Velcade received 29 88%

Received SQ 21 72%

Darzolex received 11 33%

Average infusion time 3 hours 50 minutes

Minimum 3 hours 27 minutes

Maximum 4 hours 12 minutes

Initial 4 hours 38 minutes

References: 1. Moreau, Philippe, et al. “Subcutaneous versus

intravenous administration of bortezomib in patients with relapsed multiple myeloma: a randomised, phase 3, non-inferiority study.” The lancet oncology 12.5 (2011): 431-440.

2. Chari, Ajai, et al. “Subcutaneous Daratumumab (DARA) in Patients (Pts) With Relapsed or Refractory Multiple Myeloma (RRMM): Part 2 Update of the Open-label, Multicenter, Dose-escalation Phase 1b Study (PAVO).” Headache 5 (2018): 20.

3. Mateos, M-V., et al. “Randomized, open-label, non-inferiority, phase 3 study of subcutaneous (sc) versus intravenous (iv) daratumumab (dara) administration in patients with relapsed or refractory multiple myeloma: Columba: S823.” HemaSphere 3 (2019): 364.

4. NCCN Guidelines version 1.2020 Multiple Myeloma.

Multiple myeloma site study 2019


Patient assistance fundHow was it spent?

Imagine undergoing cancer treatment; you’re sick, scared and fighting for your life. Now imagine, in the middle of treatment, the financial toll has become so heavy you can no longer afford gas, electricity or car payments.

For too many people in our region, that’s a frightening reality — which is why the cancer patient assistance fund, overseen by Ballad Health Foundation, is so important. Known as the Circle of Hope fund, it provides assistance for things like gas vouchers, taxi fare, non-covered medications, nutritional expenses, personal care items and electric bills. This fund exists to make things a little easier for patients in their time of need.

Patient assistance fund spend detail 2015-2019CY15 CY16 CY17 CY18 CY19

Mortgage/rent 6% 6% 9% 13% 11%

Medications 18% 20% 18% 18% 15%

Utilities 36% 43% 38% 41% 43%

Gas cards 16% 21% 4% 5% 10%

Food City cards 20% 9% 30% 17% 16%

Other 4% 2% 2% 6% 6%

Total 100% 100% 100% 100% 100%

$3,000

$6,000

$9,000

$12,000

$15,000

CY15 CY16 CY17 CY18 CY19

Total spendPatient assistance fund(Average spend per month)

$5,827$6,828

$8,627

$9,706

$13,307

Cancer programs across the nation — including at Ballad Health — are increasingly providing financial assistance to cancer patients. In the latest Association of Community Cancer Centers annual report, of the cancer programs that responded, 68% are providing some sort of free assistance. How’s that money being used?(bar graphs are below)

68%Generosity at work

74% transportation

54% co-pay amounts

50% household units

40% food

22% childcare

10% other (lodging, housing, screenings, etc.)

46% insurance deductibles


Low-dose computed tomography outcomesImproved survival is the primary motivation for lung cancer screenings — after all, the best opportunity for effective treatment is with early detection. Since introducing low-dose CT lung cancer screenings, Ballad Health has surpassed national averages and uncovered lung cancers sooner.

Northwest Market

Low-dose CT lung screeningsIndian Path Community Hospital

Holston Valley Medical Center

Lonesome Pine Hospital

Mountain View Regional Hospital

Northwest Market total

January 61 41 7 6 115

February 50 33 5 8 96

March 27 40 5 7 79

April 27 55 13 7 102

May 42 59 7 4 112

June 40 57 13 6 116

July 35 59 13 12 119

August 31 82 16 5 134

September 31 88 17 8 144

October 35 83 17 4 139

November 38 60 11 7 116

Monthly average 38 60 11 7 116

Southwest Market

Low-dose CT lung screeningsJohnson City Medical Center

Franklin Woods Community Hospital

Greeneville Community Hospital

Southwest Market total

January 11 30 19 60

February 10 38 12 60

March 23 45 10 78

April 16 80 19 115

May 19 64 10 93

June 18 48 21 87

July 13 59 31 103

August 18 51 26 95

September 10 64 15 89

October 22 71 21 114

November 30 18 18 66

Monthly average 17 52 18 87


Northeast Market

Low-dose CT lung screenings

Bristol Regional Medical Center

Johnston Memorial Hospital

Russell County Hospital

Smyth County Community Hospital

Northeast Market total

January 28 39 7 4 78

February 38 28 10 1 77

March 49 21 9 3 82

April 48 30 14 6 98

May 49 26 17 6 98

June 55 33 5 3 96

July 58 32 13 4 107

August 50 29 8 4 91

September 44 28 7 6 85

October 63 38 4 5 110

November 48 30 9 4 91

Monthly average 48 30 9 4 91

Southeast Market

Low-dose CT lung screeningsJohnson County Community Hospital

Unicoi County Hospital

Sycamore Shoals Hospital

Southeast Market total

January 3 5 27 35

February 3 13 23 39

March 4 5 22 31

April 8 7 16 31

May 10 12 18 40

June 6 3 17 26

July 10 5 25 40

August 6 12 19 37

September 15 7 26 48

October 10 6 35 51

November 11 8 15 34

Monthly average 8 8 22 38

Low-dose computed tomography outcomes


The National Lung Screening Trials Research Team suggests the number of individuals who need to be screened in order to save one life is 320.

Low-dose CT lung screenings Grand totalBallad Health lives saved

January 288 0.9

February 272 0.9

March 270 0.8

April 346 1.1

May 343 1.1

June 325 1.0

July 369 1.2

August 357 1.1

September 366 1.1

October 414 1.3

November 308 1.0

Monthly average 333 11

Low-dose computed tomography outcomes

Lung CTscreening

$11–26K

$50–75K

$31–51K$18–28K

Cervicalscreening

Breastscreening

Colorectalscreening

Screening cost effectivenessCost per life-year saved

Cancer screenings save lives but as a side benefit also create significant cost savings, as measured in cost per life-year saved (see below). And diagnosing lung cancer sooner rather than later can mean $30,000 less in treatment cost (right).

Source: Pyenson B et al., “An Actuarial Analysis Shows That Offering Lung Cancer Screening as an Insurance Benefit Would Save Lives at Relatively Low Cost,” Health Affairs 31(4); Oncology Roundtable interviews and analysis.

Lung cancer stage at diagnosis

Average cost of lung cancer treatment, by stage

Nationally U.S. Dollars

Localized Regional Distant Unstaged

Source: Cancer Data Services

15% 22% 57% 6%

Late-stage Early-stage

Source: Cancer Data Services

$100,723 $69,987

$30,736 di�erence in treatment costs between early-stage and late-stage disease.


Mobile Health Coach: Breast screenings

VA

TN

DCH

Big Stone Gap

St. Paul

SneedvilleRogersville

Bulls Gap

Greeneville

Bristol

AbingdonGlade Spring

Damascus

Lebanon

Grundy

Johnson City

Gray

Kingsport

Duffield

Pennington Gap

Lee Scott

Wise Dickenson

Buchanan

Russell

Tazewell

Washington

Smyth

Wythe

Grayson

JohnsonSullivan

Carter

Unicoi

Washington

Greene

HawkinsHancock

Hamblen

Cocke

Ballad Health took the fight against breast cancer into our communities in 2019, offering free breast screenings throughout the Appalachian Highlands. Locations of screenings are depicted in the service area map below. Ballad Health was able to perform 481 free breast cancer screenings and uncover 15 abnormal results using our mobile coach — more evidence of Ballad Health saving lives and reducing the cost of care in our communities.

481 free breast cancer screenings15 abnormal results identified


Mouth, throat and skin cancer screeningsEvery year, Ballad Health offers free, lifesaving mouth, throat and skin cancer screenings during race weekend at Bristol Motor Speedway.

2015 2016 2017 2019

Total screened 98 79 47 58

Concerning findings, not specific to mouth, throat or skin CA malignancies

19 14 8 25

Concerning findings that may represent mouth, throat or skin CA malignancies/pre-malignancies

11 7 4 3

Findings as a percentage total 31% 27% 26% 48%

Hours screened 5 5 4 4

Number of providers 3 4 4 6

Screenings per hour 20 16 12 15

Screenings per provider 33 20 12 10

Mobile Health Coach: Mouth, throat and skin cancer screeningsBallad Health’s cancer care team is dedicated to fighting cancer in the Applachian Highlands, with an emphasis on early detection and advanced treatment methods.


Breast cancer accountability reportInterpreting the report: The estimated performance rates shown below provide your cancer program with an estimate of the proportion of patients concordant with measure criteria by diagnosis year. If appropriate, the Commission on Cancer standard and benchmark compliance rate is provided. This application provides our cancer programs the opportunity to examine data to determine if performance rates are representative of the care provided at the institution and to review and modify case information using the review function for the measure of interest.

Select measures Measure

Commission on Cancer standard / %

Estimated Performance Rates (%)

Review2013 2014 2015 2016

Radiation is administered within one year (365 days) of diagnosis for women under the age of 70 receiving breast conservation surgery for breast cancer (accountability)

BCSRT 4.4 / 90% 92.10 89.30 96.20 97.50 BCSRT

Tamoxifen or third-generation aromatase inhibitor is recommended or administered within one year (365 days) of diagnosis for women with AJCC T1c or Stage IB-III hormone receptor positive breast cancer (accountability)

HT 4.4 / 90% 93.50 94.10 86.40 96.60 HT

Radiation therapy is recommended or administered following any mastectomy within one year (365 days) of diagnosis of breast cancer for women with four or more positive regional lymph nodes (accountability)

MASTRT 4.4 / 90% 100.00 100.00 85.70 100.00 MASTRT

Bristol Regional Medical Center




Review2013 2014 2015 2016


BCSRT 4.4 / 90% 93.20 90.00 93.80 100.00 BCSRT


HT 4.4 / 90% 90.90 92.60 90.40 93.70 HT


MASTRT 4.4 / 90% 89.90 100.00 90.90 100.00 MASTRT

Holston Valley Medical Center


Breast cancer accountability report




Review2013 2014 2015 2016


BCSRT 4.4 / 90% 95.20 93.50 100.0 86.50 BCSRT


HT 4.4 / 90% 90.80 93.20 97.20 90.40 HT


MASTRT 4.4 / 90% 100.00 87.50 100.0 100.00 MASTRT

Johnson City Medical Center




Review2013 2014 2015 2016


BCSRT 4.4 / 90% 100.0 100.0 100.0 100.00 BCSRT


HT 4.4 / 90% 94.10 90.0 84.60 88.20 HT


MASTRT 4.4 / 90% 100.0 100.0 100.0 100.00 MASTRT

Greeneville Community Hospital

balladhealth.org/medical-services/cancer-care

ballad health cancer care 2019 annual report...velcade received 29 88% received sq 21 72% darzolex...

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