2017 WellStar Cancer Network Annual Report

(Based on CY 2016 Program Activity)

VISION: 

TO DELIVER WORLD-CLASS 

CANCER CARE. 

MISSION: 

TO ELIMINATE THE BURDEN 

OF CANCER ON OUR 

COMMUNITY BY PROVIDING 

COMPREHENSIVE 

PREVENTION & EARLY 

DETECTION, TREATMENT 

AND SURVIVORSHIP 

PROGRAMS, DELIVERED 

IN A PATIENT-CENTERED 

ENVIRONMENT BY 

IMPASSIONED CAREGIVERS. 

2 • WELLSTAR CANCER NETWORK • 2017 ANNUAL REPORT

2016: A Year of Unparalleled Growth and Achievement 

On April 1, 2016, WellStar Health System doubled in size and 

expanded its geographic scope, adding six hospitals to its 

five-hospital network. Through this monumental change, the 

WellStar Cancer Network continued enhancing programs and 

services, adding to our cancer registry a record 3,993 analytic 

cases and 1,128 non-analytic cases at WellStar Cobb, Douglas, 

Kennestone, Paulding and Windy Hill hospitals in 2016. We also 

served the most patients ever through our growing number 

of multidisciplinary Specialty Teams and Treatments (STAT) 

Clinics, which enable cancer patients to start treatment faster, 

increasing their chances of beating the disease. And, through our 

advanced radiologic cancer treatments – like CyberKnife ® and 

TomoTherapy ® – we treated 428 patients – another record. 

Center, WellStar Atlanta Medical Center – South, WellStar North 

Fulton Hospital, WellStar Spalding Regional Hospital, WellStar 

Sylvan Grove Hospital and WellStar West Georgia Medical Center 

– into the WellStar Cancer Network. 

We offer heartfelt thanks to our physicians, nurses, all clinicians, 

team members, Board members and community members for 

their support as we continue to improve our cancer care and 

extend our reach. 

Respectfully, 

In 2016, the WellStar Cancer Network was proud to have been 

granted a three-year accreditation with Gold Commendation 

by the Commission on Cancer (CoC), a quality program of the 

American College of Surgeons (ACS). The highest honor awarded 

to a cancer program, WellStar has achieved this honor twice, 

starting in 2013. Only 50 health systems in the U.S. have received 

this distinction, which would not have been possible without 

our gifted and passionate team of extraordinary healthcare 

professionals who go above and beyond every day for their 

patients. 

Our new Cancer Center at WellStar Kennestone Hospital, which 

opened in 2015, enjoyed its first full year, welcoming 4,829 

patients and caregivers for treatments, education, exercise, 

reflection and holistic healing. 

During the past year, we welcomed Chad Schaeffer, MS, FACHE 

as vice president of oncology, and look forward to his leadership 

as we integrate our new hospitals – WellStar Atlanta Medical 

Michael B. Andrews, M.D. 

Chief Cancer Officer 

David L. Parks, M.D. 

Cancer Committee Chairman 

2017 ANNUAL REPORT • WELLSTAR CANCER NETWORK • 3

Investments in Cancer 

A Successful First Year at WellStar Kennestone’s New Cancer Center 

The newly renovated WellStar Kennestone 

Cancer Center’s Survivorship and Support 

Services building opened in 2015 and has 

been a welcoming presence for thousands 

of patients and family members in 2016. 

WellStar’s goal for the $11-million, 100,000 

square-foot center was to focus on the 

whole patient – mind, body and spirit – 

through its aesthetics and programming: 

• In collaboration with the American 

Cancer Society (ACS), a Resource 

Center offers a serene setting for 

patients and family members to learn 

about their diagnosis, treatment options 

and lowering their cancer risk. The 

Center’s staff assists patients seeking 

information from in-house and online 

libraries. Kiosks allow patients to chat 

live with an ACS navigator through an 

online portal. The Center was made 

possible by a generous donation from 

Dr. David and Dana Parks. 

• The Manning Wellness Kitchen, 

a state-of-the-art demonstration 

kitchen for nutritional education 

• The Rick Gray Family Chapel 

• Integrative medicine such as yoga, 

tai chi, massage and acupuncture 

• A salon offering wig and accessory 

options for those experiencing hair 

loss and a bra and prosthesis service 

• The Garden of Courage for peaceful 

reflection and joyous celebration when 

patients complete their treatment 

• Outpatient Infusion Center 

• Center for Genetics and Individualized 

Medicine 

• STAT Clinic 

• State-of-the-art treatments, such as 

CyberKnife ® and TomoTherapy ® 


National Recognitions/Awards 

WellStar Cancer Network Distinctions 

Commission on Cancer (CoC) 

Accreditation with Gold Commendation 

Outstanding Achievement Award 

One of only 50 health systems in the nation to 

receive this distinction, five WellStar hospitals 

have been granted a three-year accreditation 

with Gold Commendation by the CoC, a 

quality program of the American College of 

Surgeons (ACS). The highest honor awarded 

to a cancer program, this distinction has been 

bestowed on WellStar twice, the first time in 

2013. WellStar Cobb, Douglas, Kennestone, 

Paulding and Windy Hill hospitals received 

the voluntary accreditation. 

Cancer Screening Designated Center 

of Excellence– Accreditation by the 

American College of Radiology 

WellStar Cobb, Douglas and North Fulton 

hospitals, and WellStar Acworth and East 

Cobb health parks 

This designation is awarded 

to lung cancer imaging sites 

that have met all of the ACR 

lung cancer screening measures, 

including participation in a 

lung cancer screening registry. 

Breast Imaging Center of Excellence 

(BICOE) Designation by the American 

College of Radiology (ACR) 

WellStar Kennestone and North Fulton 

hospitals 

BICOE designation is awarded to breast 

imaging centers that achieve excellence 

by seeking and earning accreditation in 

all of the ACR’s voluntary breast-imaging 

accreditation programs and modules, in 

addition to the Mammography Accreditation 

Program. 

A hospital is eligible to receive the ACR 

Breast Imaging Center of Excellence 

designation if it is fully accredited by the 

ACR in the following modalities: 

• Mammography (by the ACR or by an 

FDA-approved state accrediting body) 

• Stereotactic breast biopsy 

• Breast ultrasound, including the 

ultrasound-guided breast biopsy module 

• Breast MRI 

National Accreditation Program for 

Breast Centers (NAPBC) Accreditation 

by the American College of Surgeons, 

Commission on Cancer 

WellStar Kennestone Hospital 

NAPBC breast programs ensure 

multidisciplinary leadership representation 

and nationally recognized breast cancer 

quality performance measures for measuring 

quality improvement. 

The objectives of the NAPBC include: 

• Consensus development of criteria 

for breast centers and a survey process 

to monitor compliance 

• Strengthening of the scientific basis 

for improving quality care 

• Reducing the morbidity and mortality 

of breast cancer by improving screening 

mammography and advocating for 

increased access to and participation 

in clinical trials 

• Expanding programs of quality 

improvement measurement and 

benchmark comparison 


Breast Cancer Program 

WellStar’s comprehensive Breast Cancer 

Program is a model in multidisciplinary 

success, with dedicated breast surgeons, 

medical and radiation oncologists, stateof-the-art 

treatment options, genetic 

counseling and a robust support network. 

In 2016, breast surgeons performed 756 

breast surgeries at WellStar facilities, and 

2,815 patients were served by dedicated 

nurse navigators, who support patients 

throughout their journey with cancer. 

WellStar has made advances in breast 

cancer detection, treatment, surgical 

options and support: 

• After implementing a policy of confirming 

a patient’s biopsy appointment after an 

abnormal mammogram, nearly 93 percent 

of patients with abnormal mammograms 

returned for follow-ups in 2016, either 

through biopsies or active surveillance. 

• The L-Dex ® system, which identifies 

lymphedema up to 10 months before 

evidence of limb swelling, was instituted 

in 2016. Over 100 patients have 

already benefitted from this accurate 

measurement tool, which offers a noninvasive 

method of measuring tissue 

composition and fluid status. Early 

detection and intervention can help 

prevent the progression of lymphedema 

and may even reverse it. An estimated 

three to five million people in the U.S. 

live with lymphedema. 

• Survivors Offering 

Support (SOS), 

a peer-to-peer 

support program, 

was launched in 

2016. SOS matches 

breast cancer 

patients with 

volunteers who 

have had similar 

breast cancer 

experiences and 

are in a similar life 

stage. The patient 

and volunteer 

create a custom 

plan for working 

together. 

• The Shoulder to 

Lean On Project, 

created by Paola 

Berrios, a high 

school student, 

aims to educate 

and support teens 

affected by a loved one’s 

cancer diagnosis. WellStar 

team members served as 

mentors to Paola, whose 

mother was a WellStar 

breast cancer patient. 

Now a resource for WellStar 

patients, the website – and 

Paola – received the Gold 

Award, Girl Scouting’s 

highest achievement. 

(Front row l-r): Chad Schaeffer, MS, FACHE; Michael Andrews, M.D.; Kathy Dugger, BSRT (M) (CV); Phillip Israel, 

M.D.; Hilary Hahm, M.D.; (Back row l-r): Sara Owens, RN, OCN; Maureen Lavelle, RN, OCN; Aimee Popp, M.D.; 

Jay Patel, M.D.; Kimberly King-Spohn, MS, CGC; Lisa Sherman, RN, CBCN; Leena Nehru, MSW, LCSW; 

Not pictured: Carlos Alarcon, M.D.; Diane Austin, RN; Sarah Bentley, RN; Nichole Bookout, RN; Sheree 

Brown, M.D.; Marcus Crawford, M.D.; Michael Folk, M.M., R.T.(T); Heather Gatcombe, M.D.; Kate Gavin, 

Cert MDT, CLT-LANA; Catherine Goodwin, M.D.; Lynn Hanks, ARRT –R, ARRT –M; Anna Meyerson, M.D.; 

Christine Min, M.D.; Barry Roseman, M.D.; Jeralynn Scott, BSRT (M); Rhonda Wachsmuth, M.D.; Theresa 

Wang, M.D.; Leigh Webb, MPH, CTR; Keith West, M.D.; Barbara Wilson, MS, RN, AOCN, ACNS-BC 

LOOKING AHEAD 

In 2017, WellStar will introduce Hidden Scar 

Breast Cancer Surgery, an advanced approach 

in which breast surgeons will remove cancerous 

tissue through incision(s) made in inconspicuous 

areas to minimize visible scarring. The Hidden 

Scar approach may also ease the emotional 

impact of breast cancer surgery, in that 

patients have little to no visible reminder of 

the surgery, and experience a more natural 

looking breast reconstruction. 


BREAST CANCER PROGRAM QUALITY MEASURES 

Measure 

CoC 

Benchmark 

Compliance 

% Rate 

National 

% 

Georgia 

% 

Same 

Type CoC 

Program 

(INCP) % 

WellStar 

Cancer 

Network 

% 

(2014) 




% 

(2015) 

Breast conservation surgery rate for 

women with AJCC clinical Stage 0, I, 

or II breast cancer (Surveillance) 

N/A 

65% 

59% 

64% 

59% 

70% 

Image or palpation-guided needle 

biopsy to the primary site is 

performed to establish diagnosis of 

breast cancer (Quality Improvement) 

80% 

93% 

95% 

93% 

95% 

92% 

Tamoxifen or third generation 

aromatase inhibitor is 

recommended or administered 

within 1 year (365 days) of diagnosis 

for women with AJCC T1c or Stage 

IB-III hormone receptor positive 

breast cancer (Accountability) 

90% 

93% 

92% 

95% 

92% 

93% 

Radiation therapy is recommended 

or administered following any 

mastectomy within 1 year (365 days) 

of diagnosis of breast cancer for 

women with >= 4 positive regional 

nodes (Accountability) 

90% 

91% 

90% 

91% 

93% 

87% 

Radiation is administered within 

1 year (365 days) of diagnosis 

for women under the age of 70 

receiving breast conservation 

surgery for breast cancer 

(Accountability) 

90% 

93% 

94% 

94% 

93% 

95% 

Combination chemotherapy is 

recommended or administered 

within 4 months (120 days) of 

diagnosis for women under 70 with 

AJCC T1cN0 or stage IB-III hormone 

receptor negative breast cancer 


N/A 

93% 

91% 

93% 

90% 

100% 


Gastrointestinal (GI) Cancer Program 

With its leading-edge technology and 

highly trained, nationally recognized 

physicians, WellStar has become a 

destination for GI cancer staging and 

treatment. WellStar’s comprehensive, 

holistic approach includes surgery, 

advanced outpatient procedures, 

targeted chemotherapy, immune therapy/ 

biologic treatments, radiation, clinical 

trials and nutritional support. In 2016, 

the GI team embarked on an initiative 

to enhance patient recovery and reduce 

readmissions through a pre-operative 

education program and pre-habilitation 

services. Customized for oncology patients 

undergoing complex surgery and their 

caregivers, the multidisciplinary program 

focuses on: 

• Nutrition/fluid assessment 

• Preoperative physical therapy 

• Smoking cessation 

• Clear lung initiative 

• Pain expectations, when-to-seek-care 

parameters 

• Individualized, surgery-specific preop 

classes, including written material, 

for patient and caregiver, led by the 

nurse navigator at a time convenient 

for the patient 

The oncology surgeons felt that the 

number of re-admissions, within the first 

30 days following surgery, was higher 

than the national average following GI 

oncology surgeries. The re-admission rate 

for 5 South at Kennestone for GI oncology 

surgeries from January - May 2015 was 

14.77%, which exceeds the national 

re-admission threshold of 12%. 

Strategic Goal: Decrease re-admission 

rate for GI oncology surgeries on 5 South 

to less than 10% by December 31, 2016. 

Intervention developed by the team: 

• A system for increasing the frequency 

of phone calls to the patients following 

surgery by the physician office staff. 

• Post-Surgical Zones document given at 

surgical discharge to educate patients on 

symptoms to watch for and when to notify 

the physician or seek emergency care. 

• Develop 

an education 

booklet in 

conjunction 

with a class that 

explains the preop 

instructions, 

what will happen 

during the 

hospital stay, 

and what 

symptoms to 

look for after 

discharge. 

An insert of an 

illustration of the specific surgery will be 

included for each patient. 

• Develop an individualized pre/post-op 

class based upon the patient's surgical 

procedure to be facilitated by the Nurse 

Navigator. 

The readmission rate calculated after the 

intervention implementation decreased to 9%. 

In addition, an Enhanced Recovery After 

Surgery (ERAS) protocol was instituted for 

hepatobiliary and pancreatic cancer. These 

perioperative care pathways aim to hasten 

recovery after surgery by maintaining 

preoperative organ function and reducing 

postoperative stress. ERAS protocols have 

been shown to decrease complications 

and length of stay. 

(Front row l-r) Kate Vasconcellos, M.D.; Dean Kirkel, M.D.; Nancy Page, RN, OCN; Sachin Goel, M.D.; 

George Suku, M.D.; (Back row l-r) Raj Sappati, M.D.; Sartaj Sanghera, M.D.; Steven McCune, M.D., Ph.D.; 

Michael Andrews, M.D.; Roger Williams, D.O.; Justin Hart, M.D., Ph.D.; Sahir Shroff, M.D. 

Not pictured: Donna Byfield, RN, MSN, CWCON; Jaydip Datta, M.D; Scott Early, M.D.; Michael Folk, M.M., 

R.T.(T); Robin Gohacki, NP; Sujatha Hariharan, M.D.; Aaron Kefela, M.D.; Kimberly King-Spohn, MS, CGC; 

Carmen Klass, M.D., Ph.D.; Chad Kuhlman, M.D.; Hao Hai Liang, M.D.; Harry Liberman, M.D.; Thomas Murphy, 

M.D.; Leena Nehru, MSW, LCSW; Stephen Odom, M.D.; Raul Oyola, M.D.; Jeffrey Schwab, M.D.; Leigh Webb 

MPH, CTR; Rachel White, RD, CSO, LD, CNSC; Barb Wilson, MS, RN, AOCN, ACNS-BC; Mark Wyatt, M.D. 


GI CANCER PROGRAM QUALITY MEASURES 

During the past calendar year, 

WellStar’s GI program also: 

• Created a pathway for patients 

with hepatocellular cancer and 

an algorithm for transplantation 

• Incorporated biomarkers for colon 

and rectal cancer to guide therapy 

in Stage 2 disease, such as CDX-2, 

a specific marker of adenocarcinomas 

of intestinal origin 

• Enhanced preoperative staging for 

all colon and rectal cancer patients, 

ensuring uniformity, and removing 

barriers 

• Created and monitored colon 

cancer metrics 

In October 2016, WellStar’s GI 

Symposium drew more than 75 

physicians, clinicians and patients 

from across the Southeast. The fivehour 

symposium featured nationally 

known expert Robert C.G. Martin II, 

M.D., PhD, FACS, and workshops on 

state-of-the-art GI procedures. 

Measure 

Adjuvant chemotherapy 

is recommended, or 

administered within 4 months 

(120 days) of diagnosis for 

patients under the age of 80 

with AJCC Stage III (lymph 

node positive) colon cancer 


At least 12 regional lymph 

nodes are removed and 

pathologically examined for 

resected colon CA (Quality 

Improvement) 

Pre-operative chemo and 

radiation are administered for 

Clinical AJCC T3N0, T4N0 OR 

STAGE III; or Postoperative 

chemo and radiation are 

administered within 180 days 

of diagnosis for clinical AJCC 

T1-2N0 with pathologic AJCC 

T3N0, T4N0 or Stage III; or 

treatment is recommended; 

for patients under the age 

of 80 receiving resection 

for rectal cancer (Quality 

Improvement) 

CoC 

Benchmark 

Compliance 

% Rate 

N/A 

85% 

85% 

National 

% 

90% 

91% 

89% 

Georgia 

% 

89% 

91% 

91% 

Same 

Type CoC 

Program 

(INCP) % 

93% 

92% 

92% 




% 

(2014) 

93% 

89% 

94% 




% 

(2015) 

100% 

95% 

100% 


Genitourinary (GU) Cancer Program 

The GU Program serves patients with 

a combination of the latest research, 

diagnostic and treatment options, and 

clinical trials. Among the first healthcare 

systems in the area to introduce a 

multidisciplinary clinic for prostate cancer 

patients, WellStar clinicians have seen 

more than 70 patients with biopsy-proven 

prostate cancer in the last two years. The 

System has advanced prostate cancer 

care in several areas, including support, 

treatment and technology. 

In addition to traditional prostate cancer 

support groups, which are among the 

System’s most well attended, WellStar 

has initiated a peer-to-peer support 

program, connecting newly diagnosed 

prostate cancer patients with volunteer 

prostate cancer survivors. In September 

2016, Prostate Cancer Awareness Month, 

WellStar held its Fifth Annual Prostate 

Survivors Celebration, enjoyed by more 

than 60 survivors and guests. 

When appropriate, WellStar’s GU Program 

employs the active surveillance method 

with prostate cancer patients, aiming 

to avoid unnecessary biopsies and 

surgeries. To that end, in 2016, WellStar 

began using Decipher ® testing for newly 

diagnosed patients, a predictor of disease 

progression. Based on the patient’s tumorbased 

genomics, the test identifies more 

aggressive forms of cancer so clinicians 

can more appropriately plan treatment. 

In 2016, WellStar became one of the few 

Atlanta healthcare systems offering Fusion 

MRI, a process that blends ultrasound and 

MRI technologies for a detailed, accurate 

map of the prostate. Used to guide followup 

biopsies, Fusion MRIs require specially 

trained urologists for administration and 

reading. 

LOOKING AHEAD 

In early 2017, WellStar will extend its prostate cancer 

low-dose radiation (LDR) brachytherapy treatments to 

patients at WellStar Paulding Hospital. Through this 

approach, tiny radioactive seeds will be placed directly 

into the tumor, delivering low doses of radiation over 

a few months and killing the cancer cells. 

(l-r) Becky Hippensteel, RN, MBA, BSN, CNOR, CASC; Stuart Resnick, M.D.; Justin Watson, M.D.; 

William Thoms, M.D.; Justin Hart, M.D., Ph.D.; Michelle Guibault, RN, BSN, OCN; Michael Andrews, 

M.D.; Dean Kirkel, M.D.; Cesar Angeletti, M.D. 

Not pictured: Chad Schaeffer, MS, FACHE; Kim King-Spohn, MS, CGC; Nikolas Symbas, M.D.; 

Jeffrey Tharp, M.D.; Leigh Webb, MPH, CTR; Barbara Wilson, MS, RN, AOCN,ACNS-BC 

WellStar’s GU Program is developing a pre-operative 

education program and pre-habilitation services for 

cystectomy patients with the goals of educating and 

preparing patients for life after surgery, and reducing 

re-admissions and infections. Program clinicians will 

also be working to systematically follow up on bladder 

cancer patients who have undergone cystoscopies. 


GU CANCER PROGRAM QUALITY MEASURES 

Measure 

CoC 

Benchmark 

Compliance 

% Rate 

National 

% 

Georgia 

% 

Same 

Type CoC 

Program 

(INCP) % 




% 

(2014) 




% 

(2015) 

At least 2 lymph nodes are 

removed in patients under 80 

undergoing partial or radical 

cystectomy (Surveillance) 

N/A 

93% 

98% 

91% 

100% 

100% 

Radical or partial cystectomy; 

or tri-modality therapy (Local 

tumor destruction/excision with 

chemotherapy and radiation) for 

clinical T234N0M0 patients with 

urothelial carcinoma of the bladder, 

first treatment within 90 days of 

diagnosis (Surveillance) 

N/A 

59% 

62% 

59% 

62% 

64% 

Neo-adjuvant or adjuvant 

chemotherapy recommended or 

administered for patients with 

muscle invasive cancer undergoing 

radical cystectomy (Surveillance) 

N/A 

67% 

69% 

68% 

78% 

80% 


Thoracic Cancer Program 

WellStar’s Thoracic Cancer Program is a 

national leader in lung cancer screening, 

treatment and clinical research. WellStar 

is home to the largest community-based 

lung cancer screening program in the 

nation. At WellStar, lung cancers are being 

detected at early, treatable stages – 74 

percent discovered are in stage 1 or 2. 

In 2016, 1,455 people were screened for 

lung cancer, and that number is expected 

to reach 2,500 in 2017. During the last 

calendar year, WellStar physicians began 

using myPlan TM for patients diagnosed 

with early-stage lung cancer. The test 

accurately identifies which patients may 

need post-surgical chemotherapy. 

WellStar’s Specialty Teams and Treatments 

(STAT) Clinic is a WellStar distinction, 

offering patients an innovative concept 

unique in metro Atlanta. STAT clinics 

enable patients with lung, chest and 

esophageal cancers to start treatment 

faster, increasing their chances of 

beating the disease. Patients meet with 

a multidisciplinary team of physicians 

and specialists in one day, in one setting, 

allowing treatment to begin within days 

instead of weeks or months. In 2016, STAT 

patient volume increased by 54 percent 

due to a new clinic at WellStar Douglas 

Hospital and 

expanded hours 

at WellStar 

Kennestone 

Hospital. 

In 2016, thoracic 

clinical research 

at WellStar 

reached an alltime 

high. Out of 

the participating 

institutions 

– Brigham & 

Women’s/Dana 

Farber Institute, 

Georgetown, 

Northshore, 

Providence/John 

Wayne Cancer 

Institute, and 

Washington University, WellStar had the 

most participants enrolled (59 out of 

176) in an interoperative quality study 

on video-assisted thoracoscopic surgery 

(VATS). WellStar had the second highest 

participation rate – 145 patients out 

of 560 – in a prospective randomized 

study on digital versus analog pleural 

drainage (Medela Trial). WellStar was 

also one of 20 centers in the U.S. to 

(l-r) Timothy, Udoji, M.D.; Beverly Green MSN, RN, CNL; Rachel White, RD, LD, CSO; Dan Miller, M.D.; 

Gigi Bellamy, BSN, RN, OCN; Bill Mayfield, M.D.; Vickie Beckler, BSN, RN; Leena Nehru, MSW, LCSW, 

OSW-C; Steve McCune, M.D., Ph.D. 

Not pictured: Michael Andrews, M.D.; Andrew Helms, M.D.; Jonathon Herbst, M.D.; Kimberly King- 

Spohn, MS, CGC; Mark McLaughlin, M.D.; Hiren Patel, M.D.; Leigh Webb, MPH, CTR; Barbara Wilson, 

MS, RN, AOCN,ACNS-BC 

participate in a post-FDA approval study 

of Progel TM Pleural Air Leak Sealant, 

with WellStar’s Dan Miller, M.D., as the 

principal investigator. In addition, WellStar 

conducted a quality feasibility study of 

Hyperthermic IntraThoracic ExtraCorporeal 

Chemotherapy (HITeC). WellStar, the only 

system in the U.S. performing HITeC, has 

treated 28 patients. 

COMMUNITY OUTREACH 

In addition to promoting healthy lifestyles, early detection and screening for cancer, 

WellStar offers a robust lung cancer screening program. In 2016, we found 23 lung 

cancers and 25 total cancers out of 1,455 screened from nine screening locations. 


Measure 

At least 10 regional lymph nodes 

are removed and pathologically 

examined for AJCC stage IA, 

IB, IIA, IIB resected NSCLC 

(Surveillance) 

Surgery is not the first course of 

treatment for cN2, M0 lung cases 

(Quality Improvement) 

Systemic chemotherapy is 

administered within 4 months 

to day preoperatively or 

day of surgery to 6 months 

postoperatively or it is considered 

for surgically resected cases with 

pathologic lymph node pN1/pN2 

NSCLC (Quality Improvement) 

THORACIC CANCER PROGRAM QUALITY MEASURES 

CoC 

Benchmark 

Compliance 

% Rate 

N/A 

85% 

85% 

National 

% 

43% 

93% 

93% 

Georgia 

% 

54% 

94% 

92% 

Same 

Type CoC 

Program 

(INCP) % 

46% 

92% 

94% 




% 

(2014) 

72% 

86% 

92% 




% 

(2015) 

79% 

100% 

100% 


Gynecologic (GYN) Cancer Program 

The GYN cancer program made important 

strides over the past year, extending its 

reach to four locations, with plans for a 

fifth. In addition to offices in Riverdale 

and at WellStar Cobb and Kennestone 

hospitals, the program now sees patients 

at WellStar North Fulton Hospital, and in 

September 2017, an office will open at 

WellStar Vinings Health Park. To help guide 

and support women through treatment, 

nurse navigator Susan Willard, BSN, RN, 

OCN, spearheads a gynecology-specific 

cancer patient support group at Cobb 

Hospital. 

Jeffrey Hines, M.D., and Amy Carroll, 

M.D., perform a wide range of complex 

surgeries, including robotic, on virtually all 

types of gynecological cancers, including 

cervical, endometrial, ovarian, vaginal, 

vulvar and gestational trophoblastic 

disease. They oversee two state-of-theart 

chemotherapy centers – in Austell and 

Riverdale – dedicated to gynecologic 

cancer. In addition, the doctors conduct 

quarterly, strategic multidisciplinary 

meetings. Drs. Hines and Carroll 

participate in weekly treatment planning 

conferences with their colleagues in 

radiation oncology and medical oncology. 

Additionally, they work closely with partner 

services, including genetic counseling, 

nutrition, social work and palliative 

medicine. 

In 2016, the physicians partnered with 

colleagues from Northwest Georgia 

Oncology Centers on several industrysponsored 

clinical trials for patients with 

gynecologic malignancies. 

LOOKING AHEAD 

Plans are underway to expand our 

gynecologic oncology services by 

adding an additional gynecologic 

oncologist, and by increasing our 

physicians’ availability to see patients 

at WellStar Kennestone and North 

Fulton hospitals. Additionally, we have 

plans to expand our offering of clinical 

trials with the addition of Gynecologic 

Oncology Group (GOG) protocols. 

(l-r) Jeffrey Hines, M.D.; Marla Franks, M.D.; 

Susan Willard, BSN, RN, OCN; Michele 

Daniel, BSN, RN; Kathy Gresham, MSN, RN; 

Chad Schaeffer, MS, FACHE 

Not pictured: Michael Andrews, M.D.; Amy 

Carroll, M.D.; Nicole Dinnall; Scott Early, M.D.; 

Milele Francis, M.D.; Heather Gatcombe, 

M.D.; Kimberly King-Spohn, MS, CGC; Carlos 

Osmon, M.D.; Leigh Webb, MPH, CTR; 

Barbara Wilson, MS, RN, AOCN, ACNS-BC 


Measure 

Use of Brachytherapy in patients 

treated with primary radiation 

with curative intent in any stage of 

cervical cancer (Surveillance) 

Chemotherapy administered 

to cervical cancer patients who 

received radiation for stage 

IB2-IV cancer (Group 1) or with 

positive pelvic lymph nodes, 

positive surgical margins, and/or 

positive parametrium (Group 2) 


Radiation therapy completed within 

60 days of initiation among women 

diagnosed with any stage of 

cervical cancer (Surveillance) 

Chemotherapy and/or radiation 

administered to patients with 

Stage IIIC or IV Endometrial cancer 


Endoscopic, laparoscopic, 

or robotic performed all for 

Endometrial cancer (excluding 

sarcoma and lymphoma), for 

all stages except stage IV 


Salpingo-oophorectomy with 

omentectomy, debukling/ 

cytoreduction surgery, or pelvic 

exenteration in Stage I-IIIC Ovarian 

Cancer (Surveillance) 

GYN CANCER PROGRAM QUALITY MEASURES 

CoC 

Benchmark 

Compliance 

% Rate 

N/A 

N/A 

N/A 

N/A 

N/A 

N/A 

National 

% 

73% 

89% 

79% 

83% 

75% 

72% 

Georgia 

% 

83% 

92% 

81% 

80% 

83% 

73% 

Same 

Type CoC 

Program 

(INCP) % 

78% 

90% 

81% 

83% 

78% 

72% 




% 

(2014) 

91% 

94% 

100% 

75% 

92% 

71% 




% 

(2015) 

93% 

100% 

75% 

77% 

91% 

86% 


Melanoma Program 

A multidisciplinary team was established 

to address incidence of melanoma in 

the communities we serve. The team 

collaborated to bring multimodality 

treatments to our patients, and in 

2016, WellStar treated 102 patients 

for melanoma. 

LOOKING AHEAD 

WellStar is one of the few centers in 

Georgia that will offer FDA-approved 

T-VEC (Imlygic TM ), the first oncolytic 

virus therapy for patients with locally 

advanced melanoma that cannot be 

completely removed with surgery. 

Patients receive T-VEC as a series of 

intralesional injections, administered 

in conjunction with other systemic 

therapies. 

T-VEC, approved by the FDA in 2015, 

will be just one of the many options 

available to WellStar melanoma patients. 

Dermatologists, surgical oncologists 

and medical oncologists work together 

in the System’s comprehensive, 

multidisciplinary melanoma program, 

offering a variety of treatment paradigms, 

including targeted drugs, immune 

therapy and radiation. 

(l-r) Nancy Page, RN, OCN; Sartaj Sanghera, M.D.; Hao Hai Liang, M.D.; Michael Andrews, M.D.; 

Robin Gohacki, NP; Sahir Shroff, M.D.; Dean Kirkel, M.D. 

Neurooncology Program 

WellStar’s comprehensive neurooncology 

capabilities are comparable to those 

typically found in large academic 

centers. Round-the-clock neurosurgeons, 

neurologists, neuroradiologists and 

neurointensivists handle virtually any type 

of neurooncologic disease of the brain and 

spine. A neurointensive care unit staffed by 

neurologists is a WellStar distinction, as is 

the System’s state-of-the-art CyberKnife ® 

Robotic Radiosurgery System for patients 

with inoperable or surgically complex 

tumors. Sophisticated technology includes 

functional imaging to identify speech and 

motor areas near tumors, diffusion tensor 

imaging for identifying nerve pathways in 

the brain and intraoperative CT guidance, 

which assists with tumor resection. 

Recently, WellStar’s neurooncology 

program added the capability of brain and 

spinal tumor embolization, an important 

cancer therapy procedure that helps treat 

tumors by blocking the blood vessels that 

supply them. WellStar neurosurgeons 

also perform skull-based surgery on 

complicated, deep tumors of the brain. 

Neuro subspecialists include neuro 

otolaryngologists, who perform minimally 

invasive surgery on tumors of the ear, nose 

and throat. 

Not pictured: Michael Folk, M.M., R.T.(T); Justin Hart, M.D., Ph.D.; Kimberly King-Spohn, MS, CGC; 

Leena Nehru, MSW, LCSW; Elizabeth Richwine, M.D.; Chad Schaeffer, MS, FACHE; Leigh Webb, 

MPH, CTR; Barbara Wilson MS, RN, AOCN, ACNS-BC 


Navigating Breast Cancer 

Tracy Drake knew this time was different. 

She was accustomed to abnormal 

mammograms and subsequent biopsies, 

but her October 2016 biopsy confirmed 

her suspicion – invasive ductal carcinoma. 

A breast MRI two days later revealed it was 

Stage 3. 

“I could feel the lump,” said the 46-yearold 

mother. “It was nine centimeters – I 

just knew. Immediately after my biopsy, 

Maureen Lavelle, WellStar Paulding 

Hospital’s nurse navigator, got involved. I 

would have been lost without her – she was 

awesome.” Maureen, a certified oncology 

nurse, recently helped launch Paulding 

Hospital’s nurse navigator program. Nurse 

navigators support patients and their 

families from the initial diagnosis through 

post-treatment follow-up. Navigators are 

with patients during the entire treatment 

plan, and are often present during 

procedures. The navigator is often an 

invaluable source of emotional support. 

“Maureen got everything moving very 

quickly,” explained Tracy, “coordinating 

all my appointments and treatments. She 

has been with me every step of the way,” 

said Tracy. “She even went with me for my 

genetic testing.” 

Beginning in early November 2016, the 

Douglasville resident underwent dose 

dense chemotherapy at Paulding Hospital 

every two weeks, for six weeks. Then in 

early January 2017, Tracy began a 12-week 

course of single-round chemotherapy. She 

will have a mastectomy, reconstruction 

and radiation. “My treatment plan is very 

aggressive,” said Tracy. “I’ve done really 

well with the chemo – I’m staying strong 

and positive. And I was so relieved 

I tested negative for everything – I have 

two teenage girls.” Genetic testing allows 

people to learn if their family history of 

breast cancer is due to an inherited gene 

mutation. Only five to 10 percent of breast 

cancers in the U.S. are linked to such a 

mutation, according to the American 

Cancer Society. 

“I’ve learned so much about 

strength and perseverance 

from my patients,” said 

Maureen. “Tracy is incredibly 

strong – she always has a 

smile on her face.” “ 

I know I’ve done as well as I 

have because of my faith in 

God,” said Tracy. “My sister 

rallied prayer warriors across 

the country who prayed 

for me around the clock. It 

worked. “I told my husband 

of two years that the sickness 

and health part came quicker 

than we thought,” laughed 

Tracy, who reconnected three 

years ago with her high school 

sweetheart after 26 years 

and found love. “He and my 

girls have been extremely 

encouraging and supportive. 

I’m so grateful to them, to 

God – and to Maureen. 

Without her, I wouldn’t have 

known what to do.” 


Survivorship 

& Support 

WellStar understands that people 

living with cancer have needs that 

extend far beyond the medical 

aspects of care. For that reason, 

the System has invested in and 

developed programs to provide 

the additional support so important 

Helping Patients Navigate 

Their Cancer Journey 

WellStar’s well established nurse 

navigator program brings a highlypersonalized 

level of guidance and 

support to cancer patients during 

each step of treatment. Nurse 

navigators support breast, thoracic, 

GI, GU and GYN patients and their 

families from initial diagnosis through 

post-treatment follow-up. Navigators 

are with patients during the entire 

treatment plan, and often accompany 

patients to MRIs, biopsies and surgical 

procedures. In addition, the navigator 

often acts as an invaluable source of 

emotional support. In 2016, WellStar 

expanded its nurse navigator program 

to WellStar Paulding Hospital. 

Maureen Lavelle, a certified oncology 

nurse, is initially working exclusively 

with breast cancer patients. During 

the past year, the System also 

extended its reach to gynecology 

patients via nurse navigator Susan 

Willard, RN, OCN. 

Enhancing Our Support 

From support groups and a breast 

cancer survivor peer visitation 

program, to classes on coping with 

cancer and cooking demonstrations, 

WellStar offered cancer patients hope 

and help in 2016. Nearly 300 patients 

and family members attended support 

groups and mindfulness workshops 

during the last year. Well known chefs 

like Holly Chute and Henry Chandler 

shared favorite recipes and prepared 

meals in the Manning Wellness Kitchen 

at the Kennestone Cancer Center. 

Patients and guests practiced yoga, 

Tai Chi and low-impact resistance 

training at the Wellness Studio. 

WellStar’s collaborative approach to 

psycho-oncology continued to offer 

patients emotional and psychiatric 

support. Our psychologist and 

psychiatrist screened 1,395 patients 

for psychosocial distress; nine percent 

of those screened were referred for 

additional services. 

to those living with cancer. 

Extending Community Outreach 

In 2016, WellStar partnered with Loving Arms Cancer Outreach, a nonprofit 

organization working to bridge the financial gap for patients in the community 

created by cancer-related costs. WellStar’s partnership, which will provide gas and 

grocery cards for cancer patients, aims to ease patients’ financial burdens so they 

can focus on treatment plans and recovery. 


Improving Access 

STAT Clinics: 

A WellStar Distinction 

WellStar’s Specialty Teams and Treatments 

(STAT) Clinics offer cancer patients an 

innovative concept unique in metro 

Atlanta. STAT clinics enable patients to start 

treatment faster, increasing their chances 

of beating the disease. This concept, 

created at WellStar Kennestone Hospital 

in 2006, and expanded to WellStar Cobb 

Hospital in 2012, allows patients to meet 

with a multidisciplinary team of physicians 

and specialists in one day, in one setting. 

Treatment is typically started within days 

instead of weeks or months. 

In 2016, STAT clinics opened at WellStar 

Douglas and North Fulton hospitals, and 

the clinic at WellStar Kennestone Hospital 

was expanded. As a result, patient volume 

more than doubled, increasing by 54 

percent. 

Lifesaving Screening 

WellStar is home to the largest communitybased 

lung cancer screening program 

in the nation. Since 2008, the System’s 

programmatic approach has resulted in 

a dramatic stage shift; today at WellStar, 

74 percent of lung cancers are detected 

in stage 1 or 2, when the disease is more 

treatable. Just two years ago, only 36 

percent of lung cancers were detected in 

these important early stages. The System’s 

dedicated, comprehensive approach has 

been so successful that it plans to expand 

the program to include colorectal, breast 

and prostate cancer screenings. The 

System’s goal is to increase screening and, 

as a result, survival rates in its communities. 

Infusion 

In 2016, 20,831 treatments took place at 

WellStar’s six infusion centers, located at 

WellStar Cobb, Douglas, Kennestone and 

Paulding hospitals, and several ancillary 

sites. The System’s largest center, on the 

WellStar Kennestone Hospital campus, 

substantially expanded its capacity in 

2015 and subsequently opened an 

additional pod in 2016, for a total of 24 

chairs. Plans call for a similar expansion at 

Cobb Hospital, to accommodate up to 20 

patients. Infusion therapy will be part of 

a seamless, comprehensive cancer center 

planned at Cobb Hospital. 

Palliative Care 

WellStar palliative care specialists work 

closely with oncologists to ensure cancer 

patients and their families enjoy the best 

quality of life possible. People of any 

age, with any type or stage of cancer, can 

benefit from palliative care, which can be 

provided along with curative treatment. 

Palliative care clinicians specialize in 

relieving symptoms of cancer and its 

treatments, such as pain, nausea, vomiting, 

fatigue, anxiety, depression, constipation, 

diarrhea, confusion or shortness of breath. 

More than 1,000 in-hospital WellStar 

cancer patients received palliative care in 

2016. 

In 2016, WellStar extended palliative care 

access with the opening of an outpatient 

clinic near the WellStar Kennestone 

Hospital campus. 


Genetics: Center for Genetics and Individualized Medicine 

Between five and 10 percent of cancers 

are diagnosed in people with an inherited 

predisposition to increased risk. Through 

genetic risk assessment, the WellStar 

Center for Genetics and Individualized 

Medicine aims to stop cancer before it 

appears. Housed in the newly renovated 

Cancer Center at WellStar Kennestone, 

the Center for Genetics and Individualized 

Medicine includes custom-designed 

consultation rooms and an in-house lab. 

After determining whether genetic testing 

is appropriate, WellStar genetic counselors 

test for specific hereditary conditions 

known to increase the risk of various 

cancers. Counselors then recommend a 

specific plan based on the results, which 

could include increased screenings, 

lifestyle modifications and prophylactic 

medication/procedures. Each patient’s 

individualized plan, presented on an 

innovative video display, provides the best 

chance for prevention and early detection. 

The Center continues to be the highest 

volume cancer genetics program in 

Georgia and the only one providing 

services across the lifespan within the same 

department. In 2016, volume for genetic 

counseling increased approximately 

48 percent, from 2,342 units of service 

in 2015 to 3,475 units of service. The 

increase is due to an expanded service 

area, with satellite sites added in 2016 at 

WellStar West Georgia Medical Center and 

WellStar Douglas Hospital. In addition, a 

new genetics counselor came on board 

in 2015, the same year the new cancer 

center opened, which houses additional 

consultation rooms. In 2016, the Center 

also partnered with the new breast cancer 

STAT clinic at WellStar North Fulton 

Hospital to provide services to newly 

diagnosed breast cancer patients. 

Scientists are continually discovering 

new genes that cause hereditary cancer 

syndromes. In 2016, additional genes 

known to cause hereditary colon, ovarian 

and breast cancer syndromes became 

clinically available. In response, WellStar 

genetic counselors immediately began 

offering updated testing options to new 

and previous patients. 

Genetic testing results are beginning to 

impact medical oncology decisions for 

patients seeking additional treatment 

options. For example, individuals known 

to carry a BRCA gene mutation may be 

offered chemotherapy drugs specifically 

shown to improve their outcomes. And 

all patients with ovarian cancer are 

offered genetic testing to ensure optimal 

chemotherapy options. 

Clinical trials are now available through 

WellStar partners for many patients with 

metastatic breast and prostate cancer who 

carry a BRCA gene mutation. Patients who 

may qualify for these trials are offered 

genetic testing to ensure access to these 

options when available. 


Radiation Oncology: Advanced Cancer Treatment Technology 

A leader in advanced cancer 

treatment technology, WellStar is: 

• Home to Georgia’s first CyberKnife ® 

Robotic Radiosurgery System and one 

of the most active CyberKnife centers 

in the U.S. 

• One of the first in the state to offer 

TomoTherapy ® 

• The first to give patients both CyberKnife 

and TomoTherapy treatment options 

• Home to the first Elekta Flexitron ® 

High-Dose Radiation (HDR) unit in 

the U.S. and a reference training site, 

sharing best practices with other 

radiation centers 

In 2016, WellStar radiation oncologists 

performed 1,022 CyberKnife treatments 

on 249 patients, 4,540 TomoTherapy 

treatments on 179 patients and 876 HDR 

treatments on 100 patients. 

• CyberKnife is a pain-free, non-surgical 

option for patients with inoperable or 

surgically complex tumors. This state-ofthe-art 

treatment allows the physician to 

deliver an intense amount of radiation at 

the exact site of the tumor while reducing 

the negative impact on surrounding 

healthy tissue. 

• TomoTherapy is a pain-free customized 

radiation therapy system based on 

individual patient anatomy, combining 

an advanced form of intensity 

modulated radiation therapy (IMRT) with 

the accuracy of CT scanning in a single 

machine. 

• HDR brachytherapy is an internal 

radiotherapy delivered in a short 

treatment period, allowing patients 

to get back to their lives sooner. The 

radioactive source is placed temporarily 

in or close to the tumor and removed 

after a few minutes. The minimally 

invasive treatment can be delivered 

over one to 10 treatments. 

CyberKnife ® Treatment Sites 

(1,022 total treatments) 

Brain: 86, Breast: 3, Bone: 27, Head & Neck: 8, Spine: 2, Kidney: 4, 

Abdomen: 9, GYN: 1, Rectal: 2, Prostate: 8, Lung: 98, Pancreas:1 

Lung-39% 

Pancreas-

WellStar West Georgia Health Foundation: 

Working Toward a New Community Cancer Center 

WellStar Foundation: 

Grateful for Our Community’s 

World-Class Generosity 

Our physicians, team members and neighbors have a long 

WellStar West Georgia Medical Center (WGMC) has 

provided advanced cancer care for 80 years, serving 

nearly 13,500 patients each year. With increased 

demand for oncology services on the horizon, combined 

with projected population growth in west central 

Georgia, WGMC is committed to offering area families 

the most effective cancer treatments, highly trained 

clinicians, the latest technologies and compassionate 

services. To that end, the medical center’s new 

Community Cancer Center will centralize all cancer 

services, allowing WGMC to enhance the patient 

experience, add emerging technologies and treatments 

and provide more educational and support resources. 

and proud tradition of generously donating to our System 

so patients can enjoy state-of-the-art cancer facilities and 

care, close to home. In 2016, WellStar Foundation donors 

contributed nearly $1.6 million to the WellStar Cancer 

Network. The funds are used in a multitude of ways that 

benefit patients and their families – and the community at 

large. For example, the Foundation supported 166 free 

lung cancer screenings 911 free mammogram vouchers and 

services to medically underserved and uninsured patients. 


WellStar Cancer Center at Kennestone Hospital: 

Your Donations Making a Difference 

In 2015, the WellStar Foundation supported the 

Cancer Center at Kennestone Hospital with $3 million, 

that was used to bring patient-centered services such 

as the Resource Center, Manning Wellness Kitchen and 

Wellness Studio to fruition. Today, WellStar patients 

and their families continue to utilize these impactful 

resources throughout their journey toward health and 

healing of the body, mind and spirit. 

From the donor: “My wife Dana and I were inspired to 

make a donation providing patients in our community 

with a resource area after my own battle with cancer five 

years ago. I hope the Resource Center at the WellStar 

Cancer Center at Kennstone Hospital empowers other 

patients to be able to make educated decisions when 

determining a treatment plan that’s right for them.” 

– David Parks, M.D. 

Pictured: Amanda, Catherine and Daniel Pazak 

From the patient: “Because of the Resource Center, 

our 10-year-old daughter, Catherine, has access to 

resources that help her on this journey we’re going 

through with her father. We were surprised when we 

found she was even able to take books home so she 

has them every day to help her. We are so thankful 

to the Parks for making this resource available to our 

Thanks to the following donors 

who each contributed at least 

$5,000 in 2016. 

Callaway Foundation, Inc.* 

CoBank* 

Jeffrey A. Cox 

Kellie L. Cox 

East-West Church 

Dr. Jeremy Ferris* 

Family and Friends of 

Marc T. Gober 

HOPE for a Day, Inc.* 

Mr. and Mrs. Robert Harris, Jr.* 

Mr. and Mrs. Wayne Hunter* 

Kell Touchdown Club 

Mrs. Janis Kish* 

Kroger Co. Foundation* 

Aymar and Judy Manning 

Mr. and Mrs. John McKibben* 

Neighbors Fund* 

Northwest Georgia 

Oncology Centers, P.C. 

It's The Journey, Inc. 

Mr. and Mrs. Jeff Skinner* 

Susan G. Komen Greater Atlanta 

Drs. Robert and Karin Taylor* 

The Southern Credit Union* 

WGMC Auxiliary* 

WGMC TEAM (Together 

Employees Achieve Magic)2* 

*In support of WellStar West Georgia 

Health Foundation 

To donate to WellStar Cancer Network, call 770-956-GIVE (4483) 

or visit wellstar.org/give. To donate directly to WellStar West 

Georgia Medical Center, please contact Susan Ferguson at 

706-880-7332. 

family and many others.” 

– Amanda and Daniel Pazak 


wellstar.org 

9/17 CNC0228

2017 WellStar Cancer Network Annual Report

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