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2010 Cancer Annual Report

BREAST CANCER STUDY

e g t o h e T r . r e c n a C g n i t h Fig

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2009 Cancer Committee The Cancer Committee is a multidisciplinary organization responsible for assessing, planning, implementing and evaluating all cancer-related activities. The Cancer Committee maintains an exemplary cancer program to benefit all patients. The committee consists of physicians from specialties involved in cancer treatment and other representatives from St. Tammany Parish Hospital (STPH) and Mary Bird Perkins (MBP). Jack Saux, MD Hematology/Oncology Cancer Committee Chairman Greg Henkelmann, MD Radiation Oncology Cancer Liaison Physician Tumor Conference Coordinator Donna Berbling, RN, BSN Director of Hospice, STPH Debbie B. Fascio, RT (R) (M) Imaging Services, STPH Robert Capitelli, MD Sr. Vice President, Chief Medical Officer, STPH

Kathy McWhorter, RN, MSN Director of Nursing, STPH Debra Miller, RN, OCN Cancer Resource Nurse, STPH Community Outreach Coordinator, STPH David Oubre, MD Hematology Oncology Ty Ovella, MD Radiology, STPH Michelle Perry Health Initiatives Representative, ACS Juanita Schenck, LCSW Case Management, STPH

Chryl Corizzo, RN, BSN, OCN Cancer Program Director, STPH Quality Improvement Coordinator, STPH

Susan Stahl Tumor Registrar, STPH

Renea Austin-Duffin, MPA Vice President, Cancer Programs, MBP Community Outreach Coordinator, MBP

Teena Strand-Parker, RN Department Head Ambulatory Care, Pre-op, Infusion Suite, STPH

Terry Freeman, CTR Certified Tumor Registrar, Covington MBP

Brenda Truxillo, RN Vice President, Radiation Oncology Services, MBP Quality Improvement Coordinator, MBP

Vickie Hall, LPN, RT (T) Vice President, Patient Care, MBP Judy Limbaugh, MD Pathology CAPS Protocols Coordinator, STPH Nicole Magee, CTR Cancer Registry Director, MBP Registry Quality Control Coordinator, MBP Patricia Maltese, RT, MHA Department Head, Imaging Services, STPH Susan May, RN, BS Department Head, Case Management, STPH

John Verhulst, MD General Surgery Registry Quality Control Coordinator, STPH Beverly Villemuer, CTR Certified Tumor Registrar, STPH Jo Watkins, RPh Clinical Pharmacy Coordinator, STPH Angela Wilkie, PT, CLT Certified Lymphedema Therapist Outpatient Rehabilitation, STPH

CChairman'sRReport

As chairman of the STPH and MBP Cancer Committee, I am pleased to present highlights of our work in 2009. The Cancer Committee of STPH and MBP provides leadership in ensuring the provision of quality patient care through cancer-related activities that benefit not only patients and their families, but also our community. As a cancer program approved by the American College of Surgeons (ACoS) Commission on Cancer (CoC), our mission is to assure that residents have access to a full range of medical services, a multidisciplinary approach to patient care and services that improve survival and quality of life. Our program provides an array of services throughout the entire cancer care continuum including prevention, early diagnosis, pretreatment evaluation, staging, optimal treatment, rehabilitation, recurrent disease surveillance, support services and end-oflife care. Additional information about the CoC, its standards and affiliates is available at www.facs.org/cancer.

Jack Saux, MD

The Cancer Committee was active in numerous aspects of cancer control activities and services provided to patients, caregivers, health professionals and the community. Highlights include:

•• After an extensive survey process, the integrated cancer program of STPH and MBP received its three-year accreditation with commendations from the ACoS.

•• STPH became one of only two Louisiana hospitals to employ minimally invasive

equipment to diagnose and treat remote lung lesions. By permitting access to distal (peripheral) lung lesions outside the reach of a bronchoscope, the new technology has the potential to diagnose early stage lung cancers that were previously unreachable. After diagnosis, credentialed pulmonologists place clips at tumor site to assist radiation oncologist in planning treatment.

•• The Radiology staff installed a biplane room in the special procedures lab to enable radiologists to expand the number of procedures performed and shorten the time for spinal procedures that require the ability to view the posterior and lateral positions simultaneously without moving the tube or table.

•• A review of evidence-based care and published research demonstrated a lack

of support for reverse isolation of patients receiving conventional doses of chemotherapy who are admitted with short-term neutropenia. Isolation often causes anxiety and confusion for patients, families and healthcare workers. As a result of the investigation, STPH has discontinued the use of neutropenic precautions but still maintains a protective environment for the safety of patients.

•• St. Tammany Hospital Foundation donated six ambulatory chemo infusion pumps

for outpatient use for patients whose insurance prohibits them from receiving chemotherapy on an inpatient basis. Now patients needing continuous infusions can receive the most effective chemotherapy treatment for their cancer without hospitalization.

•• This year, our educational series of patient/caregiver education programs was extremely well attended. Topics included exercise during and after treatment, insomnia and depression in dealing with cancer.

STPH and MBP remain dedicated to promoting cancer education and prevention and improving all phases of diagnosis and treatment for our patients. Sincerely,

Jack E. Saux III, MD Cancer Committee Chairman 2010 STPH and MBP Cancer Annual Report

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Continuing C CareSServices IIntegratedSSupportive and C DIAGNOSTIC SERVICES Pathology Laboratory Radiology CT Scanner, Ultrasound, Nuclear Medicine, MRI Breast Center Mammography, bone density, stereotactic needle biopsy Ultrasound, Dedicated Radiologists with Specialty in Breast Disease Endoscopy Pulmonary Lung Navigation for Early Detection of Lung Cancers

• • •

• • • •

TREATMENT SERVICES Inpatient Medical Oncology Unit/Outpatient Infusion Suite • Radiation Therapy External Beam Radiotherapy Intensity Modulated Radiation Therapy (IMRT) Radiation Treatment Planning Image Fusion Medical Physics/Dosimetry Computerized Axial Tomography (CT) Dental Oncology Simulation Surgery/DaVinci Robotic Surgical System • Interventional Radiology • Percutaneous Vertebral Augmentation; Coblation of Malignant • Spinal Tumors, RF Liver Ablation; Nerve Root Ablation •

• • • • • • • • •

SUPPORTIVE/REHABILITATIVE SERVICES Cardiac/Pulmonary Rehabilitation/CancerFit Exercise & Wellness Program Enterostomal/Wound Therapy Home Health/Hospice Nutritional Services Pastoral Care/Clergy Community Support Physical/Occupational/Speech/Certified Lymphedema Therapy Social Services/Case Management

• • • • • • •

COMMUNITY OUTREACH AND EDUCATION Cancer Screenings Cancer Resource Center Patient Educational Forums

• • •

Education for Health Professionals Continuing Medical Education (CME) Continuing Nursing/Allied Health Education • Multidisciplinary Tumor Conferences • Elder Services • Genetic Cancer Risk Assessment & Counseling Program • Lymphedema Prevention Clinics & Seminars • Patient Library (www.librarything.com/catalog/stphcrc) • Pain Management • Speakers Bureau •

• • •

• •

• •

• •

RESEARCH Clinical Research Cancer Registry

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• 2010 STPH and MBP Cancer Annual Report

Physician'sR Report CCancerLLiaison P

The Cancer Liaison Physician Program was established in 1963 by the Commission on Cancer (CoC) of the American College of Surgeons (ACoS). As an ACoS multidisciplinary program, the CoC is dedicated to decreasing morbidity and mortality from cancer through education, standard setting and monitoring quality of care. Cancer Liaison Physicians (CLPs) serve as links between the CoC and the hospitals they represent, manage clinically related cancer activities within their local institutions and partner with local community agencies, such as the American Cancer Society (ACS), to accomplish community outreach goals regarding education, early detection and prevention of cancer. This year, the Cancer Committee has strengthened its program by promoting positive change within the CoC’s five priority areas. In 2009, those included: advocacy, quality improvement, ACS partnership, clinical trials and comprehensive cancer control. The STPH and MBP Cancer Committee had particular success in following the Commission directives with regard to the following:

Gregory C. Henkelmann, MD

1. We actively pursued education, implementation and monitoring of ACoS staging standards that reflect a shift in priority from pathologic to clinical staging, use of prognostic factors and national treatment guidelines. Because of the importance of staging in both patient management and outcomes, we completed a study evaluating current clinical staging practice and implemented processes to improve the use of clinical staging. 2. We completed a study evaluating the management and outcomes of patients diagnosed with breast cancer, then looked more specifically at the use of National Comprehensive Cancer Network (NCCN) Guidelines for diagnostic work-up and use of prognostic indicators for early stage breast cancer. The analysis revealed STPH patients experienced benchmark results. In fact, the majority of patients received care equal to or greater than the care provided by affiliated programs throughout Louisiana and the United States. 3. In accordance with CoC outreach initiatives, we have collaborated with ACS to identify patients’ transportation needs throughout St. Tammany Parish. We anticipate launching the Road to Recovery program in 2010. 4. The Committee has reviewed, discussed and made recommendations regarding National Cancer Data Base (NCDB) breast and colorectal quality measures. These benchmarks provide cancer programs with an indication of the proportion of breast and colorectal patients treated according to recognized standards of care by diagnosis year. Based on data directly reported from the tumor registry to the NCDB, these proportions encourage cancer programs to examine their own data and determine whether these performance rates are representative of the care provided at their own institution. In the past, these outcomes were measured annually, but in 2011 they will be available “real-time” to enable cancer programs to monitor progress on an ongoing basis. 5. I continue to facilitate tumor conferences and other CME programs where we also discuss staging and prognostic factors when applicable. Besides focusing on those objectives, I continue to attend the quarterly meetings of the Cancer Committee. I look forward to working with local and national organizations to improve our cancer program in the years ahead. Sincerely,

Gregory C. Henkelmann, MD Cancer Liaison Physician 2010 STPH and MBP Cancer Annual Report

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Delivering C Cancer C Care C Close to D HHome

Together We Coordinate the Entire Continuum of Cancer Care

The Cancer Program of STPH and MBP is the most comprehensive cancer program in the St. Tammany area, offering patients the convenience of receiving high-quality, advanced cancer care close to home. Our comprehensive cancer program has been accredited with commendation since 2003 by the American College of Surgeons (ACoS) – the gold standard for outstanding cancer programs. Approval is given only to those facilities that have voluntarily committed to provide the highest level of quality cancer care and undergo a rigorous evaluation process. The comprehensive cancer program is the only approved cancer program in west St. Tammany Parish and is focused on the entire continuum of cancer care. Mary Bird Perkins CARE Network In 2002, MBP created its early detection CARE Network outreach and support program. The CARE Network mission is to reduce cancer incidence and mortality in southeast Louisiana and to improve the quality of life for those affected by cancer. Today, as a component of the Cancer Program of STPH and MBP, the CARE Network is a best practices model for a partnership-based effort to effectively fight cancer within the community. It continues to increase public awareness of prevention and early detection by providing free cancer screenings to the medically underserved and uninsured populations throughout the parishes served by the Cancer Program. The CARE Network targets early detection programs for breast, colon, skin, oral and prostate cancers. Breast

Prostate

Colorectal

Skin

Total

Total Participants

525

189

232

215

1,161

Participants who have never been screened

125

45

154

132

456

2

0

0

2

4

Diagnosis of Cancer

January 1, 2009 - December 31, 2009

Pulmonary Navigation Program Cutting-edge technology is helping STPH physicians more effectively diagnose and treat lung cancer. STPH is the only Northshore facility utilizing electromagnetic navigation bronchoscopy (ENB), which uses global-positioning-system-like technology to examine lesions in the lung’s distant edges and can examine lymph nodes and lung lesions too small for viewing with standard equipment. In contrast to traditional bronchoscopy, ENB allows examination of 100 percent of the lungs and can be used to take samples from lesions too small for testing with a traditional bronchoscope. Needle biopsy through the patient’s chest, a procedure that carries a high risk for a collapsed lung is avoided. Treatment plans can be implemented faster than ever before and markers can be placed on lesions by special catheters to allow for surgical removal or image-guided radiation therapy that pinpoints tumors without impacting healthy tissue. Lung cancers are typically diagnosed in later stage, limiting treatment options and survival. Because it allows cancers to be diagnosed at earlier stages, ENB can improve life expectancy and quality of life for patients.

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2010 STPH and MBP Cancer Annual Report

Covington Welcomed New Radiation Oncologist R. Scott Bermudez, MD, is the latest physician to join the Southeast Louisiana Radiation Oncology Group practicing exclusively at MBP. He will be practicing at the Covington Center. Dr. Bermudez earned his bachelor’s degree with honors from Duke University and his medical degree from Harvard Medical School Pictured from left: Randy Waesche, Dr. R. Scott following a year as a Fulbright Scholar in Bermudez and Dr. Charles Wood Berlin, Germany. Dr. Bermudez held an internship at Santa Clara Valley Medical Center in San Jose, California and completed his residency program at the University of California, San Francisco, California where he was chief resident in Radiation Oncology. Dr. Bermudez was welcomed at the Greater Northshore Leadership Reception held in March 2010. Greater Northshore President’s Council Chair Kyle France, Council member Cindy Williamson and MBP Board of Directors Treasurer Randy Waesche extended words of welcome and inspiration to Dr. Bermudez. Charles Wood, MD, MBP radiation oncologist, introduced Dr. Bermudez and made reference to his new colleague’s multiple accomplishments and abilities concluding with, “Scott is the future.” “I am both honored and pleased to be able to play a role in Mary Bird Perkins’ offering state-of-the-art cancer care to such an open and welcoming community on the Northshore.” DR. BERMUDEZ 10th Annual Cancer Survivor Day

Cancer Survivor Day speakers from left: Kelly Kiviko, Patti Ellish, Susan Giovengo, Dr. James Carinder, Lorraine Jenkins, Angela Wilkie, Salli Phillips, Dr. Jack McNulty, Jamie Arton, Debbie Miller and Dr. Charles Wood  

STPH and MBP were proud to sponsor the 10th annual Cancer Survivor Day (CSD) titled Living Through and After a Cancer Diagnosis. Each June, CSD is celebrated in communities all over the country acknowledge the over 12 million cancer survivors, their caregivers and the health professionals who care for and support them through treatment.

This year’s program was held at STPH and offered a unique opportunity to participate in breakout groups and discuss specific topics with physicians and other health professional experts in their area of practice. Many topics were suggested by cancer survivors including prevention and management of lymphedema, coping with fatigue, the fear of cancer recurrence, managing pain and other side effects and reconnecting with life and family after diagnosis. Post treatment challenges of chemotherapy and radiation therapy were popular topics as was the use of acupuncture to relieve pain caused by cancer and cancer treatment. Numerous organizations providing support to those with cancer also had displays and information available throughout the morning. Over 120 attendees were present at this very successful program. Much appreciation goes to additional program sponsors: Leonard C. Thomas HOS Foundation, The Louisiana Breast Cancer Task Force and Ponchartrain Hematology Oncology.    2010 STPH and MBP Cancer Annual Report

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Activities CCommunitySSupport GGroups andA

ADULT/CHILDREN’S BEREAVEMENT GROUPS Held in short sessions, these seminars provide support for those who have experienced the death of a loved one – (985) 871-5976. BETTER BREATHERS SUPPORT GROUP

This group is designed for adults with lung disease and their caregivers who are interested in improving their quality of life – (985) 898-3785. CANCER CONNECTION NEWSLETTER

This bi-monthly newsletter provides information on cancer related support, education and rehabilitative services across the Northshore – (985) 898-4581. CANCER CONNECTION SUPPORT GROUP

Meeting on the third Wednesday of the month, this group offers a safe and positive atmosphere for expressing thoughts, feelings and expectations – (985) 898-4581. CANCER SURVIVORS DAY

Held in June, this program celebrates survivorship and provides support and recognition of cancer patients and their caregivers – (985) 898-4581. CANCERFIT EXERCISE AND WELLNESS PROGRAM

Designed for individuals completing cancer treatment or in recovery, this program incorporates a supervised, personalized approach to fitness, health and wellness education – (985) 871-6092. FREE CANCER SCREENINGS Free breast, oral, colorectal, prostate and skin cancer screenings are offered to participants without insurance who have not been screened in the past 12 months. Insurance will be billed for mammograms – (888) 616-4687. GENETIC CANCER RISK ASSESSMENT & COUNSELING PROGRAM STPH, MBP and the Leonard C. Thomas HOS Foundation sponsor free genetic counseling and screening services to individuals at high risk for cancer development. Through consultation with a specialist, patients and their families make informed decisions about their medical options, including screening for early detection, ways to reduce personal risk and expectations of genetic testing – (985) 898-4581. HOSPICE VOLUNTEER TRAINING This instructional program is presented for those interested in becoming Hospice volunteers, who provide direct patient care, office support, bereavement care, community education or fundraising assistance – (985) 871-5976. LOOK GOOD, FEEL BETTER* By offering skin, nail and hair care tips, this program aims to enhance the appearance and improve the self-image of patients undergoing cancer treatment. Professionals present a 12-step make-up guide and information about choosing and caring for a wig and dealing with skin changes. Cosmetics provided – (985) 898-4481.

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LYMPHEDEMA PREVENTION CLINICS One-on-one assessments with a certified lymphedema therapist are offered free periodically throughout the year to cancer survivors who have had lymph nodes removed – (888) 616-4687. LYMPHEDEMA THERAPY Certified lymphedema therapists specialize in the prevention and management of lymphedema (which commonly occurs after cancer treatments) through compression bandaging, manual lymphatic drainage and patient specific exercise – (985) 898-4622. NORTHSHORE BLOOD CANCER SUPPORT GROUP This organization addresses issues specific to patients with leukemia, lymphoma, myeloma and myelodysplastic syndrome. Co-sponsored by the Leukemia and Lymphoma Society and the International Myeloma Foundation, the group meets the second Saturday of the month – (985) 898-4581. PATIENT EDUCATIONS FORUMS Offered throughout the year, these programs feature a variety of topics for cancer patients, their families, friends and caregivers – (985) 898-4481 ROAD TO RECOVERY* When no other resource is available, volunteer drivers bring St. Tammany Parish patients to and from cancer treatment appointments. To learn more or to volunteer, contact the Cancer Resource Center – (985) 898-4581. RESTORATIVE YOGA CLASSES Sponsored by the Leonard C. Thomas HOS Foundation, these classes are structured according to individual capabilities for cancer patients and their caregivers. Call for class schedules – (504) 975-4430. TOBACCO CESSATION When combined with other tobacco cessation efforts, structured classes can greatly increase the chances of quitting for good. Classes regularly scheduled – (985) 898-4581. WIG RESOURCE CENTER* This community service offers wigs, turbans, hats and scarves free to women undergoing cancer treatment. Our private fitting area is located in the Cancer Resource Center – (985) 898-4481.

*

Co-sponsored by American Cancer Society and STPH

2010 STPH and MBP Cancer Annual Report

Breast C CancerD Diagnosis andT Treatment EEarlySStageB

Excluding cancers of the skin, breast cancer is the most common malignancy in women—accounting for nearly one in four cancer diagnoses. In 2009, the American Cancer Society (ACS) estimated 192,370 American women and 1,910 men were newly diagnosed with invasive breast cancer. Approximately 2,700 Louisianans were diagnosed with breast cancer that same year. Furthermore, ACS predicted 62,280 new cases of carcinoma in situ of the breast (lobular and ductal) would be diagnosed nationwide with ductal carcinoma in situ (DCIS) comprising 85% of cases. Sadly, approximately 40,170 women and 440 men nationwide died from this disease; some 690 of those deaths occurred in Louisiana. And, while the incidence of breast cancer has increased over the past few decades, the mortality rate shows a decline. That trend may be due to detection of cancers at earlier stages, which allows for more varied and effective treatments. Table 1 provides a summary of overall breast cancer cases and deaths by age. Table 1: Estimated New Female Breast Cancer Cases and Deaths by Age, 2009* Age

In Situ Cases

Invasive Cases

Deaths

Younger than 45

6,460

18,640

2,820

45 and Older

55,820

173,730

37,350

Younger than 55

24,450

62,520

8,890

55 and Older

37,830

129,850

31,280

Younger than 65

40,940

120,540

17,200

65 and Older

21,340

71,830

22,970

All ages

62,280

192,370

40,170

* Rounded to the nearest 10th. Data Source: Estimated cases based on 1995-2005 incidence rates from 41 states as reported by NAACCR, representing about 85% of the U.S. population. Estimated deaths based on U.S. Mortality Data, 1969-2006, National Center for Health Statistics, Centers for Disease Control and Prevention, 2009. American Cancer Society, Surveillance Research, 2009.

The etiology of the majority of breast cancer cases diagnosed today is unknown. Many factors are associated with an increased risk of developing breast cancer (Table 2). Except for female gender and increasing age, these risk factors are only linked to a small number of the breast cancer cases. Most breast cancers continue to be sporadic, developing in women with no known risk factors. Approximately 5% to 10% of all breast cancer cases result from inherited genetic abnormalities (BRAC1 and BRAC2 genes). Women with a strong family history of breast cancer should receive a genetic risk assessment. If the evaluation determines

they are at significant risk, these patients need to receive counseling related to breast cancer risk reduction strategies. (Table 3). The seriousness of invasive breast cancer is strongly influenced by the stage of the disease (i.e., extent or spread of the cancer when it is first diagnosed). The American Joint Committee on Cancer (AJCC) classification of tumors uses information on tumor size and spread within the breast and nearby organs (T), lymph node involvement (N) and the presence or absence of distant metastases (the spread to distant organs) (M).

Table 2: Risk Factors Associated With Breast Cancer Development •• Female •• Age (65 or older, although risk increases across all ages until age 80) •• Two or more first-degree relatives with breast cancer diagnosed at an early age •• Personal history of breast cancer •• High breast-tissue density •• Biopsy confirmed hyperplasia •• High-dose radiation to chest Factors that affect circulating hormones: •• A long menstrual history •• Obesity after menopause •• Recent use of oral contraceptives or postmenopausal estrogens and progestin •• Having no children or her first child after age 30, never breastfeeding Other Factors: •• Alcohol consumption •• Personal history of endometrial or ovarian cancer •• Height (tall) •• High socioeconomic status •• Ashkenazi Jewish heritage American Cancer Society, 2009

Table 3: Factors That May Indicate Hereditary Breast Cancer

•• Breast cancer diagnosed before age 50 •• Breast and ovarian cancer in the same individual •• Bilateral breast cancer, first cancer before age 50 •• Ovarian cancer diagnosed at any age •• Male breast cancer, any age •• A relative known to have a BRCA1/BRCA2 mutation •• Ashkenazi Jewish ancestry

2010 STPH and MBP Cancer Annual Report

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Once the T, N and M are determined, a stage of I, II, III or IV is assigned. Stage I and II are considered early stage breast cancer, while stages III and IV are considered later stage. National trends reflect a majority of new breast cancer cases are diagnosed as early stage, which corresponds to improved survival. Five-year survival rates for localized disease approach 98% for all races.

Table 4: Breast Cancer Statistics of 2000-2006 Cancer Cases: Patients Diagnosed and/or Treated at STPH/MBP Compared to NCDB Benchmark Data1 DEMOGRAPHICS

NCDB n= 1,219,311 (%)

STPH/MBP n= 547 (%)

 

 

100

100

Gender Female Age at Diagnosis

The STPH and MBP Breast Cancer Experience The Cancer Committee initially compared patterns of treatment and survival outcomes of STPH and MBP breast cancer patients with data from the National Cancer Data Base (NCDB). Table 4 Breast Cancers cases from all approved cancer programs across the United States, in the NCDB (1,219,311 cases) with breast cancers diagnosed and/or treated at STPH and MBP (547 cases) between 2000 and 2006. Approximately 25% of the cases in both the NCDB and STPH and MBP data sets were diagnosed in women less than 50 years of age. Both groups demonstrated similar numbers of non-invasive Stage 0 (carcinoma in situ) cases; similarities were also noted in the percentage of women diagnosed with early stage breast cancer (69% and 65% respectively) versus late stage breast cancer (11% in both groups). No meaningful variations were noted in race. As expected, a majority of the breast cancer histologies were infiltrating ductal carcinomas. Overall, treatment patterns at STPH and MBP and those noted in the NCDB were quite similar; but, this comparison provides only a broad overview. It does not accurately portray important prognostic or predictive factors that ultimately determine which treatments (chemotherapy, hormone or other therapies) are most beneficial for individual patients.

 

30-39

4

5

40-49

18

19

50-59

25

27

60-69

22

21

70-79

19

19

80-89

10

8

90+

1

1

Race

 

Caucasian

81

91

African American

10

7

Hispanic

4

2

Other/Unknown 2

5

1

AJCC Stage

 

0

18

15

I

38

40

II

27

29

III

8

8

IV

3

3

UNK

5

4

Histology

 

Infiltrating Ductal Carcinoma

67

63

Lobular Carcinoma, NOS

9

10

Infiltrating Ductal & Lobular Carcinoma

6

3

Other Specified Types

18

23

In Situ

19

15

Malignant

81

85

Behavior

Treatment

 

 

 

 

Management of Early Stage Breast Cancer

Surgery Only

26

22

Physicians analyze each breast cancer case to develop an individualized treatment plan based on specific characteristics of the individual patient’s tumor. The patient’s age, menopausal and health status, the individual tumor size, histology, grade, axillary lymph node status, estrogen and progeterone receptor content, HER2 status and presence of distant metastasis are all factors in deciding tumor stage, surgical intervention and the need for additional chemotherapy, radiation, hormonal and/or HER2 therapy.

Surgery/Radiation

12

10

Surgery/Chemotherapy

9

16

Surgery/Radiation/Chemotherapy

10

11

Surgery/Radiation/Hormone Therapy

14

8

Surgery/Hormone Therapy

7

13

Surgery/Radiation/Chemo/Hormone

7

8

Surgery/Chemo/Hormone

3

9

Other Specified Therapy

9

2

No First Course Therapy

4

3

8

May not equal 100% due to rounding errors; NCDB data represents all reported cases from 1,346 hospitals, all types in all states. 2 Includes Native Americans, Asian/Pacific Islanders, other races or unknown. 1

2010 STPH and MBP Cancer Annual Report

The National Comprehensive Cancer Network (NCCN) Practice Guidelines in Oncology for Invasive Breast Cancer (v.1.2009) provides a reference for the diagnosis and staging of new breast cancer cases. It is important to note that the guidelines present a framework for physicians and are not absolute; diagnostic testing ordered should be individualized to the patient. Table 5 presents an overview of tests commonly ordered in the work-up of early stage breast cancers and the use of those tests at STPH and MBP. Information gleaned from pathology review, ER and PR receptor status, and Her2 status is essential in making treatment decisions. The majority of patients diagnosed and/or treated at STPH and MBP had the recommended prognostic/ predictive tests. The remainder were diagnosed at another facility, where ER/PR/Her2 was unavailable, and treated at STPH and MBP (Class 2 cases). Depending on symptoms or other abnormal staging studies, additional studies may be warranted. However, unless the patient is symptomatic, NCCN guidelines discourage the use of PET or PET/CT scanning for the staging of clinical Stage I or II breast cancer. Table 5: STPH and MBP Work-up Use of Prognostic Factors Based on NCCN Practice Guidelines in Oncology* WORKUP

Chemotherapy and/or endocrine therapy and/or biologic therapies may also be considered depending on ER, PR and Her2 status. Long-Term Patient Outcomes The observed five-year survival rate of patients treated at STPH and MBP was compared with those of other approved community hospital cancer programs across the country and within the state. Overall and by stage, survival rates for patients treated at STPH and MBP were comparable or exceeded that of other NCDB hospitals. The results are presented in Table 6. Only in Stage IV were the results less favorable than those of the NCDB benchmark study. The small numbers of STPH and MBP Stage IV patients made it difficult to evaluate the significance of this comparison. Table 6: Observed Survival Rate Comparisons (%) for Breast Cancer Cases Between NCDB and Patients Treated at STPH and MBP NCDB Comm Hosp Only 1998-2001

NCDB State of LA 1998-2001

STPH/MBP (%)* 1998-2003

AJCC Stage

%

%

%

All Stages

81

80

83

0

94

95

98

I

89

89

89

%*

II

80

80

83

ERA

Performed

95

III

53

53

59

PRA

Performed

96 

IV

16

16

9

Her2 status

Performed

90

(n=87,125)

(n=7,977)

(n=362)

*600 Breast Cancer Cases from Registry Data 1998-2008, Class 0-2, Stages I, IIA, IIB and T3, N1, MO

Treatment Decisions Women with Stage I breast cancer have small tumors that have not spread to either the lymph nodes or other distant sites. Women with Stage II disease generally have smaller tumors and no (or minimal) lymph node involvement and no metastasis. Breast conservation surgery (lumpectomy, surgical axillary staging and whole breast radiation) is the primary treatment for the majority of these women. Patient preferences are also considered. It is well established that breast conservation therapy (lumpectomy with radiation to the breast) is equivalent to mastectomy with axillary node dissection. However, prior radiation to the chest wall, radiation during pregnancy, multiple diffuse malignantlooking microcalcifications, positive pathologic margins and other contraindications may prevent patients from becoming a candidate for this type of procedure. Other relative contraindications include active connective tissue disease involving the skin, tumors greater than five centimeters and a positive BRAC mutation.

AJCC: American Joint Commission on Cancer *Five-year survival from STPH Registry data 1998-2003 by stage

Surveillance/Follow-up Post Treatment: Women should expect to have a physical exam every 4-6 months for a five year period, then annually thereafter. Mammography is generally done every 12 months, but may be done at 6-12 months on completion of breast conservation surgery. An annual gynecologic exam is recommended if patients are on tamoxifen. Bone density testing may be expected if on aromitase inhibitors as a baseline and then on a periodic basis. Routine testing of tumor markers, liver function tests, or routine bone scans or x-rays are generally not recommended in asymptomatic patients because they provide no advantage in survival or ability to palliate recurrent disease. Decisions regarding follow-up testing should be individualized and mutual decisions made between the physician and patient. Discussion In 2009, the U.S. Preventative Services Task Force caused widespread confusion by recommending women begin regular mammograms at age 50 and only repeat the test

2010 STPH and MBP Cancer Annual Report

9

every other year. The American Cancer Society (ACS) disagrees with this position and continues to recommend women get annual mammograms starting at age 40 (Table 7). ACS has long recognized mammography as the gold standard in the early detection of breast cancer and strongly encourages women to partner with their physicians to determine when and how often to receive mammograms. The American College of Surgeons (ACoS) released comments in November 2009 strongly supporting the ACS position. Members of the STPH and MBP Cancer Committee—and many other approved cancer programs across the country—support the ACS recommendations. Table 7: Screening Guidelines for the Early Detection of Breast Cancer in Average-Risk, Asymptomatic Women Age 20 and Older* Breast Self Examination (BSE) Beginning in their 20s, women should be told about the benefits and limitations of BSE. Importance of prompt reporting of any new breast symptoms to a health care professional should be emphasized. Women who choose to perform BSE should receive instruction and have their technique reviewed. It is acceptable for women to choose not to do BSE or to do irregularly. Clinical Breast Examination (CBE) For women in their 20s and 30s, CBE should be part of a periodic health exam, preferably at least every three years. Asymptomatic women aged 40 and over should continue a CBE as part of a periodic health exam, preferably annually and prior to a mammogram. Mammography Begin annual mammogram at age 40. *American Cancer Society, 2009

This study alone demonstrated nearly a quarter of women diagnosed with breast cancer in approved cancer programs are below the age of 50. Fortunately, the majority of all women are diagnosed with early stage cancer, so the opportunity for effective treatments can impact long-term survival. As a result of this study, the Cancer Program will continue to educate and promote the ACS guidelines for cancer screenings. Current ACS Provider Screening Summary for cancer and other screening recommendations were sent to primary care providers at the end of 2009. The STPH and MBP Cancer Program also provides numerous breast cancer screenings to women across the Northshore. Healthcare providers are available to discuss screening recommendations with patients who otherwise might wait for the appearance of a problem to seek care. These free screenings (including clinical breast exam and mammography) are offered to St. Tammany residents considered to be at high risk for cancer development in later stages because of lack of access to care.

10

The NCCN, American Society of Clinical Oncology and other organizations stress the importance of genetic counseling. Access to a geneticist or genetic counselor is such an important provision of quality cancer care that the ACoS will soon require the presence of a geneticist or genetic program representative for cancer committee participation. For several years, STPH and MBP have been fortunate to have access to a geneticist, and recently the demand for genetic counseling services has warranted a larger commitment of his time. For more information on the Genetic Risk Assessment and Counseling Program or make a referral, call (985) 898-4581. Lastly, physicians at STPH and MBP are now using an advanced diagnostic test to help address a critical question for breast cancer patients: Which treatment is right for me? Oncotype DX® evaluates 21 genes within a patient’s tumor sample taken from the initial biopsy to gauge their activity. The results are rated on a scale of 0 to 100; the score corresponds to a patient’s likelihood of benefitting from chemotherapy and the probability of recurrence within 10 years of diagnosis. What does that mean for an individual diagnosed with early stage breast cancer? By identifying individuals unlikely to benefit from chemotherapy (a low recurrence score), physicians and their patients may choose to forego this treatment, which lowers both the adverse effects and cost for these patients and increases overall confidence in decisions about the patient’s health. The American Society of Clinical Oncology and the NCCN both recommend this new multigene expression test to predict the value of chemotherapy and likelihood of recurrence for patients with node-negative breast cancer that is estrogen-receptor positive and/or progesterone-receptor positive. Post-menopausal women with hormone-receptor positive, lymph-node positive invasive breast cancer may wish to discuss with their physician whether this test might be beneficial for them as well. The Cancer Registry began collection of oncotype results in 2009, so that in future studies, its use in appropriate patients and outcomes can be measured. References American Cancer Society. Cancer Facts & Figures 2009. Atlanta: American Cancer Society; 2009. American Cancer Society. Breast Cancer Facts & Figures 2009-2010. Atlanta: American Cancer Society, Inc. National Cancer Data Base (NCDB), Commission on Cancer, American College of Surgeons, Benchmark Reports at www.fasc.org. American College of Surgeons Voices Strong Support for the ACS Screening Mammography Guidelines press release available at http://www.facs.org/ news/mammography1109.html. AJCC Cancer Staging Manual, 7th edition, Springer, 2009. www.oncotypedx.com.

2010 STPH and MBP Cancer Annual Report

TammanyP Parish SSt.T HHospital and MaryB BirdP Perkins C Cancer C Center C CancerR RegistryS Summary M

The American College of Surgeons (ACoS), the National Cancer Institute’s Surveillance Epidemiology and End Results (SEER) program and the Louisiana Tumor Registry set guidelines for the collection of cancer cases nationwide by approved programs. High importance is placed on data quality using these guidelines, and a sample of the cases is reviewed by physician members of the Cancer Committee for quality assurance. Once part of the registry database, these cases are followed for the life of the patient. The registries at STPH and MBP capture a complete summary of the history, diagnosis, treatment and disease status for every cancer patient. The registrars’ work leads to accurate information and data analysis, which influences the way we care for cancer patients. The STPH Cancer Registry reference date is 1993, and it contains data on 7,077 cancer cases. During the year 2009, there were 721 new cancer cases entered into the STPH registry database. Of these, 494 were analytic cases (newly diagnosed and/or received all or part of their first course of treatment at this facility). The top five sites were breast, lung, colorectal, kidney/ renal pelvis and prostate.

The MBP Cancer Registry reference date is 1998, and it contains data on 2,867 cancer cases. During the year 2009, there were 318 new cancer cases entered into the MBP-Covington registry database. Of these, 266 were analytic cases (newly diagnosed and/or received all or part of their first course treatment at this facility). The top four analytic sites treated were breast, lung, prostate and rectum. Brain malignancies and nonHodgkin’s lymphoma tied for fifth place. The registry maintains cancer data that is available for use by clinical and administrative staff at STPH and MBP. All information collected is kept completely confidential. During 2009, the registry received requests for statistical reports including analytic studies, annual statistics, research activities, quality management studies, healthcare delivery, reporting to the National Cancer Data Base (NCDB) and participation in the Facility Information Profile System (FIPS) on the American Cancer Society’s website www.cancer.org. Data is submitted to the Louisiana Tumor Registry in compliance with state reporting requirements by SEER. This data is also used to support statewide improvements in cancer detection and treatment. The registry also participates in the NCDB Cancer Program Practice Profile activities.

2010 NON-SMALL CELL LUNG CANCER STUDY The STPH and MBP Cancer Committee also completed the 2010 Non-Small Cell Lung Cancer Management and Outcomes study. This report may be viewed online at www.stph.org or www.marybird.org. Copies of the Non-Small Cell Lung Cancer study may be obtained by calling the STPH Tumor Registry at (985) 898-4125 or the MBP Tumor Registry at (225) 215-1237

2010 STPH and MBP Cancer Annual Report

11

St. Tammany Parish Hospital 2009 Distribution Site Table* CLASS SEX AJCC STAGE AT DIAGNOSIS* A N/A M F 0 I II III IV All Sites 721 494 226 291 430 40 166 85 68 76 Blood/Bone Marrow 41 26 15 27 14 0 0 0 0 0 Leukemia 22 13 9 14 8 0 0 0 0 0 Myeloma 11 7 4 8 3 0 0 0 0 0 Other Hematopoietic 8 6 2 5 3 0 0 0 0 0 Breast 166 104 62 2 164 15 46 31 9 2 Central Nervous System 8 5 3 3 5 0 0 0 0 0 Brain 7 4 3 3 4 0 0 0 0 0 Other Nervous System 1 1 0 0 1 0 0 0 0 0 Digestive System 119 85 34 70 49 6 19 12 20 20 Anus, Anal Canal, Anorectum 2 0 2 0 2 0 0 0 0 0 Bile Ducts 3 2 1 2 1 0 2 0 0 0 Colon 43 37 6 23 20 6 11 6 9 4 Esophagus 10 5 5 7 3 0 2 0 1 0 Liver 6 6 0 5 1 0 1 0 4 1 Other Digestive 3 2 1 3 0 0 0 0 0 0 Pancreas 19 10 9 9 10 0 0 0 1 8 Rectum & Rectosigmoid 26 17 9 17 9 0 3 6 3 4 Small Intestine 2 2 0 0 2 0 0 0 1 0 Stomach 5 4 1 4 1 0 0 0 1 3 Endocrine-Thyroid 16 15 1 4 12 0 13 1 0 0 Eye 1 0 1 0 1 0 0 0 0 0 Female Genital 76 59 17 0 76 8 27 4 11 8 Cervix Uteri 8 6 2 0 8 0 2 1 3 0 Cervix In Situ Ca 4 4 0 0 4 4 0 0 0 0 Corpus Uteri 30 29 1 0 30 3 22 1 1 2 Ovary 24 14 10 0 24 0 3 2 6 3 Vagina 1 0 1 0 1 0 0 0 0 0 Vulva 5 4 1 0 5 1 0 0 1 1 Other Female Genital 4 2 2 0 4 0 0 0 0 2 Lymphatic System 32 19 13 15 17 0 6 2 5 6 Hodgkin’s Disease 3 3 0 2 1 0 0 1 0 2 Non-Hodgkin’s Lymphoma** 29 16 13 13 16 0 6 1 5 4 Male Genital 49 35 14 49 0 0 2 25 2 5 Prostate 47 33 14 47 0 0 0 25 2 5 Testis 2 2 0 2 0 0 2 0 0 0 Oral Cavity/Pharynx 14 5 9 9 5 0 1 1 1 2 Nasopharynx 5 2 3 4 1 0 0 1 0 1 Nasal Cavity, Sinus, Ear 2 1 1 1 1 0 0 0 1 0 Salivary Glands, Major 1 1 0 0 1 0 1 0 0 0 Tongue 4 1 3 4 0 0 0 0 0 1 Mouth, Other & Nos 2 0 2 0 2 0 0 0 0 0 Respiratory/Intrathoracic 90 56 34 48 42 0 8 1 17 26 Larynx 2 1 1 2 0 0 0 0 0 1 Lung/Bronchus, Non-Small Cell 73 46 27 37 36 0 8 1 16 19 Lung/Bronchus, Small Cell 12 6 6 7 5 0 0 0 1 5 Other Respiratory & Thoracic 1 1 0 1 0 0 0 0 0 0 Pleura 2 2 0 1 1 0 0 0 0 1 Skin 27 15 12 15 12 2 8 4 0 1 Melanoma of Skin 26 15 11 15 11 2 8 4 0 1 Other Skin Cancer 1 0 1 0 1 0 0 0 0 0 Soft Tissue 3 1 2 1 2 0 1 0 0 0 Unknown or Ill-Defined 12 10 2 10 2 0 0 0 0 0 Urinary Tract 67 59 8 38 29 10 35 5 3 6 Bladder 26 22 4 17 9 10 7 2 1 2 Kidney and Renal Pelvis 38 35 3 19 19 0 27 3 2 3 Ureter 3 2 1 2 1 0 1 0 0 1 *Staging is based on mixed AJCC/Collaborative staging. Note: AJCC Stage-Analytic Cases only. **Includes one or more lymphoma cases coded to non-lymphatic sites. Abbreviations: M=Male; F=Female; A=Analytical; Unk=Unknown; NA=Not Applicable; AJCC=American Joint Commission on Cancer. SITE GROUP

12

TOTAL CASES

2010 STPH and MBP Cancer Annual Report

NA 47 26 13 7 6 0 5 4 1 5 0 0 0 0 0 2 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 10 0 0 0 0

UNK 10 0 0 0 0 1 0 0 0 3 0 0 1 2 0 0 0 0 0 0 1 0 1 0 0 0 0 0 1 0 0 0 0 1 1 0 0 0 0 0 0 0 3 0 2 0 0 1 0 0 0 0 0 0 0 0 0

Mary Bird Perkins Cancer Center 2009 Distribution Site Table* SITE GROUP

TOTAL CASES

CLASS

SEX

AJCC STAGE AT DIAGNOSIS*

A

N/A

M

F

0

I

II

III

IV

NA

UNK

318

266

52

164

154

4

58

79

46

53

16

10

Blood/Bone Marrow

2

1

1

2

0

0

0

0

0

0

1

0

Myeloma

2

1

1

2

0

0

0

0

0

0

1

0

Breast

78

68

10

1

77

4

30

22

11

1

0

0

Central Nervous System

8

8

0

3

5

0

0

0

0

0

8

0

Brain

8

8

0

3

5

0

0

0

0

0

8

0

Digestive System

37

33

4

27

10

0

4

14

4

8

0

3

Anus, Anal Canal, Anorectum

3

3

0

0

3

0

0

2

1

0

0

0

Colon

4

1

3

4

0

0

0

0

0

1

0

0

Esophagus

7

6

1

5

2

0

0

2

0

4

0

0

Pancreas

4

4

0

2

2

0

1

3

0

0

0

0

Rectum & Rectosigmoid

16

16

0

14

2

0

2

7

3

2

0

2

Stomach

3

3

0

2

1

0

1

0

0

1

0

1

Endocrine-Other

1

1

0

1

0

0

0

0

0

0

1

0

Female Genital

12

11

1

0

12

0

3

2

3

3

0

0

Cervix Uteri

5

5

0

0

5

0

2

1

1

1

0

0

Corpus Uteri

4

4

0

0

4

0

1

1

1

1

0

0

Vulva

3

2

1

0

3

0

0

0

1

1

0

0

Lymphatic System

17

15

2

6

11

0

7

6

1

1

0

0

Hodgkin’s Disease

8

7

1

2

6

0

0

6

1

0

0

0

Non-Hodgkin’s Lymphoma**

9

8

1

4

5

0

7

0

0

1

0

0

Male Genital

55

44

11

55

0

0

1

31

4

2

0

6

Prostate

54

43

11

54

0

0

0

31

4

2

0

6

Testis

1

1

0

1

0

0

1

0

0

0

0

0

Oral Cavity/Pharynx

15

15

0

11

4

0

3

0

3

9

0

0

Floor of Mouth

1

1

0

0

1

0

0

0

0

1

0

0

Gum, Other Mouth

3

3

0

1

2

0

1

0

0

2

0

0

Hypopharynx

1

1

0

1

0

0

0

0

0

1

0

0

Nose, Nasal, Middle Ear

1

1

0

1

0

0

0

0

1

0

0

0

Salivary Glands

2

2

0

1

1

0

1

0

0

1

0

0

Tongue

3

3

0

3

0

0

0

0

1

2

0

0

Tonsil

4

4

0

4

0

0

1

0

1

2

0

0

Respiratory/Intrathoracic

73

60

13

46

27

0

10

2

20

28

0

0

Larynx

8

7

1

7

1

0

3

1

1

2

0

0

Lung/Bronchus

64

53

11

38

26

0

7

1

19

26

0

0

Trachea, Other Respiratory

1

0

1

1

0

0

0

0

0

0

0

0

Skin

7

2

5

3

4

0

0

1

0

0

0

1

Melanoma of Skin

6

1

5

2

4

0

0

0

0

0

0

1

Other Non-Epithelial Skin

1

1

0

1

0

0

0

1

0

0

0

0

Soft Tissue

2

1

1

0

2

0

0

1

0

0

0

0

Unknown or Ill-Defined

6

6

0

5

1

0

0

0

0

0

6

0

Urinary Tract

5

1

4

4

1

0

0

0

0

1

0

0

Kidney and Renal Pelvis

4

1

3

3

1

0

0

0

0

1

0

0

Other Urinary Ograns

1

0

1

1

0

0

0

0

0

0

0

0

All Sites

*Staging is based on mixed AJCC/Collaborative staging. Note: AJCC Stage-Analytic Cases only. **Includes one or more lymphoma cases coded to non-lymphatic sites. Abbreviations: M=Male; F=Female; A=Analytical; Unk=Unknown; NA=Not Applicable; AJCC=American Joint Commission on Cancer.

2010 STPH and MBP Cancer Annual Report

13

1202 South Tyler Street Covington, LA 70433 www.stph.org

39 Starbrush Circle Covington, LA 70433 www.marybird.org

STPH-101 (10/10) WPS


2010 Mary Bird Perkins Cancer Center/St. Tammany Parish Hospital Annual Report