Chairman Report………………………………………..………….……………………………………page 3 Breast Cancer Report……………………………………………………………...…...............page 4-5 CHRISTUS St. Michael Health System Report……..……….………..…………………..page 6-7 Pancreatic Cancer Report……………..............................................................page 8-9 A Survivor’s Story……………..…………………..…………………………………………………..page 10 Wadley Regional Medical Center Report……………….………………….……………….page 11 Joint Cancer Program Moderators……………………………………………………………..page 12 Community Breast Cancer Education………………………………………………………….page 13 Joint Cancer Committee……………….…………………………………………………………….page 14 Cancer Registry Report……………………………………………………………………………..page 15
t is my pleasure to introduce the 2010 Cancer Program Report. The Cancer Registry is the workhorse of the Joint Cancer Program of CHRISTUS St. Michael Health System and Wadley Regional Medical Center and has maintained Accreditation of the Commission on Cancer (CoC) as an Approved Community Comprehensive Cancer Program since 1989. In 2010, the survey by the CoC was the primary focus of the registry. Much hard work and preparation were rewarded by a CoC Three-Year Accreditation Award. Both CHRISTUS St. Michael and Wadley Regional Medical Center received multiple areas of commendation. In the Performance Report for each hospital, Dr. Marvin Lopez, the CoC surveyor, was very complimentary of the cancer registry staff and our Joint Cancer Program. Please take time to review the cancer statistics and analysis for our community. Pancreatic and breast cancer are featured in the 2010 report. I extend my thanks to Dr. Ranga Balasekaran and Dr. J.D. Patel for their accompanying articles. On behalf of the Joint Cancer Committee, I wish to express appreciation to Mrs. Dianne Ketchum and her cancer registry staff for all the hard work resulting in the production of this report.
reast cancer is the most common site of cancer seen in women in Texarkana in 2010. This cancer totals 37% of the total cancers seen at CHRISTUS St. Michael and Wadley Regional Medical Center. Excluding cancers of the skin, breast cancer, accounting for nearly 1 in 4 cancers in women, is the most common cancer among women in the U.S. Local statistics on breast cancer have revealed 1,014 female breast cancer cases in the last five years, with 14 cases being males. There were 83% early stage and 14% late stage cancers, and 3% unknown/not applicable stage. Distribution of cases by race were 79% Caucasian, 20% African-American women and 1% other in 2010. Breast cancer incidence and death rates generally increase with age. According to the American Cancer Society (ACS), 95% of new cases and 97% of breast cancer deaths occurred in women aged 40 and older. White women have a higher incidence of breast cancer than African American women beginning at age 45. In contrast, African American women have a higher incidence rate before age 45 and are more likely to die from breast cancer at every age. Besides being female, age is the most important risk factor for breast cancer. Figure 1 shows a woman’s risk of being diagnosed with breast cancer at different ages. Figure 2 represents local incidence trends by race and stage at diagnosis in the years 2006-2010. This graph suggests 84% of our cases are local-regional stage and 15% are Stage 3 and 4 cancers.
Many of the known breast cancer risk factors, such as age, family history, age at first full-term pregnancy, early menarche, late menopause, and breast density, are not easily modifiable. However, other factors associated with increased breast cancer risk (postmenopausal obesity, use of combined estrogen and progestin menopausal hormones, alcohol consumption, and physical inactivity) are modifiable. Gene expression analysis has led to the identification of molecularly defined subtypes of breast cancer that are distinct biological features, clinical outcomes, and responses to chemotherapy. Treatment strategies are now being developed based on an individual’s tumor characteristics . A patient’s response to chemotherapy is influenced not only by the tumor’s genetic characteristics but also by inherited genetic variations that affect a person’s ability to absorb, metabolize, and eliminate drugs. This new information has assisted in the development of more effective and less toxic chemotherapeutic agents. For postmenopausal women with hormone receptorpositive breast cancer, an aromatase inhibitor therapy should be incorporated at some point during adjuvant treatment. This treatment strategy reduces the risk of breast cancer recurrence compared to five years of tamoxifen alone. Figure 3 indicates when breast cancer is diagnosed at its earliest stage, survival is excellent. Early diagnosis is the key.
Figure 1
CSMHS & WRMC Breast Cancer by Age Distribution, Y2006-2010
30%
>Approximately 207,090 new cases of invasive breast cancer in U.S. women were estimated in 2010 and 54,010 new cases of carcinoma in situ (CIS).
27%
25% 22% 20%
16%
18%
15%
11%
10%
5% 2%
5%
0% 30-39 40-49 50-59
Figure 2
60-69 70-79
80-89
90+
CSMHS & WRMC Breast Cancer by Race and AJCC Stage, Y2006-2010 40% 30%
10% 4%
12%
20% 10%
18%
26% 18%
0%
1%
>ACS estimated 1,970 new cases of breast cancer in men in 2010. >Breast cancer is the most common form of cancer among women in the U.S., except for skin cancer. >Breast cancer ranks second among cancer deaths in women, exceeded only by the number of lung cancer deaths in women, were expected to be 71,080 in 2010. >Inflammatory breast cancer (IBC) accounts for about 1% of all breast cancers diagnosed in the U.S.
0%
6% Stage 0 Stage 1 Stage 2
>The American Cancer Society (ACS) estimated 39,840 breast cancer deaths in women in 2010.
2% Stage 3
Sources: American Cancer Society Breast Cancer Facts and Figures, 2010. The American Society of Clinical Oncology Clinical Practice Guideline; UAMS AHEC Southwest Cancer Registry database for CHRISTUS St. Michael Health System and Wadley Regional Medical Center; National Cancer Database, Commission on Cancer.
Stage 4
Whites
African-Am
TABLE 1
1 Yr-Texarkana
1 Yr- NCDB
3 Yr-Texarkana
3 Yr- NCDB
5 Yr-Texarkana
5 Yr- NCDB
Stage I Stage II Stage III Stage IV
98% 96% 92% 67%
99% 98% 94% 64%
93% 86% 76% 38%
96% 91% 77% 36%
88% 79% 49% 23%
92% 85% 65% 21%
ur mission, “To Extend the Healing Ministry of Jesus Christ” means that each and every person at the W. Temple Webber Cancer Center at CHRISTUS St. Michael Health System takes great pride in assuring that all of the needs of our patients are being met – physically, emotionally and spiritually. We continually evaluate our services to enhance and innovate the services provided to our patients and their families. For three years in a row, we have maintained one of the top patient satisfaction scores possible ranking in the top 99th percentile of Cancer Centers in the U.S. in the Press Ganey database. Even with satisfaction scores such as these, we are still striving to improve. Maintaining a vision of how our services look from our customer’s viewpoint, we realize there are always opportunities for improvement. In 2010, three areas were targeted for improvements: services, technology and facilities. Our efforts are paying off. In the area of service, the idea of providing our patients with one person who would help “walk” through and navigate cancer care services from diagnosis to survivorship is now a reality. Our first Clinical Patient Navigator joined the Cancer Center in July 2011. For well over 10 years, our social workers have provided Diagnostic Patient Navigation and help connect patients to diagnostic services in the area of breast cancer. Working with the Texarkana Affiliate of the Susan G. Komen for the Cure and the Texas Breast & Cervical Cancer Services programs, we link underserved and uninsured patients to resources for obtaining breast and cervical cancer diagnostic services. Over the past
year, 647 screening mammograms were provided under this service and 656 other diagnostic procedures were performed. Technology changes and innovations in the area of cancer treatment are constantly evolving in order to provide the types of services our patients and their physicians seek. High-dose rate radiation therapy was added in November 2010 at the Cancer Center at CHRISTUS St. Michael. Used for specific kinds of cancer, this specialized therapy targets lung, gynecologic, and breast cancers. In August 2011, our Chemotherapy and Radiation received a much-needed expansion. This included eight additional chemotherapy chairs and specialized changing rooms for patients undergoing radiation therapy. The Cancer Center at CHRISTUS St. Michael is the first and only cancer treatment center in our service area with both an in-house Medical Oncologist and Radiation Oncologist. This assures a higher level of care for patients being served by both physicians and provides direct and personal supervision by the Medical Oncologist to patients receiving infusion services. As we continue to plan for the future, our hopes are that by 2012 we will be providing clinical research trials to patients in our community. There will then be no need to go to larger cancer centers away from home for these services. Helping our patient stay close to home with their loved ones and receive the type of health care needed and guided by Our Mission drives us to seek excellence each and every day.
ancreatic cancer is a devastating disease that is the fourth leading cause of cancer-related death in the U.S. It is an insidious disease that is often only discovered at advanced stages. Surgical resection is the only potentially curative treatment, but unfortunately only 15 to 20 percent of patients are candidates for pancreatectomy due to the late presentation of the disease. More than 40,000 cases of pancreatic cancer are diagnosed annually in the U.S. It is rare before age 45 and the mortality rates follow incidence rates because of the poor prognosis. The national incidence is higher in men and higher in blacks compared to whites and other races. Figure 1 illustrates our local distribution of pancreatic cancer diagnosed at both local hospitals based on race and stage. There were a total of 103 cases diagnosed locally for the five-year period of 2006 to 2010. The majority were unresectable with advanced stage at the time of diagnosis. Figure 2 illustrates the local distribution of pancreatic cancer based on age and gender. Locally, there were slightly more women than men diagnosed with pancreatic cancer for this time period. The major risk factors include smoking, hereditary predisposition to pancreatic cancer, chronic pancreatitis and diabetes. Most patients present with pain, weight loss or jaundice. The majority of patients have unresectable disease by the time symptoms occur and the diagnosis is made. The most common sites of distant metastases include the liver, peritoneum, lungs and also bone. CA 19 -9 is a serum tumor marker that is frequently elevated in pancreatic cancer and can be useful in monitoring for recurrence after potentially curative surgery. Patients are considered resectable if they demonstrate no distant metastases, no radiographic evidence of superior mesen-
teric vein and portal vein abutment, distortion, tumor thrombus or venous encasement, and clear fat planes around the celiac axis, hepatic artery and superior mesenteric artery. Endoscopic ultrasound (EUS), which is not available in our community, is the most accurate modality for local T and N staging and predicting vascular invasion. EUS guided fine needle aspiration biopsy is the best modality for obtaining tissue diagnosis. CT scanning will evaluate for distant metastasis and complement EUS for determining resectability. Those rare patients that qualify for surgery are referred to tertiary centers with pancreatic surgeons for their surgery. Adjuvant concurrent chemoradiotherapy is recommended for all patients with resected pancreatic cancer. Neoadjuvant chemoradiotherapy can be considered in the setting of clinical trials. For those patients that are unresectable and have a good performance status, systemic chemotherapy provides benefit with improving disease-related symptoms and up to a 4 month survival benefit when compared to best supportive care alone. ERCP is available in our community for those that require relief of biliary obstruction for palliation. Table 1 illustrates the 1year, 3-year and 5-year survival rates for patients locally and nationally with pancreatic cancer by stage. The local survival rate is less than national rate for all stages of disease for 3-year and 5-year survival, but the number of patients in these groups is too small to make any inferences. Pancreatic cancer is an insidious devastating cancer that is often discovered at advanced stages. Long term prognosis is dismal even after potentially curative resection and chemoradiotherapy.
Figure 1
>An estimated 44,030 Americans will be diagnosed with pancreatic cancer in the U.S. and over 37,660 will die from the disease. >Pancreatic cancer is one of the few cancers for which survival has not improved substantially over nearly 40 years. >Pancreatic cancer has the highest mortality rate of all major cancers. >74% of patients die within the first year of diagnosis. >94% of pancreatic cancer patients will die within five years of diagnosis. Only 6% will survive more than five years.
Figure 2
Average life expectancy after diagnosis with metastatic disease is just three to six months. There are no detection tools to diagnose pancreatic cancer in its early stages when surgical removal of the tumor is still possible. The National Cancer Institute (NCI) spent an estimated $97.1 million on pancreatic cancer research in 2010. This represents a mere 2% of the NCI’s $5billion cancer research budget for that year. Source for statistics: American Cancer Society
TABLE 1
1 YR-Texarkana
1 YR- NCDB
Stage I Stage II Stage III Stage IV
60% 44.4% 50% 9.4%
46.6% 50.3% 33% 12.1%
3 YR-Texarkana 3 YR- NCDB 5 YR- Texarkana 5 YR- NCDB
20% 11.1% 0% 3.1%
21.2% 16.3% 4.9% 2.2%
20% 11.1% 0% .3.1%
*Data Sources: National Cancer Database by jbanasiak@facs.org; UAMS AHEC-SW Cancer Registry Y2003-2007; CHRISTUS St. Michael Health System & Wadley Regional Medical Center
15.7% 9.2% 2.5% 1.3%
eanette Akin, RN, MS, Chief Nursing Officer at Wadley Regional Medical Center, knows first hand what it feels like to hear that scary phrase, “you’ve got cancer.” On Friday, January 29, 2011, Jeanette began to have severe chest pain and was suspicious of either a gallbladder attack or heart attack. Either way, she knew that she needed to get to the Emergency Room at Wadley. After initial treatment in the ER, she was admitted to the Telemetry Unit for further testing. By Saturday morning, the cardiologist had assured her that it was not her heart. “I was feeling much better until the routine gallbladder test showed an unexpected finding of a mass on my right kidney,” Jeanette recalls. “Within minutes of having the test performed, my physician came in to tell me while I did have a problem with my gallbladder, the bigger problem was that I had kidney cancer.” As a trained nurse, Jeanette knew her symptoms pointed toward a gallbladder problem since heart issues had been ruled out and she was expecting surgery. The mass on her right kidney, however, was a total surprise. “My twin sister, Jennifer, was sitting by my bed when I was told and she immediately grabbed my hand. I could see the shock on her face and the tears in her eyes. Although I was shocked, I moved quickly from shock to acceptance because having worked with the involved radiologists and physicians for years, I had absolute confidence in their diagnosis and treatment plan.” Being a person of faith, Jeanette’s first response was to pray. As it always had before and still does every day, this provided her with a sense of peace and comfort and helped her to move on to the next thing….telling family and close friends. Having a large extended family in the Texarkana area, Jeanette knew this news would spread
rapidly once it was shared. “I knew I had to call my son, Chris, in New York before a “tweet” went out from one of my extended family or my church’s prayer chain. I needed Jennifer to tell my mother and brother in person. I needed to call my boss. It was all coming so fast, all the things I needed to do.” Having worked with physicians in the community for almost 39 years, Jeanette knew that she would be in good hands right here in Texarkana at Wadley. By the middle of Saturday afternoon, the plan was coming together. Dr. Sorenson and Dr. Parham had coordinated their schedules to remove her gallbladder and kidney on the following Tuesday. “My son and his family had a plane trip booked so they could be here. As my daughter-in-law, Megan, put it, ‘we want unfiltered information!’” she said. By Tuesday evening, the surgery was over and the wait began for the pathology report. When the report came back, it was good news – no evidence the cancer had spread beyond the kidney. The follow-up radiology studies were also negative. Jeanette’s philosophy on her cancer journey, “We all face difficult times in our lives. Having faith in God and being surrounded by people who love and care for us makes those difficult times much easier to get through. Today, I can say that I truly understand when someone tells me they have been diagnosed with cancer, but before January 30, 2011, I could only imagine what they were going through. I also have a better understanding of the importance of support and resources that help patients cope with cancer related illness and treatment. Each day is a gift and I don’t take my good health for granted. So for now, I continue my life’s journey, now as a survivor.”
oward Morris, M.D. has been the Medical Director of the Radiation Oncology department at CHRISTUS St. Michael Health System since May 1988. Dr. Morris has moderated the cancer conferences and educational conferences held at CHRISTUS St. Michael on the second and fourth Friday of each month since 1990. He is an Assistant Professor at UAMS in Little Rock, Ark., and his specialty training is head & neck and GYN . Dr. Morris is an active member of the Joint Cancer Committee and has served as Chairman in the past. He is the Medical Advisor for the Texarkana Unit American Cancer Society and participates in the annual Relay for Life activities. He is the Commission on Cancer Liaison for CHRISTUS St. Michael and promotes the CoC initiatives at this facility. Douglas Trippe, M.D., Radiologist with Advanced Imaging, is the moderator of the Wadley Cancer Conferences on the third Friday of each month. Dr. Trippe is Medical Director of Wadley Radiology and P.E.T. Imaging Center. His expertise in the area of breast cancer diagnosis has enhanced the tumor board discussions at Wadley Regional Medical Center. George W. English, III, M.D., is a native of Philadel-
phia, Penn., where he completed his residencies at the University of Pennsylvania and Thomas Jefferson University Hospital. He is an AP/CP board certified pathologist with fellowships in OB/GYN and Perinatal Pathology as well as in Hematopathology with Molecular Diagnostics and is sub board certified in Hematology as well as Coagulation Medicine. He is President of Pathology Services of Texarkana and Medical Director of Laboratories and Cancer Liaison Physician for Wadley Regional Medical Center. Dr. English gave the tumor board physicians a presentation on "Update on Molecular Diagnostics in Breast Cancer with Prediction of Benefit from Endocrine Therapy" in 2010. His presentation included explanations of the molecular classification and grading of breast cancer and to explain Proteinomic and Genomic expressions of breast cancer. Dr. English helped the participants to understand the determination of a Recurrence Score and its application and how to appreciate its influence on chemoendocrine predictive factors in treatment of breast cancer. We appreciate Dr. Morris, Dr. Trippe and Dr. English for their support in the Cancer Program and the Joint Cancer Committee.
or the past four years, UAMS AHEC inception in 1999, the Komen Texarkana Race for Southwest and Texarkana College have co- the Cure has raised more the $4 million. Up to 75 hosted the Texarkana Breast Health percent of the funds raised at the Komen Race for Symposium to bring more breast cancer- the Cure remain in the Komen Texarkana service related education to area health care professions. area to provide breast health screening, and The one-day conference brings in local and education for uninsured or underinsured women. r e g i o n al professional The remaining 25% goes to speakers who share their fund national research to knowledge and experience discover the causes of breast with breast cancer. cancer and, ultimately, its Additionally, a breast cancer cures. For information about survivor is invited to speak, Komen Texarkana Race for sharing personal experience the Cure, please call Terrie with the audience from the Arnold, Executive Director, at patient perspective. 903-791-9585 or visit The symposium is www.komentexarkana.org. supported by a community The American Cancer grant from the Susan G. Society—Texarkana Unit staff Mike Finley, MD, speaks during the 2011 Breast Komen for the Cureand volunteers are saving Health Symposium held at Texarkana College. Texarkana Affiliate awarded lives and creating more to UAMS AHEC Southwest for breast health birthdays by helping people stay well, through outreach, education and clinical services. education and prevention messaging; by helping In addition to the symposium, other breast cancer people get well through programs and services such educations efforts are occurring in the Texarkana as Reach to Recovery, a one-on-one support service area. The annual Susan G. Komen Race for the for breast cancer patients; free wigs and gas cards Cure—the largest series of 5K runs/fitness walks in and other services, by finding cures through the world—raises significant funds and awareness research; and by fighting back through advocacy for the fight against breast cancer, celebrates efforts at the local, state, and national level. breast cancer survivorship and honors those who Contact us 24/7 at 1-800-227-2345 or visit us onhave lost their battle with the disease. Since its line at www.cancer.org.
he Joint Cancer Committee is composed of medical oncologist, radiation oncologist, diagnostic radiologist, pathologist, pharmacy, social workers, administration, quality improvement and oncology nurses. The committee is multi-disciplinary and governs the components of the cancer program to include the cancer registry, patient care evaluations, clinical
oncology research and performance improvements. The Joint Cancer Committee meets quarterly and subcommittee members meet as needed to accomplish the duties and responsibilities of this committee. The UAMS AHEC Southwest Cancer Registry staff would like to thank all the cancer committee members for their support and guidance during 2010.
J. Alan Solomon, MD, Chair Collom & Carney Clinic George W. English, III, MD Pathology Services of Texarkana, LLP Jack H. McCubbin, MD Collom & Carney Clinic Mike Finley, MD CHRISTUS. St. Michael Health System
J. D. Patel, MD Collom & Carney Clinic Joe Robbins, MD CHRISTUS St. Michael Health System Bryan J. Griffin, MD CHRISTUS St. Michael Health System Howard Morris, MD CHRISTUS St. Michael Health System
Robert Parham, MD Collom & Carney Clinic Chris McMillian, MD Wadley Regional Medical Center H. Anthony Tran, MD New Hope Cancer Institute Ranga Balasekaran, MD Texarkana Gastroenterology
Dianne Ketchum, CTR UAMS AHEC SW Cancer Registry Donna Marlar, BAAS, LPN, CTR UAMS AHEC SW Cancer Registry Christy Dabbs UAMS AHEC SW Cancer Registry Tammy McKamie, MSN, RN, OCN Wadley Regional Medical Center Kim Lewis, RN Wadley Regional Medical Center
Jena Teer, LSW Wadley Regional Medical Center Jodie Martindale, RHIT Wadley Regional Medical Center Gary Upp, MHSA CHRISTUS St. Michael Health System Tracy Wade, RHIA CHRISTUS St. Michael Health System Mike Jones, BS PHA CHRISTUS St. Michael Health System
Dianne Greenhaw, RN Wadley Regional Medical Center Turner Bratton, PharmD Wadley Regional Medical Center Mary Miller, MSSW, LCSW CHRISTUS St. Michael Health System John Phillips, COO CHRISTUS St. Michael Health System
he cancer registry, under the umbrella of UAMS AHEC Southwest, has collected and reported data for the past 21 years totaling 25,044 patients with a follow-up rate of 93% for both facilities. The cancer registry staff accessioned 1,003 newly diagnosed cancer cases in 2010 for both facilities. Our staff coordinated 37 tumor board meetings and educational conferences in 2010, with a total of 116 case presentations at CHRISTUS St. Michael Health System (CSMHS) and Wadley Regional Medical Center (WRMC). One of the responsibilities of the UAMS AHEC Southwest Cancer Registry is to provide accurate and complete information to cancer committee members, physicians, administrators, the state registries and the National Call for Data. The goal of the collection of this data is to show improvements in patient care and in patient outcomes. Preparation for the Commission on Cancer survey was the major focus for the cancer registry staff in 2010. Documentation of the components of the cancer programs for WRMC and CSMHS to meet the requirements set forth by the CoC resulted in our seventh successful survey with commendations
for these institutions. Education was another major focus for the cancer registry staff in 2010 with revisions in the manuals of the standard setters across the nation. Manuals which were recently updated were the AJCC Cancer Staging Manual, Collaborative Staging Manual, a new Hematopoietic Database Manual and Multiple Primary Calculator. All of the functions of a registry are equally important in the management of a successful database that allows for the analysis of data in a meaningful manner. Current follow-up of cancer patients is essential to the survival analysis outcome data. The evaluation of long-term studies identifies treatments which are more effective to allow improved patient outcomes. I would like to add a “Big Thank You� to the tumor board moderators, pathologists, radiologist and physicians who present cases to the Cancer Conferences held at WRMC and CSMHS each week. Also appreciation is given to Donna Marlar and Christy Dabbs for their excellent data collection and dedication to the cancer program in Texarkana.
www.ruralhealth.uams.edu/ahecsw