2008 Our Lady Of the Lake Cancer Annual Report

CANCER PROGRAM OF OUR LADY OF THE LAKE AND MARY BIRD PERKINS

2008 Annual Report

Lung/Bronchus Non-Small Cell Cancer Study

Chairman’s Letter

On behalf of the Cancer Committee of the Cancer Program of Our Lady of the Lake (OLOL) and Mary Bird Perkins (MBP), I am pleased to present the 2008 Cancer Annual Report. On the pages that follow, you will read about recent highlights of the Cancer Program, as well as a 10 year study on non-small cell lung cancer, the disease site we chose to feature in this year’s report.

During 2007, the Cancer Program accomplished many clinical, programmatic, quality improvement and community outreach goals focused on the vital needs of cancer patients and the community at large.

The highlight of 2007 was the national recognition the Cancer Program received for its excellence in cancer care. The Cancer Program was selected by the National Cancer Institute (NCI), part of the National Institutes of Health, as one of only 14 sites in the country to participate in its prestigious Community Cancer Centers Program (NCCCP) pilot. The Cancer Program was chosen based on its medical leadership, community outreach and experience in conducting clinical trials.

The NCI recognizes that 85 percent of cancer patients are treated at community cancer centers across the nation. To that end, the NCCCP pilot is extending NCI programs into local communities. This will bring more Americans in contact with high-quality, community-based cancer care, increase participation in clinical trials, reduce cancer healthcare disparities and improve information sharing among community cancer programs. A successful pilot may lead to the nationwide launch of the NCCCP in 2010.

We have enjoyed our participation in the NCCCP pilot over the last year and are honored to work with this elite group of hospitals and centers dedicated to enhancing the delivery of community-based cancer care in the United States. Our hard work has only just begun.

One important initiative of the Cancer Program is the work being done to develop a collaborative, multidisciplinary approach for assessing, planning, monitoring, coordinating and evaluating the delivery of cancer care services for its colon and rectal patients. The primary goal of the Colorectal Cancer Multidisciplinary Disease Site Initiative is to establish clinical pathways and best practices for the treatment of colon and rectal cancers. This new initiative will allow us to ensure a seamless approach to comprehensive cancer care.

This approach also includes an emphasis on early detection and prevention. The Cancer Program continued to increase public awareness about cancer by providing free screenings to the medically underserved. In recognition of several cancer awareness months, the Cancer Program held free screenings for breast, colorectal, prostate and skin cancer.

Last, but certainly not least, I am pleased to report that the Cancer Program of Our Lady of the Lake and Mary Bird Perkins earned three-year approval from the American College of Surgeons (ACoS) Commission on Cancer (CoC). The Cancer Program had zero deficiencies and earned approval with 11 total commendations. The CoC is dedicated to improving survival and quality of life for cancer patients through best practice standards, prevention, research, education and quality of care initiatives. Approval is given only to those facilities that have voluntarily committed to provide the best in cancer care and undergo a rigorous evaluation process. Obviously, this is the result of hard work and dedication of the many team members that support the Cancer Program.

Many thanks are due to this tireless group.

It has been a great year. The Cancer Program looks forward to continuing its efforts in the fight against cancer.

Sincerely,

David S. Hanson, MD, FACP

2008 CANCER ANNUAL REPORT

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2007 Cancer Committee

The Cancer Committee is a multidisciplinary group responsible for planning, initiating, implementing, evaluating and improving 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 OLOL and MBP.

PHYSICIANS David S. Hanson, MD

Hematology/Oncology Cancer Committee Chairman Tumor Conference Coordinator

Brian W. Webb, MD

Pathology Annual Report Committee Chairman PCE Subcommittee Chairman Cancer Registry Advisor ACoS Cancer Liaison Physician

M. Giles Fort III, MD Gynecological Oncology

Sheldon A. Johnson, MD Radiation Oncology

HEALTHCARE PROFESSIONALS Reverend Mark Adams OLOL Chaplain

Donna Bryant, MSN, OCN, ANP-C, CCRC MBP Clinical Research Executive Director

Tandra Davison, BSIE, CPHQ

OLOL Performance Improvement OLOL Quality Improvement Coordinator

Melissa DuBois, CTR

Cancer Program Coordinator OLOL Registry Quality Control Coordinator

Renea Austin-Duffin, MPA

MBP CARE Network Executive Director Community Outreach Coordinator

Kevin Guidry, MHA

Jeffrey Littleton, MD

OLOL Cancer Center Administrator

Ryan Majoria, MD

MBP Cancer Registry Director MBP Registry Quality Control Coordinator

General Surgery Radiology

Nicole Magee, CTR

Gerald P. Miletello, MD

Suzanne Neve, CTR, RHIA

Susan E. Nelson, MD

Jacqueline O’Neill, LCSW

Anna M. Pou, MD

Salli Phillips, LCSW, OSW-C

M. Patrick Stagg, MD

Gena Skelton, RN, BSN

Hematology/Oncology

Gerontology/Palliative Care Otolaryngology

Hematology/Oncology

Cancer Registrar

OLOL Cancer Liaison

MBP Social Services Director

OLOL Cancer Center Nurse Manager

Brenda Truxillo, RN, LRT

MBP Radiation Oncology Vice President MBP Quality Improvement Coordinator

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OUR LADY OF THE LAKE | MARY BIRD PERKINS

Cancer Liaison Physician’s Report

The Cancer Liaison Physician Program was established in 1963 by the Commission on Cancer (CoC) of the American College of Surgeons. As an ACoS multidisciplinary program, the CoC is dedicated to decreasing morbidity and mortality from cancer through education, setting standards and monitoring quality of care. Cancer Liaison Physicians (CLP) 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.

During 2007-2008, the CoC defined five priority areas for CLP activity that include advocacy, quality improvement, ACS partnership, clinical trials and comprehensive cancer control. The CoC recommended implementation of at least one objective or activity from any of the five areas that would result in a positive change within our Cancer Program.

During the course of my second year as CLP for the Cancer Program, we have been successful in following the Commission’s directive in at least two of the focus areas: 1) ACS representatives now attend each of the quarterly meetings of the Cancer Committee to report upcoming activities and initiatives. Their presence has resulted in a more informative and engaging presentation of this important information and an improved relationship overall between ACS and the Cancer Program.

2) I have been involved with our patient care evaluation (PCE) study regarding the adequacy of lymph node dissection of resected specimens for colon cancer. The findings have resulted in some procedural changes related to the gross dissection and improved retrieval of small pericolic lymph nodes. These changes may ultimately improve the accuracy and reliability of the pathologic tumor staging.

In addition to my involvement within the focus areas, I have continued my efforts to better understand my role and responsibilities as CLP by participating in two CoC-sponsored web conferences titled Collaborative Stage Got You Confused and Learn How to Meet Two of Your Five Focus Areas.

Another CLP activity is attendance of the quarterly meetings of the Cancer Committee. At these meetings, I report on the quality assurance studies I personally perform regarding the use of College of American Pathologists’ (CAP) checklists on all pathology reports with a cancer diagnosis. Efforts continue to use these checklists to standardize pathology reports and cancer diagnoses across different institutions within the community to ensure completeness and accuracy.

“The CoC is dedicated to decreasing morbidity and mortality from cancer through education, setting standards and monitoring of the quality of care.”

I look forward to working with local and national organizations to facilitate communication and collaboration in the years ahead.

Sincerely,

Brian W. Webb, MD 2008 CANCER ANNUAL REPORT

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Cancer-Related Services

Treatment

Medical Oncology

Chemotherapy Hormonal/Antihormonal Therapy Immunotherapy Infusion Therapy Peripheral Stem Cell Transplantation

OLOL • • • • •

Radiation Oncology

Radiation Therapy

External Beam Radiotherapy

High Dose Rate Brachytherapy (HDR)

Image Guided Radiation Therapy (IGRT)

Intensity Modulated Radiation Therapy (IMRT) •

Prostate Seed Implants •

SirSpheres

Stereotactic Radiosurgery

Treatment Planning •

Computerized Axial Tomography (CT) •

Image Fusion (CT, MRI, PET)

Medical Physics/Dosimetry •

Positron Emission Tomography (PET)

Virtual Simulation

Dental Oncology

•

Surgical Oncology

•

Support Services

MBP

CancerFit Enterostomal Therapy Nutritional Support Occupational, Physical and Speech Therapies Pastoral Care Respiratory Therapy Social Services

• • • • • • •

• • • • • • • • • • • •

•

•

Other Services

Lymphedema Prevention Clinics • Pain Management Patient Transportation

• • •

Education

Professional Education

Allied Health Cancer Grand Rounds • Continuing Education (CE) • Continuing Medical Education (CME) • Graduate Medical Education (GME) • Medical Library

Community Education

Cancer Resource Call Center Cancer Screenings Community Library Community Outreach Elderly Services Speakers Bureau

Case Management

Tumor Conferences

Research

4

• • • • •

• • • • • •

• • • •

•

•

•

Clinical Research

•

•

Tumor Registry

•

•

OUR LADY OF THE LAKE | MARY BIRD PERKINS

Tumor Conferences

Multidisciplinary treatment planning conferences are held weekly to improve cancer patients’ care. The cases of patients from the Cancer Program are selected for presentation and discussion based on the case complexity, unusual presentation of disease or special interest. Physician representatives from appropriate disciplines attend and participate in the conferences.

In October 2007, the Cancer Committee presented a facility-wide didactic CME conference titled Selective Internal Radiation Therapy Treatment in Metastatic Colorectal Cancer by Seza Gulec, MD, FACS. During 2007, 162 cases were presented at the standard weekly OLOL/MBP tumor conference.

The cases reviewed included neoplasms of the following types and sites.

Blood/Bone Marrow.....................................2 Bone............................................................ 1 Brain/Nervous System..................................2 Breast.........................................................34 Digestive System........................................ 37 Endocrine.....................................................2 Female Genital..............................................4 Lymphatic System....................................... 12 Male Genital............................................... 13 Oral Cavity/Pharynx......................................8 Respiratory/Intrathoracic............................ 19 Skin............................................................ 10 Soft Tissue....................................................5 Unknown Primary.........................................3 Urinary Tract............................................... 10

To schedule cases for presentation, physicians may call Dianne Griffin at 225.215.1238.

2008 CANCER ANNUAL REPORT

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An Overview: Non-Small Cell Lung Cancer Non-small cell lung cancer is a disease in which a malignant tumor arises from the cells of either the lung proper (alveolar cells) or the cells of the airways (bronchi). Tumors arising from the airways are also termed bronchogenic lung cancer.

The lungs are complex organs that are enclosed by the thoracic cage and carry out respiratory interface with the environment to provide oxygen to the body tissues and eliminate carbon dioxide. The trachea and bronchial tree serve as a conduit that delivers air to the final site of gas exchange, the alveolus or air sac. There are approximately 28 divisions of the bronchial tree before finally reaching the alveolus. The largest airway is the trachea which ranges from 14 to 20 millimeters in diameter. The smallest airways are measured in micrometers (1/1000 inches). The bronchi course throughout the lung tissue accompanied by a rich vascular supply of arteries and veins as well as lymphatic channels. Lymph nodes lie alongside the bronchi within the lungs as well as both pulmonary hila (the “root” of the lung). Lymph nodes are also found in the mediastinum (center portion of the chest containing the heart, great vessels and trachea).

Before cigarette smoking became prevalent, cancers of the lung were exceptionally rare. Cancers of the lung have mirrored the rise of cigarette smoking worldwide. There is a clear causative link between cigarette smoking and lung cancer in a relationship that is dose-related.

Carcinoma of the lung is divided into two main types. Small cell lung cancer (roughly 20 percent of cases) usually arises from neuroendocrine cells of the bronchial tree and presents with bulky mediastinal lymph node involvement and early distant metastases.

Non-small cell lung cancer (roughly 80 percent of cases) includes all other cell types. Adenocarcinoma, squamous cell carcinoma, large cell carcinoma and bronchioloalveolar cell are the most common cell types.

Epidemiology Lung cancer is the leading cause of cancer death worldwide of both men and women. The epidemiology of lung cancer has been examined for over 50 years and has been well documented. Developed nations have the highest rates of lung cancer with underdeveloped nations generally having lower rates. Lung cancer rates vary widely with race, geographic distribution and gender. It is estimated in the United States roughly 215,000 people will die of lung and bronchus cancer in 2008. Incidence overall is 80 per 100,000 persons with the highest rate among men being African-American at 108 per 100,000 persons and the highest rate among women being roughly equal between whites and African-Americans at roughly 56 per 100,000 persons. In the United States, there has been a progressive decline in incidence overall among men over the past 10 years; but, this trend has not been met by a decline in incidence in women, whose lung cancers are still increasing by a small amount. In the United States, the highest incidence of lung cancer occurs in the South and Southeast; the West and Northwestern states have the lowest incidence. Louisiana has one of the highest rates in the country at around 80 to 105 per 100,000 persons. In developed countries as the incidence of non-small lung cancer has increased, adenocarcinoma has been diagnosed with increasing frequency as the squamous cell cancer percentage has declined. This phenomenon is typically attributed to a change in cigarette types. Filtered “lighter” cigarettes are thought to allow deeper inhalation and, therefore, deeper penetration of carcinogens to the periphery of the lung, where adenocarcinomas tend to arise. The survival rates of lung cancer patients generally mirror the incidence rates, which reflect the extremely high case mortality rate across all geographic locations.

Risk Factors Tobacco smoking is far and away the leading causative risk factor for development of cancer of the lung and bronchus. Specifically, the introduction of manufactured cigarettes heralded the dramatic increase of lung cancer rates during the 1930s through the 1960s. Possible explanations include the addition of chemical agents that enhanced the cigarette’s addictive properties and nicotine delivery to the body.

There are other factors that can act in concert with cigarette smoking to increase the risk of developing lung cancer. The first occupational respiratory carcinogen discovered was radon gas, noted in underground miners with increased rates of lung cancer.

Indoor radon gas is now widely recognized as a major respiratory carcinogen. The other major respiratory carcinogen associated with increased lung cancer risk is asbestos. Asbestos was widely used in a number of industries due to its heat-resistant properties but, it has been widely eliminated since the 1970s. Other putative risk factors include smog and city air pollution, arsenic, chromates

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OUR LADY OF THE LAKE | MARY BIRD PERKINS

and polycyclic aromatic hydrocarbons. In developing countries, pollution from wood-burning stoves used for cooking is also associated with lung cancer development.

Dietary risk factors including high-fat, low-vegetable intake have been the subject of considerable investigation. No causative link has been established. Chronic infectious and inflammatory conditions, such as tuberculosis and silicosis that lead to extensive scarring of the lung, have also been associated with increased cancer risk (so-called scar carcinoma). As with many other cancers, lower socioeconomic status, poor access to healthcare and education and ethnic factors are all associated with an increased risk for lung cancer development. While there is no clear genetic predisposition for lung cancer development, molecular studies are ongoing to determine the basis for genetic and molecular alterations that occur in the pathogenesis of lung cancer.

Clinical Findings Unfortunately, by the time lung cancer is clinically evident (i.e., symptoms such as cough or chest pain are present) it is usually at an advanced stage. Small, early stage lung cancers are typically asymptomatic. Cough is the most common complaint, but is a nonspecific finding. Hemoptysis (coughing up of blood) is always worth investigation in individuals at risk for lung cancer. Chest pain or discomfort may also be present but is, again, nonspecific. Dyspnea (breathlessness) as well as wheezing may also be reported due to blockage of major airways by tumor. Advanced stage cancers can also present with hoarseness due to impingement upon the laryngeal nerves, which control the vocal cords, as well as facial swelling due to impingement upon the large vein (superior vena cava), which drains blood from the head and neck areas. Metastatic disease is common and presents with symptoms such as bone pain, fractures, seizures and arrhythmias due to metastases to the bones, central nervous system and pericardium. Local invasion of the spine and brachial plexus (nerve bundle controlling the arms) are also possible presenting with nerve deficits corresponding to the site of invasion.

Screening Numerous screening trials over the past four decades have utilized various modalities including sputum cytology, chest radiograph and computed tomography (CT) of the chest. Unfortunately, no trial has established any of these modalities as an effective screening tool and, therefore, no screening for lung cancer can be recommended at this time.

Diagnosis/Staging Small tumors of the lung (one centimeter or less) are not easily detected on standard chest radiographs. Computed tomography of the lung is much more sensitive at detecting these smaller lesions. That being said, a diagnosis of lung cancer can be quite elusive because many tumors found in the lung are difficult to sample by biopsy due to the anatomy and structure of the lung itself. The main modalities to diagnose lung cancer are percutaneous needle biopsy and bronchoscopy. Percutaneous biopsy is generally performed by a specially skilled radiologist under the guidance of an imaging modality such as CT. A needle is placed in the suspect lesion to extract a small sample for examination under a microscope. This technique can be limited if the tumor size is too small or if it is in the center of the lung. Passing through the lung tissue with a needle poses a risk of pneumothorax (lung collapse).

Bronchoscopy is the passage of a small, flexible scope with a light source and a camera at the end into the bronchial tree. Needles and forceps (pincers) can be passed through the bronchoscope into the lung to obtain tissue. Again, with small and peripheral tumors, the diagnostic yield drops considerably. Newer modalities such as navigational bronchoscopy (which uses a GPS-like system to guide a biopsy device to the target area), are being perfected. Surgical or excisional biopsy remains the gold standard.

However, it does require an open surgical procedure and is quite invasive.

Staging (determination of the extent of disease) of lung cancer is divided into two categories; invasive and non-invasive. Staging is crucial because the stage of disease determines the treatment modality. Non-invasive staging modalities include CT of the chest as well as positron emission tomography (PET) of the whole body. CT can determine location and size of mediastinal and hilar lymph nodes, size and location of tumors as well as examine the remainder of the chest for metastatic or other suspect lesions. PET scanning has become much more commonplace in the last five years and is an essential part of cancer staging. Not only does it aid in determining activity of mediastinal and hilar lymph nodes but can also pinpoint areas outside the chest that harbor metastatic disease. Both PET and CT imaging are limited by inability to image lesions smaller than one centimeter as well as to differentiate between cancer and infection or inflammation.

2008 CANCER ANNUAL REPORT

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An Overview: Non-Small Cell Lung Cancer — continued Invasive staging techniques include mediastinoscopy, bronchoscopic endobronchial ultrasonography (EBUS) and endoscopic ultrasonography (EUS). The staging of lung cancer is primarily done to establish presence or absence of spread to regional lymph nodes in the pulmonary hila and mediastinum. Mediastinoscopy is a surgical procedure in which a rigid scope (tube) is inserted into the mediastinum. Lymph nodes are extracted whole and subsequently examined under the microscope for evidence of metastatic disease. EBUS is a newer technique in which a flexible bronchoscope, equipped with a small ultrasound device on its tip, is used to visualize the mediastinal and hilar lymph nodes. Then, a needle can be passed down the length of the bronchoscope and samples taken from each lymph node for microscopic examination. EUS is similar in technique, but instead of the scope being passed into the airway, the scope is passed into the esophagus. Because of the close proximity of the esophagus to both the lung and the mediastinum, some of the deeper mediastinal lymph nodes can be sampled by this technique. Numerous studies have shown all three modalities to be safe and effective in staging lung cancer. EBUS and EUS have the advantage of being less invasive, and recent studies indicate these techniques may access a greater range of lymph nodes than mediastinoscopy.

Treatment Lung resection (lobectomy) is the primary treatment of early stage lung cancer (Stage I and II). This technique involves making an incision in the chest wall between the ribs and removing either all (pneumonectomy) or a portion of the lung (lobectomy).

Thoracoscopy is a less invasive approach and involves making several small incisions in the chest wall and inserting rigid scopes through the incisions with an image sent to a video screen (VATS or video-assisted thoracoscopic surgery). This approach can be used to perform lobectomy with a smaller incisional wound. Prior to any planned operation, a patient’s operability must be determined by ensuring the patient will have sufficient lung function following surgery. Cardiac stress testing is also frequently performed since smokers often have coexistent coronary atherosclerosis. Many times, patients will not have sufficient underlying lung function to warrant surgery because smoking has damaged lung tissue. Many of these patients have severe obstructive lung disease (COPD) due to emphysema or chronic bronchitis. Surgery for early stage lung cancer holds the best chance at long-term, disease-free survival.

For patients who are not surgical candidates for any of the reasons described above, chemotherapy and radiation therapy remain the primary treatment modalities. Chemotherapy may vary by cell type, but it is usually a combination of a platinum-based drug, such as carboplatin or cisplatin and a taxane (taxol-derivative), such as taxol or taxotere. Newer chemotherapy drugs, such as bevacizumab (Avastin) which disrupt the tumor blood supply, are also being used in combination with traditional drugs. In patients who do undergo surgical resection of larger tumors, chemotherapy following surgery (adjuvant chemotherapy) is commonplace. A number of trials are examining whether chemotherapy given both prior to (neoadjuvant) and after surgical resection improve survival.

Radiation therapy or radiotherapy is the delivery of focused-beam radiation to the tumor site. It can be used before, during and after chemotherapy depending on the treatment protocol. When used in combination with chemotherapy (chemoradiotherapy), there is good evidence the tumor killing activity of both modalities are additive. Newer radiotherapy devices, such as TomoTherapy and focused-beam radiosurgery, can limit the radiation exposure to normal surrounding tissues and allow for higher radiation doses to be delivered to the tumor. Studies are currently ongoing in other countries as well as the United States comparing radiosurgical devices to traditional open surgery with the intent to cure early stage lung cancer.

Prognosis The prognosis overall for lung cancer is quite sobering. The overall five-year survival rate across stage and geographic location was 15.2 percent from 1996 to 2004. As with many solid organ tumors, the earlier the stage at discovery, the better the prognosis. Only 16 percent of lung cancers are discovered when the tumor is still localized (Stage I). Approximately 25 percent of cancers are found after it spreads to loco-regional lymph nodes (Stage II and III). A full 52 percent of cancers are discovered when distant metastases (stage IV) are already present. Five-year survival rates by stage are as follows: 50 percent for Stage I, 21 percent for Stages II and III and 3 percent for Stage IV. For cancers of unknown stage at the time of diagnosis, five-year survival is roughly 8 percent. Lung cancer remains the number one preventable cause of cancer death worldwide and will remain the number one cancer killer for the foreseeable future.* *Source: http://seer.cancer.gov/statfacts/html/lungb.html

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OUR LADY OF THE LAKE | MARY BIRD PERKINS

Figure 1 Year of Diagnosis for Non-Small Cell Lung Cancer During the past five years (2003 to 2007), an average of 150 cases of non-small cell lung cancer were diagnosed and/or received initial therapy at OLOL or MBP per year. Although the number of cases seen each year has increased since 2003, the numbers have been reasonably stable over the last few years.

Year Number of Cases Per Year OLOL/MBP 2003 – 2007 2007

2006 2005 2004

2003

0

50

100

150

200

Figure 2 Age at Diagnosis and Comparison with National Statistics Although non-small cell lung cancer can be seen across a broad age range, the majority of cases are typically diagnosed between the sixth and seventh decades. Our data parallel the National Cancer Data Base (NCDB); however, a slightly higher percentage of cases occurring in patients under 60 years of age are seen in our local population, possibly reflecting a higher prevalence of cigarette smoking among our younger population. The drop incidence at the beginning of the eighth decade most likely reflects the accelerating mortality from all causes in these elderly patients.

Age

# of Cases

Percentage Percentage

0 - 39

5

<1%

<1%

40 - 49

58

7.8%

5.3%

50 - 59

133

17.8%

15.6%

60 - 69

240

32.1%

28.8%

70 - 79

226

30.3%

34.6%

80 - 89

82

11%

14.4%

90+

3

<1%

<1%

OLOL/MBP 2003 - 2007 NCDB 2000 - 2005

Figure 3 Gender, Race and Comparison with National Statistics Non-small cell lung cancer is typically more common in men than in women with a reported male to female ratio of more than 3:1. Our local data show a similar ratio and closely parallel those of the NCDB. When looking at race, our local data show a greater percentage of non-small cell lung cancer arising in African-Americans (more than twice that is seen in the national statistics), while other races appear underrepresented. This no doubt reflects the makeup of our local population.

# of ALL RACES CAUCASIAN AFRICAN-AMERICAN ALL OTHER RACES Gender Cases Percentage Percentage Percentage Percentage Percentage Percentage Percentage Percentage Male

434

58.1%

57.2%

43.1%

47.7%

14.7%

6.3%

0.1%

3.3%

Female

313

41.9%

42.8%

33.1%

36.4%

8.7%

4.1%

0.3%

2.2%

Total

747

100%

100%

76.2%

84.1%

23.4%

10.4%

0.4%

5.5%

OLOL/MBP 2003 - 2007

NCDB 2000 - 2005

2008 CANCER ANNUAL REPORT

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An Overview: Non-Small Cell Lung Cancer â&#x20AC;&#x201D; continued Figure 4 Histologic Types and Comparison with National Statistics Although often considered a single type of lung cancer, non-small cell carcinoma actually refers to a large and diverse group of tumors that can be separated into a number of distinct subtypes by their differentiation and histologic appearance.

For the purposes of comparison with available national statistics, non-small cell carcinomas have been grouped into six major histologic types. For most all types, our population of patients closely parallels the national statistics. The slightly higher percentage of non-small cell carcinoma, not otherwise specified (NOS) cases within our group, may reflect a higher percentage of cases diagnosed by cytology rather than tissue biopsy. Although proportionately more cases of adenosquamous carcinoma were diagnosed within our population when compared to the national statistics, the overall percentage is still quite small within both groups.

OLOL/MBP

NCDB

Adenocarcinoma

Adenosquamous Carcinoma

Bronchiolar Carcinoma

Large Cell Carcinoma

Squamous Cell Carcinoma

Non-Small Cell Carcinoma, NOS

Figure 5 American Joint Commission on Cancer (AJCC) Stage at Diagnosis and Comparison with National Statistics For the past five years (2003 â&#x20AC;&#x201C; 2007), our local data for the distribution of non-small cell lung cancer by AJCC stage parallel the national statistics, but for a slight increase in the number of more advanced Stage IV tumors.

AJCC/CS Mixed Stage

Percentage Percentage

0

0.0%

<1%

Stage I

159

21.3%

23.3%

Stage II

50

6.7%

7.4%

Stage III

182

24.4%

25.3%

Stage IV

305

40.8%

35.3%

Unknown

51

6.8%

8.4%

OLOL/MBP 2003 - 2007

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# of Cases

Stage 0

NCDB 2000 - 2005

OUR LADY OF THE LAKE | MARY BIRD PERKINS

Figure 6 Treatment Modalities: First Comparison with National Statistics Treatment for non-small cell lung cancer depends greatly on the extent of disease, i.e. the combined clinical and pathologic stage. Lower stage tumors may require only some form of surgical resection while more advanced tumors usually require multiple treatment modalities including surgery, radiation therapy and/or chemotherapy. Our local data reveal a smaller percentage of cases treated by surgery alone and a significantly higher percentage of cases requiring multiple treatment modalities compared to national statistics, probably reflecting the higher percentage of advanced stage tumors present within the local population.

Treatment Modalities

# of Cases

Percentage Percentage

Radiation/Chemotherapy

189

25.3%

20.4%

Radiation

128

17.1%

15.7%

Surgery

124

16.6%

21.1%

Chemotherapy

84

11.2%

11.6%

Surgery/Radiation/Chemotherapy

45

6.0%

3.1%

Surgery/Chemotherapy

17

2.3%

<1%

Surgery/Radiation

12

1.6%

<1%

Other

0

0.0%

6.7%

None

148

19.8%

21.3%

OLOL/MBP 2003 - 2007

NCDB 2000 - 2005

Figure 7 Relative Five-Year Survival Rates and Comparison with National Statistics Non-small cell lung cancer is one of the most lethal malignancies with an overall five-year survival rate of only 16 percent according to national statistics. While early detection significantly improves survival rates, it is notable that more than half the patients diagnosed with even the lowest stage lesion (Stage 1) succumb to the disease within five years. Our local data reflect an overall survival rate that closely parallels that of the NCDB, but decreased survival rates for Stage II and Stage III cancers.

Stage I

Stage II Stage III Stage IV

Overall

0%

5%

10%

OLOL/MBP 1998 - 2000

15%

20%

25%

30%

35%

40%

45%

NCDB 1998 - 2000

2008 CANCER ANNUAL REPORT

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OLOL Cancer Registry Summary

The Cancer Registry is an integral component of the Commission on Cancer (CoC) approved program and plays a vital role in the success of the program. The registry collects and analyzes demographic, diagnostic, treatment and staging data on cancer patients treated at OLOL. The OLOL Cancer Registry reference date is 1987, and it contains data on 24,954 cancer cases.

All new cases identified are abstracted, coded and staged in accordance with guidelines set by the American College of Surgeons (ACoS), the National Cancer Instituteâ&#x20AC;&#x2122;s Surveillance Epidemiology and End Results (SEER) program and the Louisiana Tumor Registry. High importance is placed on data quality using these guidelines, and a sample of the cases is reviewed by a radiation oncologist for quality assurance. Once part of the registry database, these cases are followed for the life of the patient. In 2007, the OLOL Cancer Registry maintained a follow-up rate averaging 90 percent meeting the ACoS minimum standard of 90 percent.

Of the 1,470 newly accessioned cases in 2007, 1,340 were analytic* and 130 were non-analytic. The top five sites treated were colorectal, non-small cell lung, prostate, kidney and pelvis and breast.

The registry maintains cancer data that are available for use by clinical and administrative staff at OLOL. All information collected is kept completely confidential. During 2007, the registry received requests for statistical reports including analytic studies, annual statistics, research activities, quality management studies, reporting to the state cancer registry, healthcare delivery, reporting to the National Cancer Data Base (NCDB) and participation in the Facility Information Profile System (FIPS) on the American Cancer Societyâ&#x20AC;&#x2122;s (ACS) Web site www.cancer.org. * Analytic cases are those diagnosed and/or receiving all or part of the first course of therapy at OLOL.

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OUR LADY OF THE LAKE | MARY BIRD PERKINS

OLOL 2007 SITE DISTRIBUTION TABLE

Site Group All Sites Blood/Bone Marrow Leukemia Myeloma Other Hematopoietic Bone Brain Breast Digestive System Anus, Anal Canal, Anorectum Bile Duct Colon Esophagus Gallbladder Liver Pancreas Rectum & Rectosigmoid Small Intestine Stomach Other Digestive Endocrine Thyroid Other Endocrine Female Genital Cervix Uteri Corpus Uteri Fallopian Tubes Ovary Vulva Lymphatic System Hodgkin’s Disease Non-Hodgkin’s Lymphoma Male Genital Prostate Testis Oral Cavity/Pharynx Hypopharynx Lip Mouth, Floor of Mouth, Other & NOS Nasopharynx Nasal Cavity, Sinus, Ear Oropharynx Salivary Glands, Major Tongue Tonsil Other Oral Cavity/Pharynx Other Nervous System Respiratory/Intrathoracic Larynx Lung/Bronchus, Non-Small Cell Lung/Bronchus, Small Cell Pleura Other Respiratory/Intrathoracic Skin Melanoma of Skin Other Skin Cancer Soft Tissue Unknown or Ill-Defined Urinary Tract Bladder Kidney & Renal Pelvis Ureter

Total Cases 1470 55 33 17 5 2 35 99 303 4 4 150 12 3 23 35 54 4 12 2 48 43 5 25 2 5 2 12 4 73 10 63 206 201 5 61 5 3 11 2 9 1 3 14 10 3 28 275 30 203 37 4 1 34 31 3 13 36 177 72 104 1

Class A N/A 1340 46 28 14 4 1 34 79 285 3 4 145 10 3 20 33 52 4 11 0 48 43 5 16 0 2 2 9 3 62 9 53 193 188 5 53 5 1 9 2 8 1 2 13 10 2 28 250 26 188 34 2 0 32 29 3 11 31 171 71 99 1

130 9 5 3 1 1 1 20 18 1 0 5 2 0 3 2 2 0 1 2 0 0 0 9 2 3 0 3 1 11 1 10 13 13 0 8 0 2 2 0 1 0 1 1 0 1 0 25 4 15 3 2 1 2 2 0 2 5 6 1 5 0

M

Sex

825 28 16 10 2 1 21 5 158 2 2 67 9 1 14 19 32 2 9 1 16 12 4 0 0 0 0 0 0 33 3 30 206 201 5 52 4 3 7 2 7 1 3 12 10 3 4 147 17 112 14 3 1 21 19 2 5 15 113 54 58 1

F

0

I

Stage II

III

IV

Not App

Unknown

645 27 17 7 3 1 14 94 145 2 2 83 3 2 9 16 22 2 3 1 32 31 1 25 2 5 2 12 4 40 7 33 0 0 0 9 1 0 4 0 2 0 0 2 0 0 24 128 13 91 23 1 0 13 12 1 8 21 64 18 46 0

58 0 0 0 0 0 0 9 9 1 0 5 0 0 0 0 3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 3 0 0 0 0 2 2 0 0 0 35 34 1 0

291 0 0 0 0 0 0 27 67 0 1 41 2 1 2 0 17 0 3 0 29 29 0 2 0 0 0 1 1 17 3 14 7 3 4 16 1 1 3 0 2 0 1 6 2 0 0 46 5 37 2 2 0 8 7 1 1 0 71 18 52 1

301 0 0 0 0 0 0 20 48 1 1 27 3 0 0 3 8 2 3 0 4 4 0 2 0 1 0 0 1 13 3 10 156 155 1 5 0 0 2 0 0 0 0 1 2 0 0 23 6 16 1 0 0 6 6 0 4 0 20 12 8 0

192 0 0 0 0 0 0 11 67 1 1 42 1 0 4 4 12 0 2 0 3 3 0 7 0 1 1 4 1 6 0 6 19 19 0 5 1 0 0 0 1 0 0 3 0 0 0 47 5 38 4 0 0 7 7 0 1 0 19 3 16 0

255 0 0 0 0 1 0 8 67 0 1 24 3 2 6 19 9 1 2 0 2 2 0 2 0 0 1 1 0 18 3 15 9 9 0 19 2 0 4 1 4 0 1 2 5 0 0 105 5 81 19 0 0 2 2 0 0 0 22 3 19 0

156 46 28 14 4 0 34 0 4 0 0 1 0 0 1 1 0 1 0 0 5 0 5 0 0 0 0 0 0 0 0 0 0 0 0 3 0 0 0 0 1 0 0 0 0 2 28 3 0 3 0 0 0 1 0 1 1 31 0 0 0 0

87 0 0 0 0 0 0 4 23 0 0 5 1 0 7 6 3 0 1 0 5 5 0 3 0 0 0 3 0 8 0 8 2 2 0 5 1 0 0 1 0 1 0 1 1 0 0 23 2 13 8 0 0 6 5 1 4 0 4 1 3 0

NOS: Not Otherwise Specified | A: Analytic | N/A: Non-Analytic | M: Male | F: Female | Not App: Not Applicable 2008 CANCER ANNUAL REPORT

13

MBP Cancer Registry Summary

The Cancer Registry is an integral component of the Commission on Cancer (CoC) approved program and plays a vital role in the success of the program. The registry collects and analyzes demographic, diagnostic, treatment and staging data on cancer patients treated at MBP. The MBP Cancer Registry reference date is 1989, and it contains data on 10,856 cancer cases.

All new cases identified are abstracted, coded and staged in accordance with guidelines set by the American College of Surgeons (ACoS), the National Cancer Instituteâ&#x20AC;&#x2122;s Surveillance, Epidemiology and End Results (SEER) program and the Louisiana Tumor Registry. High importance is placed on data quality using these guidelines, and a sample of the cases is reviewed by a radiation oncologist for quality assurance. Once part of the registry database, these cases are followed for the life of the patient. The MBP Cancer Registry maintained a follow-up rate averaging 95 percent, exceeding the ACoS minimum standard of 90 percent.

Of the 859 newly accessioned cases in 2007, 786 were analytic* and 73 were non-analytic. The top five sites treated were breast, prostate, non-small cell lung, colorectal and brain.

The registry maintains cancer data that is available for use by clinical and administrative staff at MBP. All information collected is kept confidential in accordance with HIPAA regulations.

During 2007, the registry received requests for statistical reports including analytic studies, annual statistics, research activities and quality management studies. The registry participated in the National Cancer Data Base (NCDB) Annual Call for Data and the Breast e-QuIP study.

In addition, the registry participated in the Facility Information Profile System (FIPS) initiative on the American Cancer Societyâ&#x20AC;&#x2122;s (ACS) Web site www.cancer.org. * Analytic cases are those diagnosed and/or receiving all or part of the first course of therapy at MBP.

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OUR LADY OF THE LAKE | MARY BIRD PERKINS

MBP 2007 SITE DISTRIBUTION TABLE

Site Group All Sites Blood/Bone Marrow Myeloma Brain Breast Digestive System Anus, Anal Canal, Anorectum Bile Duct Colon Esophagus Liver Pancreas Rectum & Rectosigmoid Stomach Endocrine Thyroid Other Endocrine Female Genital Cervix Uteri Corpus Uteri Ovary Vagina Vulva Lymphatic System Hodgkin’s Disease Non-Hodgkin’s Lymphoma Male Genital Prostate Oral Cavity/Pharynx Hypopharynx Mouth, Floor of Mouth, Other & NOS Nasopharynx Nasal Cavity, Sinus, Ear Oropharynx Salivary Glands, Major Tongue Tonsil Other Oral Cavity/Pharynx Other Nervous System Respiratory/Intrathoracic Larynx Lung/Bonchus, Non-Small Cell Lung/Bronchus, Small Cell Pleura Skin Melanoma of Skin Other Skin Cancer Soft Tissue Unknown or Ill-Defined Urinary Tract Bladder Kidney & Renal Pelvis Ureter

Total Cases 859 13 13 24 236 86 10 3 8 9 3 11 39 3 6 3 3 38 20 10 2 2 4 24 7 17 176 176 52 4 7 3 6 3 1 9 16 3 1 171 21 122 27 1 4 3 1 5 11 12 4 7 1

Class A N/A 786 11 11 21 221 80 10 3 4 8 2 11 39 3 5 2 3 36 20 10 0 2 4 20 6 14 162 162 52 4 7 3 6 3 1 9 16 3 1 154 21 109 24 0 2 1 1 4 9 8 3 5 0

73 2 2 3 15 6 0 0 4 1 1 0 0 0 1 1 0 2 0 0 2 0 0 4 1 3 14 14 0 0 0 0 0 0 0 0 0 0 0 17 0 13 3 1 2 2 0 1 2 4 1 2 1

M

Sex

422 10 10 14 0 45 2 1 6 7 3 5 20 1 4 2 2 0 0 0 0 0 0 12 3 9 176 176 45 3 6 1 4 3 1 9 15 3 0 99 17 69 12 1 3 2 1 3 4 7 1 6 0

F

0

I

Stage II

III

IV

Not App

Unknown

437 3 3 10 236 41 8 2 2 2 0 6 19 2 2 1 1 38 20 10 2 2 4 12 4 8 0 0 7 1 1 2 2 0 0 0 1 0 1 72 4 53 15 0 1 1 0 2 7 5 3 1 1

35 0 0 0 34 0 0 0 0 0 0 0 0 0 0 0 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 1 0 0 0 0 0 0 0 0 0 0

137 0 0 0 85 3 0 2 0 0 0 0 1 0 0 0 0 8 1 7 0 0 0 11 1 10 5 5 2 1 0 0 0 0 0 0 1 0 0 22 5 15 2 0 1 0 1 0 0 0 0 0 0

237 0 0 0 49 20 7 0 2 1 1 2 7 0 0 0 0 4 3 0 0 1 0 3 3 0 140 140 6 0 3 0 0 0 0 2 1 0 0 11 4 5 2 0 0 0 0 2 0 2 2 0 0

144 0 0 0 34 28 2 1 0 3 0 5 15 2 0 0 0 15 10 2 0 1 2 3 2 1 12 12 10 1 1 0 0 0 0 4 4 0 0 37 4 28 5 0 1 1 0 1 0 3 0 3 0

158 0 0 0 13 21 0 0 2 1 1 2 14 1 2 2 0 8 6 0 0 0 2 3 0 3 4 4 27 2 3 2 5 3 1 2 9 0 0 77 7 57 13 0 0 0 0 0 0 3 1 2 0

51 11 11 21 0 0 0 0 0 0 0 0 0 0 3 0 3 0 0 0 0 0 0 0 0 0 0 0 4 0 0 0 1 0 0 0 0 3 1 1 0 1 0 0 0 0 0 1 9 0 0 0 0

24 0 0 0 6 8 1 0 0 3 0 2 2 0 0 0 0 1 0 1 0 0 0 0 0 0 1 1 3 0 0 1 0 0 0 1 1 0 0 5 1 3 1 0 0 0 0 0 0 0 0 0 0

NOS: Not Otherwise Specified | A: Analytic | N/A: Non-Analytic | M: Male | F: Female | Not App: Not Applicable

2008 CANCER ANNUAL REPORT

15

Overview

The Cancer Program has been recognized nationally for its excellence in cancer care. It has been selected by the National Cancer Institute (NCI) as one of only 14 sites in the country, and the only one in the Gulf South, to participate in its new and prestigious National Community Cancer Centers Program (NCCCP) pilot. The Cancer Program of OLOL and MBP was chosen based on its ability and experience in conducting clinical trials and providing leadership and healthcare outreach in the communities it serves. A successful pilot will lead to the nationwide launch of the NCCCP in 2010.

The Cancer Program of OLOL and MBP coordinates the entire continuum of cancer care.

For over a century combined, we have delivered—with compassion and excellence—the most advanced cancer care available to Louisiana citizens.

The Cancer Program is the most comprehensive cancer program in the greater Baton Rouge area, offering patients the convenience of receiving high-quality, advanced cancer care in one location close to home. The Cancer Program has been accredited since 1992 by the American College of Surgeons (ACoS)–the gold standard for community-based cancer care. 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. Recently, after an on-site visit by a physician surveyor, the Cancer Program of Our Lady of the Lake and Mary Bird Perkins had zero deficiencies and earned approval with eleven total commendations.

The Cancer Program provides nearly 42,000 cancer treatments and accessions over 2,100 new cancer cases annually, which is approximately 11 percent of new cases in the state each year. The Cancer Program addresses care for a broad variety of primary sites, with the most commonly seen being lung, breast, digestive system, prostate and urinary cancers.

Approximately 15 percent of newly accessioned cases are indigent patients. The gender distribution of new cases is 55 percent male and 45 percent female. Almost 20 percent of cases present at late stages, which is consistent with Louisiana’s high cancer mortality rates and fuels the commitment for outreach and improvement found within the Cancer Program and its medical staff. Of the 41,986 treatments delivered, 16 percent of those treatments were to indigent patients.

Throughout September 2007, National Prostate Cancer Awareness Month, over 300 men were screened for prostate cancer. In addition to recognizing national cancer awareness months, the Cancer Program offers free cancer screenings and educational programs throughout the year. These events provide diagnostic and educational services to underserved and uninsured populations throughout the greater Baton Rouge region.

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OUR LADY OF THE LAKE | MARY BIRD PERKINS

5000 Hennessy Boulevard Baton Rouge, LA 70808-4398 (225) 765-8879 ololrmc.com

4950 Essen Lane Baton Rouge, LA 70809-3432 (225) 767-0847 marybird.org