2011 Cancer Annual Report
R E CTAL CANCE R ST UDY
Fighting Cancer Together
The Cancer Program of
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 Mary Bird Perkins Cancer Center (MBPCC) and St. Tammany Parish Hospital (STPH).
Jack Saux, MD
Hematology/Oncology Cancer Committee Chairman
Health Initiatives Representative, American Cancer Society
Greg Henkelmann, MD
Patricia Maltese, RT, MHA
Radiation Oncology, MBPCC Cancer Liaison Physician Tumor Conference Coordinator
Department Head, Imaging Services, STPH
Arlyn Arceneaux, RN, BSN, OCN Department Head Medical Oncology Unit, STPH
Donna Berbling, RN, BSN Director of Hospice, STPH
Scott Bermudez, MD Radiation Oncology, MBPCC
Patricia Braly, MD GYN Oncology
Shelley Cameron Department Head Decision Support, STPH
Robert Capitelli, MD Sr. Vice President, Chief Medical Officer, STPH
Chryl Corizzo, RN, BSN, OCN Cancer Program Director, STPH Quality Improvement Coordinator, STPH
Susan May, RN, BS Department Head, Case Management, STPH
Kathy McWhorter, RN, MSN Director of Nursing, STPH
Debra Miller, RN, OCN Cancer Resource Nurse, STPH Community Outreach Coordinator, STPH
Kerry Milton, RN, MSHA Sr. Vice President, Chief Nursing Officer Administration, STPH
David Oubre, MD Hematology/Oncology
Ty Ovella, MD Radiology, STPH
Allison Rome, MD Hematology/Oncology
Juanita Schenck, LCSW Case Management, STPH
Renea Austin-Duffin, MPA
Danielle Spell, CTR
Vice President, Cancer Programs, MBPCC Community Outreach Coordinator, MBPCC
Certified Tumor Registrar, MBPCC
Terry Freeman, CTR
Tumor Registrar, STPH
Certified Tumor Registrar, Covington MBPCC
Teena Strand-Parker, RN
Vickie Hall, LPN, RT (T) Vice President, Patient Care, MBPCC
Department Head Ambulatory Care, Pre-op, Infusion Suite, STPH
Judy Limbaugh, MD
John Verhulst, MD
Pathology CAPS Protocols Coordinator, STPH
General Surgery Registry Quality Control Coordinator, STPH
Nicole Magee, CTR
Beverly Villemuer, CTR
Cancer Registry Director, MBPCC Registry Quality Control Coordinator, MBPCC
Jo Watkins, RPh
Certified Tumor Registrar, STPH Clinical Pharmacy Coordinator, STPH
2011 MBPCC AND STPH CANCER ANNUAL REPORT
As chairman of the Mary Bird Perkins Cancer Center (MBPCC) and St. Tammany Parish Hospital (STPH) Cancer Committee, I am pleased to present highlights of the 2011 Cancer Program Annual Report. The Cancer Committee of MBPCC and STPH provides leadership by ensuring 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 through cancer-related activities that benefit patients and their families. As a cancer program approved by the American College of Surgeons Commission on Cancer (CoC) we provide quality care through an array of services throughout the entire cancer care continuum including prevention, early diagnosis, pre-treatment evaluation, staging, optimal treatment, rehabilitation, recurrent disease surveillance, support services and end-of-life care. The Cancer Committee was active in numerous aspects of cancer control activities and services provided to patients, caregivers, health professionals and the community. Below are just a few examples:
Jack Saux, MD
In Spring 2010, STPH improved interpretation of mammography films by installing digital mammography systems at the Breast Center and Paul Cordes Outpatient Pavilion.
The hospital completed a report on the management and outcomes of colon and rectal cancers, which can be found on page 7.
To educate and assist physicians in a smooth transition to the American Joint Commission on Cancer Staging Manual, the committee presented updated staging information to medical staff, tumor registrars and other professionals through webinars, the distribution of pocket stagers, discussions at tumor conferences and the physician newsletter.
A site coordinator was added to develop and implement a process to monitor compliance with the Risk Evaluation and Management Strategy (REMS) devised by the FDA for administration of erythrocytestimulating agents (Procrit) to patients with cancer related anemia. After qualifying as a registered site in August 2010, the Committee implemented the new policy and sent a letter to physicians explaining the protocol required for hospital compliance with this federally mandated process.
Patient safety is paramount in the provision of quality care. Actions were taken to elevate competency of the staff providing care. The Oncology Safety Council assured compliance with recently published American Society of Clinical Oncology/Oncology Nursing Society Chemotherapy Safety Standards. The Safety Council also spearheaded the first annual oncology nurse certification (OCN) review course, which resulting in an increase in the number of OCN-certified nurses. To further encourage staff to seek specialty certification, the hospital instituted a reimbursement policy for successful certification. The first formal annual Chemotherapy Competency lab was held with 100% of oncology nurses in attendance.
Over 780 people were screened at 35 free cancer screenings offered in St. Tammany and Washington Parishes. More than 1,750 people learned about cancer care including cancer early detection and wellness information as it relates to cancer through community education and health fair initiatives.
As MBPCC and STPH enter a new phase in our longstanding partnership to elevate local cancer care to the highest level, several elements of the intensified partnership are already in place. MBPCC has relocated its Northshore radiation therapy and support services to the first floor of the Charles A Frederick Medical Office Complex located directly across from STPH’s main hospital building. In addition, STPH constructed a new skybridge connecting the buildings to ensure cancer center patients, physicians and visitors easier, safer and direct access to the main campus. The Cancer Program of Mary Bird Perkins and St. Tammany Parish Hospital remains dedicated to promoting cancer education and prevention and improving all phases of diagnosis and treatment for our patients.
Jack E. Saux, III, M.D.
Medical Oncologist Cancer Committee Chair
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 (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 (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. This year, the Cancer Committee has strengthened its program by promoting positive change within the CoC’s five priority areas. In 2010, those included: advocacy, quality improvement, ACS partnership, clinical trials and comprehensive cancer control.
Gregory C. Henkelmann, MD
The MBPCC/STPH Cancer Committee had particular success in following the Commission directives with regard to the following:
This year, the committee sought to increase documentation of American Cancer Society (ACS) services and referrals by 25%. To that end, ACS representatives began to track the number of referrals and types of services patients received and reported that data at Committee meetings. Documentation of referrals increased well above benchmark for the Cancer Program.
The Committee also worked with ACS to train and support the Road to Recovery Program where volunteer drivers bring patients living in St. Tammany Parish to and from cancer related treatment/ appointments when no other resource is available. This new program will grow as the years pass.
The Committee increased the number of free cancer screenings offered in St. Tammany and Washington Parishes, and offered oral screenings in targeted areas of the Northshore based on identified need. In 2010, the Cancer Program of Mary Bird Perkins and St. Tammany Parish Hospital held 35 screening events and screened 780 patients, a 10% increase over the prior year.
The Committee reviewed the Cancer Practice Profile Reports for measures pertaining to both breast and colorectal cancers to ensure that patients received care concordant with recommended standards of care.
In July 2010, STPH revised the patient centered oral care protocol to reflect evidence based care from the Oncology Nursing Society. Primary changes included recommendations for the addition of the use of cold water or ice prior to, during and after bolus 5FU or melphalan, if the patient can tolerate it. The oral care protocol is used for those on chemotherapy and also having radiation to the oral cavity and neck area.
In addition to focusing on those objectives, I continue to attend the quarterly meetings of the Cancer Committee, serve as physician advisor for the annual management and outcome study and to assist in facilitation of monthly tumor conferences. I look forward to working with local and national organizations to improve our cancer program in the years ahead.
Greg C. Henkelmann, MD Radiation Oncologist, Mary Bird Perkins Cancer Center
2011 MBPCC AND STPH CANCER ANNUAL REPORT
Integrated Supportive and Continuing Care Services DIAGNOSTIC SERVICES Pathology Laboratory Radiology CT Scanner, Ultrasound, Nuclear Medicine, MRI PET-CT Scanner • 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
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Inpatient Medical Oncology Unit/Outpatient Infusion Suite Radiation Therapy • External Beam Radiotherapy • Brachy Therapy • Radiation Treatment Planning • Image Fusion • Medical Physics/Dosimetry • Positron Emission Tomography (PET-CT) • Dental Oncology • 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
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Cancer Screenings • Cancer Resource Center Patient Educational Forums • Education for Health Professionals
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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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Delivering Cancer Care Close to Home Together We Coordinate the Entire Continuum of Cancer Care The Cancer Program of Mary Bird Perkins Cancer Center and St. Tammany Parish Hospital is the most comprehensive cancer program in the St. Tammany Parish 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) â€“ 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.
Commitment to Early Detection and Outreach The Cancer Program of Mary Bird Perkins and St. Tammany Parish Hospital brings free cancer screenings, prevention and education services to the Northshore each year. This effort has been underway since 2002 when the early detection program began. With our mobile medical clinic, the Early Bird, we offer these screenings to participants at times and locations convenient to them. In 2010, we screened 780 participants in St. Tammany and Washington Parishes, 41% of whom had never been screened. Patient navigation plays a crucial role in early detection. A nurse navigator, present at each screening event, ensures all patients with abnormal findings receive timely follow-up. They serve as a consistent guide to assist with providing education materials, answering questions, and identifying and addressing barriers to care. In 2010, 16% of screening participants had an abnormal finding that required followâ€“up. Through our commitment to community education and health fair initiatives, more than 1,750 people learned about cancer care including cancer early detection and wellness information as it relates to cancer. 2010 Cancer Screening Details Total Participants Total Events Participants Never Screened Participants Navigated Cancers Diagnosed
January 1-December 31, 2010 St. Tammany and Washington Parishes
2011 MBPCC AND STPH CANCER ANNUAL REPORT
11th Annual Cancer Survivor Day Staff members of The Cancer Program of Mary Bird Perkins and St. Tammany Parish Hospital hosted a picnic in June to celebrate National Cancer Survivors Day. This day is recognized annually in communities across the country to celebrate the 12 million cancer survivors in the United States, their caregivers and the health care professionals who care for and support them through treatment. “This year we wanted our survivors to have a fun, relaxing atmosphere where they could enjoy the company of their caregivers, families and each other, so we held an outdoor picnic,” said Chryl Corizzo, cancer program director. “We had a tremendous turnout – more than 300 people came to celebrate. It was so wonderful so see everyone laughing and sharing stories with each other.” Physicians, nurses, therapists, volunteers and other support staff joined in the celebration. Sherri Blackwell, patient financial counselor said, “We see the patients interact in the waiting room when they’re going through treatment. It was a treat to see them interact in a different way. Through events like Cancer Survivors Day, they can enjoy their survivorship with their families and others who have gone through the same thing.” Many thanks to the following community organizations that supported the event: Cole’s Party City, Louisiana Breast Cancer Task Force, Mandeville Fellowship Christian Church, Target and Wal-Mart.
Volunteer Highlight: Stephanie Swords Fredericks Prevalence of cancer in Stephanie Swords Fredericks’ family caused changes beyond just the emotional. After losing a sister to pancreatic cancer, dealing with her own skin cancer in her twenties and breast cancer in 2007, Fredericks made a life-changing decision. “I was in banking for almost 30 years, when God put in my heart to make a positive change for myself and others,” she said. “I was challenged with finding something I was passionate about that would fill my desire to help people, especially cancer patients.” Fredericks graduated from massage therapy school, obtained specialty training in oncology massage therapy and certification as a lymphedema specialist. Monday and Wednesday mornings, she offers free hand massages in the St. Tammany Parish Hospital infusion suite. “My first day of volunteering made me feel like I was in the happiest place on earth except for maybe Disney World,” Fredericks explained. “Sometimes I would go to my car to cry – not because I was sad, but because of how amazing the patients were.” With a tear in her eye, she adds, “Everyone says I provide massage therapy as well as emotional therapy along the way. Helping our patients is just plain therapy for me. What I never expected was to get back way more than I give. I hope to continue serving cancer patients through my volunteering and through my practice.”
Not only is Stephanie’s kind spirit needed during times like this, but she
shares a common bond with the patients. She’s felt the fear that we have, and it is therapeutic to be able to talk to her while she is massaging my hands. Thank you, Stephanie, for giving your time freely for a passion you love.
Community Support Groups and Activities 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.
Clinic for Wound Care Committed to successfully treating difficult, poor-healing wounds with a program tailored to the individual patient’s needs. Located in the Outpatient Pavilion – (985) 871-6088.
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 and Counseling Program STPH, MBPCC 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 selfimage 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.
Lymphedema Prevention Free 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 – (985) 898-4622.
Lymphedema Therapy Certified lymphedema therapists specialize in the prevention and management of lymphedema (which sometimes 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
2011 MBPCC AND STPH CANCER ANNUAL REPORT
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
Management of Colon and Rectal Cancers Overview Colorectal cancer (CRC) is the third most frequently diagnosed cancer and the second leading cause of cancer death in the United States. This year, an estimated 101,340 cases of colon and 39,870 cases of rectal cancer are expected to occur. Colorectal cancer incidence rates have been decreasing for most of the past two decades. That decline is largely attributed to the increased use of CRC screening tests that allow the detection and removal of CRC polyps before they progress to cancer. An estimated 49,380 deaths from CRC are expected to occur in 2011, accounting for about 9 percent of all cancer deaths. CRC mortality rates have declined in both men and women over the past two decades due to a reduction in incidence rates and improvements in early detection and treatment.
Diagnosis of Colon and Rectal Cancer Most colon and rectal cancers are believed to start as a polyp, which is a small abnormal growth in the lining of the large intestine. Fortunately, most polyps are not cancerous, but their presence may be detected during a colonoscopy or sigmoidoscopy. Only a biopsy of tissue from the polyp or tumor can confirm or rule out the presence of rectal cancer. Patients with early stage CRC are usually asymptomatic; therefore, screening is frequently necessary to detect CRC in its early stages. Advanced disease may cause rectal bleeding, blood in the stool, a change in bowel habits and cramping pain in the lower abdomen. In some cases, blood loss from the cancer leads to anemia (low red blood cell count), causing symptoms such as weakness and excessive fatigue. Due to an increase in CRC incidence in younger adults in recent years, timely evaluation of symptoms consistent with CRC in adults under age 50 is especially important.
Staging of Colon and Rectal Cancer Staging is performed with the use of physical exam CT, MRI and, in rectal cancer, endorectal ultrasound. The stage of cancer describes the extent or severity of a cancer diagnosis. The three factors that determine stage are:
The tumor’s (T) depth of penetration and extension to adjacent structures.
The extent to which the cancer has spread to regional lymph nodes (N), and the number of lymph nodes affected.
The evidence of distant spread of disease also known as metastasis (M).
National Comprehensive Cancer Network (NCCN) recommendations suggest genotyping tumor tissue (by KRAS and BRAF testing) is useful in determining the appropriate treatment plan for patients with Stage IV metastatic disease. The receptor for epidermal growth factor receptor (EGFR) is present in 19% of CRC tumors, allowing for targeted treatment with monoclonal antibodies medications. Mutations in the KRAS gene predict lack of response to therapy with monoclonal antibodies. Although not required for staging, several prognostic, site-specific factors are important in reviewing the pathology evaluation including: the status of proximal, distal and radial margins; lymphovascular or perineural invasion; and, extra-nodal tumor deposits. The prefixes p (pathologic staging) and yp (pathologic staging following neoadjuvant therapy and surgery) are designations of utmost importance when comparing stage, management and—especially— patient outcomes and survival.
Stage 0, also called in situ (or noninvasive CRC), is a very early stage of cancer that is contained within the innermost lining of the colon or rectum.
Stage I or higher is invasive colon or rectal cancer.
The defining characteristic of Stage III is the detection of cancer in one or more surrounding lymph nodes.
Stage IV colon or rectal cancer is characterized by evidence of distant disease spread (metastasis).
In Stage I or Stage II cancer, there is no lymph node involvement and no distant spread of disease.
The stages are subdivided using lettering systems. For example, a colon cancer tumor staged as IIB has penetrated more deeply into the wall of the colon than a stage IIA colon cancer tumor.
Treatment of Rectal Cancer Treatments are dramatically different between colon and rectal cancer. This discussion will focus on rectal cancer treatment. The CLINICAL STAGE of the rectal cancer is the foundation for all treatment recommendations for rectal cancer. In contrast to colon cancer where surgical resection is usually the initial treatment, clinical Stage II and III rectal cancers usually should receive pelvic irradiation and chemotherapy before surgery. Early stage rectal cancer may be treated with surgery alone; however, more advanced disease is likely to be treated with a combination of chemotherapy, radiation therapy and surgery.
Surgery Rectal Surgery Surgery is a mainstay of treatment for virtually all patients and involves the removal of the rectal tumor as well as some surrounding healthy tissue. Most types of rectal surgery involve the removal of the lymph nodes near the tumor (exceptions to lymph node removal include polypectomy and transanal excision). For surgeries with lymph node removal, the NCCN Guidelines for Rectal Cancer recommend removing and sampling at least 12 lymph nodes, so that an adequate assessment of cancer staging can be made. Total mesorectal excision is the preferred surgical technique for anterior or abdominoperitoneal resection. This type of surgery removes a “tumor package” along with the lymph nodes in the vicinity of the rectum.
Anterior Resection An anterior resection is often used to remove a rectal tumor that is in the upper rectum (i.e., close to the colon). This procedure involves a surgical incision in the abdomen using minimally invasive (laparoscopic) or open techniques and removal of the portion of the large intestine with the rectal tumor as well as some healthy tissue on either side of the tumor. Upper rectal cancer is treated similarly to colon cancer. Chemotherapy is indicated postoperatively for Stage III disease.
Low Anterior Resection A low anterior resection is often used to remove a rectal tumor in the mid and low rectum also with minimally invasive or open surgery. This procedure involves a surgical incision in the abdomen and removal of the portion of the large intestine with the rectal tumor as well as some healthy tissue on either side of the tumor. The surgeon reconnects the rectum together with another segment of the rectum to the anus. In some cases, the end of the colon or loop of small intestine is brought to the skin forming a colostomy or ileostomy, which is connected to a collection bag outside the body. This procedure is performed to allow a portion of the large intestine to rest and heal; it may be either permanent or reversed with another surgical procedure later. A total mesorectal excision is the preferred surgical technique. The NCCN Guidelines recommend the use of chemotherapy and radiation therapy prior to a total mesorectal excision for patients with clinical Stage II or Stage III mid or low rectal cancer.
Abdominoperineal Resection An abdominoperineal resection is a surgical procedure used to treat some tumors in the lower portion of the rectum close to the anus. This type of surgery is used to treat rectal tumors close to or involving the anal sphincter (i.e., the muscle involved in closing the anus). Abdominal resection
involves removal of the rectum and the anus, followed by permanent colostomy. Similar to low anterior resection, the preferred surgical technique is a total mesorectal excision. The NCCN Guidelines recommend chemotherapy and radiation therapy prior to an abdominoperineal resection for patients with clinical Stage II or Stage III rectal cancer.
Transanal Excision This type of surgery is appropriate for some patients with small, early-stage tumors that have not penetrated very deeply into the wall of the rectum. A transanal excision is performed through the anus; therefore, no surgical incision is made in the abdomen. Only the tumor and a section of healthy tissue surrounding the tumor are removed; hence, the large intestine is not divided into two sections during surgery. Other considerations for transanal excision include:
Tumor location in a region of the rectum close enough to the anal opening to be reached by the surgical equipment;
Low grade tumor; and, Lack of lymph node involvement detected on imaging.
Since no lymph nodes are removed with this procedure, in some situations, a colorectal ultrasound lymph node biopsy is performed at a different time from the procedure. It is important to note that this surgery is inappropriate for patients whose tumors have positive margins, lymphovascular invasion and poorly differentiated tumors. These high-risk features would warrant transabdominal resection.
Transanal Endoscopic Microsurgery (TEM) This instrumentation allows for a more precise transanal excision and removal of early cancers more proximally from the anal opening. Local recurrence rates are improved as compared to traditional local excision.
Combination (Chemoradiation) Therapy) The NCCN Guidelines recommend patients with clinical Stage II and Stage III mid and low rectal cancer receive a combination of chemotherapy and radiation therapy (called chemoradiation therapy) before surgery, unless there is a medical contraindication. Chemotherapy drugs are given to destroy cancer cells that may have spread beyond the tumor and to make radiation therapy more effective. In contrast to colon cancers, rectal cancers are typically more difficult to completely remove. Chemoradiation is used to help shrink the rectal tumor, so it can be more effectively removed during surgery. Doses of both chemotherapy and radiation also help prevent return of the cancer to the rectum and its spread to more distant sites.
2011 MBPCC AND STPH CANCER ANNUAL REPORT
Chemoradiation takes around six weeks to complete. Radiation therapy is given daily, typically Monday through Friday, for a total of 28 to 30 treatments. The chemotherapy drug 5-fluorouracil, or 5-FU, is usually administered as a continuous intravenous infusion (via a chemotherapy pump device) throughout the radiation therapy.
Chemotherapy If chemotherapy is given following surgery, it is called adjuvant chemotherapy, and it is typically given for six to eight months. Chemotherapy is given in addition to surgery to kill any cancer cells that may have spread beyond the tumor. Studies have shown adjuvant chemotherapy for rectal cancer increases the likelihood of long-term survival by preventing the cancer from returning. Even if 5-FU (with or without other drugs like oxaliplatin and leucovorin) or other chemotherapeutic agents are administered preoperatively, adjuvant therapy for Stage II and Stage III rectal cancer is recommended. However, not all patients with rectal cancer need to receive chemotherapy. For example:
injury. When pelvic irradiation is needed after surgery, more small bowel is typically in the field of irradiation. Consequently, when irradiation is delivered after surgery rather than before surgery, there is more risk for small bowel injury. Compared with preoperative irradiation, postoperative irradiation has a higher incidence of stricture at the site where the rectum is reconnected. A landmark randomized study demonstrated that the efficacy and toxicity are improved when clinically staged II and III rectal cancer patients are treated with preoperative rather than postoperative irradiation.
Discussion No significant variances were noted between groups in age, gender, race/ethnicity, stage of patients at diagnosis or in treatment patterns survival rates were comparable in review of patients diagnosed with rectal cancer in approved Community Cancer Centers across the U.S., in Louisiana and at Mary Bird Perkins/St. Tammany Parish Hospital.
Observed Five Year Rectal Cancer Survival Rates and Comparison with National Statistics
Chemotherapy is not recommended for individuals with Stage 0 or Stage I rectal cancer;
State of LA (%)*
Chemotherapy is recommended for patients Stage III upper rectal cancer; and,
Chemotherapy is recommended for those with Stage II or Stage III mid and low rectal cancer.
Unlike chemotherapy that travels throughout the body, irradiation is delivered only to the area where it is aimed. For treatment of rectal cancer, irradiation is delivered to the area of the rectal cancer, as well as the pelvic lymph nodes. In virtually all cases, irradiation is delivered with concurrent chemotherapy. In most cases, this chemotherapy is concurrent continuous infusion 5-FU. Radiation doses of 50.4 to 54 Gy are delivered in 28 to 30 treatments over a six-week period.
The technique of pelvic irradiation is very important. Every effort is made to exclude areas that do not need to be treated. The most important area to exclude from irradiation is the uninvolved small bowel. When irradiation and chemotherapy are delivered before surgery, the vast majority of the small bowel can usually be excluded from the high dose radiation area. This exclusion significantly reduces the risk of small bowel
*Rounded to the nearest percent. May not equal 100% due to rounding errors. AJCC = American Joint Commission on Cancer / = insufficient data MBPCC/STPH data includes 61 cases diagnosed in 2003 (AJCC 6th edition staging) from STPH Registry NCDB data includes all 2003 cases diagnosed in 431 Community Cancer Centers in all states State of LA data includes all 2003 cases diagnosed in 28 Cancer Programs in LA
Known limitations include the small sample size and the inability to identify patients in the National Cancer Data base (NCDB) sample who were staged clinically before multimodal treatment (y pathologic classification).
Hereditary Colorectal Cancer
Long Term Surveillance/Follow-Up
Approximately 20 percent of colorectal cancer cases are hereditary; so, first-degree relatives of patients with newly diagnosed colorectal adenomas or invasive colorectal cancer are at an increased risk for CRC. Known genetic susceptibility syndromes include Lynch Syndrome (also known as hereditary nonpolyposis CRC or HNPCC) and familial adenomatous polyposis (FAP). The NCCN recommends all patients with a diagnosis of CRC be counseled with regard to family history. Indications that would warrant further evaluation include any personal or family history of:
Patients with a personal history of CRC should have long-term follow-up testing and cancer surveillance as demonstrated below:
CRC in two or more close relatives; one of whom was diagnosed at age 50 or younger
Two HNPCC-related cancers in one individual An Individual with CRC and first-degree relative with CRC; and/or HNPCC-related extracolonic cancer, and/ or a colorectal adenoma (cancer diagnosed at age 50 or younger and adenoma at age 40 younger)
Full Amsterdam Criteria (three relatives with CRC, one a first-degree relative who is related to the other two generations)
Affected & one affected relative diagnosed at 50 or younger); or Modified Amsterdam Criteria (includes HNPCC-related cancers)
CRC that demonstrates microsatellite instability (MSI-high)
HNPCC – related cancers include colorectal, endometrial, ovarian, urinary, stomach, small intestine, iliary and brain.
Mismatch Repair Genes NCCN also strongly recommends consideration of Mismatch Repair (MMR) protein testing for all CRC patients who are less than 50 years of age due to an increased risk in this group. DNA MMR genes (MLH1, MSH2, MSH6) mutations are found in individuals with Lynch Syndrome, which accounts for 2 to 5 percent of all colon cancer cases.
Northshore physicians and patients may access a geneticist who can perform risk assessments, patient and family counseling and appropriate testing for genetic susceptibility. The geneticist can be reached at (985) 898-4581.
History and physical every three to six months for two years, then every six months for a total of five years
Carcinoembryonic antigen (CEA) tumor marker every three to six months for two years, then every six months for a total of five years
CT scan of abdomen and pelvis annually for three years Colonoscopy at one year, then as clinically indicated.
Family recommendations for colonoscopy screening are included in the table below. Family History Criteria
First-degree relative diagnosed with CRC age 50 to 60
Beginning age 40; repeat every five years
First-degree relative diagnosed with CRC age at 50 or younger; or two related firstdegree relatives diagnosed with CRC at any age
Beginning age 40, or 10 years before earliest CRC diagnosis; repeat every three to five years depending on family history
First-degree relative diagnosed with CRC at age 60 or greater; or two related second-degree relatives diagnosed with CRC, any age
Beginning age 50; repeat every five years
One second-degree relative or any third-degree relative (s) diagnosed with CRC; or first-degree relative with non-advanced adenoma
Treat as average risk patients Colonoscopy is preferred screening
References: American Cancer Society. Cancer Facts and Figures 2011. Atlanta: American Cancer Society National Cancer Data Base (NCDB). Commission on Cancer, American College of Surgeons, Benchmarking Reports at www.facs.org. NCCN Clinical Practice Guidelines in Oncology. Colorectal Cancer Screening, Version 2.2011. www.nccn.org. NCCN Clinical Practice Guidelines in Oncology. Colon Cancer, Version 3.2011. www.nccn.org. NCCN Clinical Practice Guidelines in Oncology. Rectal Cancer, Version 4.2011. www.nccn.org.
Free colorectal cancer screenings are available at various locations throughout the year. Visit www.marybird.org/STPH to view available dates or call (888) 616-4687 for more information.
2011 MBPCC AND STPH CANCER ANNUAL REPORT
Mary Bird Perkins Cancer Center and St. Tammany Parish Hospital 2010 Cancer Registry Summary 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 MBPCC and STPH capture a complete summary of the history, diagnosis, treatment and disease status for every cancer patient. Registrars’ work leads to better information that is used in the management of cancer, and ultimately, cures. The MBPCC Cancer Registry-Covington facility reference date is January 1, 1999. Accreditation with the American College of Surgeons (ACoS) was achieved on May 14, 2003. Including cases from 2010, the MBPCC Covington tumor registry database contains data on 3,352 cancer cases. During 2010, there were 332 new cancer cases entered into the MBPCC Covington tumor registry database. Of these, 267 were considered to be analytic cases (newly diagnosed and/or received all or part of their first course treatment at this facility). The top five sites treated were:
•• •• •• •• ••
Breast (79) Lung (48) Prostate (46) Rectum (13) Esophagus (9)
The STPH Cancer Registry reference date is 1993, and it contains data on 7,798 cancer cases.
During the year 2010, there were 697 new cancer cases entered into the STPH registry database. Of these, 500 were analytic cases (newly diagnosed and/or received all or part of their first course treatment at this facility). The top five sites seen were:
•• •• •• •• ••
Breast (106) Lung (51) Colon (48) Prostate (32) Uterus (29)
All new cases identified are abstracted, coded and staged in accordance with guidelines established by the American College of Surgeons (ACoS), the National Cancer Institute’s Surveillance, Epidemiology and End Results (SEER) program and the Louisiana Tumor Registry (LTR). High importance is placed on data quality using these guidelines, and a physician specializing in oncology reviews a sample of the cases for quality assurance. Once part of the registry database, these cases are followed for the life of the patient. The registry maintains cancer data that are available for use by clinical and administrative staff at MBPCC and STPH. All information collected is kept completely confidential. During 2010, 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 to support statewide improvements in cancer detection and treatment. The registry also participates in the NCDB Cancer Program Practice Profile activities.
Mary Bird Perkins Cancer Center 2010 Distribution Site Table Number of Cases per Stage Site Group
Head and Neck
Esophagus Stomach Rectosigmoid Junction Rectum Anus Liver Pancreas Larynx Lung-Small Cell CA Lung-Non-Small Cell CA Melanoma-Skin
Female Genital System
Male Genital System Urinary System Brain/Nervous System Hemic and Lymphatic Other/Unknown
Site Tongue Salivary Gland Gum & Other Mouth Tonsil Oropharynx Hypopharnyx
Breast Cervix Uterus Vagina Vulva Prostate Other Male Genital Kidney and Renal Pelvis Brain Non-Hodgkin Lymphoma Plasma Cell Tumors Other and Unspecified
Stage 0 9
Stage I 51
Stage II 78
Stage III 45
Stage IV 57
0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 8 8 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 1 0 0 0 1 2 0 0 0 0 2 0 0 2 4 0 3 7 0 0 35 35 2 1 0 0 3 0 0 0 0 0 0 0 2 0 2 0 0
1 0 1 1 0 0 3 3 0 1 5 0 0 2 11 1 0 1 2 1 1 23 23 0 1 0 2 3 35 0 35 0 0 0 0 0 0 0 0 0
0 0 0 0 1 0 1 1 0 0 3 1 0 0 5 0 3 14 17 0 0 11 11 2 1 1 2 6 5 0 5 0 0 0 0 0 0 0 0 0
4 2 0 7 1 0 14 3 1 0 1 1 1 0 7 2 5 21 28 0 0 2 2 0 0 1 0 1 4 0 4 1 1 0 0 0 0 0 0 0
0 0 0 0 0 0 0 2 1 0 3 0 0 0 6 0 0 1 1 0 0 0 0 0 1 0 0 1 2 0 2 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 2 0 0 2 0 1 1 0 0 4 4 0 5 5 5 5
5 3 1 8 2 1 20 9 2 1 13 4 1 2 32 7 8 40 55 1 1 79 79 4 6 2 4 16 46 1 47 1 1 4 4 2 5 7 5 5
2011 MBPCC AND STPH CANCER ANNUAL REPORT
St. Tammany Parish Hospital 2010 Distribution Site Table Number of Cases per Stage Site Group
Head and Neck
Soft Tissue Skin Breast
Female Genital System
Male Genital System
Site Tongue Gum & Other Mouth Tonsil Oropharynx Esophagus Stomach Colon Rectosigmoid Junction Rectum Anus Liver Other Biliary Pancreas Retroperiteum Larynx Lung-Small Cell CA Lung-Non-Small Cell CA Lung-Other Types Pleura Soft Tissue and Heart Melanoma-Skin Other Non-Epithelial Skin Breast Cervix Uterus Ovary Vulva Other Female Genital Prostate Testis Bladder Kidney and Renal Pelvis Ureter
Brain Other CNS
Hemic and Lymphatic
Hodgkin Lymphoma Non-Hodgkin Lymphoma Plasma Cell Tumors Leukemia Other and Unspecified
Stage 0 49
Stage I 145
Stage II 92
Stage III 82
Stage IV 64
0 0 0 0 0 0 0 12 0 1 0 0 0 0 0 13 0 0 1 0 0 1 0 0 2 0 2 19 19 1 2 0 2 0 5 0 0 0 9 0 0 9 0 0 0 0 0 0 0 0 0 0 0 0 0
1 1 0 0 2 0 3 6 0 4 0 0 1 2 0 16 3 0 8 0 1 12 0 0 15 0 15 42 42 4 17 3 0 0 24 0 3 3 10 13 0 23 0 0 0 6 0 6 1 1 0 0 2 0 0
0 0 0 0 0 3 1 9 0 4 0 1 0 0 0 18 0 1 4 0 0 5 1 1 0 0 0 31 31 0 0 1 2 0 3 24 0 24 3 3 1 7 0 0 0 0 0 0 0 3 0 0 3 0 0
0 0 0 1 1 0 1 19 1 0 1 0 0 3 0 25 1 3 12 1 0 17 0 0 1 1 2 6 6 1 6 4 1 1 13 6 1 7 0 3 1 4 0 0 0 2 0 2 1 4 0 0 5 0 0
1 0 1 1 3 3 2 2 0 0 0 0 0 7 0 14 0 3 14 1 0 18 0 0 1 0 1 4 4 0 2 4 0 1 7 2 0 2 2 4 0 6 0 0 0 1 0 1 2 6 0 0 8 0 0
0 0 0 0 0 0 1 0 0 0 0 0 1 0 1 3 0 1 1 1 0 3 0 0 1 0 1 4 4 0 1 0 0 1 2 0 0 0 1 1 0 2 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 2 0 0 0 0 0 0 0 0 2 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 1 0 0 2 0 0 0 0 0 2 0 4 4 8 0 2 2 0 0 4 17 21 17 17
2 1 1 2 6 6 10 48 1 9 1 1 2 12 1 91 4 8 40 3 1 56 1 1 20 2 22 106 106 6 29 13 5 3 56 32 4 36 25 24 2 51 4 4 8 9 2 11 4 14 4 17 39 17 17
The Cancer Program of
1203 South Tyler Street Covington, LA 70433
1202 South Tyler Street Covington, LA 70433
STPH-101 (12/11) WPS
2011 Cancer Program of Mary Bird Perkins and St. Tammany Parish Hospital Cancer Annual Report