THE CANCER PROGRAM OF OUR LADY OF THE LAKE AND MARY BIRD PERKINS
RECTAL CANCER STUDY
2011 ANNUAL REPORT
2010 Cancer Committee
The Cancer Committee is a multidisciplinary team responsible for planning, initiating and assessing 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 Our Lady of the Lake Regional Medical Center (OLOL) and Mary Bird Perkins Cancer Center (MBPCC). PHYSICIANS
HEALTHCARE PROFESSIONALS
David S. Hanson, MD
Reverend Mark Adams
Hematology/Oncology Cancer Committee Chairman
Brian W. Webb, MD
Pathology CoC Liaison Physician Community Outreach Coordinator
William Anderson, MD Gastroenterology
Louis Barfield, MD General Surgery
Mitchell Z. Berger, MD Medical Director
Vince Cataldo, MD Medical Oncology
Michael DiLeo, MD Otolaryngology
Alec Hirsch, MD General Surgery
Sheldon A. Johnson, MD Radiation Oncology
Mark Kantrow, MD Palliative Care
Ryan Majoria, MD
Diagnostic/Interventional Radiology
Mark Posner, MD Urology
M. Patrick Stagg, MD Medical Oncology
Brad Vincent, MD Pulmonology
Chaplain
Tammy Asmus, RT (R)(T)
Director of Radiation Therapy Operations
Sheila Alexander, CTR Cancer Registrar
Auban A. Burr, MBA Program Manager
Donna Bryant, MSN, OCN, ANP-C, CCRC Executive Director, Clinical Research
Marilyn Shalley-Damberg, RN, MSN, MBA Multidisciplinary Cancer Care Manager
Renea Austin-Duffin, MPA
Vice President, Cancer Programs
Terry Freeman, CTR Cancer Registrar
Vickie Hall, LPN, RTT
Vice President, Radiation Oncology
Suzanne Hotard, RN, OCN Patient Navigator
Gena D. Kalil, RN, MSN, NE-BC Cancer Center Nurse Manager
Lance Lemoine, PT, DPT, OCS, FAAOMPT Rehabilitation Services
Nicole Magee, CTR
Cancer Registry Director
Suzanne Neve, CTR, RHIA Cancer Registrar
Jacqueline G. O’Neill, LCSW Cancer Liaison
Salli Phillips, LCSW, OSW-C Social Services Director
Kathy Probst, CTR, CCRP Cancer Program Coordinator
Lynda Suhrer-Roussel, PhD Quality Management
Amy Stuckey Williams, MBA
American Cancer Society Representative
Jill Tomkins, RN
Clinical Research Nurse
Alison Walker, BA, MA, MHA, FACHE
Rectal Cancer Study
Vice President, Planning & Business Development
Chairman’s Letter
On behalf of The Cancer Committee of Our Lady of the Lake and Mary Bird Perkins, I am pleased to present the 2011 Cancer Annual Report. In the pages that follow, you will learn about The Cancer Program’s accomplishments from throughout the year and results from a study on rectal cancer, our 2010 featured disease site. During 2010, The Cancer Program completed Year Four of our affiliation with the National Cancer Institute (NCI) Community Cancer Centers Program (NCCCP), focusing our efforts on enhancing access to care, improving quality of care and expanding cancer research in the community setting. Our Cancer Program is one of only 30 cancer centers nationwide that was competitively selected by NCCCP to create the standard for community cancer care throughout the country. Through our participation in NCCCP, The Cancer Program has launched initiatives to ensure cancer services are available to underserved minorities, who may have an increased risk for cancer and who often face many barriers to accessing care. The underserved include poor, uninsured, rural, racial and ethnic populations in which there is often a great disparity in care and survivorship. Specifically, The Cancer Program has made great strides in increasing the numbers of Hispanic and Vietnamese individuals screened for cancer. That success reflects well upon the efforts of our community outreach coordinators, who speak Spanish and Vietnamese fluently, and have become a part of the fabric of these communities. Because today there are nearly 12 million cancer survivors—representing approximately 4% of the U.S. population—resources were dedicated in 2010 to developing our Survivorship Program. This unique service provides patients with truly comprehensive, multidisciplinary care, including patient education, psychosocial support, follow-up care guidelines and other complementary therapies. Survivorship is a cornerstone of NCCCP and helps patients transition to a life without cancer and acclimate to their new normal. There was also growth in 2010 when lung cancer was added to our array of multidisciplinary teams (MDCs) consisting of oncology specialists. While other NCCCP sites across the U.S. have found developing MDCs challenging, we are fortunate to have launched four teams: colorectal, brain, head and neck and lung. We are enjoying this success, thanks to the physicians and staff members who make participating in the MDC teams a priority, demonstrating their dedication to providing the highest level of patient care. The Cancer Program is moving forward with great enthusiasm, and our team has set its sights on providing the highest level of cancer care for all. With God’s help, all is possible. Sincerely,
David S. Hanson, MD, FACP
2011 CANCER ANNUAL REPORT
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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 of the quality of care. Cancer Liaison Physicians (CLPs) serve as links between the CoC and the hospitals they represent, manage clinically-related cancer activities within their local institutions and partner with local community agencies, such as the American Cancer Society (ACS), to accomplish community outreach goals regarding education, early detection and prevention of cancer. The CoC has established five well-defined priority areas for CLP activity: advocacy, quality improvement, ACS partnership, clinical trials and comprehensive cancer control. The CoC has recommended implementation of at least one objective or activity from any of the five areas that results in a positive change within our cancer program. Throughout my fourth year of being CLP for The Cancer Program, I feel we have succeeded in a number of key areas. The Cancer Program has seen significant increases from the prior year in: 1) participation in community health fairs and the annual Minority Cancer Awareness event (greater than 20%); and, 2) the total number of people screened for cancers of the breast, colon prostate and skin (ranging from increases of 15% to 55%). ACS representatives continue to attend each quarterly meeting of the Cancer Committee to update us on their upcoming activities and initiatives. Their participation has resulted in a more informative and engaging presentation of this important information and an improved relationship overall between the ACS and The Cancer Program. In the area of quality improvement, The Cancer Program has met its goals to: 1) increase palliative care consults generated from The Cancer Program by 10%; 2) increase accruals to Total Cancer Care bio-repository (tissue bank); and 3) develop a radiation treatment process using Volumetric Arc Therapy to decrease treatment time from 20 minutes to two minutes. Furthermore, the development of electronic interfaces between Pathology Group of Louisiana’s new anatomic pathology information system and tumor registries statewide is expected to significantly improve the reporting of cancer cases to our own Cancer Program, state and regional tumor registries. In addition to the focus areas, I continue to attend the quarterly meetings of the Cancer Committee. There, 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. Also, a recent 2012 mandate from the CoC has required CLPs to be involved in a quarterly review and analysis of current National Cancer Data Base (NCDB) statistics for a particular site with comparison to data from our local tumor registry, similar to the rectal cancer statistics reviewed within this Annual Report. I continue to look forward to working with all the dedicated people involved with The Cancer Program in order to improve the quality of care and service to all our cancer patients. Sincerely,
Brian W. Webb, MD
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THE CANCER PROGRAM OF OUR LADY OF THE LAKE and MARY BIRD PERKINS
THE CANCER PROGRAM OF OUR LADY OF THE LAKE AND MARY BIRD PERKINS
Tomorrow’s Cancer Care — Right Here, Right Now.
With nearly 12 million cancer survivors in the United States, there is a growing need for comprehensive survivorship services. A highlight of NCCCP Year Four was the launch of a Survivorship Program to help those ending active treatment to establish their “new normal.”
NCCCP — Year Four Update For the fourth year, The Cancer Program of Our Lady of the Lake and Mary Bird Perkins is helping to create a national standard for community cancer care. Through the National Cancer Institute (NCI) Community Cancer Centers Program (NCCCP), 30 competitively chosen hospitals are working to bring the latest scientific advances and evidence-based care within easy reach for cancer patients in underserved rural, suburban and inner-city locations across the United States. NCI launched the NCCCP pilot program in 2007 as a public-private partnership with 16 community hospitals, including The Cancer Program for Our Lady of the Lake and Mary Bird Perkins. In 2010, NCI expanded the network with stimulus funding from the American Recovery and Reinvestment Act (ARRA) and added 14 more sites.
A $2 million grant from ARRA is funding 14 projects for The Cancer Program of Our Lady of the Lake and Mary Bird Perkins through April 2012. The objective of the initiative is make cancer prevention and care available to all and with a focus on disparate populations. NCCCP Focus Areas NCCCP sites are working to achieve the program’s goals of: • • •
enhancing access to care improving the quality of care expanding research
Reducing Cancer Healthcare Disparities The Cancer Program’s success in reaching underserved Vietnamese and Hispanic populations increased significantly through the efforts of our two bilingual community outreach coordinators. Coordinators speak
their native language, Vietnamese and Spanish, and work within their respective cultures to provide early detection and screening information. This includes visiting churches and businesses, establishing media relationships and engaging civic organizations. Of the minorities served in NCCCP Year Four, 11% were Asian and 11% were Hispanic. The Cancer Program now has a tool to ensure we are reaching our target audience of underserved minorities. We have developed an Early Detection Screening and Patient Navigation Database, a powerful program that accurately and efficiently tracks, measures and creates reports on our screening and navigation patients.
2011 CANCER ANNUAL REPORT
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Key Accomplishments by Focus Area The role of our patient navigators is to provide educational resources, answer questions, facilitate appointments and help guide patients and their families through the difficult journey of cancer care. If there are issues or challenges that might interfere with a patient receiving treatment, navigators work to help resolve those problems, so timely care can be delivered. Navigators can help address lack of transportation, language barriers, difficulties with reading or understanding printed materials or family/financial constraints. Expanding Survivorship and Palliative Care Programs
Cancer Program team members attend the NCCCP annual conference each year to share best practices and learn from the successes of other NCCCP designated sites.
This helps The Cancer Program make more strategic and informed decisions based on real-time data. Results show that 34% of all patients screened during NCCCP Year Four were minorities. Prioritizing Underserved Accrual to Clinical Trials The Cancer Program’s Clinical Trials Program has launched initiatives to enhance underserved accrual to clinical trials. An outreach program is helping to increase primary care physicians’ awareness of national clinical trials in their local communities. To date, 42 primary care physician clinics have been visited—27 located in rural communities. Physician outreach statistics show that 52% are defined as rural and 37% are African American, Hispanic or Asian. Based on additional NCCCP factors, 17% of the outreach population is considered minority. Adding an early phase clinical trials program has improved access to new advances and provided more options for the treatment of cancer. Additionally,
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a clinical research advisory council was established to promote research awareness among patients and providers within our 11 parish service area. Additional clinical research staffing was added at Earl K. Long Medical Center, which includes a research navigator to assist potential and current research patients.
The Cancer Program has launched a survivorship program and hired a full-time survivorship navigator as a supplement to our multidisciplinary care teams. Once patients have completed active treatment, they may be enrolled. The program offers psychosocial resources and referrals, as well as information regarding followup care and patient education. Just as other caregivers guided patients through diagnosis and treatment, the survivorship navigator guides patients along the way as they enter this newest phase of their cancer journey.
Through each of these efforts, Year Four underserved patient accruals for clinical trials include 26% African American, 50% elderly and 57% rural patients. Promoting Evidence-based Care As a complement to our four multidisciplinary teams, our patient navigators assist colorectal, brain, head and neck and lung patients through the treatment process. Since the program began in July 2010, navigators have assisted 314 patients.
THE CANCER PROGRAM OF OUR LADY OF THE LAKE and MARY BIRD PERKINS
Hispanic and Vietnamese speaking volunteers help facilitate communication between patients and clinicians at the Minority Cancer Awareness Event each year.
In 2010, The Cancer Program of Our Lady of the Lake and Mary Bird Perkins launched a lung cancer multidisciplinary cancer care team. Representatives from the colorectal, head and neck, brain and lung multidisciplinary teams pictured here include: Drs. Scott Thurston, Jon Olson, Louis Barfield and Andrew McWhorter.
Palliative Care is a relatively new and growing specialty. It helps patients attain the highest possible quality of life by focusing on relieving pain, other symptoms and stresses of cancer or other serious illness. Unlike hospice patients, individuals enrolled in palliative care are not necessarily terminal. The Cancer Program’s palliative care service has expanded to include a nurse practitioner assigned specifically to the inpatient oncology unit. As a result, palliative care referrals have increased 62% over the prior year. Increased palliative care referrals may also be attributed to continuing education, increased awareness and understanding of palliative care, collaboration with oncologists and other healthcare providers and increased accessibility. Implementing Information Technology We continue to enhance quality and service by storing data in a secure,
centralized database for departments such as Patient Navigation, Survivorship, Palliative Care, Total Cancer Care® and Clinical Trials. Through this centralized database, each patient’s cancer experience across the entire continuum is documented and viewable. Having access to that information helps us to better customize treatments, support services and patient and family needs. Other NCCCP sites have expressed interest in utilizing this tool in their locations, and we are committed to helping other sites as they deploy this technology.
quality tissue samples are collected to support personalized medicine. As a top-performing partner with Moffitt Cancer Center’s Total Cancer Care (TCC®) program, The Cancer Program collected more than 900 specimens during Year Four. Since TCC’s® inception in June 2008, 1,700 patients have consented to participate in the program. These successful statistics are a result of staff members’ hands-on approach to specimen collection and patient screening methods.
Promoting High Quality Biospecimen Collection To advance cancer research, The Cancer Program is actively participating in the collection of high-quality biospecimens using standardized collection and storage procedures. This endeavor helps to build a community-based research platform in which patient data and high-
2011 CANCER ANNUAL REPORT
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The Cancer Program’s Community Outreach Partnerships Boost Cancer Program’s Efforts to Defeat Cancer Throughout the country, there is growing enthusiasm for the way community partnerships help promote cancer screenings in underserved populations. While The Cancer Program has always incorporated the partnership model in its plans, 2010 was a banner year for teaming up with other organizations to touch more lives and effectively fight cancer in the community. All Screenings 2010 Breast
Prostate
Colorectal
Skin
Oral
Total
2766
1177
1409 39% returned
1307
126
6785
72
25
119
28
4
248
Participants Never Screened Before
673 (24%)
342 (29%)
871 (62%)
1050 (80%)
112 (89%)
3048 (45%)
Participants Navigated
745 (27%)
100 (8%)
13 (1%)
247 (19%)
10 (8%)
1115 (16%)
22
8
1
22
0
53
Total Participants Total Events
Diagnosis of Cancer *18-parish service area
A shining example of how partnerships can make a different is The Cancer Program’s annual barbershop prostate screening. Targeted to appeal to underserved African American men, this program was planned in collaboration with Blue Cross and Blue Shield of Louisiana and 100 Black Men of Metro Baton Rouge. The barbershop, a gathering place where men may more openly talk about personal issues, has shown nationally to serve as a prime screening site. More than 80 men were screened at Webb’s Barbershop during National Prostate Cancer Awareness Month in September, demonstrating the power of community collaboration between organizations that share the goal of promoting early detection and screening. Community Organizations Partner to Reach Minorities The success of The Cancer Program’s Annual Minority Cancer Awareness (MCA) event is a direct result of community partners teaming up to promote cancer screenings for the underserved. Thanks to the invaluable support and generous contributions of so many, this year’s event resulted in nearly 500 people being screened for breast, colorectal, skin, prostate and oral cancers. In addition, nearly 200 people had their blood pressure, glucose level and vision checked. Thanks to the following sponsors for their invaluable support and resources: 100 Black Men of Metro Baton Rouge; Allied Health Waste Services of Baton Rouge; Associated Grocers; Baton Rouge Coca-Cola; Blue Bell Creameries; Cabot Cheese; Dot Calm; The Fields Family; Flowers Bakery; Raising Cane’s Chicken Fingers; Sable International; The University Club; and Whole Foods. MCA Stats 2010 Breast
131
Skin
Oral
Total
Prostate Total Participants
82
Participants Never Screened Before
(50%)
Total Participants
45
80
*40% return rate
132
108
496
Participants Navigated
Participants Never Screened Before
15
43
96
121
103
378
Diagnosis of Cancer
(33%)
(54%)
(73%)
(92%)
(95%)
(76%)
14
3
2
12
8
39
(31%)
(4%)
(2%)
(9%)
(7%)
(8%)
1
1
0
1
0
3
Participants Navigated Diagnosis of Cancer
6
Prostate Colorectal
Webb’s Barbershop 2010
THE CANCER PROGRAM OF OUR LADY OF THE LAKE and MARY BIRD PERKINS
Participants Uninsured Minority Patients
41 42 (51%) 0 51 (62%) 78 (95%)
Support Services and Activities CancerFit Exercise and Wellness Program
Patient Education Seminars
Designed for individuals completing cancer treatment or in recovery, this program incorporates a supervised, personalized approach to fitness, health and wellness education, (225) 231-3800.
Experts in cancer and other healthcare professionals provide education on topics relevant to cancer patients and their friends, family and caregivers. Classes scheduled monthly, (225) 215-1546.
Cancer Survivor’s Day
Pet Therapy
Held annually in June, this program celebrates survivorship and provides support and recognition of cancer patients and their caregivers, (225) 215-1291.
Our Pet Therapy Program is held every first Thursday of the month and helps promote health and a sense of wellbeing through positive interactions with certified pet therapy dogs, (225) 215-1291.
Free Cancer Screenings Free breast, colorectal, oral, prostate and skin cancer screenings offered to participants without insurance who have not been screened in the past 12 months. Insurance is billed for mammograms, (225) 215-1234.
Restorative Yoga Classes
Genetic Cancer Risk Assessment and Counseling
When no other resource is available, volunteer drivers bring patients to and from cancer treatment appointments, (225) 927-0782.
Through consultation with a doctor specializing in genetics, patients and their families make informed decisions about their medical options, including screening for early detection, ways to reduce personal risk and genetic testing, (225) 765-8988. Look Good, Feel Better By offering skin, nail and hair care tips, this program aims to enhance the appearance and improve the self-image of patients undergoing cancer treatment. Twice a month, professionals present a 12-step make-up guide and information about choosing and caring for a wig and dealing with skin changes. Cosmetics provided, (225) 215-1343.
CancerFit Exercise and Wellness Program
These classes are structured according to individual capabilities of cancer patients and their caregivers. Classes regularly scheduled, (225) 938-9629. Road to Recovery
Tobacco Cessation Classes When combined with other tobacco cessation efforts, structured classes can greatly increase the chances of quitting permanently. Classes regularly scheduled, (225) 215-1274.
Pet Therapy
Inpatient Tobacco Cessation One-on-one tobacco cessation counseling is available for all Cancer Program patients and their family at no cost. Sessions are led by a Certified Tobacco Treatment Specialist who guides patients through the process of quitting, (225) 215-1274.
Cancer Survivor’s Day
2011 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 MBPCC • • • • •
Radiation Oncology
Radiation Therapy External Beam Radiotherapy Image Guided Radiation Therapy (IGRT) Intensity Modulated Radiation Therapy (IMRT) Volumetric Modulated Arc Therapy (VMAT) High Dose Rate Brachytherapy (HDR) Prostate Seed Implants • Stereotactic Radiosurgery COMS Eye Plaque 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
CancerFit • Complementary Therapy Enterostomal Therapy • Nutritional Support • Occupational, Physical and Speech Therapies • Patient Navigation • Pet Therapy Pastoral Care • Respiratory Therapy • Social Services •
• • • • • • • • • • • • •
• • • •
•
Other Services
Lymphedema Prevention Clinics Pain Management • Patient Transportation • Tobacco Cessation
• • • •
Education
Professional Education
Allied Health Cancer Grand Rounds Continuing Education (CE) Continuing Medical Education (CME) Graduate Medical Education (GME) Medical Library
• • • • •
• • • •
• • • •
• •
•
•
Clinical Research
•
•
Tumor Registry
•
•
Community Education
Cancer Screenings Community Outreach Elderly Services Speakers Bureau
Case Management
Tumor Conferences
Research
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THE CANCER PROGRAM OF OUR LADY OF THE LAKE and MARY BIRD PERKINS
•
AN OVERVIEW |
Rectal Cancer
Background The rectum is part of the body’s digestive system. The digestive system removes and processes nutrients from foods and helps pass waste material out of the body. The digestive system includes the esophagus, stomach and the small and large intestines. The first three feet of the large intestine are called the large bowel or the colon. The last six inches of large bowel compromise the rectum and the anal canal. Cancers of the colon and rectum are the third most frequently diagnosed cancers in both American men and women. Most colon and rectal cancers are believed to start as polyps, which are small abnormal growths in the lining of the large intestine. Fortunately, most polyps prove not to be cancerous. Diagnosis of Rectal Cancer The presence of a rectal polyp or tumor may be detected during a colonoscopy or sigmoidoscopy; but, only a biopsy of tissue from the polyp or tumor can confirm or rule out the presence of rectal cancer. Usually there are no symptoms of early-stage rectal cancer unless the cancer bleeds or obstructs the rectum. In addition to confirming a diagnosis of cancer, a biopsy specimen provides information about: • whether the cancer is non-invasive (localized to layer of tissue where it began) or invasive (has spread deeper into the wall of the colon); and • the grade of the tumor cells (i.e., how much the cancer cells resemble healthy cells under a microscope). Staging of Rectal Cancer Staging describes the extent or severity of a cancer diagnosis. The stage of a rectal cancer is characterized by three factors: • how deeply the tumor has penetrated into the wall of the rectum; • whether cancer has spread to regional lymph nodes, and if so, the number of lymph nodes affected; and • whether there is evidence of distant spread of disease (metastasis).
Staging is performed with the use of physical exam, CT, MRI and endorectal ultrasound. Stage 0 rectal cancer, also called rectal cancer “in situ,” is a very early stage of disease—usually appearing as a polyp—that has not spread beyond the innermost lining of the rectum. At this stage, the cancer is considered noninvasive rectal cancer. It does not have the potential to spread to other parts of the body, and, therefore, the polyp is not classified as malignant.
cases, the end of the colon or loop of small intestine is matured to the skin forming a colostomy or ileostomy, which is connected to a collection bag outside the body. The aim of both procedures is to allow a portion of the large intestine to rest and heal. The procedures can also be performed on a temporary basis and reversed later. However if an abdominoperineal resection (removal of entire rectum and anus) is performed, a permanent colostomy is required.
Rectal cancer that is diagnosed as Stage I or higher is considered invasive rectal cancer. Stage I disease partially invades the rectal wall. Stage II disease is characterized by a tumor that has penetrated the wall and lodges in the perirectal fat. Neither Stage I nor II rectal cancers have lymph node involvement or distant spread of the disease. The defining characteristic of Stage III is disease detected in one or more surrounding lymph nodes. Stage IV is distinguished by evidence of distant disease spread or metastasis.
Transanal Excision
Treatment of Rectal Cancer Staging is the foundation for all treatment recommendations. Very 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. Such surgery involves removal of the rectal tumor as well as some healthy tissue in the vicinity of the tumor. In most types of rectal surgery, with the exception of polypectomy and transanal excision, lymph nodes in the area near the tumor are also removed. For those types of rectal surgeries, the NCCN Guidelines for Rectal Cancer recommend that at least 12 lymph nodes are removed and sampled, so an adequate assessment of cancer stage can be made. If the rectal tumor has been removed by a lower anterior resection, the surgeon may be able to reconnect the rectum and thus avoid a permanent colostomy. In some
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 around the tumor are removed; hence, the large intestine is not divided into two sections during surgery. Other indications 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 during this procedure, there are no lymph node biopsies performed after transanal excision. Transanal Endoscopic Microsurgery (TEM) This instrumentation allows for a more precise transanal excision and allows removal of early cancers from the anal opening. Local recurrence rates are improved as compared to traditional local excision. 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). Using minimally invasive (laparoscopic) or open techniques, this abdominal procedure involves the removal of the portion of the large intestine with the 2011 CANCER ANNUAL REPORT
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AN OVERVIEW |
Rectal Cancer
rectal tumor as well as some healthy tissue on either side of the tumor. Upper rectal cancer is treated similar 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 an abdominal incision 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. A total mesorectal excision (TME) is the preferred surgical technique. This type of surgery removes a “tumor package� along with the lymph nodes in the vicinity of the rectum. NCCN Guidelines recommend chemotherapy and radiation prior to surgery for patients with Stages II or III mid or low rectal cancer. Abdomino-perineal Resection An abdomino-perineal resection is a surgical procedure used to treat some tumors in the lower portion of the rectum close to the anus. TME principles are also followed. In particular, rectal tumors close to or involving the anal sphincter (i.e., the muscle involved in closing the anus) are usually treated by this type of surgery. Abdominal resection involves removal of the rectum and the anus, followed by colostomy. Similar to low anterior resection, the preferred surgical technique is a total mesorectal excision. NCCN Guidelines recommend chemotherapy and radiation prior to an abdomino-perineal resection for patients with Stages II or III rectal cancer. THERAPY Combination Therapy (Chemoradiation Therapy) The NCCN Guidelines recommend patients with Stage II or 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.
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Chemotherapy drugs are given to destroy cancer cells that may have spread beyond the tumor. Certain chemotherapy drugs also make radiation therapy more effective. Radiation therapy uses highenergy beams to kill cancer cells in a particular area of the body. In the treatment of rectal cancer, radiation therapy is focused in the pelvis. Side effects of radiation therapy can include diarrhea, abdominal pressure, discomfort in the rectal area, a burning sensation during urination, more frequent urination, skin irritation, nausea and fatigue and sexual side effects. For rectal cancers, chemotherapy and irradiation are often used before surgery. One of the reasons for this approach is that rectal cancers are typically more difficult to completely remove than most colon cancers. Chemoradiation is used to help shrink the rectal tumor, so it can be more easily removed during surgery. It also helps prevent the cancer’s return and its spread to more distant sites. Chemoradiation therapy 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 course of radiation therapy. A landmark randomized study demonstrated that the efficacy and toxicity are improved when Stages II or III rectal cancer patients are treated with chemoradiation before surgery rather than after surgery. Chemotherapy Chemotherapy drugs are given to destroy cancer cells including those that may have spread beyond the tumor. Chemotherapy administered after surgery is called adjuvant chemotherapy, which typically lasts for six to eight months. Studies have shown adjuvant chemotherapy for rectal cancer increases the likelihood of long-term survival by preventing the cancer from returning. Even if preoperative chemoradiation is administered,
THE CANCER PROGRAM OF OUR LADY OF THE LAKE and MARY BIRD PERKINS
adjuvant therapy for Stages II and III rectal cancer is recommended. Adjuvant chemotherapy typically includes the drug 5-FU with or without other drugs like oxaliplatin and leucovorin. Possible side effects include intestinal disturbances (i.e. nausea, vomiting or diarrhea), numbness or pain and a decreased production of certain types of blood cells. Not all patients with rectal cancer need chemotherapy. For example, chemotherapy is not recommended for those with Stages 0 or I. However, chemotherapy is recommended for Stage III upper rectal cancer and Stage II or III mid and low rectal cancer. Radiation Therapy Unlike chemotherapy that travels throughout the body, irradiation is delivered only to the intended treatment area. To treat rectal cancer, irradiation is delivered to the cancer site as well as the pelvic lymph nodes. In virtually all cases, irradiation is delivered with concurrent continuous infusion 5-FU. Radiation doses of 50.4 to 54 Gy are delivered in six weeks over a period of 28 to 30 treatments. The technique of pelvic irradiation is very important, and every effort is made to avoid areas that do not require treatment. The most crucial area to protect from irradiation is the uninvolved small bowel. When irradiation and chemotherapy are delivered before surgery, the vast majority of the small bowel is usually spared from the high dose radiation area, which significantly reduces the risk of small bowel injury. When pelvic irradiation is needed after surgery, more small bowel is usually in the field of irradiation. Therefore, there is more risk for small bowel injury when irradiation is delivered after surgery rather than before surgery. Compared with radiation therapy before surgery, radiation therapy after surgery has a higher incidence of stricture at the site where the rectum is reconnected.
Rectal Cancer
AN OVERVIEW |
OLOL/MBPCC Rectum Review 2001-2010 (Compared to NCDB Data for Cases Diagnosed 2000-2008) 514 Cases
GENDER Male Female RACE Caucasian African American Other AGE AT DIAGNOSIS < 29 30-39 40-49 50-59 60-69 70-79 80-89 > 90 Mean Age Median Age STAGE AT DIAGNOSIS Stage 0 Stage I Stage II Stage III Stage IV Not Applicable Unknown HISTOLOGY Adenocarcinoma, NOS Low Grade(Low/Moderate) High Grade(High/Undifferentiated) Unknown Mucinous Adenocarcinoma Neuroendocrine Tumor Other Specified Types* *Other: Lymphoma – 1; Melanoma – 1 FIRST COURSE OF TREATMENT Surgery Only Surgery/Chemotherapy Systemic Before Surgery Systemic After Surgery Surgery/Chemotherapy/Radiation Systemic Before Surgery Systemic After Surgery Radiation/Chemotherapy No Systemic Treatment or No Surgery Radiation Alone Surgery/Radiation Chemotherapy Only *NCDB- Other Specified Therapy = 10%
OLOL/MBPCC # of Cases
OLOL/MBPCC %
NCDB %
290 224
56% 44%
58% 42%
388 119 7
76% 23% 1%
81% 9% 10%
2 23 72 125 135 100 52 5 62 61
<1% 5% 14% 24% 26% 20% 10% 1%
<1% 3% 10% 22% 24% 24% 14% 2%
19 120 115 136 73 10 41
4% 23% 22% 26% 14% 2% 8%
7% 25% 19% 20% 12% <1% 16%
473 332 66 75 26 13 2
92% 70% 14% 16% 5% 3% <1%
83% NA NA NA 4% 5% 8%
174 40 4 36 215 127 88
34% 8% 1% 7% 42% 25% 17%
36% 5%
39 19 14 9 4
8% 4% 3% 2% <1%
33% (Separate percentages for before and/or after treatment are not available) 8% 8% NA NA NA
2011 CANCER ANNUAL REPORT
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AN OVERVIEW |
Rectal Cancer
Observed Survival Rate Comparison for Rectal Cancer Cases National Cancer Data Base (NCDB) cases diagnosed in 2003 OLOL/MBPCC cases diagnosed in 2003-2006 (Shown in Percentages) 100
The observed five-year survival rate of patients treated at OLOL and MBPCC was compared with those of other CoC approved programs as reported through the NCDB. Overall and by stage, our local data were comparable to that of other NCDB reporting hospitals. Only in Stage III patients results were less favorable than those of other hospitals reporting to NCDB. This may be attributable to the small number of Stage III cases seen at OLOL/MBP.
80
60
40
20
100 82
76
78
77 62
39 56
Stage II
Stage III
20
8
56 59
0 Stage 0
Stage I
n
OLOL/MBPCC
n
NCDB
Quality Improvement Rectal Cancer Measure The quality improvement measure used by the Cancer Program Practice Profile Reports (CP3R) and the Rapid Quality Reporting System (RQRS) for rectal cancer treatment states “radiation therapy is considered or administered within six months (180 days) of diagnosis for patients under the age of 80 with clinical or pathologic AJCC T4NOMO or Stage III receiving surgical resection for rectal cancer.” This measure was developed by the Commission on Cancer (CoC) in partnership with the American Society for Clinical Oncology (ASCO) and the National Comprehensive Cancer Network (NCCN) to assist facilities in monitoring their individual performance rates.
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Stage IV
Overall
The information provided by CP3R is not as current as that of the newly created Rapid Quality Reporting System (RQRS). RQRS is a web-based reporting system that advances evidenced-based treatment through a prospective alert system for CoC-accredited cancer programs. Pertinent information from the Tumor Registry is submitted to RQRS on a monthly basis. Once submitted, the data in RQRS is updated immediately. The rate is computed on data directly reported from CoCapproved cancer programs’ registries to the National Cancer Data Base (NCDB). The performance rates, 95% confidence intervals around those rates, and the number of cases included in the denominator are updated nightly for each comparison group.
THE CANCER PROGRAM OF OUR LADY OF THE LAKE and MARY BIRD PERKINS
The hospital registrar, cancer program administrator, cancer liaison physician and the cancer committee chair receive monthly reports informing the recipient of the current performance rate. Again, the information provided by RQRS is considerably more current than that of the CP3R. In 2009, OLOL and MBPCC began voluntary participation in the RQRS Beta Testing process. RQRS, after being extensively field tested at 65 CoCaccredited cancer programs for over two years, extended voluntary enrollment to other CoC-accredited facilities on September 19, 2011.
AN OVERVIEW |
Rectal Cancer
The Cancer Program Practice Profile Reports (CP3R) (Based on data for diagnosis year 2008) Facility Comparison Groups Our Lady of the Lake Mary Bird Perkins Cancer Center The State of Louisiana Mid-South Division of the American Cancer Society All CoC Approved Cancer Programs
Performance Rate
100% 100% 93.7% 89.2% 89.7%
95% CI
(100-100) (100-100) (88.3-99.1) (86-92.4) (88.8-90.6)
Rapid Quality Reporting System (RQRS) Performance Rate (Based on data for diagnosis year 2010) Facility Comparison Groups
Performance Rates
# of Cases
95% CI
Our Lady of the Lake
100%
N=7
(95% CI: 100-100)
Mary Bird Perkins Cancer Center
100%
N=8
(95% CI: 100-100)
NCCCP
81%
N=84
(95% CI: 72.6-89.3)
Comprehensive (28)
82.3%
N=124
(95% CI: 75.5-89)
All Beta Sites (57)
84.1%
N=182
(95% CI: 78.7-89.4)
Rectal Cancer Screening Guidelines Beginning at age 50, men and women should begin screening with one of the examination schedules below: 1. A colonoscopy every 10 years 2. A flexible sigmoidoscopy (FSIG) every five years* 3. A double-contrast barium enema every five years* 4. CT Colonography (virtual colonoscopy) every five years* 5. An at-home, multiple sample Guaiac-based fecal occult blood test (gFOBT) or fecal immunochemical test (FIT) every year* 6. Stool DNA (sDNA), Interval Uncertain* *Colonoscopy should be done if test results are positive. Guidelines provided by American Cancer Society (www.cancer.org)
2011 CANCER ANNUAL REPORT
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OLOL and MBPCC Integrated Cancer Registry Summary The Cancer Registry is an integral component of our 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 and MBPCC in Baton Rouge. Our Lady of the Lake OLOL Cancer Registry reference date is January 1, 1987. Accreditation with the American College of Surgeons (ACoS) was achieved on October 19, 1990. With the inclusion of cases from 2010, the OLOL tumor registry database contains data on 29,859 cases. All new cases identified are abstracted, coded and staged in accordance with guidelines established by 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, including Cancer Committee physician members 10% random review of analytic cases for quality assurance. Once part of the registry database, these cases are followed for the life of the patient. During 2010, there were 1,454 new cancer cases entered into the OLOL registry database. Of these, 1,282 were analytic cases (newly diagnosed and/or received all or part of their first course treatment at this facility). The top five sites were lung, prostate, colon, kidney/renal pelvis and bladder. OLOL Top Five Analytic Sites N/621
Lung.................................................. N/179 Prostate............................................. N/165 Colon................................................. N/135 Kidney/Renal Pelvis............................ N/78 Bladder.............................................. N/64
Mary Bird Perkins Cancer Center The MBPCC Cancer Registry reference date is January 1, 1989. Accreditation with the American College of Surgeons (ACoS) was achieved on August 24, 1992. Including cases from 2010, the database contains data on 14,560 cancer cases. All new cases identified are abstracted, coded and staged in accordance with guidelines established by 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 radiation oncologist reviews a sample of the
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cases for quality assurance. Once part of the registry database, these cases are followed for the life of the patient. During 2010, there were 1,049 new cancer cases entered into the MBPCC registry database. Of these, 739 were analytic cases (newly diagnosed and/or received all or part of their first course treatment at this facility). The top five sites were breast, lung, prostate, larynx and rectum. MBPCC– Top Five Analytic Sites N/521
Breast........................................... N/209 Lung............................................. N/147 Prostate........................................ N/111 Larynx........................................... N/32 Rectum......................................... N/22
OLOL and MBPCC Integrated Cancer Registry The registries maintain cancer data that are available for use by clinical and administrative staff at OLOL and MBPCC. All information collected is kept completely confidential. During 2010, the registries received requests for statistical reports including analytic studies, annual statistics, research activities, quality management studies, healthcare delivery, reporting to National Cancer Data Base (NCDB) and participation in the Facility Information Profile System (FIPS) on the American Cancer Society’s website. The Tumor Registry continually provides data for the four multidiscplinary teams: colorectal, brain, head and neck and lung. This year OLOL/MBPCC was chosen to participate in the beta-testing phase of the Rapid Quality Reporting System (RQRS). The RQRS program is sponsored by the Commission on Cancer and became available to other approved facilities on September 19, 2011. Participation in this program is voluntary. Data is submitted to the Louisiana Tumor Registry in compliance with state reporting requirements to support statewide improvements in cancer detection and treatment. The registry also participates in the NCDB Cancer Program Practice Profile activities. OLOL & MBPCC – Data Submission
THE CANCER PROGRAM OF OUR LADY OF THE LAKE and MARY BIRD PERKINS
Louisiana Tumor Registry (LTR) National Cancer Data Base (NCDB) Facility Information Profile System (FIPS) Rapid Quality Reporting System (RQRS)
OLOL 2010 Site Distribution Table Site Group Head and Neck
# of Cases per Stage Site Lip Tongue Salivary Gland Floor of Mouth Gum & Other Mouth Nasopharynx Tonsil Oropharynx Hypopharnyx Pharynx/Other Oral
Digestive System
Esophagus Stomach Small Intestine Colon Rectosigmoid Junction Rectum Liver Intrahepatic Bile Duct Gallbladder Other Biliary Pancreas Retroperitoneum Peritoneum/Omentum/Mesentery
Respiratory System
Nose/Nasal Cavity/Mid Ear Larynx Lung-Small Cell CA Lung-Non-Small Cell CA Lung-Other Types Pleura
Bone
Bones and Joints
Soft Tissue
Soft Tissue and Heart
Skin
Melanoma-Skin Other Non-Epithelial Skin
Breast
Breast
Female Genital System
Cervix Uterus Ovary Vulva
Male Genital System
Prostate Testis Penis
Urinary System
Bladder Kidney and Renal Pelvis Ureter Other Urinary
Brain/Nervous System
Brain Other CNS
Thyroid/Endocrine
Thyroid Endocrine
Hemic and Lymphatic
Hodgkin’s Lymphoma Non-Hodgkin’s Lymphoma Plasma Cell Tumors Leukemia
Other/Unknown
Other and Unspecified
Stage 0 55 0 0 0 0 0 0 0 0 0 0 0 0 0 0 18 0 7 0 0 0 0 0 0 0 25 0 0 0 0 0 0 0 0 0 0 0 4 0 4 2 2 0 0 0 1 1 0 0 0 0 22 1 0 0 23 0 0 0 0 0 0 0 0 0 0 0 0 0
Stage I 269
Stage II 293
Stage III 175
1 2 2 2 3 0 2 0 2 0 14 0 3 1 28 0 18 4 0 1 1 1 1 0 58 1 14 4 26 1 2 48 0 0 2 2 23 0 23 6 6 1 2 1 0 4 0 1 0 1 22 51 2 1 76 0 0 0 19 0 19 0 18 0 0 18 0 0
0 0 2 0 2 0 1 0 0 0 5 2 2 1 25 1 11 2 0 0 0 4 0 0 48 0 6 2 14 0 0 22 2 2 0 0 2 1 3 14 14 0 0 1 0 1 154 1 2 157 8 5 0 0 13 0 0 0 4 0 4 5 19 0 0 24 0 0
1 1 0 1 0 1 3 2 1 0 10 0 5 1 34 2 14 3 0 0 0 1 0 0 60 1 1 9 33 2 0 46 0 0 1 1 6 2 8 8 8 0 1 3 0 4 6 0 0 6 7 10 0 0 17 0 0 0 3 0 3 3 9 0 0 12 0 0
Stage IV 202 0 7 5 2 4 0 4 0 1 0 23 2 8 2 24 0 5 2 0 0 0 11 0 0 54 0 7 12 56 5 1 81 0 0 1 1 4 0 4 6 6 1 1 4 0 6 4 0 0 4 4 8 1 0 13 0 0 0 1 0 1 2 7 0 0 9 0 0
Unk 75
NA 213
Analytic Total 1282
0 1 0 0 1 1 0 1 0 0 4 3 3 0 4 0 1 2 1 0 1 4 1 0 20 0 2 3 3 2 1 11 3 3 4 4 3 0 3 2 2 0 2 2 0 4 1 0 0 1 1 2 0 0 3 0 0 0 2 0 2 1 4 0 0 5 13 13
0 0 0 0 0 1 0 0 0 1 2 0 5 4 2 0 0 1 0 0 0 2 0 2 16 2 1 0 6 1 0 10 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 1 0 0 1 40 59 99 0 18 18 0 0 10 15 25 41 41
2 11 9 5 10 3 10 3 4 1 58 7 26 9 135 3 56 14 1 1 2 23 2 2 281 4 31 30 138 11 4 218 5 5 8 8 42 3 45 39 39 2 6 11 1 20 165 2 2 169 64 78 3 1 146 40 59 99 29 18 47 11 57 10 15 93 41 41
2011 CANCER ANNUAL REPORT
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MBPCC 2010 Site Distribution Table Head and Neck
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Number of Cases per Stage Tongue Salivary Gland Floor of Mouth Gum & Other Mouth Nasopharynx Tonsil Oropharynx Hypopharnyx
Digestive System
Esophagus Stomach Colon Rectum Anus Liver Other Biliary Pancreas
Respiratory System
Nose/Nasal Cavity/Mid Ear Larynx Lung-Small Cell CA Lung-Non-Small Cell CA Lung-Other Types
Soft Tissue
Soft Tissue and Heart
Skin
Melanoma-Skin Other Non-Epithelial Skin
Breast
Breast
Female Genital System
Cervix Uterus Vagina Vulva Other Female Genital
Male Genital System
Prostate
Urinary System
Bladder Kidney and Renal Pelvis
Eye
Eye and Orbit
Brain/Nervous System
Brain Other CNS
Thyroid/Endocrine
Endocrine
Hemic and Lymphatic
Hodgkin’s Lymphoma Non-Hodgkin’s Lymphoma Plasma Cell Tumors
Other/Unknown
Other and Unspecified
Stage 0 31 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 30 30 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Stage 1 132 1 2 0 0 0 1 0 0 4 0 1 0 1 1 0 0 2 5 0 9 2 20 2 33 1 1 0 0 0 67 67 2 5 0 1 0 8 0 0 0 0 0 0 0 0 0 0 0 0 0 14 0 14 0 0
Stage II 206 0 1 0 1 2 1 0 0 5 2 1 0 6 3 0 0 4 16 0 5 1 6 0 12 1 1 0 0 0 63 63 0 1 0 1 0 2 93 93 3 0 3 1 1 0 0 0 0 0 3 7 0 10 0 0
THE CANCER PROGRAM OF OUR LADY OF THE LAKE and MARY BIRD PERKINS
Stage III 157 2 0 1 0 2 3 1 2 11 1 1 1 11 3 0 0 3 20 0 3 8 46 1 58 0 0 1 2 3 43 43 3 1 1 1 0 6 13 13 0 0 0 0 0 0 0 0 0 0 0 3 0 3 0 0
Stage IV 137 8 5 4 4 0 5 2 3 31 3 0 1 2 0 3 0 2 11 0 13 8 48 2 71 2 2 2 0 2 5 5 0 0 0 1 0 1 4 4 4 5 9 0 0 0 0 0 0 0 0 1 0 1 0 0
Unk 23 0 1 0 1 0 0 0 0 2 5 1 0 2 3 0 1 0 12 0 1 0 3 0 4 3 3 0 0 0 1 1 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
NA 53 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 2 2 0 0 0 0 0 0 1 1 0 0 0 1 1 2 2 20 4 24 1 1 0 0 5 5 16 16
Analytic Total 739 11 9 5 6 4 10 3 5 53 11 4 2 22 10 3 1 11 64 1 32 19 123 5 180 7 7 3 4 7 209 209 5 7 1 4 1 18 111 111 7 6 13 3 3 20 4 24 1 1 3 25 5 33 16 16
Tomorrow’s Cancer Care— Right Here, Right Now.
As a partner of the National Cancer Institute’s (NCI) National Community Cancer Centers Program (NCCCP), we are developing a national model for community cancer centers. This means cancer patients in our own community are receiving the highest standard of care available—right here, right now. The quality of our Cancer Program is underscored by our selection by NCI, a world leader in cancer research.
We are proud to be the only site in Louisiana, the only site in the Gulf South and one of 30 centers across the nation working with NCI to improve cancer care for patients in community settings. The Cancer Program of
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www.marybird.org
Defeating cancer together.
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