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Cancer Center
A National Cancer Institute
Community Cancer Centers Program
2013
Annual
Report
www.billingsclinic.com/cancer
Table of Contents
»» Directors’ Report
1
»» Welcome New Physicians
8
»» American College of Surgeons Accreditation
2
»» 2013 Patient Care Evaluation Study
9
»» Unique Programs to Billings Clinic Cancer Center
2
»» Cancer Registry Milestones
15
2
3
4
5
5
• 2012 Primary Site Table
• Cancer Registry
16
19
•
•
•
•
•
•
Specialty Radiation Therapy
Research Program
Specialty Support Programs
Outreach Programs
Arts-in-Medicine
Inpatient Cancer Care: The Journey to Inpatient
Pediatric Oncology Care
»» New Programs at Billings Clinic
• National Accreditation Program for Breast Cancers
• Reger Family Center for Breast Health
• iPad Donation Helps Patients Stay Connected
ii
2013 Cancer Center
Annual Report
6
7
7
7
7
»» Awards, Presentations,
Publications and Recognitions
24
Director’s Report - 2013
A
t the end of every year we reflect on the accomplishments of that year
with pride. Why, because the focus of our programs are on the patients
receiving best practice medicine and care. The best quality, patient safety,
service and value are not only words in our vision, they are core to the
physicians’ and staff ’s guiding principles. As we reflect, we put pen to paper to
write this annual report, not only for us to share the information with
everyone, but to archive the successes and the challenges of the year.
So, we welcome you to the 2013 Billings Clinic Cancer Center’s Annual Report.
The contents of this document not only outline the Cancer Center’s meaningful
achievements, but also report our cancer statistics for the past year and a
quality study reviewing our patients’ care and/or experience at the center.
In addition to the programs you will read in the pages that follow, we also want
to share the other unique features of our cancer program:
Jo Duszkiewicz
Administrative Director
• NCI Community Cancer Centers Program (NCCCP) since 2007: a program
that focuses on improving cancer care in underserved populations,
increasing access to cancer clinical trials and improving cancer care delivery
across the continuum of care
• Advisory Board of Cancer Survivors: a group of cancer
survivors meets regularly to discuss opportunities for cancer
programs and advise the cancer leadership on ways to improve
our services offered
• Stem Cell Transplant Program (SCT): only accredited (American
Association of Blood Banks) SCT program in Montana and Wyoming
• Outpatient palliative/symptom management program and
clinic: a team of palliative care experts meets with patients to
assist in symptom management and quality of life issues
• Cancer Care Delivery Research (CCDR): through many community
partnerships, active research has been a focus throughout the year
• Pediatric Oncology, Gynecologic Oncology, Naturopathic Medicine and
Genetic counseling are clinical programs that are uniquely integrated into
our extensive cancer care services
• Multidisciplinary Cancer Clinics: six cancer site-specific clinics are
coordinated by patient care navigators and offer cancer patients access to
multiple cancer and other specialists in a timely manner
1
Randall Gibb, MD
Medical Director
We hope you enjoy and find value in this report. In addition to
reviewing this 2013 annual report, we encourage you to visit our
Billings Clinic Cancer Center website to familiarize yourself with
all of our cancer related programs and services.
American College of Surgeons Accreditation
The American College of Surgeons (ACoS)
Commission on Cancer (CoC) is a consortium
of professional organizations focused on
improving cancer outcomes through quality,
multidisciplinary, and comprehensive cancer care delivery. There are different
Cancer Program categories based on type of organization, services provided,
and number of new cancer cases diagnosed and/or treated annually at a facility.
Billings Clinic is considered a Comprehensive Community Cancer Program,
the highest non-academic community hospital category.
Programs accredited by the ACoS CoC undergo a rigorous reaccreditation
survey every three years. This involves an assessment of the program’s
compliance with the requirements for all standards, completion of an online
Survey Application Readiness (SAR) tool with supporting documentation, and
an onsite visit by an ACoS CoC surveyor to review program performance.
This year, Billings Clinic underwent its third successful survey and
received three-year accreditation with commendation at the silver
level. Commendation, which reflects performance beyond the
basic CoC standards, was received for six out of the eight
standards including: clinical trial accrual, Cancer Registry
education, annual report, compliance with pathology reporting
according to College of American Pathologist (CAP) guidelines,
oncology nurse certification, and registry abstraction timeliness.
At the conclusion of the onsite visit, the surveyor stated Billings
Clinic was among the top three programs nationally that he has
had the pleasure of surveying. This comment helps validate the
continual pursuit of providing excellent cancer care by our many
multidisciplinary teams!
Unique Programs to Billings Clinic
Specialty Radiation Therapy
Billings Clinic is proud to announce the expansion
of radiosurgical services in the region with a new
approach to treating brain tumors using the
Gamma Knife Perfexion®. Our physicians have
completed training with the most renowned
Neurosurgeons and Radiation Oncologists from the
University of Pittsburgh and Cleveland Clinic to expand
their expertise in the field of stereotactic radiosurgery.
Gamma Knife is used for the precise determination and targeting of various
intracranial abnormalities, as well as for diagnostic and therapeutic
procedures. This technology, with its dose-planning system, Gamma Plan, is a
unique device used to non-invasively treat brain tumors and vascular
2
malformations in the brain. Gamma Knife
delivers very high doses of ionizing radiation to
select, well-circumscribed targets in the brain. It
is used to treat vascular disorders, benign tumors,
metastases and other malignant tumors, and
functional disorders such as epilepsy and
Parkinson’s disease.
The Gamma Knife Perfexion® unit will be the
first in Montana, as well as the four state region that includes
Wyoming, North Dakota, South Dakota, and Idaho. Clinical
treatment with the Gamma Knife is anticipated to begin in
March 2014.
Unique Programs (Cont’d)
Research Program
The Total Cancer Care® Program was initiated earlier this year at
Billings Clinic. This collaborative program with Moffitt Cancer Center
in Tampa, Florida helps us learn more about the specific molecular
biology of cancer as it relates to treatment effectiveness.
It involves sending tissue from patients diagnosed with lung cancer,
breast cancer, colorectal cancer, and melanoma to Moffitt’s
biorepository where they not only use the tissue to study the cancer,
but also help identify patients for potential clinical trials based on the
specific cancer characteristics.
Billings Clinic continues
to demonstrate a strong
commitment to the use
of clinical trials in cancer
treatment. In 2013,
Billings Clinic enrolled
102 cancer patients
(7% of analytic cases) on
clinical trials.
Billings Clinic Cancer Center Research
Collaborative involvement
Associate Susan Carter, meets with a
in several community
patient to discuss clinical trial options.
awareness programs
continues to help promote awareness of cancer clinical trials. In
February, we celebrated Cancer Clinical Trial awareness month with
the Montana Cancer Consortium (MCC) and Montana Cancer
Control Coalition (MTCCC). Articles were written in newspapers
across the state, educational programs were broadcast on community
television, and messages were distributed using social media. Later in
May, Billings Clinic celebrated International Research Week with the
Research Center, Center for Translational Research, Nursing Research
committee, and Cancer Research department setting up posters with
findings from locally conducted research. Additionally, a lunch and
learn program was held to educate staff and the community at large
about the research opportunities at Billings Clinic.
3
Changes have occurred at the national level with the reorganization of
cooperative groups into the National Clinical Trial Network (NCTN).
The NCTN will now be comprised of 4 adult groups: Southwestern
Oncology Group (SWOG), Alliance (formerly NCCTG, CALGB, and
ACSOG), NRG (formerly NSABP, RTOG and GOG), and ACRIN
(ACRIN and ECOG). The Children’s Oncology Group (COG) will
remain separate. Furthermore, the Community Cancer Oncology
Program (CCOP) and National Cancer Institute Community Cancer
Centers Program (NCCCP) programs are merging into the National
Community Oncology Research Program (NCORP). We are
collaborating with MCC and other oncology providers within the
region on the writing of a proposal for funding. While NCORP will
continue to place a strong emphasis on clinical trial accrual, Cancer
Care Delivery Research (CCDR) is a new program component which
will focus on oncology care delivery models, cost, quality, and
outcomes. Billings Clinic will take an active leadership role in both
components of the new program.
Unique Programs (Cont’d)
Specialty Support Programs
A dedicated team of oncology professionals has progressively
developed an extensive array of specialty support programs to address
patients’ and families’ holistic needs over the past ten years. This team
includes ten patient navigators, three licensed social workers/
professional counselors, two oncology dietitians, three certified
lymphedema specialists/physical therapists, a speech therapist, a
genetic counselor, a symptom management nurse, and a lay navigator.
Through their expertise, patients’ and families’ physical, psychosocial,
and spiritual needs are addressed in a comprehensive and inclusive
manner through specialty consultations, as well as group activities
such as lunch and learn programs, support groups, annual retreats
targeted to specific patient populations, and survivorship education.
Additionally, a Facebook group (Billings Clinic Cancer Pathways) was
created this fall as a mechanism to utilize social media to further
promote awareness among our patients of these wonderful programs
and services. Please consider joining this group by going to
www.facebook.com/groups/billingscliniccancerpathways
4
Survivorship support is one area Billings Clinic has been working
diligently on over the past year to better integrate electronic medical
record (EMR) tools and nurse navigation processes for improved
efficiencies in providing cancer patients with survivorship documents.
Initial provision of survivorship documents (a comprehensive
treatment summary and survivorship care plan) began in 2010 when
Billings Clinic launched a 2-year pilot study supported through the
National Cancer Institute’s Community Cancer Centers Program
(NCCCP). While high levels of satisfaction with the survivorship
documents were noted among patients, caregivers, and primary care
providers, the time required to complete the survivorship documents
(average three hours) was prohibitive.
Lean Six Sigma tools SIPOC (suppliers, input, process, output,
customers) diagram, process map, waste walk, fishbone diagram,
cause and effect prioritization matrix were applied to survivorship
processes to improve efficiency. Institute of Medicine specifications
influenced survivorship document design while National
Comprehensive Cancer Network guidelines established surveillance
plans. EMR forms captured discrete data elements tracked by
navigators as patients progressed through the continuum, thereby
creating a data repository which could later populate the treatment
summary. Standard order sets for surveillance and site-specific
survivorship care plans outlining late- and long-term effects of
treatment, follow-up care, wellness strategies, and resources were
created in the EMR. Four months post-implementation, we are
pleased to report these system enhancements have yielded a much
improved average of 45-60 minutes to compile the treatment
summary and survivorship care plan. Through collaborative
process improvement, roadblocks to providing survivorship
documents were reduced, thereby improving the quality of care
provided to cancer survivors.
Unique Programs (Cont’d)
Outreach Programs
Billings Clinic 43-County Service Area
Toole
Flathead
Sanders
Libe
rt
y
with Oncology Clinic and Physician Outreach
Daniels
Locations
Glacier
Hill
Lincoln
Missoula
Lewis &
Clark
Bow
Gallatin
Wheatland Golden
Sweet
Grass
Bozeman
Madison
Dillon
Secondary
Tertiary
Billings Clinic Oncology Sites
Dawson
Livingston
Park
Garfield
Petroleum
Lewistown
Rosebud
Musselshell
Prairie
Custer
Roundup
Valley
Big
Timber Columbu
s
Glendive
Forsyth Miles City
Dunn
Wibaux
Fallon
Stark
Dickinson
Slope
Baker Bowman
Adams
Yellowstone
Billings
Carbon
Red Lodge
Powell
Cody
Park
Hot
Springs
Hardin
Powder
River
Big Horn
Sheridan
Campbell
Sheridan
Greybull
Johnson
Gillette
Bighorn
Buffalo
Lovell
Carter
Crook
Worland
Washakie
Thermopolis
Medical Oncology:
Outreach services
are provided in eight
different sites throughout the region by our expert team of medical
oncologists/hematologists. The frequency of visits to each community
is dependent upon volume demands. This year a new outreach clinic
was started in Worland, Wyoming, which is staffed by Dr. Robert
Joseph from our Cody Oncology hub.
Oncology Main Clinic Locations
Medical Oncology Outreach
Gynecologic Oncology Outreach
Fremont
Riverton
Casper
Gynecologic Oncology: In addition to gynecology oncology surgical
and clinical services provided in Missoula and Helena, clinical
outreach was resumed in Bozeman this fall.
Cody Oncology and Infusion Center:
The Billings Clinic Cody Oncology
and Infusion Center has been in
full operation since November
2012, providing full-time medical
oncology and infusion coverage to
the north-central Wyoming
region. Since Dr. Robert Joseph’s
arrival in March of 2013, this
service has experienced a 53%
increase in volume.
5
er
Deer
Lodge SilverButte
Meagher
Sidney
ng
Hetti
Granite
Anaconda Jefferson
Williston
Richland McKenzie
McCone
Fergus
Judith
Basin
Williams
Wolf Point Culbertson
Phillips
Cascade
Divide
Sheridan
Roosevelt
Valley
Glasgow
Chouteau
Missoula
Primary
Blaine
Pondera
Teton
Lake
Ravalli
Havre
Billings
y
Golden Valle
Billings Clinic is
committed to
collaborating with
local healthcare
facilities to provide
quality oncology
specialty services
throughout our vast
geographic region.
The Cody Oncology team works closely with the Billings Oncology
team to provide comprehensive services both locally, as well as via
telemedicine. Additionally, this team actively participates in
multi-disciplinary tumor boards and weekly rounds, enrolls patients
to clinical trials, and provides supportive services for patients.
The Cody Infusion Center is staffed five days a week with an RN
skilled in providing a variety of treatments, including chemotherapy
and a multitude of infusions for other diagnoses. As an increasing
array of infusion referrals are received, infusion services continue to
expand so that patients living in the north-central Wyoming region
can receive treatments closer to home.
Arts-in-Medicine
The arts have proven to reduce anxiety,
depression, and other difficult emotions that
often accompany a cancer diagnosis. Billings
Clinic Cancer Center’s healing arts program
was bolstered by the LIVESTRONG
Foundation’s Community Impact Project
grant to replicate the Creative Centers
Artist-in-Residence program. This $15,000 grant funded two local
artists and all art supplies needed for the program.
The artists, Mur Quaglia and Brooke Atherton, worked at the bedside
and chair-side creating art with patients. They created snowflakes,
fabric art, paintings, necklaces, a collaborative staff painting, and
several other projects. They empowered patients and families with the
creative process during treatment and at special retreats and events.
Oncology Certified Nurse
Linda Allen, RN, visits with a
patient in Billings Clinic Cody’s
infusion center.
A large scale piece called the Healing Garden will be available early
2014 to showcase the work of several survivors and mark the impact
of this wonderful grant. A variety of Arts-in-Medicine workshops will
continue to be offered at the Cancer Center supported through funds
donated to the Cancer Wellness program.
Unique Programs (Cont’d)
Inpatient Cancer Care: The Journey to Inpatient Pediatric Cancer Care
In 2012, Billings Clinic added two new team members to our
Pediatric Center, Dr. Courtney Lyle, MD, pediatric hematologist/
oncologist, and Jill Wineinger, RN, BSN, pediatric nurse clinician.
Since joining Billings Clinic, Dr. Lyle and Jill have worked with the
Inpatient Cancer Care (ICC) team to develop expertise in providing
inpatient oncology care for pediatric patients ages nine to
17 years old.
Pediatric Chemotherapy and Biotherapy Provider Program for 21 ICC
staff members. The same staff members are also now Pediatric
Advanced Life Support (PALS) trained and certified.
The unit also obtained pediatric specific equipment to meet the
medical needs of this patient population. The unit now has a special
emergency code cart for pediatric emergencies
called a Broselow cart. Staff completed
“Broselow Training – How to use Color Coding
in Pediatric Emergencies”. Age-specific
diversional activities were also acquired such as
movies, videos, and electronic games.
To prepare the staff to safely and effectively
care for pediatric oncology patients, a
robust education plan was developed.
During the first part of 2013, Dr. Lyle
presented education to staff on pediatric
System changes to the electronic medical
end-of-life care during the Hot Topics in
record (EMR) were made to accommodate the
Pediatrics Nursing workshop. In addition,
special medical orders needed to care for this
she met with the ICC team and presented
age population. Both Dr. Lyle and Jill worked
education on childhood cancers. This
with the oncology nurse informaticist to
interactive education provided
develop pediatric oncology orders in the EMR
opportunities for staff to ask questions and
which outline evidence-based cancer treatment
Dr. Courtney Lyle and Jill Wineinger, RN, (right)
feel more comfortable with the care of such
visit with ICC nurses who have been trained to
regimens for chemotherapy/biotherapy.
a young group. Jill also provided several
provide pediatric cancer care.
educational opportunities including
In September, a Pediatric Practice Advisory
“A Child-Centered Approach in a Healthcare Setting” which increased
Committee (PPAC) was developed to streamline all pediatric care
staff knowledge of pediatric growth and development.
throughout the organization. This committee will allow current
Billings Clinic partnered with Rocky Mountain Hospital for Children
in Denver, Colorado to obtain additional expertise in pediatric
nursing education. Two pediatric nurses from Rocky Mountain
Hospital for Children came to Billings Clinic and provided the
Association of Pediatric Hematology/Oncology (APON)
6
policies to be updated to better serve the pediatric population in the
acute care setting.
With the support and training provided by both Dr. Lyle and Jill, ICC
has admitted 12 patients ages nine – 15 in 2013, with an average
length of stay of three-to-four days.
New Programs
NAPBC Accreditation
Earlier this year, Billings Clinic
was granted three-year, full
accreditation designation by
the National Accreditation
Program for Breast Centers (NAPBC), a program administered by the
American College of Surgeons. The NAPBC is a consortium of
professional organizations dedicated to the improvement of the care
and monitoring of outcomes for patients with diseases of the breast.
NAPBC accreditation signifies a facility’s dedication to providing the
highest level of quality breast care through compliance with nationally
established program standards. Standards set by the NAPBC ensure
patients receiving care at a NAPBC-accredited center have access to
comprehensive and coordinated breast care, state-of-the-art services,
and a multidisciplinary team approach.
Reger Family Center for Breast Health
The 4,300-squarefoot Reger Family
Center for Breast
Health opened in
October 2013 on
the second floor of
the Billings Clinic
Cancer Center. The center offers complete breast diagnostic services
in a private, comfortable environment. Features include a spa-like
atmosphere, specialty coffee and comfortable seating in the lobby,
private changing rooms with doors that enter directly to the
mammography suite, and warm spa robes or capes.
Mammography, breast ultrasound, stereotactic breast biopsy, and
bone densitometry (DEXA scan) suites are all located together so that
7
comprehensive evaluations can be completed in a single location.
Additionally, tomosynthesis technology, which provides the highest
resolution mammography to detect early breast cancers, is now
available at Billings Clinic.
A retail Breast Boutique is also housed within the Reger Family
Center for Breast Health. The Breast Boutique has two private fitting
rooms and the region’s only experienced certified fitter to assist
women with pre- and post-breast surgery needs. The boutique, staffed
Monday through Friday, is open to anyone in need of mastectomy and
breast-cancer merchandise including bras, prostheses, camisoles,
scarves, hats, lotions, and other personal care items. One
improvement this boutique brings to the community is the ability
for Billings Clinic to bill purchases directly to patients’ insurance,
rather than patients having to pay for products upfront and then
be reimbursed.
iPad Donation Helps
Patients Stay Connected
United Luv, a family t-shirt company,
gifted nine iPads to Billings Clinic for
oncology patient use during lengthy
cancer treatments. This gift was in
memory of one of the founding
members of United Luv whose vision
was to provide iPads to area cancer centers to help others battling
cancer stay connected with family and friends during treatment. This
very special gift was matched by the Billings Clinic Foundation for a
total of 18 iPads available to patients receiving cancer treatment in the
Infusion Center, Inpatient Cancer Care unit, and Pediatric Oncology.
Welcome New Physicians
We want to extend a grand welcome to the new oncologists who
joined Billings Clinic in 2013. The clinical contributions they bring
to cancer care in the region are truly outstanding.
Dr. Robert Joseph
Billings Clinic welcomed Dr. Robert Joseph to our
Billings Clinic Cody Oncology and Infusion Center
as a medical oncologist and hematologist in March
2013. Dr. Joseph attended medical school at the
University of Illinois School of Medicine in Chicago,
Illinois, and finished the Straight Medical Internship in Los Angeles
County, University of Southern California (LAC/USC). He completed
his residencies in hematology/oncology at Veterans Affairs
Wadsworth, University of California, Los Angeles Medical Centers
and at LAC/USC Medical Center.
Dr. Michelle Proper
Billings Clinic welcomed Dr. Michelle Proper to our
Cancer Center as a Radiation Oncologist in October
2013. Dr. Proper completed medical training at
University of Illinois at Chicago – College of
Medicine, and her residency in Radiation Oncology
at University of Colorado, Denver, Colorado. Dr. Proper specializes in
treating all types of cancer with radiation therapy, but has a special
interest in treating breast, gynecologic, and gastrointestinal cancers.
Her prior research involved Stereotactic Body Radiation Therapy,
which is used at Billings Clinic for certain cancers.
8
Dr. Pamela Smith
Billings Clinic welcomed Dr. Pamela Smith to our Cancer
Center as a Medical Oncologist and Hematologist in
September 2013. Dr. Smith completed medical training
and residency at The University of Colorado Health
Sciences Center, Denver, Colorado, and her fellowship in
Hematology and Oncology at Tufts Medical Center, Boston, Massachusetts.
Dr. Erin Stevens
Billings Clinic welcomed Dr. Erin Stevens to our Cancer
Center as a Gynecologic Oncologist in August 2013. Dr.
Stevens completed medical training at New York Medical
College in Valhalla, New York, her residency at Stony
Brook Medical Center in Stony Brook, New York, and her
fellowship in Gynecologic Oncology at The State University of New York
(SUNY) Downstate Medical Center in Brooklyn, New York. She also spent
time serving OB /GYN patients in Miles City. Dr. Stevens specializes in the
diagnosis and treatment for all types of female reproductive cancers and
pre-cancerous conditions.
Dr. Venu Thirukonda
Billings Clinic welcomed Dr. Venu Thirukonda to our
Cancer Center as a medical oncologist and hematologist in
July 2013. Dr. Thirukonda completed medical training at
Madurai Medical College in Madurai, India, and his
fellowship in hematology and oncology at Montefiore
Medical Center, Albert Einstein College of Medicine in Bronx, New York.
2013 Patient Care Evaluation Study
Use of Herceptin in
HER-2 Positive Breast Cancer
The Billings Clinic Cancer Center embarked
on a study in 2013 to evaluate the use of
Herceptin in invasive HER-2 positive breast
cancer cases (N=81) between 2009 and 2012.
In addition, stage at diagnosis and overall
survival for all Billings Clinic breast cancer
cases was compared to national survival rates
using data from the National Oncology
Data Base (NODB), National Cancer
Data Base (NCBC), and Montana Cancer
Registry (MCR).
Background
Breast cancer is the most common malignancy
diagnosed in women and the second leading
cause of cancer-related deaths in women
(Figure 1). These statistics shed light onto the
importance of continued focus on quality
outcomes for this wide-reaching disease.
HER-2, or human epidermal growth factor
receptor 2, is overexpressed in about 20% of
breast cancers. Targeting HER-2 with the
monoclonal antibody trastuzumab
(Herceptin) improves survival in both earlystage and advanced breast cancer
(Trastuzumab plus Adjuvant Chemotherapy
for Operable HER2-Positive Breast Cancer;
Edward Romond, et al; N Engl J
Med2005:353:1673.
9
Figure 1: Ten Leading Cancer Types for the Estimated New Cancer Cases and Deaths By Sex, United States,
2013. Seigel, Naishadham, & Jemal. CA: A Cancer Journal for Clinicians, 2013. Vol 63, No. 1, pp. 11-30.
Estimates are rounded to the nearest 10 and exclude basal cell and squamous cell skin cancers and in situ
carcinoma except urinary bladder.
Patient Care Evaluation Study (Cont’d)
Randomized Phase 2 Trial of Trastuzumab
Combined With Docetaxel in Patients with
HER2-Positive Metastatic Breast Cancer; M
Martin et al; J Clin Onc 2005:23;4265).
Women with early stage (stages I-III) breast
cancer with HER-2 overexpression should
receive treatment with chemotherapy and
Herceptin as adjuvant therapy. Furthermore,
clinical trials have shown survival
improvement in node-positive and high-risk
node-negative (tumor > 1cm) cancers when
Herceptin is added to chemotherapy. For
node-negative patients with tumors smaller
than 1cm, there are no randomized clinical
trial data. Based on the increased risk of
recurrence for tumors that overexpress
HER-2, the National Comprehensive Cancer
Network (NCCN) recommends the use of
Herceptin and chemotherapy for small
tumors (Figure 2).
Because of potential cardiac toxicity from
Herceptin and side effects from
chemotherapy, not all patients are
candidates for systemic treatment. Patients
with metastatic breast cancer and HER-2
positive disease also benefit from Herceptin
therapy as a single agent or when added to
hormonal therapy or chemotherapy.
10
NCCN Guidelines for Herceptin Use in HER-2 Positive Early Stage Breast Cancer
Hormone Receptor Positive
Tumor Size
Node Status
Treatment*
≤ 0.5cm
neg
H
≤ 0.5cm
pos, <2mm
H, T ± C
≥ 0.6cm
neg
H, T, C
Any
pos
H, T, C
Hormone Receptor Negative
Tumor Size
Node Status
Treatment*
≤ 0.5cm
neg
none
≤ 0.5cm
pos, <2mm
T+C
≥ 0.6cm
neg
T+C
Any
pos
T+C
* T = trastuzumab (herceptin)
H = hormone therapy
C = chemotherapy
Figure 2: NCCN Guidelines for Herceptin Use in HER-2 Positive Early Stage Breast Cancer.
Patient Care Evaluation Study (Cont’d)
Quality Measures
and Outcomes
In an effort to assess quality
and improve outcomes, the
Billings Clinic Cancer
Committee undertook a
retrospective review of Billings
Clinic cancer registry patients
with invasive HER-2 positive
breast cancer diagnosed
between 2009 and 2012 and the
use of Herceptin. Additionally,
stage at diagnosis and overall
survival for all breast cancers
diagnosed at Billings Clinic was
compared to national statistics
including data obtained from
the NODB, NCBC, and MCR.
A total of 762 patients were
diagnosed with breast cancer at
Billings Clinic between 2009
and 2012, of which 81 were
HER-2 positive invasive breast
cancers (Graph 1).
Of the 81 patients with HER-2
positive invasive breast cancer,
65 patients (80.2%) received
Herceptin as part of their
systemic therapy (Graph 2).
11
Billings Clinic Breast Cancer Patients Diagnosed 2009 - 2012
241
250
200
184
183
154
150
100
50
25
24
0
2009
18
2010
2011
Number of Breast Cancers
15
2012
Number of HER2+ Breast Cancers
* One HER-2 positive patient did not have an invasive breast cancer
Graph 1: This shows the annual distribution by year of diagnosis for the 762 breast cancers and 82 HER-2
positive cases diagnosed during the years 2009-2012. Note one of the HER-2 positive cases reported during
this timeframe was not an invasive breast cancer.
Herceptin Given for Billings Clinic Patients Diagnosed 2009 - 2012
with HER-2 Positive Invasive Breast Cancer
16
Yes
65
No
Graph 2: This shows Herceptin was given
for Billings Clinic cancer patients
diagnosed 2009-2012 with HER-2
positive invasive breast cancer in 80.2% of
cases. In 9 additional cases, Herceptin
was discussed; this equates to 91.4% of
HER-2 positive invasive breast cancer
patients either received or were
considered for Herceptin.
Patient Care Evaluation Study (Cont’d)
Reasons identified as to why Herceptin was not given to 16 HER-2
positive invasive breast cancer patients included (Graph 3):
• 5 patients declined
Additionally, adjuvant Herceptin use in early stage invasive breast
cancer patients at Billings Clinic was reviewed based on tumor size,
nodal status, and estrogen receptor status (Figure 3).
Invasive Breast Cancer - Hormone Receptor Positive
• 3 patients had no follow-up care at Billings Clinic
• 3 patients enrolled in a clinical trial in which they received
lapatinib instead
• 1 patient died within 3 days of diagnosis
• 1 patient had significant comorbidities which precluded systemic
therapy
• 1 patient was treated with hormone therapy alone because of
advanced age (93 years old with metastatic disease)
# Patients
# Patients Receiving
Herceptin
pT1, PT2, pT3 and pN0 or
pN1mi
29
22
Tumor ≤ 0.5 cm or
microinvasive, pN0
4
3
Tumor 0.6 - 1.0 cm
6
6
Tumor > 1 cm
19
13
Tumor ≤ 0.5 cm or
microinvasive, pN1mi
• 1 patient had a tumor that was 95% HER-2 negative and only 5%
HER-2 positive
Node positive
22
20
• 1 patient with no apparent reason
Node X
2
1
Node blank
8
4
Reasons HER-2 Positive Invasive Breast Cancer Patients Did Not
Receive Herceptin (Diagnosed 2009-2012)
No follow-up care
1
Lapatinib given
1
Died w/i 3 d
1
3
1
3
Comorbidities
HT only
95% neg/5% pos
Unknown
Graph 3: This graph shows 31% of HER-2 positive invasive breast cancer
patients did not receive Herceptin due to their own choice; 19% did not
pursue follow-up care beyond diagnosis; 19% received Lapatinib on
clinical trial; and the other 31% due to a variety of other single-cause
reasons.
12
# Patients
# Patients Receiving
Herceptin
pT1, PT2, pT3 and pN0 or
pN1mi
11
11
Tumor ≤ 0.5 cm or
microinvasive, pN0
0
0
Tumor ≤ 0.5 cm or
microinvasive, pN1mi
0
0
Tumor 0.6 - 1.0 cm
3
3
Tumor > 1 cm
8
8
Node positive
7
5
Node X
1
1
Node blank
2
1
Declined
5
1
Invasive Breast Cancer - Hormone Receptor Negative
Figure 3: This shows 76% of hormone receptor (HR) positive patients and
100% of HR negative patients with smaller tumors and node negative tumors
received Herceptin per NCCN guidelines. 91% of HR positive and 71.4% of
HR negative node positive patients received Herceptin.
Patient Care Evaluation Study (Cont’d)
Overall 5-Year Survival for Breast Cancer Cases
Billings Clinic vs. Montana Cancer Registry
2009-2011
Graphs 4, 5, and 6 depict Billings Clinic overall 5-year survivorship for
breast cancer by stage compared to the NODB, MCR, and NCDB
respectively. Billings Clinic overall survival for breast cancer is
comparable to survival rates from these regional and national
benchmarks
Graphs 7 and 8 depict stage at diagnosis for breast cancers diagnosed at
Billings Clinic versus all other hospitals in the NODB. A lower rate of
Stage 0 and slightly higher rate of Stage III breast cancers was noted for
Billings Clinic as compared to all other hospitals in the NODB, although
progress was noted in 2012 with an increasing rate of stage 0 cancers
diagnosed. To further investigate this, stage at diagnosis was also
compared using the NCDB whereby similar trends were found when
comparing to other hospitals in Montana, as well as the ACS’s Great West
comprehensive cancer center program (Graphs 9 and 10).
1
Percent Survival
0.9
0.8
MT Stage I
0.4
MT Stage II
0.3
MT Stage III
Year 1
Year 2
Year 3
Year 4
Year 5
MT Stage IV
Graph 5: This demonstrates the 5-year survival rate by stage of disease
for all Billings Clinic breast cancers (stages I-IV) as compared with the
Montana Cancer Registry.
BC Stage 0
BC Stage I
70.0
NODB Stage II
BC Stage II
BC Stage III
60.0
50.0
BC Stage IV
40.0
NCDB Stage 0
30.0
NCDB Stage I
20.0
NODB Stage III
10.0
NODB Stage IV
0.0
Graph 4: This demonstrates the 5-year survival rate by stage of disease
for all Billings Clinic breast cancers (stages 0-IV) as compared with the
National Oncology Data Base.
13
0.5
BC Stage III
NODB Stage I
60+ mo
BC Stage IV
0.6
80.0
0.5
12-24 mo 24-36 mo 36-48 mo 48-60 mo
BC Stage III
0.7
BC Stage II
NODB Stage 0
0-12 mo
BC Stage II
0.8
BC Stage I
0.6
0.2
0.9
BC Stage 0
BC Stage IV
0.3
BC Stage I
Overall 5-Year Survival for Breast Cancer Cases
Billings Clinic vs. National Cancer Database
2003-2006
0.7
0.4
1
0.2
Percent Survival
Overall 5-Year Survival for Breast Cancer Cases
Billings Clinic vs. National Oncology Database
2009-2012
Percent Survival
Stage at Diagnosis and Survival Comparison
NCDB Stage II
NCDB Stage III
Dx
1 Year
2 Year
3 Year
4 Year
5 Year
NCDB Stage IV
Graph 6: This demonstrates the 5-year survival rate by stage of disease
for all Billings Clinic breast cancers (stages 0-IV) as compared with the
National Cancer Data Base.
Patient Care Evaluation Study (Cont’d)
Stage at Diagnosis for Breast Cancers in the NODB
2009-2012
Stage at Diagnosis for Breast Cancers at Billings Clinic
2009-2012
50
45
40
35
30
25
20
15
10
5
0
45.65
40.96
39.76
38.7
28.26
25
11.7
11.17
11.74
9.04 8.7
26.51
24.46
8.7
11.96
3.91
2.13
BC 2009
3.26
BC 2010
0
I
II
13.86
11.41
7.83
4.82
3.26
BC 2011
III
IV
6.63
0.6
BC 2012
88
50
45
42.1
41.07
39.4
37.82
40
35
30
25.23
24.63
24.7
25.07
25
18.53
18.85
18.43
20 18.76
15
9.14
9.36
8.43
8.42
10
3.82 2.87
3.76 4.12
3.68 2.57
3.87 4.94
5
.08
.1
.04
.09
0
All Other NODB 2009
All Other NODB 2010
All Other NODB 2011
All Other NODB 2012
Unknown
0
I
II
III
IV
88
Unknown
Graphs 7 and 8: This demonstrates lower rates of Stage 0 and slightly higher rates of Stage III breast cancer diagnosed at Billings Clinic as compared to all other hospitals in the NODB.
Stage at Diagnosis for Breast Cancers at All Other Montana Hospitals
in National Cancer Database
2009-2011
50
40
39.84
30
27.64
20 18.86
18.27
21.53
2.28 3.09
Other MT 2009
0
I
18.74
9.46
4.08
8.29
10
0
45.01
41.92
9.98
4.61
.33
Other MT 2010
II
III
IV
20.89
.77
Stage at Diagnosis for Breast Cancers at All Other ACS Great West Region
Comprehensive Cancer Center Programs in National Cancer Database
2009-2011
Graphs 9 and 10: Similar
findings are noted when
looking at data within the
NCDB; Billings Clinic has
a lower percentage of
breast cancers diagnosed at
Stage 0 and slightly higher
rates of Stage III.
Other MT 2011
N/A
Unknown
50
30
20
21.13
23.82
19.79
8.38
3.52
10
0
43.72
42.4
39.3
40
I
19.61
9.1
.07
3.77
Other Great West 2009
0
22.44
3.77
.13
2.37
Other Great West 2010
II
III
IV
N/A
22.74
8.72
3.77
.07 1.36
Other Great West 2011
Unknown
Conclusions
Thus, Billings Clinic Cancer Center outcomes for the treatment of breast
cancer compare favorably to national outcomes. Specifically, use of
Herceptin in HER-2 positive invasive breast cancers is highly concordant
with the NCCN guidelines, based on hormone receptor status, tumor size,
and nodal status. About 10-11% of patients with breast cancer treated at the
Billings Clinic had HER-2 positive invasive breast cancer, and the majority
of these patients received Herceptin (80%). Of the 20% of patients who did
not receive Herceptin, 6% refused Herceptin as recommended by the
14
oncologist, 4% received lapatinib as alternate treatment according to clinical
trial enrollment, and 4% did not pursue additional follow-up beyond
diagnosis. In addition, stage at diagnosis and overall survival are similar to
national benchmarks, with slight improvements noted of recent at Billings
Clinic with increased diagnosis of stage 0 breast cancers. This is an area that
will need to continue to be monitored in order to ensure this upward trend
continues so that stage at diagnosis is more closely aligned with national
benchmarks.
Cancer Registry Milestones
This has been a year of significant technological advances for the Billings Clinic Cancer Registry.
In March, the Registry initiated use of an
automated, case-matching file importation process
for its encounter-based case finding system,
reducing manual processing time significantly.
Following, in July, the Registry also fully
implemented a second case-finding methodology
(E-Path) that utilizes artificial medical intelligence
to electronically review pathology reports. This
state-of-the-art software has likewise contributed
to manual processing reductions and has produced
an added benefit of locating eligible patients more
quickly for clinical trials. The E-Path software
utilized by the cancer registry is a product of
Artificial Intelligence in Medicine, Inc., an
information technology and software development
company based in Toronto, Ontario.
organizations, the Montana Cancer Registrars
Association (MCRA) and National Cancer Registrars
Association (NCRA). This year, the registrars traveled to
Bozeman for the statewide meeting and one attended
the NCRA annual meeting in San Francisco. These
events provide important opportunities for networking,
sharing “best practices”, and keeping abreast of the latest
developments in the field.
(l-r) Cancer Registrars
(back row) Kerrie Robertson, Lori
Frank, and Technical Assistant Lee
Ann Carranco.
(front row) Marcia Schermerhorn
and Barb Shevela
To maintain their educational credentials, our
certified tumor registrars participate in a number of
self-study activities throughout the year, as well as attend state and
national meetings sponsored by their respective professional
15
The Registry continues to actively participate in the
Commission on Cancer’s Rapid Quality Reporting
System (RQRS) and provides support for other quality
initiatives such as ongoing monitoring of quality
measures for continued recognition as an NAPBC
accredited breast center. It also just concluded
participation in the National Cancer Institute-sponsored
PROSSES study, and has begun participation in
Total Cancer Care® through the Moffitt Cancer Center
in Tampa, Florida.
2012 Primary Site Table
-- Cancer Cases
All Cases
* Analytic
Cases
M
F
Alive
**
Exp
Stg 0
Stg I
Stg II
Stg III
Stg IV
***
N/A
****
NSR
*****
Unk
ORAL CAVITY & PHARYNX
34
33
20
14
25
5
2
8
4
1
17
0
0
1
Lip
3
3
1
2
3
0
1
2
0
0
0
0
0
0
Tongue
10
10
5
5
8
2
1
2
1
1
4
0
0
1
Salivary Glands
3
3
2
1
3
0
0
2
0
0
1
0
0
0
Floor of Mouth
1
1
0
1
1
0
0
1
0
0
0
0
0
0
Gum & Other Mouth
3
2
1
2
2
1
0
1
0
0
1
0
0
0
Primary Site
Nasopharynx
1
1
1
0
1
0
0
0
0
0
1
0
0
0
Tonsil
10
10
8
2
9
1
0
0
2
0
8
0
0
0
Hypopharynx
3
3
2
1
2
1
0
0
1
0
2
0
0
0
DIGESTIVE SYSTEM
217
208
111
106
142
75
4
17
42
65
55
0
5
20
Esophagus
23
23
18
5
9
14
1
3
3
6
8
0
0
2
Stomach
17
16
9
8
6
11
0
2
2
5
5
0
1
1
Small Intestine
12
12
3
9
11
1
0
0
1
7
3
0
0
1
Colon Excluding Rectum
66
62
34
32
56
10
2
7
17
19
13
0
0
4
Cecum
9
9
4
5
9
0
0
1
3
5
0
0
0
0
Appendix
4
4
2
2
3
1
0
0
1
0
2
0
0
1
Ascending Colon
17
16
9
8
15
2
0
3
5
4
3
0
0
1
Hepatic Flexure
6
5
4
2
4
2
0
1
1
1
1
0
0
1
Transverse Colon
4
4
2
2
2
2
0
0
3
0
1
0
0
0
Descending Colon
2
2
0
2
2
0
1
0
1
0
0
0
0
0
Sigmoid Colon
21
20
12
9
18
3
1
1
3
9
5
0
0
1
Large Intestine, NOS
3
2
1
2
3
0
0
1
0
0
1
0
0
0
Rectum & Rectosigmoid
42
40
24
18
36
6
1
4
11
11
9
0
0
4
Rectosigmoid Junction
7
7
3
4
5
2
0
1
1
2
3
0
0
0
Rectum
35
33
21
14
31
4
1
3
10
9
6
0
0
4
Anus, Anal Canal & Anorectum
4
2
1
3
3
1
0
0
1
1
0
0
0
0
Liver & Intrahepatic Bile Duct
9
9
2
7
4
5
0
0
1
3
2
0
2
1
Liver
7
7
2
5
2
5
0
0
1
2
1
0
2
1
Intrahepatic Bile Duct
2
2
0
2
2
0
0
0
0
1
1
0
0
0
Gallbladder
4
4
1
3
1
3
0
0
1
0
3
0
0
0
Other Biliary
4
4
3
1
3
1
0
0
1
2
0
0
0
1
16
2012 Primary Site Table
Cont’d -- Cancer Cases
All Cases
* Analytic
Cases
M
F
Alive
**
Exp
Stg 0
Stg I
Stg II
Stg III
Stg IV
***
N/A
****
NSR
*****
Unk
Pancreas
22
22
13
9
2
20
0
1
4
5
8
0
0
4
Retroperitoneum
1
1
1
0
1
0
0
0
0
1
0
0
0
0
Peritoneum, Omentum & Mesentery
11
11
0
11
8
3
0
0
0
5
4
0
0
2
Primary Site
DIGESTIVE SYSTEM - cont’d
Other Digestive Organs
2
2
2
0
2
0
0
0
0
0
0
0
2
0
RESPIRATORY SYSTEM
176
172
90
86
98
78
2
43
19
32
71
0
0
5
Larynx
10
10
9
1
9
1
1
3
2
1
3
0
0
0
Lung & Bronchus
166
162
81
85
89
77
1
40
17
31
68
0
0
5
BONES & JOINTS
1
1
0
1
1
0
0
0
0
0
0
0
0
1
SOFT TISSUE INCLUDING HEART
6
5
5
1
5
1
0
1
3
0
0
0
0
1
SKIN - EXCLUDING BASAL & SQUAMOUS
162
157
102
60
152
10
90
46
5
6
1
0
1
8
Melanoma - Skin
156
152
98
58
148
8
90
44
5
5
1
0
0
7
6
5
4
2
4
2
0
2
0
1
0
0
1
1
BREAST
Other Non-Epithelial Skin
172
168
0
172
166
6
24
75
43
12
12
0
1
1
FEMALE GENITAL SYSTEM
267
190
0
267
244
23
1
102
11
41
22
0
3
10
Cervix Uteri
84
26
0
84
80
4
0
9
1
11
4
0
0
1
Corpus & Uterus, NOS
116
115
0
116
106
10
1
80
6
9
13
0
1
5
Corpus Uteri
108
107
0
108
101
7
1
76
4
9
11
0
1
5
Uterus, NOS
8
8
0
8
5
3
0
4
2
0
2
0
0
0
41
38
0
41
34
7
0
5
4
20
4
0
2
3
Ovary
Vagina
5
2
0
5
5
0
0
1
0
0
0
0
0
1
Vulva
21
9
0
21
19
2
0
7
0
1
1
0
0
0
MALE GENITAL SYSTEM
166
142
166
0
158
8
0
39
54
22
12
0
0
15
Prostate
163
139
163
0
155
8
0
36
54
22
12
0
0
15
3
3
3
0
3
0
0
3
0
0
0
0
0
0
URINARY SYSTEM
122
113
87
35
105
17
34
42
8
12
8
0
0
9
Urinary Bladder
61
54
50
11
50
11
32
9
4
3
3
0
0
3
Kidney & Renal Pelvis
58
56
37
21
54
4
1
33
4
8
4
0
0
6
3
3
0
3
1
2
1
0
0
1
1
0
0
0
Testis
Ureter
17
2012 Primary Site Table
Primary Site
All Cases
Cont’d -- Cancer Cases
* Analytic
Cases
M
F
Alive
**
Exp
Stg 0
Stg I
Stg II
Stg III
Stg IV
***
N/A
****
NSR
*****
Unk
EYE & ORBIT
2
1
1
1
1
1
0
0
0
0
0
0
1
0
BRAIN & OTHER NERVOUS SYSTEM
51
46
13
38
37
14
0
0
0
0
0
0
46
0
Brain
20
18
8
12
11
9
0
0
0
0
0
0
18
0
Cranial Nerves Other Nervous System
31
28
5
26
26
5
0
0
0
0
0
0
28
0
ENDOCRINE SYSTEM
78
73
35
43
76
2
0
36
3
4
6
0
23
1
Thyroid
52
50
19
33
51
1
0
36
3
4
6
0
0
1
Other Endocrine including Thymus
26
23
16
10
25
1
0
0
0
0
0
0
23
0
LYMPHOMA
59
55
30
29
49
10
0
13
9
18
12
0
0
3
Hodgkin Lymphoma
9
8
4
5
9
0
0
0
5
3
0
0
0
0
8
8
4
4
8
0
0
0
5
3
0
0
0
0
Hodgkin - Nodal
Hodgkin - Extranodal
Non-Hodgkin Lymphoma
NHL - Nodal
NHL - Extranodal
1
0
0
1
1
0
0
0
0
0
0
0
0
0
50
47
26
24
40
10
0
13
4
15
12
0
0
3
37
34
19
18
27
10
0
4
3
14
10
0
0
3
13
13
7
6
13
0
0
9
1
1
2
0
0
0
MYELOMA
22
22
7
15
14
8
0
0
0
0
0
0
22
0
LEUKEMIA
46
43
27
19
35
11
0
0
0
0
0
0
43
0
Lymphocytic Leukemia
25
23
16
9
20
5
0
0
0
0
0
0
23
0
Acute Lymphocytic Leukemia
2
2
1
1
2
0
0
0
0
0
0
0
2
0
Chronic Lymphocytic Leukemia
20
18
12
8
16
4
0
0
0
0
0
0
18
0
3
3
3
0
2
1
0
0
0
0
0
0
2
0
Myeloid & Monocytic Leukemia
Other Lymphocytic Leukemia
17
17
9
8
11
6
0
0
0
0
0
0
17
0
Acute Myeloid Leukemia
13
13
6
7
7
6
0
0
0
0
0
0
13
0
Chronic Myeloid Leukemia
4
4
3
1
4
0
0
0
0
0
0
0
4
0
Other Leukemia
4
3
2
2
4
0
0
0
0
0
0
0
3
0
Other Acute Leukemia
2
2
1
1
2
0
0
0
0
0
0
0
2
0
Aleukemia, Subleukemic & NOS
2
1
1
1
2
0
0
0
0
0
0
0
1
0
MESOTHELIOMA
5
5
3
2
1
4
0
2
2
0
1
0
0
0
MISCELLANEOUS
52
48
33
19
28
24
0
0
0
0
0
0
48
0
1,638
1,482
730
908
1,341
157
424
203
213
217
0
0
0
TOTAL
Exclusions: Not Male and Not Female
* Analytic: Patients diagnosed and/or received
any of first course treatment at Billings Clinic.
18
** Exp: Expired
297
*** N/A: Case is not eligible for staging. An AJCC staging scheme has
not been developed for this site or histology is excluded from an
AJCC site scheme.
**** NSR: No staging required
193
75
***** Unk: Cases that do not
have enough information to
stage or the physician considered
it unstageable.
Cancer Registry
Age at Diagnosis by Gender
Analytic vs. Non-Analytic Cases - Last 5 Years
Analytic Cases, Accession Year 2012
250
224
1600
Male
172
Number of Cases
166
200
184
150
105
104
81
19
28
11
0-29
100
78
50
35
19
30-39
8 15
40-49
50-59
60-69
70-79
1400
80-89
90+
0
Age Groups
According to the most recent and available national data from SEER (Surveillance
Epidemiology and End Results) for years 2006-2010 inclusive, the median age at
diagnosis for all cancer sites is age 66 for men and age 65 for women. The data above for
Billings Clinic shows a similar pattern with the median age at diagnosis for men at 66
and for women at 64.
Number of Cases
233
Female
1800
1200
1616
1608
176
155
1440
1453
2008
2009
1680
178
1502
1758
183
1575
1638
156
1482
1000
800
600
400
200
0
2010
2011
2012
Registry Accession by Year of First Contact
Analytic Cases
Non-Analytic Cases
The graph shows a small decline in analytic cases in 2012 after 4 consecutive
years of increase (orange bar). This pattern is not unlike the experience of other
cancer programs regionally and nationally and may reflect continuing weakness
in the national economy, as well as changes in oncology practice patterns,
including those related to the diagnosis and treatment of prostate cancer.
Analytic cases are those diagnosed and/or receiving part or all of the entire first
course of treatment at Billings Clinic. Non-analytic cases (lavender bar) include
those who may only receive follow-up care or treatment for a recurrence at
Billings Clinic. The total number of cases for each year, inclusive of analytic and
non-analytic cases, is noted at the top of each bar or column.
19
Cancer Registry (Cont’d)
Breast Cancer over 5 Years
Prostate Cancer over 5 Years
Number and Percent of Total Female Analytic Cases
Number and Percent of Total Male Analytic Cases
168 21% T
2012
186 22% T
234 29% T
2010
184 23% T
2009
0
50
100
150
200
174 27% T
136 20% T
2008
250
Number of Cases
The bar graph above shows a changing pattern over time for the primary
diagnosis of breast cancer for women at Billings Clinic. The numbers at the right
end of each bar indicate actual number of cases and total percentage of this
cancer for each year.
20
163 24% T
2010
2009
165 21% T
2008
206 27% T
2011
Accession Year
Accession Year
2011
139 21% T
2012
0
50
100
150
200
Number of Cases
The bar graph above shows fluctuation over time for the primary diagnosis
of prostate cancer for men at Billings Clinic. The numbers at the right end
of each bar indicate actual number of cases and total percentage of this
cancer for each year.
250
Cancer Registry (Cont’d)
Trends in Cancers Seen at Billings Clinic Over Last 5 Years
1000
900
Number of Cases
800
700
Uterus
600
Prostate
500
Breast
Melanoma
400
Lung
300
Colon
200
100
0
2008
2009
2010
2011
2013
Calendar Year
The stacked graph [above] shows a 5 year trend for the primary cancers seen at Billings Clinic, irrespective of gender. The American Cancer Society
(ACS) ranks breast, prostate, lung, melanoma and colon cancers as the top 5 cancers in terms of incidence nationally. Our rankings are similar to
those of ACS with one exception: uterine cancer ranks 6th in terms of numbers of cases seen at Billings Clinic while bladder cancer ranks in 6th
place nationally according to ACS estimates. Our higher rate of uterine cancers treated is likely reflective of our widely recognized regional expertise
with gynecological cancers, having a dynamic treatment program led by a board certified gynecologic oncologist, trained in advanced robotic
surgical techniques.
21
Cancer Registry (Cont’d)
Top Five Cancers - Female
National data from the American Cancer Society
(years 2010-2012) indicate the leading cancers for
women remain breast (28-31%), lung (14%), and
colorectal (9-10%) cancers. Billings Clinic data for
the last 5 years (2008-2012) for women is shown
in the pie charts herein. While breast cancer
remains our primary female cancer, representing
approximately 22-29% of all female cancers at
Billings Clinic, uterine cancer is second (9-13%)
followed by lung cancer (8-12%). This variation
from national statistics is likely reflective of our
widely recognized expertise in gynecologic
cancers, having the only such program in
Montana, Wyoming and North Dakota.
Year 2008
Year 2009
Based on Analytic Cases N = 762
Based on Analytic Cases N = 806
All Others
273
36%
Uterus
79
10%
Uterus
85
11%
All Others
336
42%
Lung
74
10%
Colorectal
59
8%
Lung
77
10%
Melanoma
112
15%
Colorectal
64
8%
Melanoma
60
7%
Year 2010
Year 2011
Year 2012
Based on Analytic Cases N = 813
Based on Analytic Cases N = 845
Based on Analytic Cases N = 811
All Others
310
38%
Uterus
73
9%
Colorectal
62
8%
Melanoma
66
8%
Breast
168
21%
Breast
186
22%
Breast
234
29%
22
Breast
184
23%
Breast
165
22%
Uterus
111
13%
All Others
344
41%
All Others
316
39%
Uterus
115
14%
Lung
84
10%
Lung
95
11%
Lung
68
8%
Colorectal
51
6%
Melanoma
58
7%
Melanoma
58
7%
Hematological
70
9%
Cancer Registry (Cont’d)
Top Five Cancers - Male
A review of the most recent national data available from
the American Cancer Society (years 2010-2012) indicates
the primary 3 cancers for men have remained unchanged
with prostate cancer in the lead for men (28-29% of all
male cases) followed by lung (14-15%) and colorectal (9%)
cancers. Statewide data over a five year period (2006-2010)
from the Montana Central Tumor Registry reflects a
similar pattern. Billings Clinic data shown in the pie charts
herein for years 2008-2012 indicates a break from this
pattern. While prostate cancer remains the primary male
cancer at Billings Clinic, melanoma takes second place
followed by lung cancer for men. This variance from
national and state trends is likely a function of our
recognized expertise as a resource and referral site for
dermatology and specialized skin cancer therapies
including Mohs surgery.
Year 2008
Year 2009
Based on Analytic Cases N = 677
Based on Analytic Cases N = 646
All Others
220
32%
Melanoma
116
17%
All Others
216
33%
Melanoma
82
13%
Lung
67
10%
Colorectal
68
10%
Lung
74
11%
Hematological
49
8%
Hematological
70
10%
Colorectal
51
8%
Year 2010
Year 2011
Year 2012
Based on Analytic Cases N =688
Based on Analytic Cases N = 749
Based on Analytic Cases N = 671
Prostate
163
24%
All Others
241
35%
Prostate
206
28%
Melanoma
96
14%
All Others
254
34%
Colorectal
59
9%
Hematological
57
8%
Prostate
139
21%
Melanoma
81
11%
Lung
72
10%
23
Prostate
174
27%
Prostate
136
20%
Melanoma
94
14%
All Others
247
37%
Lung
78
12%
Lung
80
11%
Colorectal
57
8%
Hematological
71
9%
Colorectal
54
8%
Hematological
59
9%
Awards, Presentations, Publications and Recognitions
Bette Bohlinger
Leadership Award
Sarah Porter-Osen, NCCCP
Coordinator, received the 2013
Bette Bohlinger Leadership Award
at the annual Montana Cancer
Control Coalition (MTCCC) statewide
meeting. Sarah has been actively
involved with MTCCC’s Screening
and Early Detection team and is an
advocate for programs which provide
cancer screening for under- and
un-insured women. Sarah also led
MTCCC in the implementation of a
successful statewide “Ask Me”
campaign to encourage colorectal
cancer screening. We are so proud
of Sarah in her commitment to the
cancer community.
24
Awards, Presentations, Publications and Recognitions (Cont’d)
Peer-Reviewed Publications
• Alvarex, R.D., Gray, H.J., Timmins, P.F. III., Gibb, R.K., Edelson,
M., Fowler, J.M., Havrilesky, L.J., McCauley, D.L., Nash, J.D.,
Rahaman, J., Rash, J.K., Rodabaugh, K.J., Powell, M.A., Bristow,
R.E., Brown, J.V., Tewari, D., Cliby, W.A., Anastasia, P., Robinson,
W.R. III., Shahin, M.S., Cantrell, L.A., Cloven, N.G., Gold, M.A.,
Hope, J.M., Muntz, H.G., Sorosky, J.I., Elkas, J.C., Frumovitz,
M.M., Jewell, E., Spillman, M.A., & Naumann, R.W. (2013). We
need a new paradigm in gynecologic cancer care: SGO proposes
solutions for delivery, quality and reimbursement policies.
Gynecologic Oncology, 129(1), 3-4.
• Brant, J.M. (2013). Breathlessness with pulmonary metastases: A
multimodal approach. Journal of the Advanced Practitioner in
Oncology, 4(6), 415-422.
• Brant, J.M. (Ed). (2013). Advances in the management of
breakthrough cancer pain. Pain Management Nursing/Seminars in
Oncology Nursing. Medical Meeting Reporter. St Louis: Elsevier.
• Brant, J.M., & Hall, B. (2013). Taste and smell alterations and
anorexia and cachexia in cancer. In D. Camp-Sorrell and B.
Hawkins InPractice etextbook.
• Brant, J.M., & Wickham, R. (Eds). (2013). Statement on the Scope
and Standards of Oncology Nursing Practice. Pittsburgh: ONS Press.
• Forsythe, L.P., Rowland, J.H., Padgett, L., Blaseg, K., Siegel, S.D.,
Dingman, C.M., & Gillis, T.A. (2013). The cancer psychosocial care
matrix: A community-derived evaluative tool for designing quality
psychosocial cancer care delivery. Psycho-Oncology, 22(9), 19521963.
• Leshchenko, V., Kuo, P.Y., Jiang, Z., Thirukonda, V.K., & Parekh, S.
(2013). Integrative genomic analysis of Temozolomide resistance
in Diffuse Large B Cell Lymphoma. Clinical Cancer Research,
[epub ahead of print].
25
• Lillington, L., Scaramuzzo, L., Friesse, C., Sein, E., Harrison, K.,
LeFebrvre, K., & Fessele, K. (2013). Improving oncology nursing
practice one patient, one nurse, one day at a time: Design and
evaluation of a quality education workshop for oncology nurses.
Clinical Journal of Oncology Nursing, 17(6), 584-587.
• Lyle, C.A., Gibson, E., Lovejoy, A., & Goldenberg, N.A. (2013).
Acute prognostic factors for post thrombotic syndrome in children
with limb DVT: A bi-institutional cohort study. Thrombosis
Research, 131 (1): 37-41.
• Lyle, C.A., & Crawford, J.R. (2013). Neuro-diagnostic principles.
In R.F. Keating, J.T. Goodrich, & R.J. Packer Tumors of the Pediatric
Central Nervous System (2nd Ed).
• Lyle, C.A., & Goldenberg, N.A. (2013). Venous thrombosis. In
E.M. Da Cruz, D. Ivy, & J. Jaggers (Eds.) Pediatric and Congenital
Cardiology, Cardiac Surgery, and Intensive Care.
• Nair, V.S., Keu, K.V., Luttgen, M.S., Kolatkar, A., Vasanawala, M.,
Kuschner, W., Bethel, K., Iagaru, A.H., Hoh, C., Schrager, J.B., Loo,
B.W. Jr., Bazhenova, L., Nieva, J., Gambhir, S.S., & Kuhn, P. (2013).
An observational study of circulating tumor cells and (18)F-FDG
PET uptake in patients with treatment-naïve non-small cell lung
cancer. PLoS One, 8(7), e6773.
• Newton, P., Mason, J., Bethel, K., Bazhenova, L., Nieva, J., Norton,
L., & Kuhn, P. (2013). Spreaders and sponges define metastasis in
lung cancer: A Markov chain Monte Carlo mathematical model.
Cancer Research, 73(9), 2760-2769.
• Rule, P., & Brant, J.M. (2013). Monoclonal gammopathy of
undetermined significance – Making it understandable to patients.
Clinical Journal of Oncology Nursing, 17(6), 614-619.
Awards, Presentations, Publications and Recognitions (Cont’d)
• Salz, T., McCabe, M.S., Onstad, E.E., Shrujal, S.B., Deming, R.L.,
Franco, R.A., Glenn, L.A., Harper, G.R., JumonVille, A.J., Payne,
R.M., Peters, E.A., Salner, A.L., Schallenkamp, J.M., Williams, S.R.,
Yiee, K., & Oeffinger, K.C. Survivorship care plans: Is there buy-in
from oncology providers. Cancer (accepted for publication).
• Singh, L., & Stevens, E. (2013). Leg pain and gynecologic
malignancy. Journal of Hospice & Palliative Medicine, 30(6),
594-600.
• Stevens, E., Aquino, J., Barrow, N., & Lee, Y.C. (2013). Ectopic
production of human chorionic gonadotropin from a synovial
sarcoma. Obstetrics & Gynecology, 121(2Pt2 S1), 468-471.
• Stevens, E., Pradhan, T., Chak, Y., & Lee, Y.C. (2013). A case of
malignant transformation of endometriosis in a cesarean section
scar. Journal of Reproductive Medicine, 58(3), 264-266.
• Weber, A. (2013). A nurse-led symptom management clinic. In
J.M. Brant (Ed). Advances in the management of breakthrough
cancer pain. Pain Management Nursing/Seminars in Oncology
Nursing. Medical Meeting Reporter. St Louis: Elsevier.
• Weickhardt, A.J., Doebele, R.C., Purcell, W.T., Bunn, P.A., Oton,
A.B., Rothman, M.S., Wierman, M.E., Mok, T., Popat, S., Bauman,
J., Nieva, J., Novello, S., Ou, S.H., & Camidge, D.R. (2013)
Symptomatic reduction in free testosterone levels secondary to
crizotinib use in male cancer patients. Cancer, 119(13), 2383-2390.
• Zaren, H.A., Nair, S., Go, R.S., Enos, R.A., Lanier, K.S., Thompson,
M.A., Zhao, J., Fleming, D.L., Leighton, J.C., Gribbin, T.E., Bryant,
D.M., Carrigan, A., Corpening, J.C., Csapo, K.A., Dimond, E.P.,
Ellison, C., Gonzales, M.M., Harr, J.L., Wilkinson, K., & Denicoff,
A.M. (2013). Early-phase clinical trials in the community: Results
from the National Cancer Institute Community Cancer Centers
Program early-phase working group baseline assessment. Journal
of Oncology Practice, 9(2), e55-e61.
26
Published Abstracts from National Conferences
• Blaseg, K., White, D., Schallenkamp, J.S., Stephens, C., Needham,
C.S., & Nieva, J. (2013). The effects of multi-disciplinary clinics on
the variability in timeliness of care for lung cancer patients.
American Society of Clinical Oncology annual meeting, Chicago,
IL. Journal of Clinical Oncology, 31(18 suppl), e17533.
• Guitarte, C., Stevens, E., Abulafia, O., & Lee, Y.C. (2013). Glassy
cell carcinoma of the cervix: A systematic review and metaanalysis. Gynecologic Oncology, 130(1), e149-e150.
• Nguyen, M.T., LaFargue, C., Karsy, M., Stevens, E., McKernan, S.,
Pua, T., Goerlick, C., Tedjarati, S., & Pradhan, T.S. (2013). Routine
cystoscopy after robotic gynecologic oncology surgery: Increasing
urinary injury detection or simply achieving medical-legal benefit?
Gynecologic Oncology, 130(1), e60.
• Stevens, E., & Henretta, M.S. (2013). Beyond the dark side of the
moon: Evaluating the quality of web-based information at the end
of life. SGO 44th Annual Meeting on Women’s Cancer, Los
Angeles, CA. Gynecologic Oncology, 130(1), e141.
• Stevens, E., Pardo-Maxis, C., Lee, Y.C. & Abulafia, O. (2013).
Defining practice patterns: What is “standard” postoperative care?
A survey of the SGO membership. Gynecologic Oncology, 130(1),
e57-e58.
Poster Presentations at National Conferences
• Anderson, C., Gradwohl, R., Nelson, L., & Brant, J.M. (2013). An
oncology specific preceptor program: A path to oncology nursing
knowledge, commitment and retention. Oncology Nursing Society
Annual Congress, Washington, DC.
• Blumberg, J., Stevens, E., Zachariah, P., & Ogburn, P. (2013).
Cervidil and induction of labor: Do two Cervidils make a
difference? ACOG Annual Clinical Meeting 2013, New Orleans, LA.
Awards, Presentations, Publications and Recognitions (Cont’d)
• Budnick, L., Herbert, W., Griffin, T., Swoboda, E., Stevens, E., &
Ninivaggio, C. (2013). Web-based application of the perineal
simulator as a tool for medical students and interns to learn
perineal anatomy and obstetric laceration classification.
APGO/CREOG, Phoenix, AZ.
• Ciemins, E.L., Brant, J.M., Kersten, D., Mullette, B., & Dickerson,
D. (2013). A patient-centered strategy to palliative care: A
qualitative approach. Academy Health, Washington, DC.
• Garretto, D., & Stevens, E. (2013). The significance of excess
gestational weight gain and delivery lacerations. ACOG Annual
Clinical Meeting, New Orleans, LA.
• Garretto, D., & Stevens, E. (2013). Validating a “term BMI” using
mode of delivery, estimating blood loss, and neonatal weight.
ACOG Annual Clinical Meeting, New Orleans, LA.
• Guitarte, C., Stevens, E., Abulafia, O., & Lee, Y.C. (2013). Glassy
cell carcinoma of the cervix: A systematic review and metaanalysis. SGO 44th Annual Meeting on Women’s Cancer, Los
Angeles, CA.
• Nguyen, M.T., LaFargue, C., Karsy, M., Stevens, E., McKernan, S.,
Pua, T., Goerlick, C., Tedjarati, S., & Pradhan, T.S. (2013). Routine
cystoscopy after robotic gynecologic oncology surgery: Increasing
urinary injury detection of simply achieving medical-legal benefit?
SGO 44th Annual Meeting on Women’s Cancer, Los Angeles, CA.
• Nichols, K., Anderson, C., Gradwohl, R., & Brant, J.M. (2013).
Prevention of cerebellar toxicity from cytosine-arabinoside
(Ara-C): Development of a nurse educational training program
and assessment protocol. Oncology Nursing Society Annual
Congress, Washington, DC.
27
• Pett, M., Beck, S.L., Towsley, G.L., Berry, P.H., Brant, J.M., Smith,
E.L., & Guo, J.W. (2013). Confirmatory factor analysis of the Pain
Care Quality Survey (PainCQ©). Health Services Research, 48(3),
1018-1038.
• Stevens, E., Gartman, C., Michl, J., & Sarafraz-Yazdi, E. (2013).
Evaluation of PNC-27 mediated toxicity in an intraperitoneal
mouse model of human ovarian cancer. Western Association of
Gynecologic Oncologists Annual Meeting, Seattle, WA.
• Stevens, E., & Henretta, M.S. (2013). Beyond the dark side of the
moon: Evaluating the quality of web-based information at the end
of life. SGO 44th Annual Meeting on Women’s Cancer,
Los Angeles, CA.
• Stevens, E., Pardo-Maxis, C., Lee, Y.C., & Abulafia, O. (2013).
Defining practice patterns: What is “standard” postoperative Care?
A survey of the SGO membership. SGO 44th Annual Meeting on
Women’s Cancer, Los Angeles, CA.
• Swoboda, E., & Stevens, E. (2013). Assessing the self confidence of
graduating chief residents in performing hyperectomies by
modality and type of surgical assistant. APGO/CREOG, Phoenix,
AZ.
• Von Walstrom, G., Stevens, E., Fatehi, M., Salame, G., Lee, Y.C.,
Gorelick, C., & Economos, K. (2013). Clinical utility of a
chemoresponse assay for gynecologic malignancies. Western
Association of Gynecologic Oncologists Annual Meeting,
Seattle, WA.
• Weber, A., Waitman, K., Blaseg, K., & Brant, J. (2013). A nurseled symptom management clinic. Oncology Nursing Society Annual
Congress, Washington, DC.
Awards, Presentations, Publications and Recognitions (Cont’d)
Podium Presentations at National Conferences
• Design and evaluation of a quality educational workshop for
oncology nurses
Quality and Safety Education for Nurses, Atlanta, GA.
Presented by: Leah Scaramuzzo, RN, MSN, AOCN®, Oncology
Nurse Clinician
• Effective mentoring of resident-led research projects
APGO/CREOG Annual Meeting, Phoenix, AZ.
Presented by: Erin Stevens, MD, Gynecologic Oncology
• Evidence-based medicine: Why the reluctance to follow
guidelines and data?
APGO/CREOG Annual Meeting, Phoenix, AZ.
Presented by: Erin Stevens, MD, Gynecologic Oncology
• Getting patients active: Using quality measures to drive
practice change
Oncology Nursing Society, Washington, DC.
Presented by: Leah Scaramuzzo, RN, MSN, AOCN®, Oncology
Nurse Clinician
• Integrating Cerner applications to deliver treatment summaries
and survivorship plans
Cerner Health Conference, Kansas City, MO.
Presented by: Karyl Blaseg, RN, MSN, OCN®, Manager of Cancer
Programs
• Overcoming opioid-induced oversedation in hospitalized
patients: Nurse-driven research, quality improvement, and
evidence-based practice
National Magnet Conference, Orlando, FL.
Presented by: Jeannine Brant, PhD, APRN, AOCN®, Nurse
Scientist and Oncology Clinical Nurse Specialist
28
• Stomping cancer through culture
Spirit of Eagles’ Changing Patterns of Cancer in Native
Communities: Strength through Tradition and Science,
Albuquerque, NM.
Presented by: Shawna Cooper, Patient Advocate
• Surgical anatomy: Tips and tricks
Downstate Annual OB/GYN Review Course, Brooklyn, NY.
Presented by: Erin Stevens, MD, Gynecologic Oncology
• Telemedicine and telesurvivorship
NAPBC Lead your Breast Program to Excellence conference,
Chicago, IL.
Presented by: Jorge Nieva, MD, Chair of Hematology
and Oncology
Regional Presentations
• Breast cancer in Wyoming 2013
Powell Valley Healthcare providers, Powell, WY
Presented by: Robert Joseph, MD, Cody Oncology
• Cancer survivorship
Billings Clinic Primary Care Fall Workshop, Billings, MT
Presented by: Jorge Nieva, MD, Chair of Hematology
and Oncology
• Cancer survivorship
Oncology for Primary Care Physicians Conference, Kalispell, MT
Presented by: Justine DeRousse, PA-C, Cody Oncology
• Cervical cancer: Screening, prevention and treatment
Billings Clinic Women’s Health Symposium, Billings, MT
Presented by: Erin Stevens, MD, Gynecologic Oncology
• Communication techniques with palliative and end-of-life care
End-of-Life Nursing Education Consortium (ELNEC), Billings, MT
Presented by: Jennifer Finn, LCSW, OSW-C, Cancer Programs
Awards, Presentations, Publications and Recognitions (Cont’d)
• Cultural differences with end-of-life care
End-of-Life Nursing Education Consortium (ELNEC), Billings, MT
Presented by: Shawna Cooper, Oncology Patient Advocate
• Cultural sensitivity and reflections on hope and cancer
Big Sky Oncology Nursing Society Conference, Billings, MT
Presented by: Meg Hatch, MDiv, Pastoral Care
• End-of-life care
End-of-Life Nursing Education Consortium (ELNEC), Billings, MT
Presented by: Jeannine Brant, PhD, APRN, AOCN®, Nurse
Scientist and Oncology Clinical Nurse Specialist
• Enteral tubes: What, where, how
Big Sky Oncology Nursing Society Conference, Billings, MT
Presented by: Beth Hall, RD, CLC, CSO, LN, Oncology Dietitian
• Ethical and legal challenges in palliative care
End-of-Life Nursing Education Consortium (ELNEC), Billings, MT
Presented by: Erin Stevens, MD, Gynecologic Oncology
• Grief, loss, and bereavement
End-of-Life Nursing Education Consortium (ELNEC), Billings, MT
Presented by: Meg Hatch, MDiv, Pastoral Care
• New drug therapies for metastatic prostate cancer
Big Sky Urology Conference, Big Sky, MT
Presented by: Ala’a Muslimani, MD, Hematology and Oncology
• Nurse navigators’ role in cancer survivorship
Big Sky Oncology Nursing Society Conference, Billings, MT
Presented by: Karyl Blaseg, RN, MSN, OCN®, Manager of
Cancer Programs
• Pain management in palliative care
End-of-Life Nursing Education Consortium (ELNEC), Billings, MT
Presented by: Jeannine Brant, PhD, APRN, AOCN®, Nurse
Scientist and Oncology Clinical Nurse Specialist
29
• Palliative care and end-of-life care
Big Sky Oncology Nursing Society Conference, Billings, MT
Presented by: Jennifer Finn, MSW, OSW-C, Oncology
Social Worker
• Pediatric oncology
Billings Clinic Primary Care Fall Workshop, Billings, MT
Presented by: Courtney Lyle, MD, MAS, Pediatric Oncology
• Pediatric end-of-life care
Hot Topics in Pediatric Nursing, Billings, MT
Presented by: Courtney Lyle, MD, MAS, Pediatric Oncology
• The science of clinical trials
Montana Cancer Control Consortium annual meeting, Bozeman, MT
Presented by: Jorge Nieva, MD, Chair of Hematology
and Oncology
• Scientific basis of targeted therapeutics
Big Sky Oncology Nursing Society Conference, Billings, MT
Presented by: Pam Smith, MD, Hematology and Oncology
• Symptom management at end-of-life
End-of-Life Nursing Education Consortium (ELNEC), Billings, MT
Presented by: Kathryn Waitman, DNP, AOCNP®, Hematology and
Oncology; Alison Weber, RN, BSN, Cancer Programs; Jennifer
Finn, LCSW, OSW-C, Cancer Programs; Linda Shelton, PT,
Cancer Programs
• Treatment of bone metastasis in prostate cancer
Big Sky Urology Conference, Big Sky, MT
Presented by: Ala’a Muslimani, MD, Hematology and Oncology
• Treatment modalities: Surgery, transplant, radiation therapy,
chemotherapy, targeted therapy, and biotherapy
Big Sky Oncology Nursing Society Conference, Billings, MT
Presented by: Venu Thirukonda, MD, Hematology and Oncology
• When to refer to a Gynecologic Oncologist
Billings Clinic Primary Care Fall Workshop, Billings, MT
Presented by: Erin Stevens, MD, Gynecologic Oncology
Awards, Presentations, Publications and Recognitions (Cont’d)
Billings Clinic Grand Rounds Presentations
• Anemia
Presented by: Ala’a Muslimani, MD, Hematology and Oncology
• Collaborative management of breast cancer
Presented by: Simone Davion, MD, Pathology; Ala’a Muslimani,
MD, Hematology and Oncology; Michelle Proper, MD, Radiation
Oncology
• Myths versus realities: Gynecologic cancers
Presented by: Erin Stevens, MD, Gynecologic Oncology
30
Cancer Center
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Community Cancer Centers Program
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For questions about cancer or if you need
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