Download Cancer Program Annual Report 2016

Cancer Program Annual Report 2016
An American College of Surgeons Approved Program
Chi e f E xe cu t i ve ’ s Me s s ag e
Welcome to our 2016 Annual Cancer Program Report. I am proud to
share this past year’s work with you.
Pancreatic cancer remains to be one of the more difficult cancers for us to
find and diagnose early. National Cancer Institute data tells us that there will
be more than 53,000 new cases of pancreatic cancer in 2016. Pancreatic
cancer represents 3 percent of all cancers but is the cause of approximately
7 percent of all cancer deaths.
Jeff Fee
Chief Executive
Our local providers and caregivers take care of pancreatic cancer patients
every day here and in conjunction with experts from our Providence Cancer
Institute.
In 2015, Providence St. Patrick Hospital purchased endoscopic
ultrasound equipment. Our partners in the Western Montana Clinic
gastroenterology department are experts in using this equipment to help
diagnose pancreatic cancers.
I would also like to introduce you to Juan Mejia, M.D. Dr. Mejia is a
board-certified liver and pancreatic surgeon who is the newest member
of our Western Montana/Eastern Washington care team. He comes to
Montana 1-2 times per month, in person or through our new telemedicine
technology, to help us take care of pancreatic cancer patients.
The Montana Cancer Center and our Providence Cancer Institute are
committed to the fight against pancreatic cancer through research, genomics
and investments in infrastructure to diagnose and treat this terrible disease.
Thank you for your interest in learning more about our program.
Jeff Fee, Chief Executive
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2016 Cancer Annual Report • Providence Health & Services
Ca nce r C o m m i t t e e C h ai r ’ s Me s s ag e
Sarah Scott, M.D.
Medical Oncologist
Cancer Committee Chair
This year’s annual report will focus on pancreatic cancer. Over 50,000
cases of pancreatic cancer are diagnosed each year in the United States,
and the cure rate is disappointingly low. Because most patients come to
medical attention late in the disease course, only 15-20 percent of patients
are candidates for surgery, which is the only curative therapy. Even those
who undergo surgical resection of their cancer have a poor prognosis, with
5-year survival rates of 25-30 percent for patients with lymph-node negative
disease and 10 percent for those with positive lymph nodes. Pancreatic
cancer is the fourth leading cause of death among men and women in the
United States.
Diagnosis and management of pancreatic cancer require a multidisciplinary,
team-based approach. This year’s annual report will review the use of
imaging studies, including endoscopic ultrasound, for the diagnosis and
staging of pancreatic cancer; methods of surgical excision and pathologic
review; and the role of radiation and systemic therapy in pancreatic cancer
treatment.
The Montana Cancer Center at Providence St. Patrick Hospital provides
coordinated care for pancreatic cancer patients through a team-based
approach. We are pleased to announce that we now provide comprehensive
staging with endoscopic ultrasound, performed by Eric Stone, M.D., and
on-site oncologic surgery consultation through Juan Mejia, M.D. from
Providence Liver and Pancreas Surgery Center in Spokane, Washington.
Sarah Scott, M.D.
Medical Oncologist
Cancer Committee Chair
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2016 Cancer Annual Report • Providence Health & Services
Pancreatic
Cancer Imaging
Pancreatic cancer remains one of
the most lethal cancers worldwide,
with a 5-year survival rate of less
than 5 percent. It is the fourth leading
Bruce Turlington, M.D.
Radiologist
cause of cancer mortality in the United
States and the eighth worldwide. In general,
pancreatic cancer is synonymous with
pancreatic ductal adenocarcinoma, with
the cancer cells arising from the ductal
system of the pancreas. Pancreatic ductal
adenocarcinoma makes up 80-90 percent
of all primary malignant tumors arising from
the pancreas. Due to the absence of early
symptoms and the propensity of pancreatic
cancer to invade adjacent structures, many
patients present with advanced disease at
the time of diagnosis. Only 10-20 percent
of diagnosed patients are candidates for
surgical resection and possible cure. In those
patients with resectable disease, the survival
rate is only 23 percent.
In spite of these grim statistics, there is a
continued effort to achieve early detection
and accurate tumor staging by imaging.
The various imaging modalities include
ultrasound (US); computed tomography
(CT); magnetic resonance imaging (MRI);
endoscopic ultrasound (EUS) and positron
emission tomography and computerized
tomography (PET/CT). Some institutions
are also now using combined PET and MRI
imaging (PET/MRI).
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2016 Cancer Annual Report • Providence Health & Services
Ultrasound, given its relative low cost and
availability, is often the first-line imaging
test for patients presenting with abdominal
pain or jaundice. However, the accuracy of
pancreatic US is highly dependent on the
operator’s experience. The test may also be
limited by patient size and bowel gas which
prevents penetration of the ultrasound
beam to the area of interest. In patients
with a pancreatic head tumor, ultrasound
often shows enlargement of the bile ducts
and pancreatic duct, producing what is
called the “double-duct sign.” US correctly
identifies the presence of pancreatic cancer
in approximately 75 percent of patients
(sensitivity of 75 percent). Ultrasound’s
weakness is in the detection of cancers
arising within the body or tail of the
pancreas (75 percent of cancers occur in
the head) or small cancers (those with the
greatest chance of surgical cure).
In many medical institutions, CT using
a dedicated pancreatic protocol is the
primary imaging test in patients with
suspected pancreatic cancer. It provides
a comprehensive assessment of local and
distant/metastatic disease in a single session.
The typical appearance of pancreatic cancer
on CT is that of a mass which enhances,
or “lights up,” less than the surrounding
pancreas. Well-performed pancreatic
Figure 1.
Figure 2.
Figure 1. CT image showing pancreatic cancer involving the head and neck of the pancreas, with tumor infiltrating around the superior mesenteric vein.
Figure 2. Magnetic resonance cholangiopancreatography (MRCP) image demonstrating the “double duct” sign, with dilated bile ducts and pancreatic duct.
protocol CT has a sensitivity of up to 80-90 percent for
detection and staging. Currently, it is probably the best
test to evaluate involvement of critical blood vessels
around the pancreas, the presence of which may make
the cancer unresectable. However, CT may not detect
small metastases to the liver, non-enlarged lymph nodes,
or the peritoneum.Very small tumors or those that take
up CT contrast similarly to adjacent pancreatic tissue
(10-15 percent of cancers) may also be difficult to
identify on CT.
Endoscopic ultrasound allows excellent visualization
of the pancreas from the stomach or small bowel.
It is probably the most sensitive imaging test for the
detection of small tumors in the head of the pancreas.
EUS may also be used for local tumor staging.EUS
allows for safe tissue diagnosis by needle biopsy, called
fine needle aspiration (FNA). Combined EUS-FNA has
a reported sensitivity for detecting pancreatic cancer
exceeding 90 percent. EUS is limited in evaluating
metastatic disease and also requires special endoscopic
expertise, making it less readily available compared to
other imaging tests.
MRI scanners and techniques have improved
considerably in recent years. Studies comparing CT and
MRI have found that tumor detection and assessment
of resectability are similar with both forms of imaging.
Compared with CT, MRI is more costly, takes longer
and is more likely to be limited by artifacts. MRI may be
particularly helpful in problem solving, such as when a
mass is not visible with other imaging modalities. MRI
using specific intravenous contrast agents and imaging
sequences can be very useful in evaluating liver lesions
as well.
PET/CT has been reported to improve the detection
of metastatic disease when combined with pancreatic
protocol CT in patients with CT features of resectable
disease, potentially sparing patients from unnecessary
surgery.
Recently, whole-body integrated PET/MR imaging
systems have become available for clinical use. A
prospective study has concluded that PET/MR imaging
performance is comparable to PET/CT combined with
pancreatic protocol CT.
In summary, there have recently been notable
improvements in pancreatic imaging. Given the certain
advantages and disadvantages of each type of imaging
test, multimodality imaging is being increasingly used in
patients with pancreatic cancer, not only for diagnosis,
but also for post treatment follow-up.
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The Pathology
of Pancreatic Neoplasms
The pancreas is composed of
exocrine and endocrine glands. The
Carl Muus, M.D.
Pathologist
exocrine portion comprises approximately
80 percent of the gland volume and
consists of the digestive enzyme–producing
acinar epithelial cells which drain into
progressively larger ducts, ultimately
draining into the main pancreatic duct.
The endocrine pancreas, located in the
islets of Langerhans, consists of several
types of neuroendocrine cells producing
insulin, glucagon, somatostatin, gastrin,
and pancreatic polypeptide. Tumors of the
pancreas typically arise from the ductal
epithelium of the exocrine pancreas, less
commonly from the neuroendocrine cells
of the islets, or rarely from the exocrine
acinar glands. Tumors of the pancreas
can be divided into predominantly solid
or predominantly cystic tumors. The solid
tumors tend to be aggressive with a short
survival, and the cystic tumors tend to be
benign or indolent.
Of the solid tumors, the most common
type is adenocarcinoma arising from
the pancreatic ducts. The general term
“pancreatic cancer” usually refers to this
entity. Although not the predominant
type of pancreatic epithelium, tumors
arising from the pancreatic ductal
epithelium account for 85 percent of
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2016 Cancer Annual Report • Providence Health & Services
pancreatic malignancies. Pancreatic
ductal adenocarcinoma (PDAC) incidence
is increasing over the last few decades
in developed countries. Most cases are
sporadic with known risk factors of high
dietary fats and smoking. Approximately
10 percent of the cases are familial and
may be associated with BRCA mutation,
FAMMM syndrome, Lynch syndrome, PeutzJeghers, Fanconi’s anemia and others. The
disease usually presents in patients over 50
years old with jaundice due to blockage
of the common bile duct, weight loss or
back pain. Most PDAC occur at the head
of the pancreas and are often inoperable/
high stage at presentation. This is probably
due to the absence of a pancreatic capsule
allowing unrestricted extension through the
gland and into the surrounding tissue. It is
the most common metastatic malignancy
associated with an unknown primary site.
Molecular alterations are common in PDAC
and include gene mutations of KRAS, p53,
SMAD4, and CDKN2A.
Pancreatic ductal adenocarcinoma is usually
a poorly circumscribed sclerotic tumor
difficult to distinguish from secondary
pancreatitis in the surrounding gland.
The most common microscopic pattern
is tubular. The tumor can vary from welldifferentiated to poorly differentiated. The
Figure 1. Pancreatic carcinoma
well-differentiated tumor can be very problematic for
the pathologist. The malignant glands may closely mimic
benign glands of chronic pancreatitis. The malignant
glands can be very sparse and have a desmoplastic
stroma similar to chronic pancreatitis (figure 1, 2). To
aid in the diagnosis of a well differentiated PDAC, the
pathologists will look for an infiltrating versus lobular
pattern and search for perineural or vascular invasion
(figure 3). Diagnosis may be very difficult in core
biopsies and especially difficult in fine-needle aspiration
samples obtained percutaneously or by endoscopic
ultrasound.
Figure 2. Chronic pancreatitis
Other less common variants of PDAC include colloid
carcinoma, squamous cell carcinoma, medullary
carcinoma, micropapillary carcinoma, large duct
carcinoma, lobular carcinoma, and foamy gland pattern.
The foamy gland pattern is especially subtle and closely
mimics benign glands.
Figure 3. Perineural invasion
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Figure 4. PanIN-3a
Figure 5. Pancreatic neuroendocrine tumor
The postulated precursor lesion for PDAC is called
pancreatic intraepithelial neoplasia (PanIN) which is
divided into 3 grades (1a, 1b, 2, 3). PanIN 1 shows
mucinous metaplasia with no significant atypia. It is
a fairly common incidental finding, but is believed
to be neoplastic because the cells contain the same
KRAS mutations seen in PDAC. PanIN 2 and 3 have
progressively more cytologic atypia and are seen more
commonly with adenocarcinoma. If PanIN 3 is seen in
the needle core biopsy without cancer, it is likely that
PDAC is somewhere in the gland (figure 4).
accounting for 1–2 percent of all pancreatic cancers.
Most are nonsyndromic with nonspecific symptoms;
however, a few patients will undergo fat necrosis due
to lipase secretion into the blood. Long-term survival
is poor with a few patients surviving more than 5
years. Solid pseudopapillary neoplasms are low-grade,
but potentially malignant tumors occurring at a mean
age of 30 years old and predominantly in women.
Microscopically these tumors tend to degenerate
resulting in dyshesive cells except for preservation
around vessels giving a pseudopapillary pattern.
Other solid tumors of the pancreas tend to be wellcircumscribed without the fibrotic stroma seen in the
usual type of adenocarcinoma. These tumors include
pancreatic neuroendocrine tumor (PanNET), solid
pseudopapillary neoplasm, and acinar carcinoma.
PanNET arises from the endocrine cells of the islets of
Langerhans and can be broadly divided into functional/
syndromic tumors that produce a clinical syndrome
associated with excess hormone (insulin, glucagon,
gastrin, etc.) or those without. Most cases are sporadic,
but some are associated with multiple endocrine
neoplasia (MEN). The behavior of these tumors is
difficult to predict based on histology, and all are
considered potentially malignant. Tumors less than 2
cm, with a low proliferative index (low mitotic rate),
without necrosis, without vascular invasion, and lacking
extrapancreatic extension have a better prognosis
(figure 5). Acinar cell carcinoma is an uncommon tumor
The group of cystic neoplasms tend to be either
benign or indolent low-grade malignancies. Cystic
neoplasms are now more commonly diagnosed with
more frequent imaging studies and increased detection
of subclinical tumors. Cystic neoplasms with mucinous
lining epithelium are the most problematic because they
are all considered premalignant. The most common
is intraductal papillary mucinous neoplasm (IPMN)
accounting for 70 percent of mucinous tumors. IPMN
may involve the main pancreatic duct or branch ducts
and may be lined by gastric, intestinal, oncocytic, or
pancreaticobiliary epithelium. Main duct IPMN will
have a complex florid papillary lesion which can be
diagnosed by imaging (figure 6). This type is more likely
to harbor high-grade dysplasia or invasive cancer and
is generally excised. The branch duct IPMN may appear
as multiple cysts and may not require surgery. The
diagnosis of branch duct IPMN may be difficult by fine
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2016 Cancer Annual Report • Providence Health & Services
Figure 6. Intraductal papillary mucinous neoplasm
needle aspiration. At endoscopic ultrasound the aspirate
sample may consist of only mucin without diagnostic
epithelium. Contaminant gastric mucosa or duodenal
mucosa from an endoscopic ultrasound sample may
lead to a false positive diagnosis of branch duct IPMN.
A second type of mucinous tumor in this category is
mucinous cystic neoplasm with ovarian stroma. This
tumor has a very strong female predominance with a
median age of 50 years. They are large multilocular
cysts histologically similar to ovarian mucinous tumors.
A diagnostic pre-requisite is ovarian type stroma
surrounding the cyst similar to its ovarian counterpart.
Invasive carcinoma may arise in these tumors, especially
if there is this dysplasia present at diagnosis.
be benign, although rare metastases have occurred.
Finally, there is a newly described uncommon entity
called intraductal tubulo-papillary neoplasm of the
pancreas (ITPN, WHO 2010). This pancreatic intraductal
tumor forms a solid mass of tubules which may obscure
its intraductal nature. The biologic behavior of these
tumors is yet to be determined.
In recent years we have learned much about the biology
of pancreatic tumors, and the classification system has
been refined and better defined. However, given the
relative inaccessability of the gland, the usual small
tissue sample size, and well-differentiated morphology
of some tumors simulating benign glands, this area
of pathology continues to be a difficult diagnostic
challenge.
Serous cystic tumors are typically composed of
microcysts and are found in the pancreas body and
tail of older women. The cysts are lined by a single
layer of bland flattened cuboidal tumor cells with clear
cytoplasm. These tumors are generally considered to
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2016 Cancer Annual Report • Providence Health & Services
The Role
of Endoscopic Ultrasound
Eric Stone, M.D.
Gastroenterology
Endoscopic ultrasound (EUS) was first introduced
into clinical practice in 1980. Since its introduction,
the technology has proven to be a valuable tool in a
variety of clinical settings. Its indications and role have
continued to expand, including in the care of many
oncology patients. EUS technology incorporates a
standard flexible upper endoscope with an ultrasound
transducer embedded in its tip. A standard EUS
endoscope can be passed through the mouth down to
the level of the duodenal sweep. It can alternatively be
incorporated as part of a sigmoidoscopy examination
of the distal colon and rectum. The ultrasound imaging
allows for a detailed examination of the wall of the GI
tract and also of the surrounding structures and viscera
of the upper abdomen located nearby.
An EUS can provide diagnostic information but may
also play a role in staging a variety of different cancers,
particularly esophageal, gastric, pancreatic, and rectal. In
this way, an EUS often provides valuable information for
the oncology team to assist them in ensuring the proper
treatment plan. The EUS examination is frequently
complementary to CT and PET scan images. The ability
to define the individual wall layers and to assess the
relationship of the tumor to the surrounding structures
specifically allows for an accurate assessment of local
tumor extension. Local extension is generally one of
the key factors in most GI cancer staging. EUS also
adds value by providing a detailed assessment of any
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2016 Cancer Annual Report • Providence Health & Services
malignant regional lymph nodes that may be present, a
second key component in the TNM staging schema.
In addition to the specific value of the images that
can be obtained, an EUS often allows the opportunity
to perform a fine needle aspiration (FNA) from the
lumen into a mass or nearby lymph node. An EUS also
provides easy access for tissue sampling in those regions
adjacent to the lumen, such as the mediastinum, GE
junction/celiac take off, pancreas, liver, hepatic hilum,
and common bile duct. These are anatomic regions that
sometimes may not be amenable to a safe CT-guided
FNA via a percutaneous route.
EUS frequently provides good views of several upper
abdominal viscera, including the liver, the spleen
and even the left adrenal gland, but the pancreas, in
particular, can be well-visualized by EUS. As
follow-up for pancreatic lesions identified by other
imaging modality (such as CT), an EUS can be helpful in
distinguishing some benign lesions in the pancreas from
other more-concerning lesions. As an example, EUS
imaging features (sometimes combined with an FNA for
cyst fluid analysis) can assist in establishing the diagnosis
of certain cystic lesions, such as an intrapapillary
mutinous neoplasm (IPMN), which are associated with
a risk for future malignant transformation and thus
require further surveillance.
Role of Surgery
in the Management of
Pancreatic Cancer
Juan Mejia, M.D.
Liver/Pancreas Surgeon
Pancreatic adenocarcinoma is the most common
type of pancreatic cancer, accounting for up to 85
percent of pancreatic cancer cases. Other less frequent
forms of pancreatic cancer include neuroendocrine
tumors of the pancreas and pancreatic pseudopapillary
tumors. Since adenocarcinoma of the pancreas
comprises the majority of pancreatic cancers and
also has a more complex management strategy, the
role of surgery reviewed here addresses specifically
adenocarcinoma of the pancreas.
The pancreas is divided into 5 different anatomic
sections starting with the head and uncinate process in
the middle of the abdomen, and following the pancreas
to the left, the different sections are in order: neck, body
and tail. The tail of the pancreas ends in the left upper
quadrant by the spleen.
Approximately 80 percent of adenocarcinomas of the
pancreas occur in the head.
Presentation and Diagnosis
The distal third portion of the common bile duct, which
carries bile produced in the liver to the duodenum,
travels through the head of the pancreas. Therefore,
cancer of the head of the pancreas typically presents
with symptoms which are associated with obstruction
of the bile duct. These signs or symptoms include:
painless jaundice, tea-colored urine and chalky colored
stools. Other presentations can include new onset
diabetes, depression, dyspepsia, weight loss, back
pain and abdominal pain. Some patients can develop
cholangitis (infection of the bile ducts) and pancreatitis
(inflammation of the pancreas). Cancers of the body
and tail area usually present with pain or are found
incidentally when doing tests for other reasons.
Initial workup for patients presenting some of the signs
and symptoms mentioned above usually includes liver
function tests and an abdominal ultrasound. The liver
function tests can show an elevated total bilirubin and
alkaline phosphatase. The abdominal ultrasound may
show findings such as dilated bile ducts or a pancreatic
mass. More sensitive studies for identifying lesions in
the pancreas include an abdomen CT with contrast,
endoscopic ultrasound (EUS) or abdomen MRI with
contrast.
Clinical Classification
Once a diagnosis of pancreatic cancer has been
confirmed, most cancer institutions use a clinical
classification to determine treatment options and
sequencing. This clinical classification uses imaging
studies (EUS, CT and/or MRI) to place patients in one the
following categories:
•Resectable
•
Borderline Resectable
•Unresectable
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Resectable: patients in this category have no
metastatic disease or involvement of nearby vessels
such as portal vein (PV), superior mesenteric vein (SMV),
inferior vena cava (IVC), hepatic artery, celiac artery, or
superior mesenteric artery (SMA). The current standard
recommendation for a patient presenting with a cancer
meeting these criteria is to proceed with surgery first
followed by a period of healing and recovery, followed
by systemic chemotherapy, and if indicated, radiation
therapy.
Borderline Resectable: this group of patients tend to
present with a cancer that is involving nearby vessels;
however, the degree of involvement of the vessels is not
severe enough that it could result in a high probability of
leaving cancer behind at the time of resection (positive
margins). Involvement of the vessels is quantified by
the degrees of the circumference of the vessel that is in
contact with the cancer. In general, in this category, the
veins (PV, SMV) can be completely (360°) involved as
long as the involved segment can be resected and then
reconstructed. For the arteries, it is accepted to have
up to 180° involvement of the SMA, and it is accepted
to have tumor contact with the common hepatic artery
(as long as the celiac and the hepatic artery bifurcation
are not involved). The standard recommendation for
patients with borderline resectable cancer is to undergo
chemotherapy first (neoadjuvant). The type and duration
of the chemotherapy is determined by the medical
oncologist in conjunction with the surgeon. In general,
patients may do anywhere from 3 to 6 months of
neoadjuvant chemotherapy. At the end of the planned
chemotherapy course, the imaging studies (usually
CT scans) are repeated to ensure the cancer has not
metastasized or progressed locally. If none of the latter
findings are noted on the repeat imaging, surgery would
be the next step. Most surgeons would wait an average
of 4 weeks to schedule the surgery in order to allow
recovery from the chemotherapy.
Unresectable: unfortunately, for adenocarcinoma
of the pancreas, the majority of patients present in
the unresectable category. Patients with unresectable
pancreatic cancers are patients who have metastasis
to other organs, with the liver and the lungs being the
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2016 Cancer Annual Report • Providence Health & Services
most common sites, and/or patients with a pancreatic
cancer that has advanced locally to the point where
there would be no way to completely remove all the
cancer with an operation or there is no known benefit
to doing such extensive surgery. This group of patients
will usually have unreconstructable portal vein or
superior mesenteric vein involvement, involvement of
the celiac artery or greater than 180° involvement of
the SMA. Patients in the unresectable category are not
candidates for a potentially curative surgery, therefore
cure is not an attainable goal in this scenario. The main
treatments for patients in this setting are chemotherapy,
radiation therapy and best supportive care.
Surgical Fitness
Pancreas surgery is considered major surgery. Part of
the evaluation prior to surgery consists of ensuring
patients will have a healthy recovery from the surgery.
A significant portion of the outcomes from such an
operation is weighted on the patient’s baseline health
going into surgery. A cardiopulmonary risk, physicial
fitness and nutrition assessment are completed. Any
modifiable factors should be optimized prior to surgery,
this may involve consults with primary care physicians,
cardiologists, pulmonologists, nutritionists,
anesthesiologists and physical therapists.
Operations
Surgery is the one treatment for pancreatic cancer that
offers the opportunity of a cure. The final decision
to proceed with surgery or not is usually made in a
multidisciplinary tumor board discussion with the
direction of the patient’s wishes.
Surgery for cancers that are located to the right of
the neck of the pancreas can be resected with a
pancreaticoduodenectomy. For cancers located to the
left of the neck of the pancreas, the operation would be
a distal pancreatectomy. A distal pancreatectomy can
involve resection of the spleen if there is concern that
the spleen or splenic vessels are involved.
A standard pancreaticoduodenectomy (aka Whipple
surgery) is the most complex surgery of the pancreas.
A whipple surgery involves resecting a small portion
of the distal stomach (antrum), the distal third of the
bile duct, the gallbladder, the head of the pancreas,
the duodenum and proximal jejunum en bloc with the
regional lymph nodes. Once this area is removed, the
different structures are reconnected by the following
anastomosis: pancreatico-jejunostomy, hepaticojejunostomy and gastro-jejunostomy.
A distal pancreatectomy involves dividing the pancreas
at the level of the neck and then removing the body and
tail of the pancreas, en bloc with the regional lymph
nodes and with or without the spleen.
Complications
Data supports that pancreas surgery should be done by
surgeons with specialized training in pancreas surgery
who are considered to do a high-volume of cases at
high volume centers. The possibility of any complication
after a whipple surgery at specialized centers is around
30 percent and mortality is less than 2 percent. Some of
the complications specific to pancreas surgery include
leaks from the pancreas, which has an incidence of
around 15 percent, and delayed gastric emptying with
an incidence of 10 percent.
Five-Year Survival for Five Frequent Sites for All Stages at Diagnosis
% of total cases
97%
100%
88%
99%
91%
SPH
79%
80%
66%
National*
63%
57%
60%
40%
18% 18%
20%
0
Breast
Colorectal
Lung
Prostate
Urinary Bladder
*2016 Cancer Facts & Figures, American Cancer Society
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2016 Cancer Annual Report • Providence Health & Services
Analyzing Pancreatic
Outcomes and the Role of Chemotherapy
The pancreas lies behind the stomach and in front of the spine. There are
two kinds of cells in the pancreas. Exocrine pancreas cells make enzymes that are released
into the small intestine to help the body digest food. Neuroendocrine pancreas cells make
hormones such as insulin and glucagon that are important in controlling blood sugar levels.
Most pancreatic cancers are from the exocrine cells.
The incidence of carcinoma of the pancreas has markedly increased over the past several
decades and ranks as the third leading cause of cancer death in the United States. Of the
824 analytic cases entered into the St. Patrick Hospital tumor registry 18 were pancreatic
cancer. This frequency of pancreatic cancer is similar national findings.
Michael Snyder, M.D.
Medical Oncologist
Montana Cancer Specialists
Percent of Total Cases by Year for Pancreatic Cancer
.16
.14
.12
.10
.08
.06
.04
.02
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
National Cancer Data Base
SPH
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2016 Cancer Annual Report • Providence Health & Services
.0
Risk factors include cigarette smoking, obesity and family history. Clinical features include jaundice, light-colored
stools, dark urine, and pain in the upper or middle abdomen, weight loss, anorexia and fatigue. Diagnosis is
typically made with the help of a CT scan or ERCP followed by a biopsy. Because pancreatic cancer is rarely found
early and it has an overall survival rate less than 6 percent, prognosis is determined by the stage and whether it
is surgically resectable. Both the stage and survival statistics for patient’s entered into the registry at St. Patrick
Hospital are comparable to national findings.
Stage at Diagnosis for Pancreatic Cancer
60%
55%
50%
SPH
National Cancer Data Base
44%
40%
30%
23%
20%
10%
0
17%
7%
Stage I
12% 13%
9% 11%
9%
Stage II
Stage III
Stage IV
Unknown
In circumstances where the tumor is localized to the pancreas, which happens in about 25 percent of cases, fiveyear survival is about 15 percent.
Observed Survival by Stage for Patients with Pancreatic Cancer at SPH
100%
Stage IV
90%
Stage III
80%
70%
Stage II
60%
Stage I
50%
40%
30%
20%
10%
0%
0
1
2
3
4
5
Surgical resection is the mainstay of curative treatment and provides a survival benefit to patients with small
localized pancreatic cancers. If a patient can undergo surgical resection, their survival is improved with the addition
of adjuvant chemotherapy using gemcitabine and Xeloda as recently shown in the European Study group for
Pancreatic cancer (ESPAC) trial. Other palliative agents which can be beneficial include Abraxane and Tarceva.
Studies looking at targeted agents and immuno stimulatory drugs are ongoing. We still have a long way to go in
the treatment of pancreatic cancer.
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2016 Cancer Annual Report • Providence Health & Services
The Role of
Radiation Therapy in
Pancreatic Cancer
Katherine L. Markette, M.D.
Radiation Oncologist
In general, radiation is not the initial treatment
of choice in patients with early stage disease.
As other authors have discussed, any patient treated with
curative intent will have surgical resection as the pivotal
therapeutic step.
For the 20 percent of patients who undergo initial
surgery, National Comprehensive Cancer Network
(NCCN) guidelines recommend postsurgical therapy and
offer either chemotherapy alone or chemotherapy/chemo
radiation. To date, randomized trials have failed to resolve
the debate regarding the role of radiation in the adjuvant
setting. One of the issues is that 11-26 percent of
patients experience distant progression during a course
of standard radiation therapy. It is hoped that newer
radiation techniques with shorter duration may allow
additional weeks of high-dose chemo and reduce this risk
of distant progression (see SBRT below).
At presentation, approximately 40 percent of patients
have no evidence of distant spread but are borderline
surgical candidates or have disease that is felt to be
too extensive for complete resection. Neoadjuvant
treatment for these patients is appropriate; however no
standard treatment regime currently exists. Randomized
trials comparing neoadjuvant chemotherapy verses
neoadjuvant chemo radiotherapy have not provided a
clear answer. Two separate meta-analyses concluded
there was no survival benefit of adding of radiation to
chemotherapy neoadjuvantly. NCCN guidelines offer
either chemotherapy or chemo radiotherapy; however
16
2016 Cancer Annual Report • Providence Health & Services
it is increasingly common to treat with chemotherapy
initially and consider the addition of chemo radiation
in selected patients do not achieve resectability
with chemotherapy alone. The treatment of these
nonmetastatic but borderline or unresectable cases
continues to evolve.
Stereotactic body radiation (SBRT), also called stereotactic
ablative radiotherapy, allows for very high doses of
radiation with a short delivery time. Stanford University
first published a clinical report in 2004 on 15 patients
with advanced pancreatic cancer treated with SBRT. All
patients ultimately died of metastatic disease, but local
control was 100 percent.
This study started a cascade of clinical studies, with
markedly varied results. Varied fraction regimes, field
size and patient parameters have made meta-analysis
difficult. Multiple studies with larger doses per fraction
or larger field sizes have reported significant acute and
late toxicity, primarily mucositis or ulceration. On balance,
one retrospective review showed promising response
rates and no acute grade 3 toxicity and long-term grade
3 toxicity was minimal. The standardization of SBRT
through the use of clinical trials is still forthcoming.
Palliative use of radiation is considered for those who are
elderly or who are not candidates for definitive therapy,
and it can be used for obstruction, pain or bleeding.
Metastatic sites may also be amenable to short-course
radiation for symptom relief.
2015 Analytic Cases
Primary Site
Total
Male
Female
Stage 0
Stage I
Stage II
Stage III
Stage IV
None
ORAL CAVITY & PHARYNX
23
13
10
1
6
5
2
9
0
Tongue
14
5
9
1
4
3
1
5
0
Salivary Glands
1
1
0
0
0
0
1
0
0
Floor of Mouth
2
2
0
0
0
1
0
1
0
Gum & Other Mouth
1
1
0
0
1
0
0
0
0
Tonsil
5
4
1
0
1
1
0
3
0
DIGESTIVE SYSTEM
115
72
43
1
15
22
28
36
13
Esophagus
10
9
1
0
0
3
1
4
2
Stomach
10
7
3
0
0
4
1
5
0
Small Intestine
6
3
3
0
0
0
3
1
2
Colon
35
20
15
1
8
7
9
9
1
Rectum & Rectosigmoid
16
11
5
0
3
1
11
1
0
Anus, Anal Canal & Anorectum
7
2
5
0
1
4
1
1
0
Liver & Intrahepatic Bile Duct
6
4
2
0
1
0
2
1
2
Gallbladder
2
0
2
0
0
1
0
1
0
Other Biliary
2
2
0
0
0
0
0
1
1
Pancreas
18
13
5
0
2
2
0
11
3
Peritoneum, Omentum
1
0
1
0
0
0
0
1
0
Other Digestive Organs
2
1
1
0
0
0
0
0
2
RESPIRATORY SYSTEM
113
56
57
2
16
13
17
60
5
Nose, Nasal Cavity & Middle Ear
4
0
4
0
0
1
0
2
1
Larynx
6
3
3
0
1
2
0
2
1
Lung & Bronchus
103
53
50
2
15
10
17
56
3
BONE & JOINT
2
1
1
0
1
0
0
0
1
SOFT TISSUE
4
2
2
0
1
1
0
1
1
SKIN - Melanoma
32
18
14
1
22
3
5
1
0
Skin - Other
4
3
1
0
1
0
3
0
0
BREAST
121
4
117
18
47
40
6
4
6
FEMALE GENITAL SYSTEM
19
0
19
1
5
2
3
5
3
Corpus & Uterus, NOS
7
0
7
0
4
1
1
0
1
Ovary
9
0
9
0
1
0
2
4
2
Vulva
1
0
1
0
0
1
0
0
0
MALE GENITAL SYSTEM
81
81
0
0
16
38
18
9
0
Prostate
77
77
0
0
14
38
16
9
0
Testis
4
4
0
0
2
0
2
0
0
URINARY SYSTEM
89
63
26
35
24
7
9
13
1
Urinary Bladder
60
46
14
32
12
5
4
7
0
Kidney & Renal Pelvis
24
14
10
0
12
2
4
6
0
Ureter
5
3
2
3
0
0
1
0
1
EYE & ORBIT
8
6
2
0
0
3
2
0
3
BRAIN & OTHER NERVOUS SYSTEM
34
20
14
0
0
0
0
0
34
Brain
19
12
7
0
0
0
0
0
19
Cranial Nerves Other Nervous System
15
8
7
0
0
0
0
0
15
ENDOCRINE SYSTEM
54
11
43
0
36
1
7
3
7
Thyroid
49
9
40
0
36
1
7
3
2
Other Endocrine including Thymus
5
2
3
0
0
0
0
0
5
LYMPHOMA
38
24
14
0
5
11
7
10
5
Hodgkin Lymphoma
5
3
2
0
0
3
1
1
0
Non-Hodgkin Lymphoma
33
21
12
0
5
8
6
9
5
MYELOMA
18
11
7
0
0
0
0
0
18
LEUKEMIA
30
15
15
0
0
0
0
0
30
Lymphocytic Leukemia
19
11
8
0
0
0
0
0
19
Myeloid & Monocytic Leukemia
11
4
7
0
0
0
0
0
11
MISCELLANEOUS
38
22
16
0
0
0
0
0
38
Total
824
423
401
59
195
146
108
151
165
17
2016 Cancer Annual Report • Providence Health & Services
2016 Screening
and Prevention Community Outreach
For the Montana Cancer Center
at Providence St. Patrick Hospital,
Leann Gooley, BSN, RN, ONC
Cancer Center Program
Navigator
Community Outreach
Coordinator
screening, prevention and community
outreach has been an integral piece of our
Commission on Cancer (CoC) and National
Accreditation for Breast Centers (NAPBC)
certified Cancer Center of Excellence. The
opportunity for our staff and volunteers
to participate in community outreach
events has allowed us to interact with our
community members and educate them
about cancer screening and prevention.
In February, Providence St. Patrick Hospital
held one of our most popular and largely
attended outreach events, the Heart Expo.
This event is well attended with over 850
participants and offers a wide range of
educational opportunities to promote
screening and prevention. A wide variety
of vendors participated, offering education
about the prevention of heart disease,
cancer and diabetes, as well as literature
and demonstrations on nutrition, healthy
cooking and exercise. On-site lab draws
were offered. The Montana Cancer Center
participated by staffing a table and giving
out materials about nutrition and activity
for the prevention of cancer, and an ACS
booklet called Cancer Facts for Women
and Men. Skin cancer prevention was also
highlighted with literature and samples of
sunscreen were provided.
18
2016 Cancer Annual Report • Providence Health & Services
Women 4 Wellness was one of our two
spring outreach events in 2016. This annual
event is a health fair provided for the
Confederated Salish and Kootenai Tribes
at the Salish Kootenai College campus in
Pablo, Montana. This outreach is directed
towards preventative education, health
promotion and on-site free screenings and
tests. The Montana Cancer Center shared
a table with Providence St. Joseph Medical
Center. Our focus was education regarding
breast health. We had several hands-on,
multi-type breast self-exam models to open
conversations about self-breast exams.
Attendees were given a brochure that
addressed current guidelines for the
screening and prevention of cancers that
most often affect women and tips to reduce
cancer risk. We provided information for
nutrition and activity, smoking cessation,
HPV vaccination guidelines, and skin cancer
prevention. The event was well attended
with approximately 1,300 participants and
100 vendors.
Our social worker Jamie Bussiere, MSW,
MPH, LCSW, OSW-C, and Ryan Mellem,
Pharm-D had the opportunity to speak at
the Breast Brunch in Town, a fundraising
event sponsored by the University of
Montana’s Kappa Epsilon Professional
Pharmacy Fraternity. Mr. Mellem discussed
new cancer treatment drugs for breast cancer and Ms.
Bussiere talked about resources and ways to support
people diagnosed with breast cancer. The proceeds
from this event were donated to a breast cancer support
fund, a national initiative of this fraternity.
This year The Montana Cancer center at Providence St.
Patrick Hospital in partnership with Camp Mak-a-Dream,
held a one-day event for cancer patients and their
caregivers at Gold creek. Different targeted offerings
included facilitated discussion groups, speakers, yoga,
and healthy cooking demonstrations.
In October, many staff, volunteers, patients and their
friends and families turned out for one of our biggest
outreach events, Team-Up Montana football game,
survivor parade, and tailgate party hosted by Providence
Montana Health Foundation. This event is a fundraiser
for direct financial assistance for cancer patients in
need. The survivor parade honors and acknowledges
our cancer survivors with the spirit of bagpipe music,
colored survivor and team jerseys, and supporters
lining the parade path clapping and cheering them
on. The tailgate party has a festive air, with many
St. Patrick Hospital volunteer employees serving a
delicious barbeque meal. It is a time of smiles, hugs,
acknowledgment, and sometimes tears.
In October many staff, volunteers, patients,
and their friends and families turned out for
one of our biggest outreach events, TeamUp Montana football game, survivor parade,
and tailgate party hosted by Providence
Montana Health Foundation. This event is a
fundraiser for direct financial assistance for
cancer patients in need.
19
2016 Cancer Annual Report • Providence Health & Services
5-Year Comparison of Analytic Cases by Percent of Total Cases
Primary Site
2015
2014
2013
2012
2011
Oral Cavity & Pharynx
2.8%
2.2%
2.5%
3.5%
2.4%
Tongue
1.7%
1.1%
1.2%
1.3%
0.7%
Salivary Glands
0.1%
0.1%
0.5%
0.5%
0.2%
Floor of Mouth
0.2%
0.1%
0.1%
0.5%
0.1%
Gum & Other Mouth
0.2%
0.3%
0.1%
0.3%
0.6%
Nasopharynx
--
--
--
--
0.1%
Tonsil
0.6%
0.5%
0.5%
0.6%
0.3%
Oropharynx
--
--
--
0.3%
0.1%
Hypopharynx
--
0.1%
0.1%
--
0.3%
Digestive System
14.1%
14.2%
14.1%
16.3%
11.0%
Esophagus
1.2%
0.8%
0.9%
1.2%
0.8%
Stomach
1.2%
0.8%
0.8%
1.4%
1.2%
Small Intestine
0.7%
0.9%
0.5%
0.4%
0.5%
Colon
4.3%
4.6%
4.4%
5.0%
4.9%
Rectum
2.0%
1.4%
3.3%
2.9%
1.5%
Anus
0.9%
0.4%
0.3%
1.0%
0.2%
Liver/Biliary
0.8%
1.0%
0.8%
0.8%
0.5%
Gallbladder
0.2%
--
--
0.1%
--
Pancreas
2.2%
4.2%
2.3%
2.3%
0.9%
Retroperitoneum
--
--
--
0.1%
--
Other
0.6%
0.1%
0.8%
1.1%
0.5%
Respiratory System
13.5%
13.1%
15.4%
15.1%
15.6%
Nose, Nasal Cavity,Middle Ear
0.5%
0.1%
0.1%
0.1%
--
Larynx
0.7%
0.6%
1.1%
1.2%
1.0%
Lung
12.3%
12.4%
14.2%
13.8%
14.6%
Bones & Joints
0.2%
0.4%
--
0.1%
--
Soft Tissue
0.5%
0.1%
0.8%
0.9%
0.3%
Skin
4.4%
6.5%
4.6%
4.3%
7.6%
Melanoma
3.9%
6.1%
4.6%
4.0%
7.4%
Skin-not Melanoma
0.5%
0.4%
--
0.3%
0.2%
Breast
14.8%
18.4%
17.1%
19.5%
15.6%
Gynecologic
2.1%
2.3%
2.0%
3.3%
2.7%
Cervix Uteri
--
0.5%
0.1%
0.4%
0.2%
Corpus Uteri
0.9%
1.2%
1.3%
1.3%
1.5%
Ovary
1.1%
0.6%
0.5%
1.0%
0.8%
Vulva
0.1%
--
0.1%
0.5%
--
Other
--
--
--
0.1%
0.2%
Male Genital System
9.9%
10.4%
11.2%
9.1%
18.4%
Prostate
9.4%
9.7%
10.6%
7.4%
17.9%
Testis
0.5%
0.7%
0.3%
1.3%
0.5%
Penis
--
--
0.1%
0.4%
--
Other
--
--
0.2%
--
--
Urinary System
10.8%
7.8%
8.5%
8.3%
9.4%
Urinary Bladder
7.4%
4.0%
4.2%
4.8%
5.1%
Kidney & Renal Pelvis
2.8%
3.5%
3.6%
3.5%
3.7%
Ureter
0.6%
0.3%
0.7%
--
0.6%
Eye & Orbit
1.0%
0.1%
0.8%
0.9%
0.8%
Brain & CNS
4.0%
2.0%
4.4%
3.2%
2.8%
Brain & CNS,Malignant
2.1%
1.9%
2.1%
2.1%
1.5%
Brain & CNS ,Benign
1.9%
0.1%
2.3%
1.1%
1.3%
Endocrine System
6.6%
6.0%
3.1%
3.5%
3.0%
Thyroid
6.0%
5.7%
3.0%
3.0%
2.4%
Other
0.6%
0.3%
0.1%
0.5%
0.6%
Lymphoma
4.7%
6.1%
5.7%
4.7%
5.0%
Hodgkin Lymphoma
0.7%
0.8%
0.6%
0.5%
0.7%
Non-Hodgkin Lymphoma
4.0%
5.3%
5.1%
4.2%
4.3%
Myeloma
2.2%
1.7%
1.4%
1.4%
0.8%
Leukemia
3.7%
3.7%
4.7%
3.2%
1.8%
Mesothelioma
--
0.4%
0.4%
0.3%
0.1%
All Other
4.7%
4.6%
3.3%
2.4%
2.7%
Total
824
766
766
780
884
20
2016 Cancer Annual Report • Providence Health & Services
Tumor Board
provides multidisciplinary care for patients
Providence St. Patrick Hospital’s tumor board
conferences are held weekly to provide a forum for
multidisciplinary, consultative discussions of cancer
cases. The tumor board’s goals are to continually
improve patient care and provide continuing education
for clinicians. The group discusses diagnoses, treatment
options and research protocols, along with followup strategies that help determine the best possible
treatment plans for our patients.
Through an agreement with the University of
Washington School of Medicine, we can provide
continuing education credits to physicians attending the
tumor board discussions. Each conference is accredited
for 1.0 hour CME credit.
In 2015, there were 46 tumor board conferences held
with 164 cancer cases discussed.
For more information about the tumor
board, please contact LaDonna Shepard, CTR,
at the cancer program office at:
406-329-5654.
21
2016 Cancer Annual Report • Providence Health & Services
Cancer Registry
provides important data
The cancer registry at Providence St. Patrick Hospital is
an important data collecting system used to maintain
and analyze clinical cancer information for all inpatients
and outpatients diagnosed and/or treated for cancer
here.
early detection and treatment of a recurrence or early
diagnosis of a subsequent cancer. To date, the registry
is following about 6,300 cases annually. The registry
currently maintains a 94 percent follow-up rate on all
patients.
The data are used for research, educational, and
outcome measurement purposes. Established Jan. 1,
1993, the registry is required by state law to identify
and report all malignant (and certain benign) tumors
to the Montana Central Tumor Registry in Helena. Data
also are submitted to the National Cancer Data Base
(NCDB), Rapid Quality Reporting System (RQRS), and the
Facility Information Profile System (FIPS) data-sharing
project with the American Cancer Society that provides
comparative analysis with other hospitals of similar
size. Data collected in the registry include information
related to demographics, diagnostics, stages of disease,
treatments, vital status and follow-up information.
For information about the cancer registry,
contact Nancy Chaffin, CTR, at 406-329-5609.
In 2015, a total of 923 cases were accessioned, 824
of which were analytic. Analytic cases are those that
have been diagnosed and/or received their first course
of treatment at Providence St. Patrick Hospital. Nonanalytic cases are those that have been diagnosed and
received their first course of treatment elsewhere.
Lifetime follow-up of all cancer patients is one of the
cancer registry’s primary goals. In addition to research
and other scientific value, the cancer registry provides
important reminders to physicians and patients to
continue regular oncology examinations, ensuring
22
2016 Cancer Annual Report • Providence Health & Services
Left to right: Michael J. Snyder, M.D., FACP; Sarah M. Scott, M.D.; Linda M. Ries, M.D.; John W. Linford, M.D.; Jeffrey A. Stephenson, M.D., FACRO;
Alan W. Thomas, M.D., FACP; Katherine L. Markette, M.D., FACRO; Margaret M. Menendez, M.D.
2016 Cancer Committee Membership
Kristy Beck-Nelson, CMPE, regional director of
Oncology Service Line, Western Montana Region
JoAnn Hoven, MA, marketing and communication
liaison
Jennifer Bennett, program manager,
Camp Mak-A-Dream
Beth Jones, camp director, Camp-Mak-A-Dream
Jamie Bussiere, MSW, MPH, LCSW, OSW-C, oncology
social worker
Stacie Campo, M.D., surgeon
Margaret Carnegie, M.D., women’s care specialist
Nancy Chaffin, CTR, cancer registrar
Mary Frank, CLT, physical therapist
Holly Frydenlund, BA, clinical oncology research
coordinator
Leann Gooley, BSN, RN, OCN, cancer care program
navigator
Lori Grimes, BSN, RN, quality specialist
Deborah Hayes, American Cancer Society,
quality of life manager
Christopher Jons, M.D., medical director, Acute
Palliative Care Program
Kari Leach, RD, LN, clinical dietitian
Ryan Mellem, Pharm-D, MPH, pharmacist
Carl J. Muus, M.D., pathologist
Sarah Scott, M.D., medical oncology, cancer
committee chair
LaDonna Shepard, CTR, cancer program coordinator
Jeffrey Stephenson, M.D., FACRO, radiation oncologist
Alan Thomas, M.D., FACP, medical oncologist,
cancer liaison physician
Bruce Turlington, M.D., diagnostic radiologist
23
2016 Cancer Annual Report • Providence Health & Services
Non-Profit
Organization
US Postage
PAID
Missoula, MT
Permit #220
500 W. BROADWAY
MISSOULA, MT 59802
Address service requested
Montana geographic distribution of patients diagnosed and/or
intially treated at Providence St. Patrick Hospital in 2015.
5
38
824 total with 31 from outside of Montana
Visit Providence St. Patrick Hospital at www.providence.org/montana
©2016 Providence St. Patrick Hospital