Download Prostate cancer survival data

2005 Annual Report
of the
St. Mary-Corwin Cancer Program
Based on 2004 data
During the period of July, 2004 through October, 2005, the Cancer
Program at St. Mary-Corwin was involved in many activities which
helped to improve care for the patients and communities we
serve. Many of those activities will be summarized below. The
Cancer Committee, consisting of physicians (both oncologists and
non-oncologists), clinical staff, and support staff, is the group
which reviews cancer care in our hospital, and is responsible for
initiating and promoting changes in prevention, early detection,
treatment and post-treatment care. The Cancer Services staff,
with the Adminstrative and Medical Directors, work to carry out the
commitment of the Cancer Committee and the hospital to
improvement in cancer care. During the past year, we have had a
change in leadership which will allow Cancer Services to be even
more active in incorporating most aspects of cancer care in our
improvement efforts.
Many departments within the hospital are regularly involved in the
care of cancer patients. Diagnostic Imaging (formerly Radiology)
is the department where many patients have their first evaluation
which may lead to the diagnosis of cancer. The Diagnostic
Imaging department at St. Mary-Corwin has added access to
PET/CT scanning in the past year, dramatically improving our
ability to detect small cancers in the lung, as well as detect spread
of the cancer to areas which were not apparent on other imaging
tests. In addition to PET/CT, the imaging department has added
high-speed, multi-slice CT equipment, which is needed to
eventually provide virtual colonoscopy and other new diagnostic
procedures
Pathology continues to provide improved diagnostic capabilities,
with continued emphasis on the use of molecular identification of
unique characteristics of cancers to better classify expected
behavior of those cancers. During this past year, our pathologists
have also introduced new reporting using the College of American
Pathologists schema which clearly identifies the scientificallyvalidated elements required on a pathology report. This
improvement has helped all clinicians better understand the
pathology reports and the significance of the findings.
Our cancer program is actively involved in clinical trials which are performed in
conjunction with many other cancer programs around the country through our
membership in CCRP (Colorado Cancer Research Program), and its affiliation
with the major cooperative research groups around the country. We completed
entry of patients in two major cancer prevention trials, the STAR breast cancer
prevention trial, and SELECT prostate cancer prevention trial, and were among
the top contributors for both studies. Results of these studies will not be
available for some time, and all patients are still being followed at regular
intervals. In addition, we have entered patients on treatment trials for
lymphoma, breast cancer, and leukemia, among others. We are currently
entering patients on the national trial evaluating the efficacy of treating women
who have early stage breast cancer with partial breast irradiation after removal
of the cancer, as opposed to treatment of the entire breast, which has been the
standard treatment for several decades. We have also received grant support
for a program to evaluate the factors which have led women to participate in
clinical trials, so that we may be able to improve our participation rates in the
future.
Our Radiation Therapy department continues to expand it’s
technology, and has been providing advanced treatment for
prostate cancer, head and neck cancer, and gynecologic cancer
using IMRT (Intensity Modulated Radiation Therapy). In addition,
many patients with prostate cancer are now being treated with
HDR (High Dose Rate) implants, which allow tailoring of the dose
of radiation within the prostate, reducing the doses to tissues
outside the prostate, and minimizing the amount of time required
for treatment. With IMRT, HDR implants, and LDR (low dose-rate)
implants, localized prostate cancer may be treated in an optimal
way depending on the patient’s needs and the status of the
cancer
The Surgery Department, in conjunction with general surgeons,
has made minimally invasive cancer a greater focus, with a move
toward laparoscopic surgery for many cancers in the abdomen
and pelvis. This change in approach may lead to faster recovery,
with less trauma to internal tissues. Robotic surgery is being
evaluated to provide even greater access to internal structures
with improved recovery times.
Our support services continue to expand and impact more cancer
patients. We provide a pain team to help in management of
patients with pain, both acute and chronic. We have a palliative
care team which provides help in getting needed care for patients
who are at the end of life, or whose focus of care is shifting from
curative to palliative, to improve quality of life. We have support
groups for patients who are actively receiving treatment, for
families and other care-givers, and for women who have had
breast cancer. We work closely with the American Cancer Society
to provide wigs and styling for those who are losing hair, and are
sponsors of the “Look Good, Feel Better” program. We also have
been active supporters of the Susan G. Komen Foundation Race
for the Cure, and have received grant support for mammograms
for underserved women, for help in preventing and treating
lymphedema, and for arts in the healing of women with breast
cancer. Our genetics counselor is sponsored in part by a grant
from the Race for the Cure.
Breast Cancer Task Force
In August of 2004 the Cancer Committee convened a group of
physicians, staff, and patients to review the status of breast
cancer diagnosis and treatment in our community. The task force
heard that screening mammograms were generally available,
including for those who had no or inadequate insurance. It was
apparent that the time from screening mammogram to biopsy for
those women who need biopsy may be longer than desirable, and
the task force suggested several ways to reduce that time. A
study of the time to diagnostic mammogram and time to biopsy
revealed a general decline in that time over the past 18 months,
but the interval from diagnostic mammogram to biopsy remains
approximately 7 days. Further work on this has been proposed, to
achieve biopsy in less than 7 days when possible.
Cancer Registry
Our cancer registry has been active since 1968, and has more than 22,000
cases in the database. We cooperate with the National Cancer Database to
provide information which is useful in determining trends in cancer care across
the country. This past year we helped evaluate the effect of surgical margins
for excisional biopsy (lumpectomy) on the likelihood of recurrence for women
with early stage breast cancer, and we have reviewed data comparing our rate
of adjuvant treatment of Stage III colon cancer to the rate throughout the
country. Other studies are being proposed.
During 2004, a total of 729 new cancer patients were entered into the database.
Of those, 668 were analytic cases. The distribution of the main sites of cancer
is shown on the accompanying graph, which also includes comparative data for
2001-2003.
Main Sites of Cancers Seen at SMC 2001 thru 2004
2004
2003
2002
2001
Number of cases
0
Breast
Prostate gland
Lung and bronchus
Colorectal
Urinary bladder
Thyroid gland
Kidney and renal pel
Non-Hodgkin's lympho
Leukemias
Melanomas of the ski
20
40
60
80
100
120
140
160
180
The majority of patients reside in Pueblo county, though many
patients come from the surrounding rural counties, as well as
Northern New Mexico. The following graph demonstrates the
county of residence for our patients from 2004.
2004 Number of Patients vs. Colorado Counties
Weld
Saguache
Rio Grande
Pueblo
Prowers
98
Phillips
Park
Colorado Counties
Otero
Mineral
Las Animas
Huerfano
# patients
Fremont
El Paso
Custer
Crowley
Costilla
Conejos
Cheyenne
Chaffee
Bent
Baca
Alamosa
0
50
100
150
200
250
Number of Patients
300
350
400
450
500
The Future of cancer services at St. Mary-Corwin Medical Center
In early 2006, a new 42,000 sq. ft. cancer center will open. This new center,
dedicated to Father Roger Dorcy, will provide a much expanded area for
radiation therapy, chemotherapy, and a wide array of support services, all
conveniently accessible from a dedicated entrance. Our new center will provide
space for educational activities, community activities related to cancer, a library
containing a broad selection of information about cancer as well as computer
access to national cancer databases, a Lance Armstrong Foundation supported
information center for survivors of cancer, and ready access to genetics
counseling, support groups, general counseling for cancer patients and
families, healing arts activities, and lymphedema management. Our pain team,
palliative care team, and clinical trials team will be officed in the cancer center,
and our outpatient chemotherapy and infusion center will be immediately
adjacent to our entry and our healing garden. We are delighted to be able to
provide all these services in one location for our patients, our survivors and our
community.
Review of Data for 2004
Prostate Cancer:
During the past several years, prostate cancer has been in the top
two most-frequent cancer sites seen at SMC. In 2004, a total of
158 new prostate cancer patients were added to the database.
This represents a significant increase when compared to 2003,
and is higher than any previous year.
PROSTATE CANCER CASES YEARS 1995-2004
180
160
140
NUMBER OF CASES
120
100
80
60
40
20
0
1995
1996
1997
1998
1999
2000
1995-2004
2001
2002
2003
2004
The stage at time of diagnosis has also changed over the past 10
years, with a decline in advanced stage (III and IV), and an increase in
Stage II. The increase in Stage II may in part be related to improved
reporting of early stages, and in part due to early diagnosis from
screening tests.
AJCC STAGE GROUP FOR PROSTATE CA 1995-2004
100%
90%
80%
70%
UNK
% Cases
60%
NA
4
50%
3
2
1
40%
0
30%
20%
10%
0%
1995
1996
1997
1998
1999
2000
YEARS 1995-2004
2001
2002
2003
2004
The age of men diagnosed with prostate cancer has also
changed over the past 10 years, with a significant trend
toward diagnosis at a younger age. This change almost
certainly reflects the use of screening tests, particularly
PSA.
PROSTATE CA 1995-2004 AGE DISTRIBUTION/10 YR INCREMENTS
100%
90%
80%
70%
UNKN
60%
85+
75-84
50%
65-74
55-64
40%
45-54
30%
20%
10%
0%
1995
1996
1997
1998
1999
2000
YEARS 1995-2004
2001
2002
2003
2004
The methods of treatment have also changed during the
past 10 years, with a continued emphasis on radiation
therapy, but with the introduction of cryosurgery in 2003,
surgical treatment of Stage II prostate cancer increased
dramatically at SMC. When comparing treatment of our
patients with that of patients in similar cancer programs in
Colorado in 2001, it appears that fewer patients are
surgically treated, with a higher proportion of treatment
with radiation.
100%
90%
80%
SR
SH
S
RC
RH
R
H
D
70%
60%
50%
40%
30%
20%
10%
Stage 2 treatment
2004
2003
2002
2001
Colorado
2001
2000
1999
1998
1997
1996
1995
0%
2003-2004 FREQUENCY OF SURGERY CODES
40
35
NUMBER OF PATIENTS
30
25
2004
20
2003
15
10
5
0
CRYOABLATION
TURP
SURGERY TYPE
PROSTATECTOMY
Prostate cancer has a long natural history, with many men
dying of causes unrelated to their prostate cancer. A
minimum of 10 year follow-up is required to assess outcome
of patients diagnosed with prostate cancer at various
stages. We chose to review the outcome of men diagnosed
in the period 1990-1995, to determine if the management
used for our patients led to results which are comparable to
those for patients throughout Colorado. Since the reporting
of stage was not uniformly AJCC in that era, we are
comparing our AJCC-staged patients with those staged as
either localized, regional, or distant.
When we look at all patients in both SMC and Colorado
databases, we see that the survival out to 10 years is
virtually identical. At 10 years, SMC patients with
distant disease at diagnosis have a slightly better
survival. Similarly, SMC patients with Stage I and II
have slightly better survival at 10 years than patients
with Localized disease in Colorado as a whole. SMC
Stage III patients had worse survival at 10 years than
did Colorado patients with Regional disease. These
differences may relate more to staging designations
than to management, and it is clear that overall survival
for patients with prostate cancer is similar at SMC
when compared to Colorado.
Prostate cancer survival data:
•For the total group of men with prostate cancer treated at SMC,
the survival is the same as for Colorado as a whole
•For early stage prostate cancer, patients treated at SMC had a
slightly improved survival as compared with Colorado as a whole
Prostate Cancer Survival SMC and Colorado
100
90
80
70
% Observed Survival
All Colorado
Localized Colorado
60
Regional Colorado
Distant Colorado
50
All SMC
I SMC
II SMC
40
III SMC
IV SMC
30
20
10
0
1
3
5
Years of Survival
10
Treatment of prostate cancer has changed in the past 10
years, and outcome of treatment may well change, but
evaluation of that change will require review when 10 year
survival data is available.
Ductal Carcinoma In Situ of the Breast
Over the past 20 years, a significant change in
management of DCIS has occurred. Mastectomy was the
preferred treatment 20 years ago, but currently many
women are treated with excision of the cancer
(lumpectomy), followed by radiation therapy. Data from a
review of patient with DCIS treated with lumpectomy alone
suggested that there were no good predictors of those
women whose cancers were most likely to recur.
Radiation therapy has generally been used to reduce the
risk of recurrence. A review of treatment of DCIS at SMC,
compared with treatment reported in the NCDB (National
Cancer DataBase), may be seen in the following graphs.
DCIS TREATMENT SMC vs. NCDB
90
80
70
60
% Cases
2000 SMC
2001 SMC
50
2003 SMC
2004 SMC
40
2000 NCDB
2001 NCDB
30
20
10
0
Biopsy only
Surgery, no radiation
Treatment
S+R
When evaluating the data demonstrating a much higher
percentage of patients receiving radiation therapy at SMC
than throughout the country as a whole, it is important to
recognize that SMC is a referral center for radiation therapy.
Some women with DCIS in our region may be diagnosed and
operated at other area hospitals and not referred for
radiation therapy (and not entered in our Cancer Registry),
while those diagnosed and operated at other area hospitals
and referred for radiation therapy are entered in our
Registry, skewing the data toward a higher percentage of
radiation therapy. Similarly, many locations elsewhere in
the country do not have radiation therapy associated with
the reporting hospital, leading to under-reporting of that
treatment. It is our commitment to offer radiation therapy to
most women with DCIS, based on the data cited above.
Women with DCIS have an extremely low likelihood of
nodal spread of their cancer. It is generally not
recommend that lymph nodes be removed surgically.
During 2003-4 we noted an upswing in the percentage of
women who had nodal evaluation. We have followed this
over the past 15 years, and noted a general decline in the
rate of nodal evaluation, as would be expected.
% DCIS NODES EXAMINED
1
0.9
0.8
% PATIENTS
0.7
0.6
0.5
NODES EXAMINED
0.4
0.3
0.2
BENCHMARK OF <5% OF
PATIENTS HAVE NODES
EXAMINED
0.1
0
1990
1991
1992
1993
1994
1995
1996
1997
YEAR
1998
1999
2000
2001
2002
2003-4
We have also tracked the type of surgical management of
DCIS, and have found that over 80% of women are now
treated by breast conservation, as would be expected
based on outcomes data.
DCIS Surgical Mangement
1.2
1
% of Patients
0.8
No Surgery
Breast-Conserving
Mastectomy
0.6
0.4
0.2
0
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003-4
Acknowledgements
Special thanks to our cancer registrars, Dinah Torrence and
Nancy Millsap, who have provided data for our analyses, and
who have been tireless in their pursuit of quality data
acquisition.
Thanks to the members of the Cancer Committee who have
worked hard to help us assess and improve the quality of care
we provide at St. Mary-Corwin Cancer Center
2005 Cancer Committee Members
Dr. Joel Ohlsen, Chairman
Dr. Rina Shinn
Dr. Stephen Girard
Dr. Michael Bryant
Dr. Vaughan Cipperly
Dr. Marlow Sloan
Dr. James Meeuwsen
Dr. Tony Feliz
Dr. Marc Johnson
Dr. Scott Potts
Dr. Louise Schottstaedt
Dr. John Stageberg
Dr. Louis Balizet
Dr. Frank Settipani
Dr. Travis Archuletta
Radiation Oncology
General Surgery
General Surgery
Radiation Oncology
Medical Oncology
Medical Oncology/Palliative Care
Obstetrics and Gynecology
Urology
Radiology
Pathology
Family Practice
Radiation Oncology
Medical Oncology
Medical Oncology
Medical Oncology
Multi-Disciplinary Members:
Donna Fritz, RN, MN, ONC
Clinical Nurse Specialist
Kathy Young, RN
Oncology Unit Clinical Area Coordinator
Donna Pinson, RN, MSN
Quality Resources
Libby Samaras, RN, MSN, AOCN Clinical Trial Coordinator
Dinah Torrence, CTR, RHIT
Certified Tumor Registrar
Nancy Millsap, RHIT, CTR
Tumor Registrar