Download Stage II Colorectal Cancer - Saint Agnes Medical Center

2013
CANCER PROGRAM
ANNUAL REPORT
2003-2012 COLORECTAL CANCER
Praneetha Narahari, MD
®
Ellen Malek, CTR
Saint Agnes Medical Center
Cancer Registry
1303 East Herndon Avenue
Fresno, CA 93720
559 450-3570
www.samc.com
INTRODUCTION

Colorectal cancer (CRC) is cancer that starts in the colon or the rectum, both part
of the large intestine. It can be also be referred to separately as Colon or Rectal
Cancer. Of note, the Rectosigmoid (colon/junction) is an anatomical point which serves
to distinguish the colon (proximal sigmoid) and the extraperitoneal portion of the rectum.





Colorectal cancer is the third most common cancer for both men and women in
the United States. The estimated number of CRC cases for 2013 in the US are
102,480 new cases of colon cancer and 40,340 new cases of rectal cancer (1) and
300 expected new cases of colon cancer in Fresno County (2).
Overall lifetime risk of developing colorectal cancer is about 1 in 20 (5%). The risk
is slightly lower for women than men.
While most people diagnosed with colorectal cancer do not have a family history
of the disease those that do, have a significantly higher chance of being diagnosed
with CRC. It is important to know your Family History (3) and share that
information with your healthcare provider.
Colorectal cancer is the third leading cause of death in the United States when
men and women are considered separately and second leading cause when both
sexes are combined.
But the good news is that colorectal cancer is one of the most preventable cancers.
The American Cancer Society believes that preventing colorectal cancer, not just
finding it early, should be the reason for getting tested. For people of average risk
for CRC screening should begin at age 50. This suggestion along with healthy
lifestyle and dietary choices are important considerations. (4)
ANATOMY OF THE COLON
DATA











For the purposes of analysis, data includes analytic cases, those diagnosed and/or
received all or part of first course treatment at SAMC and for comparison, include
histologies per National Cancer Data Base (6) criteria which excludes cases of
lymphoma but does include neuroendocrine/carcinoid tumors (20) and sarcomas (2).
During the study period, 2003-2012 there were 1,477 analytic colorectal cancer
cases diagnosed and/or treated at Saint Agnes Medical Center.
Between 2003-2007 the average number of analytic cases seen per month was
172. In contrast, between 2008-2012 that number was 123 cases per month.
Over the ten year period, 51% (753) were men and 49% (724) were women.
Median age at diagnosis was 72. Age distribution of the observed patients was
20-29 years old 0.5% (8), 30-39 1% (18), 40-49 7% (98), 50-59 15% (227), 60-69
20% (294), 70-79 27% (400), 80-89 24.5% (361), 90 years old and older 5% (71).
When compared to National Cancer Data Base data, Saint Agnes colorectal
cancer patients appear to reflect a slightly older population with a higher
portion, 29.5% compared to 22%, age 80 and older.
The race/ethnicity breakdown noted Non-Hispanic White accounted for 74%
(1087), Hispanic 16% (231), Asian 7% (108), Black 3% (48) and Other (3).
Cases comprised 66% (972) Colon Cancer and 34% (505) Rectum and
Rectosigmoid Cancers.
98.5% of the colorectal cancer cases were diagnosed by positive histology.
As expected the majority of the cases 96.5% were adenocarcinomas. The
remainder encompassed 2% (32) carcinoma, nos, 1% (20) neuroendocrine
(carcinoids tumors) and 0.5% included (3) squamous cell, (2) small cell, nos and
(2) sarcoma.
Stage at diagnosis was found to be similar to state and national data; although,
Saint Agnes Cancer Registry data demonstrated notably less unknown stage at
diagnosis, 3% compared to 9%.
2003-2012 SAMC COLORECTAL CANCER
COMPARISON TO NATIONAL CANCER DATA BASE
AGE AT DIAGNOSIS
SAMC N=1477
NCDB (1659 hospitals)
29.5%
27% 27%
23%
18%
22%
20%
15%
10%
8.5%
49 & Under
50-59
60-69
70-79
80 & Over
Resources: SAMC Cancer Registry, NCDB Benchmark Comparison Reports 2000-2011
STAGES OF COLORECTAL CANCER
o Polyp: Most colon cancers develop
from non-cancerous growths often
arising from adenomatous polyps or
polypoid adenoma.
o Stage 0 (in situ): Cancer has formed,
but is not yet growing inside the colon
or rectum walls.
o Stage I (local): Cancer is now growing
in the colon or rectum walls; nearby
tissue is not affected.
o Stage II-III (regional): Growth beyond
the colon or rectum walls and into
tissue or lymph nodes.
o Stage IV (distant): Cancer has spread
to other parts of the body such as liver
or lungs.
2003-2012 SAMC COLORECTAL CANCER
COMPARISON TO NATIONAL CANCER DATA BASE
STAGE AT DIAGNOSIS
SAMC N=1477
Comp Comm CA Programs (all states)
NCDB (1659 hospitals)
27%
26%
24%
22% 22%
23%
23%
23%
21%
17%
15%
16%
9% 9%
7% 7%
5%
3%
0
I
II
Stage
III
IV
UNK
Resources: SAMC Cancer Registry, NCDB Benchmark Comparison Reports 2000-2011
2003-2012 SAMC COLON CANCER
TREATMENT BY STAGE N=972
Stage
Surgery
0
N=46
I
II
III
N=242 N=286 N=209
IV
N=163
93.5% 94% 77% 35% 29%
SAMC
TOTAL
Comp
Comm CA
Programs
N=512,688
64%
62%
61%
27%
26%
26%
NCDB
N=888,824
Surg + Chemo
0%
1%
21% 62% 39%
Other Specified Tx
2%
0%
2%
3%
15%
4%
6%
7%
4.5%
5%
0%
0%
17%
5%
6%
6%
None
*SURVIVAL
Overall 5 Year

61.0%
55.2%
Similar treatment practice was observed when comparing Colon Cancer
treatment by stage of those seen at Saint Agnes Medical Center between
2003-2012 and data compiled by the National Cancer Data Base for the years
2000-2011 for Comprehensive Community Cancer Programs from 815
hospitals and aggregate national data from 1660 hospitals; therefore, only
overall comparison data is displayed. *National Cancer Data Base
comparison of overall 5 year survival for the years 2003-2006 is provided.
Resource: 2003-2006 NCDB Survival Reports
2003-2012 SAMC RECTOSIGMOID COLON CANCER
TREATMENT BY STAGE N=143
Comp
Comm CA
Programs
N=54,578
0
I
II
III
IV
N=8
N=35
N=31
N=37
N=25
SAMC
TOTAL
Surgery
88%
86%
48%
32%
28%
50%
50%
48%
Surg + Chemo
0%
0%
26%
46%
40%
25%
18%
19%
Surg + Rad + Chemo
12%
11%
26%
19%
12%
18%
18%
19%
Other Specified Tx
0%
0%
0%
3%
20%
4%
8%
9%
None
0%
3%
0%
0%
0%
3%
5%
5%
Stage
*SURVIVAL
Overall 5 Year

67.1%
NCDB
N=97,343
58.3%
Similar treatment practice was observed when comparing Rectosigmoid Colon
Cancer treatment by stage of those seen at Saint Agnes Medical Center between
2003-2012 and data compiled by the National Cancer Data Base for the years
2000-2011 for Comprehensive Community Cancer Programs from 802 hospitals
and aggregate national data from 1622 hospitals; therefore, only overall
comparison data is displayed. *National Cancer Data Base comparison of overall
5 year survival for the years 2003-2006 is provided.
Resource: 2003-2006 NCDB Survival Reports
2003-2012 SAMC RECTUM CANCER
TREATMENT BY STAGE N=362
0
I
II
III
IV
N=16
N=113
N=75
N=70
N=57
Surgery
88%
54%
24%
11.5%
7%
31%
36%
35%
Surg + Chemo
0%
0%
5%
10%
19%
6%
5%
5%
Rad + Chemo
0%
4%
12%
4%
14%
8%
8%
8%
Surg + Rad + Chemo
6%
33%
58%
71.5%
32%
42%
35%
35%
Other Specified Tx
0%
3%
1%
3%
10.5%
4%
8%
9%
None
6%
6%
0%
0%
17.5%
9%
7%
7%
Stage
*SURVIVAL
Overall 5 Years

Comp
Comm CA
Programs
N=145,592
SAMC
TOTAL
60.6%
NCDB
N=266,365
59.2%
With minor exception, similar treatment practice was observed when comparing
Rectum Cancer treatment by stage of those seen at Saint Agnes Medical Center
between 2003-2012 and data compiled by the National Cancer Data Base for the
years 2000-2011 for Comprehensive Community Cancer Programs from 805
hospitals and aggregate national data from 1637 hospitals; therefore, only overall
comparison data is displayed. *National Cancer Data Base comparison of overall
5 year survival for the years 2003-2006 is provided.
Resource: 2003-2006 NCDB Survival Reports
STAGE II/III RECTUM CANCER N= 145
SPHINCTER SPARING SURGERY


The treatment of cancers of the mid to lower rectum and, generally of Stage II or
Stage III disease, can often result in a permanent stoma (opening in the body)
referred to as a colostomy. However, skilled surgeons aided by a change in the
sequencing of treatment, in many cases can remove the tumors while preserving
bodily function. Most often this is accomplished using ‘neoadjuvant’ treatment,
the combination of chemotherapy and radiation before surgery to reduce the size
of the tumor and make it easier to remove with clear surgical margins which
allows preservation of the anal sphincter (surgery less than a total proctectomy).
As mentioned, 362 rectum cancers were accessioned into the SAMC Cancer
Registry between 2003-2012 and 145 of these were Stage II/III cases. Of note,
data collection codes do not allow a distinction to be made for upper, mid or lower
rectum and must be considered in the interpretation of the data.


Of the 145 Stage II/III cases, 9% (13) did not undergo a surgical resection as
treatment for their disease. 91% (132) were felt to be appropriate for surgery.
Of those who had surgery, 65% (86) had less than a than a total proctectomy and
35% (46) required a total proctectomy.
To evaluate the use of combined treatment for sphincter preservation we
analyzed 70 Stage II/III rectum cancer cases that had neoadjuvant chemo and
radiation. During the 5 year intervals between 2003-2007 35% (11) required less
than a total proctectomy and 65% (20) required total proctectomy. However,
during 2008-2012 we see a reversal of the percentages, with 64% (25) undergoing
less than a total proctectomy and 36% (14) having had a total proctectomy.
STAGE II COLORECTAL CANCER ( 3, 4,
T
WHO RECEIVED CHEMOTHERAPY




T
LYMPH NODE NEGATIVE)
N=137
Adjuvant chemotherapy is not recommended for routine use in patients with Stage II
colorectal cancer. However, for certain subgroups that may be at higher than average risk for
recurrence, it may be reasonable to consider its use. Features in Stage II CRC that are
associated with increased risk of recurrence include inadequate lymph node sampling (<12),
T4 disease, involvement of the visceral peritoneum and poorly differentiated histology. Other
consideration include presence of lymphovascular invasion, obstruction, perforation, positive
surgical margin (7). Evidence is inconsistent that adjuvant chemotherapy is associated with
improved overall survival when compared to surgery alone. The decision to use adjuvant
chemotherapy is complicated and requires thoughtful consideration by both the patient and
their physician (8).
During the study period, 2003-2012 there were 392 Stage II colorectal cancers accessioned
into the Cancer Registry. Of these, 35% (137) received chemotherapy as part of first course
treatment. When this practice was reviewed over a twenty year period 1993-2012, Saint
Agnes oncologists utilized chemotherapy for Stage II CRC in a consistent manner which was
comparable with national patterns of care; although, NCDB comparison data does not display
the sequence in which chemotherapy was given i.e. neoadjuvant versus adjuvant.
Of the 377 Stage II CRC cases treated by surgical resection, 21% (81) received adjuvant
chemotherapy. Of those, 37% (30) had less than 12 regional lymph nodes removed/examined
at the time of surgery which likely contributed to the decision to treat with adjuvant
chemotherapy.
When we looked at the survival of patients treated at Saint Agnes Medical Center with
Stage II colorectal cancer over the years 1993-2012 an increased survival was observed for
those who received chemotherapy when compared to those who did not. 2003-2006 NCDB
comparison data indicates our survival numbers for colorectal cancer are better than
average as far as the institution of chemotherapy and survival.
1993-2012 SAMC STAGE II COLORECTAL CANCER
RECEIVED SYSTEMIC TREATMENT
BY
5 YEAR INTERVALS
39%
41%
37%
34%
Adjuvant
Chemo
36%
1993-1997
N=147
Adjuvant
Chemo
34%
1998-2002
N=249
Adjuvant
Chemo
23%
Adjuvant
Chemo
24%
2003-2007
N=239
2008-2012
N=153
Resource: SAMC Cancer Registry
NATIONAL CANCER DATA BASE COMPARISON
2000-2011 STAGE II COLORECTAL CANCER
RECEIVING SYSTEMIC TREATMENT
SAMC N=520
38%
37%
Comp Comm CA Programs (all states)
37%
NCDB (all hospitals)
36%
35%
34%
33%
33%
32%
32%
31%
30%
29%
Chemo Given
Resources: SAMC Cancer Registry, NCDB Benchmark Comparison Reports 2000-2011
1993-2012 SAMC STAGE II COLORECTAL CANCER
SURVIVAL BY YEAR
N=788
No Chemo N=428
120%
100%
Chemo Given N=297
96.6%
84.8%
89.7%
85.4%
77.2%
80%
79.9%
70.6%
76.1%
60.2%
60%
51.3%
40%
20%
0%
YR 1
YR 2
YR 3
YR 4
YR 5
Resource: SAMC Cancer Registry
NATIONAL CANCER DATA BASE COMPARISON
2003-2006 STAGE II COLORECTAL CANCER
5 YEAR SURVIVAL
70.5%
SAMC
N=131
66.1%
NCDB
N=75,512
Resources: SAMC Cancer Registry, NCDB Survival Reports
NATIONAL CANCER DATA BASE
CANCER PROGRAM PRACTICE PROFILE REPORTS (CP3R)
FOR COLON



CP3R performance rates provided match the specifications of the colon and rectal
cancer care measures endorsed by the National Quality Forum.
The American College of Surgeons Commission on Cancer’s National Cancer
Data Base ratings are based on Cancer Registry annual data submissions.
The ratings provide approved cancer programs such as Saint Agnes Cancer
Program, an opportunity to evaluate the proportion of colorectal cancer patients
treated according to evidence based practice guidelines which ensures that we
achieve and maintain the highest level of care for our patients.




& RECTAL CANCERS
Colon measure (ACT): adjuvant chemotherapy is considered or administered within 4
months (120 days) of diagnosis for patients under age of 80 with AJCC Stage III (lymph
node positive) colon cancer.
Colon measure (12RLN): at least 12 regional lymph nodes are removed and
pathologically examined for resected colon cancer.
Rectum measure (AdjRT): Radiation therapy is considered or administered within 6
months (180 days) of diagnosis for patients under age 80 with clinical or pathologic
AJCC T4N0M0 or Stage III receiving surgical resection for rectal cancer.
Saint Agnes Medical Center’s Cancer Program met and/or exceeded compliance
for each of the three colorectal cancer performance measures evaluated by the
National Cancer Data Base for 2009, 2010 and 2011. Findings are displayed on
the following 3 graphs.
NATIONAL CANCER DATA BASE COMPARISON
CANCER PROGRAM PERFORMANCE
COLON MEASURE ACT
SAMC
Calif
NCDB (all hospitals)
100%
84%
2009
88%
83% 84%
2010
90%
86% 83%
89%
2011
Resource: NCDB Cancer Program Practice Profile Reports (CP3R)
NATIONAL CANCER DATA BASE COMPARISON
CANCER PROGRAM PERFORMANCE
COLON MEASURE 12RLN
SAMC
89%
84% 85%
2009
Calif
80%
85% 87%
2010
NCDB (all hospitals)
88% 87% 88%
2011
83%
2012
Resources: SAMC Cancer Registry, NCDB Cancer Program Practice Profile Reports (CP3R)
NATIONAL CANCER DATA BASE COMPARISON
CANCER PROGRAM PERFORMANCE
RECTUM MEASURE ADJRT
SAMC
94% 94%
Calif
NCDB (all hospitals)
100%
100%
91% 93%
90% 93%
83%
2009
2010
2011
Resource: NCDB Cancer Program Practice Profile Reports (CP3R)
2003-2012 SAMC COLORECTAL CANCER
DIAGNOSED AGE 50 & UNDER N=147




Studies acknowledge that the patient population, age 50 and younger, is more likely to
be diagnosed with late-stage colorectal cancer. It is believed that many people may not
suspect cancer when symptoms like bleeding, abdominal pain, or a change in bowel
habits strike someone in their 30s or 40s. The result is often a delay in diagnosis. (9)
During the study period 2003-2012 there were 147 (10%) cases of colorectal cancer that
were diagnosed at age 50 or younger (inclusive of one patient diagnosed with two
simultaneous colon primaries). Of the 147 cases, stage at diagnosis distribution showed
5% (6) were Stage 0, 27% (40) Stage I, 18% (26) Stage II, 29% (43) Stage III and 18% (26)
were Stage IV. When comparing stage at diagnosis by age our findings clearly reflect a
higher stage at diagnosis for those age 50 and under. Additionally, 11% (16) of these
patients had a personal history of at least one other primary cancer.
Saint Agnes Cancer Program would like to relay the message stressed by experts, “Just
because you’re under 50 doesn’t mean you’re not at risk.” Regardless of age, if you
experience symptoms such as the ones noted and/or have a family history of colorectal
cancer especially in a relative who had CRC before age 50, speak with your healthcare
provider immediately to investigate your concerns.
Since 2006 following the Bethesda Guidelines (10), efforts by our Cancer Committee have
helped ensure managing physicians of patients age 50 and younger who have a diagnosis
of colorectal cancer established at Saint Agnes Medical Center or those identified with
other types of cancer meeting criteria, are informed that their patient may be at risk of a
hereditary cancer predisposition syndrome. In these instances, genetic consultation and
testing may be indicated for better patient care. In hopes of preventing future cancers,
we feel that armed with this knowledge, patients, families and their physicians can
make informed decisions about their health care now and in the future.
2003-2012 SAMC COLORECTAL CANCER
STAGE BY AGE
N=1477
Age 50 & Under
Age Over 50
29%
27%
27.5%
26%
18%
20.5%
18%
16%
4%
5%
4%
2%
0
I
II
III
IV
UNK
Resource: SAMC Cancer Registry
SUMMARY / RECOMMENDATIONS






Saint Agnes Medical Center strives to provide the highest level of cancer care to those
who put their trust in us. As the data presented reveals our Saint Agnes team of
cancer professionals are treating colorectal cancer patients appropriately and
consistent with the highest quality cancer care as compared to the national data.
Saint Agnes Medical Center survival numbers for colorectal cancer indicate we are
better than average as far as the institution of chemotherapy and Survival.
Our Saint Agnes cancer specialists guided by the vision to deliver optimum care and
outcomes for our patients will continue to utilize the best treatments and newest
technologies. For example, in the future individualized care plans for colorectal cancer
will include the use of genomic assays to guide decisions about chemotherapy rather
than the stage of disease.
The American Cancer Society has identified colorectal cancer as a major priority
because the application of existing knowledge has such great potential to prevent
cancer, diminish suffering, and save lives. With this in mind, Saint Agnes Medical
Center would like to convey the importance of knowing the facts about colorectal cancer.
Don’t let embarrassment guide your decision to get screened or to seek medical advice if
you experience symptoms.
Screening has the potential to prevent colorectal cancer because most colorectal
cancers develop from adenomatous polyps. Polyps are noncancerous growths in the
colon and rectum. Though most polyps will not become cancerous, detecting and
removing them through screening can actually prevent cancer from occurring.
Furthermore, being screened at the recommended frequency (beginning at age 50 for
those of average risk) increases the likelihood that when colorectal cancer is present,
it will be detected at an earlier stage, when it is more likely to be cured, treatment is
less extensive, and the recovery is much faster.
In addition to screening, Saint Agnes Medical Center encourages everyone to know
their family history. In the case of colorectal cancer, sharing this information can
help spare you or your loved ones from a diagnosis of colorectal cancer or provide a
significant advantage by catching it early. Know your genes!
SOURCES
(1)
American Cancer Society; www.cancer.org
(2)
California Cancer Facts & Figures 2013
(3)
Family Health Portrait; www.samc.com/genetic-counseling
(4)
American Cancer Society; www.cancer.org
(5)
SAMC Cancer Registry database; www.samc.com
*Comment: This report is developed from our hospital based registry experience which is not ‘population based’ data.
(6)
American College of Surgeons, Commission on Cancer’s
National Cancer Data Base; www.facs.org
NCDB Benchmark Comparison Reports
Cancer Program Practice Profile Reports (CP3R)
(7)
National Cancer Institute; www.cancer.gov
(8)
American Society of Clinical Oncology Recommendations;
www.Cancer.net
(9) WebMD article, ‘Colorectal Cancer on the Rise in Adults Under 50’, citing
Archives of Internal Medicine, Dec.12, 2011; www.webmd.com/colorectal-cancer/news/20111212
(10) National Comprehensive Cancer Network (NCCN) Guidelines for Detection,
Prevention & Risk Reduction, Revised Bethesda Guidelines ; www.nccn.org