Download 2014 Prostate Cancer Study - Eastern Connecticut Health Network

The 2014 Cancer Program Annual Public Reporting of Outcomes/Annual Site Analysis
Statistical Data from 2013
More than 70 percent of all newly diagnosed cancer patients are treated in the more than
1,500 Commission on Cancer (CoC)-accredited cancer programs nationwide. For patients
and the community, the quality standards established by the CoC ensure a comprehensive
approach to care and information about clinical trials and new treatment options.
MMH has been a CoC accredited Cancer Program since November 2000. To earn
accreditation, we must successfully complete an on-site CoC review every three years that
assesses our compliance with the CoC standards, including assurance that patients are
afforded access to a full range of diagnostic and treatment services. It is recognition of the
quality of our comprehensive, multidisciplinary patient care.
ECHN strives to provide access to enhanced cancer care and services in a comfortable
environment close to home. Patients are guided through the continuum of care with
continued support, while they experience precise treatment and management plans tailored
to their individual needs. Our team takes pride in the fact that we are continually working to
enhance services, treatments and technologies available to our patients.
Annually, the Cancer Program publishes a Public Reporting of Outcomes/Annual Site
Analysis. We have selected prostate cancer as our focus this year due to the common nature
of this malignancy and the potential benefits derived from early diagnosis. In addition, the
American College of Surgeons, Commission on Cancer encourages hospitals, treatment
centers and facilities to improve the quality of patient care through a variety of
improvement programs. One of the latest revisions to the program standards includes
patient outcomes. The goal is to ensure that evaluation and treatments conform to
evidence-based national treatment guidelines. Each year a physician performs a study to
assess whether ECHN cancer patients are evaluated and treatment according to evidence
based national treatment guidelines. ECHN is extremely proud to share our patient’s
outcomes results in this report. Analyses of the 2013 newly diagnosed prostate cancer
patients indicate ECHN exceeds the national and state average in many areas.
Analysis of Prostate Cancer at Easter Connecticut Health Network
Using Cancer Registry Data
Goal: To determine whether a community-based comprehensive cancer program can
provide care to prostate cancer patient’s that is competitive to care provided at
academic/tertiary care centers in terms of techniques and outcomes. The ECHN Cancer
Registry and national data base were used for this comparative study.
Criteria: Data includes records of newly diagnosed patients seen at ECHN or referred from
another facility for complete or part of first course of treatment. Comparative retrospective
analyses were performed using the National Cancer Data Base (NCDB) including
Comprehensive Community Cancer Hospitals in all states.
Source: Cancer Registry Data Base at ECHN.
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Number of Prostate Cancer Cases Diagnosed and/or Treated by
Year
New Cases: According to the American Cancer Society (ACS) it is estimated there are nearly
3 million men with a history of prostate cancer living in the US as of January 1st, 2014 and an
additional 233,000 men will be diagnosed in 2014. Prostate cancer is the most frequently
diagnosed cancer in men aside from skin cancer. For reasons that remain unclear, incidence
rates are about 60% higher in African-Americans than in non-Hispanic whites. Incidence
rates for prostate cancer changed substantially between the mid-1980’s and mid1990’s and
have since fluctuated widely from year to year, in large part reflecting changes in the use of
the prostate-specific antigen (PSA) blood test for screening.
Comparative analysis of the NCDB data to ECHN data (please see below) notes a decrease in
the number of newly cases from 2011 to 2012 both locally and nationally. In 2011 ECHN
diagnosed 117 new cases with 87 cases diagnosed in 2012. Although this shows a 25%
decrease in the number of cases diagnosed annually, it remains our third most common
malignancy diagnosed and treated at ECHN. Similarly, the NCDB shows 55,894 newly
diagnosed cases in 2011 and 45,084 diagnosed in 2012 (data was not available to compare
for 2013). This represents a decrease of 19%.
The decrease in volume could be attributed to the new PSA screening criteria introduced at
that time. Until recently, many doctors and professional organizations encouraged yearly
PSA screening for men beginning at age 50. Some organizations recommended that men,
who are at higher risk of prostate cancer, including African American men and men whose
father or brother had prostate cancer, begin screening at age 40 or 45. However, as more
has been learned about both the benefits and harms of prostate cancer screening a number
of organizations have begun to caution against routine population screening. Although some
organizations continue to recommend PSA screening, there is widespread agreement that
any man who is considering getting tested should first be informed in detail about the
potential harms and benefits.
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Number of Prostate Cancer Cases Diagnosed and/or Treated by Year
118
117
115
92
87
ECHN Newly Diagnosed Prostate Cancer Cases
2009 - 2013
2010
2009
ECHN
118
115
59064
55454
2011
2012
2013
117
87
92
55894
45084
NCDB Newly Diagnosed Prostate Cancer Cases
2009-2012
NCDB
2009
59064
2010
55454
2011
55894
2012
45084
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Age Group of Prostate Cancer
ECHN versus Comprehensive Community Cancer Programs in All States
714 Hospitals (NCDB)
Newly Diagnosed Prostate Cancers
ECHN vs NCDB
Age at Diagnosis
25%
43%
39%
25%
23%
24%
9%
2%
7%
3%
40-49
50-59
60-69
70-79
80+
ECHN
2%
25%
39%
25%
9%
NCDB
3%
23%
43%
24%
7%
Risk Factors: The only well established risk factors for prostate cancer are increasing age,
African ancestry, or a family history of the disease. Studies suggest that a diet high in
processed meat or dairy foods may be a risk factor and obesity appears to increase the risk
of aggressive prostate cancer.
Above, NCDB data shows 74% of all prostate cancer cases were diagnosed in men 60 years
of age or older and 97% occurred in men 50 or older. Similar to the NCDB data, ECHN
diagnosed 73% of men age 60 or older with 98% diagnosed in men 50 or older.
Grade & Stage of Prostate Cancer at Diagnosis
Every cancer has a system of staging and grading that is specific to that type of cancer. Stage
describes how advanced a cancer is, whereas grade describes how much or little it looks
like normal tissue and how likely it is to spread. The stage and grade can help select and
predict the prognosis of the cancer.
The most commons grading system for prostate cancer is the Gleason score. It is based on
how the tissue sample looks. Grade 1 looks most like normal tissue and grade 5 looks very
different. Because more than one pattern is frequently seen in a sample, the 2 most
commonly seen patterns are added together to give you a Gleason score. It is uncommon to
see scores less than 6. Gleason 6 cancers are called low grade, Gleason 7 are intermediate
grade and Gleason 8, 9 and 10 are high grade. Images of the grades can be seen below:
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Prostate cancer is staged by the tumor, node and metastasis (TNM) staging system. ECHN,
as well as nationally, identify most newly diagnosed cases at Stage II. This means the
majority of prostate cancers are discovered in the local or regional stages for which the 5year survival rate approaches 100%.
Stage at Diagnosis: ECHN versus Comprehensive Community Cancer Programs
in All States - 714 Hospitals (NCDB)
57% 57%
Newly Diagnosed Prostate Cancer
ECHN versus NCDB
Stage at Diagnosis
32%
23%
10%
5%
6% 6%
0%
3%
STAGE I
STAGE II
STAGE III
STAGE IV
UNKNOWN
ECHN
32%
58%
5%
5%
0%
NCDB
24%
57%
10%
6%
3%
Stage: ECHN continues to diagnose and treat early stage cases in a manner higher than the
national average. 89% of ECHN patients were diagnosed with Stage I or II disease compared
to the NCDB at 80%. Only 10% of ECHN patients were diagnosed with late stage disease
compared with 16% nationally.
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Treatment at Diagnosis
Decision making regarding initial treatment choice is made as a collaborative effort
between clinicians and the patient, taking into consideration the patient’s physical status,
possible co-morbidities, social economic support systems, treatment options and personal
preferences. The approach to treatment is influenced by age stage and grade of cancer, as
well as co-existing medical conditions and should be discussed with the individual patient.
Surgery (open, laparoscopic or robotic-assisted), external beam radiation or radioactive
seed implants (brachytherapy) may be used to treat early stage disease. Data show similar
survival rates for patients with early stage disease treated with any of these methods and
there is no current evidence supporting a “best” treatment for prostate cancer. Hormonal
therapy may be added in some cases. More advanced disease is treated with hormonal
therapy, radiation therapy and or other treatments. Side effects of various forms of
treatment should be considered in selecting appropriate management.
First Course Treatment: ECHN versus Comprehensive Community Cancer
Programs in All States - 714 Hospitals (NCDB)
52%
Newly Diagnosed Prostate Cancer
ECHN vs NCDB
First Course Treatment
35%
18%
19%
20%
15%
12%
10%
7%
7%
3%
2%
Surgery Only
Radiation Only
RT & Hormone
Hormone Only
Active
Surveillance
Other
ECHN
35%
18%
15%
10%
20%
2%
NCDB
52%
19%
12%
3%
7%
7%
Treatment: The above table reflects the treatment pattern comparison between ECHN and
national data. ECHN data reflects a much higher rate of active surveillance (20% vs 7%) and
a much lower rate of surgery only (35% vs 52%). Accumulating evidence suggests that
careful observation (active surveillance), rather than immediate treatment, is an
appropriate option for men with less aggressive tumors and for older men. An approach
such as this may be recommended if your cancer is not causing any symptoms, is expected
to grow slowly (based on Gleason score), and is small and contained within the prostate.
This type of approach is not likely to be a good option if you have a fast-growing cancer (for
example, a high Gleason score) or if the cancer is likely to have spread outside the prostate
(based on PSA levels). Men who are young and healthy are less likely to be offered active
surveillance, out of concern that the cancer will become a problem over the next 20 or 30
years.
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During active surveillance, prostate cancer is carefully monitored for signs of progression. A
PSA blood test and digital rectal exam (DRE) are usually administered periodically along
with a repeat biopsy of the prostate at one year and then at specific intervals thereafter. If
symptoms develop, or if tests indicate the cancer is growing, treatment might be warranted.
Survival
The majority (83%) of prostate cancer cases are discovered in the local or regional stages,
for which the 5-year survival rate approaches 100%. Over the past 25 years, the 5 year
survival rate for all stages combined has increased from 68% to almost 100%. Obesity and
smoking are associated with an increased risk of dying from prostate cancer. According to
the most recent data, 10 and 15 year survival rates are 99% and 94% respectively.
Due to the minimal number of cases with higher stage disease treated at ECHN, survival
rates could only be calculated with Stage II disease. Comparative analysis shown below
reveals that survival analysis for Stage II patients compare favorably and are relatively the
same (91.5% vs 90.8%).
Survival for Prostate Cancer Case Diagnosed and/or Treated at ECHN
ECHN Survival Data
Stage of Disease 0.0 yr 1.0 yr 2.0 yr 3.0 yr 4.0 yr 5.0 yr 95% Confidence Interval
Stage II
100.0 99.6
98.5
96.3
93.4
91.5
88.1 - 94.9
NCDB Survival Data
Stage of Disease 0.0 yr 1.0 yr 2.0 yr 3.0 yr 4.0 yr 5.0 yr 95% Confidence Interval
Stage II
100.0 98.7
97.1
95.3
93.2
90.8
90.7 - 90.9
Physician Critique
Each year, a Cancer Program Physician performs a study to assess whether ECHN cancer
patients are evaluated and treated according to evidence based national guidelines. In 2014,
an analysis of prostate cancer was performed using ECHN and NCDB data. The area
reviewed was for prostate cancer patients diagnosed in 2013 as that was the latest year of
complete data available at the time of review. The NCDB data included cases from 714
hospitals accredited by the Commission on Cancer (CoC). The guidelines referenced were
the National Comprehensive Cancer Network (NCCN). This study must determine that the
diagnosis evaluation is adequate and the treatment plan is concordant with the NCCN
guidelines. Should any problems be identified in either area, they could be used for a
performance improvement.
As part of our chart review we utilized the NCCN Guidelines Version 2.2014, Prostate
Cancer, to assess if concordant therapy was selected for the patients treatment plan.
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Our analysis included all 2013 newly diagnosed prostate cancer cases looking at their age at
diagnosis, PSA value, Gleason Score, DRE, clinical stage at diagnosis, risk group, work up and
treatment received and then determined if the chart was concordant with the NCCN
recommendations. If the case was not, we then sought documentation as to why that
particular treatment option was selected.
Assessment and Evaluation of Treatment Planning
Age at Diagnosis:
As noted earlier, the majority of men diagnosed with prostate cancer are 60 years or older.
Keeping with national statistics ECHN data shows 73% of men age 60 years old greater
compared to NCDB at 74%. In addition, only a small percentage of men are diagnosed
younger than 50 years of age (ECHN = 2% vs NCDB= 3%). Overall, 98% of the men
diagnosed in 2013 were age 50 or greater.
AJCC Clinical Stage Completed by the Managing Physician
All patients with prostate cancer should be assigned a clinical stage at diagnosis. Stage
describes how advanced a cancer is. Prostate cancer is staged by the tumor (T), node (N)
and metastasis (M), as well as the Digital Rectal Exam (DRE), PSA and Gleason grade score.
Clinically staging the patient’s disease at diagnosis allows for efficient treatment planning.
It also enables the comparison of outcome results with national benchmarks, screening for
clinical research accruals and provides a baseline for prognostic information.
2013 newly diagnosed prostate cancer cases were reviewed and 100% had AJCC clinical
stage completed by the managing physician. Of those, 96% were diagnosed in local or
regional stages. According to the most recent data, the 10 year survival rate for this stage of
disease is 99%.
Results: 100% of the cases were concordant with staging completed by the managing
physician.
Risk Groups: Criteria to determine the patient’s appropriate risk group include the
Gleason score, PSA value, number of biopsy cores positive and stage of disease. The 2013
ECHN Risk Groups are as follows:
Very Low
19%
Low
10%
Intermediate 50%
High
19%
Very High
0%
Metastatic
2%
Staging Work Up:
NCCN guidelines recommend a staging work up completed for those individuals with
certain T values, Gleason scores and suspicion of lymph node involvement for those patients
with a life expectancy greater than 5 years or symptomatic.
Results: 41% of the patients underwent a bone scan, pelvic CT or MRI. Review of each case
noted concordance with NCCN guidelines when ordering the tests and there were no
patients that did not receive the appropriate work up – 100% concordance.
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Treatment:
Decision making regarding initial treatment choice is made in a collaborative effort between
clinicians and the patient, taking into consideration the patient’s physical status, possible
co-morbidities, social economic support systems and treatment options. The approach to
treatment is influenced by age and co-existing medical problems.
According to NCCN guidelines primary treatment options vary depending on age, stage and
grade of cancer, as well as other medical conditions, Early stage disease may be treated with
active surveillance, surgery (open, laparoscopic or robotic-assisted), external beam
radiation or radioactive seed implants (brachytherapy). Data show similar survival rates for
patients with early stage disease treated with any of these methods and there is no current
evidence supporting a “best” treatment for prostate cancer. More advanced disease is
treated with hormonal therapy, chemotherapy, radiation therapy and/or other treatments.
NCCN guidelines recommend treatment based on the patients risk group, as well as
expected survival (<10 years versus ≥ 10 years life expectancy).
Risk Group → Treatment
Very Low
Active Surveillance – 75%
Low
Active Surveillance – 0%
Surgery – 17%
RT – 8%
Surgery – 40%
RT – 60%
Intermediate
Active Surveillance – 24%
RT/Lupron – 30%
Surgery – 22%
Hormone – 6%
RT – 15%
Refused – 3%
Surgery – 38%
Hormone -23%
RT – 0%
No Treatment (expired) – 8%
High
Active Surveillance – 0%
RT/Lupron – 31%
Results:
Intermediate – active surveillance cases were reviewed – active surveillance is
recommended for those patients with less than a 10 year life expectancy – review noted all
cases had documentation as why this treatment option was selected. 100% concordance
Overall Treatment
Looking below at ECHN vs NCDB data, ECHN reflects a higher rate of active surveillance
(20% vs 7%) and a lower rate of surgery (35% vs 52%). Accumulating evidence (NCCN
guidelines) suggests careful observation (active surveillance), rather than immediate
treatment, is an appropriate option for men with less aggressive tumors and for older men.
ECHN
NCDB
Surgery
Radiation
RT &
Hormone
Hormone
Active
Surveillance
Other
35%
18%
15%
10%
20%
2%
52%
19%
12%
3%
7%
7%
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Survival:
Nationally the majority (83%) of prostate cancer cases are discovered in the local or
regional stages, for which the 5-year survival rate approaches 100%. Over the past 25 years,
the 5 year survival rate for all stages combined has increased from 68% to almost 100%.
Obesity and smoking are associated with an increased risk of dying from prostate cancer.
According to the most recent data, 10 and 15 year survival rates are 99% and 94%
respectively. Survival rates at ECHN (91.5%) are comparative to those nationally (90.8%)
Conclusion/Analysis: Overall the diagnosis, treatment and outcomes of prostate
cancer at ECHN and the NCDB are relatively similar. ECHN exceeds in the area of stage
at diagnosis and is on par with age, and survival when compared to national standards.
Review of NCCN guidelines shows that ECHN met 100% concordance in staging work up
and treatment recommendations for all risk groups. Therefore, we have determined that
ECHN can and does provide care to our prostate cancer patient’s that is comparative to care
provided at academic/tertiary care centers in terms of techniques and outcomes.
Prostate cancer continues to be a disease seen frequently in our country, state and
community. Cure rates are clearly related to early diagnosis. The continued monitoring of
trends in the patterns of care of prostate care at ECHN to national patterns will ensure that
our patients continue to receive the best possible care.
Our comprehensive team approach combines state-of-the-art technology, clinical expertise
and compassionate care. We bring together experts from all disciplines to develop a
complete diagnosis, treatment and support plan to fight your particular cancer, and to get
you back to living life.
We at ECHN will continue our commitment to provide a unique continuum of care driven by
advanced technology, supportive resources and the extraordinary dedication of a highly
skilled team of compassionate professionals providing patients and their families with the
highest quality diagnosis and cancer treatment close to home.
Submitted by David Rosenberg, MD, Urologist
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