Download The Cancer Institute of New Jersey at Cooper Cancer Registry

The Cancer Institute of New Jersey at Cooper
2005
Cancer Registry Annual Report
Table of Contents
Introduction from Cancer Committee Chairman
2
Cancer Committee Chairman’s 2005 Report
3
Cancer Registry Report for 2005
8
Statistical Summary
10
Site Specific Studies
18
The Cancer Institute of New Jersey and Affiliate
2004 Short-term Prostate Study
18
The Cancer Institute of New Jersey at Cooper
2005 Long-term Lung Study
29
Cancer Committee Members
39
Glossary/References
41
1
Introduction from Cancer Committee Chairman
Dear Friend,
I am excited to report that 2005 has been a year of dramatic growth for the
Cancer Institute of New Jersey (CINJ) at Cooper. As you will see in this
detailed report, the clinical volume seen at CINJ at Cooper has increased
significantly. This volume is reflected in both new patient appointments
as well as follow-up appointments across all departments and divisions
engaged in our program.
As patient volumes grew, we identified the need for additional clinical staff
and began an aggressive recruitment effort in several clinical specialty areas.
To accommodate the growth of our patients and staff, we have also
expanded our clinical facilities.
This year we also saw the launch of our basic research initiative in
collaboration with UMDNJ-Robert Wood Johnson School of Medicine
and the Coriell Institute. This is an exciting endeavor and I look forward
to its continued progression.
Through our affiliation with the Cancer Institute of New Jersey and
continued state funding we have been able to expand our clinical services,
research and outreach activities to meet the growing need for outstanding
cancer detection and care for the residents of South Jersey. Our focus on
providing a multidisciplinary approach to cancer care is stronger than ever
and an emphasis on patient- and family-centered care continues to guide
each of our programs.
We look forward to 2006. All indicators lead us to expect another year of
growth within our disease specific programs. Our focus on patient and
family-centered care will continue to guide us and our investment in basic
and clinical research activities will remain firm.
Sincerely,
Generosa Grana, M.D.
Director of the Cancer Institute of New Jersey at Cooper
Head, Division of Hematology-Oncology
Associate Professor of Medicine
UMDNJ-Robert Wood Johnson School of Medicine
Cooper University Hospital
2
Cancer Committee Chairman’s 2005 Report
GOALS
The Cancer Committee goals for 2005 revolved around the expansion of the
disease specific programs, a focus on patient and family experiences within the
cancer program and the growth of the complementary medicine program.
DISEASE SPECIFIC PROGRAMS
Within the disease specific program, significant energy was spent on
identifying key staffing needs, strategic capital needs, research priorities and
crucial patient care issues within each specific disease site. The six disease
specific programs include:
• Breast Cancer Program
• Leukemia & Lymphoma Program
• Gastrointestinal Cancer Program
• Genitourinary Cancer Program
• Gynecologic Oncology Cancer Program
• Lung Cancer Program
In addition to these six programs, activity also revolved around the
development of the Head and Neck Cancer Program, the Neuro-Oncology
Program and the Geriatric Oncology Program. For each of these programs,
a nurse coordinator was appointed, tumor boards were organized and
carried out and quarterly planning meetings were put in place. Within each
of the disease specific projects, significant attention was paid to community
and physician educational programs as well as clinical research.
CLINICAL SERVICES
CINJ at Cooper clinical services involve activities of:
• Hematology-Oncology
• Dermatology
• Gynecologic Oncology
• Neuroscience
• Radiation Oncology
• Oral & Maxillofacial Surgery
• Surgical Oncology
• Pediatric Hematology & Medical Oncology
• Radiology
• Research
• Pathology
Each of these departments, divisions or programs has come together to
work as a unit, focusing on systematic programmatic growth and addressing
programmatic needs. Within each of these areas, there has been significant
growth in terms of patient volume, faculty recruitment and clinical
research activity.
3
• Gynecologic Oncology, under the leadership of Dr. David Warshal,
continues to play a leading role within the Gynecologic Oncology
Group and continues to draw patients from all of Southern New Jersey,
as well as the Philadelphia suburbs.
• Radiation Oncology, under the leadership of Dr. Steven DiBiase, has
grown to include two radiation oncologists in addition to Dr. DiBiase.
Cancer Center funding has resulted in significant enhancements in
technology currently available at Cooper within the two radiation
therapy sites in Voorhees and Camden.
• Surgical Oncology has seen significant growth and expansion of
outpatient services.
• Hematology Oncology has also seen significant growth in clinical
services across the four locations where cancer services are delivered
(Stratford, Willingboro, Voorhees and Camden).
Many facilities have been renovated to enhance the patient’s experience
and accommodate growth in the program. New staff members were
recruited across each of these sites and again significant programmatic
growth continues.
Investing in Radiology, under the leadership of Dr. Ray Baraldi, has
continued to be a priority for inpatient and outpatient delivery areas. The
Voorhees outpatient imaging site will focus on women’s imaging and
cancer-related imaging while the spectrum of services available at the
hospital will also increase.
Dr. Roland Schwarting, as chairman of the Department of Pathology, has
started to reorganize this key department. Funds from CINJ at Cooper will
help transform this department into a state-of-the-art program equipped to
meet the needs of a growing cancer program. With an emphasis on molecular
diagnostic technology, as well as enhancements in clinical and other services,
Dr. Schwarting will oversee the evolution of the pathology department.
The Diane Barton Complementary Medicine Program continues to grow
under the leadership of Bonnie Mehr. Completely supported through
philanthropic means, the program has expanded to include an increasing
array of outpatient services, as well as services provided in the hematologyoncology inpatient unit at Cooper University Hospital. Focusing on the
utility of Complementary Medicine services and the benefit of these services
in conjunction with standard treatment, cancer patients are getting broad
support during their cancer experience.
4
The Behavioral Medicine Program, under the leadership of Dr. Erin
O’Hea, has grown significantly. The post-doctoral students from La Salle
University rotate through our program and provide ongoing services to our
patients. Dr. Edwin Boudreux is also providing services in the Camden
setting to both inpatient and outpatient areas. Focusing on behavioral
health services as well as research around cancer and cancer survivorship,
the program has thrived.
COMMUNITY OUTREACH
Significant energy has been focused on the dissemination of cancer screening
and information regarding cancer prevention and early detection. Under
the leadership of Evelyn Robles-Rodriguez, N.P., Director of Community
Outreach Programs for CINJ at Cooper, the activities of this program have
grown significantly. Cooper has taken a leading role in the tri-county area and
is working closely with the state in identifying needs as well as developing
strategies to reach the community. Continued funding through the
Department of Health and Senior Services has allowed Cooper to continue
to provide significant numbers of screening services to uninsured and
underinsured individuals residing in Camden County (breast cancer, cervical
cancer, colorectal cancer and prostate cancer). To successfully reach the
community, we have worked closely with local and community organizations,
as well as other healthcare institutions within the Camden County area.
BASIC RESEARCH
Under the leadership of Dr. Peter Melera, significant energy has been
focused on developing an infrastructure for basic cancer research. Dr. Melera,
with support from CINJ at Cooper, has invested in novel equipment needed
to support the growing research infrastructure. Recruitment of faculty has
begun with the recruitment of Dr. Judy Keen whose focus is on breast cancer
and estrogen receptor modulation. Continued recruitment for additional
faculty will ensue. Under the leadership of Dr. Melera, the Molecular
Medicine Division of the medical school has begun to take shape.
5
EDUCATION
Significant emphasis has been placed on community education, physician
and nursing education, as well as and patient education. A full array of
community education programs have been sponsored by CINJ at Cooper
this past year. Physicians and nurses across the departments and divisions
have spent significant time working to disseminate cancer screening,
prevention and early detection, as well as treatment information to the
community. Physician and Nurse Education Programs have also been
supported or sponsored by CINJ at Cooper. These programs have targeted
both primary care physicians, as well as nursing and other healthcare
providers. Patient education programs have been carried out by nurse
coordinators and other nursing staff as well as by physicians within the
cancer program.
CME Programs – 2005
• New Concepts in Gynecologic Disease
• Advancing Science through Clinical Research
• Breast Cancer Update for the Primary Care Provider
• Lung Cancer Update
• Colorectal Cancer Update
• Prostate Cancer Update: Screening, Diagnosis and Treatment
6
Community Programs – 2005
• In the Looking Glass
• Colorectal Cancer Update & Awareness Program
• Caring for Yourself After Breast Cancer
• Race for the Cure
• Relay for Life
• Cancer Survivors’ Day
• Run for Dad
• Walk for the Whisper
• Prostate Cancer Update & Awareness Seminar
• Cancer & the Jewish Woman
• Don’t Put It off Any Longer…Quit Smoking Today
• CINJ Network Event
• Breast Cancer Update: Recent Advances
• 2nd Annual Lesbian Health Conference
• Light the Night
• Making Strides Against Breast Cancer Walk
• South Jersey Lung Cancer Walk and Rally
• Don’t Let Your Life Go Up In Smoke – Lung Community Program
• Celebration of Life and Remembrance
7
Cancer Registry Report for 2005
Diane M. Bush, CTR, Registry Manager
A cancer registry is an information system designed for the collection,
management, and analysis of data on persons with the diagnosis of a
malignant or neoplastic disease (cancer). The registry is an important
component of the cancer program as it provides vital statistics and
information to staff, administration and the public.
The Cancer Registry of The Cancer Institute of New Jersey (CINJ) at
Cooper has a reference date of 1996. The registry abides by the guidelines
set forth by the American College of Surgeons, Commission on Cancer.
Data for analytic cases, those patients who were diagnosed and/or treated
at Cooper, is submitted to the New Jersey State Cancer Registry, under the
Department of Health and Human Services, and to the National Cancer
Database of the Commission on Cancer for outcome evaluations and use in
various types of epidemiological investigations. Data items collected by the
registry for Analytic Cases include: demographic information, diagnostic
work-up, first course of therapy, time of recurrence, disease–free survival
intervals, subsequent treatment, and lifetime follow-up.
Cases are ascertained from the following: Disease Indexes, Pathology/Cytology
Reports, Specialized IT Reports, Physician Consult/Treatment/Follow-up
Letters and monthly files are created from the hospital mainframe
HealthQuest and IDX by the IT department. The files are created according
to software vendor specifications that include the “Reportable List” from
the State of NJ Ca Registry, and are retrieved by the cancer registry manager,
then downloaded into the registry software IMPAC.
Annette Harley, CTR, joined the staff in March 2005 and Jacqueline EllisRiffle earned her CTR in September 2005. The registry currently has four
Certified Tumor Registrars (CTR). All registry staff are members of the
National Cancer Registrars Association and the Oncology Registrars
Association of NJ. The registry manager attended the Survey Savvy
Workshop in November 2005 given by the American College of Surgeons
in preparation for the upcoming survey on December 13, 2006.
The purpose of Annual Follow up for analytical patients is to ensure continued
medical surveillance and to monitor the health status of the population
under investigation. It is also a mandatory component of the American
College of Surgeons (ACOS) approvals program. The follow up rate for
the last quarter of 2005 is 96.78%.
8
The American College of Surgeons, Commission on Cancer Program
Standards 2004 mandates review of 10% of annual analytic caseload for
each facility. Analytical cases for 2005 were reviewed by Registry Physician
Advisor - Robert Somer, M.D., Cancer Liaison - Umar Atabek, M.D., Alex
Hageboutrous, M.D., Justin Harmon, D.O., James Stevenson, M.D. and
David Warshal, M.D.
As a Teaching Hospital Cancer Program, a mandatory 4% of our patient
population must be on Clinical Trials. In the year 2005, 164 patients
participated in various Research/Clinical Trials or 13% of the total analytical
caseload for 2005.
CINJ at Cooper had a total of 184 Tumor Boards for 2005 with treatment
options for 875 prospective patients discussed at our multidisciplinary
tumor boards. A Head and Neck Tumor Board was added in July 2005.
Video Conferencing between Camden and Voorhees locations began in
November 2005 and the first of a quarterly series of Thoracic-Oncology
Grand Rounds (didactic lecture) began on December 7, 2005.
The Cancer Institute of New Jersey’s Performance Improvement
Committee currently monitors 20 indicators in 9 separate areas of activity:
nurse coordinators, outpatient social work, radiation oncology, outpatient
nutrition, hematology oncology, hem-onc inpatient nursing unit, outpatient
chemotherapy infusion, gynecology oncology, and cancer registry. Its PI
process was presented at the Survey Savvy Workshop sponsored by the
American College of Surgeons-Commission on Cancer by the registry
manager and was recommended to be a BEST PRACTICE by the National
Cancer Data Base - Research Division. If chosen, our PI process will be
utilized as an example and training tool for other facilities.
2005 Goals
Our four goals were all achieved in 2005:
• Clinical – initiate a Palliative Care Program
• Community Outreach – expand The Dr. Diane Barton Complimentary
Medicine Program to include art therapy, music therapy and journaling
• Quality Improvement – begin the “First Impressions Program,” where
individuals, not associated with the cancer program, spend time in
satellite outpatient office waiting areas to observe the interaction
between staff and patients
• Programmatic Goal – create a Disease Specific Project, whereby
participants would identify staffing needs, capital needs, research
priorities and patient care issues within specific disease sites
9
Statistical Summary of Cancer Registry Data
The reference date for the Cancer Registry is January 1, 1996. The registry
database is composed of 25,694 cases, as of October 10, 2006. Information
collected includes: analytical cases, history of cancer, suspense cases (cases
waiting to be abstracted), slide review only (reportable only to NJ State
Cancer Registry), and other non-reportable cases such as cases entered for
registry use only.
Top Five Cancer Sites (Male and Female Combined)
Percent of Total Annual Analytic Cases 2001-2005
80%
70%
Top 5 Combined
60%
Colon/Rectum
50%
Prostate
40%
Uterus
(Corpus/Cervix)
30%
Lung
20%
Breast
10%
0%
2001
2002
2003
2004
2005
58.9%
60.8%
67.4%
68.2%
61.3%
# Pts / %
# Pts / %
# Pts / %
# Pts / %
# Pts / %
98 8.9%
94 8.9%
99 10%
102 8.5%
108 8.3%
103 9.3%
108 10.2%
82 8.8%
141 11.8%
128 9.8%
Uterus (Corpus/Cervix)
109 10.3%
113 10.8%
114 11.8%
142 11.9%
125 9.5%
Lung
116 10.6%
108 10.2%
93 9.9%
124 10.4%
152 11.7%
Breast
218 19.8%
219 20.7%
261 26.8%
306 25.6%
286 22%
Top 5 Combined Sites
Colon/Rectum
Prostate
10
Male vs. Female by Age Group and SEER Summary Stage Analysis 2005
Percent of Gender for Total Analytic Cases 2001-2005
Male N=1,997; Female N=3,609
Male vs. Female by Age Group at Diagnosis
Male
Female
29.1
30%
27.1
25%
21.9
20%
23.0
20.7
19.1
18.4
15%
10%
8.6
7.6 8.1
6.9
5%
1.9
2.7
13.1
0.7 1.1
0%
-29
40-49
30-39
50-59
60-69
70-79
80-89
90+
In 2005, the highest incidences of cancer were diagnosed between the ages of
60+, representing 29.1% of the male population and 23.0% of the female
population and the majority had localized tumors, as seen below.
Male vs. Female by SEER Summary Stage at Diagnosis
Male
45%
Female
43.9
41.8
40%
35%
30%
25%
23.5
20%
23.3
18.5
16.5
15%
11.3
9.5
10%
6.9
5%
4.8
0%
In Situ
Localized
Regional
Distant
Unknown
11
Class of Case and County at Diagnosis 2005
Percent of Total Analytic Cases 2005
Class of Case Designation
Class of Case 2 41%
Class of Case 1 57%
Class of Case 0 3%
In 2005: there were 57% Class of Case 1 cases, indicating The Cancer
Institute of New Jersey at Cooper diagnosed and treated the majority of its
patients. There were 41% Class of Case 2 cases, who were diagnosed elsewhere and came to The Cancer Institute of New Jersey at Cooper for
treatment. While the remaining 3% were Class of Case 0 cases – diagnosed
at The Cancer Institute of New Jersey at Cooper but went elsewhere for
treatment.
County of Residence at Diagnosis
Gloucester 13.3%
Atlantic 6.8%
Burlington 18.2%
Cumberland 3.9%
Other 21.7%
Camden 46.9%
Out of State 2.5%
Salem 2.3%
Cape May 2.2%
Mercer 1.7%
Ocean 1.6%
Other County in State 0.7%
County breakdown in 2005: 46.9% cases came from Camden, 18.2% from
Burlington, 13.31% from Gloucester and remaining 21.7.9% from mixed
counties and out-of state.
12
Cancer Incidence 2005
The Cancer Institute of New Jersey at Cooper compared to
Estimated American Cancer Society (ACS)
Percent of Gender for Total Analytic Cancer Cases 2005
Top 10 Primary Sites* (FEMALES)
The Cancer Institute of New Jersey at Cooper
The American Cancer Society (Estimated New Cases)
35
31.9
30
26.0
25%
20%
15.1
15%
12.0
11.1
9.5
10%
5.4
5%
1.2
2.4
1.3
2.1
2.2 2.4
2.7
4.1
7.7
6.4
6.4
3.4
2.9
0%
Urinary
Bladder
Kidney &
Renal Pelvis
Pancreas
Lymphoma Colon/Rectum
(Non-Hodgkin)
Ovary
Thyroid
Lung/
Uterus
Bronchus (Corpus/Cervix)
Breast
In 2005,The Cancer Institute of New Jersey at Cooper is lower than the
ACS estimated new female cases in Urinary/Bladder, Kidney/Renal/Pelvis,
Non-Hodgkin’s Lymphoma, Colon/Rectum, Lung and Breast but higher
than the ACS estimated cases in Ovary, Thyroid, Uterus(Cervix & Corpus).
Pancreas is comparable at 2.2% and the estimated % is 2.4%.
13
The Cancer Institute of New Jersey at Cooper compared to
Estimated American Cancer Society (ACS)
Percent of Gender for Total Analytic Cancer Cases 2005
Top 10 Primary Sites* (MALES)
The Cancer Institute of New Jersey at Cooper
The American Cancer Society (Estimated New Cases)
35%
32.7
30%
27.0
25%
20%
15.4
15%
13.2
11.2
10%
10.1
6.6
5%
3.0
1.6
3.0
1.9
3.0 2.8
3.0
3.2 2.7
3.6 4.1
4.4
2.3
0%
Esophagus
Stomach
Leukemia
Urinary
Bladder
Oral Cavity Lymphoma
Pancreas
& Pharynx (Non Hodgkin)
Colon/
Rectum
Lung/
Bronchus
In 2005,The Cancer Institute of New Jersey at Cooper is lower than
the ACS estimated new male cases in Urinary Bladder, Non-Hodgkin’s
Lymphoma and Prostate but higher than the ACS estimated cases in
Esophagus, Stomach, Lung, Colon/Rectal and Pancreas. Leukemia is
comparable at 2.8 % and the estimated % is 3.0 %.
14
Prostate
2005 Primary Site Distribution Table
Sex
PRIMARY CANCER SITE
Vital Status
InSitu
Regional
Unk
Localized
Distant
# Cases
% Total
M
F
19
1.46
16
3
17
2
1
4
9
4
1
0
Lip
0
0
0
0
0
0
0
0
0
0
0
0
Tongue
7
0.54
6
1
6
1
1
2
3
1
0
0
Salivary Glands
1
0.08
1
0
1
0
0
0
0
0
1
0
Floor of Mouth
1
0.08
0
1
1
0
0
1
0
0
0
0
Gum & Other Mouth
2
0.15
2
0
2
0
0
0
2
0
0
0
Nasopharynx
3
0.23
2
1
3
0
0
1
1
1
0
0
Tonsil
2
0.15
2
0
1
1
0
0
2
0
0
0
Oropharynx
3
0.23
3
0
3
0
0
0
1
2
0
0
Hypopharynx
0
0
0
0
0
0
0
0
0
0
0
0
Other Oral Cavity & Pharynx
0
0
0
0
0
0
0
0
0
0
0
0
227
17.43
128
99
148
79
20
56
84
61
6
0
Esophagus
19
1.46
14
5
8
11
0
4
7
7
1
0
Stomach
21
1.61
15
6
10
11
1
6
6
6
2
0
Small Intestine
5
0.38
0
5
3
2
1
3
1
0
0
0
Colon, Excluding Rectum
81
6.22
45
36
67
14
10
18
37
16
0
0
Cecum
18
1.38
6
12
14
4
1
5
8
4
0
0
Appendix
0
0
0
0
0
0
0
0
0
0
0
0
Ascending Colon
18
1.38
8
10
15
3
1
5
8
4
0
0
Hepatic Flexure
5
0.38
3
2
5
0
1
0
4
0
0
0
Transverse Colon
6
0.46
4
2
6
0
2
1
1
2
0
0
Splenic Flexure
1
0.08
1
0
1
0
0
0
1
0
0
0
Descending Colon
2
0.15
1
1
2
0
0
0
2
0
0
0
Sigmoid Colon
23
1.77
17
6
19
4
4
6
10
3
0
0
Large Intestine, NOS
8
0.61
5
3
5
3
1
1
3
3
0
0
Rectum & Recto sigmoid
27
2.07
18
9
25
2
6
10
9
2
0
0
Rectosigmoid Junction
9
0.69
5
4
8
1
3
3
1
2
0
0
Rectum
18
1.38
13
5
17
1
3
7
8
0
0
0
Anus, Anal Canal
5
0.38
0
5
5
0
0
3
2
0
0
0
Liver
9
0.69
7
2
4
5
0
7
0
1
1
0
Intrahepatic Bile Duct
1
0.08
1
0
0
1
0
1
0
0
0
0
Gallbladder
7
0.54
3
4
5
2
2
0
2
3
0
0
Other Biliary
4
0.31
2
2
2
2
0
0
2
0
2
0
Pancreas
39
3.00
21
18
13
26
0
4
11
24
0
0
Retroperitoneum
2
0.15
1
1
0
2
0
0
2
0
0
0
Peritoneum, Omentum
6
0.46
0
6
5
1
0
0
5
1
0
0
Other Digestive Organs
1
0.08
1
0
1
0
0
0
0
1
0
0
Oral Cavity & Pharynx
Digestive System
Alive Exp
SEER Summary Stage at Diagnosis
B/B
15
Sex
PRIMARY CANCER SITE
Vital Status
SEER Summary Stage at Diagnosis
InSitu
Regional
Unk
Alive Exp
Localized
Distant
# Cases
% Total
M
F
166
12.75
83
83
77
89
2
29
34
92
9
0
Nose, Nasal Cavity & Middle Ear
0
0.00
0
0
0
0
0
0
0
0
0
0
Larynx
14
1.08
10
4
9
5
2
6
3
3
0
0
Lung & Bronchus
152
11.67
73
79
68
84
0
23
31
89
9
0
Pleura
0
0
0
0
0
0
0
0
0
0
0
0
Trachea, Mediastinum & Heart
0
0
0
0
0
0
0
0
0
0
0
0
Bones & Joints
0
0.00
0
0
0
0
0
0
0
0
0
0
Soft Tissue
5
0.38
4
1
3
2
0
3
2
0
0
0
Skin (Excl Basal & Squamous Ca)
14
1.08
6
8
14
0
1
12
0
1
0
0
Melanoma
14
1.08
6
8
14
0
1
12
0
1
0
0
Other Non-Epithelial Skin
0
0
0
0
0
0
0
0
0
0
0
0
Breast
286
21.97
1
285 279
7
70
128
78
10
0
0
Female Genital System
207
15.90
0
207 182
25
11
90
62
42
2
0
Cervix Uteri
37
2.84
0
37
32
5
0
19
16
2
0
0
Corpus Uteri
85
6.53
0
85
80
5
0
55
27
2
1
0
Uterus, NOS
3
0.23
0
3
2
1
0
0
2
1
0
0
Ovary
53
4.07
0
53
44
9
0
7
11
34
1
0
Vagina
8
0.61
0
8
5
3
2
4
2
0
0
0
Vulva
18
1.38
0
18
17
1
8
5
4
1
0
0
Other Female Genital
3
0.23
0
3
2
1
1
0
0
2
0
0
Male Genital System
134
10.29
134
0
131
3
1
108
18
7
0
0
Prostate
128
9.83
128
0
125
3
0
106
16
6
0
0
Testis
5
0.38
5
0
5
0
1
1
2
1
0
0
Penis
0
0
0
0
0
0
0
0
0
0
0
0
Other Male Genital
1
0.08
1
0
1
0
0
1
0
0
0
0
Urinary System
49
3.76
28
21
35
14
8
34
2
4
1
0
Urinary Bladder
24
1.84
14
10
16
8
7
14
1
1
1
0
Kidney & Renal Pelvis
24
1.84
13
11
18
6
1
20
0
3
0
0
Ureter
0
0.00
0
0
0
0
0
0
0
0
0
0
Other Urinary
1
0.08
1
0
1
0
0
0
1
0
0
0
Eye & Orbit
1
0.08
1
0
0
1
0
0
0
1
0
0
Respiratory System
16
B/B
Sex
PRIMARY CANCER SITE
SEER Summary Stage at Diagnosis
InSitu
Regional
Unk
Alive Exp
Localized
Distant
% Total
M
F
Brain & Other Nervous System 35
2.69
21
14
23
12
0
18
2
0
0
15
Brain
20
1.54
14
6
11
9
0
16
2
0
0
2
Cranial Nerves, Other Nervous
15
1.15
7
8
12
3
0
2
0
0
0
13
Endocrine System
65
4.99
9
56
65
0
0
48
10
0
2
5
Thyroid
58
4.45
5
53
58
0
0
47
9
0
2
0
Other Endocrine
7
0.54
4
3
7
0
0
1
1
0
0
5
42
3.23
17
25
35
7
0
15
10
17
0
0
3
0.23
0
3
3
0
0
0
3
0
0
0
Nodal Disease
3
0.23
0
3
3
0
0
0
3
0
0
0
Extranodal Disease
0
0
0
0
0
0
0
0
0
0
0
0
39
3.00
17
22
32
7
0
15
7
17
0
0
Nodal Disease
26
2.00
11
15
22
4
0
8
5
13
0
0
Extranodal Disease
13
1.00
6
7
10
3
0
7
2
4
0
0
Myeloma
13
1.00
6
7
8
5
0
0
0
13
0
0
Leukemia
24
1.84
14
10
15
9
0
1
0
23
0
0
7
0.54
4
3
7
0
0
0
0
7
0
0
Acute Lymphocytic
2
0.15
0
2
2
0
0
0
0
2
0
0
Chronic Lymphocytic
3
0.23
2
1
3
0
0
0
0
3
0
0
Other Lymphocytic
2
0.15
2
0
2
0
0
0
0
2
0
0
Myeloid & Monocytic
16
1.23
10
6
7
9
0
1
0
15
0
0
Acute Myeloid
13
1.00
8
5
4
9
0
0
0
13
0
0
Acute Monocytic
0
0
0
0
0
0
0
0
0
0
0
0
Chronic Myeloid
2
0.15
1
1
2
0
0
0
0
2
0
0
Other Myeloid/Monocytic
1
0.08
1
0
1
0
0
1
0
0
0
0
1
0.08
0
1
1
0
0
0
0
1
0
0
Other Acute Leukemia
0
0
0
0
0
0
0
0
0
0
0
0
Aleukemic, Subleukemic
1
0.08
0
1
1
0
0
0
0
1
0
0
Mesothelioma
2
0.15
2
0
1
1
0
0
0
2
0
0
Kaposi Sarcoma
0
0.00
0
0
0
0
0
0
0
0
0
0
13
1.00
4
9
7
6
0
1
0
3
9
0
1302
100
30
20
Lymphoma
Hodgkin
Non-Hodgkin
Lymphocytic
Other
Miscellaneous
TOTALS:
# Cases
Vital Status
474 828 1040 262 114 547 311 280
B/B
17
Site Specific Studies for 2005
The Cancer Institute of New Jersey and Affiliate Short-Term Study: Prostate Cancer
Using data from 2004
Analysis by Robert A. Somer, M.D.
PURPOSE: This study examines Prostate Cancer diagnosed and treated at
CINJ and its affiliates in the State of New Jersey between January 1, 2004
and December 31, 2004. Data includes age at diagnosis, stage of disease,
histology and grade of tumor, the patients’ race, whether significant family
history was present, treatment modalities utilized, and clinical status of
patient. National data are from the Benchmark Reports from the
NationalCancerDataBase from 2001. Data were accrued from 1,246 hospitals
of all types, and accounted for 108,312 cases of newly-diagnosed prostate
cancer in that year. The CINJ affiliate data were obtained from tumor
registry records from 2004.
NATIONAL STATISTICS: In 2005, the American Cancer Society estimates
there will be 234,460 new cases of prostate cancer in the United States and
there will be 27,350 deaths. This cancer accounts for 33% of all cancers in
males and is the third leading cause of cancer death of men in the United
States. One in six men will have a lifetime risk of prostate cancer. AfricanAmerican males have a prostate cancer incidence rate up to 60% higher
than White males. Although prostate cancer death rates have been steadily
declining among White and African-American men since the 1990s, rates in
African-American men still remain more than twice that of age-matched
White men.
STATE OF NEW JERSEY STATISTICS: The American Cancer Society
estimates that 7,720 new cases of prostate cancer will be diagnosed in
New Jersey, which makes our state the 7th leading state of prostate cancer
incidence. It is also estimated that 900 New Jersey men will die of
prostate cancer.
SIGNS AND SYMPTOMS: Early stages of prostate cancer do not cause
symptoms. In some cases, or in more advanced disease, men with prostate
cancer may experience the need to urinate frequently, especially at night;
difficulty starting urination or holding back urine; weak or interrupted flow
of urine; painful or burning urination; difficulty in having an erection or
painful ejaculation; or blood in urine or semen. More advanced disease may
present with pain or stiffness in the lower back, hips, or upper thighs. Many of
these symptoms, however, are similar to those caused by benign conditions.
18
RISK FACTORS: The major known risk factors for prostate cancer are age,
ethnicity and family history. Age is the single most important factor in the
development of prostate cancer. More than 70% of all prostate cancers
occur in men older than 65 years of age. African-American men are 65%
more likely to develop prostate cancer than White men, whereas Asian
men living in Asia have the lowest incidence. African-American men
appear to get more high-risk disease and are more than twice as likely to
die from it as White men. Genetic studies suggest approximately 9% of
prostate cancers are purely hereditary, although approximately 25% of men
with prostate cancer have a history of the disease within their family. Men
who have a first-degree relative within their family with a history of being
diagnosed with prostate cancer have twice the risk of men who have no
family history of prostate cancer. With 2 close relatives, a man’s risk
increase five-fold, and with 3 or more, the risk exceeds 90%. International
studies suggest that a diet high in saturated fats may be associated with a
high risk of prostate cancer. Furthermore, recent studies suggest that obesity
may increase the risk of developing prostate cancer and may correlate with
survival from the disease. Although there are no conclusive data, other diet
and environmental factors may play a role as well.
At CINJ and its affiliates, from January 1, 2004 to December 31, 2004,
nine hundred sixty seven men were diagnosed with prostate cancer. At the
time of the diagnosis, over 36% of the men were between the ages of 60
and 69, and 95% were older than 50 years old (Graph #1). These numbers
are very similar to the Benchmark Data referenced above where 36.6% of
men diagnosed with prostate cancer were between the ages of 60 and 69,
and 97.64% were older than 50 years old. At CINJ and its affiliates, 77.0%
of men diagnosed with prostate cancer in 2004 were White, and 17.7% of
men were African-American (Graph #2). National data from 2001 reveals
excellent parallels, with 80.0% of prostate cancer diagnoses occurred in
White men, 12.75% occurred in African-American men, 3.65% occurred
in Hispanic individuals, and 3.46% occurred in Asian men.
19
Graph 1
CINJ Partner & Affiliate 2004 Prostate Study: By Age Group
345
350
300
288
250
191
200
150
91
100
47
50
4
1
0
30-39
40-49
50-59
60-69
70-79
80-89
90-99
Graph 2
CINJ Partner & Affiliate 2004 Prostate Study: By Race
Other 5%
African-American 18%
White 77%
20
SCREENING AND EARLY DETECTION: The U.S. Preventive Services
Task Force concluded that evidence is insufficient to recommend for or
against routine screening for prostate cancer using prostate specific antigen
(PSA) testing or digital rectal examination (DRE), even though 5-year
survival for prostate cancer now exceeds 99% which is likely attributed to
early diagnosis and treatment. Although there is no unanimous opinion
from major scientific and medical communities, the American Cancer
Society recommends that prostate cancer screening (PSA blood test and
DRE) should be offered annually, beginning at age 50, to men who have a
life expectancy of at least 10 years. Men at high risk, such as those with a
1st degree-relative with prostate cancer diagnosed at an early age, should
begin testing at age 45. Men at even higher risk (because they have several
first-degree relatives who had prostate cancer at an early age) or AfricanAmerican men might even begin testing at age 40. Information should be
provided to all men about what is known and uncertain about the limitations
of early detection and screening so that they can make an informed decision
about testing.
At CINJ and its affiliates, over seven hundred fifty patients had an elevated
PSA test, which required further work-up. Only 68 out of the 967 patients
who were diagnosed with prostate cancer had a negative PSA screening
test, and may have been diagnosed through the digital rectal examination
(Graph #3).
DIAGNOSIS: Whereas the digital rectal exam and the PSA may indicate
further testing is required, it is not diagnostic. Prostate biopsy is the only
method to diagnose prostate cancer. The biopsy is typically performed using
local anesthesia. During a biopsy, a transrectal ultrasound is used to view
and guide a needle (or multiple needles) into the prostate to take small
samples of tissue. Physicians will usually take 12 or more tissue samples or
“cores” during a biopsy. These specimens are then examined for the presence
of cancer, the size of the cancer area, and the type of cancer cells present.
The pathologist will assign a score called a Gleason score, which estimates
how aggressive the prostate cancer looks under the microscope.
Whereas most prostate cancers are determined to be described histologically
as adenocarcinomas, the CINJ data set from its affiliates was very similar to
the National Benchmark Data. At CINJ and its affiliates, 919 (95%) of men
were classified as having adenocarcinoma of the prostate gland. Benchmark
data show that 95.33% of prostate cancers were classified as adenocarcinoma.
At CINJ and its affiliates, pathology from 513 biopsies revealed Gleason
score < 6 cancers, pathology from 238 biopsies revealed Gleason score 7
cancers, and 122 biopsies were classified as 8 or above.
21
Graph 3
CINJ Partner & Affiliate 2004 Protate Study: PSA Results
967 Cases Results in Total Numbers and Percentages
Unknown 77, 8%
Borderline 11, 1%
Not Done 52, 5%
Negative 68, 7%
Positive 759, 79%
Graph 4
CINJ Partner & Affiliate 2004 Protate Study: Biopsy
967 Cases Results in Total Numbers and Percentages
Biopsy of Other Site 10, 1%
No Biopsy 71, 7%
Biopsy of Primary Site 886, 92%
Graph 5
CINJ Partner & Affiliate 2004 Protate Study: Histology
967 Cases Results in Total Numbers and Percentages
Adenocarcinoma 919, 95%
Others 48, 5%
22
Graph 6
CINJ Partner & Affiliate 2004 Protate Study: Tumor Grade
967 Cases Results in Total Numbers and Percentages
Grade 1 8, 1%
Unknown 22, 2%
Grade 3 357, 37%
Grade 2 580, 60%
Graph 7
CINJ Partner & Affiliate 2004 Protate Study: Gleason Score
967
600 Cases
487
500
400
300
238
Number of Cases
200
100
54
26
0
94
64
4
Gleason Gleason Gleason Gleason Gleason Gleason Unknown
6
7
8
9
10
5
STAGING: The digital rectal exam is the primary method of evaluating the
local stage of prostate cancer. This, along with the patient’s PSA and pathologic Gleason score will determine what methods of treatment may be recommended. CT scans, bone scans, and other studies may also be performed
to ensure the disease has not metastasized to other parts of the body.
Eighty one percent of patients in the Benchmark data set had localized disease, 8% had stage III disease, and 5.34% had advanced (Stage IV) disease.
At CINJ, 84% of patients were diagnosed with localized disease, 5.4% had
stage III disease, and 3.3% had advanced (Stage IV) disease. Although these
23
differences are not statistically significant, there appears to be a trend
towards diagnosing earlier disease at CINJ. Reasons for this are likely multifactorial, including more aggressive screening programs, improved patient
knowledge about prostate cancer when comparing 2001 data to data three
years later in 2004, where there may be improved patient willingness to
undergo screening for prostate cancer, and random chance due to the small
sample size at CINJ and its affiliates compared to the Benchmark data. It is
important to recognize that 5 year survival rates over the same comparator
time periods have increased as well, likely evidencing a trend towards earlier
diagnosis as seen in this project.
Graph 8
CINJ Partner & Affiliate 2004 Protate Study: AJCC 6th Edition Clinical Stage
967 Cases Results in Total Numbers and Percentages
Unknown 105, 11%
Stage 1 11, 1%
Stage 4 32, 3%
Stage 3 18, 2%
Stage 2 801, 83%
Graph 9
CINJ Partner & Affiliate 2004 Protate Study: AJCC 6th Edition Path Stage
967 Cases Results in Total Numbers and Percentages
Stage 1 2, 0%
Stage 2 257, 27%
Stage 3 53, 5%
Stage 4 19, 2%
Stage 99 636, 66%
24
TREATMENT: There are many treatment options for prostate cancer.
These include various types of surgery, radiation, hormone deprivation
therapy, chemotherapy, dietary changes and the use of various herbal
supplements. The treatment choice takes into account age and expected life
span, feelings about the side effects associated with each treatment, comorbid
disease, the stage and grade of the cancer, and the likelihood that each type
of treatment will be curative. Prostatectomy is the standard surgery that
attempts to cure prostate cancer. It is used most often in cancers that are
thought not to have spread outside of the gland (stage T1 or T2 cancers)
and entails removing the entire prostate gland plus some surrounding tissue
(including the seminal vesicles). This may be accomplished through different
approaches including a radical prostatectomy, radical perineal prostatectomy,
and laparoscopic prostatectomy. In patients who are not candidates for
curative surgery and have trouble urinating, a palliative transurethral
resection of the prostate (TURP) may be performed to relieve symptoms.
Radiation therapy uses high-energy rays or particles to kill cancer cells.
Two main types of radiation therapy are used: external beam radiation and
brachytherapy. External Beam Radiation Therapy (EBRT) is focused on the
prostate gland from a source outside the body. Aside from being used as an
initial treatment for early stage cancer, external beam radiation can also be
used to help relieve bone pain when the cancer has spread to a specific area
of bone. Three-dimensional conformal radiation therapy (3DCRT) uses
special computers to precisely map the location of the prostate. Intensity
modulated radiation therapy (IMRT) is an advanced form of 3D therapy. It
uses a machine that moves around the patient as it delivers radiation. In
addition to aiming beams from several directions, the intensity of the beams
can be adjusted to minimize the dose of radiation reaching the most sensitive
normal tissues while delivering a uniformly high dose to the cancer.
Brachytherapy (also called seed implantation or interstitial radiation therapy)
uses small radioactive pellets, or “seeds,” each about the size of a grain of
rice, that are placed directly into the prostate.
The goal of hormone therapy (also called androgen deprivation therapy (ADT)
or androgen suppression therapy) is to lower levels of androgens, such as
testosterone, in the body. Androgens, produced mainly in the testicles, can
stimulate prostate cancer cells to grow. Lowering androgen levels can usually
make prostate cancers shrink or grow more slowly. But hormone therapy
does not cure prostate cancer and is not a substitute for curative treatment.
Hormone therapy may be used in several situations: As first-line (initial)
therapy in patients unable to have surgery or radiation or can’t be cured by
these treatments because the cancer has already spread beyond the prostate
gland; after initial treatment, such as surgery or radiation therapy, if the
cancer remains or comes back; as an addition (adjuvant) to radiation therapy
25
as initial treatment in certain groups of men at high risk for cancer recurrence;
and before surgery or radiation (neoadjuvant therapy), in an attempt to
shrink the cancer and make the other treatment more effective
There are several methods used for androgen suppression therapy including
an orchiectomy, luteinizing hormone-releasing hormone (LHRH) analogs,
luteinizing hormone-releasing hormone (LHRH) antagonists, antiandrogens,
ketoconazole, corticosteroids, estrogens or combinations of the above.
Unfortunately, many hormone treatments are not without side effects, and
these may include hot flashes, breast tenderness and growth of breast tissue,
osteoporosis leading to bone fractures, anemia, decreased mental acuity, loss
of muscle mass, weight gain, fatigue, decrease in HDL cholesterol, depression,
and loss of libido.
Chemotherapy may be used if prostate cancer has spread outside of the
prostate gland and hormone therapy is no longer effective. The chemotherapy
drug docetaxel (Taxotere) has been shown to prolong life in patients with
advanced prostate cancer who have failed hormone therapy, and has been
approved for use in patients with advanced prostate cancer by the FDA in
combination with prednisone. The chemotherapy drug mitoxantrone has
been shown to palliate symptoms from prostate cancer in men with
advanced disease and has been approved for use by the FDA in combination
with prednisone as well. Other chemotherapy drugs used to treat prostate
cancer include doxorubicin, estramustine, etoposide, cyclophosphamide,
vinblastine, paclitaxel and carboplatin.
From January 1st, 2004 through December 31st, 2004 at CINJ and its
affiliates, three hundred sixty four (37.6%) men were treated with radical
prostatectomy, which was a very similar percentage to national data reporting
34.78% of their population undergoing radical prostatectomy. National
data reported 55.61% of men did not receive surgery for their primary
treatment of their prostate cancer. CINJ’s data from its affiliates revealed
very similar statistics, reporting that 56.2% of patients did not receive
surgery for their primary treatment. Radiation therapy, including external
beam and brachytherapy, accounted for 36.2% of therapies given for localized
prostate cancer at CINJ. Exactly 41% of men received some form of radiation
as primary treatment for localized prostate cancer per the Benchmark
Data. Hormone therapy accounted for 27.98% of therapies in the national
data set, and 34.4% of treatment for prostate cancer included hormones in
CINJ’s affiliate data set. It appears that there may be a difference in terms
of utilizing hormone treatments sooner in the treatment of prostate cancer
in CINJ’s affiliate data set. Reasons for this may include more aggressive
therapies, including clinical trials, regional variations in beliefs of treatment
and statistical chance.
26
SURVIVAL: Annual screenings with PSA and digital rectal exam have
made prostate cancer a very treatable disease. If diagnosed at an early stage,
surgery and/or radiation can potentially cure prostate cancer. However,
every year, 70,000 men require additional treatment due to a recurrence of
prostate cancer. Because prostate cancer is a relatively slow-growing cancer,
the 5-year survival rate for prostate cancer diagnosed at all stages is 100%.
The relative 10-year survival rate is 84% and the 15-year survival rate is 56%.
At CINJ and its affiliates, 70.53% of men diagnosed with prostate cancer
remain without evidence of disease recurrence, and only 20.5% have evidence
of recurrence.
CONCLUSIONS: When comparing the two respective data sets from
CINJ and its affiliates and National Cancer Data Base, this analysis reveals
very similar statistics, with no obvious outlying data. Demographics, diagnosis, treatment modalities and historical survival endpoints appear very
similar between the two data sets. Interestingly, as I have updated this
year’s dataset from last year, it appears that CINJ’s affiliates have diagnosed
more African American prostate cancers compared to the year before,
which may speak for increased awareness among physicians for screening
high risk populations, coupled with increased public awareness.
Furthermore, New Jersey is now the 7th leading state in prostate cancer
diagnosis (up from 9th leading state last year). Furthermore, more surgeries
have been performed this past year compared to last year, which may be
related to minimally invasive techniques, and younger age of diagnosis
choosing more aggressive therapies.
Robert A. Somer, M.D.
Director, Cooper Prostate Cancer Center
The Cancer Institute of New Jersey at Cooper
Assistant Professor of Medicine
Robert Wood Johnson Medical School
References:
American Cancer Society website (www.cancer.org)
Prostate Cancer Foundation website (www.prostatecancerfoundation.org)
American College of Surgeons website (www.facs.org)
*Report written based on physician review of 967 prostate cancer cases
submitted by 11 out of 15 CINJ Partner and Affiliate Hospitals including
Cooper University Hospital.
27
Graph 10
CINJ Partner & Affiliate 2004 Protate Study: Surgery
967 Cases Results in Total Numbers and Percentages
Unknown 10, 1%
Radical Prostatectomy 364, 48%
None 344, 45%
Local Excision 49, 6%
Graph 11
CINJ Partner & Affiliate 2004 Protate Study: Radiation
967 Cases Results in Total Numbers and Percentages
Brachytyerapy 136, 14%
Unknown 1, 0%
External Beam 216, 22%
None 614, 64%
Graph 12
CINJ Partner & Affiliate 2004 Protate Study: Hormones
967 Cases Results in Total Numbers and Percentages
Unknown 17, 2%
Yes 333, 34%
No 617, 64%
28
The Cancer Institute of New Jersey at Cooper Long Term Study: Lung Cancer
Using data from 1999-2005
Analysis by James Stevenson, M.D.
PURPOSE: To examine cases of lung cancer diagnosed and treated at CINJ
at Cooper/Cooper University Hospital in Camden, NJ from 2000-2005.
For comparative purposes, lung cancer data from the National Cancer
Database of 2003 is examined also.
NATIONAL STATISTICS: Lung Cancer estimates for 2006 published by
the American Cancer Society indicate that 174,470 new cases of lung
cancer were expected in the United States in 2006; 92,700 male cases and
81,770 female cases. Mortality estimates were 162,460 deaths from lung
cancer in 2006; 90,330 male deaths and 72,130 female deaths. Lung cancer
is by far the #1 cancer killer in both genders, and 31% of all cancer deaths
are due to lung cancer. The age-adjusted mortality rates from lung cancer
have been steadily declining in men since peaking in the early 1990s while
in women mortality rates have reached a plateau and have not shown a
decline in the past 10-15 years. Lifetime probability of developing lung
cancer is 1 in 13 for men and 1 in 17 for women. The likelihood of mortality
for African-American males is 1.3 that of white males, while the rates are
similar for African-American and white women. Mortality estimates for
Hispanic men and women are less than half those for whites.
STATE OF NEW JERSEY: New Jersey ranks 10th in expected incidence
and mortality of lung cancer in 2006, with 4,960 cases and 4,620 deaths
estimated. Estimates for 2005 ranked New Jersey 9th in the United States
in total population.
SCREENING: There is no routine screening test recommended for lung
cancer, even in those at highest risk. A randomized trial of over 50,000
patients comparing annual CXR vs. low-dose spiral CT scan screening for
current/former smokers recently completed accrual and initial results are
expected in 2009.
SIGNS AND SYMPTOMS: Lung cancer at its earliest stages is frequently
asymptomatic, but common presenting symptoms include shortness of
breath, cough, hemoptysis, and chest pain. Advanced-stage disease may be
associated with similar symptoms as well as those referable to distant
metastasis, including headache, seizures, fatigue, weight loss, abdominal
pain, and bone pain.
RISK FACTORS: The leading risk factor for the development of lung cancer
by far is cigarette smoking, associated with 85% of cases. Lung cancer risk in
former smokers remains elevated in those who have a greater than 10 pack/
year smoking history and does not decline to the risk seen in nonsmokers.
Other risk factors include radon exposure, which the EPA estimates is
29
implicated in 21,000 lung cancer deaths yearly, and exposure to second-hand
smoke, estimated to cause 3,000 deaths per year in the U.S. Exposure to other
environmental/workplace carcinogens, including asbestos and automobile
exhaust, also increases lung cancer risk. Chronic lung disease and prior
therapeutic radiotherapy to the chest increase risk as well. Recent data
suggest that there may be a familial risk factor for lung cancer, particularly
in families with nonsmokers who develop lung cancer.
DIAGNOSIS: A diagnosis of lung cancer is typically made following an
abnormal CXR or CT scan. Tissue from lung masses is frequently obtained
by bronchoscope or by percutaneous aspiration. Cervical mediastinoscopy
may prove both diagnostic and can aid in staging. Biopsy of a suspected
mediastinal site (i.e. liver, adrenal gland) can also provide a diagnosis and
confirm metastatic disease. Infrequently patients with a highly suspicious
lung nodule (hypermetabolic on PET scan) will have an intraoperative
biopsy performed by thoracotomy/thoracoscopy followed immediately by
definitive resection.
WORKUP/STAGING: An abnormal CXR or chest CT scan typically
initiates the staging process. A total body PET/CT scan is also recommended
to further assess for mediastinal involvement as well as extrathoracic
metastasis. Invasive or pathologic staging of the mediastinum is recommended
in patients with potential early stage disease who have mediastinal
lymphadenopathy on PET/CT scan or who have centrally located tumors.
This can be accomplished by cervical mediastinoscopy or by endoscopic
needle aspiration using ultrasound guidance. Brain imaging is recommended
in patients with stage III/IV disease.
TREATMENT: In early-stage lung cancer (Stages I and II) the treatment
of choice is surgical resection, consisting of lobectomy, bilobectomy, or
pneumonectomy with mediastinal lymph node sampling. Wedge resection
is inferior to lobectomy in both local recurrence and survival rates. Patients
with early–stage disease who are not candidates for surgery because of
co-morbidity should receive definitive radiotherapy. Radiosurgery may be
the treatment of choice for those with clinical stage IA tumors, especially
those with poor lung function. Adjuvant cisplatin-based chemotherapy has
been shown to prolong survival in resected stage II-IIIA patients. Any benefit
in stage IB patients is less clear although one randomized trial revealed
improved survival in patients with tumors > 4 cm and significant improvement in disease-free survival in all stage IB patients. Adjuvant chemotherapy
is not recommended for patients with stage IA disease. Adjuvant radiotherapy
is recommended for patients with positive surgical margins, mediastinal
nodal disease, and in subsets of patients with chest wall involvement.
Patients who are identified as stage IIIA by imaging studies or invasive staging
should be considered for preoperative chemotherapy or chemoradiation.
30
Definitive chemoradiation in patients with stage IIIA disease is also an
option although trimodality therapy with surgical resection following
chemoradiation may provide benefit in subsets of patients, particularly
those with pathologic nodal complete responses. A large randomized trial is
presently comparing pre- and post-operative chemotherapy to preoperative
chemoradiation in stage IIIA patients. Stage IIIB patients with T4 tumors
and/or N3 disease should also receive chemotherapy and radiotherapy,
preferably administered concurrently. Patients with “wet” IIIB disease
(malignant pleural effusion) and stage IV disease should primarily receive
systemic chemotherapy, with radiotherapy reserved for symptom palliation
of specific sites (e.g. bone metastasis). Stage III/IV patients with poor performance status (ECOG 3-5) are not candidates for chemotherapy and
should receive supportive/palliative care.
SURVIVAL: The overall five-year survival for all stages of lung cancer is
15%. This number has remained constant over that past 30-40 years.
Surgery is the only curative modality for lung cancer, although a small percentage of patients with locoregional disease survive > 5 years when treated with chemoradiation alone. Five-year survival for pathologic stage I A/B
patients who is 67/57%, stage II A/B is 55/39%, stage IIIA 23%, and stage
IIIB/IV < 5%.
DATA: From 2000-2005 there were 723 cases of lung cancer seen at CINJ at
Cooper/Cooper University Hospital, 52% male and 48% female. 71% were
aged 60 or greater (Graph #1). There was a history of current/former
cigarette smoking in 83% (smoking history unknown in 12%). Race/ethnicity
statistics revealed 69% white (including Hispanic), 23% black, 2%
Japanese/Chinese/Vietnamese/Native American/Filipino/Other, and 5%
unknown. Hispanic patients represented 4.5% of the total (Graph #2).
Histologic classification was 15.5% small cell, 81% non-small cell (47%
adenocarcinoma, 19% squamous cell carcinoma), 3.5% other or “neoplasm”
(Graph #3). Clinical stage was known in 531 patients: 10% stage I, 4%
stage II, 31% stage III, 55% stage IV (Graph #4).
The demographics of the Cooper patient data set are fairly similar to the
National Cancer Database statistics for 2003 except for the percentage of
black and Hispanic lung cancer patients, which is over twice the NCDB
number (23% vs. 11% and 4.5% vs. 2.2%). AJCC stage percentage was
similar for Cooper patients when compared to NCDB statistics for 2003.
31
Graph 1
CINJ at Cooper Lung Study: Male vs. Female by Age Group at Diagnosis
Percent of Gender for Total Analytic Lung Cancer Cases 2000-2005
Male N=376; Female N=347
Male
Female
40%
34.3
35%
31.4
29.1
30%
29.7
25%
20%
18.1
19.6
19.6
15%
9.8
10%
7.4
7.4
8.1
5%
0
0%
0.3
-29
0.8
1.7
30-39
0.5
40-49
50-59
60-69
Graph 2
CINJ at Cooper Lung Study: Male vs. Female by Race
Total Analytic Lung Cancer Cases 2000-2005
Male
Female
300
272
259
250
200
Number of Patients
150
100
88 85
50
11
0
White
69%
(includes
Hispanic=4.5%)
32
Black
23%
2
Other
3%
5
1
Unknown
5%
70-79
80-89
1.7
90+
Graph 3
CINJ at Cooper Lung Study: by ICD-O-3* Histology
Morphology Terms (Codes) & Number of Cases/Percent of Total
Adenocarcinoma (8140)
Non-Small Cell Carcinoma (8046)
236, 33%
143, 20%
Small Cell Carcinoma (8041)
111, 15%
Squamous Cell Carcinoma (8070)
97, 13%
Carcinoma (8010)
43, 6%
Bronchioloalveolar Carcinoma (8250)
17, 2%
Malignant Neoplasm (8000)
16, 2%
Large Cell Carcinoma (8012)
13, 2%
Adenosquamous Carcinoma (8560)
Combined Small Cell Carcinoma (8045)
10, 1%
1
Squamous Cell Carcinoma,
Keratinizing (8071)
Spindle Cell Carcinoma (8032)
9, 1%
Mucoepidermoid Carcinoma (8430)
1
Carcinoid (8240)
1
4
Acinar Cell Carcinoma (8550)
Papillary Adenocarcinoma (8260)
1
4
Adenocarcinola, Mixed Subtypes (8255)
Mucinous Adenocarcinoma (8480)
1
3
Large Cell Neuroendocrine Carcinoma (8013)
Signet Ring Adenocarcinoma (8490)
1
3
Squamous Cell Carcinoma,
Large Cell, Nonkeratinizing (8072)
Neuroendocrine Carcinoma (8246)
2
1
Giant Cell Carcinoma (8031)
2
Squamous Cell Carcinoma,
Small Cell, Nonkeratinizing (8073)
Mucin-Producing Adenocarcinoma (8481)
1
2
Graph 4
CINJ at Cooper Lung Study: Male vs. Female by Clinical Stage
Number of Cases by Gender for Total Analytic Lung Cancer Cases 2000-2005
Male N=376; Female N=347
Clinical Stage
Male
Female
1A
1B
2
2B
3A
3B
4
88
99
347 Total
Number of Cases 00
50
100
50
150
200
100
250
300
150
350
400
200
250
300
350
400
376 Total
3A
1B
3B
4
88
99
2B
2B
2
1A
1
0
Clinical Stage
CINJ at Cooper Lung Study: First Course of Treatment 2000 vs. 2005
Surgical resection was performed in 129 of the 723 Cooper lung cancer
patients from 2000-2005 (18%) surgery was the initial form of therapy in
11%. 51% received radiotherapy as part of their treatment (16.1% as initial
treatment), and 50% received chemotherapy (12.3% initial). Twenty percent
of Cooper patients received no therapy for their lung cancer. 75% had
expired at the time of this analysis (Graph #5). NCDB statistics for 2003
indicated that 18% of patients received surgery as initial therapy, 9%
received chemotherapy, and 23% received no treatment. Survival statistics
from the NCDB for non-small cell and small cell lung cancer patients are
presented in graphs #6 and #7, while survival for all Cooper patients seen
in 1999-2000 are shown in graph #8.
34
Graph 5
CINJ at Cooper Lung Study: First Course of Treatment 2000 vs. 2005
by SEER Stage at Diagnosis
Total Analytic Lung Cancer Patients
2000
2005
No Treatment
Radiation Only
Surgery & Chemotherapy
Radiation & Chemotherapy
Chemotherapy Only
3 11 2 2
No Treatment
Surgery Only
Surgery & Radiation
Radiation & Chemotherapy
1
10
14
Localized
Unknown
4
9
7
5 12 2
2
Chemotherapy Only
Radiation & Chemotherapy
Surgery & Chemotherapy
No Treatment
Radiation & Chemotherapy
Surgery & Chemotherapy
Surgery Only
No Treatment
No Treatment
Surgery Only
Radiation Only
Surgery & Chemotherapy
Radiation & Chemotherapy
Chemotherapy Only
Surgery, Radiation & Chemotherapy
4 3
9 2
11
5 1
Regional
2 5
4
6
9
41
Surgery, Radiation & Chemotherapy
Chemotherapy Only
Radiation & Chemotherapy
Surgery & Chemotherapy
Radiation Only
Surgery Only
No Treatment
No Treatment
Surgery Only
Surgery & Radiation
Radiation Only
Surgery & Chemotherapy
Radiation & Chemotherapy
Chemotherapy Only
Surgery, Radiation & Chemotherapy
14
2 1 10
2
23
10
3
Distant
17
3
12
2
28
25
2
Surgery, Radiation & Chemotherapy
Chemotherapy Only
Radiation & Chemotherapy
Surgery & Chemotherapy
Radiation Only
Surgery Only
No Treatment
35
COMMENTS: There were several disparities in lung cancer patients treated
at Cooper from 2000-2005 compared with NCDB statistics. Patient demographics were fairly similar except for the higher percentage of blacks and
Hispanics treated at Cooper. This is not surprising given the fact that a
significant portion of the Cooper patient base is drawn from the city of
Camden, which has a largely black and Hispanic population. Also of note is
the difference in patients receiving surgery as their initial therapy for lung
cancer: 7% fewer patients at Cooper had surgery. Multiple publications
have documented that blacks (especially black males) are significantly less
likely to have surgery for lung cancer than other racial/ethnic groups; however at each stage of lung cancer black patients who receive therapy have
similar survival to other patients. The inner-city population of Camden is
known to be medically underserved, and this disparity only serves to
underscore this. Therefore lung cancer awareness (coupled with smoking
cessation programs) needs to be highlighted at all levels of entry into the
health care system, and we have recently submitted a grant proposal to the
Robert Wood Johnson Foundation with this as a primary objective.
The fact that < 20% of lung cancer patients receive surgery as initial treatment highlights the need to identify a useful and cost-efficient screening
tool for at-risk patients. If low-dose CT scans become a standard screening
tool in the future, then awareness efforts (especially in urban areas) will
become even more critical.
Also of note is that patients in the Cooper database were somewhat more
likely to receive chemotherapy as initial therapy (12% vs. 9%). The fact that
over 50% of patients present with stage IIIB/IV disease, for which it has been
well-known since the early 1990’s that chemotherapy can prolong survival
and improve overall quality of life, shows that the medical community is
failing in this regard. Again, lung cancer awareness efforts, directed both to
the general public and health-care professionals should help to dispel the
long-standing myth that in most cases treatment for lung cancer is futile.
James P. Stevenson, M.D.
Co-Director, Cooper Comprehensive Lung Cancer Program
The Cancer Institute of New Jersey at Cooper
Associate Professor of Medicine
Roberty Wood Johnson Medical School
36
Graphs 6, 7 and 8
National Cancer Database (NCDB) Observed 5-Year Survival by AJCC Stage at Diagnosis
Graph 6: Analytic Non-Small Cell Lung Cancer Patients First Seen in 1998
100%
90%
80%
70%
60%
50%
Stage 1: N=16, 100
40%
Percent Surviving
30%
Stage 2: N=5, 991
20%
Stage 3: N=18, 134
Overall: N=63, 077
Stage 4: N=22, 662
10%
0%
At
Diagnosis
After
1 Year
After
2 Years
After
3 Years
After
4 Years
After
5 Years
Stage 1
100%
80.2%
66.3%
56.3%
48.5%
42.2%
Stage 2
100%
66.7%
46.5%
36.1%
28.7%
24.1%
Stage 3
100%
45.1%
23.2%
14.8%
10.8%
8.3%
Stage 4
100%
20.6%
7.6%
4%
2.7%
2%
Overall
100%
47.3%
30.8%
23.5%
19.2%
16.2%
Graph 7: Analytic Small Cell Lung Cancer Patients First Seen in 1998
100%
90%
80%
70%
60%
50%
Percent Surviving
40%
30%
Stage 1: N=1, 063
Stage 2: N=626
Stage 3: N=4, 469
Overall: N=14, 489
Stage 4: N=8, 290
20%
10%
0%
At
Diagnosis
After
1 Year
After
2 Years
After
3 Years
After
4 Years
After
5 Years
Stage 1
100%
64.7%
35%
24.6%
20.4%
17.3%
Stage 2
100%
63.2%
31.3%
20.5%
16.5%
13.3%
Stage 3
100%
50.7%
21.7%
13.8%
10.3%
8.5%
Stage 4
100%
22.1%
5.1%
2.6%
1.8%
1.3%
Overall
100%
35.9%
13.7%
8.5%
6.5%
5.2%
37
Graph 8: Analytic Lung Cancer Patients First Seen in 1999 and 2000
100%
90%
80%
70%
60%
50%
Stage 1: N=21
Percent Surviving
40%
38
Stage 2: N=10
30%
20%
Stage 3: N=65
Overall: N=199
Stage 4: N=103
10%
0%
At
Diagnosis
After
1 Year
After
2 Years
After
3 Years
After
4 Years
After
5 Years
Stage 1
100%
85.7%
61.9%
57.1%
47.6%
47.6%
Stage 2
100%
70%
50%
30%
30%
30%
Stage 3
100%
32.3%
16.9%
12.3%
12.3%
10.8%
Stage 4
100%
30.1%
12.6%
9.7%
6.8%
4.9%
Overall
100%
38.7%
21.1%
16.6%
14.1%
12.5%
2005 Cancer Committee
Deepali Agarwal
PI Coordinator
Umar Atabek, M.D.
Attending Surgeon
Jaime Austino, R.N.
Genitourinary and Head & Neck Nurse
Coordinator
Raymond Baraldi, M.D. Chief, Department of Radiology
Diane Bush, CTR
Manager, Cancer Registry Department
Edison Catalano, M.D.
Chief, Department of Pathology
Dana Clarke-Scott
Director, Health Information Management
Susan Coakley,
M.H.A., C.C.R.P.
Manager, Hematology/
Medical Oncology Clinical Research
Francis DelRossi, CSW
Social Worker
Steven DiBiase, M.D.
Chief, Department of Radiation Oncology
Tara Elk
Events Coordinator
Generosa Grana, M.D.
Director, The Cancer Institute of New Jersey
at Cooper
Head, Division of Hematology/
Medical Oncology
Kay Hannigan, R.N.
Gastrointestinal Cancer Nurse Coordinator
Samuel Hughes, M.D.
Radiation Oncologist
Christina Hunter, R.N.
Clinical Oncology Nurse Educator
Alex Khariton
Administrative Director, Department of Radiation
Oncology
Frank Koniges, M.D.
Attending Surgeon
Robert Lumpe
Staff Chaplain, Pastoral Care
Susan Maltman,
R.N., B.S.N, O.C.N
Clinical Practice Nurse Manager,
Division of Gynecologic Oncology
Denise Mealey
Director, Patient Care Services
Bonnie Mehr
Manager, The Dr. Diane Barton Complementary
Medicine Program
39
Alicia Michaux, R.D.
Outpatient Nutritionist
Rachelle Munic,
M.B.A., PA-C
Assistant Vice President, CINJ at Cooper
Alice O’Brien, R.N.
Leukemia & Lymphoma Program
Nurse Coordinator
Erin O’Hea, Ph.D.
Director, Behavioral Medicine
Betty Oliker
Physician Liaison
Raul Parra, M.D.
Chief, Department of Surgery
Vickie Riskie, R.N.
Clinical Nurse Manager, Inpatient Oncology Unit
Evelyn Robles-Rodriguez, Oncology Advanced Practice Nurse
R.N.
Director of Oncology Outreach
Arthur Siegel, M.D.
Director, Palliative Medicine Program
Ann Steffney, R.N.
Breast Cancer Nurse Coordinator
James Stevenson, M.D.
Co-Associate Director, Lung Cancer Program
Jackie Sutton
Director, Pharmacy Department
Wendy Topeka, R.N.
Gynecologic-Oncology Nurse Coordinator
Jackie Tubens, R.N.
Clinical Practice Manager, Department of
Radiation Oncology
Edward Viner, M.D.
Chief, Department of Medicine
Charu Vora, R.N.
Lung Cancer Nurse Coordinator
David Warshal, M.D.
Head, Division of Gynecologic Oncology
Lorna Rodriguez, M.D., Representative, The Cancer Institute of New Jersey
Ph.D.
40
GLOSSARY/REFERENCES
Glossary
Summary Staging:
Most basic way of categorizing the spread of cancer from its point of origin.
Summary Stage has five main categories:
Insitu:
A neoplasm that fulfill all microscopic criteria for malignancy except invasion.
Localized:
A neoplasm that appears entirely confined to the organ of origin.
Regional:
Tumor extension beyond the limits of the organ of origin.
Distant:
Tumor cells have broken away from the primary tumor, have traveled to
other parts of the body and have begun to grow at the new location.
Unknown:
Sufficient evidence is not available to adequately assign a stage.
Class of Case:
A determination of the patient’s first diagnostic and treatment status of
cancer at the first admission to the hospital or presentation for outpatient
treatment.
Analytic:
Cases that are first diagnosed and/or received all or part of their first
course of therapy at this facility.
Non-Analytic:
Cases that are first seen at this facility after a completed first course of
therapy or were first diagnosed at autopsy.
References
The American Cancer Society 2005 Facts and Figures
American College of Surgeons –National Cancer Data Base (NCDB) —
Benchmark Reports
The Cancer Institute of New Jersey at Cooper Cancer Registry statistics
The Cancer Institute of New Jersey of New Brunswick and affiliate hospital
Cancer Registries
41
CINJ at Cooper
11/2006