Issue No. 22 / October 2010
In this issue Risk factors Genetic risk assessment program Signs and symptoms
cancer update PROFILES IN CANCER MEDICINE
Types of bladder cancer Diagnosing bladder cancer Treating bladder cancer Surviving bladder cancer Multidisciplinary cancer care Graham Cancer Center renews accreditation Cancer case distribution at Christiana Care Graham Cancer Center awarded funding to expand research
Treating Bladder Cancer – a multidisciplinary team approach Bladder cancer is the sixth most common cancer in Delaware. Like most cancers, early treatment for bladder cancer works best. Patients who choose an experienced cancer center with a qualified team of specialists broaden their treatment options and improve their outcomes. In 2009, the Delaware Cancer Registry recorded 241 diagnosed cases of bladder cancer. Of those, more than one-third (from Delaware and out-of-state) were diagnosed and/or received initial treatment at the Helen F. Graham Cancer Center at Christiana Care.
Prevalence of bladder cancer In 2010, the Delaware Division of Public Health reported 1,104 new bladder cancer cases diagnosed between 2002 and 2006. Caucasian men accounted for 74.5 percent of these cases. During that period, of the 256 Delawareans who died from bladder cancer, 70.7 percent were men. Although bladder cancer deaths are declining in Delaware, the rate of decline (1.7 percent) is slower than the U.S. rate (2.3 percent). Bladder cancer remains the eighth most common cause of cancer mortality in our state. Most often, bladder cancer is diagnosed when it is still confined to the lining of the bladder. Historically, approximately 30 percent of newly diagnosed cancers have invaded (continued on next page)
(continued from previous page)
PROFILES IN CANCER MEDICINE
the bladder wall muscle or surrounding organs, reducing the chance of cure. However, doctors are seeing increasing numbers of both men and women with more aggressive and more advanced tumors. Ongoing efforts to improve early diagnosis and accurate staging are critical to achieving better outcomes. Five cancer specialists with the Helen F. Graham Cancer Center share their insights for a multidisciplinary approach to treating this urinary tract cancer. They are urologist and surgeon Bruce N. Benge, M.D.; medical oncologist Stephen S. Grubbs, M.D.; radiation oncologist Viroon Donavanik, M.D.; Cancer Research Director Kandie Dempsey, MS, RN, OCN, CCRP; and Oncology Data Center Director Robert McBride.
Risk factors The risk for bladder cancer increases with age. This type of cancer is uncommon in people under age 40. Bladder cancer occurs twice as often in Caucasians than any other racial group. The risk for bladder cancer is two to three times higher for men than women. Smoking is the biggest risk factor for bladder cancer, and smoking cessation can prevent this cancer. Exposure to certain workplace chemicals can increase the risk for this cancer. Uncommon causes of bladder cancer include some drugs used to treat other cancers as
well as a bladder parasite infection common in tropical climates. People who have had bladder cancer have an increased risk of getting it again.
Genetic Risk Assessment Program People with a family history of bladder cancer have a higher risk of getting the disease. Scientists are looking at whether certain genes are involved. The Christiana Care Genetic Risk Assessment Program offers counseling and genetic testing for people at risk for all types of cancer in their families. Knowing the risk for hereditary cancer is important for better surveillance, early detection and prompt treatment.
Bruce N. Benge, M.D
Stephen S. Grubbs, M.D.
Viroon Donavanik, M.D.
Kandie Dempsey, MS, RN, OCN, CCRP
Bladder Cancer Cases at Christiana Care by Sex 1995 to 2009
Robert McBride
Males: 971 cases Females: 377 cases
Bladder Cancer Cases at Christiana Care by Race / Ethnicity 1995 to 2009
•
Other/Unknown: 4 cases Asian: 4 cases Asian Indian: 5 cases Spanish/Hispanic: 14 cases African-American: 92 cases
• • •• Source: Christiana Care Oncology Data Center
2 Christiana Care Health System
Tr e a t i n g B l a d d e r C a n c e r
Caucasian: 1,229 cases
Signs and symptoms
Types of bladder cancer
The most common symptom of bladder cancer is blood in the urine (hematuria). A simple urine test (urinalysis) can determine the presence of blood that may only be seen microscopically. Although the following are associated with other conditions such as urinary tract infection, they may be signs of bladder cancer: • Frequent or painful urination • Urge to urinate without result • Lower back pain • Fatigue
The bladder is a hollow organ in the lower part of the abdomen that functions as a holding tank for urine. It works like a balloon, expanding and contracting to collect and empty urine made by the kidneys as they clean the blood.
in the bladder due to parasitic or other chronic infection, and adenocarcinomas that develop in the glandular cells of the inner lining.
Ninety percent of all bladder cancers are transitional cell carcinomas, which can be non-invasive or invasive into the wall of the bladder. Less common are squamous cell carcinomas, thin flat cells that form
Diagnosing bladder cancer The work-up for diagnosing bladder cancer starts with a detailed medical history and physical exam. A urinalysis will show if there is blood in the urine or other abnormalities. A common and reliable test for bladder cancer is called a cystoscopy. A thin tube with a camera attached is inserted through the urethra into the bladder to check for signs of cancer. A cystoscopy can remove tissue samples for a biopsy and even some superficial tumors without surgery. Other testing may include ultrasound, CT scan, MRI, or an intravenous pyelogram to X-ray the urinary system using a special dye.
Staging A process called staging determines the extent of the bladder cancer, size of the tumor and how widely it has spread. Staging uses a system developed by the American Joint Committee on Cancer and provides information for determining treatment and predicting survival. (continued on next page) S TAG E S O F B L A D D E R CA N C E R : STAGE 2: Cancer has spread to the muscle wall of the bladder. STAGE 1: Cancer has formed and spread to the connective tissue under the inner lining of the bladder. STAGE 0is: Cancer is a flat, non-invasive carcinoma in situ that grows on the lining of the bladder. STAGE 0a: Cancer is a non-invasive papillary carcinoma that grows like tiny mushrooms from the lining of the bladder.
STAGE 0: Abnormal cells that could become cancer are confined to the lining of the bladder.
STAGE 3: Cancer has grown completely through the bladder into the fatty tissue surrounding it and may have spread to the prostate, uterus or vagina. STAGE 4: Cancer has grown through the bladder wall and into the pelvic or abdominal wall. Cancer may have spread to one or more lymph nodes or to other parts of the body. Cancer Update 3
(continued from previous page)
PROFILES IN CANCER MEDICINE
Treating bladder cancer For some early stage, non-invasive cancers, a transurethral resection of the bladder tumor (TURBT) is possible. Doctors use a tool with a small wire loop on the end, inserted into the bladder through the urethra, to remove the cancer or to burn the tumor away with highenergy electricity. Patients at high risk for recurrence of bladder cancer may receive bacillus Calmette-Guérin (BCG) therapy after surgery. This form of inside-the-bladder (intravesical) immunotherapy involves filling the bladder with a solution containing a type of bacterium also used to fight tuberculosis. The BCG delivered through a catheter stimulates the immune system to destroy remaining cancer cells and reduces the risk of cancer recurrence.
Surgery Surgery is the most common, and currently the preferred, treatment for muscle wall invasive bladder cancer. Depending on the location and extent of the cancer, the surgeon may need to do a radical cystectomy to remove the entire bladder. Nearby tissues and organs are also removed to prevent cancer recurrence or spreading to other parts of the body. In men, the bladder, prostate and lymph nodes are removed. In women, in addition to the bladder and lymph nodes, the uterus, ovaries and part of the vagina may be removed.
4 Christiana Care Health System
Tr e a t i n g B l a d d e r C a n c e r
Building a new bladder After removing the bladder, the surgeon needs to make a new way for the body to store and pass urine. There are different ways to create what is called a urinary diversion. An ileal conduit, for example, uses a small piece of intestine as a new pipeline for urine to drain through an opening in the skin and into a collection bag. A continent diversion uses intestinal tissue to create a urinary pouch. A catheter drains urine through a channel created out of the small bowel or the appendix brought out to the abdominal wall. An innovative “neobladder” technique uses a small segment of bowel or colon to construct a new bladder that attaches to the urethra so patients can pass urine normally.
ureters
urethra An innovative “neobladder” technique uses a small segment of bowel or colon to construct a new bladder that attaches to the urethra. With a neobladder, patients can pass urine normally. Not all patients qualify for this procedure, but advances in technology and refinements in the
technique have made the neobladder an important procedure for people whose cancer was diagnosed at an advanced stage. With the neobladder, patients can remain functional without altering their quality of life as much as other surgical options. The Helen F. Graham Cancer Center at Christiana Care offers a full range of bladder reconstructive options. On a national scale, Christiana Care surgeons perform a relatively high volume (among the top 10th percentile) of radical cystectomies and bladder reconstructive surgeries for both men and women. Our experience and success with these procedures offer patients greater opportunity for the best possible outcomes.
Chemotherapy and radiation therapy With advances in radiation therapy and chemotherapy, doctors are sometimes able to treat cancer while preserving the bladder. This allows many patients to maintain urinary function and allows many men to be able to preserve erectile function as well. At the Helen F. Graham Cancer Center at Christiana Care, radiation oncologists use the latest technologies for more precise treatment planning and to safely deliver powerful radiation to the tumor. With three-dimensional conformal radiation, intensity modulated radiation therapy (IMRT) and image-guided radiotherapy (IGRT), radiation oncologists can size and shape the radiation beam to destroy cancer cells more effectively without harming nearby healthy tissues and organs.
M E M B E R S O F T H E M U LT I D I S C I P L I NA RY G E N I TO U R I NA RY CA N C E R C E N T E R T E A M
Chemotherapy is an important treatment for bladder cancer, potentially before and after surgery, to improve results. Chemotherapy combined with radiation therapy may be used after surgery to target any remaining cancer cells and help prevent recurrence. Chemoradiation therapy is also used to treat invasive cancers when surgery is not an option.
Researching new ways to fight cancer At the Helen F. Graham Cancer Center at Christiana Care, several investigational chemotherapy and radiation therapy clinical trials offer patients with bladder cancer additional treatment options. Participation for eligible patients in the following studies comes from membership in the Community Clinical Oncology Program a national clinical research group sponsored by the National Cancer Institute (NCI). CA N C E R T R I A L S
RTOG 0524: Studies the effects of combining paclitaxel and trastuzumab with daily radiation as an alternative treatment to surgery for invasive bladder cancer in patients who are not surgical candidates.
Urologic Surgeons Bruce Benge, M.D. David Cozzolino, M.D. Andrew Glick, M.D. Michael Lobis, M.D. Steven Terranova, M.D. Francis Schanne, M.D.
Surviving bladder cancer When bladder cancer is found and treated early, the chances for survival are good. According to the latest available figures (2003-2005), patients at Christiana Care with stages 0-1 bladder cancer have a five-year survival rate of 56.7 percent. Five-year survival rates are lower for patients with more deeply invasive cancer (stages 2-4),decreasing from 24.3 to 16.4 percent and underscoring the need for better treatments through clinical trials. The Helen F. Graham Cancer Center is among an elite group of research centers working with pharmaceutical companies, other research sites and the NCI to streamline clinical pathways for the most promising new anti-cancer therapies. These efforts, along with the Helen F. Graham Cancer Center’s continued outreach as an NCI-selected Community Cancer Center (NCCCP), offer the opportunities
RTOG 0712: Employs chemotherapy and radiation therapy in an attempt at bladder preservation (no surgical bladder removal) for muscle invasive bladder cancer.
CALGB 90601: Evaluates the benefit of adding bevacizumab, an antibody designed to inhibit blood vessel growth, to standard gemcitabine and cisplatin chemotherapy for advanced, transitional cell cancer.
Medical Oncologists Stephen Grubbs, M.D. Andrew Himelstein, M.D. Jamal Misih, M.D. Michael Guarino, M.D.
Radiation Oncologists Viroon Donavanik, M.D. Adam Raben, M.D. Nurse Navigator Tina Scherer, RN
to participate in new bladder cancer clinical trials. These may lead to better cure rates and longer survival.
Multidisciplinary cancer care At the Helen F. Graham Cancer Center, patients who have bladder cancer and their family members meet with a team of cancer specialists, including a medical oncologist, a surgeon and a radiation oncologist, at the Multidisciplinary Genitourinary Cancer Center. Together they discuss the latest thinking and most promising treatments. With help from an oncology nurse navigator, patients easily access the many support services available, including nutrition counseling, social work, wellness coaching, psychological counseling, pain and symptom management, oncology rehabilitation, genetic counseling, and support groups, including the cancer companion and survivorship programs.z
M U LT I D I S C I P L I NA RY CA N C E R C E N T E R S AT T H E H E L E N F. G R A H A M CA N C E R C E N T E R
• • • • • • • •
Lung/Cyberknife Breast Cancer Cancer Survivorship Genetic Risk Assessment Genitourinary Cancer Head & Neck Cancer Hepatobiliary/Pancreatic Cancers Hepatoma Screening
• Lymphoma • Melanoma/Soft Tissue & Bone Sarcoma • Mind, Body & Spirit Wellness • Rectal/Anus Cancers • Pain & Symptom Management • Skin Cancer • Thoracic/Esophageal Cancers • Young Adult Follow-up Cancer Update 5
Helen F. Graham Cancer Center at Christiana Care renews accreditation from Commission on Cancer Report praises clinical trials and efforts to reduce disparities The American College of Surgeons Commission on Cancer granted three-year accreditation with commendation to the Helen F. Graham Cancer Center on March 26. The Commission on Cancer has accredited the cancer program at Christiana Care since 1985.
“This is an excellent cancer program that should serve as an example of how multidisciplinary care and clinical trials can be delivered in a private practice setting,” says the Commission on Cancer performance report for the Helen F. Graham Cancer Center.
The Commission certifies that receiving care at the Helen F. Graham Cancer Center ensures ensures that the patient will have access to the following: • Comprehensive care including a complete range of state-of-the-art services and equipment.
The report commends a “terrific clinical outreach program geared toward reducing disparities in the community” and “phenomenal clinical trial accrual each year.” Patient enrollment rates into clinical trials at the Cancer Center are nearly seven times the national average – 26 percent, compared to the national rate of 4 percent.
• A multidisciplinary team approach to coordinate the best available treatment options.
“Accreditation from the Commission on Cancer validates the dedication of our physicians and staff who are committed to providing exceptional care to our patients,” says Nicholas J. Petrelli, M.D., Bank of America endowed medical director. “Our goal is to exceed the quality standards.”
• A cancer registry that offers lifelong patient follow-up.
• Information about ongoing cancer clinical trials and new treatment options. • Access to prevention and early detection programs, cancer education and support services.
• Ongoing monitoring and improvements in cancer care. • Quality care close to home. z
F E AT U R E D E M P L OY E E
“It is very rewarding to be part of a multidisciplinary cancer treatment team, assisting the doctors, nurses, social workers, nutritionists and psychologists to provide outstanding care to our patients. My role is to make sure that medical records and scans are ready for the team to review before they meet with the patient. I've been here four years, and I'm so proud of the work I do to help our patients and their families have a positive, comforting experience at the Helen F. Graham Cancer Center.” — Lori Walick, Patient and Physician Access Coordinator
6 Christiana Care Health System
Christiana Ca are Ca ancerr Prog gram 2009 9 Ana alytic** Case Disstribu ution Ye ear Seen at Chrisstiana Ca are Health Syste em
2009 Casses by AJCC Sta age Grou ups
PRIMARY SITE
2003
2004
2005
2006
2007
2008
2009
0
I
II
III
IV
ORAL
52
60
67
51
68
73
78
1
15
7
14
33
8
Lip
0
3
1
2
3
1
4
0
3
0
0
1
0
Tongue
19
10
21
18
26
25
26
1
4
3
5
10
3
Mouth
27
34
35
23
26
40
41
0
7
4
6
20
4
Pharynx
6
13
10
8
13
7
7
0
1
0
3
2
1
DIGESTIVE
425
418
401
444
460
498
442
5
88
98
104
104
43
Esophagus
34
32
15
18
29
36
29
0
7
3
12
5
2
Stomach
29
31
32
35
35
34
25
0
8
1
2
9
5
Unk/NA
Small Intestine
9
14
7
8
8
16
15
0
2
1
0
3
9
Colon
191
157
171
178
168
179
158
4
36
44
39
31
4
Rectum/Rectosigmoid
69
72
67
81
76
80
68
1
12
12
29
8
6
Liver
29
22
21
29
35
30
32
0
11
3
9
7
2
Pancreas
47
63
63
67
69
83
77
0
4
24
8
36
5
Other Digestive
17
27
25
28
40
40
38
0
8
10
5
5
10
RESPIRATORY
463
467
444
472
430
458
440
0
98
22
104
205
11
Larynx
20
30
35
20
21
28
32
0
10
5
5
11
1
Lung
440
430
406
451
401
421
399
0
85
17
99
191
7
Other Respiratory
3
7
3
1
8
9
9
0
3
0
0
3
3
BONE & CONNECTIVE TISSUE
17
21
17
24
28
25
28
0
6
0
8
4
10
Bone
3
4
6
5
4
7
5
0
2
0
0
1
2
Connective Tissue
14
17
11
19
24
18
23
0
4
0
8
3
8
MELANOMA
117
114
116
121
118
145
160
42
64
12
14
8
20
Other Skin Cancer
7
4
6
7
9
13
6
0
0
1
1
0
4
BREAST
556
488
557
534
597
639
703
200
256
161
51
24
11
FEMALE ORGANS
184
196
182
194
229
198
228
5
112
20
37
47
7
Cervix Uteri
27
31
37
27
48
33
41
0
18
6
10
7
0
Corpus Uteri
90
97
98
103
113
101
110
1
70
10
10
12
7
Ovary
49
53
41
47
54
37
52
1
13
1
13
24
0
Other Female Organs
18
15
6
17
14
27
25
3
11
3
4
4
0
MALE ORGANS
374
329
328
381
407
401
302
1
8
252
24
13
4
Prostate
357
319
316
368
393
390
290
0
0
250
23
13
4
Testis
17
8
10
11
13
11
10
0
7
2
1
0
0
Other Male Organs
0
2
2
2
1
0
2
1
1
0
0
0
0
URINARY
171
198
190
179
188
179
199
50
81
24
12
21
11
Bladder
94
117
91
100
109
83
104
48
25
16
4
7
4
Kidney/Renal Pelvis
68
77
90
68
72
89
90
2
53
8
7
13
7
Other Urinary
9
4
9
11
7
7
5
0
3
0
1
1
0
EYE
0
1
1
1
0
1
0
0
0
0
0
0
0
BRAIN/CNS
66
103
92
116
113
123
116
0
0
0
0
0
116 43
ENDOCRINE
75
68
94
72
95
117
129
0
64
8
8
6
Thyroid
68
61
77
60
69
93
94
0
64
8
8
6
8
Endocrine/Other
7
7
17
12
26
24
35
0
0
0
0
0
35
LEUKEMIA
28
43
58
60
68
79
37
0
0
0
0
0
37
OTHER HEMATOPOIETIC
147
130
137
145
138
189
174
0
41
37
42
23
31
Hodgkin’s
23
6
23
18
10
20
20
0
3
10
4
3
0
Non-Hodgkin
102
103
96
102
102
130
126
0
38
27
38
20
3
Multiple Myeloma
22
21
18
25
26
39
28
0
0
0
0
0
28
ALL OTHER/UNDEFINED
90
69
55
62
67
80
70
0
2
0
1
4
63
TOTAL
2772
2709
2745
2863
3015
3218
3112
304
835
642
420
492
419
* Analytic cases are only cases that are newly diagnosed and/or newly treated at Christiana Care Health System in 2009. Source: Christiana Care Oncology Data Center. Prepared by R. McBride, CTR.
Cancer Update 7
Non-Profit Org. US Postage
PAID Wilmington, DE Permit No. 357
P.O. Box 1668 Wilmington, Delaware 19899 www.christianacare.org
One of only 30 cancer centers in the nation selected for the National Cancer Institute Community Cancer Centers Program.
Helen F. Graham Cancer Center awarded $2.8 million in stimulus funding to expand cancer research The Helen F. Graham Cancer Center is part of a network of community-hospital cancer centers working to provide research-based cancer care spanning the full cancer continuum
The Helen F. Graham Cancer Center at Christiana Care is expanding cancer research with help from a $2.8 million grant from the National Cancer Institute (NCI). The funding is part of $80 million from the American Recovery and Reinvestment Act (ARRA) awarded to 16 members of the NCI Community Cancer Centers Program (NCCCP) and supports an additional 14 new network sites.
The grant makes it possible for the Cancer Center to expand community outreach programs, improve health care disparities, leverage information technology to benefit patient safety, and enhance survivorship and palliative care. The award will also help promote smoking cessation among cancer survivors and boost genetic counseling and breast cancer research. As a NCI-selected community cancer center, The Helen F. Graham Cancer Center is part of a network of
community-hospital cancer centers working to provide research-based cancer care spanning the full cancer continuum – from prevention, screening, diagnosis, treatment and survivorship through end-of-life care. “The continued funding of the NCCCP demonstrates the success that this network has brought to patients in their community cancer centers,” says Nicholas J. Petrelli, M.D., Bank of America endowed medical director of the Helen F. Graham Cancer Center at Christiana Care. “We are proud to be part of this elite group of cancer centers across the country as we continue to make progress in all aspects of cancer care.” z
8 Christiana Care Health System Christiana Care is a private not-for-profit regional health care system and relies in part on the generosity of individuals, foundations and corporations to fulfill its mission. Cancer Update is produced by Christiana Care Health System. Entire publication © Christiana Care Health System, 2010. All rights reserved.
11CANC12