Cancer Update November 2009

Issue No. 20 / November 2009

In this issue Risk factors Genetic assessment program

cancer update

Signs and symptoms

PROFILES IN CANCER MEDICINE Diagnosing endometrial cancer

Treating endometrial cancer

Surviving endometrial cancer Multidisciplinary cancer care

Cancer case distribution at Christiana Care

Top marks for cancer control in Delaware

Treating endometrial cancer– a multidisciplinary approach Most endometrial cancers (up to 85 percent) are diagnosed early and can be cured with proper treatment. Patients who choose an experienced hospital with a qualified team of specialists broaden their treatment options and improve their outcomes. In 2008, the Delaware Cancer Registry recorded 152 diagnosed cases of endometrial cancer. Of those, 93 (from Delaware and out of state) were diagnosed and/or received initial treatment at Christiana Care.

Prevalence of endometrial cancer The National Cancer Institute (NCI) estimates that uterine cancer will strike 42,160 women in the United States this year. Most uterine cancers start in the lining, or endometrium. Approximately 80 percent are typical endometrioid adenocarcinomas, which are slow to spread, usually diagnosed at an early stage and have high survival rates. Other types, often more aggressive, include clear cell and serous carcinomas, which are likely to be diagnosed at later stages and be more difficult to cure.

The numbers of new cases of and deaths from endometrial cancer are rising in the United States. According to the NCI, this type of cancer will claim the lives of as many as 7,780 U.S. women this year. Diagnosing it in a timely manner and accurately staging it are critical to improving overall outcomes.

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PROFILES IN CANCER MEDICINE

Treating endometrial cancer–a multidisciplinary approach Five cancer specialists with the Helen F. Graham Cancer Center share their insights for a multidisciplinary approach to treating this most-common cancer to affect the female reproductive organs. They are gynecologic oncologist Mark E. Borowsky, M.D., director of Gynecologic Oncology; gynecologic oncologist Mark G. Cadungog, M.D.; radiation oncologist Michael Sorensen, M.D.; certified genetic counselor Zohra Ali-Khan Catts, MS, CGC, director of Genetic Counseling at the Helen F. Graham Cancer Center; and Robert McBride, director of the Christiana Care Oncology Data Center.

Risk factors A woman’s risk for endometrial cancer increases with age, and women usually are diagnosed after age 50.

Use of estrogen without progesterone and morbid obesity are among the most significant risk factors because they lead to a hormonal imbalance of high estrogen levels. Excess estrogen levels can cause a condition called endometrial hyperplasia, a pre-cancerous overgrowth of the endometrium, as well as endometrial cancer.

Mark E. Borowsky, M.D

Mark G. Cadungog, M.D.

Other contributors include diabetes, early first menstruation, late menopause or never having a pregnancy. Certain types of ovarian tumors, treatment with tamoxifen for breast cancer and prior pelvic radiation therapy also increase the risk for endometrial cancer. Caucasian women are at greater risk than other women.

Michael Sorensen, M.D.

Genetic Risk Assessment Program In 5 to 10 percent of cases, endometrial cancer is inherited. In some families, endometrial cancer is associated with an increased risk of breast or thyroid cancer and, in others, an increased risk for colon or ovarian cancer. Individuals who carry certain genetic traits such as those associated with Lynch Syndrome or Cowden Syndrome are at increased risk for developing endometrial and other cancers.

The Christiana Care Genetic Risk Assessment Program offers counseling and genetic testing for people at high risk for all types of cancer in their families and includes testing for Lynch and Cowden syndromes. Knowing people’s risk for hereditary endometrial cancer is important so that high-risk patients may be surveyed more closely, improving the potential for early detection and prompt treatment.

2 Christiana Care Health System

Zohra Ali-Khan Catts, MS, CGC

Signs and symptoms

Robert McBride

Most endometrial cancers (75 percent) develop in women after menopause when menstrual periods have stopped. In approximately 90 percent of postmenopausal women with endometrial cancers, abnormal vaginal bleeding or abnormal discharge will signal that something is wrong. Endometrial cancer occurs in a smaller percentage of women (25 percent) before menopause and is sometimes signaled by prolonged periods or bleeding between periods.

Patients with advanced disease may experience symptoms including trouble urinating, pelvic pain and unintended weight loss as well as changes in bowel function and abdominal distension. A bloody cough can be a sign that cancer has spread to the lungs.

Diagnosing endometrial cancer The work-up for diagnosing endometrial cancer starts with a detailed medical history and physical exam, followed by an endometrial biopsy, usually done in the office. Other testing may include a chest X-ray, blood tests, ultrasound, CT scans and MRIs. Staging Following a diagnosis of endometrial cancer, surgical staging determines the extent of the disease, how large the cancer is and how widely it has spread. Staging uses a system developed by the American Joint Committee on Cancer and provides information for determining further treatment and predicting survival.

STAGE I.

Cancer is confined to the body of the uterus (corpus).

Stage IA. Stage IB. Stage IC.

Cancer is confined to the endometrium.

Cancer has spread less than halfway through the muscle wall of the uterus (myometrium).

Cancer has spread more than halfway through the myometrium.

STAGE II.

Cancer has spread to the cervix in the lower part of the uterus but not to lymph nodes or distant organs.

Stage IIA. Stage IIB.

Cancer is in the body of the uterus and the glands lining the cervix.

Cancer has spread past the lining into the connective tissue of the cervix.

STAGE III. Cancer has spread locally outside the uterus.

Stage IIIA. Stage IIIB. Stage IIIC.

Cancer has spread to the outer surface of the uterus, fallopian tubes, ovaries or peritoneal fluid in the lining of the pelvis or abdomen.

Cancer has spread to the vagina.

Cancer has spread to the lymph nodes near the uterus.

STAGE IV. Cancer has spread to the inner lining of the bladder or bowel, to the lymph nodes and/or to distant organs.

Stage IVA. Stage IVB.

Cancer has not spread to distant sites.

Cancer has spread to organs away from the uterus, such as lungs or bones.

Fallopian tube Ovary

Uterus Endometrium Tumor Myometrium Cervix

Vagina

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Cancer Update 3

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PROFILES IN CANCER MEDICINE

Treating endometrial cancer The primary treatment for endometrial cancer is surgery by a specially trained surgeon called a gynecologic oncologist. The surgery removes the uterus, cervix, fallopian tubes, ovaries and regional lymph nodes.

The gynecologic oncologist takes samples of the peritoneal fluid and possibly other tissues after exploring the abdomen and pelvis. The operation also removes any disease spread beyond the uterus to other organs.

A complete staging surgery by a gynecologic oncologist improves survival. Approximately 75 percent of patients with endometrial cancer can now have laparoscopic surgery. At Christiana Care, patients who are candidates for laparoscopic surgery benefit from the advanced da Vinci速 robotic laparoscopy system. The da Vinci laparoscopic surgery drastically reduces pain and blood loss compared to open surgery that requires a traditional abdominal incision. Most laparoscopic patients leave the hospital the next day.

Whether a patient needs treatment after surgery depends on if and where the cancer has spread as well as on the age and overall health of the patient.

Additional, or adjuvant, treatment options include radiation and/or chemotherapy or hormone therapy.

Radiation therapy Christiana Care offers the latest radiation therapy for endometrial cancer. Generally, radiation treatment follows surgery, but in some cases, preoperative radiation treatments are required to shrink advanced-stage tumors. When delivered in combination, radiation treatments are between cycles or after chemotherapy is completed.

Preventing recurrence. Intravaginal brachytherapy (IVB) following surgery can prevent Stage I endometrial cancer recurrences, which are usually in the vagina. With IVB, the radiation oncologist places a small cylinder containing the radiation source inside the vagina. Using CT-based computer planning, IVB treats localized areas in the vagina safely and precisely in just a few minutes without harming surrounding healthy tissues and organs such as the bladder, rectum and intestines. Patients receive IVB alone or in combination with other therapies.

Christiana Care is the primary site in Delaware and surrounding areas offering IVB as an outpatient procedure. Many centers require a two- to three-day

4 Christiana Care Health System

hospital stay for this treatment. A typical course consists of three to six IVB treatments delivered over two to three weeks. Patients enjoy greater mobility and fewer complications while they relax and recuperate between treatments in the comforts of their home.

External beam radiation is another treatment option that reduces the risk of recurrent endometrial cancer along the upper vagina and adjacent lymph nodes in the pelvic/abdominal area. The standard course of external radiation therapy consists of five to five-and-a-half weeks of daily radiation. Comparison studies could lead to broader treatment options, such as using IVB with chemotherapy versus external radiation therapy to treat early-stage uterine cancer or using Intensity Modulated Radiation Therapy (IMRT) with IVB.

Treating recurrent or advanced cancer. A recurrence of endometrial cancer after surgery calls for aggressive treatment. If cancer recurs only in the pelvis, radiation treatment could be curative.

Typically, treatment includes a combination of external beam radiation and a high-dose form of brachytherapy. One example is interstitial brachytherapy, also called a Syed implant. Interstitial brachytherapy is useful for precisely directing high doses of radiation to deeply infiltrating tumors and to previously treated areas of the vagina and surrounding peritoneal tissues. Patients receive five to six treatments twice daily while hospitalized over the course of a week or longer.

Researching new ways to fight cancer

Patients whose recurrent cancer is inoperable are potential candidates for the Cyberknife® Robotic Radiosurgery System, the latest noninvasive alternative to surgery. Cyberknife delivers maximum doses of radiation directly to cancer tumors with extreme accuracy while minimizing exposure to surrounding tissues and organs. This is particularly important following previous radiation treatments to the site.

A small percentage of women (approximately 5 percent) who are not candidates for surgery due to other health problems derive some benefit from external radiation and brachytherapy to treat their endometrial cancer. However, the outlook in these rare cases is not as good as for those who are able to have surgery.

Treatment is usually palliative, particularly if the cancer is advanced or fast growing.

Chemotherapy Women with advanced or extensive recurrent endometrial cancer can improve survival with adjuvant chemotherapy.

Most often the drugs used alone or in combination are doxorubicin, paclitaxel, cisplatin or carboplatin. Christiana Care continues to offer patients participation in national clinical trials using these medications as well as combinations of new drugs.

Hormone therapy Some studies are looking at hormone therapy to treat endometrial cancer. Certain types of advanced tumors are receptive to therapy with progesterone and other drugs such as tamoxifen or aromatase inhibitors. A woman of child-bearing age with early endometrial cancer might want to use hormone therapy to temporarily shrink tumors and permit a pregnancy, but this treatment is not standard for endometrial cancer and may increase the chances that the cancer will spread. Gynecologic oncologists can consult with women and help them understand all the options and develop an effective treatment plan.

Christiana Care’s Cancer Research Program is one of the largest community-based hospital programs in the country, bringing patients the benefits of translational and clinical studies focused on cancer treatment and prevention. As a top recruiting member of NCI’s Community Clinical Oncology Program (CCOP), the Delaware/Christiana Care CCOP offers access to the latest Gynecologic Oncology Group (GOG) and Radiation Therapy Oncology Group (RTOG) clinical trials, testing new drugs and systemic therapies integrated with the latest radiation technologies and surgical techniques to treat endometrial cancer.

The following active trial is one example:

GOG 0238

Testing whether pelvic radiotherapy combined with cisplatin chemotherapy is more promising with respect to progression-free survival than pelvic radiotherapy alone in patients with recurrent endometrial cancer limited to the pelvis and vagina.

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, newly discovered anti-cancer therapies. These efforts, along with Christiana Care’s continued outreach as a Community Cancer Center as selected by the National Cancer Institute, offer the opportunity to participate in new endometrial cancer clinical trials. These may lead to better cure rates and longer survival. (continued on next page)

Cancer Update 5

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PROFILES IN CANCER MEDICINE

Surviving endometrial cancer When we talk about survival rates, we define survivors as those patients who have lived one or more years beyond their initial diagnosis of endometrial cancer. Survival rates are a national benchmark for treatment success and an important indicator of Christiana Care’s experience and effectiveness in treating cancer.

At Christiana Care, the Oncology Data Center (ODC) collects, manages, analyzes and reports cancer data for all patients diagnosed and/or receiving treatment at Christiana Care. The ODC helps Christiana Care maintain its certification by the American College of Surgeons’ Commission on Cancer as a teaching hospital cancer program. One of the certification’s requirements is to report all newly diagnosed cancer cases to the National Cancer Data Base because longterm follow-up of cancer survivors is a significant national objective. Registry data from Christiana Care provides a basis to evaluate cancer care and to assist physicians in devising the best treatment strategies for their patients.

Data in Table 1, collected by ODC Director Robert McBride, show the latest available national survival figures for patients with endometrial cancer compared with patients in Delaware and with those diagnosed and/or treated at Christiana Care. These figures show Christiana Care’s success in treating all stages of endometrial cancer.

TABLE 1.

Endometrial Cancer Five-Year Survival Rates by Stage Diagnosis Years AJCC Stage

1997-2001

2002-2005

CCHS Delaware NCDB

CCHS Delaware NCDB

1

92.7%

92.5%

87.6%

91.7%

89.2%

N/A

2

81.0%

66.5%

75.7%

66.0%

41.0%

N/A

3

48.3%

46.5%

53.8%

42.6%

50.4%

N/A

4

6.3%

9.5%

24.4%

13.5%

8.1%

N/A

82.4%

81.6%

79.0%

75.8%

74.1%

N/A

All Stages

Data Sources: Christiana Care Health System (CCHS), Delaware Cancer Registry and National Cancer Data Base (NCDB)

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Multidisciplinary cancer care The multidisciplinary approach to treating cancer at the Helen F. Graham Cancer Center offers patients the opportunity to discuss and make decisions about their course of treatment in a group meeting with their doctors and family members. This is the time to examine all relevant standard treatment options and clinical trial opportunities. Weekly tumor conferences consider selected cases within a broader gathering of health professionals. These settings provide for an interchange of views from all pertinent medical specialties as well as an opportunity to learn about and consider various treatment options in concert with National Comprehensive Cancer Network (NCCN) guidelines.

Patients tell Christiana Care through regularly disseminated satisfaction surveys, letters and cards that this approach has been extremely helpful. The many support services available to patients through the Helen F. Graham Cancer Center are integral components of multidisciplinary cancer care. They include access to pain and symptom management, oncology rehabilitation, nutrition counseling, social work, wellness coaching, psychological counseling and support groups, including our cancer companion and survivorship programs. Christiana Care’s experience confirms that offering easy access to these services and the help of the oncology nurse care coordinator contribute greatly to improving quality of life for our patients. z

Multidisciplinary Cancer Centers at the Helen F. Graham Cancer Center • Anorectal Cancer •Breast Cancer •Pain and Symptom Management •Genetic Risk Assessment •General Oncology •Genitourinary Cancer

•Gynecology Oncology •Head and Neck Cancer •Hepatobiliary/ Pancreatic Cancers •Hepatoma Screening Center •Brain /Spinal Cord •Lymphoma

•Thoracic and Esophageal Cancer •Thyroid Cancer •Upper Gastrointestinal/ Melanoma/ Sarcoma/Bone •Young Adult Follow-up •Wellness

2008 Oncology Data Center Analytic* Case Distribution at Christiana Care Health System Year Seen at Christiana Care PRIMARY SITE

2008 Cases by AJCC Stage Groups

2003

2004

2005

2006

2007

2008

0

I

II

III

IV

Unk/NA

ORAL Lip Tongue Mouth Pharynx

52 0 19 27 6

60 3 10 34 13

67 1 21 35 10

51 2 18 23 8

68 3 26 26 13

74 1 25 40 8

0 0 0 0 0

12 1 3 8 0

6 0 3 3 0

15 0 6 7 2

31 0 8 18 5

10 0 5 4 1

DIGESTIVE Esophagus Stomach Small Intestine Colon Rectum/Rectosigmoid Liver Pancreas Other Digestive

425 34 29 9 191 69 29 47 17

418 32 31 14 157 72 22 63 27

401 15 32 7 171 67 21 63 25

444 18 35 8 178 81 29 67 28

460 29 35 8 168 76 35 69 40

501 37 34 16 178 81 31 84 40

12 0 0 0 10 1 0 0 1

104 9 9 1 48 19 6 6 6

104 5 3 3 42 13 5 26 7

111 9 5 1 44 26 14 7 5

125 13 13 2 29 17 5 41 5

45 1 4 9 5 5 1 4 16

RESPIRATORY Larynx Lung Other Respiratory

463 20 440 3

467 30 430 7

444 35 406 3

472 20 451 1

430 21 40 8

461 28 1 9

1 1 0 0

101 5 90 0

25 6 24 0

151 8 105 1

170 7 163 5

13 1 19 3

BONE & CONN. TISSUE Bone Connective Tissue

17 3 14

21 4 17

17 6 11

24 5 19

28 4 24

25 7 18

0 0 0

7 1 6

7 1 6

1 0 1

4 2 2

6 3 3

MELANOMA Other Skin Cancer

117 7

114 4

116 6

121 7

118 9

146 13

34 0

60 3

20 1

9 1

6 1

17 7

BREAST

556

488

557

534

597

640

150

239

149

52

26

24

FEMALE ORGANS Cervix Uteri Corpus Uteri Ovary Other Female Organs

184 27 90 49 18

196 31 97 53 15

182 37 98 41 6

194 27 103 47 17

229 48 113 54 14

200 35 101 37 27

2 0 1 0 1

85 15 60 8 2

23 3 9 3 8

41 7 14 12 8

29 5 7 13 4

20 5 10 1 4

MALE ORGANS Prostate Testis Other Male

374 357 17 0

329 319 8 2

328 316 10 2

381 368 11 2

407 393 13 1

405 394 11 0

0 0 0 0

9 0 9 0

347 346 1 0

21 20 1 0

14 14 0 0

14 14 0 0

URINARY Bladder Kidney/Renal Pelvis Other Urinary

171 94 68 9

198 117 77 4

190 91 90 9

179 100 68 11

188 109 72 7

182 85 89 8

47 43 2 2

74 18 56 0

19 11 6 2

13 3 9 1

22 7 14 1

7 3 2 2

EYE

0

1

1

1

0

1

0

0

0

0

0

1

BRAIN/CNS

66

103

92

116

113

125

0

0

0

0

0

125

ENDOCRINE Thyroid Endocrine/Other

75 68 7

68 61 7

94 77 17

72 60 12

95 69 26

117 93 24

0 0 0

69 69 0

5 5 0

3 3 0

8 8 0

32 8 24

LEUKEMIA

28

43

58

60

68

79

0

0

0

0

0

79

OTHER HEMATOPOIETIC Hodgkin’s Non-Hodgkin’s Multiple Myeloma

147 23 102 22

130 6 103 21

137 23 96 18

145 18 102 25

138 10 102 26

189 20 130 39

0 0 0 0

43 1 42 0

34 8 26 0

43 6 37 0

27 4 23 0

42 1 2 39

ALL OTHER/UNDEFINED

90

69

55

62

67

81

0

2

1

0

2

76

2772

2709

2745

2863

3015

3239

246

808

741

461

465

518

TOTAL

1

* Analytic cases are only cases that are newly diagnosed and/or newly treated at Christiana Care Health System in 2008.

Data Source: 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 14 cancer centers in the nation selected for the National Cancer Institute Community Cancer Centers Program.

Top marks for cancer control in Delaware State cancer control program earns national honors

Community Clinical Oncology Program is accrual champion The Cancer and Leukemia Group B, known as CALGB, places Christiana Care’s Community Clinical Oncology Program (CCOP) at the top in accrual, or recruiting patients for clinical trials.

Christiana Care’s accrual rate is 26 percent, far above the national average of 3-4 percent. That is due, in part, to recruiting community physicians to CCOP and placing nurses in the offices of oncology practices to enroll patients. Clinical trials play an essential role in cancer research. z

Dr. Petrelli and William Bowser, Esq., chair of the Delaware Cancer Consortium Advisory Council, accepted the award from former President George H.W. Bush and former First Lady Barbara Bush.

The Delaware Cancer Consortium (DCC) is the winner of the 2009 Exemplary State Comprehensive Cancer Control Implementation Award. The honor comes from C-Change, a group of business, government and nonprofit leaders dedicated to eradicating cancer. The Helen F. Graham Cancer Center plays a leading role in the consortium. The DCC’s accomplishments include the following:

• Mortality rates in Delaware dropped by more than twice the national average.

• Delaware is first in the nation for the percentage of people who have had a colonoscopy or sigmoidoscopy in the last five years.

• Delaware is third in the United States in the percentage of women over 50 who have had a Pap smear within three years or a mammogram within two years. z

“These awards exemplify the leadership and commitment of the individuals at Christiana Care and the Helen F. Graham Cancer Center and organizations such as the Delaware Cancer Consortium and the National Cancer Institute Community Clinical Oncology Program, who are all working together to lower the cancer burden in our state.”

–N ICHOLAS J. P ETRELLI , M.D. Bank of America endowed medical director of the Helen F. Graham Cancer Center and member of the DCC’s Advisory Council.

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, 2009. All rights reserved.

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